Which upper limb robotics has your hospital tested and is using? NONE? Then you don't have a functioning stroke hospital. Your doctor should know about all this research and be able to tell you in detail how it applies to your recovery. My doctor knew nothing about stroke rehab as proven by his writing three prescriptions of E.T.(Evaluate and Treat) to PT, OT and ST, dumping everything on the therapists. I could easily train a monkey to write those prescriptions.
robotics (293 posts to August 2011)
upper limb (533 posts to November 2012)
upper extremity (33 posts to December 2017)
Impact of the robotic-assistance level on upper extremity function in stroke patients receiving adjunct robotic rehabilitation: sub-analysis of a randomized clinical trial
Journal of NeuroEngineering and Rehabilitation volume 19, Article number: 25 (2022)
Abstract
Background
Robotic therapy has been demonstrated to be effective in treating upper extremity (UE) paresis in stroke survivors. However, it remains unclear whether the level of assistance provided by robotics in UE training could affect the improvement in UE function in stroke survivors. We aimed to exploratorily investigate the impact of robotic assistance level and modes of adjustment on functional improvement in a stroke-affected UE.
Methods
We analyzed the data of 30 subacute stroke survivors with mild-to-severe UE hemiplegia who were randomly assigned to the robotic therapy (using ReoGo System) group in our previous randomized clinical trial. A cluster analysis based on the training results (the percentage of each stroke patient’s five assistance modes of robotics used during the training) was performed. The patients were divided into two groups: high and low robotic assistance groups. Additionally, the two groups were sub-categorized into the following classes based on the severity of UE functional impairment: moderate-to-mild [Fugl-Meyer Assessment (FMA) score ≥ 30] and severe-to-moderate class (FMA < 30). The outcomes were assessed using FMA, FMA-proximal, performance-time in the Wolf motor function test (WMFT), and functional assessment scale (FAS) in WMFT. The outcomes of each class in the two groups were analyzed. A two-way analysis of variance (ANOVA) was conducted with robot assistance level and severity of UE function as explanatory factors and the change in each outcome pre- and post-intervention as the objective factor.
Results
Overall, significant differences of the group × severity interaction were found in most of the outcomes, including FMA-proximal (p = 0.038, η2 = 0.13), WMFT-PT (p = 0.021, η2 = 0.17), and WMFT-FAS (p = 0.045, η2 = 0.14). However, only the FMA score appeared not to be significantly different in each group (p = 0.103, η2 = 0.09).
Conclusion
An optimal amount of robotic assistance is a key to maximize improvement in post-stroke UE paralysis. Furthermore, severity of UE paralysis is an important consideration when deciding the amount of assistance in robotic therapy.
Trial registration Trial enrollment was done at UMIN (UMIN 000001619, registration date was January 1, 2009)
Background
In terms of the general background of the stroke rehabilitation, hemiplegia of the upper extremity (UE) is one of the most encountered conditions in hospital-admitted stroke survivors, affecting two-thirds of this population. Hemiplegia of the UE causes functional impairment of the arm and hand, thus negatively impacting the daily activities of stroke survivors [1, 2]. Rehabilitation therapy is considered the foundation of stroke treatment for improving the motor skills and quality of life of survivors. Further, repetitive training is an effective method to facilitate recovery from stroke and assist in restructuring the neural networks [3, 4].
Therefore, in stroke rehabilitation, robots have been widely utilized by clinicians, as they allow the user to perform repetitive movements consistently and precisely [5]. Robotic therapy enables patients to perform repetitive training with voluntary movements by providing mechanical assistance to the upper limbs, which can hardly move voluntarily due to the sequelae of stroke. In stroke rehabilitation, “active assistive training” is a traditional method that has been employed in many clinical settings (the patient attempts a voluntary movement while the therapist provides some form of limb support and mechanical assistance to complete the desired movement).
Reportedly, in terms of robotic therapy in patients with stroke, the guidelines stipulated by the American Heart/Stroke Association are effective for the treatment of UE paresis in stroke survivors [6]. However, whether robotic therapy can produce better UE recovery compared to conventional rehabilitation remains unclear. Further, a previous randomized controlled trial (RCT) showed no significant difference between conventional rehabilitation and robotic therapy in UE functionality improvement in stroke survivors [7,8,9]. A systematic review also indicated that each robotic therapy and a high-intensity conventional approach produced similar effects on UE improvement in stroke survivors [10]. Additionally, another systematic review and meta-analysis concluded that robotic therapy could produce more significant improvement than active assistive training, but the effect size of robotic therapy appeared to be relatively small [11].
In the study of robotic therapy applications, one of the most developed paradigms is the investigation of robot-generated assistance. Recent robotic therapy using assistive controllers, such as force-field, intelligence difficulty (the exercise via audiovisual) [12], and feedforward controllers, allow stroke survivors to move their affected UE more independently. This exercise could be conducted in a similar way as “active assist” exercise, which is manually assisted by a rehabilitation therapist. The developed rehabilitation robot behaviour mode is composed of two concepts: error reduction and error augmentation. The error reduction concept indicates that the use of robot assistance can reduce the risk of movement error occurrence by allowing the performance of appropriate exercises, which can reinforce the process of motor learning [13, 14]. In contrast, the error augmentation concept stipulates that, to exaggerate movement errors, challenging-based assistive controller should be used in resistance training, which facilitates the process of motor learning [15]. Considering the nature of robotic treatment according to the two different types of concepts mentioned above, robotic treatment program in stroke rehabilitation has become more complex in recent years.
Some previous studies recommend the error reduction strategy using robotic assistance in UE training for improving UE function in stroke survivors. Rowe et al. [16] investigated the appropriate amount of robotic assistance using finger exoskeleton robotics and found that greater robotic assistance improved the UE function on the affected side compared to less robotic assistance in post-stroke practice (there was no significant difference, but there was a significant improvement in the secondary outcomes). On the other hand, several researchers have reported the possibility of negative effects from physical active assistive exercises [17, 18]. These studies suggest that excessive robotic assistance in intentional movements may contribute to the Slacking Hypothesis (decreased motor output, energy expenditure, and attention performed by the subject during the exercise). This would highlight the importance of providing “assistance-as-needed” in active assistive exercises [15]. These findings suggest that it remains unclear whether a positive rehabilitation outcome correlates with the level of robotic assistance provided for a stroke survivor to complete UE voluntary movement training.
Therefore, the purpose of this exploratory study was to examine the trend of the impact of robotic assistance level in order to derive data for future prospective controlled trial. In this paper, we defined “the level of robotic assistance” as “the amount of physical support generated by a robot when performing an active assistive exercise”. “Robotic therapy” was defined as a therapy using robotic assistance to improve the affected UE function of stroke patients with different severities of UE paralysis.
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