Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment

Background: Stroke is a leading cause of functional impairments globally, often resulting in long-term disability and a substantial impact on individuals, families, and caregivers. Learned nonuse, a phenomenon where motor deficits persist after a stroke due to central nervous system suppression, is a significant challenge in stroke rehabilitation. Constraint-Induced Movement Therapy (CIMT) is a well-established neurorehabilitation approach based on behavioural training, which includes repetitive task-specific training, behavioural techniques, and constraining the use of the more affected upper extremity. CIMT has been successful in improving functionality in chronic hemiparetic stroke patients, promoting cortical reorganization and neural plasticity.
 Method: This study involved 60 stroke survivors aged 20 or older, selected purposively and meeting specific criteria. Participants underwent an 8-week Modified CIMT (M-CIMT) program with auditory cueing for the hemiparetic upper limb. Data collection included pre-test and post-test assessments using the Wolf Motor Function Test (WMFT) and the Motor Activity Log (MAL) to evaluate functional activity. The M-CIMT program comprised warm-up sessions, M-CIMT protocols, and cool-down exercises, conducted five days a week.
 Results: Following participation in the M-CIMT program, significant improvements were observed in WMFT and MAL scores. The mean pre-test score of 46.60 seconds decreased to a mean post-test score of 16.85 seconds, with highly significant t-values of 14.292 and -51.356 and a p-value of 0.0, indicating a strong correlation between the two datasets. The analysis revealed that M-CIMT effectively enhanced upper extremity function in chronic stroke patients.
 Conclusion: This study highlights the effectiveness of the Modified CIMT protocol, emphasizing repeated use and a distributed practice schedule, in reducing upper-limb impairment and improving upper-limb use and function in chronic stroke patients. The significant improvement in post-test scores underscores the promise of M-CIMT as a valuable approach for upper extremity rehabilitation following chronic stroke, offering hope for enhanced recovery and improved quality of life for affected individuals.
 Keywords: Stroke; Rehabilitation; Upper Extremity; Constraint-Induced Movement Therapy; Motor Activity

The trunk acts as proximal support with which limbs execute smooth and purposeful movement. Furthermore, as upper extremity functions are an integral component of daily living activities, exploring the association between trunk and upper extremity recovery will guide therapists in developing appropriate rehabilitation goals and interventions. The objectives of this study were to (1) assess the association between trunk and upper extremity recovery in the subacute stroke population and (2) assess the effect of trunk control on upper extremity impairment and function with age, gender, and duration of stroke as mediators using mediation analysis in subacute stroke individuals. This cross-sectional study included 54 subacute stroke participants with a mean age of 58.37 ± 6.11 years. The trunk impairment scale (TIS) assessed the trunk's stability, mobility, and coordination. The level of upper extremity impairment was evaluated using the Fugl-Meyer Assessment scale (FMA). The quality and quantity of upper limb motor functions were measured using the Wolf motor function test (WMFT). The TIS exhibited moderate positive correlations with the FMA-UE, WMFT-time scale (TS), and WMFT-functional ability scale (FAS) at p < 0.001. The mediation analysis reported a profound mediation effect of post-stroke duration on the association of trunk and upper limb recovery. The study results substantiated that trunk control significantly correlates with upper limb impairment and the quality and quantity of its use in the subacute stroke population. Post-stroke duration proved to mediate the association between trunk and upper limb recovery. Therefore, the assessment and intervention of trunk and upper extremity motor control considering the post-stroke duration is vital and should be incorporated in stroke rehabilitation aiming at functional independence.

Retention of upper limb function in stroke survivors who have received constraint-induced movement therapy: the EXCITE randomised trial

This study evaluated and compared the effectiveness on upper motor extremity function between proprioceptive neuromuscular facilitation which has been frequently used in clinical practice, and action observation training in terms of improving upper motor extremity function. A study with a single-subject design (A-B-C-A`) was conducted with a patient who was diagnosed with left hemiplegia. A repeated-measure analysis was conducted to assess results of the Wolf Motor Function Test (WMFT), Box and Block Test (BBT), and grip and pinch strength test performed daily in the study for 4 weeks. The results of the analysis indicated that the WMFT score, BBT score, grip strength, and pinch strength were improved from 29.60 to 39 (24.10%), from 1.67 to 4.93 each (EA) (66.22%), from 2.06 to 2.66 libras (lbs) (22.61%), and from 1.57 to 1.93 lbs (18.94%), respectively, from the baseline period to treatment period B. The values were improved from 29.60 to 42.20 (29.86%), from 1.67 to 7 EA (76.21%), from 2.06 to 3.47 lbs (40.57%), and from 1.57 to 1.67 lbs (6.12%), respectively, from the baseline period to treatment period C. From treatment period B to treatment period C, the WMFT score, BBT score, and grip strength were improved from 39 to 42.20 (7.58%), from 4.93 to 7 EA (29.56%), and from 2.66 to 3.47 lbs (23.20%), respectively, but pinch strength was decreased from 1.93 to 1.67 lbs (15.83%). In conclusion, proprioceptive neuromuscular facilitation and action observation training both have positive effects on upper extremity motor function. However, we suggest that the posttreatment effect of action observation training was better than that of proprioceptive neuromuscular facilitation.

BackgroundVirtual reality (VR)-based rehabilitation is considered a beneficial therapeutic option for stroke rehabilitation. This pilot study assessed the clinical feasibility of a newly developed VR-based planar motion exercise apparatus (Rapael Smart Board™ [SB]; Neofect Inc., Yong-in, Korea) for the upper extremities as an intervention and assessment tool.MethodsThis single-blinded, randomized, controlled trial included 26 stroke survivors. Patients were randomized to the intervention group (SB group) or control (CON) group. During one session, patients in the SB group completed 30 min of intervention using the SB and an additional 30 min of standard occupational therapy; however, those in the CON group completed the same amount of conventional occupational therapy. The primary outcome was the change in the Fugl–Meyer assessment (FMA) score, and the secondary outcomes were changes in the Wolf motor function test (WMFT) score, active range of motion (AROM) of the proximal upper extremities, modified Barthel index (MBI), and Stroke Impact Scale (SIS) score. A within-group analysis was performed using the Wilcoxon signed-rank test, and a between-group analysis was performed using a repeated measures analysis of covariance. Additionally, correlations between SB assessment data and clinical scale scores were analyzed by repeated measures correlation. Assessments were performed three times (baseline, immediately after intervention, and 1 month after intervention).ResultsAll functional outcome measures (FMA, WMFT, and MBI) showed significant improvements (p < 0.05) in the SB and CON groups. AROM showed greater improvements in the SB group, especially regarding shoulder abduction and internal rotation. There was a significant effect of time × group interactions for the SIS overall score (p = 0.038). Some parameters of the SB assessment, such as the explored area ratio, mean reaching distance, and smoothness, were significantly associated with clinical upper limb functional measurements with moderate correlation coefficients.ConclusionsThe SB was available for improving upper limb function and health-related quality of life and useful for assessing upper limb ability in stroke survivors.Trial registrationThe study was registered with the clinical research information service (CRIS) (KCT0003783, registered 15 April 2019; retrospectively registered).

Background Transcutaneous auricular vagus nerve stimulation (taVNS) is regarded as a potential method for recovery in stroke. The effectiveness of taVNS in acute and subacute stroke should be further discussed as previously, only a few small-scale trials have focused on chronic stroke patients. The objective of this study is to investigate the effect and safety of taVNS on upper limb motor function in subacute ischemic stroke patients. Methods Twenty-one subacute ischemia stroke patients with single upper limb motor function impairment were enrolled and randomly assigned to conventional rehabilitation training with real or sham taVNS, delivered for 15 consecutive days. Electrodes were fixed to the cymba conchae of the left ear with or without electrical stimulation. Conventional rehabilitation training was performed immediately after the end of real or sham taVNS by the same therapists. Baseline assessments were performed on day 0 of enrollment, and posttreatment evaluations were performed at 15 days, 4 weeks, and 12 weeks after the first intervention. The assessment included the upper limb Fugl-Meyer assessment (FMA-U), the Wolf motor function test (WMFT), the Functional Independence Measurement (FIM), and Brunnstrom stage. Heart rate (HR) and blood pressure (BP) were measured before and after each taVNS intervention. At the same time, any adverse effects were observed during the procedure. Outcomes were assessed by a blind evaluator. Results There were no significant differences in FMA-U, WMFT, FIM, and Brunnstrom scores between the two groups at baseline (P > 0.05). At the endpoint, the FMA-U, WMFT, and FIM scores were significantly higher than before treatment (P < 0.05), and there was a significantly greater improvement of those measurements in taVNS group compared with sham-taVNS group (P < 0.05). Significant improvements in FMA-U score were found between groups at follow-up. Only one case of skin redness occurred during the study. Conclusions This study revealed that taVNS appeared to be beneficial to the recovery of upper limb motor function in subacute ischemia stroke patients without obvious adverse effects. Trial registration. This trial is registered with ChiCTR1800019635 on 20 November 2018 (http://www.chictr.org.cn/showproj.aspx?proj=32961).

EEG predicts upper limb motor improvement after robotic rehabilitation in chronic stroke patients

Effective rehabilitative therapies are needed for patients with long-term deficits after stroke. In this multicenter, randomized, controlled trial involving 127 patients with moderate-to-severe upper-limb impairment 6 months or more after a stroke, we randomly assigned 49 patients to receive intensive robot-assisted therapy, 50 to receive intensive comparison therapy, and 28 to receive usual care. Therapy consisted of 36 1-hour sessions over a period of 12 weeks. The primary outcome was a change in motor function, as measured on the Fugl-Meyer Assessment of Sensorimotor Recovery after Stroke, at 12 weeks. Secondary outcomes were scores on the Wolf Motor Function Test and the Stroke Impact Scale. Secondary analyses assessed the treatment effect at 36 weeks. At 12 weeks, the mean Fugl-Meyer score for patients receiving robot-assisted therapy was better than that for patients receiving usual care (difference, 2.17 points; 95% confidence interval [CI], -0.23 to 4.58) and worse than that for patients receiving intensive comparison therapy (difference, -0.14 points; 95% CI, -2.94 to 2.65), but the differences were not significant. The results on the Stroke Impact Scale were significantly better for patients receiving robot-assisted therapy than for those receiving usual care (difference, 7.64 points; 95% CI, 2.03 to 13.24). No other treatment comparisons were significant at 12 weeks. Secondary analyses showed that at 36 weeks, robot-assisted therapy significantly improved the Fugl-Meyer score (difference, 2.88 points; 95% CI, 0.57 to 5.18) and the time on the Wolf Motor Function Test (difference, -8.10 seconds; 95% CI, -13.61 to -2.60) as compared with usual care but not with intensive therapy. No serious adverse events were reported. In patients with long-term upper-limb deficits after stroke, robot-assisted therapy did not significantly improve motor function at 12 weeks, as compared with usual care or intensive therapy. In secondary analyses, robot-assisted therapy improved outcomes over 36 weeks as compared with usual care but not with intensive therapy. (ClinicalTrials.gov number, NCT00372411.)

Objective To investigate the effect of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with task-oriented training on the recovery of upper limb motor function of stroke patients. Methods A total of 42 patients with hemiplegia after stroke were randomly divided into control group (N = 20) and treatment group (N = 22). Control group received routine rehabilitation training and task-oriented training, and treatment group received low-frequency (1 Hz) rTMS over the contralesional cortex addition to routine rehabilitation and task-oriented training. Fugl-Meyer Assessment Scale for Upper Extremity (FMA-UE) and Wolf Motor Function Test (WMFT) were used to evaluate upper limb motor function of all patients before treatment, after 4-week treatment and 3 months after treatment. The latency and central motor conduction time (CMCT) of motor-evoked potential (MEP) in the contralesional cortex were recorded and analyzed. Results Compared with control group, FMA-UE score ( P = 0.006) and WMFT score ( P = 0.024) were significantly increased in treatment group. There was significant difference in FMA-AUE score ( P = 0.000) and WMFT score ( P = 0.000) at different time points. Compared with before treatment, FMA-UE score ( P = 0.000, for all) and WMFT score ( P = 0.000, for all) of patients in both groups were all significantly increased after 4-week treatment and 3 months after treatment. Besides, FMA-UE score ( P = 0.000, for all) and WMFT score ( P = 0.000, for all) 3 months after treatment were higher than those after 4-week treatment. There was no statistically significant difference between 2 groups on the latency ( P = 0.979) and CMCT ( P = 0.807) of MEP before and after treatment, and so was the difference on the latency ( P = 0.085) and CMCT ( P = 0.507) of MEP in the contralesional cortex at different time points (before treatment, after 4-week treatment and 3 months after treatment). Conclusions Low-frequency rTMS over the contralesional cortex combined with task-oriented training could greatly promote upper limb motor function of patients after stroke, and should be recommended to clinical application. DOI: 10.3969/j.issn.1672-6731.2017.04.004

Background. To assess upper extremity (UE) capabilities following stroke, the Wolf Motor Function Test (WMFT) measures time to complete 15 UE tasks and 2 strength tasks, but takes 30 to 45 minutes for the clinician to complete. Objective. In an effort to streamline the WMFT, this study evaluated the association between the magnitude of improvement on any timed task of the WMFT and the change score on all other tasks among participants in the Extremity Constraint Induced Therapy Evaluation (EXCITE) trial. Methods. This association was evaluated using regression methods according to chronicity and controlling for key covariates (functional level, gender, concordance) for log mean WMFT scores. Results. After controlling for covariates, 6 tasks (hand to table [front], hand to box [front], reach and retrieve, lift can, lift pencil, and fold towel) influenced the overall WMFT score for survivors meeting EXCITE criteria and treated within 3 to 9 months poststroke. Six different tasks (extend elbow weight, hand to box [front], lift can, lift pencil, turn key in lock, and fold towel) influenced the overall WMFT score for those receiving constraint-induced movement therapy (CIMT) 1 year later. The importance of certain tasks relative to others may best represent overall UE function, but this streamlining enables the clinician to prioritize these tasks in the evaluation. Conclusions. The delineation of those tasks depends on the time poststroke from enrollment to CIMT. This study demonstrates that the WMFT can be streamlined from 17 to 6 tasks.

Mental Practice With Motor Imagery: Evidence for Motor Recovery and Cortical Reorganization After Stroke

Aim: To determine the effects of Hand-arm Bimanual Intensive Training on fine motor skills of chronic stroke patients. Methods: A randomized control trail was conducted at District Head Quarter Hospital Sargodha. Twenty-eight stroke patients were randomized into 2 groups. All patients were examined by using Questionnaire of Disabilities of Arm, Shoulder, and Hand (DASH), Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT). Control group was treated with Conventional Physical Therapy and experimental group with Hand Arm Bimanual Intensive Training. There were 3 sessions every week for a total of 12 sessions over the course of 4 weeks. At the beginning of the intervention, two weeks later, and four weeks later, all outcomes were evaluated. Data analysis was done with SPSS version 21. Results: Intra group analysis showed statistically significant results (p&lt;0.001) in each group after 4 weeks of treatment indicating improvement in Disabilities of Arm, Shoulder, and Hand (DASH), Action Research Arm Test (ARAT) and Wolf Motor Function Test (WMFT) of both groups. However, based on their mean differences, experimental group demonstrated greater progress across all outcome measures which is indicated through Inter group analysis that statistically significant difference was present between two groups in DASH, ARAT and WMFT with p-values 0.045, 0.046 and 0.043 respectively at end of treatment. Practical implications: HABIT pays attention to bimanual training which is highly related to most ADL tasks so there is need to evaluate the effectiveness of HABIT-related interventions. This will help to promote improvements in upper extremity functions and to enhance the level of independence among stroke patients. Conclusion: Study concluded that both conventional physical therapy and hand arm bimanual intensive training (HABIT) are helpful in improving upper extremity fine motor abilities in chronic stroke patients, but HABIT is more beneficial as compared to usual conventional and routine rehab treatments. Keywords: HABIT, fine motor skills, physical therapy, upper extremity, stroke.

Virtual reality (VR) training allows the creation of the most applicable practice environment incorporated into computer-generated multisensory imagery. The purpose of this study was to investigate the effects of a virtual training program based on a RAPAEL smart glove on the upper extremity function and quality of life of community-dwelling individuals with chronic hemiparetic stroke. Thirty-six outpatients diagnosed as having a first stroke were selected to receive a therapeutic rehabilitation program at local rehabilitation units. Participants were allocated randomly into two groups: the non-immersive VR training (intervention) group and the recreational activity (control) group. The intervention group received non-immersive VR training using a RAPAEL smart glove for 30 minutes per session, 3 days a week for 8 weeks. The control group performed recreational activities for the same period and also participated in a conventional rehabilitation program for 30 minutes per session, 3 days a week for 8 weeks as an additional therapy. To analyze the effects of the non-immersive VR intervention on upper extremity function, four clinical measures, namely the box and block test (BBT), the Wolf motor function test (WMFT), the Jebsen-Taylor hand function test (JTT), and a grip strength test, were used in this study. For the secondary clinical outcome, the trail-making test (TMT) was used to determine any improvement in cognitive function. At week 8, upon completion of the non-immersive VR-training the intervention group demonstrated significantly greater WMFT scores (73.0±12.9 to 81.6±7.5), BBT scores (27.3±8.9 to 34.2±7.1), and grip strength (19.2±8.2 to 23.8±8.5) compared with WMFT scores (70.4±12.1 to 73.2±13.1), BBT scores (27.1±10.5 to 28.8±12.9), and grip strength (18.4±4.2 to 18.3±4.9) in the control group. This study suggests that virtual upper extremity training using the RAPAEL smart glove has reasonable and beneficial effects on upper extremity and cognitive function for chronic hemiparetic stroke survivors.

Introduction: There are various techniques practiced in upper limb rehabilitation in stroke patients. One of the effective techniques is constraint induced movement therapy.But adherence to this intense protocol is difficult. So a shorter protocol, Modified constraint induced movement therapy (MCIMT) was introduced. Objective: To study the effect of modified constraint induced movement therapy as an adjunct to conventional therapy on upper extremity performance in chronic stroke patients. Methodology: After the ethics committee approval an informed consent was taken from the participants. 30 subjects, known cases of chronic stroke, out of which 15 were divided into the experimental group and the other 15 formed the control group. Experimental group received Modified constraint induced movement therapy along with conventional therapy. They were evaluated for motor function in terms of fugl Meyer scale and the wolf motor function test, functional use of affected upper extremity in ADL using the motor activity log. Results: Experimental group showed statistically significant improvement in all outcome measures. Conclusion: Modified constraint induced movement therapy as an adjunct to conventional therapy was effective in improving the motor function and functional use of the affected upper extremity in chronic stroke patients.

Studies on nonhuman primates have demonstrated that the cortico-rubro-spinal system can compensate for damage to the pyramidal tract (PT). In humans, so-called alternate motor fibers (aMF), which may comprise the cortico-rubro-spinal tract, have been suggested to play a similar role in motor recovery after stroke. Using diffusion tensor imaging, we examined PT and aMF in the context of human motor recovery by relating their microstructural properties to functional outcome in chronic stroke patients. PT and aMF were reconstructed based on their origins in primary motor, dorsal premotor, and supplementary motor cortices in 18 patients and 10 healthy controls. The patients' degree of motor recovery was assessed using the Wolf Motor Function Test (WMFT). Compared to controls, fractional anisotropy (FA) was lower along ipsilesional PT and aMF in chronic stroke patients, but clusters of higher FA were found bilaterally in aMF within the vicinity of the red nuclei. FA along ipsilesional PT and aMF and within the red nuclei correlated significantly with WMFT scores. Probabilistic connectivity of aMF originating from ipsilesional primary motor cortex was higher in patients, whereas the ipsilesional PT exhibited lower connectivity compared to controls. The strong correlations observed between microstructural properties of bilateral red nuclei and the level of motor function in chronic stroke patients indicate possible remodeling during recovery. Our results shed light on the role of different corticofugal motor tracts, and highlight a compensatory function of the cortico-rubro-spinal system which may be used as a target in future restorative treatments.