[ARTICLE] An Assist-as-Needed Controller for Passive, Assistant, Active, and Resistive Robot-Aided Rehabilitation Training of the Upper Extremity – Full Text

Abstract

Clinical studies have demonstrated that robot-involved therapy can effectively improve the rehabilitation training effect of motor ability and daily behavior ability of subjects with an upper limb motor dysfunction. This paper presents an impedance-based assist-as-needed controller that can be used in robot-aided rehabilitation training for subjects with an upper extremity dysfunction. Then, the controller is implemented on an end-effector upper extremity rehabilitation robot which could assist subjects in performing training with a spatial trajectory. The proposed controller enables subjects’ arms to have motion freedom by building a fault-tolerant region around the rehabilitation trajectory. Subjects could move their upper limb without any assistance within the fault-tolerant region while the robot would provide assistance according to the subjects’ functional ability when deviating from the fault-tolerant region. Besides, we also put forward the stiffness field around the fault-tolerant region to increase the robot’s assistance when subjects’ hand is moving outside the fault-tolerant region. A series of columnar rigid walls would be constructed in the controller according to the subjects’ functional ability, and the stiffness of the wall increases as the motion performance deteriorates. Furthermore, the controller contains five adjustable parameters. The controller would show different performances by adjusting these parameters and satisfy the requirement of robot-aided rehabilitation training at different rehabilitation stages such as passive, assistant, active, and resistant training. Finally, the controller was tested with an elderly female participant with different controller parameters, and experimental results verified the correctness of the controller and its potential ability to satisfy the training requirements at different rehabilitation stages. In the close future, the proposed controller in this work is planned to be applied on more subjects and also patients who have upper limb motor dysfunctions to demonstrate performance of the controller with different parameters.

1. Introduction

In recent years, the number of subjects with upper extremity motor dysfunctions caused by stroke, spinal cord injuries, and accidents has been dramatically increasing year by year [1], severely limiting their motor and activities of daily living (ADL) abilities. This not only brings physical inconvenience to the subjects but also brings financial and mental burden to their families. Research results have showed that compared with the traditional manual rehabilitation therapy, robot-aided rehabilitation training could carry out high-intensity repetitive and task-oriented training tasks [2], and clinical research studies have also shown that robot-aided rehabilitation therapy could effectively improve the rehabilitation effect on patients’ upper extremity motor abilities [3,4]. To satisfy the patient’s requirements at different rehabilitation stages, different types of upper limb rehabilitation robots have been developed, which can be divided into two categories [5]: the end-effector type [6,7] and the exoskeleton type [8,9]. Generally, exoskeleton type upper limb rehabilitation robots could implement rehabilitation training of a single joint; however, additional interactive forces and torques between the patient’s arm and the robot would occur [10]. Compared with the traditional rehabilitation training methods, the end-effector type upper limb rehabilitation robot has better superiority during upper limb rehabilitation training [11]. Clinical comparative trial results have also showed that compared with the exoskeleton upper limb rehabilitation robot, intervention with the end-effector rehabilitation robot was more effective in terms of the active participation of patients with mild and severe stroke [12].According to the Brunstorm theory, patients with an upper limb motor disorder in the early recovery stage experience difficulties in moving their arm, and therapists or robots are required to carry out repeated passive training. Therefore, a stiff position controller is required to be applied in such passive training. The rehabilitation effect of the passive training method would be not great with the recovery of the patient’s motor ability because the active participation of the patients will be ignored in those position controllers. For patients with partial motor control ability, robot intervention to a minimum extent could stimulate and promote the brain neuroplasticity of patients [13,14]. Studies have shown that task-oriented rehabilitation training is only effective when it is associated with task-oriented movements involving effort by the subject actively [15]. Therefore, a controller needs to be developed to provide necessary assistance or correction to complete rehabilitation training tasks according to the patient’s functional ability. Controllers with such characteristics are called assist-as-needed (AAN) controllers, also known as assistance or corrective controllers. At present, AAN controllers have been used in lower limb rehabilitation [16], finger rehabilitation [17], and upper limb rehabilitation [18] to stimulate the patient’s active participation during rehabilitation training. The results of a clinical trial proved that an upper limb rehabilitation robot with an AAN controller could provide intensive and repeated rehabilitation training and could also promote the active participation and motion performance of patients, promoting the motor recovery [19].Regarding robot-aided training with the AAN characteristic, impedance control is often applied to assist patients during robot-aided rehabilitation training tasks [20]—the schematic diagram is shown in Figure 1. Clinical studies on stroke patients [21,22] showed that rehabilitation robots with the impedance control strategy have a better effect on reducing the upper limb muscle strength and improving the motor function of patients than robot-assisted therapy that simply mimics traditional therapy [23,24,25]. Although the impedance control strategy allows a patient’s arm to deviate from the training trajectory, the patient’s spatial freedom is limited. Assistance from the robot is always given as a restoring force to assist the patients once they are deviating from the planned trajectory. Therefore, scholars have developed an impedance-based AAN strategy to increase the patient’s freedom, which can be mainly divided into two categories: the band-type controller and the window-type controller. The window-type controller defines a predetermined trajectory and a moving window that allows the patient’s arm to move freely. When the patient’s arm lies outside the moving window, the patient’s arm would be corrected into the moving window by the robot’s assistance force [26,27]. Another band-type controller is based on the fault-tolerant region (FTR), which constructs a fault-tolerant band that allows the patient to move freely by establishing the inner and outer boundary of the FTR. The patient’s spatial freedom is limited in the window-type AAN controller, while the band-type AAN controller allows the patient to have complete freedom and choose his/her own trajectory without being assisted by the robot. The patient’s arm has complete freedom when moving in the FTR, while the robot will apply an assistance force to assist the patient’s arm to finish the rehabilitation training task when deviating from FTR. Research studies have also been conducted to explore increasing the patient’s freedom. Ying et al. [28] first developed a rope-driven exoskeleton rehabilitation robot and then added a fault-tolerant area around the predetermined trajectory to increase the patient’s spatial freedom. Hamed et al. [29] validated the feasibility by adding a plane channel around the predetermined trajectory based on a two-link rehabilitation robot. Although the band-type AAN controller has shown positive results in clinical trials, its tendency or ‘‘slacking’’ for the patient to rely heavily on the assistance force has been recorded [30]. The robot will not apply any assistance or correction as long as the patient’s arm is moving within the FTR, which will greatly reduce the active participation of patients. A velocity curve could be added in the FTR which will build a virtual movement in the FTR. When the patient’s arm is stagnant or moving too slowly in the FTR, the controller will generate a moving wall to push the patient’s arm to catch up with the virtual movement to complete the training task and avoid the slacking.

Figure 1. The diagram scheme of the impedance control; the black curve is the desired trajectory, while the blue curve is the actual trajectory.

To better adjust the assistance force of the AAN controller, it is necessary to evaluate the patient’s real-time motor ability or functional ability. One can conclude that there are mainly two classifications for the evaluation of a patient’s functional ability based on the current literatures: the sensor-based [31,32] and model-based [33] evaluation techniques. Although there is more of a theoretical basis for the evaluation of upper limb motor ability for model-based methods, the modeling results are difficult to use to accurately evaluate the patient’s true motion intention, while sensor-based evaluation methods can more intuitively express the patient’s motion state. Some studies have already used the position deviation between the actual trajectory of a patient’s hands and the expected trajectory which was calculated to represent the functional ability of patients during rehabilitation training [34].[…]

Continue

[ARTICLE] Occupational therapy for adults with problems in activities of daily living after stroke – Full Text

Abstract

Background

A stroke occurs when the blood supply to part of the brain is cut off. Activities of daily living (ADL) are daily home‐based activities that people carry out to maintain health and well‐being. ADLs include the ability to: eat and drink unassisted, move, go to the toilet, carry out personal hygiene tasks, dress unassisted, and groom. Stroke causes impairment‐related functional limitations that may result in difficulties participating in ADLs independent of supervision, direction, or physical assistance.

For adults with stroke, the goal of occupational therapy is to improve their ability to carry out activities of daily living. Strategies used by occupational therapists include assessment, treatment, adaptive techniques, assistive technology, and environmental adaptations. This is an update of the Cochrane review first published in 2006.

Objectives

To assess the effects of occupational therapy interventions on the functional ability of adults with stroke in the domain of activities of daily living, compared with no intervention or standard care/practice.

Search methods

For this update, we searched the Cochrane Stroke Group Trials Register (last searched 30 January 2017), the Cochrane Controlled Trials Register (The Cochrane Library, January 2017), MEDLINE (1946 to 5 January 2017), Embase (1974 to 5 January 2017), CINAHL (1937 to January 2017), PsycINFO (1806 to 2 November 2016), AMED (1985 to 1 November 2016), and Web of Science (1900 to 6 January 2017). We also searched grey literature and clinical trials registers.

Selection criteria

We identified randomised controlled trials of an occupational therapy intervention (compared with no intervention or standard care/practice) where people with stroke practiced activities of daily living, or where performance in activities of daily living was the focus of the occupational therapy intervention.

Data collection and analysis

Two review authors independently selected trials, assessed risk of bias, and extracted data for prespecified outcomes. The primary outcomes were the proportion of participants who had deteriorated or were dependent in personal activities of daily living and performance in activities of daily living at the end of follow‐up.

Main results

We included nine studies with 994 participants in this update. Occupational therapy targeted towards activities of daily living after stroke increased performance scores (standardised mean difference (SMD) 0.17, 95% confidence interval (CI) 0.03 to 0.31, P = 0.02; 7 studies; 749 participants; low‐quality evidence) and reduced the risk of poor outcome (death, deterioration or dependency in personal activities of daily living) (odds ratio (OR) 0.71, 95% CI 0.52 to 0.96; P = 0.03; 5 studies; 771 participants; low‐quality evidence). We also found that those who received occupational therapy were more independent in extended activities of daily living (OR 0.22 (95% CI 0.07 to 0.37); P = 0.005; 5 studies; 665 participants; low‐quality evidence). Occupational therapy did not influence mortality (OR: 1.02 (95% CI 0.65 to 1.61); P = 0.93; 8 studies; 950 participants), or reduce the combined odds of death and institutionalisation (OR 0.89 (95% CI 0.60 to 1.32); P = 0.55; 4 studies; 671 participants), or death and dependency (OR 0.89 (95% CI 0.64 to 1.23); P = 0.47; 4 trials; 659 participants). Occupational therapy did not improve mood or distress scores (OR 0.08 (95% CI ‐0.09 to 0.26); P = 0.35; 4 studies; 519 participants; low‐quality evidence). There were insufficient data to determine the effects of occupational therapy on health‐related quality of life. We found no studies of consenting carers prior to study participation and therefore there were no carer‐related outcomes in our review. There were insufficient data to determine participants’ and carers’ satisfaction with services.

Using GRADE, the quality of evidence was low. The major limitation was the number of studies at unclear risk of selection bias and an inevitable high risk of performance and detection bias, as both participants and occupational therapists could not be blinded to the intervention. In addition, there was a sparseness of data for our outcomes of interest and we downgraded the quality of our evidence for these reasons.

Authors’ conclusions

We found low‐quality evidence that occupational therapy targeted towards activities of daily living after stroke can improve performance in activities of daily living and reduce the risk of deterioration in these abilities. Because the included studies had methodological flaws, this research does not provide a reliable indication of the likely effect of occupational therapy for adults with stroke.

Plain language summary

Occupational therapy for adults with problems in activities of daily living after stroke

Review question
What are the effects of occupational therapy for adults with stroke on activities of daily living?

Background
Different parts of the brain carry out different functions: seeing, sensation, balance, movement, understanding language, behaviour, problem solving, and emotion. A stroke occurs when the blood supply to part of the brain is cut off. If the blood supply is cut off to a part of the brain that carries out a particular function (such as seeing, moving arms and legs, or speaking), then these body parts or body functions will not work as they should.

Activities of daily living (ADLs) are daily household‐based activities that people carry out to maintain health and well‐being. ADLs include eating and drinking, moving about, going to the toilet, personal hygiene, dressing and undressing, and grooming. When stroke changes how body parts or functions work, then the ability to carry out ADLs can become affected.

For adults with stroke, the goal of occupational therapy is to improve ability to carry out ADLs. Strategies used by occupational therapists include activity‐based interventions, adaptive techniques, assistive technology, and environmental adaptations.

Study characteristics
We found nine studies up to January 2017, involving 994 participants, that looked at the benefits of occupational therapy interventions for adults with stroke who had problems with activities of daily living. This is an update of the Cochrane review first published in 2006.

Key result
We found that occupational therapy for people with stroke can improve their ability to carry out these daily activities and stop them deteriorating in those abilities. We found no evidence that occupational therapy reduced rates of death or the need to be cared for in an institution, or affected mood or distress of the participant. We did not collect data on carer‐related outcomes or participant satisfaction with the service.

Quality of the evidence
There were few studies measuring our outcomes of interest and we judged the quality of the evidence to be of low‐quality. Many of the studies did not report methods sufficiently clearly and it was not possible to mask the occupational therapy from the person giving or receiving the treatment; this could also have influenced the results in our studies. We did not have sufficient good‐quality evidence to be certain of our results and we cannot be certain that future studies will not change these conclusions.

Continue

[WEB SITE] Play Therapeutic Games with EDNA to Aid Stroke Rehab

A new touch-screen therapy tool could accelerate the recovery of patients who have experienced a stroke and change the way rehabilitation is delivered in hospitals and homes, RMIT University researchers suggest in a media release.

Designed for people with acquired brain injuries, EDNA is a digital rehabilitation software that delivers therapy through a series of fun and challenging therapeutic games via a touchscreen device.

Findings from a randomized clinical trial showed stroke patients who incorporated EDNA into their treatment programs experienced an improvement two to three times greater than those who received only conventional therapy, according to the release, from RMIT University.

The digital form of rehabilitation was intended to maintain patient engagement, improving compliance and recovery, says RMIT University lead researcher, Associate Professor Jonathan Duckworth.

“We designed EDNA so that patients could be doing therapy without it feeling like therapy,” he adds.

EDNA features a range of therapeutic games that involve tangible and graspable tools with augmented feedback, promoting brain plasticity to regain motor, cognitive and functional ability.

Performance data is then collected in the cloud, allowing therapists to remotely review the integrated data, monitor recovery and deliver tailored treatment programs.

While the results couldn’t yet be used to predict longer-term recovery, the findings were promising and showed the value of including EDNA as part of a therapy toolkit, Duckworth states.

“EDNA is the first upper-limb brain injury rehabilitation system to integrate clinic and home therapy to monitor recovery, so there’s great potential to transform the industry and improve outcomes for patients.”

The recent clinical trial, published in the Journal of NeuroEngineering and Rehabilitation, involved a specialized table-top touch screen.

A new study is now underway at Sydney’s Prince of Wales hospital using a portable version that allows for increased treatment frequency with independent therapy at home.

Principal investigator and neuropsychologist from the University of Sydney, Dr Jeff Rogers, shares in the release that the innovative technology had delivered benefits for stroke patients that had exceeded expectations.

“We’ve worked closely with patients in testing and designing EDNA to ensure it will actually be used and we’re really happy with the results,” he says.

Study co-author, Professor Peter Wilson from the Australian Catholic University, comments that a home-based therapeutic solution had the potential to reduce the number of weekly hospital visits and aligned with recent trends towards patient-centered rehabilitation.

“Patients can struggle to maintain therapy activities between sessions, so having a portable device to take home and use on their own could increase therapy uptake and speed up recovery,” he says.

[Source(s): RMIT University, MedicalXPRess]

 

via Play Therapeutic Games with EDNA to Aid Stroke Rehab – Rehab Managment

[ARTICLE] Assist-as-needed control strategy for upper-limb rehabilitation based on subject’s functional ability – Full Text

Abstract

The assist-as-needed technique in robotic rehabilitation is a popular technique that encourages patients’ active participation to promote motor recovery. It has been proven beneficial for patients with functional motor disability. However, its application in robotic therapy has been hindered by a poor estimation method of subjects’ functional or movement ability which is required for setting the appropriate robotic assistance. Moreover, there is also the need for consistency and repeatability of the functional ability estimation in line with the clinical procedure to facilitate a wider clinical adoption. In this study, we propose a new technique of estimation of subject’s functional ability based on the Wolf Motor Function Test. We called this estimation the functional ability index. The functional ability index enables the modulation of robotic assistance and gives a more consistent indication of subjects’ upper-limb movement ability during therapy session. Our baseline controller is an adaptive inertia-related controller, which is integrated with the functional ability index algorithm to provide movement assistance as when needed. Experimental studies are conducted on three hemiplegic patients with different levels of upper-limb impairments. Each patient is requested to perform reaching task of lifting a can from table-to-mouth according to the guidelines stipulated in the Wolf Motor Function Test. Data were collected using two inertial measurement unit sensors installed at the flexion/extension joints, and the functional ability score of each patient was rated by an experienced therapist. Results showed that the proposed functional ability index algorithm can estimate patients’ functional ability level consistently with clinical procedure and can modify generated robotic assistance in accordance with patients’ functional movement ability.

Introduction

The assist-as-needed (AAN) robotic strategy is a popular strategy for encouraging patients’ active participation in robot-assisted rehabilitation therapy. Numerous clinical outcomes have suggested the effectiveness of the AAN scheme to induce neuroplasticity in patients with neurological impairment.¹ The AAN strategy focuses on providing the minimal amount of robotic assistance necessary for a patient to complete a movement,² thus a significant effort is required from the patient. If the patient can perform the task flawlessly, robotic assistance is withdrawn. However, if the patient cannot complete the given task, assistance is offered only as much as it is needed.³

Deploying robotic assistance in accordance with the AAN strategy still come with many shortcomings.^3,4 One major issue is how to appropriately estimate patients’ functional ability to set the correct level of robotic assistance. Another issue is the consistency of the estimated subject’s functional ability with clinical data and the repeatability across a wide range of subjects. An appropriate estimation of subject’s functional ability consistent with clinical data can give a realistic basis for deploying robotic assistance, since it gives a measure of subject’s actual disability level or recovery progress.^5,6

A few strategies of AAN have been proposed recently which have attempted to address the challenges in the scheme. Wolbrecht et al.⁷ proposed a model-based robotic assistance strategy which can enable a robot to learn the patients’ ability in real time based on a radial-basis function (RBF). The RBF is applied under an adaptive control framework.

Another AAN strategy was proposed by Pehlivan et al.³ The authors introduced a minimal assist-as-needed (mAAN) strategy which uses a Kalman filter to estimate subjects’ functional inputs instead of the RBF technique that is a sensor-less force estimation strategy. Under the scheme, the ANN strategy is achieved in the following two ways: (1) by updating the derivative feedback gain to modify the bounds of allowable error on the desired trajectory and (2) by decaying a feed-forward disturbance rejection term which reduces the constraint on allowable quick movements. The combined effect could vary the robotic assistance according to the subjects’ capability.⁸ The potential limitation of this approach is the reliance on the robot model for the estimation of subject’s capability. It is well known that model errors always exist and can significantly excite the disturbance term making it difficult to accurately estimate the subject’s input. There is the implication that different robot models would produce different functional ability estimates which will hinder an appropriate standardization or deployment of robotic assistance for clinical purpose.^9,10

Pérez-Rodríguez et al.¹¹ also introduced an AAN strategy called anticipatory assistance-as-needed control algorithm capable of ensuring that the deviation from a patients’ desired trajectory is restored by giving an anticipated force assistance. This way, robotic assistance is always given as a restoring force to maintain the subject on the reference (desired) trajectory. With regards to the validity of this strategy, there are however no experimental studies till date.

Other noteworthy AAN strategies include the rule-based assistive strategy proposed by Wang et al.,¹² which is applied in Physiotherabot; the hybrid impedance control for wrist and forearm rehabilitation proposed by Akdoğan and Adli,¹³ which is applied on a 3-degree-of-freedom (3-DOF) upper-limb rehabilitation robot; and the visual error augmentation-based AAN proposed by Akdoğan et al.,¹⁴ which can provide robotic assistance as needed by amplifying tracking error to heighten the participant’s motivation.

Efforts in developing an appropriate estimation strategy for AAN robotic assistance are still on course;¹⁵ however, there has been less focus on developing appropriate estimation techniques of subject’s functional ability that are consistent with the clinical procedure and that can be integrated in the control loop to provide robotic assistance.^15,16

In this paper, we propose an ANN strategy to direct robotic assistance based on a novel functional ability index (FAI). The main originality of this work is the derivation of the new FAI estimation algorithm in accordance with the clinical procedure for the estimation of subject’s motor ability in movement task. As a preliminary investigation, we derive our FAI following the Wolf Motor Function Test (WMFT), a popular motor function test with consistency over a wide range of neurologically impaired patients. The FAI serves as input to a decay algorithm under the adaptive control law which consequently varies the robotic assistance according to the subject’s functional ability. The FAI is independent on the robot model or controller adaptation law and thus it is unaffected by modelling uncertainties.

The rest of the paper is organized as follows: section ‘System dynamic and control’ presents the dynamics for the robotic rehabilitation system, the proposed FAI, and the proposed control algorithm. Section ‘Experimental study’ presents the data collection and simulation study; section ‘Results’ describes the results; section ‘Discussion’ presents the discussion; and section ‘Conclusion’ concludes the paper.

System dynamic and control

The mechanical system

The proposed prototype of the exoskeleton system is shown in Figure 1. The system is an upper-limb rehabilitation robotic device with two active degrees of freedom (DOFs) at the shoulder and elbow joint, respectively. If actively controlled, the exoskeleton can permit abduction/adduction (AA) movement of the shoulder joint and flexion/extension (FE) movement of the elbow, thus allowing the possibility of performing the table to mouth reaching task.

Figure 1. Exoskeleton device is of 2 degrees of freedom (DOFs).

[…]

Continue —> Assist-as-needed control strategy for upper-limb rehabilitation based on subject’s functional ability – Shawgi Younis Ahmed Mounis, Norsinnira Zainul Azlan, Fatai Sado,

[A Systematic Review] The Clinical, Quality of Life and Economic Outcomes of Inpatient Rehabilitation – Full Text PDF

Abstract

Objective: To systematically review the clinical, functional and economic benefits of Inpatient Rehabilitation for the most common disorders of the nervous system: stroke, spinal cord injury, and multiple sclerosis.

Methodology: PubMed, Embase, Scopus, CEA Registry, and NHS EED databases were searched using combinations of three sets of keywords using various terms for rehabilitation, benefits, and treatments. The outcomes considered included measures of independence in activities of daily living (ADL), motor function, disability, handicap,
gait velocity, quality of life, and economics. Following the initial literature search, the abstracts and full texts of the identified studies were reviewed and assessed for inclusion by two independent researchers based on pre-determined criteria. The data of selected studies were extracted into a data extraction form and consequently were synthesized.

Results: Forty-six articles met the inclusion criteria. Particularly, 21 studies evaluated inpatient rehabilitation after (or following) stroke, 15 studies evaluated inpatient rehabilitation after SCI, and seven studies evaluated inpatient rehabilitation for MS patients. The remaining three studies referred to mixed patient population. The majority of studies indicated that inpatient rehabilitation can provide clinical and functional benefits for all patient groups under consideration. Moreover, economic evaluations indicate that rehabilitation may be cost saving or cost-effective in certain patient groups such as those with fractures and stroke.

Conclusion: The results of the present review demonstrate that inpatient rehabilitation may deliver significant health and economic benefits for patients suffering from stroke, spinal cord injury, or multiple sclerosis and for health systems. Further research is needed to improve the consistency and robustness of the available evidence.

Full Text PDF

 

[Abstract] Repetitive task training for improving functional ability after stroke – The Cochrane Library

Abstract

Background

Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.

Objectives

Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke.

Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of ‘dose’ of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention.

Search methods

We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016).

Selection criteria

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal.

Data collection and analysis

Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane ‘Risk of bias’ tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information.

Main results

We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated ‘moderate’ or ‘low’ when using the GRADE system.

There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419).

There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events.

Authors’ conclusions

There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.

Plain language summary

Repetitive task training for improving functional ability after stroke

Review question: What are the effects of repeated practice of functional tasks on recovery after stroke when compared with usual care or placebo treatments?

Background: Stroke can cause problems with movement, often down one side of the body. While some recovery is common over time, about one third of people have continuing problems. Repeated practice of functional tasks (e.g. lifting a cup) is a treatment approach used to help with recovery of movement after stroke. This approach is based on the simple idea that in order to improve our ability to perform tasks we need to practice doing that particular task numerous times, like when we first learned to write. The types of practice that people do, and the time that they spend practicing, may affect how well this treatment works. To explore this further we also looked at different aspects of repetitive practice that may influence how well it works.

Study characteristics: We identified 33 studies with 1853 participants. Studies included a wide range of tasks to practice, including lifting a ball, walking, standing up from sitting and circuit training with a different task at each station. The evidence is current to June 2016.

Key results: In comparison with usual care (standard physiotherapy) or placebo groups, people who practiced functional tasks showed small improvements in arm function, hand function, walking distance and measures of walking ability. Improvements in arm and leg function were maintained up to six months later. There was not enough evidence to be certain about the risk of adverse events, for example falls. Further research is needed to determine the best type of task practice, and whether more sustained practice could show better results.

Quality of the evidence: We classified the quality of the evidence as low for arm function, hand function and lower limb functional measures, and as moderate for walking distance and functional ambulation. The quality of the evidence for each outcome was limited due poor reporting of study details (particularly in earlier studies), inconsistent results across studies and small numbers of study participants in some comparisons.

Source: Repetitive task training for improving functional ability after stroke – French – 2016 – The Cochrane Library – Wiley Online Library

[Abstract] Caregiver-mediated exercises for improving outcomes after stroke (Cochrane review) [with consumer summary]

BACKGROUND: Stroke is a major cause of long-term disability in adults. Several systematic reviews have shown that a higher intensity of training can lead to better functional outcomes after stroke. Currently, the resources in inpatient settings are not always sufficient and innovative methods are necessary to meet these recommendations without increasing healthcare costs. A resource efficient method to augment intensity of training could be to involve caregivers in exercise training. A caregiver-mediated exercise programme has the potential to improve outcomes in terms of body function, activities, and participation in people with stroke. In addition, caregivers are more actively involved in the rehabilitation process, which may increase feelings of empowerment with reduced levels of caregiver burden and could facilitate the transition from rehabilitation facility (in hospital, rehabilitation centre, or nursing home) to home setting. As a consequence, length of stay might be reduced and early supported discharge could be enhanced.

OBJECTIVES: To determine if caregiver-mediated exercises (CME) improve functional ability and health-related quality of life in people with stroke, and to determine the effect on caregiver burden.

SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (October 2015), CENTRAL (the Cochrane Library, 2015, issue 10), Medline (1946 to October 2015), Embase (1980 to December 2015), CINAHL (1982 to December 2015), SPORTDiscus (1985 to December 2015), three additional databases (two in October 2015, one in December 2015), and six additional trial registers (October 2015). We also screened reference lists of relevant publications and contacted authors in the field.

SELECTION CRITERIA: Randomised controlled trials comparing CME to usual care, no intervention, or another intervention as long as it was not caregiver-mediated, aimed at improving motor function in people who have had a stroke.

DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials. One review author extracted data, and assessed quality and risk of bias, and a second review author cross-checked these data and assessed quality. We determined the quality of the evidence using GRADE. The small number of included studies limited the pre-planned analyses.

MAIN RESULTS: We included nine trials about CME, of which six trials with 333 patient-caregiver couples were included in the meta-analysis. The small number of studies, participants, and a variety of outcome measures rendered summarising and combining of data in meta-analysis difficult. In addition, in some studies, CME was the only intervention (CME-core), whereas in other studies, caregivers provided another, existing intervention, such as constraint-induced movement therapy. For trials in the latter category, it was difficult to separate the effects of CME from the effects of the other intervention. We found no significant effect of CME on basic ADL when pooling all trial data post intervention (4 studies; standardised mean difference (SMD) 0.21, 95% confidence interval (CI) -0.02 to 0.44; p = 0.07; moderate-quality evidence) or at follow-up (2 studies; mean difference (MD) 2.69, 95% CI -8.18 to 13.55; p = 0.63; low-quality evidence). In addition, we found no significant effects of CME on extended ADL at post intervention (two studies; SMD 0.07, 95% CI -0.21 to 0.35; p = 0.64; low-quality evidence) or at follow-up (2 studies; SMD 0.11, 95% CI -0.17 to 0.39; p = 0.45; low-quality evidence). Caregiver burden did not increase at the end of the intervention (2 studies; SMD -0.04, 95% CI -0.45 to 0.37; p = 0.86; moderate-quality evidence) or at follow-up (1 study; MD 0.60, 95% CI -0.71 to 1.91; p = 0.37; very low-quality evidence). At the end of intervention, CME significantly improved the secondary outcomes of standing balance (3 studies; SMD 0.53, 95% CI 0.19 to 0.87; p = 0.002; low-quality evidence) and quality of life (1 study; physical functioning MD 12.40, 95% CI 1.67 to 23.13; p = 0.02; mobility MD 18.20, 95% CI 7.54 to 28.86; p = 0.0008; general recovery MD 15.10, 95% CI 8.44 to 21.76; p < 0.00001; very low-quality evidence). At follow-up, we found a significant effect in favour of CME for Six-Minute Walking Test distance (1 study; MD 109.50 m, 95% CI 17.12 to 201.88; p = 0.02; very low-quality evidence). We also found a significant effect in favour of the control group at the end of intervention, regarding performance time on the Wolf Motor Function test (2 studies; MD -1.72, 95% CI -2.23 to -1.21; p < 0.00001; low-quality evidence). We found no significant effects for the other secondary outcomes (ie, patient: motor impairment, upper limb function, mood, fatigue, length of stay and adverse events; caregiver: mood and quality of life). In contrast to the primary analysis, sensitivity analysis of CME-core showed a significant effect of CME on basic ADL post intervention (2 studies; MD 9.45, 95% CI 2.11 to 16.78; p = 0.01; moderate-quality evidence). The methodological quality of the included trials and variability in interventions (eg, content, timing, and duration), affected the validity and generalisability of these observed results.

AUTHORS’ CONCLUSIONS: There is very low- to moderate-quality evidence that CME may be a valuable intervention to augment the pallet of therapeutic options for stroke rehabilitation. Included studies were small, heterogeneous, and some trials had an unclear or high risk of bias. Future high-quality research should determine whether CME interventions are (cost-)effective.

Full text (sometimes free) may be available at these link(s):      help

• DOI
• PubMed
• publisher

Source: PEDro – Search Detailed Search Results

[Abstract] Repetitive task training for improving functional ability after stroke – The Cochrane Library

First published: 14 November 2016

Abstract

Background

Repetitive task training (RTT) involves the active practice of task-specific motor activities and is a component of current therapy approaches in stroke rehabilitation.

Objectives

Primary objective: To determine if RTT improves upper limb function/reach and lower limb function/balance in adults after stroke.

Secondary objectives: 1) To determine the effect of RTT on secondary outcome measures including activities of daily living, global motor function, quality of life/health status and adverse events. 2) To determine the factors that could influence primary and secondary outcome measures, including the effect of ‘dose’ of task practice; type of task (whole therapy, mixed or single task); timing of the intervention and type of intervention.

Search methods

We searched the Cochrane Stroke Group Trials Register (4 March 2016); the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 5: 1 October 2006 to 24 June 2016); MEDLINE (1 October 2006 to 8 March 2016); Embase (1 October 2006 to 8 March 2016); CINAHL (2006 to 23 June 2016); AMED (2006 to 21 June 2016) and SPORTSDiscus (2006 to 21 June 2016).

Selection criteria

Randomised/quasi-randomised trials in adults after stroke, where the intervention was an active motor sequence performed repetitively within a single training session, aimed towards a clear functional goal.

Data collection and analysis

Two review authors independently screened abstracts, extracted data and appraised trials. We determined the quality of evidence within each study and outcome group using the Cochrane ‘Risk of bias’ tool and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) criteria. We did not assess follow-up outcome data using GRADE. We contacted trial authors for additional information.

Main results

We included 33 trials with 36 intervention-control pairs and 1853 participants. The risk of bias present in many studies was unclear due to poor reporting; the evidence has therefore been rated ‘moderate’ or ‘low’ when using the GRADE system.

There is low-quality evidence that RTT improves arm function (standardised mean difference (SMD) 0.25, 95% confidence interval (CI) 0.01 to 0.49; 11 studies, number of participants analysed = 749), hand function (SMD 0.25, 95% CI 0.00 to 0.51; eight studies, number of participants analysed = 619), and lower limb functional measures (SMD 0.29, 95% CI 0.10 to 0.48; five trials, number of participants analysed = 419).

There is moderate-quality evidence that RTT improves walking distance (mean difference (MD) 34.80, 95% CI 18.19 to 51.41; nine studies, number of participants analysed = 610) and functional ambulation (SMD 0.35, 95% CI 0.04 to 0.66; eight studies, number of participants analysed = 525). We found significant differences between groups for both upper-limb (SMD 0.92, 95% CI 0.58 to 1.26; three studies, number of participants analysed = 153) and lower-limb (SMD 0.34, 95% CI 0.16 to 0.52; eight studies, number of participants analysed = 471) outcomes up to six months post treatment but not after six months. Effects were not modified by intervention type, dosage of task practice or time since stroke for upper or lower limb. There was insufficient evidence to be certain about the risk of adverse events.

Authors’ conclusions

There is low- to moderate-quality evidence that RTT improves upper and lower limb function; improvements were sustained up to six months post treatment. Further research should focus on the type and amount of training, including ways of measuring the number of repetitions actually performed by participants. The definition of RTT will need revisiting prior to further updates of this review in order to ensure it remains clinically meaningful and distinguishable from other interventions.

Plain language summary

Repetitive task training for improving functional ability after stroke

Review question: What are the effects of repeated practice of functional tasks on recovery after stroke when compared with usual care or placebo treatments?

Background: Stroke can cause problems with movement, often down one side of the body. While some recovery is common over time, about one third of people have continuing problems. Repeated practice of functional tasks (e.g. lifting a cup) is a treatment approach used to help with recovery of movement after stroke. This approach is based on the simple idea that in order to improve our ability to perform tasks we need to practice doing that particular task numerous times, like when we first learned to write. The types of practice that people do, and the time that they spend practicing, may affect how well this treatment works. To explore this further we also looked at different aspects of repetitive practice that may influence how well it works.

Study characteristics: We identified 33 studies with 1853 participants. Studies included a wide range of tasks to practice, including lifting a ball, walking, standing up from sitting and circuit training with a different task at each station. The evidence is current to June 2016.

Key results: In comparison with usual care (standard physiotherapy) or placebo groups, people who practiced functional tasks showed small improvements in arm function, hand function, walking distance and measures of walking ability. Improvements in arm and leg function were maintained up to six months later. There was not enough evidence to be certain about the risk of adverse events, for example falls. Further research is needed to determine the best type of task practice, and whether more sustained practice could show better results.

Quality of the evidence: We classified the quality of the evidence as low for arm function, hand function and lower limb functional measures, and as moderate for walking distance and functional ambulation. The quality of the evidence for each outcome was limited due poor reporting of study details (particularly in earlier studies), inconsistent results across studies and small numbers of study participants in some comparisons.

Source: Repetitive task training for improving functional ability after stroke – French – 2016 – The Cochrane Library – Wiley Online Library