So it didn't improve upper limb ADLs, so immediate excuses were applied about wrong measurements. I expect better than that! You're fired!
This is why I hate systematic reviews and meta-analysis. They do absolutely nothing towards getting survivors recovered. Sure you get published, but the goal of all stroke research is survivor recovery. This did nothing towards that.
Effects of Robot-assisted therapy on upper limb recovery after stroke: A Systematic Review
Effects of Robot-assisted therapy on upper limb recovery after stroke: A Systematic Review
Gert Kwakkel, PhD 1,2,
Boudewijn J. Kollen, PhD 3,
Gert Kwakkel, PhD 1,2,
Boudewijn J. Kollen, PhD 3,
Hermano I. Krebs, PhD 4,5,6
1 Department Rehabilitation and Research Institute MOVE, VU University Medical Center Amsterdam, The Netherlands
2 Department Rehabilitation, Rudolf Magnus Institute of NeuroScience, University Medical Center Utrecht, The Netherlands
3 Research Bureau, IsalaKlinieken Zwolle, The Netherlands
4 Mechanical Engineering Department, Massachusetts Instituteof Technology, Cambridge, MA, USA
5 Department of Neurology and Neuroscience, Burke Instituteof Medical Research, Weill Medical College, Cornell University, White Plains, NY, USA
6 Department of Neurology, University of Maryland, School of Medicine, Baltimore, MD, USA
To present a systematic review of studies that investigates the effects of robot-assisted therapy on motor and functional recovery in patients with stroke.
Summary of Review—
A database of articles published up to October 2006 was compiled using the following MEDLINE key words: cerebral vascular accident, cerebral vascular disorders, stroke, paresis, hemiplegia, upper extremity, arm and robot. References listed in relevant publications were also screened. Studies that satisfied the following selection criteria were included: (1) patients were diagnosed with cerebral vascular accident; (2) effects of robot-assisted therapy for the upper limb were investigated; (3) the outcome was measured in terms of motor and/or functional recovery of the upper paretic limb; (4) The study was a randomised clinical trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for motor recovery and functional ability (ADL) using fixed and random effect models. Ten studies, involving 218 patients, were included in the synthesis. Their methodological quality ranged from 4 to 8 on a (maximum) 10 point scale. Meta-analysis showed anon-significant heterogeneous SES in terms of upper limb motor recovery. Sensitivity analysis of studies involving only shoulder-elbow robotics subsequently demonstrated a significant homogeneous SES for motor recovery of the upper paretic limb. No significant SES was observed for functional ability (ADL).
Conclusion—
As a result of marked heterogeneity in studies between distal and proximal arm robotics, no overall significant effect in favour of robot-assisted therapy was found in the present meta-analysis. However, subsequent sensitivity analysis showed a significant improvement in upper limb motor function after stroke for upper arm robotics. No significant improvement was found in ADL function. However, the administered ADL scales in the reviewed studies fail to adequately reflect recovery of the paretic upper limb and valid instruments that measure outcome of dexterity of the paretic arm and hand are mostly absent in selected studies. Future research on the effects of robot-assisted therapy should therefore distinguish between upper and lower robotics arm training and concentrate on kinematical analysis to differentiate between genuine upper limb motor recovery and functional recovery due to compensation strategies by proximal control of the trunk and upper limb.
Correspondence: G. Kwakkel (PhD), Senior Researcher, Dept. Rehabilitation Medicine, VU University Medical Center, de Boelelaan1117, 1081 HV Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands, E-mail: g.kwakkel@vumc.nl.
Keywords
robotics; cerebrovascular accident; Activities of daily living; Upper limb; Rebiew; systematic
Introduction
Stroke is the leading cause of disability in the United States. 750.000 individuals are affected each year and the prevalence rate is among 200–300 patients per 100.000 inhabitants.1Although prospective epidemiological studies are lacking, findings of a number of longitudinalstudies indicate that in 30% to 66% of hemiplegic stroke patients, the paretic arm remainswithout function when measured 6 months after stroke, whereas only 5% to 20% demonstratecomplete functional recovery.2The results of a systematic review involving 123 randomized clinical trials (RCTs) by vanPeppen and colleagues demonstrated that there is strong evidence that intensity as well as task specificity are the main drivers in an effective treatment program after stroke. In addition, thistraining should be repetitive, functional, meaningful and challenging for a patient.3,4However, the question as to how the effects of exercise therapy can be further enhanced in aclinical environment presents a challenge to answer. Therefore, there is a need to develop better ways to augment exercise training in a functional way. Using therapeutic adjuncts to facilitate clinical practice, such as robotics5– 11, is a new promising development. Robotics allows patients to train independently of a therapist and to improve upon their own functional level(i.e., robot-assisted therapy). In particular, there is strong evidence for robot-assisted therapy to increase treatment compliance by way of introducing incentives to the patient, such as games.In addition, by using computer assisted devices for regaining upper limb function, the robotcan easily apply new constraints, in order to optimize the required movement pattern.Therefore, the complexity of a motor task to be learned can be controlled for more preciselywith robotics than in conventional treatment approaches.Although many devices have been designed to deliver arm therapy in individuals with stroke,five of these devices, the MIT-MANUS5,6;(designed and built at the Massachusetts Instituteof Technology), the ARM-GUIDE
7 (Assisted Rehabilitation and Measurement guide), the MIME8,9;(Mirror-Image Motion Enabler), the InMotion2;Shoulder-Elbow Robot10;and the Bi-Manu-Track 11, were tested in at least one Randomized Clinical Trial (RCT). The MIT-MANUS is a robot that allows subjects to execute reaching movements in the horizontal plane.This two degrees of freedom (DoF) robot enables unrestricted movements of the shoulder and elbow joints5. The ARM-GUIDE is a trombone-like device and has four controlled DoF. ADC servo motor can assist in the movement of a subject’s arm in the reaching direction alonga linear track. Optical encoders record the position in the reach, elevation and yaw axes7. TheMIME robot consists of a six DoF robot arm. The robot enables the bilateral practice of a threeDoF shoulder-elbow movement, whereby the non-paretic arm guides the paretic arm12. The InMotion2;Shoulder-Elbow Robot, which is the commercial version of MIT-MANUS(Interactive Motion Technologies, Inc, Cambridge, MA, USA), has two DoF and providesshoulder/elbow training in the horizontal plane with a supported forearm10. The Bi-Manu-Track is designed to specifically train distal arm movements by practicing bilateral elbow pro-and supination as well as wrist flexion and extension in a mirror or parallel fashion11.In the past, several studies were unable to prove superiority of one type of conventional strokeregimen over another 13;– 16, but there is strong evidence that highly repetitive movementtraining can result in improved recovery4,16. Applying robot-assisted therapy enables patientsto practice intensively with their upper paretic limb. The objective of the present systematic
1 Department Rehabilitation and Research Institute MOVE, VU University Medical Center Amsterdam, The Netherlands
2 Department Rehabilitation, Rudolf Magnus Institute of NeuroScience, University Medical Center Utrecht, The Netherlands
3 Research Bureau, IsalaKlinieken Zwolle, The Netherlands
4 Mechanical Engineering Department, Massachusetts Instituteof Technology, Cambridge, MA, USA
5 Department of Neurology and Neuroscience, Burke Instituteof Medical Research, Weill Medical College, Cornell University, White Plains, NY, USA
6 Department of Neurology, University of Maryland, School of Medicine, Baltimore, MD, USA
Abstract
Background and Purpose—To present a systematic review of studies that investigates the effects of robot-assisted therapy on motor and functional recovery in patients with stroke.
Summary of Review—
A database of articles published up to October 2006 was compiled using the following MEDLINE key words: cerebral vascular accident, cerebral vascular disorders, stroke, paresis, hemiplegia, upper extremity, arm and robot. References listed in relevant publications were also screened. Studies that satisfied the following selection criteria were included: (1) patients were diagnosed with cerebral vascular accident; (2) effects of robot-assisted therapy for the upper limb were investigated; (3) the outcome was measured in terms of motor and/or functional recovery of the upper paretic limb; (4) The study was a randomised clinical trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for motor recovery and functional ability (ADL) using fixed and random effect models. Ten studies, involving 218 patients, were included in the synthesis. Their methodological quality ranged from 4 to 8 on a (maximum) 10 point scale. Meta-analysis showed anon-significant heterogeneous SES in terms of upper limb motor recovery. Sensitivity analysis of studies involving only shoulder-elbow robotics subsequently demonstrated a significant homogeneous SES for motor recovery of the upper paretic limb. No significant SES was observed for functional ability (ADL).
Conclusion—
As a result of marked heterogeneity in studies between distal and proximal arm robotics, no overall significant effect in favour of robot-assisted therapy was found in the present meta-analysis. However, subsequent sensitivity analysis showed a significant improvement in upper limb motor function after stroke for upper arm robotics. No significant improvement was found in ADL function. However, the administered ADL scales in the reviewed studies fail to adequately reflect recovery of the paretic upper limb and valid instruments that measure outcome of dexterity of the paretic arm and hand are mostly absent in selected studies. Future research on the effects of robot-assisted therapy should therefore distinguish between upper and lower robotics arm training and concentrate on kinematical analysis to differentiate between genuine upper limb motor recovery and functional recovery due to compensation strategies by proximal control of the trunk and upper limb.
Correspondence: G. Kwakkel (PhD), Senior Researcher, Dept. Rehabilitation Medicine, VU University Medical Center, de Boelelaan1117, 1081 HV Amsterdam, PO Box 7057, 1007 MB Amsterdam, The Netherlands, E-mail: g.kwakkel@vumc.nl.
Keywords
robotics; cerebrovascular accident; Activities of daily living; Upper limb; Rebiew; systematic
Introduction
Stroke is the leading cause of disability in the United States. 750.000 individuals are affected each year and the prevalence rate is among 200–300 patients per 100.000 inhabitants.1Although prospective epidemiological studies are lacking, findings of a number of longitudinalstudies indicate that in 30% to 66% of hemiplegic stroke patients, the paretic arm remainswithout function when measured 6 months after stroke, whereas only 5% to 20% demonstratecomplete functional recovery.2The results of a systematic review involving 123 randomized clinical trials (RCTs) by vanPeppen and colleagues demonstrated that there is strong evidence that intensity as well as task specificity are the main drivers in an effective treatment program after stroke. In addition, thistraining should be repetitive, functional, meaningful and challenging for a patient.3,4However, the question as to how the effects of exercise therapy can be further enhanced in aclinical environment presents a challenge to answer. Therefore, there is a need to develop better ways to augment exercise training in a functional way. Using therapeutic adjuncts to facilitate clinical practice, such as robotics5– 11, is a new promising development. Robotics allows patients to train independently of a therapist and to improve upon their own functional level(i.e., robot-assisted therapy). In particular, there is strong evidence for robot-assisted therapy to increase treatment compliance by way of introducing incentives to the patient, such as games.In addition, by using computer assisted devices for regaining upper limb function, the robotcan easily apply new constraints, in order to optimize the required movement pattern.Therefore, the complexity of a motor task to be learned can be controlled for more preciselywith robotics than in conventional treatment approaches.Although many devices have been designed to deliver arm therapy in individuals with stroke,five of these devices, the MIT-MANUS5,6;(designed and built at the Massachusetts Instituteof Technology), the ARM-GUIDE
7 (Assisted Rehabilitation and Measurement guide), the MIME8,9;(Mirror-Image Motion Enabler), the InMotion2;Shoulder-Elbow Robot10;and the Bi-Manu-Track 11, were tested in at least one Randomized Clinical Trial (RCT). The MIT-MANUS is a robot that allows subjects to execute reaching movements in the horizontal plane.This two degrees of freedom (DoF) robot enables unrestricted movements of the shoulder and elbow joints5. The ARM-GUIDE is a trombone-like device and has four controlled DoF. ADC servo motor can assist in the movement of a subject’s arm in the reaching direction alonga linear track. Optical encoders record the position in the reach, elevation and yaw axes7. TheMIME robot consists of a six DoF robot arm. The robot enables the bilateral practice of a threeDoF shoulder-elbow movement, whereby the non-paretic arm guides the paretic arm12. The InMotion2;Shoulder-Elbow Robot, which is the commercial version of MIT-MANUS(Interactive Motion Technologies, Inc, Cambridge, MA, USA), has two DoF and providesshoulder/elbow training in the horizontal plane with a supported forearm10. The Bi-Manu-Track is designed to specifically train distal arm movements by practicing bilateral elbow pro-and supination as well as wrist flexion and extension in a mirror or parallel fashion11.In the past, several studies were unable to prove superiority of one type of conventional strokeregimen over another 13;– 16, but there is strong evidence that highly repetitive movementtraining can result in improved recovery4,16. Applying robot-assisted therapy enables patientsto practice intensively with their upper paretic limb. The objective of the present systematic
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