Upper-limb Stroke Rehabilitation Research Articles

Muscle synergies in upper limb stroke rehabilitation: a scoping review.

Upper limb impairment is a common consequence of stroke, significantly affecting the quality of life and independence of survivors. This scoping review assesses the emerging field of muscle synergy analysis in enhancing upper limb rehabilitation, focusing on the comparison of various methodologies and their outcomes. It aims to standardize these approaches to improve the effectiveness of rehabilitation interventions and drive future research in the domain. Studies included in this scoping review focused on the analysis of muscle synergies during longitudinal rehabilitation of stroke survivors' upper limbs. A systematic literature search was conducted using PubMed, Scopus, and Web of Science databases, until September 2023, and was guided by the PRISMA for scoping review framework. Fourteen studies involving a total of 247 stroke patients were reviewed, featuring varied patient populations and rehabilitative interventions. Protocols differed among studies, with some utilizing robotic assistance and others relying on traditional therapy methods. Muscle synergy extraction was predominantly conducted using Non-Negative Matrix Factorization from electromyography data, focusing on key upper limb muscles essential for shoulder, elbow, and wrist rehabilitation. A notable observation across the studies was the heterogeneity in findings, particularly in the changes observed in the number, weightings, and temporal coefficients of muscle synergies. The studies indicated varied and complex relationships between muscle synergy variations and clinical outcomes. This diversity underscored the complexity involved in interpreting muscle coordination in the stroke population. The variability in results was also influenced by differing methodologies in muscle synergy analysis, highlighting a need for more standardized approaches to improve future research comparability and consistency. The synthesis of evidence presented in this scoping review highlights the promising role of muscle synergy analysis as an indicator of motor control recovery in stroke rehabilitation. By offering a comprehensive overview of the current state of research and advocating for harmonized methodological practices in future longitudinal studies, this scoping review aspires to advance the field of upper limb rehabilitation, ensuring that post-stroke interventions are both scientifically grounded and optimally beneficial for patients.

Technological Features of Immersive Virtual Reality Systems for Upper Limb Stroke Rehabilitation: A Systematic Review.

Stroke is the second most common cause of death worldwide, and it greatly impacts the quality of life for survivors by causing impairments in their upper limbs. Due to the difficulties in accessing rehabilitation services, immersive virtual reality (IVR) is an interesting approach to improve the availability of rehabilitation services. This systematic review evaluates the technological characteristics of IVR systems used in the rehabilitation of upper limb stroke patients. Twenty-five publications were included. Various technical aspects such as game engines, programming languages, headsets, platforms, game genres, and technical evaluation were extracted from these papers. Unity 3D and C# are the primary tools for creating IVR apps, while the Oculus Quest (Meta Platforms Technologies, Menlo Park, CA, USA) is the most often used headset. The majority of systems are created specifically for rehabilitation purposes rather than being readily available for purchase (i.e., commercial games). The analysis also highlights key areas for future research, such as game assessment, the combination of hardware and software, and the potential integration incorporation of biofeedback sensors. The study highlights the significance of technological progress in improving the effectiveness and user-friendliness of IVR. It calls for additional research to fully exploit IVR's potential in enhancing stroke rehabilitation results.

Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study.

Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)-based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke. This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation. We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion. The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke. The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system's responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches.

Enhancing Upper Limb Stroke Rehabilitation with Electromyography‐Monitored Virtual Reality–Based Games

Stroke is a significant global health concern, ranking among the top causes of death and disability. Timely poststroke recovery hinges on structured upper limb rehabilitation within the first 24–48 hr. Although virtual reality (VR) rehabilitation is promising, its accessibility is complex and cost‐limited, especially in less developed regions. In this study, we developed and assessed nonimmersive VR rehabilitation games using the Kinect Xbox One and UNITY game engine, targeting upper limb movement sequences vital for poststroke recovery. The developed games involved simple to progressively challenging movements, engaging the deltoid, biceps, and triceps muscles and aligning with poststroke rehabilitation criteria. We used peak‐to‐peak electromyography signal detection with a 20% threshold and three distinct feature extractions to represent muscle contractions during gameplay. Our cosine similarity analysis revealed the efficacy of games in meeting movement sequence criteria, benefiting mostly the shoulder motor and deltoid muscles (93% improvement) with more moderate improvements in the biceps (73%) and triceps (47%). Our results suggest that these games could contribute to upper limb stroke rehabilitation, particularly that of the deltoid muscle. This study highlights the potential of VR‐based rehabilitation games in poststroke upper limb recovery, emphasizing muscle engagement, target distances, and rehabilitation criteria in game design. Although healthy participants were involved here, future research involving poststroke patients and the exploration of more immersive, multiplanar movements hold the potential for a more comprehensive rehabilitation experience. Our study contributes to advancing the common knowledge related to VR‐based stroke rehabilitation, focusing on upper limb movement sequences with implications for therapeutic engagement and recovery.

Head-Mounted Displays for Upper Limb Stroke Rehabilitation: A Scoping Review

Upper extremity (UE) paresis is one of the most frequent and disabling clinical consequences after stroke. Head-Mounted Displays (HMDs) are wearable virtual reality devices that seem effective in promoting the recovery of functional abilities by increasing adherence levels in this population. This scoping review is aimed at collecting available evidence on the use of HMD-based immersive virtual reality systems for UE rehabilitation treatment in stroke survivors. Four electronic bibliographic databases were consulted from inception until 18 January 2023. A total of 19 clinical trials in which HMDs were used as a clinical tool for increasing UE functioning, as a single intervention or in adjunct to other rehab treatments, were included; no restrictions were applied for UE paresis severity or stroke onset. The large majority of the clinical trials involved chronic stroke patients (15 out of 19), with a wide range of UE impairments. Overall, HMD use seemed to be well-tolerated and promising for increasing UE motor function in adult chronic stroke survivors, with benefits in subjects’ arm use and independence. The possibility of executing highly realistic and task-oriented movements appears to be promising in enhancing gesture relevance, thus promoting new motor strategies in a “virtual ecological way”. Across studies, we found a high heterogeneity in protocol design and a lack of reporting that prevents us drawing conclusions regarding potential subgroups of patients that could benefit more from HMD-based interventions or suggested treatment modalities.

Occupational Therapy Practice: Time From Stroke Onset to Outpatient Upper Limb Rehabilitation.

Upper limb stroke rehabilitation has been understudied in usual occupational therapy. The study's purpose was to describe the timing and amount of usual occupational therapy in the stroke population for hospital-based outpatient upper limb rehabilitation. A multi-site study of timing and amount of occupational therapy was calculated for mild and moderate upper limb stroke impairments using the Fugl-Meyer Assessment-Upper Extremity (FMA-UE). Mild stroke participants (n = 58) had a mean of 164.25 days, and the moderate stroke participants (n = 64) had a mean of 106.75 days from the date of stroke onset to first treatment which was significantly different (p = .047). There were no significant differences in the amount of therapy between mild or moderate stroke patients. Mild stroke patients experience a longer delay in receiving outpatient occupational therapy compared with moderate impairments which may be attributed to the subtlety of the impairments that impact participation in daily activities.

Contralaterally EMG-triggered functional electrical stimulation during serious gaming for upper limb stroke rehabilitation: a feasibility study.

Virtual Reality/serious games (SG) and functional electrical stimulation (FES) therapies are used in upper limb stroke rehabilitation. A combination of both approaches seems to be beneficial for therapy success. The feasibility of a combination of SG and contralaterally EMG-triggered FES (SG+FES) was investigated as well as the characteristics of responders to such a therapy. In a randomized crossover trial, patients performed two gaming conditions: SG alone and SG+FES. Feasibility of the therapy system was assessed using the Intrinsic Motivation Inventory (IMI), the Nasa Task Load Index, and the System Usability Scale (SUS). Gaming parameters, fatigue level and a technical documentation was implemented for further information. In total, 18 patients after stroke (62.1 ± 14.1 years) with a unilateral paresis of the upper limb (MRC ≤4) were analyzed in this study. Both conditions were perceived as feasible. Comparing the IMI scores between conditions, perceived competence was significantly increased (z = -2.88, p = 0.004) and pressure/tension during training (z = -2.13, p = 0.034) was decreased during SG+FES. Furthermore, the task load was rated significantly lower for the SG+FES condition (z = -3.14, p = 0.002), especially the physical demand (z = -3.08, p = 0.002), while the performance was rated better (z = -2.59, p = 0.010). Responses to the SUS and the perceived level of fatigue did not differ between conditions (SUS: z = -0.79, p = 0.431; fatigue: z = 1.57, p = 0.115). For patients with mild to moderate impairments (MRC 3-4) the combined therapy provided no or little gaming benefit. The additional use of contralaterally controlled FES (ccFES), however, enabled severely impaired patients (MRC 0-1) to play the SG. The combination of SG with ccFES is feasible and well-accepted among patients after stroke. It seems that the additional use of ccFES may be more beneficial for severely impaired patients as it enables the execution of the serious game. These findings provide valuable implications for the development of rehabilitation systems by combining different therapeutic interventions to increase patients' benefit and proposes system modifications for home use. https://drks.de/search/en, DRKS00025761.

Design of a 6-DoF Cost-effective Differential-drive based Robotic system for Upper-Limb Stroke Rehabilitation.

This paper discusses the design, construction, and characteristics of a six degree of freedom (6-DoF) robotic upper limb stroke rehabilitation device. The device is primarily designed to be used by stroke survivors suffering from hemi-paresis, post stroke therapy. The proposed device is aimed to substitute upper limb exoskeletons or end-effector robotic arm based rehabilitation systems, which are generally bulky, expensive due to customized design, and are used only in clinical settings. The device is capable of aiding patients perform rehabilitation exercises involving abduction, adduction, flexion, and extension movements for the wrist, shoulder joints and flexion, extension, pronation, supination for the elbow joint. The device has a mobile base and uses differential drive principles for movement. The device provides an end-effector plate having force-sensitive resistors (FSRs) on which the patient can rest their hand. The mobile base of the rehabilitation system enables it to aid for a greater range of movements when compared to other end-effector-based upper limb rehabilitation devices. Additionally, a camera is mounted on top of the 6-DoF robotic system to enable finger tracking from a remote system using the MediaPipe framework, and measure the hand instability metric over time to assess patient's performance. Clinical relevance - The 6-DoF rehabilitation system is capable of aiding different range of motions for upper limb. The low-cost generic system is applicable for different physical personalities, enabling quick adoption for large patient populations who are in need of rehabilitation systems. The 6-DoF system is aimed towards clinical, and domestic usage by patients.

Non-motorised Rehabilitation Device for Performance Assessment in Upper Limb Stroke Rehabilitation: A Pilot Study

Stroke patients with upper limb disability restricted to carry out their activities of daily living. The patient needs a motivation to recover from a stroke and the patient also needs to go through a rehabilitation process at the same time. The conventional rehabilitation process scoring systems are always subjective, lack reliability and relies heavily on the ability of the trained physiotherapist that providing only rough estimates on motor function. On the other hand, robot-based assessments are objective, repeatable, and could potentially reduce the assessment time. Therefore, a simple non-motorized device was developed as a tool to objectively assess hand function of stroke patients. This study was carried out to investigate the suitability of using thedeveloped device with stroke patient populations and to evaluate the performance of clinical scores prediction of the stroke patients. A total of five patients with upper limb disability following stroke consented to take part in this study. Twelve predictive variables were investigated, relating to the total movement time, velocity, strategy, accuracy, and smoothness from three robotic assessment modules which are Draw I, Draw Diamond and Draw Circle. The hardware for measuring elbow angle hasbeen developed to measurethe shoulder movement performedby patient during the assessment process. In addition to that, the shoulder movement calculation method has been proposed and validated.The findings indicatethat the performance of prediction for all assessment modules hasbeen increased after implementing the shoulder movement calculation. It is recommended this calculation method to be used in conjunction with kinematic variables to carry out the data acquisition process in the future for improvement of effectiveness and accuracy of the robotic assessment.

Task selection for a sensor-based, wearable, upper limb training device for stroke survivors: a multi-stage approach

Purpose Post-stroke survivors report that feedback helps to increase training motivation. A wearable system (M-MARK), comprising movement and muscle sensors and providing feedback when performing everyday tasks was developed. The objective reported here was to create an evidence-based set of upper-limb tasks for use with the system. Materials and methods Data from two focus groups with rehabilitation professionals, ten interviews with stroke survivors and a review of assessment tests were synthesized. In a two-stage process, suggested tasks were screened to exclude non-tasks and complex activities. Remaining tasks were screened for suitability and entered into a categorization matrix. Results Of 83 suggestions, eight non-tasks, and 42 complex activities were rejected. Of the remaining 33 tasks, 15 were rejected: five required fine motor control; eight were too complex to standardize; one because the role of hemiplegic hand was not defined and one involved water. The review of clinical assessment tests found no additional tasks. Eleven were ultimately selected for testing with M-Mark. Conclusions Using a task categorization matrix, a set of training tasks was systematically identified. There was strong agreement between data from the professionals, survivors and literature. The matrix populated by tasks has potential for wider use in upper-limb stroke rehabilitation. IMPLICATIONS FOR REHABILITATION Rehabilitation technologies that provide feedback on quantity and quality of movements can support independent home-based upper limb rehabilitation. Rehabilitation technology systems require a library of upper limb tasks at different levels for people with stroke and therapists to choose from. A user-defined and evidence-based set of upper limb tasks for use within a wearable sensor device system have been developed.

Sensorimotor Rhythm-Brain Computer Interface With Audio-Cue, Motor Observation and Multisensory Feedback for Upper-Limb Stroke Rehabilitation: A Controlled Study.

Several studies have shown the positive clinical effect of brain computer interface (BCI) training for stroke rehabilitation. This study investigated the efficacy of the sensorimotor rhythm (SMR)-based BCI with audio-cue, motor observation and multisensory feedback for post-stroke rehabilitation. Furthermore, we discussed the interaction between training intensity and training duration in BCI training. Twenty-four stroke patients with severe upper limb (UL) motor deficits were randomly assigned to two groups: 2-week SMR-BCI training combined with conventional treatment (BCI Group, BG, n = 12) and 2-week conventional treatment without SMR-BCI intervention (Control Group, CG, n = 12). Motor function was measured using clinical measurement scales, including Fugl-Meyer Assessment-Upper Extremities (FMA-UE; primary outcome measure), Wolf Motor Functional Test (WMFT), and Modified Barthel Index (MBI), at baseline (Week 0), post-intervention (Week 2), and follow-up week (Week 4). EEG data from patients allocated to the BG was recorded at Week 0 and Week 2 and quantified by mu suppression means event-related desynchronization (ERD) in mu rhythm (8–12 Hz). All functional assessment scores (FMA-UE, WMFT, and MBI) significantly improved at Week 2 for both groups (p < 0.05). The BG had significantly higher FMA-UE and WMFT improvement at Week 4 compared to the CG. The mu suppression of bilateral hemisphere both had a positive trend with the motor function scores at Week 2. This study proposes a new effective SMR-BCI system and demonstrates that the SMR-BCI training with audio-cue, motor observation and multisensory feedback, together with conventional therapy may promote long-lasting UL motor improvement.Clinical Trial Registration: [http://www.chictr.org.cn], identifier [ChiCTR2000041119].

The Paradigm Design of a Novel 2-class Unilateral Upper Limb Motor Imagery Tasks and its EEG Signal Classification.

Multitasking motor imagery (MI) of the unilateral upper limb is potentially more valuable in stroke rehabilitation than the current conventional MI in both hands. In this paper, a novel experimental paradigm was designed to imagine two motions of unilateral upper limb, which is hand gripping and releasing, and elbow reciprocating left and right. During this experiment, the electroencephalogram (EEG) signals were collected from 10 subjects. The time and frequency domains of the EEG signals were analyzed and visualized, indicating the presence of different Event-Related Desynchronization (ERD) or Event-Related Synchronization (ERS) for the two tasks. Then the two tasks were classified through three different EEG decoding methods, in which the optimized convolutional neural network (CNN) based on FBCNet achieved an average accuracy of 67.8%, obtaining a good recognition result. This work not only can advance the studies of MI decoding of unilateral upper limb, but also can provide a basis for better upper limb stroke rehabilitation in MI-BCI.

Insights Gained From Activity Monitors for Upper Limb Stroke Rehabilitation

<h3>Research Objectives</h3> To determine if measures derived from wrist-worn activity monitors can be used as a proxy for functional arm/hand behaviors of chronic stroke survivors. <h3>Design</h3> Cross-sectional study. <h3>Setting</h3> Laboratory. <h3>Participants</h3> Chronic stroke survivors (n=20; 7 females, age: 58.4 (SD=8.9) years with mild-severe arm motor impairments (Fugl-Meyer Assessment (FMA) score: 39.4 (17.3) [1]). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> The Chedoke Arm and Hand Activity Inventory-7 (CAHAI), the FMA and the Reaching Performance Scale (RPS) were administered. For the CAHAI, participants were outfitted with two wrist-worn activity monitors (MiGo, Flint Rehabilitation Devices) and video recorded. Each video was annotated to identify movements of each arm and time in active movements. For each arm, time in active movement, movement counts, and percentage of arm use were computed from the MiGo and compared to the video recording metrics [2-3]. <h3>Results</h3> Movement metrics derived from the MiGo were strongly related to metrics from the video annotations (active movement time: r2=0.946; movement counts: r2=0.893). Asymmetries in arm use for bimanual tasks were quantified as a ratio (paretic/total movements) and expressed as a percentage of paretic arm use: 28.6 (12.6)%; and time in active movement for the paretic arm: 37.5 (10.6)% (neurotypical symmetry ratio: ∼50% [4]). Altogether, the relationship between each of the three clinical measures and MiGo metrics (Movement count, Movement time) ranged from moderate to strong (r2=0.539-0.746). <h3>Conclusions</h3> Time in active movements may be a more intuitive outcome than movement count for stroke survivors, and a valid proxy for the more standard movement count metric. Perspectives from users would provide insight about the meaningfulness of each metric for future efforts to effect durable gains in paretic arm use in the natural environment [5]. <h3>Author(s) Disclosures</h3> JR is a full-time employee of Flint Rehabilitation Devices, LLC. DZ is a full-time employee and co-owner of Flint Rehabilitation Devices, LLC.

Robot-Assisted Therapy and Constraint-Induced Movement Therapy for Motor Recovery in Stroke: Results From a Randomized Clinical Trial.

Background: Stroke is one of the leading causes of adult disability, and up to 80% of stroke survivors undergo upper extremity motor dysfunction. Constraint-Induced Movement Therapy (CIMT) and Robot-Assisted Therapy (RT) are used for upper limb stroke rehabilitation. Although CIMT and RT are different techniques, both are beneficial; however, their results must be compared. The objective is to establish the difference between RT and CIMT after a rehabilitation program for chronic stroke patients.Method: This is a randomized clinical trial, registered at ClinicalTrials.gov (ID number NCT02700061), in which patients with stroke received sessions of RT or CIMT protocol, combined with a conventional rehabilitation program for 12 weeks. The primary outcome was measured by Wolf Motor Function Test (WMFT) and Fugl-Meyer Assessment—Upper Limb (FMA-UL). Activities of daily living were also assessed.Results: Fifty one patients with mild to moderate upper limb impairment were enrolled in this trial, 25 women and 26 men, mean age of 60,02 years old (SD 14,48), with 6 to 36 months after stroke onset. Function significantly improved regardless of the treatment group. However, no statistical difference was found between both groups as p-values of the median change of function measured by WMFT and FMA were 0.293 and 0.187, respectively.Conclusion: This study showed that Robotic Therapy (RT) was not different from Constraint-Induced Movement Therapy (CIMT) regardless of the analyzed variables. There was an overall upper limb function, motor recovery, functionality, and activities of daily living improvement regardless of the interventions. At last, the combination of both techniques should be considered in future studies.

Brain-Computer Interface Coupled to a Robotic Hand Orthosis for Stroke Patients' Neurorehabilitation: A Crossover Feasibility Study.

Brain-Computer Interfaces (BCI) coupled to robotic assistive devices have shown promise for the rehabilitation of stroke patients. However, little has been reported that compares the clinical and physiological effects of a BCI intervention for upper limb stroke rehabilitation with those of conventional therapy. This study assesses the feasibility of an intervention with a BCI based on electroencephalography (EEG) coupled to a robotic hand orthosis for upper limb stroke rehabilitation and compares its outcomes to conventional therapy. Seven subacute and three chronic stroke patients (M = 59.9 ± 12.8) with severe upper limb impairment were recruited in a crossover feasibility study to receive 1 month of BCI therapy and 1 month of conventional therapy in random order. The outcome measures were comprised of: Fugl-Meyer Assessment of the Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), motor evoked potentials elicited by transcranial magnetic stimulation (TMS), hand dynamometry, and EEG. Additionally, BCI performance and user experience were measured. All measurements were acquired before and after each intervention. FMA-UE and ARAT after BCI (23.1 ± 16; 8.4 ± 10) and after conventional therapy (21.9 ± 15; 8.7 ± 11) were significantly higher (p < 0.017) compared to baseline (17.5 ± 15; 4.3 ± 6) but were similar between therapies (p > 0.017). Via TMS, corticospinal tract integrity could be assessed in the affected hemisphere of three patients at baseline, in five after BCI, and four after conventional therapy. While no significant difference (p > 0.05) was found in patients’ affected hand strength, it was higher after the BCI therapy. EEG cortical activations were significantly higher over motor and non-motor regions after both therapies (p < 0.017). System performance increased across BCI sessions, from 54 (50, 70%) to 72% (56, 83%). Patients reported moderate mental workloads and excellent usability with the BCI. Outcome measurements implied that a BCI intervention using a robotic hand orthosis as feedback has the potential to elicit neuroplasticity-related mechanisms, similar to those observed during conventional therapy, even in a group of severely impaired stroke patients. Therefore, the proposed BCI system could be a suitable therapy option and will be further assessed in clinical trials.

Efficacy of Brain-Computer Interface and the Impact of Its Design Characteristics on Poststroke Upper-limb Rehabilitation: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Background. A number of recent randomized controlled trials reported the efficacy of brain–computer interface (BCI) for upper-limb stroke rehabilitation compared with other therapies. Despite the encouraging results reported, there is a significant variance in the reported outcomes. This paper aims to investigate the effectiveness of different BCI designs on poststroke upper-limb rehabilitation. Methods. The effect sizes of pooled and individual studies were assessed by computing Hedge’s g values with a 95% confidence interval. Subgroup analyses were also performed to examine the impact of different BCI designs on the treatment effect. Results. The study included 12 clinical trials involving 298 patients. The analysis showed that the BCI yielded significant superior short-term and long-term efficacy in improving the upper-limb motor function compared to the control therapies (Hedge’s g = 0.73 and 0.33, respectively). Based on our subgroup analyses, the BCI studies that used the intention of movement had a higher effect size compared to those used motor imagery (Hedge’s g = 1.21 and 0.55, respectively). The BCI studies using band power features had a significantly higher effect size than those using filter bank common spatial patterns features (Hedge’s g = 1.25 and − 0.23, respectively). Finally, the studies that used functional electrical stimulation as the BCI feedback had the highest effect size compared to other devices (Hedge’s g = 1.2). Conclusion. This meta-analysis confirmed the effectiveness of BCI for upper-limb rehabilitation. Our findings support the use of band power features, the intention of movement, and the functional electrical stimulation in future BCI designs for poststroke upper-limb rehabilitation.

User Specific Efficiency Parameters for Brain Computer Interface (BCI) based Upper Limb Stroke Rehabilitation System

Rehabilitation after stroke through conventional manner is not quite successful due to a number of patient related issues including lack of interest in lengthy exercises, cost of therapy and dependency on healthcare professionals. In addition, around 50% of stroke survivors worldwide belong to the low and middle income countries that are unable to afford expensive rehabilitation systems. Advancements in Brain Computer Interface (BCI) technology enabling the researchers to design and develop BCI based strokerehabilitation systems by exploiting neural plasticity. This is achieved via Electroencephalogram (EEG) based computer gaming rehabilitation exercises through Motor Imagery (MI) to achieve successful neural plasticity. However, current research is largelybased on expensive bio-signal amplifiers and processing hardware that are beyond the affordability of a large population of stroke patients living in low and middle-income countries. Moreover, the efficiency of BCI based stroke rehabilitation systems thatare generally considered as the accuracy of EEG signal classifications is not the only parameter to rate the efficiency.Since the requirements of BCI based rehabilitation therapy are highly subject specific, efficiency of such systems also depends on many user specific features related to cost and performance.This paper describes a research that proposes a number of parameters for cost and efficiency along with their weightage set by the domestic users to determine the overall efficiency of the system.Inputs from different groups of users were obtained that are classified as deserving class, middle class and rich class. Results indicated that the users of different groups are giving different weights to different performance and cost parameters. The overall efficiency requirements are therefore having different meanings for different classes of users

Affordable Robotics for Upper Limb Stroke Rehabilitation in Developing Countries: A Systematic Review

Stroke incidence is increasing more rapidly in Low- and Middle-Income Countries (LMICs) than in High-Income Countries (HICs), but LMICs are not well organized to provide adequate post-stroke rehabilitation because of physical, financial and personal barriers. The use of rehabilitation robotics can help bridge in healthcare disparities but they are available in LMICs in limited number due to their high cost and this limits the number of patients that can benefit from them. This article presents a literature review on the affordable robots for upper limb stroke rehabilitation that could be suitable in low-resources clinical settings with a focus on the different techniques implemented to reduce production costs. Different approaches can be carried out: i) developing end-effector and exoskeleton robots for the rehabilitation of proximal and distal joints respectively; ii) reducing the number of degrees of freedom of the robots at minimum (one or two) allowing the rehabilitation in a planar workspace; iii) avoiding the use of conventional materials that could make the robot bulky, expensive and difficult to transport. According to the mechanical properties required by the task, stell or metal alloys could be substituted for wood, aluminum, plastic, 3D-printed materials and by the adaptation of off-the-shelf elements.

Systematic review of guidelines to identify recommendations for upper limb robotic rehabilitation after stroke.

Upper limb motor impairment is one of the most frequent stroke consequences. Robot therapy may represent a valid option for upper limb stroke rehabilitation, but there are still gaps between research evidence and their use in clinical practice. The aim of this study was to determine the quality, scope, and consistency of guidelines clinical practice recommendations for upper limb robotic rehabilitation in stroke populations. We searched for guideline recommendations on stroke published between January 1st, 2010 and January 1st, 2020. Only the most recent guidelines for writing group were selected. Electronic databases (N.=4), guideline repertories and professional rehabilitation networks (N.=12) were searched. We systematically reviewed and assessed guidelines containing recommendation statements about upper limb robotic rehabilitation for adults with stroke (PROSPERO registration number: CRD42020173386). Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and textual syntheses were used to appraise and compare recommendations. From 1324 papers that were screened, eight eligible guidelines were identified from six different regions/countries. Half of the included guidelines focused on stroke management, the other half on stroke rehabilitation. Rehabilitation assisted by robotic devices is generally recommended to improve upper limb motor function and strength. The exact characteristics of patients who could benefit from this treatment as well as the correct timing to use it are not known. This systematic review has identified many opportunities to modernize and otherwise improve stroke patients' upper limb robotic therapy. Rehabilitation assisted by robot or electromechanical devices for stroke needs to be improved in clinical practice guidelines in particular in terms of applicability.

Electroencephalogram-based neurofeedback training in persons with stroke: A scoping review in occupational therapy.

Neurofeedback training targets the relevant brain response under minimal stress. It could be a promising approach for the treatment of patients with brain injury. This review aimed to examine the existing literature to confirm the effectiveness of applied electroencephalogram (EEG)-based neurofeedback training in the area of occupational therapy for upper limb stroke rehabilitation. All relevant literature published until July 1, 2020 in five prominent databases (PubMed, CINAHL, PsycINFO, MEDLINE Complete, and Web of Science) was reviewed, based on the five-step review framework proposed by Arksey and O'Malley. After a thorough review, a total of 14 studies were included in this review. Almost studies reported significant improvements as a result of EEG-based neurofeedback training, but this had not always account for the differences in effectiveness between groups. However, the results of these studies suggested that neurofeedback training was effective as compared to the traditional treatment and more effective in combination with EEG than that with simple equipment application. This review demonstrated the effectiveness of the combination of occupational therapy and EEG-based neurofeedback training. Most of these treatments are intended for inpatients, but they may be more effective for outpatients, especially if customized to their requirements. Also, such explorations to assess the suitability of the treatment for patient rehabilitation will help reduce barriers to effective interventions. An analysis of the opinions of participants and experts through satisfaction surveys will be helpful.