A Review of Rehabilitation Devices to Promote Upper Limb Function Following Stroke

 You'll have to have your competent? doctor go through these since the table in here doesn't have a column for efficacy. And you want one that will guarantee recovery!

A Review of Rehabilitation Devices to Promote Upper Limb Function Following Stroke

Jacob Brackenridge 1 , Lynley V. Bradnam 2,3 , Sheila Lennon 2 , John J. Costi 1 and David A. Hobbs 1, * 1 Medical Device Research Institute, School of Computer Science, Engineering and Mathematics, Flinders University, Adelaide, South Australia, Austra- lia; 2 Discipline of Physiotherapy, School of Health Sciences, Flinders University, Adelaide, South Australia, Australia; 3 Discipline of Physiotherapy, Graduate School of Health, University of Technology, Sydney, NSW, Australia  

 

Abstract 

 

Background: 

 Stroke is a major contributor to the reduced ability to carry out activities of daily living (ADL) post cerebral infarct. There has been a major focus on understanding and improving rehabilitation interventions in order to target cortical neural plasticity to support recovery of upper limb function. Conventional therapies delivered by therapists have been combined with the application of mechanical and robotic devices to provide controlled and assisted movement of the paretic upper limb. The ability to provide greater levels of intensity and reproducible repetitive task practice through the application of intervention devices are key mechanisms to support rehabilitation efficacy.  

 

Results: 

 

This review of literature published in the last decade identified 141 robotic or mechanical devices. These devices have been characterised and assessed by their individual characteristics to provide a review of current trends in rehabilitation device interventions. Correlation of factors identified to promote positive targeted neural plasticity has raised questions over the benefits of expensive robotic devices over simple mechanical ones.  

 

Conclusion: 

 

 A mechanical device with appropriate functionality to support the promotion of neural plasticity after stroke may provide an effective solution for both patient recovery and to stimulate further research into the use of medical de- vices in stroke rehabilitation. These findings indicate that a focus on simple, cost effective and efficacious intervention solutions may improve rehabilitation outcomes.  

 

Keywords: 

 

 Activities of daily living, exercise therapy, paresis, recovery of function, robotics, stroke, upper extremity, mechanical devices, neural plasticity.  

 

  1. INTRODUCTION  

 

Stroke is a cerebrovascular event in which the blood supply to the brain is interrupted causing either a cerebral infarct or a haemorrhage [1]. Damage caused by stroke to the brain most often leads to hemiparesis of the contralesional side of the body. A stroke can severely affect and limit the activities of daily living (ADL) leading to increasing dependence on external assistance. In Australia alone, over 430,000 people were living with the effects of stroke in 2014 and this number is expected to grow to over 700,000 by 2032. In 2012, the total financial cost of stroke in Australia was estimated at $5 billion and this figure is likely to increase [1]. The brain has its own inbuilt mechanism to deal with injury, known as cortical neural plasticity, which is the fundamental building block by which the human brain learns and adapts to environments [2]. It is through this process of neuronal growth and synaptic modification that spontaneous recovery of function is possible. However, actual spontaneous physical recovery of arm and hand function has been identified in less than 15% of the post stroke population [3]. *Address correspondence to this author at the Medical Device Research Institute, School of Computer Science, Engineering and Mathematics, Flinders University, Adelaide, South Australia, Australia; Tel: +618 8201 3167; Fax: +618 8201 2904; E-mail: david.hobbs@flinders.edu.au Rehabilitation interventions aimed at promoting experience dependent neural plasticity are, therefore, a key factor in recovery from stroke [2, 4]. Various interventions have been developed and trialed to support neuronal adaptation. The brain itself undergoes spontaneous adaptation post stroke however, to provide functional recovery a useful reorganisation is required. In particular, innovations in technology have provided a multitude of rehabilitation techniques and devices that aim to increase brain plasticity and cortical reorganisation to achieve greater gains in functional recovery post stroke. There is an increasing trend towards the application of less therapist labour intensive modes of rehabilitation by incorporating automated devices to facilitate therapeutic manipulation of patients, in an attempt to maximise training efficacy and efficiency. These devices provide the ability to employ precise, simple or complex, repetitive motions that a therapist alone cannot match in terms of providing intensity of practice. The intensity and repetition of the training are key to the efficacy of the rehabilitation and the ability to incorporate active assistance, (via the intervention device), to the paretic arm, provides another benefit for therapist and patient alike [5-7]. Through this technological push, more and more devices incorporating robotic elements have been developed to aid therapists in providing intensive rehabilitation [8]. Therapists are key to the rehabilitation process of stroke recovery. An important factor identified in the litera- ture is that implementation of robotic or mechanical interventions for recovery may enhance the effects of therapy as an adjunct to therapist skill and experience, not replace them [5, 8-11]. In conjunction with the ability to incorporate repetitive movement and task-specific training exercises, there are several other factors that are important in providing efficacious rehabilitation with robotic devices. Patton and colleagues (2009) clearly identified that simple repetitions of movement are not sufficient to induce neural plasticity [12]. Patients must be sufficiently engaged in tasks carried out to reduce boredom leading to inefficacious training [13] and the nerv- ous system itself requires the specificity of tasks to engage the required factors for improvement induced by motor training [12]. Additionally, as noted by Patton et al. (2009) ‘Learning is error based, increasing error may accelerate learning’, the patient must be provided with constant chal- lenge, pushing them to the edge of their abilities [12]. Faster learning may therefore be facilitated by increasing the error encountered during training sessions, with the idea that targeting implicit learning (the development of skills without awareness by the patient) provides a greater learning effect [13]. The provision of real time feedback can therefore sup- port learning and increase the efficacy of interventions. Incorporation of morale and motivation for the patient through goal-oriented training and positive feedback has been shown to dramatically increase the positive outcomes of stroke rehabilitation [5]. A key contributor to the reduction of function in chronic stroke is the phenomenon of ‘learned non-use’ or ‘limb neglect’. This reduction in function due to the consistent nonuse of an affected limb is identified as an important target for successful outcomes in recovery. The possibility of providing rehabilitation interventions in the home environment early after a stroke event is an important contributor to the minimisation of potential learned non-use [13]. Upper limb use can be categorised into 3 main modes of operation, determined by the method of cooperation of the arms [14]: • Symmetrical (or In-phase) – where both arms are moved in the same manner, such as lifting in a coupled movement; • Asymmetrical (or Anti-phase) – where the arms move in opposite motions, such as when walking; • Complementary – where the motions are completely dissimilar but combined to complete a task, such as opening a container; These modes of operation and how they relate to the coupling of upper limb movements provide three methods of focus for device driven upper limb rehabilitation. Many of the current array of devices that have been developed con- centrate on particular movements of the paretic limb that reproduce these types of motions. Therapist-device interaction has also been identified as an important factor in the implementation of robotic devices in practice. A complicated device that is time consuming for a therapist to setup and initiate training may lead to disuse in favour of simpler, more easily applied methods [13]. The ease of interpretation of the data produced to provide feed- back to both the therapist and the patient may also influence the use of the device. The need for interpretation of data pro- duced during a session discourages the use of technology by therapists who may already be overloaded and time-poor. The development of upper limb rehabilitation devices has become a field of innovation due to rapid advances in robotic technology. Based on the growing understanding of the mechanisms of neural plasticity, there is an ever increasing ability to provide highly complex modes of intervention through robotic devices. However, the ability to provide complex and innovative interventions, and multiple modes of intervention may not be as useful as theory dictates. Currently, many ideas are incorporated into the functionality of devices without conclusive knowledge of the beneficial nature of these innovative modalities, or combinations of such on brain plasticity or physical function [12]. Much of the current literature regarding recovery from stroke utilising rehabilitation devices describes inconclusive results from clinical trials. Consequently, a literature search was undertaken to review devices utilised for upper limb post stroke rehabilitation. The primary aim of this review was to identify and compare the key characteristics of existing medical devices relevant to promoting upper limb recovery in stroke survivors. Previous reviews of upper limb devices have been identified, however these publications, by Maciejasz et al.(2014) [13] and Van Delden et al. (2012) [9], either focused solely on robotic devices or purely bilateral devices for their assessments. 2. SEARCH METHOD A literature search was conducted to identify rehabilita- tion devices for upper limb recovery following stroke. The scope of searches was limited to the previous twelve years in order to maintain a relevant search criteria of only the most recent devices developed. However, there was one significant, innovative device identified from 2000, which is the only exception to the search limits of January 2003 to March 2015. Computerised searches were conducted utilising the following databases with references from the articles found also scrutinized to identify relevant articles: • Institute of Electrical and Electronic Engineers (IEEE) • PubMed • Google Scholar These searches were conducted with the keywords: • Upper limb, extremity • Rehabilitation • Training • Robotic, robot • Bimanual, Bilateral • Therapy • Stroke • Paretic, Hemiparesis • Mechanical

 

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