Systematic review with network meta-analysis of randomized controlled trials of robotic-assisted arm training for improving activities of daily living and upper limb function after stroke

Just why the fuck was this review necessary?  You just look up the necessary info in that complete database of all research and stroke protocols.  Well you could if we had ANYTHING OTHER THAN fucking failures of stroke associations. 

But we don't, all survivors are screwed until we do get that.

Systematic review with network meta-analysis of randomized controlled trials of robotic-assisted arm training for improving activities of daily living and upper limb function after stroke

• Jan Mehrholz,
• Alex Pollock,
• Marcus Pohl,
• Joachim Kugler &
• Bernhard Elsner 

Journal of NeuroEngineering and Rehabilitation volume 17, Article number: 83 (2020) Cite this article

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Abstract

Background

The aim of the present study was to to assess the relative effectiveness of the various types of electromechanical-assisted arm devices and approaches after stroke.

Method

This is a systematic review of randomized controlled trials with network meta-analysis. Our primary endpoints were activities of daily living (measured e.g. with Barthel-Index) and hand-arm function (measured e.g. with the Fugl-Meyer Scale for the upper limb), our secondary endpoints were hand-arm strength (measured e.g. with the Motricity Index) and safety. We used conventional arm training as our reference category and compared it with different intervention categories of electromechanical-assisted arm training depending on the therapy approach. We did indirect comparisons between the type of robotic device. We considered the heterogeneity of the studies by means of confidence and prediction intervals.

Results

Fifty five randomized controlled trials, including 2654 patients with stroke, met our inclusion criteria.
For the primary endpoints activities of daily living and hand-arm function and the secondary endpoint hand-arm strength, none of the interventions achieved statistically significant improvements, taking into account the heterogeneity of the studies.
Safety did not differ with regard to the individual interventions of arm rehabilitation after stroke.

Conclusion

The outcomes of robotic-assisted arm training were comparable with conventional therapy.
Indirect comparisons suggest that no one type of robotic device is any better or worse than any other device, providing no clear evidence to support the selection of specific types of robotic device to promote hand-arm recovery.

Trial registration

PROSPERO 2017 CRD42017075411

Introduction

Stroke is one of the most common diseases worldwide and leads to permanent disability, reduced quality of life and thus to a high burden of disease [1]. A majority of stroke patients have limited hand and arm function and are therefore restricted in their daily activities [2]. The recovery of hand-arm function is therefore an important goal for rehabilitation after stroke [1]. In recent years, interventions such as electromechanical-assisted arm training have been introduced to improve hand and arm functions [3, 4]. It has been argued that use of electromechanical-assisted arm training can support the provision of evidence-based rehabilitation, by facilitating therapy that is intensive, frequent and repetitive [3]. However, while systematic reviews show some beneficial effects of electromechanical-assisted arm training on upper limb motor function, these effects are not clinically relevant [3, 4]. Furthermore, there is also some evidence of a detrimental effect, with one systematic review concluding that muscle tone of the upper limb might be negatively influenced by robotic-assisted arm-training [4].
The devices used in electromechanically-assisted arm therapy target the motor function of either the shoulder/elbow, elbow/wrist, wrist/hand, hand/finger or the entire upper extremity [3, 5]. There are two broad types of electromechanical devices which have been used to enable or assist arm and/or hand movement in a patient with a paretic limb following stroke:

1. (a) An external robotic arm, known as an exoskeleton, which is designed to control one or more joints of the paretic arm. The exoskeleton uses torque actuators in order to apply rotational forces to move, or assist the movement, at a joint. For example, a robotic arm could support the weight of a patient’s arm in the horizontal plane, and assist combined movement at the shoulder and elbow [5].
   
2. (b) A robotic device, known as an end-effector, which assists movement of only the distal part of the paretic arm [3, 4]. These devices generally only have contact with the patient’s hand/fingers; and move – or assist the movement – of the distal part of the arm, which may result in movement at more proximal parts of the arm. End effectors may act to move just the paretic limb, or may act to support bilateral arm movement. For example, an end effector may comprise two handles, which are held by the patient’s hands. Movement of the handles facilitates bilateral pronation/supination of the forearm and flexion/extension of the wrist. Movement of the patient’s affected arm may be passive, either driven entirely by the robot or by active movement of the unaffected arm, or may be active-assisted, supported by the robot or unaffected arm [5].
   

In addition to generating either passive or assisted movement of a paretic arm, electromechanically assisted arm therapy can give patients feedback about the joint position and the arm power used.
Electromechanical-assisted arm therapy may, alternatively, be classified based on whether the robot acts: more proximally or distally, with a one-sided / unilateral or double-sided / bilateral exercise approach, or to give support to specific joint sections. End effector-based therapy robots generally initiate movement via contact with the patient’s hand, generating movement of more proximal joints from this distal contact; while exoskeletal devices can directly guide and control movement of both proximal and distal joints via series of drive elements.
Furthermore, the torque actuators which can be used within robotic devices may have different mechanisms of action, and there is ongoing debate regarding these different approaches to control of force. For example, it remains unclear whether a compliant actuator (e.g. series elastic actuators, an elastic element attached) is any more beneficial than an assist-as-needed control mechanism (e.g. which encourages patients’ active participation), or an impedance control mechanism (e.g. an end effector that takes into account the kinematics and dynamics of the object being manipulated).
With a rapid growth in new technologies and devices over recent decades, there are now a large number of different electromechanical-assisted arm training devices designed to move, or assist movement of, the arm. The types of therapy provided by different devices differ significantly both in terms of the technologies employed and the therapy provided. There is a growing body of evidence, synthesized within systematic reviews, that demonstrates that electromechanical-assisted arm training may be beneficial for recovery of arm function after stroke, with quality of the evidence judged to be ‘high’ (using the GRADE approach) [3, 4]. However, although the evidence on robotic-assisted arm training after stroke seems robust, there remains a lack of information about the relative effects of different types of devices. The existing systematic reviews are arguably limited by their narrow focus, for example on the effectiveness of robotic-assisted arm training or electromechanical-assisted arm rehabilitation compared to control interventions [3, 4, 6]. Thus, while in practice it is crucial to know which type of robotic device performs most effectively in a given situation, the current evidence base lacks direct comparisons of two or more different types of device. Furthermore, it remains unclear which of the different devices or approaches may be most effective for certain subgroups of patients with stroke, meaning that a treating clinician will encounter difficulties in deciding which specific form of treatment to select and/or apply for a specific patient after stroke. Thus, while systematic reviews have explored the effectiveness of electro mechanical assisted arm rehabilitation [3, 4], these have not directly compared the effects of the different types of devices or therapy provided by devices, in order to determine the optimal type of electro mechanical assisted arm training for individual patients.
An approach to solving this problem is offered by network meta-analyses. These enable quantitative synopsis of an “evidence network” by combining direct and indirect effects of three or more interventions, compared to the same comparative intervention (often a control or a no-treatment intervention), within a randomized controlled trial [7]. This is also called a multiple treatment comparison [8].
In this way, network meta-analyses allow the quantitative synthesis of evidence of effectiveness of interventions directly compared within the same randomised controlled trial (direct comparisons) and interventions from different randomised controlled trials which have a common comparator (indirect comparisons) [7]. Network meta-analyses could therefore provide an efficient method for determining the relative effects of different electro mechanical assisted arm training devices and therapy approaches, without the need for new randomised controlled trials.
The aim of the present study was therefore to provide a systematic overview of current randomised controlled trials of electro mechanical assisted arm training, and to use network meta-analysis to assess the relative effectiveness of the various types of electro mechanical assisted arm devices and approaches. We aimed to evaluate the relative effect of different types of electro mechanical assisted arm training on activities of daily living, hand/arm function and hand/arm strength in patients with stroke, and to explore the safety of these devices.