Review question/objective: The objective of this review is to synthesize the best available evidence on the effectiveness of robotic assistive devices in the rehabilitation of adult stroke patients for recovery of impairments in the upper and lower limbs. The secondary objective is to investigate the sustainability of treatment effects associated with use of robotic devices.
The specific review question to be addressed is: can robotic assistive devices help adult stroke patients regain motor movement of their upper and lower limbs?
Stroke is a leading cause of long-term disability and is the third most common cause of mortality in developed countries with 15 million people suffering a stroke yearly.1 Different parts of the brain control different bodily functions. If a person survives a stroke, the effects can vary, depending on the location of brain damage, severity and duration of the stroke. Broadly, the effects of stroke can be physical, cognitive or emotional in nature. In terms of the physical effects of stroke, the loss of motor abilities of the limbs presents significant challenges for patients, as their mobility and activities of daily living (ADLs) are affected. The upper or lower limbs can experience weakness (paresis) or paralysis (plegia), with the most common type of limb impairment being hemiparesis, which affects eight out of 10 stroke survivors.2 Other physical effects of stroke are loss of visual fields, vision perception, difficulty swallowing (dysphagia), apraxia of speech, incontinence, joint pain or neuropathic pain (caused by inability of the brain to correctly interpret sensory signals in response to stimuli on the affected limbs). Cognitive effects of stroke are aphasia, memory loss and vascular dementia. Stroke patients can lose the ability to understand speech or the capacity to read, think or reason, and normal mental tasks can present big challenges, affecting their quality of life. The drastic changes in physical and cognitive abilities caused by stroke also lead to emotional effects for stroke patients. Stroke survivors can experience depression when they encounter problems in doing tasks that they can easily do pre-stroke. Along with depression, they can experience a lack of motivation and mental fatigue.
For stroke patients, rehabilitation is the pathway to regaining or managing their impaired functions. There is no definite end to recovery but the most rapid improvement is within the first six months post stroke.3 Before a patient undergoes rehabilitation, an assessment is first done to determine if a patient is medically stable and fit for a rehabilitation program. If the patient is assessed to be suitable, then depending on the level of rehabilitative supervision required, the patient could undergo rehabilitation in various settings – as an in-patient/outpatient (at either a hospital or nursing facility) or at home.3,4Rehabilitation should be administered by a multi-disciplinary team of physiotherapists, occupational therapist, speech therapist and neuropsychologists, who work together to offer an integrated, holistic rehabilitation therapy.4 Depending on the type of impairment, rehabilitation specialists will assess the appropriate therapies needed and set realistic goals for patients to achieve. Generally, stroke patients should be given a minimum of 45 min for each therapy session over at least five days per week, as long as the patient can tolerate the rehabilitation regimen.3
One of the main goals in stroke rehabilitation is the restoration of motor skills, and this involves patients undergoing repetitive, high-intensity, task-specific exercises that enable them to regain their motor and functional abilities.5,6 It is theorized that the brain is plastic in nature and that repetitive exercises over long periods can enable the brain to adapt and regain the motor functionality that has been repeatedly stimulated.7This involves the formation of new neuronal interconnections that enable the re-transmission of motor signals.8