So ask your doctor EXACTLY which ones will deliver 100% recovery. Your competent doctor better know the answer. Or don't you have a competent doctor? My definition of a competent doctor is someone who knows ALL relevant stroke research!
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, Engineer-ing and Mathematics, Flinders University, Adelaide, South Australia, Austra-lia;
2
Discipline of Physiotherapy, School of Health Sciences, Flinders Uni-versity, 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 repeti-tive 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 rehabilita-tion device interventions. Correlation of factors identified to promote positive targeted neural plasticity has raised ques-tions 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 so-lutions may improve rehabilitation outcomes.
1. INTRODUCTION
Stroke is a cerebrovascular event in which the blood sup- ply 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 num- ber 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 fun-damental 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 spontane-ous physical recovery of arm and hand function has been identified in less than 15% of the post stroke population [3].
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 reorganisa-tion is required. In particular, innovations in technology have provided a multitude of rehabilitation techniques and devices that aim to increase brain plasticity and cortical reorganisa-tion 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 ma-nipulation 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 rehabilita-tion [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 inter-ventions 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 sev-eral 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 train-ing [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 tar-geting 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 ne-glect’. This reduction in function due to the consistent non-use of an affected limb is identified as an important target for successful outcomes in recovery. The possibility of provid-ing 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 move-ment;
•
Asymmetrical (or Anti-phase) – where the arms move in opposite motions, such as when walking;
•
Complementary – where the motions are completely dis-similar 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. Cur-rently, many ideas are incorporated into the functionality of devices without conclusive knowledge of the beneficial na-ture 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 exist-ing medical devices relevant to promoting upper limb recov-ery in stroke survivors. Previous reviews of upper limb de-vices 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.
More at link.
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, Engineer-ing and Mathematics, Flinders University, Adelaide, South Australia, Austra-lia;
2
Discipline of Physiotherapy, School of Health Sciences, Flinders Uni-versity, 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 repeti-tive 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 rehabilita-tion device interventions. Correlation of factors identified to promote positive targeted neural plasticity has raised ques-tions 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 so-lutions may improve rehabilitation outcomes.
1. INTRODUCTION
Stroke is a cerebrovascular event in which the blood sup- ply 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 num- ber 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 fun-damental 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 spontane-ous physical recovery of arm and hand function has been identified in less than 15% of the post stroke population [3].
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 reorganisa-tion is required. In particular, innovations in technology have provided a multitude of rehabilitation techniques and devices that aim to increase brain plasticity and cortical reorganisa-tion 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 ma-nipulation 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 rehabilita-tion [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 inter-ventions 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 sev-eral 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 train-ing [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 tar-geting 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 ne-glect’. This reduction in function due to the consistent non-use of an affected limb is identified as an important target for successful outcomes in recovery. The possibility of provid-ing 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 move-ment;
•
Asymmetrical (or Anti-phase) – where the arms move in opposite motions, such as when walking;
•
Complementary – where the motions are completely dis-similar 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. Cur-rently, many ideas are incorporated into the functionality of devices without conclusive knowledge of the beneficial na-ture 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 exist-ing medical devices relevant to promoting upper limb recov-ery in stroke survivors. Previous reviews of upper limb de-vices 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.
More at link.
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