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Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects
2003, Archives of Physical Medicine and Rehabilitation
Stefan Hesse, MD, Gotthard Schulte-Tigges, PhD, Matthias Konrad, MD, Anita Bardeleben, MA,Cordula Werner, MA
ABSTRACT.
Stefan Hesse, MD, Gotthard Schulte-Tigges, PhD, Matthias Konrad, MD, Anita Bardeleben, MA,Cordula Werner, MA
ABSTRACT.
Objective:
To determine whether use of a robotic arm trainer for bilateral exercise in daily repetitive training for a3-week period reduced spasticity and improved motor control in the arm of severely affected, chronic hemiparetic subjects.
Design:
Before-after trial.
Participants:
Consecutive sample of 12 chronic hemiparetic patients; minimum stroke interval 6 months; patients could maximally protract the affected shoulder, hold the extended arm, or slightly flex and extend the elbow.
Interventions:
Additional daily therapy of 15 minutes with the arm trainer for 3 weeks; the 1 degree of freedom trainerenabled the bilateral passive and active practice of a forearm pronation and supination and wrist dorsiflexion and volarflex-ion; impedance control guaranteed a smooth movement.
Main Outcome Measures:
Patients’ impressions, the Mod-ified Ashworth Scale (MAS) score (range, 0–5) to assess spasticity, and the arm section of the Rivermead Motor As-sessment (RMA) score (range, 0–15) to assess motor controlwere rated before therapy, after each 3-week interval, and at followup 3 months later.
Results:
All patients had favorable impressions: the extremity felt more vivid, and 8 subjects noticed a reduction in spasticity, an ease of hand hygiene, and pain relief. The MAS score of the wrist and fingers joints decreased significantly(P<.0125) from a median of 3 (2–3) and 3 (3–4) to 2 (1–2) and2.5 (2–3). The RMA score minimally increased in 5 cases without improvement in functional tasks. The median RMA score before therapy was 2.0 (1–2) and 2.0 (1–3.75) after therapy. There were no side effects. At followup, the effects had waned.
Conclusions:
The arm trainer made possible intensive bilateral elbow and wrist training of severely affected stroke patients. Future studies should address the treatment effect in subacute stroke patients and determine the optimum treatment intensity.
Key Words:
Arm; Hemiparesis; Orthotic devices; Rehabilitation; Stroke.©
2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation THE RESTORATION OF ARM and hand function after stroke has a major role in neurorehabilitation. An early,intensive, and task specific approach is an accepted principle of upper-limb motor rehabilitation. Constraint induced movement therapy, as measured by the Wolf Motor Function Test(WMFT) and the Motor Activity Log,1is especially effective in midly affected patients.Immobilizing the nonaffected arm, however, is not effective with severely affected patients,2and, in fact, no arm rehabilitation therapy has proven superior.3To overcome this problem,our group decided to design and construct a low cost, robot-assisted arm trainer for autonomous, standardized, repetitive therapy.In the early 1990s, Hogan et al,4-6developed a robot arm(MIT-Manus) that made possible unrestricted unilateral passive and active shoulder and elbow movements in the horizontal plane. The robot has been effective in several prospective,randomized clinical studies. Recently, Volpe et al7summarizedthe data of 96 subacute hemiparetic patients who were trained either a by robot or by conventional methods. The robot trained group (1h/d for 5d/wk for 5wk) showed improved performance on the FIM™ instrument and on the Fugl-Meyer arm section and the motor power score for the shoulder and elbow. Withthe exception of the Fugl-Meyer score, the gains were maintained at 6 months. The subjects were on the average 22 days post stroke.Further, Burgar et al8resented the mirror-image motion enabler (MIME), consisting of a robot moving actively or passively the affected arm that was supported by a wrist or arm orthosis. Motions of the nonaffected forearm, which as attached to a 6-axis digitizer, commanded the mirror image movement by the robot, thus enabling the subject to practice bimanual shoulder and elbow movements in the horizontal movement. Daily therapy with the MIME in 21 chronic,moderately affected, hemiparetic subjects resulted in a significant improvement in strength of the biceps, triceps, and del-toideus muscles, and in the elbow and shoulder section of theFugl-Meyer score in the robot group.8A precursor version,reported by Lum et al,9was a robotic assist device for thebimanual practice of wrist flexion and extension. The roboticaid could substitute completely for 1 hand in a bimanual task,as was shown in healthy subjects. Clinical data were not reported.9Following the bilateral approach, we designed our robot to be a portable version that would enable the bimanual passive and active practice of a 1 degree of freedom (
df
) forearm and wrist movement, namely, forearm pronation and supination and
wrist flexion and extension. These more distal movements are an integral part of many daily activities, such as drinking and eating. Further, gentle passive movements of the joints, aimed at muscle tone reduction, and active wrist movements of the paretic side, proved more effective than conventional treatment in the restoration of upper limb motor function in subacute stroke survivors.10We present here the requested profile and its theoretical basis, the device itself, and our first clinical experiences with chronic, severely affected hemiparetic patients.We selected this population to minimize the influence of any confounding effects of spontaneous recovery.
To determine whether use of a robotic arm trainer for bilateral exercise in daily repetitive training for a3-week period reduced spasticity and improved motor control in the arm of severely affected, chronic hemiparetic subjects.
Design:
Before-after trial.
Setting:
Community rehabilitation center in Germany.Participants:
Consecutive sample of 12 chronic hemiparetic patients; minimum stroke interval 6 months; patients could maximally protract the affected shoulder, hold the extended arm, or slightly flex and extend the elbow.
Interventions:
Additional daily therapy of 15 minutes with the arm trainer for 3 weeks; the 1 degree of freedom trainerenabled the bilateral passive and active practice of a forearm pronation and supination and wrist dorsiflexion and volarflex-ion; impedance control guaranteed a smooth movement.
Main Outcome Measures:
Patients’ impressions, the Mod-ified Ashworth Scale (MAS) score (range, 0–5) to assess spasticity, and the arm section of the Rivermead Motor As-sessment (RMA) score (range, 0–15) to assess motor controlwere rated before therapy, after each 3-week interval, and at followup 3 months later.
Results:
All patients had favorable impressions: the extremity felt more vivid, and 8 subjects noticed a reduction in spasticity, an ease of hand hygiene, and pain relief. The MAS score of the wrist and fingers joints decreased significantly(P<.0125) from a median of 3 (2–3) and 3 (3–4) to 2 (1–2) and2.5 (2–3). The RMA score minimally increased in 5 cases without improvement in functional tasks. The median RMA score before therapy was 2.0 (1–2) and 2.0 (1–3.75) after therapy. There were no side effects. At followup, the effects had waned.
Conclusions:
The arm trainer made possible intensive bilateral elbow and wrist training of severely affected stroke patients. Future studies should address the treatment effect in subacute stroke patients and determine the optimum treatment intensity.
Key Words:
Arm; Hemiparesis; Orthotic devices; Rehabilitation; Stroke.©
2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation THE RESTORATION OF ARM and hand function after stroke has a major role in neurorehabilitation. An early,intensive, and task specific approach is an accepted principle of upper-limb motor rehabilitation. Constraint induced movement therapy, as measured by the Wolf Motor Function Test(WMFT) and the Motor Activity Log,1is especially effective in midly affected patients.Immobilizing the nonaffected arm, however, is not effective with severely affected patients,2and, in fact, no arm rehabilitation therapy has proven superior.3To overcome this problem,our group decided to design and construct a low cost, robot-assisted arm trainer for autonomous, standardized, repetitive therapy.In the early 1990s, Hogan et al,4-6developed a robot arm(MIT-Manus) that made possible unrestricted unilateral passive and active shoulder and elbow movements in the horizontal plane. The robot has been effective in several prospective,randomized clinical studies. Recently, Volpe et al7summarizedthe data of 96 subacute hemiparetic patients who were trained either a by robot or by conventional methods. The robot trained group (1h/d for 5d/wk for 5wk) showed improved performance on the FIM™ instrument and on the Fugl-Meyer arm section and the motor power score for the shoulder and elbow. Withthe exception of the Fugl-Meyer score, the gains were maintained at 6 months. The subjects were on the average 22 days post stroke.Further, Burgar et al8resented the mirror-image motion enabler (MIME), consisting of a robot moving actively or passively the affected arm that was supported by a wrist or arm orthosis. Motions of the nonaffected forearm, which as attached to a 6-axis digitizer, commanded the mirror image movement by the robot, thus enabling the subject to practice bimanual shoulder and elbow movements in the horizontal movement. Daily therapy with the MIME in 21 chronic,moderately affected, hemiparetic subjects resulted in a significant improvement in strength of the biceps, triceps, and del-toideus muscles, and in the elbow and shoulder section of theFugl-Meyer score in the robot group.8A precursor version,reported by Lum et al,9was a robotic assist device for thebimanual practice of wrist flexion and extension. The roboticaid could substitute completely for 1 hand in a bimanual task,as was shown in healthy subjects. Clinical data were not reported.9Following the bilateral approach, we designed our robot to be a portable version that would enable the bimanual passive and active practice of a 1 degree of freedom (
df
) forearm and wrist movement, namely, forearm pronation and supination and
wrist flexion and extension. These more distal movements are an integral part of many daily activities, such as drinking and eating. Further, gentle passive movements of the joints, aimed at muscle tone reduction, and active wrist movements of the paretic side, proved more effective than conventional treatment in the restoration of upper limb motor function in subacute stroke survivors.10We present here the requested profile and its theoretical basis, the device itself, and our first clinical experiences with chronic, severely affected hemiparetic patients.We selected this population to minimize the influence of any confounding effects of spontaneous recovery.
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