Upper Limb Robotic Rehabilitation for Patients with Cervical Spinal Cord Injury: A Comprehensive Review

Paired associative stimulation to enhance motor outcome in spinal cord injury: a systematic review of first evidence

INTRODUCTION

Spinal cord injuries (SCI) often result in motor impairment and lifelong disability.

METHODS

This systematic review, conducted in agreement with PRISMA guidelines, aimed to evaluate the effects of cortico-spinal paired associative stimulation (PAS) on motor outcomes in individuals with SCI. PubMed, Scopus/EMBASE, Pedro, and Cochrane databases were consulted from inception to 2023/01/12.

RESULTS

In 1021 articles, 10 studies involving 84 patients meet the inclusion criteria, 7 case series/study, and 3 clinical trials. Despite light differences, the included studies performed a cortico-peripheral PAS using a single transcranial magnetic stimulation and high frequency electrical peripheral nerve stimulation for a consistent number of sessions (>20). All included studies reported improvement in motor outcomes recorded via clinical and/or neurophysiological assessment.

CONCLUSION

Available evidence showed an increase in motor outcomes after PAS stimulation. Indeed, both clinical and neurophysiological outcomes suggest the effectiveness of a high number of PAS sessions in chronic individuals with SCI. Due to a limited number of studies and an unsatisfactory study design, well-designed RCTs are needed to confirm the potentiality of these approaches and clarify the adequate dose-response of PAS in the SCI population.

REGISTRATION ID

The protocol was registered on the PROSPERO database (CRD42023485703).

Effects of robotic therapy associated with noninvasive brain stimulation on motor function in individuals with incomplete spinal cord injury: A systematic review of randomized controlled trials

CONTEXT

Motor deficits are among the most common consequences of incomplete spinal cord injury (SCI). These impairments can affect patients' levels of functioning and quality of life. Combined robotic therapy and non-invasive brain stimulation (NIBS) have been used to improve motor impairments in patients with corticospinal tract lesions.

OBJECTIVES

To examine the effects of combined robotic therapy and NIBS on motor function post incomplete SCI.

METHODS

PubMed, SCOPUS, MEDLINE, PEDro, Web of Science, REHABDATA, CINAHL, and EMBASE were searched from inception until July 2023. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the selected studies quality.

RESULTS

Of 557 studies, five randomized trials (n = 122), with 25% of participants being females, were included in this review. The PEDro scores ranged from eight to nine, with a median score of nine. There were variations in treatment protocols and outcome measures, resulting in heterogeneous findings. The findings showed revealed evidence for the impacts of combined robotic therapy and NIBS on motor function in individuals with incomplete SCI.

CONCLUSIONS

Combined robotic training and NIBS may be safe for individuals with incomplete SCI. The existing evidence concerning its effects on motor outcomes in individuals with SCI is limited. Further experimental studies are needed to understand the effects of combined robotic training and NIBS on motor impairments in SCI populations.

Efficacy of telerehabilitation with digital and robotic tools for the continuity of care of people with chronic neurological disorders: The TELENEURO@REHAB protocol for a randomized controlled trial

Context

Chronic Neurological Disorders (CNDs) are among the leading causes of disability worldwide, and their contribution to the overall need for rehabilitation is increasing. Therefore, the identification of new digital solutions to ensure early and continuous care is mandatory.

Objective

This protocol proposes to test the usability, acceptability, safety, and efficacy of Telerehabilitation (TR) protocols with digital and robotic tools in reducing the perceived level of disability in CNDs including Parkinson's Disease (PD), Multiple Sclerosis (MS), and post-stroke patients.

Design Setting and Subjects

This single-blinded, multi-site, randomized, two-treatment arms controlled clinical trial will involve PD (N = 30), MS (N = 30), and post-stroke (N = 30). Each participant will be randomized (1:1) to the experimental group (20 sessions of motor telerehabilitation with digital and robotic tools) or the active control group (20 home-based motor rehabilitation sessions according to the usual care treatment). Primary and secondary outcome measures will be obtained at the baseline (T0), post-intervention (T1, 5 weeks after baseline), and at follow-up (T2, 2 months after treatment).

Main Outcome Measures

a multifaceted evaluation including quality of life, motor, and clinical/functional measures will be conducted at each time-point of assessment. The primary outcome measures will be the change in the perceived level of disability as measured by the World Health Organization Disability Assessment Schedule 2.0.

Conclusion

The implementation of TR protocols will enable a more targeted and effective response to the growing need for rehabilitation linked to CNDs, ensuring accessibility to rehabilitation services from the initial stages of the disease.

Traumatic Human Spinal Cord Injury: Are Single Treatments Enough to Solve the Problem?

Traumatic spinal cord injury (SCI) results in partial or complete motor deficits, such as paraplegia, tetraplegia, and sphincter control, as well as sensory disturbances and autonomic dysregulation such as arterial hypotension, lack of sweating, and alterations in skin lability. All this has a strong psychological impact on the affected person and his/her family, as well as costs to healthcare institutions with an economic burden in the short, medium, and long terms. Despite at least forty years of experimental animal studies and several clinical trials with different therapeutic strategies, effective therapy is not universally accepted. Most of the published works on acute and chronic injury use a single treatment, such as medication, trophic factor, transplant of a cell type, and so on, to block some secondary injury mechanisms or promote some mechanisms of structural/functional restoration. However, despite significant results in experimental models, the outcome is a moderate improvement in muscle strength, sensation, or eventually in sphincter control, which has been considered non-significant in human clinical trials. Here we present a brief compilation of successful individual treatments that have been applied to secondary mechanisms of action. These studies show limited neuroprotective or neurorestorative approaches in animal models and clinical trials. Thus, the few benefits achieved so far represent a rationale to further explore other strategies that seek better structural and functional restoration of the injured spinal cord.

The effectiveness of robotic-assisted upper limb rehabilitation to improve upper limb function in patients with cervical spinal cord injuries: a systematic literature review

Background

Spinal Cord Injury (SCI) damages corticospinal tracts and descending motor pathways responsible for transmitting signals from the brain to the spinal cord, leading to temporary or permanent changes in sensation, motor function, strength, and body function below the site of injury. Cervical SCI (cSCI), which leads to tetraplegia, causes severe functional upper limb (UL) impairments that increase falls risk, limits independence, and leads to difficulties with activities of daily living (ADLs). Robotic therapy (RT) has been developed in recent decades as a new treatment approach for people with cervical spinal cord injuries (cSCI). The present review aimed to explore current available evidence and studies regarding the effectiveness of RT for individuals with cSCI in improving UL function, identify current research gaps and future research directions.

Method

This review was conducted by searching PubMed, CINAHL, Medline, Embase, and APA PsycInfo for relevant studies published from January 2010 to January 2022. Selected studies were analyzed with a focus on the patients' self-perception of limited UL function and level of independence in activities of daily living. In addition, the JBI Critical Appraisal checklist was used to assess study quality.

Results

A total of 7 articles involving 87 patients (74 males and 13 females) were included in the analysis, with four studies utilizing exoskeleton and three studies utilizing end-effector robotic devices, respectively. The quality of these studies varied between JBI Critical Appraisal scores of 4 to 8. Several studies lacked blinding and a control group which affected internal validity. Nevertheless, four out of seven studies demonstrated statistically significant improvements in outcome measurements on UL function and strength after RT.

Conclusion

This review provided mixed evidence regarding the effectiveness of RT as a promising intervention approach to improve upper limb function in participants with cSCI. Although RT was shown to be safe, feasible, and reduces active therapist time, further research on the long-term effects of UL RT is still needed. Nevertheless, this review serves as a useful reference for researchers to further develop exoskeletons with practical and plausible applications toward geriatric orthopaedics.

Treatment of the Paretic Hand with a Robotic Glove Combined with Physiotherapy in a Patient Suffering from Traumatic Tetraparesis: A Case Report

BACKGROUND

cervical spinal cord injury leads to loss of upper limb functionality, which causes a decrease in autonomy to perform activities of daily living. The use of robotic technologies in rehabilitation could contribute to improving upper limb functionality and treatment quality. This case report aims to describe the potential of robotic hand treatment with Gloreha Sinfonia, in combination with conventional rehabilitation, in a tetraparetic patient.

MATERIAL

fifteen rehabilitative sessions were performed. Evaluations were conducted pre-treatment (T0), post-treatment (T1), and at two-months follow-up (T2) based on: the upper-limb range of motion and force assessment, the FMA-UE, the 9-Hole Peg Test (9HPT), and the DASH questionnaire. A virtual reality game-based rating system was used to evaluate the force control and modulation ability.

RESULTS

the patient reported greater ability to use hands with less compensation at T1 and T2 assessments. Improvements in clinical scales were reported in both hands at T1, however, at T2 only did the dominant hand show further improvement. Improved grip strength control and modulation ability were reported for T1. However a worsening was found in both hands at T2, significant only for the non-dominant hand. The maximum force exerted increased from T0 to T2 in both hands.

CONCLUSION

hand treatment combining physical therapy and Gloreha Sinfonia seems to have benefits in functionality and dexterity in tetraparetic patient in the short term. Further studies are needed to confirm these findings, to verify long-term results, and to identify the most appropriate modalities of robotic rehabilitation.

Rehabilitation interventions for weaning from mechanical ventilation in patients with spinal cord injury: A systematic review

BACKGROUND

Despite the fact that weaning from mechanical ventilation (MV) is one of the main rehabilitation goals in patients with spinal cord injury (SCI), controversies are still open about the optimal rehabilitation approach.

OBJECTIVE

This systematic review aimed at characterizing the rehabilitation interventions currently available to optimize weaning from MV in SCI patients.

METHODS

On April 12nd, 2022, a systematic literature search was performed in PubMed, Scopus, Web of Science, Cochrane, and PEDro, identifying studies assessing MV patients with SCI undergoing pulmonary rehabilitation. The primary outcomes were weaning duration, MV duration, and weaning success rate. Secondary outcomes were pulmonary function, extubation or decannulation time, length of stay, and safety.

RESULTS

Out of 413 records, 14 studies were included (2 randomized controlled trials, 7 observational studies, and 5 case reports). Most of the studies assessed a comprehensive rehabilitation approach, including high tidal volume ventilation, positioning, mechanical lung recruitment maneuvers, secretion management strategies, respiratory muscle training, and electrical stimulation.

CONCLUSION

Our findings suggested that a comprehensive rehabilitation intervention might have a role in reducing MV duration in patients with SCI. Further studies are needed to better characterize the optimal rehabilitation strategies for enhancing functional recovery of patients with SCI.

The Efficacity of the NeuroAssist Robotic System for Motor Rehabilitation of the Upper Limb-Promising Results from a Pilot Study

The research aimed to evaluate the efficacy of the NeuroAssist, a parallel robotic system comprised of three robotic modules equipped with human-robot interaction capabilities, an internal sensor system for torque monitoring, and an external sensor system for real-time patient monitoring for the motor rehabilitation of the shoulder, elbow, and wrist. The study enrolled 10 consecutive patients with right upper limb paresis caused by stroke, traumatic spinal cord disease, or multiple sclerosis admitted to the Neurology I Department of Cluj-Napoca Emergency County Hospital. The patients were evaluated clinically and electrophysiologically before (T1) and after the intervention (T2). The intervention consisted of five consecutive daily sessions of 30-45 min each of 30 passive repetitive movements performed with the robot. There were significant differences (Wilcoxon signed-rank test) between baseline and end-point clinical parameters, specifically for the Barthel Index (53.00 ± 37.72 vs. 60.50 ± 36.39, p = 0.016) and Activities of Daily Living Index (4.70 ± 3.43 vs. 5.50 ± 3.80, p = 0.038). The goniometric parameters improved: shoulder flexion (70.00 ± 56.61 vs. 80.00 ± 63.59, p = 0.026); wrist flexion/extension (34.00 ± 28.75 vs. 42.50 ± 33.7, p = 0.042)/(30.00 ± 22.97 vs. 41.00 ± 30.62, p = 0.042); ulnar deviation (23.50 ± 19.44 vs. 33.50 ± 24.15, p = 0.027); and radial deviation (17.50 ± 18.14 vs. 27.00 ± 24.85, p = 0.027). There was a difference in muscle activation of the extensor digitorum communis muscle (1.00 ± 0.94 vs. 1.40 ± 1.17, p = 0.046). The optimized and dependable NeuroAssist Robotic System improved shoulder and wrist range of motion and functional scores, regardless of the cause of the motor deficit. However, further investigations are necessary to establish its definite role in motor recovery.

Cardiac autonomic modulation in response to postural transition during a virtual reality task in individuals with spinal cord injury: A cross-sectional study

PURPOSE

The postural transition from sitting to standing is a moment of dysautonomic occurrence in individuals with Spinal Cord Injury (SCI). Different tools can be used to minimize this event, such as virtual reality. Thus, we aimed to analyze cardiac autonomic modulation in individuals with SCI during postural transition from the sitting to orthostatism position using a cognitive virtual reality (VR) task.

METHODS

Individuals with and without SCI were positioned on the Easy Stand® device, sitting at rest, at 0° considering the angle between the seat and the floor, elevation at 45°, and orthostatism at 90°, for 5 minutes in each position. Heart rate variability (HRV) measures of sympathovagal balance were collected (heart rate receiver: Polar V800). The groups were subdivided into two groups, one that performed VR as an intervention during the postural angle changes and another group that did not perform VR.

RESULTS

We evaluated 76 individuals, 40 with a medical diagnosis of SCI and 36 who composed the able-bodied control group without SCI, matched by age and sex. The HRV results showed that the SCI group who performed the task in VR demonstrated no significant difference in parasympathetic activation and global variability between the sitting versus 90° positions. There was better sympathovagal balance in SCI and able-bodied control groups who performed the VR task between the sitting versus 90° positions.

CONCLUSION

The use of a VR task seems to contribute to better sympathovagal balance, with the potential to reduce dysautonomia during postural changes.

Effects of blood flow restriction on spine postural control using a robotic platform: A pilot randomized cross-over study

BACKGROUND

Blood flow restriction (BFR) training improves muscle strength and functional outcomes, but the proprioceptive implications of this technique in the rehabilitation field are still unknown.

OBJECTIVE

The present study aimed at assessing the effects of BFR in terms of stabilometric and balance performance.

METHODS

In this pilot randomized cross-over study, healthy young adults were included and randomly assigned to Groups A and B. Both groups underwent a postural assessment with and without wearing a BFR device. Study participants of Group A underwent postural baseline assessment wearing BFR and then removed BFR for further evaluations, whereas subjects in Group B performed the baseline assessment without BFR and then with BFR. Stabilometric and balance performance were assessed by the robotic platform Hunova, the Balance Error Scoring System (BESS), the self-reported perceived balance (7-point Likert scale), and discomfort self-rated assessment. Moreover, the safety profile was recorded.

RESULTS

Fourteen subjects were included and randomly assigned to Group A (n: 7) and Group B (n: 7). Significant differences were shown in balance tests in static conditions performed on the Hunova robot platform in terms of average distance RMS (root-mean-square) with open eyes (OE), anteroposterior (AP) trunk oscillation range with OE, mediolateral (ML) average speed of oscillation with OE, and total excursion AP range with closed eyes (CE) (BFR: 3.44 ± 1.06; without BFR: 2.75 ± 0.72; p= 0.041). Moreover, elastic balance test showed differences in Romberg index (BFR: 0.16 ±0.16; without BFR: 0.09 ± 0.07; p= 0.047). No adverse events were reported.

CONCLUSION

Taken together, our data showed that BFR affects balance performance of healthy subjects. Further studies are needed to better characterize the possible role of BFR treatment in the context of a specific rehabilitation protocol.

The impact of rehabilitation in bone loss management of patients with spinal cord injury: A systematic review

BACKGROUND

Spinal cord injury (SCI) is a disabling condition characterized by multilevel skeletal muscle impairment and rapid cortical and trabecular bone loss. Rehabilitation is a cornerstone of the long-term management of patients with SCI; however, the optimal rehabilitation strategy for improving bone health has not been fully characterized.

OBJECTIVE

To characterize the current evidence supporting different rehabilitation interventions improving bone health in patients with SCI.

METHODS

On November 17th, 2022, five databases (PubMed, Scopus, Web of Science, Cochrane, and PEDro) were systematically searched for randomized controlled trials (RCTs) assessing SCI patients undergoing rehabilitation interventions. The primary outcomes were bone macroscopical effects. Secondary outcomes were changes in bone metabolisms and functional outcomes.

RESULTS

Out of 499 records, 11 RCTs met the eligibility criteria and were included. Electrical stimulation combined with physical exercise was assessed by 5 studies, standing intervention was assessed by 3 studies, vibration was assessed by 1 study, ultrasound therapy was assessed by 1 study, and electroacupuncture combined with a pulsed magnetic field was assessed by 1 study. The rehabilitation intervention was administered combined with pharmacological treatment (3 studies) or alone (8 studies). Positive effects in terms of BMD were reported by 3 studies. The quality assessment revealed some concerns in 9 out of 11 studies, in accordance with the Cochrane Risk of Bias assessment - version 2.

CONCLUSION

Our data suggest that multicomponent interventions including rehabilitation might be considered a suitable option to improve bone health management in SCI patients. Further studies are mandatory to characterize the optimal combination of non-pharmacological interventions reducing bone loss and improving the risk of fractures in patients with SCI.

Measuring Torque Production with a Robotic Exoskeleton during Cervical Transcutaneous Spinal Stimulation

Spinal cord injury (SCI) affects a large number of individuals in the United States. Unfortunately, traditional neurorehabilitation therapy leaves out clinical populations with limited motor function, such as severe stroke or spinal cord injury, as they are incapable of engaging in movement therapy. To increase the numbers of individuals who may be able to participate in robotic therapy, our long-term goal is to combine two validated interventions, transcutaneous spinal stimulation (TSS) and robotics, to elicit upper limb movements during rehabilitation following SCI. To achieve this goal, it is necessary to quantify the contributions of each intervention to realizing arm movements. Electromyography is typically used to assess the response to TSS, but the robot itself offers an additional source of data since the available sensors on the robot can be used to directly assess resultant actions of the upper limb after stimulation. We explore this approach in this paper. We showed that the effects of cutaneous TSS can be observed by measuring the holding torque required by the exoskeleton to keep a user's arm in a neutral position. Further, we can identify differences in resultant action based on the location of the stimulation electrodes with respect to the dorsal roots of the spinal cord. In the future, we can use measurements from the robot to guide the action of the robot and TSS intervention.

Using Artificial Neuro-Molecular System in Robotic Arm Motion Control-Taking Simulation of Rehabilitation as an Example

Under the delicate control of the brain, people can perform graceful movements through the coordination of muscles, bones, ligaments, and joints. If artificial intelligence can be used to establish a control system that simulates the movements of human arms, it is believed that the application scope of robotic arms in assisting people's daily life can be greatly increased. The purpose of this study is to build a general system that can use intelligent techniques to assist in the construction of a personalized rehabilitation system. More importantly, this research hopes to establish an intelligent system that can be adjusted according to the needs of the problem domain, that is, the system can move toward the direction of problem-solving through autonomous learning. The artificial neural molecular system (ANM system), developed early in our laboratory, which captured the close structure/function relationship of biological systems, was used. The system was operated on the V-REP (Virtual Robot Experimentation Platform). The results show that the ANM system can use self-learning methods to adjust the start-up time, rotation angle, and the sequence of the motor operation of different motors in order to complete the designated task assignment.

The improvement of the lower limb exoskeletons on the gait of patients with spinal cord injury: A protocol for systematic review and meta-analysis

BACKGROUND

Spinal Cord Injury is a severely disabling disease. In the process of Spinal Cord Injury rehabilitation treatment, improving patients' walking ability, improving their self-care ability, and enhancing patients' self-esteem is an important aspect of their return to society, which can also reduce the cost of patients, so the rehabilitation of lower limbs is very important. The lower limb exoskeleton robot is a bionic robot designed according to the principles of robotics, mechanism, bionics, control theory, communication technology, and information processing technology, which can be worn on the lower limb of the human body and complete specific tasks under the user's control. The purpose of this study was to evaluate the effect of the lower limb exoskeleton on the improvement of gait function in patients with spinal cord injury.

METHODS

The following electronic databases will be searched from inception to January 2022: PubMed, the Cochrane Library, Embase, Scopus, EBSCO, Web of Science, China National Knowledge Infrastructure, WanFang Data, Weipu Electronics. In addition, reference lists of the included studies were manually searched to identify additional relevant studies. Randomized controlled trials were collected to examine the effect of lower limb exoskeletons on lower limb functional recovery in spinal cord injury patients. We will consider inclusion, select high-quality articles for data extraction and analysis, and summarize the intervention effect of lower limb exoskeletons on the upper limb function of spinal cord injury patients. Two reviewers will screen titles, abstracts, and full texts independently according to inclusion criteria; Data extraction and risk of bias assessment were performed in the included studies. We will use a hierarchy of recommended assessment, development, and assessment methods to assess the overall certainty of the evidence and report findings accordingly. Endnote X8 will be applied in selecting the study, Review Manager 5.3 will be applied in analyzing and synthesizing.

RESULTS

The results will provide evidence for judging whether lower limb exoskeletons are effective and safe in improving lower limb function in patients with spinal cord injury.

CONCLUSION

Our study will provide reliable evidence for the effect of lower limb exoskeletons on the improvement of lower limb function in spinal cord injury patients.

INPLASY REGISTRATION NUMBER

INPLASY202180095.

Reference theories and future perspectives on robot-assisted rehabilitation in people with neurological conditions: A scoping review and recommendations from the Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE)

BACKGROUND

Robot-based treatments are developing in neurorehabilitation settings. Recently, the Italian National Health Systems recognized robot-based rehabilitation as a refundable service. Thus, the Italian neurorehabilitation community promoted a national consensus on this topic.

OBJECTIVE

To conceptualize undisclosed perspectives for research and applications of robotics for neurorehabilitation, based on a qualitative synthesis of reference theoretical models.

METHODS

A scoping review was carried out based on a specific question from the consensus Jury. A foreground search strategy was developed on theoretical models (context) of robot-based rehabilitation (exposure), in neurological patients (population). PubMed and EMBASE® databases were searched and studies on theoretical models of motor control, neurobiology of recovery, human-robot interaction and economic sustainability were included, while experimental studies not aimed to investigate theoretical frameworks, or considering prosthetics, were excluded.

RESULTS

Overall, 3699 records were screened and finally 9 papers included according to inclusion and exclusion criteria. According to the population investigated, structured information on theoretical models and indications for future research was summarized in a synoptic table.

CONCLUSION

The main indication from the Italian consensus on robotics in neurorehabilitation is the priority to design research studies aimed to investigate the role of robotic and electromechanical devices in promoting neuroplasticity.