I can't imagine many stroke hospitals putting out the big bucks to bring this in. Survivors need feasible therapy, this could only be feasible if inpatient use brought back 100% arm recovery.
Robot enhanced stroke therapy optimizes rehabilitation (RESTORE): a pilot study
Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 10 (2021)
Abstract
Background
Robotic rehabilitation after stroke provides the potential to increase and carefully control dosage of therapy. Only a small number of studies, however, have examined robotic therapy in the first few weeks post-stroke. In this study we designed robotic upper extremity therapy tasks for the bilateral Kinarm Exoskeleton Lab and piloted them in individuals with subacute stroke. Pilot testing was focused mainly on the feasibility of implementing these new tasks, although we recorded a number of standardized outcome measures before and after training.
Methods
Our team developed 9 robotic therapy tasks to incorporate feedback, intensity, challenge, and subject engagement as well as addressing both unimanual and bimanual arm activities. Subacute stroke participants were assigned to a robotic therapy (N = 9) or control group (N = 10) in a matched-group manner. The robotic therapy group completed 1-h of robotic therapy per day for 10 days in addition to standard therapy. The control group participated only in standard of care therapy. Clinical and robotic assessments were completed prior to and following the intervention. Clinical assessments included the Fugl-Meyer Assessment of Upper Extremity (FMA UE), Action Research Arm Test (ARAT) and Functional Independence Measure (FIM). Robotic assessments of upper limb sensorimotor function included a Visually Guided Reaching task and an Arm Position Matching task, among others. Paired sample t-tests were used to compare initial and final robotic therapy scores as well as pre- and post-clinical and robotic assessments.
Results
Participants with subacute stroke (39.8 days post-stroke) completed the pilot study. Minimal adverse events occurred during the intervention and adding 1 h of robotic therapy was feasible. Clinical and robotic scores did not significantly differ between groups at baseline. Scores on the FMA UE, ARAT, FIM, and Visually Guided Reaching improved significantly(NOT GOOD ENOUGH) in the robotic therapy group following completion of the robotic intervention. However, only FIM and Arm Position Match improved over the same time in the control group.
Conclusions
The Kinarm therapy tasks have the potential to improve outcomes in subacute stroke. Future studies are necessary to quantify the benefits of this robot-based therapy in a larger cohort.
Trial registration: ClinicalTrials.gov, NCT04201613, Registered 17 December 2019—Retrospectively Registered, https://clinicaltrials.gov/ct2/show/NCT04201613.
Background
The vast majority of clinical trials in stroke rehabilitation have focused on individuals with chronic stroke [1]. While therapy delivered in the chronic phase after stroke has been shown to lead to reductions in motor impairments [2,3,4], a significant opportunity for improvement in motor abilities appears to occur during the subacute phase [5]. During this time, we tend to see the most rapid recovery of motor abilities, and some studies have suggested that more intensive intervention in subacute stroke can enhance the return of motor abilities [6,7,8,9]. The present manuscript focuses on the development and pilot testing of robotic tools targeted at augmenting recovery in subacute stroke.
The first robot-based therapy studies for the post-stroke upper extremity began to appear in the late 1990s [10,11,12]. Robotics have the potential to measure and increase the number of movement repetitions an individual performs in a given time period compared to conventional therapy, and some have speculated that this should lead to improved recovery [13,14,15,16]. Robotic therapy may also provide a way of increasing the dose of therapy without necessarily requiring more therapists. Verbeek et al. (2017) noted in a recent systematic review that robotic therapy produced a significant, although small, effect on improving motor control and muscle strength, but evidence in the first 3 months after stroke was lacking [17]. This review brought to light the variety of rehabilitation robotics used for stroke recovery with two main classifications for upper-extremity robotics: end-effector and exoskeleton. End effector devices are usually simpler, only directly interacting with the most distal parts of the participant whereas exoskeleton devices can align with one or many joints allowing for direct measurement and manipulation of joint movement [18]. These robot types can be further divided into unimanual or bimanual, active or passive, and planar or 3-dimensional [19].
Our group has significant experience with a device called Kinarm (Fig. 1). It is a planar, bimanual, multi-joint robot paired with a virtual reality display [20] (Kinarm, Kingston, Ontario). To date, studies using the Kinarm exoskeleton have focused on its validity as an assessment tool for sensation, motor function, and cognition after stroke [21,22,23,24,25,26], transient ischemic attack [27], brain injury [28, 29], healthy aging [30], and many other diagnoses. Such multi-domain assessments take ~ 45 min and have been well tolerated by individuals who are only a few days post-stroke. In addition, the bimanual support the device can provide to the limbs allows for the possibility of bimanual interaction [31], which has been suggested to be a missing piece in current stroke rehabilitation programs [32, 33]. This would allow us to develop rehabilitation tasks that were engaging and could be easily implemented early after stroke in the hopes of improving upper extremity outcomes. Given this, we believed this device could potentially be used for a trial of early robotic rehabilitation if appropriate tasks were designed. Therefore, our objective was to develop new approaches to augment recovery in the subacute phase of stroke.
The Kinarm Exoskeleton. A frontal view of the Kinarm Exoskeleton
We developed a set of rehabilitation tasks, in consultation with therapists, physicians and stroke survivors, for use in a pilot trial exploring the impact of robotic rehabilitation beginning in the subacute phase post-stroke. The purpose of the current manuscript is to review the development of stroke rehabilitation tasks for the Kinarm, assess its feasibility in a small cohort of participants, as well as to present the results of the pilot study in which they were tested. We expected that participants would attend and complete at least 80% of the robotic intervention sessions with few dropouts and adverse events. We further hypothesized that subacute stroke participants who received supplemental robotic therapy using the Kinarm, while continuing with standard of care therapy, would show greater improvements on standardized clinical measures compared to those who only received standard of care.
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