Effects of Treatment Intensity in Upper Limb Robot-Assisted Therapy for Chronic Stroke: A Pilot Randomized Controlled Trial

 Any type of robotic therapy is almost assuredly only going to be available in higher income countries, so this fails the 'Leave no survivor behind' idea!

Survivors in charge wouldn't make errors like this!

Effects of Treatment Intensity in Upper Limb Robot-Assisted Therapy for Chronic Stroke: A Pilot Randomized Controlled Trial

Yu-wei Hsieh MS  Ching-yi Wu ScD, Chia-yi Lee MS, https://doi.org/10.1177/1545968310394 

Abstract

Background and Objectives. Robot-assisted therapy (RT) is a current promising intervention in stroke rehabilitation, but more research is warranted for examining its efficacy and the dose–benefit relation. The authors investigated the effects of higher intensity versus lower intensity RT on movements of forearm pronation–supination and wrist flexion–extension relative to conventional rehabilitation (CR) in patients poststroke for a mean of 21 months. In this pilot study, 18 patients with initial mean Fugl-Meyer Assessment (FMA) of 37 to 44 for the upper extremity were randomized to higher intensity RT, lower intensity RT, or CR intervention for 4 weeks. The dose of the higher intensity RT was twice the number of repetitions in the lower intensity RT. Outcome measures at pretreatment and posttreatment were administered to patients to evaluate beneficial and adverse effects of interventions. Primary outcomes were the FMA and Medical Research Council scale.

Results.  

There were significant differences in motor function (P= .04) and daily performance (P= .03) among the 3 groups. The higher intensity RT group showed better improvement in motor function, muscle strength, performance of daily activities, and bimanual ability than the other 2 groups. The intensive RT intervention did not induce higher levels of an oxidative DNA biomarker. 

Conclusions. 

Higher intensity of RT that assists forearm and wrist movements may lead to greater improvement in motor ability and functional performance in stroke patients. A sample size of only 20 to 25 in each arm of a larger randomized controlled trial is needed to confirm the findings for similar subjects.

Introduction

 Stroke remains a leading cause of permanent disability and is a large source of disease burden worldwide. 2  Robot-assisted therapy (RT) for upper extremity (UE) motor function has emerged as a possible adjunct for stroke rehabilitation, although not yet convincingly shown to be better than the same intensity of conventional focused UE therapy.RT incorporates some therapeutic elements for success in stroke motor rehabilitation into its design: intensive, repetitiveness, feedback, and bilateral training.9 Along with these advantages, patients can be trained much more often, which has been shown to lead to better outcomes and have potential to enhance motor learning (eg, the Assisted Rehabilitation and Measurement Guide). 11 Previous RT studies showed significant, if modest, improvement in UE motor function, strength, and motor control parameters in stroke patients after interventions.5,6,8 Systematic reviews found that RT significantly improved arm motor function for stroke patients but did not significantly improve daily functions.12,13 Robotics can also provide quantitative control and measurement of therapy (eg, velocity, kinematics, resistance, and range of motion), allowing for research into the treatment dosage of rehabilitation.14 Despite growing empirical evidence for the use of RT in stroke rehabilitation, rigorous research is needed to answer more specific questions that will maximize the benefits from the treatment.15 For example, what is the optimal intensity of RT? What are the relative beneficial and adverse effects of RT compared with other treatments?

Dosage in stroke rehabilitation trials usually uses the duration-based measure of therapy and provides the information regarding the amount of minutes or days per week of therapy provided.16 Most RT trials have offered the treatment in sessions lasting 30 minutes to 1.5 hours, with 3 to 5 sessions per week for 3 to 8 weeks.5,6,8,9 In the EXCITE trial for constraint-induced therapy, the training involved forcing the patient to use the affected arm for up to 6 hours daily for 10 weekdays, and the less-affected hand was placed in a mitt for a goal of 90% of the patient’s waking hours for 14 days during a 2-week period.17 In addition, one study found that in a standard rehabilitation session, the average of repetitions of the functional UE practice was 32.16 According to recent research, performing about 300 repetitions of task-specific UE training per session was feasible in stroke rehabilitation.18 Although greater duration or intensity of rehabilitation resulted in more functional improvement,19-21 current data do not allow for a prescription of how much treatment is enough to induce improvements and not harm the patient. Thus, the definition of treatment intensity as the number of movement repetitions per unit of time22 was adopted in this study and was investigated to inform the optimal dosage for further stroke rehabilitation.

Moreover, it is important to select the appropriate intensity of exercise or treatment, because exercise that is too intensive can be hazardous.23 The study found that high-intensity exercise (ie, 75% maximum oxygen consumption reached) increased oxidative stress in healthy men.23 During prolonged heavy exercise, antioxidant systems may be overwhelmed by excessive reactive oxygen species, leading to cell and tissue damage.24 Stroke patients commonly showed activity intolerance and significantly lower maximal workloads than controls during exercise.25 For healthy people, the RT protocols proposed in this study seem not to have been so stressful or reach the effort level of the previous study where increased oxidative stress was found.23 For stroke patients, however, the same intensity or amount of training may have different impacts from healthy people. In addition, the oxidative stress level has been reported to be higher in acute stroke patients than in control subjects, but the effects of training on oxidative damage have not been addressed in these studies.26,27 To date, the threshold level of training intensity that may cause oxidative stress in stroke patients remains unclear and warrants scrutiny. To address this gap in dose–response relations in stroke motor rehabilitation, this study investigated the effects of intensive RT on the 8-hydroxy-2′-deoxyguanosine (8-OHdG) level, an oxidative DNA biomarker, in stroke patients. Our goals in this study were to (a) investigate the treatment effects of RT on different outcomes relative to conventional rehabilitation (CR) in patients with stroke, (b) test the dose–response relations by using 2 groups receiving higher intensity and lower intensity RT, and (c) examine the effects of RT training on 8-OHdG, a biomarker of oxidative stress.

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