9 years, do we now have clinical results high enough caliber that stroke protocols can be written? Since we have NO STROKE LEADERSHIP, nothing will be done.
A systematic review of bilateral upper limb training devices for poststroke rehabilitation
2012, Stroke research and treatment
Hindawi Publishing Corporation Stroke Research and Treatment Volume 2012, Article ID 972069, 17 pagesdoi:10.1155/2012/972069
A.(Lex)E.Q.vanDelden, 1
C.(Lieke)E.Peper, 1
GertKwakkel, 1,2
andPeterJ.Beek 1
Hindawi Publishing Corporation Stroke Research and Treatment Volume 2012, Article ID 972069, 17 pagesdoi:10.1155/2012/972069
A.(Lex)E.Q.vanDelden, 1
C.(Lieke)E.Peper, 1
GertKwakkel, 1,2
andPeterJ.Beek 1
1 Research Institute MOVE, Faculty of Human Movement Sciences, VU University Amsterdam, Van der Boechorststraat 9,1081 BT Amsterdam, The Netherlands
2 Research Institute MOVE, Department of Rehabilitation Medicine, VU University Medical Center, De Boelelaan 1117,1081 HV Amsterdam, The Netherlands
Correspondence should be addressed to A. (Lex) E. Q. van Delden, l.van.delden@vu.nlReceived 20 July 2012; Accepted 8 October 2012Academic Editor: Stefano Paolucci Copyright © 2012 A. (Lex) E. Q. van Delden et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
. In stroke rehabilitation, bilateral upper limb training is gaining ground. As a result, a growing number of mechanical and robotic bilateral upper limb training devices have been proposed.
Objective
. To provide an overview and qualitative evaluation of the clinical applicability of bilateral upper limb training devices.
Methods
. Potentially relevant literature was searched in the PubMed, Web of Science, and Google Scholar databases from 1990 onwards. Devices were categorized as mechanical or robotic(according to the PubMed MeSH term of robotics).
Results
. In total, 6 mechanical and 14 robotic bilateral upper limb training devices were evaluated in terms of mechanical and electromechanical characteristics, supported movement patterns, targeted part and active involvement of the upper limb, training protocols, outcomes of clinical trials, and commercial availability.
Conclusion
.Initial clinical results are not yet of such caliber that the devices in question and the concepts on which they are based are firmly established. However, the clinical outcomes do not rule out the possibility that the concept of bilateral training and the accompanied devices may provide a useful extension of currently available forms of therapy. To actually demonstrate their(surplus)value, more research with adequate experimental, dose-matched designs, and sufficient statistical power are required.
1.Introduction
As technology advances, a growing number of mechanical and robotic training devices (i.e., mechanical devices with electronic, computerized control systems) for upper limb training have been proposed for stroke rehabilitation. Compared to conventional therapies, these training devices have the advantage that they allow a self-controlled increase in training intensity and frequency as well as the opportunity to train independently [1–4]. In recent years, a substantial number of these training devices have been designed specifically for bilateral upper limb training, but an integral overview and evaluation have thus far been lacking. The present study seeks to fill this lacuna.Bilateral upper limb training is by no means a new form of stroke rehabilitation. Since days long past, therapists have been creative in using appliances, such as pulleys, to move the most impaired upper limb simultaneously with the less impaired upper limb [5]. Nevertheless, the current upsurge in the interest in bilateral upper limb training hasa relatively short history and arose partly serendipitously [6, 7] and partly from insights gleaned from the motor control literature. In this literature, coupling (or interaction)effects between the two upper limbs have been investigated extensively in rhythmic interlimb coordination studies involving healthy subjects [8–12]. It is well established that healthy subjects show a basic tendency towards in phase(i.e., symmetrical movements) or anti-phase (i.e., alternating movements) coordination, with a prevalent 1:1 frequency-locking mode for upper limb bilateral movements [12]. These tendencies reflect the coupling between the upper limbs. Based on the assumption that this coupling facilitates the functional recovery of the paretic arm, it is exploited in bilateral upper limb training, usually by moving both arms and/or hands in either in phase or antiphase coordination.However, whether one pattern is to be preferred over the other is currently not evident.Recent systematic reviews produced mixed results on the superiority or inferiority of bilateral upper limb training over other interventions in post stroke rehabilitation. Two such reviews found strong evidence in support of bilateral upper limb training after stroke [13, 14]. Another review was more reticent in its conclusions than the previous two [15], and three systematic reviews concluded that bilateral training is at best similarly effective as other treatments but certainly not better [16–18]. These mixed results may be related to the heterogeneity of types of bilateral upper limb training and the devices used in clinical trials. Therefore, an overview and evaluation of clinical applicability of bilateral upper limb training devices may be helpful in directing future research in this regard.The present systematic review evaluates bilateral training devices designed for post stroke upper limb training in terms of (1) mechanical and electromechanical characteristics, (2)supported movement patterns, (3) targeted part and active involvement of the upper limb, (4) training protocols, (5)outcomes of clinical trials, and (6) commercial availability.The aim of the paper is to evaluate these aspects in a qualitative manner because not sufficient randomized clinical trials are available on the devices in question to evaluate or compare clinical outcomes statistically. We therefore aim at comparing and integrating concepts, findings, and insights from largely qualitative studies, culminating in an overview of training devices for post stroke rehabilitation, an assessment of their clinical applicability, and some general conclusions and recommendations for future developments and research.
2.Methods
Bilateral upper limb training device was defined as a device developed for upper limb rehabilitation that is either specifically designed for bilateral training or at least supports bilateral training as one of the prominent training modes,where both upper limbs perform simultaneous movements with one limb moving actively and the other limb moving actively, passively, or with assistance.Relevant literature was identified through computerized and manual searches in the following electronic databases:PubMed, Web of Science, and Google Scholar. Thesedatabases were searched using the following MeSH headings and key words:(i) cerebrovascular disorder$, cerebrovascular accident,CVA, stroke, hemiparetic stroke, paresis, hemiparesis, hemiplegia,(ii) upper extremity, upper limb$, arm$, forearm$,wrist$, hand$, finger$,(iii) bilat$, bimanual$(iv) robot$, mechan$, device.Bibliographies of review articles, empirical articles, and abstracts published in conference proceedings were also examined. In further iterations, references from retrieved articles were examined to identify additional relevant articles.In light of the recent interest in bilateral upper limb training in stroke rehabilitation literature [6, 19], only articles published from 1990 onwards were searched.Devices were selected for discussion if they met with the aforementioned definition of a device for bilateral upper limb training. Devices were categorized as robotic devices when they met the description of the PubMed MeSH term of robotics. All other devices were categorized as mechanical devices. Both categories are discussed in separate paragraphs.
3.Results
The search resulted in 311 single citations of which 70reported on 20 different bilateral training devices. Of these, 6were mechanical and 14 were robotic devices.
3.1. Mechanical Devices3.1.1. BATRAC (Tailwind).
Bilateral arm training with rhythmic auditory cueing (BATRAC) was introduced in 2000[20], together with a custom-made bilateral arm trainer. The device consists of two independent T-bar handles mounted on nearly frictionless tracks that can move in the transverse plane perpendicular to the user. The handles have to be pushed forward and pulled back, either with both upper limbs simultaneously(in-phase) or alternatingly(anti-phase), at a frequency paced by a metronome providing auditory cues. If a patient is unable to hold the handle with the hand of the most impaired upper limb, the hand is strapped onto it. The original BATRAC protocol focuses expressly on shoulder and elbow function. A modified version of the original BATRAC protocol focuses on distal upper limb function [21]. For the purpose of the latter protocol,a device was developed consisting of two manipul and a with hand grip that can be mounted on the distal ends of a chair’s arm rests (see Figure 1(a)). The manipul and a allow flexion and extension movements of the wrist in the horizontal plane and have to be moved rhythmically in pace with an auditory metronome in either a mirror-symmetrical(in-phase) or an alternating (anti-phase) fashion. Visual feedback is provided in the form of a Lissajous display, left and right hand movement amplitudes, and the relative phase(and its variability) between both hands (see Figure 1(b)). The original BATRAC protocol was first used in a pilot effect study involving a single group of patients with chronic stroke (i.e., more than 6 months after stroke onset) [20]. Fourteen patients received 6 weeks of BATRAC, three times a week, four times 5 minutes per session. Post treatment assessment revealed improvements in Fugl-Meyer Assessment(FMA), Wolf Motor Function Test (WMFT), University of Maryland Arm Questionnaire for Stroke measuring daily use of the most impaired upper limb, as well as strength measures and range of motion measures for the most and less impaired upper limb. Most of these benefits sustained at 8-week followup.Another study [22] examined the efficacy of a mod-ified version of the BATRAC protocol. In this study, 14 patients with chronic stroke participated in four 2-hour-plus BATRAC sessions per week for 2 weeks. Although no significant changes in FMA or WMFT were found as a result of this intervention, patients reported an increase in daily use of the most impaired upper limb as evidenced by a significant change on the Motor Activity Log (MAL). In a large RCT with patients with chronic stroke,BATRAC was compared with dose-matched therapeutic exercises [23]. A total of 111 patients were randomized over both intervention groups and received 6 weeks long3 training sessions per week. The improvements in upper limb function were comparable between both groups post-treatment and retained after 4 months. There were however greater adaptations in brain activation after BATRAC than after the control treatment, suggesting that both treatments referred to different underlying neural mechanisms.Currently, an RCT with 60 patients in the subacute phase after stroke (1–6 months) is being conducted [21]. In this RCT the BATRAC device for distal upper limb movements(Figure 1) is used and compared to constrained induced movement therapy and conventional physical therapy. This RCT will be completed by the end of this year and will be reported in 2013/2014.A commercial version of BATRAC, called Tailwind (seeFigure 2), is produced and sold by Encore Path, Inc. Baltimore, MD, USA and is also available at Anatomical Concepts UK Ltd., Clydeland, Scotland. This device is produced for home based training and differs from the original device, as the Tailwind also allows upward and outward movements.The BATRAC device for movements about the wrist is not commercially available.
3.1.2.Reha-SlideDuoandReha-Slide (Nudelholz).
The Reha-Slide Duo (see Figure 3) consists of a board with two sledges running on parallel tracks [24]. Two handles on the sledges can be moved forward and backward separately,similar to the Tailwind used for BATRAC. The board on which the tracks are placed can be inclined up to 20
◦
for
Figure
2: Tailwind. Reprinted with permission (http://www.tail-windtherapy.com/).
Figure
3: Reha-Slide Duo. Reprinted with permission (http://www .reha-stim.de/).
upward movements, and friction for forward and backward movements can be adjusted for both handles separately via adjustable rubber brake elements in a range from 5N to 80N(with the board horizontal).The Reha-Slide Duo was incorporated in an arm studio for upper limb rehabilitation [24]. However, no clinical results have been reported to date specifically for the Reha-Slide Duo.
2 Research Institute MOVE, Department of Rehabilitation Medicine, VU University Medical Center, De Boelelaan 1117,1081 HV Amsterdam, The Netherlands
Correspondence should be addressed to A. (Lex) E. Q. van Delden, l.van.delden@vu.nlReceived 20 July 2012; Accepted 8 October 2012Academic Editor: Stefano Paolucci Copyright © 2012 A. (Lex) E. Q. van Delden et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
. In stroke rehabilitation, bilateral upper limb training is gaining ground. As a result, a growing number of mechanical and robotic bilateral upper limb training devices have been proposed.
Objective
. To provide an overview and qualitative evaluation of the clinical applicability of bilateral upper limb training devices.
Methods
. Potentially relevant literature was searched in the PubMed, Web of Science, and Google Scholar databases from 1990 onwards. Devices were categorized as mechanical or robotic(according to the PubMed MeSH term of robotics).
Results
. In total, 6 mechanical and 14 robotic bilateral upper limb training devices were evaluated in terms of mechanical and electromechanical characteristics, supported movement patterns, targeted part and active involvement of the upper limb, training protocols, outcomes of clinical trials, and commercial availability.
Conclusion
.Initial clinical results are not yet of such caliber that the devices in question and the concepts on which they are based are firmly established. However, the clinical outcomes do not rule out the possibility that the concept of bilateral training and the accompanied devices may provide a useful extension of currently available forms of therapy. To actually demonstrate their(surplus)value, more research with adequate experimental, dose-matched designs, and sufficient statistical power are required.
1.Introduction
As technology advances, a growing number of mechanical and robotic training devices (i.e., mechanical devices with electronic, computerized control systems) for upper limb training have been proposed for stroke rehabilitation. Compared to conventional therapies, these training devices have the advantage that they allow a self-controlled increase in training intensity and frequency as well as the opportunity to train independently [1–4]. In recent years, a substantial number of these training devices have been designed specifically for bilateral upper limb training, but an integral overview and evaluation have thus far been lacking. The present study seeks to fill this lacuna.Bilateral upper limb training is by no means a new form of stroke rehabilitation. Since days long past, therapists have been creative in using appliances, such as pulleys, to move the most impaired upper limb simultaneously with the less impaired upper limb [5]. Nevertheless, the current upsurge in the interest in bilateral upper limb training hasa relatively short history and arose partly serendipitously [6, 7] and partly from insights gleaned from the motor control literature. In this literature, coupling (or interaction)effects between the two upper limbs have been investigated extensively in rhythmic interlimb coordination studies involving healthy subjects [8–12]. It is well established that healthy subjects show a basic tendency towards in phase(i.e., symmetrical movements) or anti-phase (i.e., alternating movements) coordination, with a prevalent 1:1 frequency-locking mode for upper limb bilateral movements [12]. These tendencies reflect the coupling between the upper limbs. Based on the assumption that this coupling facilitates the functional recovery of the paretic arm, it is exploited in bilateral upper limb training, usually by moving both arms and/or hands in either in phase or antiphase coordination.However, whether one pattern is to be preferred over the other is currently not evident.Recent systematic reviews produced mixed results on the superiority or inferiority of bilateral upper limb training over other interventions in post stroke rehabilitation. Two such reviews found strong evidence in support of bilateral upper limb training after stroke [13, 14]. Another review was more reticent in its conclusions than the previous two [15], and three systematic reviews concluded that bilateral training is at best similarly effective as other treatments but certainly not better [16–18]. These mixed results may be related to the heterogeneity of types of bilateral upper limb training and the devices used in clinical trials. Therefore, an overview and evaluation of clinical applicability of bilateral upper limb training devices may be helpful in directing future research in this regard.The present systematic review evaluates bilateral training devices designed for post stroke upper limb training in terms of (1) mechanical and electromechanical characteristics, (2)supported movement patterns, (3) targeted part and active involvement of the upper limb, (4) training protocols, (5)outcomes of clinical trials, and (6) commercial availability.The aim of the paper is to evaluate these aspects in a qualitative manner because not sufficient randomized clinical trials are available on the devices in question to evaluate or compare clinical outcomes statistically. We therefore aim at comparing and integrating concepts, findings, and insights from largely qualitative studies, culminating in an overview of training devices for post stroke rehabilitation, an assessment of their clinical applicability, and some general conclusions and recommendations for future developments and research.
2.Methods
Bilateral upper limb training device was defined as a device developed for upper limb rehabilitation that is either specifically designed for bilateral training or at least supports bilateral training as one of the prominent training modes,where both upper limbs perform simultaneous movements with one limb moving actively and the other limb moving actively, passively, or with assistance.Relevant literature was identified through computerized and manual searches in the following electronic databases:PubMed, Web of Science, and Google Scholar. Thesedatabases were searched using the following MeSH headings and key words:(i) cerebrovascular disorder$, cerebrovascular accident,CVA, stroke, hemiparetic stroke, paresis, hemiparesis, hemiplegia,(ii) upper extremity, upper limb$, arm$, forearm$,wrist$, hand$, finger$,(iii) bilat$, bimanual$(iv) robot$, mechan$, device.Bibliographies of review articles, empirical articles, and abstracts published in conference proceedings were also examined. In further iterations, references from retrieved articles were examined to identify additional relevant articles.In light of the recent interest in bilateral upper limb training in stroke rehabilitation literature [6, 19], only articles published from 1990 onwards were searched.Devices were selected for discussion if they met with the aforementioned definition of a device for bilateral upper limb training. Devices were categorized as robotic devices when they met the description of the PubMed MeSH term of robotics. All other devices were categorized as mechanical devices. Both categories are discussed in separate paragraphs.
3.Results
The search resulted in 311 single citations of which 70reported on 20 different bilateral training devices. Of these, 6were mechanical and 14 were robotic devices.
3.1. Mechanical Devices3.1.1. BATRAC (Tailwind).
Bilateral arm training with rhythmic auditory cueing (BATRAC) was introduced in 2000[20], together with a custom-made bilateral arm trainer. The device consists of two independent T-bar handles mounted on nearly frictionless tracks that can move in the transverse plane perpendicular to the user. The handles have to be pushed forward and pulled back, either with both upper limbs simultaneously(in-phase) or alternatingly(anti-phase), at a frequency paced by a metronome providing auditory cues. If a patient is unable to hold the handle with the hand of the most impaired upper limb, the hand is strapped onto it. The original BATRAC protocol focuses expressly on shoulder and elbow function. A modified version of the original BATRAC protocol focuses on distal upper limb function [21]. For the purpose of the latter protocol,a device was developed consisting of two manipul and a with hand grip that can be mounted on the distal ends of a chair’s arm rests (see Figure 1(a)). The manipul and a allow flexion and extension movements of the wrist in the horizontal plane and have to be moved rhythmically in pace with an auditory metronome in either a mirror-symmetrical(in-phase) or an alternating (anti-phase) fashion. Visual feedback is provided in the form of a Lissajous display, left and right hand movement amplitudes, and the relative phase(and its variability) between both hands (see Figure 1(b)). The original BATRAC protocol was first used in a pilot effect study involving a single group of patients with chronic stroke (i.e., more than 6 months after stroke onset) [20]. Fourteen patients received 6 weeks of BATRAC, three times a week, four times 5 minutes per session. Post treatment assessment revealed improvements in Fugl-Meyer Assessment(FMA), Wolf Motor Function Test (WMFT), University of Maryland Arm Questionnaire for Stroke measuring daily use of the most impaired upper limb, as well as strength measures and range of motion measures for the most and less impaired upper limb. Most of these benefits sustained at 8-week followup.Another study [22] examined the efficacy of a mod-ified version of the BATRAC protocol. In this study, 14 patients with chronic stroke participated in four 2-hour-plus BATRAC sessions per week for 2 weeks. Although no significant changes in FMA or WMFT were found as a result of this intervention, patients reported an increase in daily use of the most impaired upper limb as evidenced by a significant change on the Motor Activity Log (MAL). In a large RCT with patients with chronic stroke,BATRAC was compared with dose-matched therapeutic exercises [23]. A total of 111 patients were randomized over both intervention groups and received 6 weeks long3 training sessions per week. The improvements in upper limb function were comparable between both groups post-treatment and retained after 4 months. There were however greater adaptations in brain activation after BATRAC than after the control treatment, suggesting that both treatments referred to different underlying neural mechanisms.Currently, an RCT with 60 patients in the subacute phase after stroke (1–6 months) is being conducted [21]. In this RCT the BATRAC device for distal upper limb movements(Figure 1) is used and compared to constrained induced movement therapy and conventional physical therapy. This RCT will be completed by the end of this year and will be reported in 2013/2014.A commercial version of BATRAC, called Tailwind (seeFigure 2), is produced and sold by Encore Path, Inc. Baltimore, MD, USA and is also available at Anatomical Concepts UK Ltd., Clydeland, Scotland. This device is produced for home based training and differs from the original device, as the Tailwind also allows upward and outward movements.The BATRAC device for movements about the wrist is not commercially available.
3.1.2.Reha-SlideDuoandReha-Slide (Nudelholz).
The Reha-Slide Duo (see Figure 3) consists of a board with two sledges running on parallel tracks [24]. Two handles on the sledges can be moved forward and backward separately,similar to the Tailwind used for BATRAC. The board on which the tracks are placed can be inclined up to 20
◦
for
Figure
2: Tailwind. Reprinted with permission (http://www.tail-windtherapy.com/).
Figure
3: Reha-Slide Duo. Reprinted with permission (http://www .reha-stim.de/).
upward movements, and friction for forward and backward movements can be adjusted for both handles separately via adjustable rubber brake elements in a range from 5N to 80N(with the board horizontal).The Reha-Slide Duo was incorporated in an arm studio for upper limb rehabilitation [24]. However, no clinical results have been reported to date specifically for the Reha-Slide Duo.
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