Training modalities in robot-mediated upper limb rehabilitation in stroke: a framework for classification based on a systematic review

If robotic interventions improve upper limb motor scores and strength where the hell are the protocols supporting that? All this research and absolutely nothing that survivors can use or find. 

Training modalities in robot-mediated upper limb rehabilitation in stroke: a framework for classification based on a systematic review

 Angelo Basteris
1*
, Sharon M Nijenhuis
2
, Arno HA Stienen
3,5
, Jaap H Buurke
2,4
, Gerdienke B Prange
2,3
and Farshid Amirabdollahian
1

Abstract

Robot-mediated post-stroke therapy for the upper-extremity dates back to the 1990s. Since then, a number of robotic devices have become commercially available. There is clear evidence that robotic interventions improve upper limb motor scores and strength, but these improvements are often not transferred to performance of activities of daily living. We wish to better understand why. Our systematic review of 74 papers focuses on the targeted stage of recovery, the part of the limb trained, the different modalities used, and the effectiveness of each. The review shows that most of the studies so far focus on training of the proximal arm for chronic stroke patients.About the training modalities, studies typically refer to active, active-assisted and passive interaction. Robot therapy in active assisted mode was associated with consistent improvements in arm function. More specifically, the use of HRI features stressing active contribution by the patient, such as EMG modulated forces or a pushing force in combination with spring-damper guidance, may be beneficial. Our work also highlights that current literature frequently lacks information regarding the mechanism about the physical human robot interaction (HRI). It is often unclear how the different modalities are implemented by different research groups (using different robots and platforms). In order to have a better and more reliable evidence of usefulness for these technologies, it is recommended that the HRI is better described and documented so that work of various teams can be considered in the same group and categories, allowing to infer for more suitable approaches. We propose a framework for categorisation of HRI modalities and features that will allow comparing their therapeutic benefits.
Keywords:
 Therapeutic interaction, Robotics, Stroke, Neurorehabilitation, Arm, Wrist, Hand, Upper extremity
Introduction
Stroke is one of the most common causes of adult disabilities. In the United States, approximately 795,000 individuals experience a new or recurrent stroke each year,and the prevalence is estimated at 7,000,000 Americans over 20 years of age [1]. In Europe, the annual stroke incidence rates are 141.3 per 100,000 in men, and 94.6 in women [2]. It is expected that the burden of stroke will increase considerably in the next few years [3]. The high incidence, in combination with an aging society, indicates future increases in incidence, with a strong impact on healthcare services and related costs.Impairments after stroke can result in a variety of sensory, motor, cognitive and psychological symptoms. The most common and widely recognised impairments after stroke are motor impairments, in most cases affecting the control of movement of the face, arm, and leg on one side of the body, termed as hemiparesis. Common problems in motor function after hemiparetic stroke are muscle weakness [4-6], spasticity [4-6], increased reflexes[4], loss of coordination [4,7] and apraxia [4]. Besides, patients may show abnormal muscle co-activation, implicated in stereotyped movement patterns, which is also known as flexion synergy and extension synergy  [8,9]. Concerning the upper extremity, impaired arm and hand.


function contributes considerably to limitations in the ability to perform activities of daily living (ADL). One of the goals of post stroke rehabilitation is to regain arm and hand function, since this is essential to perform activities of daily living independently.
Stroke rehabilitation
Stroke rehabilitation is often described as a process of active motor relearning that starts within the first few days after stroke. Recovery is characterized by a high inter-individual variability, and it occurs in different processes. Some of the first events following nervous system injury are recovery due to restitution of non-infarcted penumbral areas, reduction of oedema around the lesion, and resolution of diaschisis [10-12], and comprise spontaneous neurological recovery. A longer term mechanism involved in neurological recovery is neuroplasticity, caused by anatomical and functional reorganisation of the central nervous system. Additionally, motor recovery after stroke may occur through compensational strategies. Compensation is defined as behavioural substitution, which means that alternative behavioural strategies are adopted to complete a task. In other words, function will be achieved through alternative processes, instead of using processes of true recovery alone [11-13
* Correspondence: angelobasteris@gmail.com
1 Adaptive Systems Research Group, School of Computer Science, University of Hertfordshire, College Lane, AL95HX Hatfield, United Kingdom.  Full list of author information is available at the end of the article