Arm Rehabilitation Research Articles

Gamified Practice Improves Paretic Arm Motor Behavior in Individuals With Stroke.

Stroke is a heterogeneous condition, making choice of treatment, and determination of how to structure rehabilitation outcomes difficult. Individualized goal-directed and repetitive physical practice is an important determinant of motor learning. Yet, many investigations of motor learning after stroke deliver task practice without consideration of individual capability of the learner. We developed a gamified arm rehabilitation task for people with stroke that is personalized to individual capacity for paretic arm movement, provides a high dose of practice, progresses through increasingly difficulty levels that are dependent on the performance of the individual, and is practiced in an engaging environment. The objectives of the current study were to determine if 10 days of gamified, object intercept training using the paretic arm would improve arm movement speed and clinical outcome measures of impairment or function. Individuals with chronic stroke and age-matched controls engaged in 10 days of gamified, skilled motor practice of a semi-immersive virtual reality-based intercept and release task. The paretic arm was assessed using the Fugl-Meyer Assessment (motor impairment) and Wolf Motor Function Test (motor function) before and after training. Both groups showed faster arm movement speed with practice; individuals with stroke demonstrated reduced paretic arm motor impairment and increased function after the intervention. Age and sex (for both groups), and time post-stroke were not related to changes in movement speed. Findings indicate that gamified motor training positively affects paretic arm motor behavior in individuals with mild to severe chronic stroke.

Brain-Computer Interfaces in Robotic Arm for Motor Rehabilitation after Stroke

Brain-Computer Interfaces in Robotic Arm for Motor Rehabilitation after Stroke

Comparison of surgical or non-surgical management for non-acute anterior cruciate ligament injury: the ACL SNNAP RCT.

Anterior cruciate ligament injury of the knee is common and leads to decreased activity and risk of secondary osteoarthritis of the knee. Management of patients with a non-acute anterior cruciate ligament injury can be non-surgical (rehabilitation) or surgical (reconstruction). However, insufficient evidence exists to guide treatment. To determine in patients with non-acute anterior cruciate ligament injury and symptoms of instability whether a strategy of surgical management (reconstruction) without prior rehabilitation was more clinically and cost-effective than non-surgical management (rehabilitation). A pragmatic, multicentre, superiority, randomised controlled trial with two-arm parallel groups and 1:1 allocation. Due to the nature of the interventions, no blinding could be carried out. Twenty-nine NHS orthopaedic units in the United Kingdom. Participants with a symptomatic (instability) non-acute anterior cruciate ligament-injured knee. Patients in the surgical management arm underwent surgical anterior cruciate ligament reconstruction as soon as possible and without any further rehabilitation. Patients in the rehabilitation arm attended physiotherapy sessions and only were listed for reconstructive surgery on continued instability following rehabilitation. Surgery following initial rehabilitation was an expected outcome for many patients and within protocol. The primary outcome was the Knee Injury and Osteoarthritis Outcome Score 4 at 18 months post randomisation. Secondary outcomes included return to sport/activity, intervention-related complications, patient satisfaction, expectations of activity, generic health quality of life, knee-specific quality of life and resource usage. Three hundred and sixteen participants were recruited between February 2017 and April 2020 with 156 randomised to surgical management and 160 to rehabilitation. Forty-one per cent (n = 65) of those allocated to rehabilitation underwent subsequent reconstruction within 18 months with 38% (n = 61) completing rehabilitation and not undergoing surgery. Seventy-two per cent (n = 113) of those allocated to surgery underwent reconstruction within 18 months. Follow-up at the primary outcome time point was 78% (n = 248; surgical, n = 128; rehabilitation, n = 120). Both groups improved over time. Adjusted mean Knee Injury and Osteoarthritis Outcome Score 4 scores at 18 months had increased to 73.0 in the surgical arm and to 64.6 in the rehabilitation arm. The adjusted mean difference was 7.9 (95% confidence interval 2.5 to 13.2; p = 0.005) in favour of surgical management. The per-protocol analyses supported the intention-to-treat results, with all treatment effects favouring surgical management at a level reaching statistical significance. There was a significant difference in Tegner Activity Score at 18 months. Sixty-eight per cent (n = 65) of surgery patients did not reach their expected activity level compared to 73% (n = 63) in the rehabilitation arm. There were no differences between groups in surgical complications (n = 1 surgery, n = 2 rehab) or clinical events (n = 11 surgery, n = 12 rehab). Of surgery patients, 82.9% were satisfied compared to 68.1% of rehabilitation patients. Health economic analysis found that surgical management led to improved health-related quality of life compared to non-surgical management (0.052 quality-adjusted life-years, p = 0.177), but with higher NHS healthcare costs (£1107, p < 0.001). The incremental cost-effectiveness ratio for the surgical management programme versus rehabilitation was £19,346 per quality-adjusted life-year gained. Using £20,000-30,000 per quality-adjusted life-year thresholds, surgical management is cost-effective in the UK setting with a probability of being the most cost-effective option at 51% and 72%, respectively. Not all surgical patients underwent reconstruction, but this did not affect trial interpretation. The adherence to physiotherapy was patchy, but the trial was designed as pragmatic. Surgical management (reconstruction) for non-acute anterior cruciate ligament-injured patients was superior to non-surgical management (rehabilitation). Although physiotherapy can still provide benefit, later-presenting non-acute anterior cruciate ligament-injured patients benefit more from surgical reconstruction without delaying for a prior period of rehabilitation. Confirmatory studies and those to explore the influence of fidelity and compliance will be useful. This trial is registered as Current Controlled Trials ISRCTN10110685; ClinicalTrials.gov Identifier: NCT02980367. This award was funded by the National Institute of Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/140/63) and is published in full in Health Technology Assessment; Vol. 28, No. 27. See the NIHR Funding and Awards website for further award information.

An sEMG Signal-based Robotic Arm for Rehabilitation applying Fuzzy Logic

An sEMG Signal-based Robotic Arm for Rehabilitation applying Fuzzy Logic

Motor imagery-based brain–computer interface rehabilitation programs enhance upper extremity performance and cortical activation in stroke patients

BackgroundThe most challenging aspect of rehabilitation is the repurposing of residual functional plasticity in stroke patients. To achieve this, numerous plasticity-based clinical rehabilitation programs have been developed. This study aimed to investigate the effects of motor imagery (MI)-based brain–computer interface (BCI) rehabilitation programs on upper extremity hand function in patients with chronic hemiplegia.DesignA 2010 Consolidated Standards for Test Reports (CONSORT)-compliant randomized controlled trial.MethodsForty-six eligible stroke patients with upper limb motor dysfunction participated in the study, six of whom dropped out. The patients were randomly divided into a BCI group and a control group. The BCI group received BCI therapy and conventional rehabilitation therapy, while the control group received conventional rehabilitation only. The Fugl–Meyer Assessment of the Upper Extremity (FMA-UE) score was used as the primary outcome to evaluate upper extremity motor function. Additionally, functional magnetic resonance imaging (fMRI) scans were performed on all patients before and after treatment, in both the resting and task states. We measured the amplitude of low-frequency fluctuation (ALFF), regional homogeneity (ReHo), z conversion of ALFF (zALFF), and z conversion of ReHo (ReHo) in the resting state. The task state was divided into four tasks: left-hand grasping, right-hand grasping, imagining left-hand grasping, and imagining right-hand grasping. Finally, meaningful differences were assessed using correlation analysis of the clinical assessments and functional measures.ResultsA total of 40 patients completed the study, 20 in the BCI group and 20 in the control group. Task-related blood-oxygen-level-dependent (BOLD) analysis showed that when performing the motor grasping task with the affected hand, the BCI group exhibited significant activation in the ipsilateral middle cingulate gyrus, precuneus, inferior parietal gyrus, postcentral gyrus, middle frontal gyrus, superior temporal gyrus, and contralateral middle cingulate gyrus. When imagining a grasping task with the affected hand, the BCI group exhibited greater activation in the ipsilateral superior frontal gyrus (medial) and middle frontal gyrus after treatment. However, the activation of the contralateral superior frontal gyrus decreased in the BCI group relative to the control group. Resting-state fMRI revealed increased zALFF in multiple cerebral regions, including the contralateral precentral gyrus and calcarine and the ipsilateral middle occipital gyrus and cuneus, and decreased zALFF in the ipsilateral superior temporal gyrus in the BCI group relative to the control group. Increased zReHo in the ipsilateral cuneus and contralateral calcarine and decreased zReHo in the contralateral middle temporal gyrus, temporal pole, and superior temporal gyrus were observed post-intervention. According to the subsequent correlation analysis, the increase in the FMA-UE score showed a positive correlation with the mean zALFF of the contralateral precentral gyrus (r = 0.425, P < 0.05), the mean zReHo of the right cuneus (r = 0.399, P < 0.05).ConclusionIn conclusion, BCI therapy is effective and safe for arm rehabilitation after severe poststroke hemiparesis. The correlation of the zALFF of the contralateral precentral gyrus and the zReHo of the ipsilateral cuneus with motor improvements suggested that these values can be used as prognostic measures for BCI-based stroke rehabilitation. We found that motor function was related to visual and spatial processing, suggesting potential avenues for refining treatment strategies for stroke patients.Trial registration: The trial is registered in the Chinese Clinical Trial Registry (number ChiCTR2000034848, registered July 21, 2020).

Real-time adaptive super twisting algorithm based on PSO algorithm: application for an exoskeleton robot

Abstract In this paper, an online adaptive super twisting sliding mode controller is proposed for a non-linear system. The adaptive controller has been designed in order to deal with the unknown dynamic uncertainties and give the best trajectory tracking. The adaptation is based on an optimal Particle Swarm Optimization (PSO) algorithm whose goal is online tuning the parameters through focusing on decreasing the objective function. The novelty of this study is online handling parameters setting in the conventional super twisting algorithm, bypass heavy offline calculation, and also avoid the instability and abrupt changing of the controller’s parameters for better actuators lifetime. This novel approach has been applied on an upper limb exoskeleton robot for arm rehabilitation. Despite the changes of the dynamic model of the system which defers from one patient to another due to the direct interactions between the wearer and the exoskeleton, this control technique preserves its robustness with respect to bounded external disturbances. The effectiveness of the proposed adaptive controller has been proved in simulation and then in real-time experiment with two human subjects. A comparison between the proposed approach and classic super twisting algorithm has been conducted. The obtained results show the performance and efficiency of the proposed controller.

Protocol of a pilot randomized clinical trial to evaluate nutritional support and rehabilitation on prevention of skeletal muscle mass loss during neoadjuvant chemotherapy in patients with esophageal cancer.

Subtotal esophagectomy with lymph node dissection followed by neoadjuvant chemotherapy (NAC) is the standard treatment for stage II-III esophageal cancer. Esophagectomy is still associated with high morbidity rates, and reducing these rates remains challenging. Among several complications, postoperative pneumonia (PP) is sometimes fatal, which has been reportedly caused by sarcopenia. Thus, nutritional support and rehabilitation may be promising for preventing skeletal muscle mass loss and reduce the incidence of PP. This single-center, randomized, open-label, pilot trial will randomize a total of 40 patients with esophageal cancer in a 1:1 ratio either to ISOCAL Clear + rehabilitation arm or only rehabilitation arm. Although all patients will be educated about rehabilitation by a specialized physician and will be asked to undergo the prespecified rehabilitation program, patients treated with ISOCAL Clear + rehabilitation arm will be supplemented by 400 mL of ISOCAL Clear (Nestlé Japan Ltd, Tokyo, Japan) per day during two courses of NAC with docetaxel, cisplatin, and fluorouracil. Body composition will be assessed using Inbody (Inbody Co., Ltd., Tokyo, Japan) just before starting NAC and surgery. The primary endpoint is the change of skeletal muscle index (SMI) during NAC. Secondary endpoints include (i) body weight, total skeletal muscle mass, appendicular skeletal muscle mass, and lean body mass index changes; (ii) the percentage of ISOCAL Clear continuation; (iii) appetite evaluation; (iv) the percentage of targeted calorie achievement; (v) adverse events of NAC; (vi) postoperative complication rates; and (vii) postoperative hospital stay. This prospective trial assesses the efficacy of nutritional support in addition to rehabilitation during NAC for patients with esophageal cancer. The results will be utilized in assessing whether the effects of nutritional support by ISOCAL Clear are promising or not and in planning future larger clinical trials.

Ab. No. 179 Feasibility of Cardiac Rehabilitation in Patients With Heart Failure at Tertiary Hospital

Introduction: Cardiovascular disease is a major contributor to disease burden globally. Heart failure (HF) emerged as a major global health issue with an estimated worldwide prevalence of &gt;37.7 million. Cardiac rehabilitation (CR) has been demonstrated to improve functional status, and quality of life, reduction in hospital lengths of stay, treatment costs and reduce depression in patients with heart failure. Despite the growing evidence of the benefits of CR, uptake remains low with only 30% taking part in CR. The aim of this study was therefore to incorporate a standard and hybrid model of training and to assess outcomes in terms of reduce hospital admissions, improvements in quality of living, depression, and exercise tolerance. We sought to establish the feasibility of two different models of CR and to identify potential barriers to participate in CR. Methods: This feasibility study used mixed methods to describe characteristics and changes in a cohort of patients with heart failure. Study participants were prospectively recruited and allocated into institution-based cardiac rehabilitation (IBCR) arm, a hybrid cardiac rehabilitation (HCR) arm. After 6-month follow-up, participants were invited to participate in focus group discussions. The primary measure of feasibility was the ability of study participants to attain a mean adherence rate of at least 25%. Result: This study found that CR is feasible for patients with an adherence rate of 48% for IBCR and an adherence rate of 40% for HCR. Both study arms showed significant changes in scores. Participants in focus group discussions identified barriers to cardiac rehabilitation. Conclusion: CR is a feasible treatment intervention for heart failure. There is a need for further research to evaluate the efficacy of cardiac rehabilitation and development of innovative ways to improve treatment adherence.

Design of Matlab/Opensim Robust Controller of an Exoskeleton for Disuse Muscular Atrophy Rehabilitation of A Human Arm

Abstract The mean goal of this paper is to describe the design and control approach of an exoskeleton for rehabilitation of the disuse muscular atrophy of a human arm. This work includes three main parts: Firstly, the exoskeleton model wes design by Autodesk Inventor 3D software. Secondly, the dynamic simulation of the designed exoskeleton model attached to the human arm was performed using OpenSim software and its Matlab API extension, and finally a robust control law was simulated in order to ensure tracking of the rehabilitation trajectories applied by the exoskeleton to the human arm. OpenSim software makes it possible to simulate movements with musculoskeletal models, namely, the human arm. Rehabilitation in this case consists in a precise exercises given by the therapist. In our case, it is the repetitive trajectories given to the exoskeleton that must be controlled. A sliding mode controller was used since it is a robust control and ensures the best solutions to uncertainty issues. Through simulation, we tested some rehabilitation reference trajectories for the elbow and shoulder. The controller ensures high performances in terms of trajectory tracking in the presence of initial errors and also in the presence of model parameter errors. That showed the effectiveness of the exoskeleton control.

Assistance control strategy for upper-limb rehabilitation robot based on motion trend

Abstract. Robot-assisted rehabilitation has proven to improve a subject's upper-extremity motor function. However, it is still challenging to control the robot to provide minimal assistance based on the subject's performance. This paper proposes a motion-trend-based assistance control strategy to solve this problem. The control strategy provides the corresponding normal and tangential forces by constructing an adaptive virtual assistance force field around a predetermined training trajectory. In the normal direction, a performance function based on the position-tracking error and normal motion trend is established to adjust the normal assistance force field strength in real time; in the tangential direction, a performance function based on the tangential interaction force and tangential motion trend is established to adjust the tangential assistance force field strength in real time. Additionally, good motion trends can quickly reduce the assistance force field. The normal motion trend represents the state of the subject moving toward the target trajectory, and the tangential motion trend represents the state of increasing tangential interaction force. Finally, the performance of this control strategy was evaluated by training experiments with eight healthy subjects. Preliminary experiments showed that the normal assist force in the active movement phase was 92.48 % smaller than that in the poor phase, and the tangential assist force was 90.73 % smaller than that in the slack phase. And the normal assist force and tangential assist force will become zero within 0.2 s when the subject has a good tendency to move. This shows that the control strategy proposed in this paper can quickly adjust the assistance according to the subject's motor performance. In addition, the assistance can be quickly reduced when the subject has a good movement trend. Future work will incorporate OpenSim (muscle and bone simulation software) to develop a pathway suitable for the subject's arm rehabilitation.

Design and Characterization of a Self-Aligning End-Effector Robot for Single-Joint Arm Movement Rehabilitation

Traditional end-effector robots for arm rehabilitation are usually attached at the hand, primarily focusing on coordinated multi-joint training. Therapy at an individual joint level of the arm for severely impaired stroke survivors is not always possible with existing end-effector robots. The Arm Rehabilitation Robot (AREBO)—an end-effector robot—was designed to provide both single and multi-joint assisted training while retaining the advantages of traditional end-effector robots, such as ease of use, compactness and portability, and potential cost-effectiveness (compared to exoskeletons). This work presents the design, optimization, and characterization of AREBO for training single-joint movements of the arm. AREBO has three actuated and three unactuated degrees of freedom, allowing it to apply forces in any arbitrary direction at its endpoint and self-align to arbitrary orientations within its workspace. AREBO’s link lengths were optimized to maximize its workspace and manipulability. AREBO provides single-joint training in both unassisted and adaptive weight support modes using a human arm model to estimate the human arm’s kinematics and dynamics without using additional sensors. The characterization of the robot’s controller and the algorithm for estimating the human arm parameters were performed using a two degrees of freedom mechatronic model of the human shoulder joint. The results demonstrate that (a) the movements of the human arm can be estimated using a model of the human arm and robot’s kinematics, (b) AREBO has similar transparency to that of existing arm therapy robots in the literature, and (c) the adaptive weight support mode control can adapt to different levels of impairment in the arm. This work demonstrates how an appropriately designed end-effector robot can be used for single-joint training, which can be easily extended to multi-joint training. Future work will focus on the evaluation of the system on patients with any neurological condition requiring arm training.

A PID-Controlled Approach in the Design of a Physiotherapy Robot for Upper Arm Rehabilitation

The main objective to develop controller for the rebab robot, therefore to achieve the main objective, the subsequent objective is to formulate the mathematical modelling of 2 DOF of upper arm, to develop upper arm rebab robot, evaluate the performance of the controller and facilitate the creation of new and more improved devices for physiotherapy robot ; therefore, this research will investigate rehabilitation robots, it have shown a high potential for improving the patient’s mobility, improving their functional movements and assisting in daily activities. However, this technology is still an emerging field and suffers from several challenges like compliance control and dynamic uncertain caused by the human–robot collaboration. The main challenge addressed in this thesis is to develop a controller to the rehab robot and formulate the mathematical modelling of 2 DOF of upper arm. Ensure that the exoskeleton robot provides a suitable compliance control that allows it to cooperate perfectly with humans even if the dynamic model of the exoskeleton robot is uncertain. The PID controller is a widely used control algorithm that aims to regulate a system's output by continuously adjusting its input. In the context of a two-degree-of-freedom (2-DOF) robot arm, the PID controller plays a crucial role in achieving precise and accurate arm movements. The Proportional-Integral-Derivative (PID) controller employs three main components to achieve control: proportional, integral, and derivative terms.

Robotic arm training in neurorehabilitation enhanced by augmented reality – a usability and feasibility study

BackgroundRobotic therapy and serious gaming support motor learning in neurorehabilitation. Traditional monitor-based gaming outputs cannot adequately represent the third dimension, whereas virtual reality headsets lack the connection to the real world. The use of Augmented Reality (AR) techniques could potentially overcome these issues. The objective of this study was thus to evaluate the usability, feasibility and functionality of a novel arm rehabilitation device for neurorehabilitation (RobExReha system) based on a robotic arm (LBR iiwa, KUKA AG) and serious gaming using the AR headset HoloLens (Microsoft Inc.).MethodsThe RobExReha system was tested with eleven adult inpatients (mean age: 64.4 ± 11.2 years; diagnoses: 8 stroke, 2 spinal cord injury, 1 Guillain-Barré-Syndrome) who had paretic impairments in their upper limb. Five therapists administered and evaluated the system. Data was compared with a Reference Group (eleven inpatients; mean age: 64.3 ± 9.1 years; diagnoses: 10 stroke, 1 spinal cord injury) who trained with commercially available robotic therapy devices (ArmeoPower or ArmeoSpring, Hocoma AG). Patients used standardized questionnaires for evaluating usability and comfort (Quebec User Evaluation of Satisfaction with assistive technology [QUEST]), workload (Raw Task Load Index [RTLX]) and a questionnaire for rating visual perception of the gaming scenario. Therapists used the QUEST, the System Usability Scale and the short version of the User Experience Questionnaire.ResultsTherapy with the RobExReha system was safe and feasible for patients and therapists, with no serious adverse events being reported. Patients and therapists were generally satisfied with usability. The patients’ usability ratings were significantly higher in the Reference Group for two items of the QUEST: reliability and ease of use. Workload (RTLX) ratings did not differ significantly between the groups. Nearly all patients using the RobExReha system perceived the gaming scenario in AR as functioning adequately despite eight patients having impairments in stereoscopic vision. The therapists valued the system’s approach as interesting and inventive.ConclusionsWe demonstrated the clinical feasibility of combining a novel robotic upper limb robot with an AR-serious game in a neurorehabilitation setting. To ensure high usability in future applications, a reliable and easy-to-use system that can be used for task-oriented training should be implemented.Trial registrationEthical approval was obtained and the trial was registered at the German Clinical Trials Register (DRKS00022136).

Is a novel digital system for arm and hand rehabilitation suitable for stroke survivors? A qualitative process evaluation of OnTrack

Objectives and designNational guidelines emphasise the need to enhance arm and hand recovery poststroke. OnTrack is a 12-week package aiming to address this need. Feasibility was evaluated in a single-arm...

Virtual reality in upper extremity rehabilitation of Multiple Sclerosis patients

Background: Virtual reality (VR) has emerged as a promising approach in the field of healthcare, particularly in the context of multiple sclerosis (MS), offering new possibilities for rehabilitation and improving the quality of life for individuals affected by this chronic neurological condition. Methods: The electronic databases PubMed, Google Scholar, and PEDro were thoroughly searched using medical subject headings and free text related to multiple sclerosis, virtual reality, upper limb, and rehabilitation. The review followed the PRISMA guidelines. Results: A total of 4 articles were included in the review. These articles examined the effects of VR in upper limb rehabilitation on patients with MS. The majority (n=2) of the studies compared VR with usual care, while one examined tele-VR and one with non-serious games. Conclusion: VR interventions have shown promise in enhancing manual dexterity, upper limb rehabilitation, and arm function in MS patients. The use of serious games for arm rehabilitation has also demonstrated potential benefits in improving functional outcomes in MS patients.

Pareto-based Dynamic Difficulty Adjustment of a competitive exergame for arm rehabilitation

Although Dynamic Difficulty Adjustment (DDA) in rehabilitation-based exergames features the conflicting objectives of intensity and performance, traditional DDA methods have only addressed this problem in terms of single or weighted objectives. Deviating from previous works, this work presents a Pareto-based DDA (PDDA) for a Competitive rehabilitation-based exergame which is capable of generating a set of trade-off solutions between the two conflicting objectives. Consequently, based on the rehabilitative needs, a unique solution is selected via the trade-off worth information of the generated solutions to modify the game parameters or difficulty. In order to evaluate the performance of the proposed PDDA, two experimental studies were conducted based on 12 and 10 unimpaired participants respectively. The first study which was aimed at evaluating the performance of the proposed PDDA in terms of the in-game parameters shows that the proposed PDDA is capable of generating multiple trade-off solutions as well as effectively adjust the game parameters or difficulty. The second study which was aimed at evaluating the proposed PDDA in term of user experience shows that PDDA demonstrate statistical difference with a random DDA method in terms of the Intrinsic Motivation Inventory (IMI) and the Flow Experience Measure (FEM) metrics. Since rehabilitation outcomes generally rely on both intensity and performance, the ability of the proposed PDDA to increase effort, enjoyment, competence, and flow will help to greatly facilitate frequent and intense exercise as well as performance in rehabilitation-based exergame.

Supporting stroke survivors to meet their personal rehabilitation needs in community-based arm rehabilitation: development of initial programme theories to explore what may work for whom, how and under what circumstances.

This study explored what worked for whom, how and under what circumstances in a community-based augmented arm rehabilitation programme that was designed to enable stroke survivors to meet their personal rehabilitation needs. A mixed methods realist-informed study of data from a randomised controlled feasibility trial, comparing augmented arm rehabilitation after stroke with usual care. The analysis was designed to develop initial programme theories and refine these through triangulation of qualitative and quantitative trial data. Participants with a confirmed stroke diagnosis and stroke-related arm impairment were recruited from five health boards in Scotland. Only data from participants in the augmented group were analysed. The augmented intervention comprised evidence-based arm rehabilitation (27 additional hours over 6 weeks) including self-managed practice, and focused on individual rehabilitation needs identified through the Canadian Occupational Performance Measure (COPM). The COPM indicated to which extent rehabilitation needs were met following the intervention, the Action Research Arm Test provided data on changes in arm function, and qualitative interviews provided information about the context and potential mechanisms of action. Seventeen stroke survivors (11 males, age range 40-84 years, NIHSS median (IQR) 6 (8)) were included. Median (IQR) COPM Performance and Satisfaction scores (min.1-max.10) improved from pre-intervention 2 (5) to post-intervention 5 (7). Findings suggested that meeting rehabilitation needs was facilitated by strengthening participants' sense of intrinsic motivation (through grounding exercises in everyday activities linked to valued life roles, and enabling them to overcome barriers to self-managed practice), and via therapeutic relationships (through trust and expertise, shared decision-making, encouragement and emotional support). Collectively, these mechanisms enabled stroke survivors to build confidence and gain mastery experience necessary to engage in new self-managed practice routines. This realist-informed study enabled the development of initial programme theories to explain how and in what circumstances the augmented arm rehabilitation intervention may have enabled participants to meet their personal rehabilitation needs. Encouraging participants' sense of intrinsic motivation and building therapeutic relationships appeared instrumental. These initial programme theories require further testing, refinement, and integration with the wider literature.

Downward adjustment of rehabilitation goals may facilitate post-stroke arm motor recovery

Objective: Patients starting with physical rehabilitation often hold unrealistically high expectations for their recovery. Because of a lower-than-expected rate of recovery, such unrealistic goals have been linked to adverse effects on mental health. Additionally, overtraining due to overly ambitious goals can lead to suboptimal recovery. We investigated the effectiveness of adjusting rehabilitation goals to a more realistic level as a strategy to select appropriate exercise intensity and achieve better recovery outcomes. Design: Patients with arm paralysis from recent stroke were recruited and went through 6–8 weeks of telerehabilitation and in-clinic rehabilitation programme conducted at 11 US sites (N = 124). Main Outcome Measures: Adjustment of recovery goal was assessed in two timepoints during the rehabilitation programme and arm motor function was assessed before and after the clinical trial. Results: Greater use of goal adjustment strategies predicted better recovery of arm motor function, independent from therapy compliance. This pattern was observed only when the choice of exercises is patient-regulated rather than directed by a physical therapist. Conclusion: Benefits from goal adjustment were more pronounced among patients who entered the programme with poorer motor functions, suggesting that goal adjustment is the most beneficial when goals of complete recovery are most unrealistic.

Botulinum Toxin-A Treatment of Post-Stroke Spasticity Is Associated with Changes in Interhemispheric Parietal Cortex Connectivity (P12-8.001)

<h3>Objective:</h3> To assess resting-state functional connectivity (rsFC) of the ipsilesional superior parietal lobule (SPL) and intraparietal sulcus (IPS) using functional magnetic resonance imaging (fMRI) in chronic stroke patients with hemiparesis both with and without post-stroke spasticity (PSS) and to explore the relationship between SPL/IPS resting-state functional connectivity (rsFC) and PSS severity. <h3>Background:</h3> Posts-stroke spasticity hampers effective rehabilitation of the paretic arm and lowers the quality of life. Effective PSS treatment with botulinum neurotoxin (BoNT) is associated with transient decrease in task-related fMRI activation of the ipsilesional SPL and IPS. We hypothesized that this would be reflected in changes in rsFC of the SPL/IPS. <h3>Design/Methods:</h3> Fourteen chronic stroke patients with upper limb weakness and PSS (the PSS group) and 8 patients with comparable weakness but no PSS (the control group) underwent clinical and spasticity evaluation and 3 fMRI examinations, at baseline (W0) and 4 and 11 weeks after BoNT (W4 and W11, respectively). Seed-based rsFC of the atlas-based SPL and IPS was evaluated using a group×time interaction analysis and the change in rsFC of SPL/IPS was correlated with change in PSS (modified Ashworth scale), integrity of the ipsilesional somatosensory afferent pathway (evoked potential N20 latency), and age. <h3>Results:</h3> In the PSS group, transient improvement in PSS was associated with increase in rsFC between the ipsilesional IPS and the contralesional SPL at W4. The interhemispheric connectivity was negatively correlated with PSS severity at baseline and with PSS improvement at W4. These changes in the posterior parietal interhemispheric rsFC suggest that previously observed task-related changes in SPL/IPS were independent of actual task performance. <h3>Conclusions:</h3> We propose adaptation of the internal forward model as the possible underlying mechanism and discuss its potential association with increased limb use or improved motor performance, as well as its potential contribution to the clinical effects of BoNT. <b>Disclosure:</b> The institution of Prof. Hlustik has received research support from Czech Health Research Council (AZV CR). Dr. Hok has nothing to disclose. Tomas Veverka has nothing to disclose. Markéta Trnecková has nothing to disclose. Pavel Otruba has nothing to disclose. Jana Zapletalova has nothing to disclose. Zbynek Tudos has nothing to disclose. Prof. Lotze has received publishing royalties from a publication relating to health care. Dr. Kanovsky has nothing to disclose.

Analysis of the therapeutic interaction provided by a humanoid robot serving stroke survivors as a therapeutic assistant for arm rehabilitation.

Objective: To characterize a socially active humanoid robot's therapeutic interaction as a therapeutic assistant when providing arm rehabilitation (i.e., arm basis training (ABT) for moderate-to-severe arm paresis or arm ability training (AAT) for mild arm paresis) to stroke survivors when using the digital therapeutic system Evidence-Based Robot-Assistant in Neurorehabilitation (E-BRAiN) and to compare it to human therapists' interaction. Methods: Participants and therapy: Seventeen stroke survivors receiving arm rehabilitation (i.e., ABT [n = 9] or AAT [n = 8]) using E-BRAiN over a course of nine sessions and twenty-one other stroke survivors receiving arm rehabilitation sessions (i.e., ABT [n = 6] or AAT [n = 15]) in a conventional 1:1 therapist-patient setting. Analysis of therapeutic interaction: Therapy sessions were videotaped, and all therapeutic interactions (information provision, feedback, and bond-related interaction) were documented offline both in terms of their frequency of occurrence and time used for the respective type of interaction using the instrument THER-I-ACT. Statistical analyses: The therapeutic interaction of the humanoid robot, supervising staff/therapists, and helpers on day 1 is reported as mean across subjects for each type of therapy (i.e., ABT and AAT) as descriptive statistics. Effects of time (day 1 vs. day 9) on the humanoid robot interaction were analyzed by repeated-measures analysis of variance (rmANOVA) together with the between-subject factor type of therapy (ABT vs. AAT). The between-subject effect of the agent (humanoid robot vs. human therapist; day 1) was analyzed together with the factor therapy (ABT vs. AAT) by ANOVA. Main results and interpretation: The overall pattern of the therapeutic interaction by the humanoid robot was comprehensive and varied considerably with the type of therapy (as clinically indicated and intended), largely comparable to human therapists' interaction, and adapted according to needs for interaction over time. Even substantially long robot-assisted therapy sessions seemed acceptable to stroke survivors and promoted engaged patients' training behavior. Conclusion: Humanoid robot interaction as implemented in the digital system E-BRAiN matches the human therapeutic interaction and its modification across therapies well and promotes engaged training behavior by patients. These characteristics support its clinical use as a therapeutic assistant and, hence, its application to support specific and intensive restorative training for stroke survivors.