Abstract
Despite upper extremity function playing a crucial role in maintaining one’s independence in activities of daily living, upper extremity impairments remain one of the most prevalent post-stroke deficits. To enhance the upper extremity motor recovery and performance among stroke survivors, two training paradigms in the fields of robotics therapy involving modifying haptic feedback were proposed: the error-augmentation (EA) and error-reduction (ER) paradigms. There is a lack of consensus, however, as to which of the two paradigms yields superior training effects. This systematic review aimed to determine (i) whether EA is more effective than conventional repetitive practice; (ii) whether ER is more effective than conventional repetitive practice and; (iii) whether EA is more effective than ER in improving post-stroke upper extremity motor recovery and performance. The study search and selection process as well as the ratings of methodological quality of the articles were conducted by two authors separately, and the results were then compared and discussed among the two reviewers. Findings were analyzed and synthesized using the level of evidence. By August 1st 2017, 269 articles were found after searching 6 databases, and 13 were selected based on criteria such as sample size, type of participants recruited, type of interventions used, etc. Results suggest, with a moderate level of evidence, that EA is overall more effective than conventional repetitive practice (motor recovery and performance) and ER (motor performance only), while ER appears to be no more effective than conventional repetitive practice. However, intervention effects as measured using clinical outcomes were under most instance not ‘clinically meaningful’ and effect sizes were modest. While stronger evidence is required to further support the efficacy of error modification therapies, the influence of factors related to the delivery of the intervention (such as intensity, duration) and personal factors (such as stroke severity and time of stroke onset) deserves further investigations as well.
Highlights
Stroke, referred to as cerebrovascular accident (CVA), is one of the leading causes of disablement among adults [1, 2]
The reason why EA was found to more effective than standard repetitive practice while ER was not could be due to the fact haptic guidance and assistive therapy are more effective in the initial stage of motor learning while error-based learning is more used in the later stage of learning
In response to the research questions posed in this paper, the following conclusions were drawn with regards to the population of chronic stroke: (1) Interventions involving an EA paradigm were more effective compared to interventions without error modification at improving upper extremity impairments, disabilities and reaching trajectory control; (2) Interventions involving ER paradigm were not more effective compared to interventions without error modification at improving upper extremity impairments and disabilities and; (3) Interventions involving an EA paradigm were more effective compared to interventions involving an ER paradigm to improve reaching trajectory control
Summary
Referred to as cerebrovascular accident (CVA), is one of the leading causes of disablement among adults [1, 2]. Motor impairments are some of the most prevalent issues post stroke and restoring upper extremity function is one of the top priorities of people with stroke [7]. Severe upper extremity impairments post-stroke often hinder the ability to take care for oneself and perform ADLs [9]. Restoration of upper extremity motor functions is crucial for stroke patients to regain their independence, studies have shown that only 35 to 70% of people with stroke recover to the level of arm ability that is considered functional [10–12] while more than 50% have persistent upper extremity impairments [13]
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