You could get the same effects by just grasping your cane in front of you and pushing it forward, backward and side to side. No robotics though, so not cool enough for your therapists to suggest.
Telerehabilitation using a 2-D planar arm rehabilitation robot for hemiparetic stroke: a feasibility study of clinic-to-home exergaming therapy
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 207 (2024)
Abstract
Background
We evaluated the feasibility, safety, and efficacy of a 2D-planar robot for minimally supervised home-based upper-limb therapy for post-stroke hemiparesis.
Methods
The H-Man, end effector robot, combined with web-based software application for remote tele-monitoring were evaluated at homes of participants. Inclusion criteria were: strokes > 28 days, Fugl-Meyer Motor Assessment (FMA) > 10-60/66, presence of a carer and absence of medical contraindications. Participants performed self-directed, minimally supervised robotics-assisted therapy (RAT) at home for 30 consecutive days, after 2 therapist-supervised clinic on-boarding sessions. Web-based compliance measures were: accessed sessions of > 20 min/day, training minutes/day and active training hours/30 days. Clinical outcomes at weeks 0, 5 (post-training), 12 and 24 (follow-up) consisted of FMA, Action Research Arm Test (ARAT) and WHO-Stroke Specific Quality of Life (SSQOL). To estimate immediate economic benefits of the home-based robotic therapy, we performed cost-effectiveness analysis (CEA), followed by budget impact analysis (BIA).
Results
Altogether, all 12 participants completed Home-RAT without adverse events; 9 (75.0%) were males, mean (SD) age, 59.4 years (9.5), median (IQR) stroke duration 38.6 weeks (25.4, 79.6) baseline FMA (0–66) 42.1 ± 13.2, ARAT (0–57) 25.4 ± 19.5, SSQOL (0–245) 185.3 ± 32.8. At week 5 follow-up, mean (SD) accessed days were 26.3 days ± 6.4, active training hours of 35.3 h ± 14.7/30 days, or ~ 6 days/week and 77 training minutes ± 20.9/day were observed. Significant gains were observed from baseline across time; ΔFMA 2.4 at week 5 (FMA 44.5, CI 95% 39.7–49.3, p < 0.05) and ΔFMA 3.7 at week 24 (FMA 45.8, CI 95% 40.5–51, p < 0.05); ΔARAT 2.6 at week 5 (ARAT 28.0, CI 95% 19.3–36.7, p < 0.05), and ΔARAT 4.8 at week 24 (ARAT 30.2, CI 95% 21.2–39.1, p < 0.05). At week 5 follow-up, 91% of participants rated their overall experience as satisfied or very satisfied. Incremental CEA observed savings of -S$144/per cure over 24 weeks, BIA—potentially 12% impact reduction over five years.
Conclusions
This study demonstrates the feasibility, acceptability, safety, clinical efficacy, and cost-effectiveness of a home-based, web-enabled telemonitored carer-supervised robotics-aided therapy.
Trial registration: NCT05212181 (https://clinicaltrials.gov).
Introduction
Stroke is a disorder characterized by significant impairment of sensorimotor and cognitive functions. Globally, stroke is the second-leading cause of death, accounting for 11.6% of total deaths and the third-leading cause of death and disability combined, accounting for 5.7% of total disability-adjusted life years (DALYs) [1].
In particular, hemiparetic weakness is common after stroke [2, 3], affecting 70–80% of stroke survivors. In terms of upper extremity (UE) motor function, only 10–20% of stroke survivors achieve complete or useful upper limb recovery [4, 5]. Thus, stroke should be regarded as a long-term condition requiring continuing support [6].
Stroke rehabilitation aims to maximise functional independence and improve the patient’s quality of life through a combination of reduction of impairment and learning of compensatory motor strategies [7]. Greater functional independence in the patient leads to reduced caregiver burden, better quality of life and potentially lower costs of care [8]. Current evidence in stroke rehabilitation emphasises the need for repetitive, intensive and adaptive task-specific UE training to facilitate motor relearning and neuroplasticity [9, 10].
Upper-limb Robotics-Assisted Therapy (RAT) can deliver task-specific, repetitive, intensive UE exercises safely with comparable clinical outcomes and improved neuroplasticity [11,12,13]. Current studies on RAT and dose-matched conventional therapy show comparable effects on improving motor outcome with high levels of safety and acceptability, with reduced supervision of therapist. [14,15,16,17]. Thus, RAT provides a potential solution to provide quality-ensured upper limb intensive therapy and decrease therapists’ workload [12, 18].
The development of table-top, portable, simple to use, upper limb end effectors has afforded innovative, effective, low-cost solutions comparable to more complex exoskeletal robots. A typical model is the current device tested, a 2-dimensional planar end effector robot which is a portable, low-cost commercial model with haptic handle. (www.articares.com) (Fig. 1a) This was combined with a web-based telerehabilitation platform and clinically applied as a potential innovation to extend clinic RAT and circumvent barriers such as scheduling, limited access from pandemic-related lockdowns, through decentralized and minimally supervised home-based therapy [14, 19,20,21,22].
H-Man upper-limb rehabilitation robot. a Robot and graphic interface for exergames. b Study participant training at home with the H-Man
It had also long been assumed that stroke patients reach a plateau in their recovery within 6 months of their stroke, however, several studies challenge this assumption. A proportion of interventions delivered > 6 months post-stroke demonstrated a positive benefit for individuals in the chronic stage of stroke [23]. Ward et al. reported results of a clinic-based UE rehabilitation programme consisting of 90 h over 3 weeks, for chronic stroke survivors (median time 18 months post-stroke) with severe UE disability (mean Fugl-Meyer-Motor Assessment (FMA) score 26/66), who achieved clinically significant gains of 42% in motricity and 50% gains in motor function, which persisted for 6 months [24, 25].
These findings suggest that given the length of time needed for post-stroke UE recovery in relation to motor and functional benefits, substantial provisions should be made for post-hospitalisation rehabilitation to be continued for months to years after the initial stroke. However, challenges remain in matching therapy provision to optimise recovery or neuroplasticity in the poststroke subacute to chronic phase, in large part related to healthcare resource limitations and various barriers. For example, a 2014 Singaporean study found that, in general, post-hospital rehabilitation attendance was low [26]. While 87.1% of the patients viewed rehabilitation as beneficial, overall longitudinal attendance rate fell from 100% as inpatient to 20.3% at 3 months, 9.8% at 6 months, 6.3% at 9 months and 4.3% at 12 months. Reasons for this included physical and social barriers, which were high initially, but decreased with time, while the prevalence of financial and perceptual barriers increased with time [26].
Home-based training and telerehabilitation combined with technology deployment at home or nursing facilities are various methods which can increase therapy delivery without over-burdening healthcare manpower. [19, 22, 27]. Also, home-based therapy combined with telerehabilitation and technology are potential methods to optimise therapy intensity and circumvent traditional barriers to access, such as transportation, scheduling and staff availability [19].
Telerehabilitation (TR) for stroke rehabilitation has emerged as a feasible way to deliver various services asynchronously or simultaneously, thus prolonging, or intensifying hospital or clinic-based treatments without concomitant strain on healthcare resources and circumventing physical barriers or clinic scheduling. Stroke patients who completed home-based telerehabilitation achieved outcomes equal to or better than those from conventional care during the first 3 months of stroke. Home-based self-managed UE therapy can also be regarded as another method for extending UE rehabilitation beyond the clinic. A systematic review by Westlake et al., showed largely equivalent efficacy between clinic and purposely designed, self-managed UE home programmes [27,28,29,30].
A large randomised controlled trial (RCT) of 124 subacute and chronic strokes with moderate to severe UE impairment established that 36 h of 70 min each of telerehabilitation, combining computer games with and without supervision, was non-inferior to dose-matched clinic-based rehabilitation, with both groups achieving 7.86–8.36 FMA gains after 6 weeks of training [31]. Reports involving minimally- or un-supervised home-based actuated robot aided training with asynchronous therapist monitoring are sparse, hence this novel therapeutic approach requires further study to determine its feasibility, safety and efficacy and role in stroke rehabilitation.
However, development of medical robotic devices suitable for home-based use still lags with respect to other technologies involved in telerehabilitation such as digital telecommunications and virtual reality. There is a need for less complex and user-friendly robotic systems designed specifically for non-clinical environments [32]. However, most commercially available robots for rehabilitation usually have large dimensions and are complex and costly to operate, which makes them suitable only for clinical settings. Consequently, to-date, there are few publications pertaining to minimally supervised or unsupervised telerehabilitation at home involving RAT.
Hence, this pilot study aimed to evaluate the feasibility, safety, and efficacy of carer-minimally supervised RAT using a portable arm robot, H-Man (Articares Pte Ltd, Singapore) within homes of patients, supervised by carers (i.e., family members or untrained paid helpers,) supported by a web-based platform and remote telemonitoring. For this study, we termed H-Man and web-based platform as “Home-RAT”. Analysis of the experimental data involved both longitudinal assessment of standardised outcome measures and patient-reported outcomes. Secondary outcomes evaluated included the cost-effectiveness and budget impact of Home-RAT.
The innovations of this study fall into four main categories: user acceptance, initial training effectiveness, asynchronous interaction with the clinician and clinical efficacy.
The study’s hypothesis was that telerehabilitation using a carer-minimally supervised portable robot at home for 30 days and clinic remote telemonitoring by occupational therapists (OT) would be feasible to achieve the following outcomes:
- i.
75% of sample achieving an active day defined as any log-in of > 20 min/day continuously.
- ii.
< 10% drop out rate of enrolled participants during the 30-day robot-assisted home training period.
- iii.
< 10% of participants’ adverse events related to robotics-assisted therapy such as arm pain, shoulder pain, increased spasticity on clinically measured scales by independent assessors.
