Exoskeleton-Robot Assisted Therapy in Stroke Patients: A Lesion Mapping Study

I'm sure that someplace in the joining of these three sets this research was already accomplished and no protocols came out of it. Just like NO PROTOCOLS will come out of this one either. 

• exoskeleton (105 posts)
• upper extremity (4 posts)
• upper limb (270 posts)

https://www.frontiersin.org/articles/10.3389/fninf.2018.00044/full?

Antonio Cerasa^1,2*†, Loris Pignolo^1†, Vera Gramigna², Sebastiano Serra¹, Giuseppe Olivadese², Federico Rocca², Paolo Perrotta², Giuliano Dolce¹, Aldo Quattrone^2,3 and Paolo Tonin^1*

• 1

S. Anna Institute and Research in Advanced Neurorehabilitation (RAN) Crotone, Crotone, Italy

²Neuroimaging Unit, IBFM-CNR, Catanzaro, Italy

³Neuroscience Research Centre, University Magna Græcia, Catanzaro, Italy

Background: Technology-supported rehabilitation is emerging as a solution to support therapists in providing a high-intensity, repetitive and task-specific treatment, aimed at improving stroke recovery. End-effector robotic devices are known to positively affect the recovery of arm functions, however there is a lack of evidence regarding exoskeletons. This paper evaluates the impact of cerebral lesion load on the response to a validated robotic-assisted rehabilitation protocol.

Methods: Fourteen hemiparetic patients were assessed in a within-subject design (age 66.9 ± 11.3 years; 10 men and 4 women). Patients, in post-acute phase, underwent 7 weeks of bilateral arm training assisted by an exoskeleton robot combined with a conventional treatment (consisting of simple physical activity together with occupational therapy). Clinical and neuroimaging evaluations were performed immediately before and after rehabilitation treatments. Fugl-Meyer (FM) and Motricity Index (MI) were selected to measure primary outcomes, i.e., motor function and strength. Functional independance measure (FIM) and Barthel Index were selected to measure secondary outcomes, i.e., daily living activities. Voxel-based lesion symptom mapping (VLSM) was used to determine the degree of cerebral lesions associated with motor recovery.

Results: Robot-assisted rehabilitation was effective in improving upper limb motor function recovery, considering both primary and secondary outcomes. VLSM detected that lesion load in the superior region of the corona radiata, internal capsule and putamen were significantly associated with recovery of the upper limb as defined by the FM scores (p-level < 0.01).

Conclusions: The probability of functional recovery from stroke by means of exoskeleton robotic rehabilitation relies on the integrity of specific subcortical regions involved in the primary motor pathway. This is consistent with previous evidence obtained with conventional neurorehabilitation approaches.

Introduction

Several systematic and meta-analytic reviews have confirmed that robotic-assisted devices elicit robust motor recovery in patients with stroke, mainly in relation to the upper limb intervention (Masiero et al., 2007; Bertani et al., 2017; Lo et al., 2017). Early research on robotic therapy for the upper limb was based on end-effector robots, which hold the patient’s hand or forearm at one point and generate forces at the interface. Recently this field of study has shifted towards an exoskeleton device, which overcomes many of the inherent limitations of end-effector robots (Lo and Xie, 2012). Compared to conventional therapy, exoskeletons have the potential to provide intensive rehabilitation consistently for a longer duration and irrespective of the skills and fatigue level of the therapist (Huang and Krakauer, 2009; Lo and Xie, 2012).

The Automatic Recovery Arm Motility Integrated System (ARAMIS) is a concept robot and prototype for the neurorehabilitation of the paretic upper limb developed at the Institute S. Anna—Crotone, Italy. ARAMIS was designed with two computer-controlled, symmetric and interacting exoskeletons, which compensate for the inadequate strength and accuracy of the paretic arm movements and the effect of gravity during rehabilitation. The basic idea is to exploit proprioceptive inputs using passive, repetitive, interactive, high-intensive bilateral movement training, which has been demonstrated to enhance motor recovery in stroke patients (Stinear et al., 2008; Choo et al., 2015; Saleh et al., 2017; Gandolfi et al., 2018). This device has been widely validated (Colizzi et al., 2009; Dolce et al., 2009; Pignolo et al., 2012) with respect to conventional neurorehabilitation approaches, demonstrating high degree of upper limb recovery as assessed by the Fugl-Meyer (FM) scale (Fugl-Meyer et al., 1975). The FM is a performance-based impairment index designed to assess motor functioning, balance, sensation and joint functioning in patients with post-stroke hemiplegia. Overall, FM together with the Modified Ashworth Scale (MAS) and functional independance measure (FIM) (Keith et al., 1987), are the most reliable clinical scales employed to unravel motor recovering after robotic-treatment in stroke patients (Bertani et al., 2017).

Despite this large amount of evidence confirming the effectiveness and robustness of robotic-assisted rehabilitation in promoting motor recovery the underlying pathophysiology is still unclear. In fact, some biomarkers have been effectively demonstrated to predict therapeutic response or recovery following stroke (Burke Quinlan et al., 2015). Generally, research has focused on the neural substrate of motor recovery obtained with a conventional neurorehabilitation approach (Shelton and Reding, 2001; Murphy and Corbett, 2009; Carrera and Tononi, 2014; Choo et al., 2015; Lee et al., 2017; Siegel et al., 2018), whereas little attention has been paid to robotic-assisted therapy with exoskeleton devices (Formaggio et al., 2013; Fan et al., 2016; Gandolfi et al., 2018). Overall, preservation of the corticospinal tract is considered as a hallmark for good recovery of impaired motor function in patients with brain injury (Hendricks et al., 2002; Swayne et al., 2008; Stinear, 2010). Within this pathway there are several critical hubs that have been associated with functional recovery after conventional therapy. Mounting evidence from functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI) as well as resting-state functional connectivity studies have demonstrated that the increased activity in ipsilateral primary motor cortex and the morphological integrity of the posterior limb of the capsula interna predict the positive clinical outcome (Shelton and Reding, 2001; Stinear et al., 2012; Stinear and Ward, 2013; Favre et al., 2014; Rehme et al., 2015). Moreover, lesions in the globus pallidus, and putamen (together with corona radiata, internal capsule) were also associated with poor recovery (Lee et al., 2017).

This study, thus, assesses the effects of lesion location on the response to rehabilitation training obtained with an exoskeleton robot device. The aim is to expand knowledge of the neural basis of stroke rehabilitation and the prognosis of upper limb disorders.