Introduction

Each year, about 795 000 Americans suffer from a stroke. Up to 70% regain some function, but 30% remain permanently disabled, making stroke one of the leading causes of serious, long-term disability [1]. Developing ways to promote faster and greater recovery following a stroke is a key focus in research and clinical settings. There is a general consensus that recovery in chronic stroke is increased when exercises provide high-intensity, repetitive practice of desired movements [2, 3], and take a functional focus [4, 5]. However, lack of time and resources due to cost constraints on health care reimbursement hinder therapists from providing such training. Therapeutic adjuncts, such as robotic devices, might help address this challenge [6].

While robotic devices can help provide intense, repetitive training, research comparing the impact of robotic devices and conventional therapy on behavioral improvement following stroke have yielded modest but positive results in terms of impairment reduction, but not functional improvement [2, 7–12]. For example, in their study comparing the use of the MIT-MANUS to intensive and conventional therapist-directed training, Lo et al. found significant motor impairment reduction of the trained limb after 36 weeks of robotic training when compared to conventional therapy, corroborating the results of previous studies of robotic manipulators [9]. However, the impact of robotic manipulators on improvement of activities of daily living (ADL) following stroke is less clear, with studies typically finding only modest [2] to no change [7, 9].(Well, if you don't have the hand recovered there really are no usable ADLs you can do.)

One reason could be that the manipulators tested do not allow their users to practice moving the limb in fully naturalistic ways, since they typically have a reduced number of degrees of freedom (DOF) compared to the human upper extremity, and functional tasks typically require coordinated motion of many joints in both the proximal and distal upper extremity [11]. Motor learning is also often task-specific [13], and training multiple functional tasks within one training session might be expected to yield better overall gains than training only one, less-functional task [4].

Exoskeletal robotic devices can be designed to follow the anatomy of the arm, and thus could assist in more naturalistic movements [11, 14]. However, only a few studies to date have assessed the efficacy of exoskeletons on improving behavioral outcomes post-stroke. For example, studies and single-case studies of arm and hand exoskeletons found significant behavioral improvement that were maintained up to six months after completion of the exoskeletal training and that translated into a significant positive impact on activities of daily living [11, 12]. Studies from our group that compared table-top exercise groups to both non-robotic (T-WREX, now ArmeoSpring [15]) and robotic (Pneu-WREX, [10]) three DOF exoskeleton-based training groups obtained significant functional gains of the trained upper limb after 8 weeks, and the gains obtained in the exoskeleton training groups tended to exceed those due to table-top exercises groups.

In the present study we examined the therapeutic effects of an exoskeleton that simultaneously trains the shoulder, elbow, forearm, wrist and hand. The goals of this study were twofold. First, we wanted to evaluate the effect of a training program that used the exoskeleton to train both the proximal and distal arm on behavioral outcomes and its impact on activities of daily living post-stroke. We hypothesized that the robotic exoskeletal training would be beneficial for increasing the function of the trained limb, having a positive impact on ADLs, and that those gains would be maintained over time. Secondly, we wanted to evaluate the relative impact of two different types of robotic training —multijoint functional and single joint training—on the ability to move the arm. We hypothesized that multijoint functional robotic training that included a variety of computer games imitating different activities of daily living would have a greater impact on the overall gains of the trained limb than training focused solely on single joint robotic training, implemented as tracking of a virtual phantom of individual joints, one at a time.