Posts Tagged hemiparesis

[Abstract] A Home-based Bilateral Rehabilitation System with sEMG-based Real-time Variable Stiffness


Bilateral rehabilitation allows patients with hemiparesis to exploit the cooperative capabilities of both arms to promote the recovery process. Although various approaches have been proposed to facilitate synchronized robot-assisted bilateral movements, few studies have focused on addressing the varying joint stiffness resulting from dynamic motions. This paper presents a novel bilateral rehabilitation system that implements a surface electromyography (sEMG)-based stiffness control to achieve real-time stiffness adjustment based on the user’s dynamic motion. An sEMG-driven musculoskeletal model that incorporates muscle activation and muscular contraction dynamics is developed to provide reference signals for the robot’s real-time stiffness control. Preliminary experiments were conducted to evaluate the system performance in tracking accuracy and comfortability, which showed the proposed rehabilitation system with sEMG-based real-time stiffness variation achieved fast adaption to the patient’s dynamic movement as well as improving the comfort in robot-assisted bilateral training.


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[Abstract] Restoring Activities of Daily Living Using an EEG/EOG-Controlled Semiautonomous and Mobile Whole-Arm Exoskeleton in Chronic Stroke


Stroke survivors with chronic paralysis often have difficulties to perform various activities of daily living (ADLs), such as preparing a meal or eating and drinking independently. Recently, it was shown that a brain/neural hand exoskeleton can restore hand and finger function, but many stroke survivors suffer from motor deficits affecting their whole upper limb.

Therefore, novel hybrid electroencephalography/electrooculography (EEG/EOG)-based brain/neural control paradigms were developed for guiding a whole-arm exoskeleton. It was unclear, however, whether hemiplegic stroke survivors are able to reliably use such brain/neural-controlled device.

Here, we tested feasibility, safety, and user-friendliness of EEG/EOG-based brain/neural robotic control across five hemiplegic stroke survivors engaging in a drinking task that consisted of several subtasks (e.g., reaching, grasping, manipulating, and drinking). Reliability was assumed when at least 75% of subtasks were initialized within 3 s. Fluent control was assumed if average “time to initialize” each subtask ranged below 3 s. System’s safety and user-friendliness were rated using Likert-scales.

All chronic stroke patients were able to operate the system reliably and fluently. No undesired side effects were reported. Four participants rated the system as very user-friendly. These results show that chronic stroke survivors are capable of using an EEG/EOG-controlled semiautonomous whole-arm exoskeleton restoring ADLs.


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[ARTICLE] Effect of mirror therapy on hand functions in Egyptian chronic stroke patients – Full Text



Most stroke survivors (more than 60%) suffer from persistent neurological impairments that significantly affect activities of daily living. Hand functions are essential for doing daily living and working activities. Mirror therapy is shown to be effective in improving hand functional recovery in stroke patients.


This study aimed to determine the effect of mirror therapy on improving hand functions in Egyptian chronic stroke patients.

Subjects and methods

Thirty chronic ischemic stroke patients from both sexes participated in the study. Their ages ranged from 45 to 65 years. They were randomly assigned into two equal groups: the study group that received a selected physical therapy program in addition to the mirror therapy and the control group that received the same selected physical therapy program but without a mirror therapy. Treatment sessions were conducted three times per week for 8 weeks. Range of motion (ROM) of the wrist extension and forearm supination, hand grip strength, and the time of Jebson Hand Function Test (JHFT) were measured before and after the treatment program.


There were statistically significant increases in the range of motion of the wrist extension and forearm supination and hand grip strength with a decrease in the time of Jebson Hand Function Test in both groups post-treatment. Post-treatment improvement was more significant in the study group compared to the control group.


Mirror therapy had a positive effect on improving hand motor functional skills in a sample of Egyptian chronic stroke patients.


Upper limb paresis is one of the most common and disabling consequences of stroke that significantly limits activity. It has been stated that 85% of stroke patients complain of hemiparesis and that 55 to 75% of them continue to have deficits in the upper extremity activities [1]. Approximately 30–66% of stroke patients never recover hand motor functional skills, which seriously impacts their performance of the activities of daily life [2].

Numerous rehabilitation techniques for stroke patients have been used to improve hand motor functional skills. These techniques include exercise training for the arm paresis [3], impairment-oriented training of the arm or Bobath therapy for severe arm paresis after stroke, functional electrical stimulation [4], robot-assisted rehabilitation [5], and bilateral arm training [6] constraint-induced movement therapy [78]. However, most of those rehabilitation techniques for the upper extremity paresis are intensive, involve high equipment costs, and require therapist’s manual interaction for a long time, which makes the administration of those treatments difficult for all patients [9].

Mirror therapy (MT) is a cheap, easy, and, most importantly, patient-directed treatment that may improve the recovery of hand motor functional skills [10,11,12,13]. MT consists of repeated bilateral, symmetrical movements in which the patient moves the affected body part as much as he/she could while observing the reflection of the same unaffected body part in a mirror placed in between those body parts while obscuring the affected part [14]. Researches of neural activities stated that MT might stimulate the areas within the somatosensory and premotor cortex and/or the mirror neuron system in the fronto-temporal region and superior temporal gyrus. This cortical stimulation might produce motor output in patients with stroke [1516].

This study was designed to assess the efficacy of mirror therapy on improving hand motor functions in a sample of Egyptian chronic stroke patients.[…]


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[ARTICLE] Automated functional electrical stimulation training system for upper-limb function recovery in poststroke patients – Full Text


• We developed an accelerometry system to detect the motion intention of poststroke patients for triggering FES.

• A visual game module was combined with this automated FES training system.

• This system can reduce variability in compound movements produced by poststroke patients and FES.

• An optimal threshold of triggering can defined for each patient for specific tasks.



This paper describes the design and test of an automated functional electrical stimulation (FES) system for poststroke rehabilitation training. The aim of automated FES is to synchronize electrically induced movements to assist residual movements of patients.


In the design of the FES system, an accelerometry module detected movement initiation and movement performed by post-stroke patients. The desired movement was displayed in visual game module. Synergy-based FES patterns were formulated using a normal pattern of muscle synergies from a healthy subject. Experiment 1 evaluated how different levels of trigger threshold or timing affected the variability of compound movements for forward reaching (FR) and lateral reaching (LR). Experiment 2 explored the effect of FES duration on compound movements.


Synchronizing FES-assisted movements with residual voluntary movements produced more consistent compound movements. Matching the duration of synergy-based FES to that of patients could assist slower movements of patients with reduced RMS errors.


Evidence indicated that synchronization and matching duration with residual voluntary movements of patients could improve the consistency of FES assisted movements. Automated FES training can reduce the burden of therapists to monitor the training process, which may encourage patients to complete the training.

1. Introduction

Hemiplegia is a common sequela experienced by stroke survivors; it leads to dysfunction in the upper and lower limbs. Various rehabilitation strategies have been adopted to help patients recover limb motor functions [1,2]. The methods of rehabilitation training currently adopted in clinic for poststroke patients are generally high-intensity, repetitive task-oriented paradigms that are practiced daily with outcome feedback [1]. Information on movement kinematics and muscle activation is often used to adjust the training strategy and to ensure that recovery progresses in the desired direction [3,4]. An inappropriate regimen in rehabilitation training may result in abnormal activation of muscles [4] and may lead to reduced effectiveness in motor functional recovery or even increased risk of muscle contracture and spasticity [5,6].

Functional electrical stimulation (FES) may potentially increase the effectiveness of rehabilitation training. It uses electrical stimulation to assist patients in producing physical movements [7] and to facilitate the training of patients’ voluntary muscle contraction [8]. Several studies have reported that FES improves the plasticity of the cerebral cortex and can be easily performed by therapists because it does not require extensive manual operations [9][10][11][12]. Evidence suggests that FES is a useful modality for rehabilitation training with explainable neural mechanisms.

Progress has been made in FES applications to aid the recovery of motor functions in patients poststroke [13], and novel technologies have been integrated into FES paradigms, including gaming [14] and intelligence applications [15][16][17]. However, even though many control strategies have been developed to generate electrical stimulation patterns, these control strategies have not been widely translated into routine clinical uses [18][19][20][21][22] due to the controller is too complex, or needs to be adjusted according to the patient’s condition. Notably, a recent development in neuromotor control theory focusing on the modular organization of multiple muscle activations has led to the formulation of synergy-based FES strategies [23][24][25]. This approach provides a feasible solution for multi-channel FES control using residual muscle activities from the patient [23,[25][26][27][28]]; and it leverages the idea that normal movement kinematics can be generated out of muscle synergies [23].

We have evaluated the synergy-based FES training paradigm in a short-term clinical intervention study. A five day of intervention using synergy-based FES was carried out in poststroke patients. The outcome of the short-term intervention was measured by changes in Fugl-Meyer scores and movement kinematics. Results of evaluations prior to and post intervention showed improvements in both Fugl-Meyer scores and movement kinematics [25]. In a subsequent analysis, synergy-based FES training demonstrated evidence in reorganizing neural circuits in the brain, which led to repairing of impaired muscle activation pattern towards the normal pattern [29].

In this study, we present a design and verification of an autotriggered FES system with a synergy-based stimulation strategy and used RMS errors to analyze the movement process of the patients for each trial by using acceleration. This automated FES training system is designed to continuously integrate with FES clinical protocol therapeutic intervention in stroke rehabilitation [30].

The automated FES training system with a gaming interface and accelerometer triggered generation of multiple channels of electrical stimulations to a group of targeted muscles. In this automated FES training system, we anticipated improved consistency of patient movements during rehabilitative training. If successful, the study will provide a training protocol that induces smaller RMS errors across movement trials.

2. Methods and materials

2.1. Design of the automated FES system

Fig. 1 presents a schematic of the components and experimental environment of the automated trigger FES system. The system was composed of a gaming device, an elbow cast including a radiofrequency identification (RFID) reader and an accelerometer, a multichannel FES system, and a computer. The software for the development of the training game (named Picking Apples) was created using Unity (version 2018.1.3f1, Unity Technologies Inc., CA, USA). For ease of operation, the RFID device and the Li-ion battery were mounted in the elbow cast. The RFID information and accelerometer data were transmitted wirelessly by Bluetooth (Fig. 1A).

Fig 1
Fig. 1. Illustration of the FES system. (A) The automated trigger FES system operation. (B) The experimental setup with the automated trigger FES system. The experiment was performed using the affected upper limb of the subject, which was fixed in a golden yellow plastic elbow cast. Stimulation electrodes were placed on the seven target muscles. A pair of electrodes (4 cm × 4  cm) was placed on each muscle: the red electrode represented the positive pole and the black the negative. The initial and target points are circles with a diameter of 2.5 cm.


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[ARTICLE] Contributions of Stepping Intensity and Variability to Mobility in Individuals Poststroke – Full Text


Background and Purpose—

The amount of task-specific stepping practice provided during rehabilitation poststroke can influence locomotor recovery and reflects one aspect of exercise dose that can affect the efficacy of specific interventions. Emerging data suggest that markedly increasing the intensity and variability of stepping practice may also be critical, although such strategies are discouraged during traditional rehabilitation. The goal of this study was to determine the individual and combined contributions of intensity and variability of stepping practice to improving walking speed and distance in individuals poststroke.


This phase 2, randomized, blinded assessor clinical trial was performed between May 2015 and November 2018. Individuals between 18 and 85 years old with hemiparesis poststroke of >6 months duration were recruited. Of the 152 individuals screened, 97 were randomly assigned to 1 of 3 training groups, with 90 completing >10 sessions. Interventions consisted of either high-intensity stepping (70%–80% heart rate reserve) of variable, difficult stepping tasks (high variable), high-intensity stepping performing only forward walking (high forward), and low-intensity stepping in variable contexts at 30% to 40% heart rate reserve (low variable). Participants received up to 30 sessions over 2 months, with testing at baseline, post-training, and a 3-month follow-up. Primary outcomes included walking speeds and timed distance, with secondary measures of dynamic balance, transfers, spatiotemporal kinematics, and metabolic measures.


All walking gains were significantly greater following either high-intensity group versus low-variable training (all P<0.001) with significant correlations with stepping amount and rate (r=0.48–60; P<0.01). Additional gains in spatiotemporal symmetry were observed with high-intensity training, and balance confidence increased only following high-variable training in individuals with severe impairments.


High-intensity stepping training resulted in greater improvements in walking ability and gait symmetry than low-intensity training in individuals with chronic stroke, with potential greater improvements in balance confidence.


The increasing incidence1 and current survival rates of individuals who experience a stroke have resulted in a substantial patient population with neurological deficits that limit locomotor capacity and postural stability.2,3 In individuals with chronic (>6 months) stroke, mobility limitations4,5 lead to reduced cardiopulmonary capacity that can further exacerbate locomotor deficits.3 Previous work6,7 suggests specific exercise training parameters, including the frequency, intensity, time, and type, can influence changes in health and fitness in individuals with and without neurological injury.8 These parameters represent the dose of exercise interventions, although their contributions to locomotor recovery poststroke are uncertain. Early studies advocated that large amounts of stepping practice with focus on normalizing gait patterns was a critical determinant of improved mobility.9–11 Unfortunately, a multicenter trial using this strategy revealed limited gains beyond conventional approaches.12 Additional research indicates treadmill exercise at submaximal aerobic intensities determined during baseline testing can improve walking endurance poststroke,13–15 although changes in walking speed or other mobility outcomes (balance or transfers) are inconsistent or negligible. The combined findings imply that these dosage parameters may not be critical to locomotor recovery poststroke.

An alternative hypothesis is that specific training variables can influence locomotor recovery when their manipulation substantially challenges the physiological demands associated with functional mobility. In particular, pilot studies indicate stepping training at cardiovascular intensities that are oftentimes greater than those achieved during baseline testing can improve multiple measures of locomotor and cardiopulmonary function.16–18 In addition, increasing the variability and difficulty of stepping tasks (eg, multidirectional walking, stair climbing, overground walking on uneven, or compliant surfaces) requires increased neuromuscular coordination and postural control that may improve mobility and dynamic stability.16,17,19

Despite these findings, clinical implementation of high-intensity stepping training in variable contexts is limited. Specific concerns include the potential for cardiovascular events,20 despite data indicating no additional risks compared to standard interventions.21 Additional concerns include practice of abnormal kinematic strategies, particularly in those with severe neuromuscular impairments during difficult, variable tasks. Such training deviates considerably from traditional interventions that focus on correcting abnormal gait patterns,9,10,12 although available data suggest gait kinematics can improve with variable stepping training.16,17,22

The present study examined the relative contributions of stepping intensity and variability on mobility outcomes in ambulatory individuals with chronic stroke. Using a randomized, controlled trial design, we hypothesized that high-intensity stepping training in variable contexts would result in greater gains in locomotor outcomes as compared to more traditional training focused on forward walking or low-intensity training of variable stepping tasks. Additional outcomes included alterations in transfers, dynamic balance and balance confidence, spatiotemporal kinematics, peak metabolic capacity, and potential adverse events. Results from this trial could indicate the potential utility of high-intensity training of variable, difficult tasks to improve mobility poststroke.[…]

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[Abstract + References] The effectiveness of extracorporeal shock wave therapy for improving upper limb spasticity and functionality in stroke patients: a systematic review and meta-analysis

To assess the effectiveness of Extracorporeal Shock Wave Therapy for reducing spasticity and improving functionality of the upper limb in stroke survivors.

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, PEDro, REHABDATA, Scielo, Scopus, Web of Science, Tripdatabase and Epistemonikos from 1980 to April 2020 was carried out.

The bibliography was screened to identify randomized controlled clinical trials that applied extracorporeal shock waves to upper limb spastic muscles in post-stroke individuals. Two reviewers independently screened references, selected relevant studies, extracted data and assessed risk of bias using the PEDro scale. The primary outcome was spasticity and functionality of the upper limb.

A total of 1,103 studies were identified and 16 randomized controlled trials were finally included (764 individuals) were analyzed. A meta-analysis was performed and a beneficial effect on spasticity was found. The mean difference (MD) on the Modified Ashworth Scale for comparison extracorporeal shock wave versus sham was −0.28; with a 95% confidence interval (CI) from −0.54 to −0.03. The MD of the comparison of extracorporeal shock wave plus conventional physiotherapy versus conventional physiotherapy was −1.78; 95% CI from −2.02 to −1.53. The MD for upper limb motor-function using the Fugl Meyer Assessment was 0.94; 95% CI from 0.42 to 1.47 in the short term and 0.97; 95% CI from 0.19 to 1.74 in the medium term.

The extracorporeal shock wave therapy is effective for reducing upper limb spasticity. Adding it to conventional therapy provides an additional benefit.

via The effectiveness of extracorporeal shock wave therapy for improving upper limb spasticity and functionality in stroke patients: a systematic review and meta-analysis – Rosa Cabanas-Valdés, Pol Serra-Llobet, Pere Ramón Rodriguez-Rubio, Carlos López-de–Celis, Mercé Llauró-Fores, Jordi Calvo-Sanz, 2020

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[Abstract + References] An intention-based online bilateral training system for upper limb motor rehabilitation


Bilateral rehabilitation training robotic systems have potential to promote the upper limb motor recovery of post-stroke hemiparesis patients through providing the synchronization motion between the impaired limb and contralateral limb. The active rehabilitation training based on patients’ intention can also promote the recovery effect by stimulating the activity of the ipsilateral hemisphere and contralateral hemisphere. In this paper, a novel intention-based bilateral training system using biomedical signals which represents the muscle activity information and active motion intention was proposed to promote the rehabilitation training effect. The proposed system can provide the synchronization motion to the impaired limb by the exoskeleton device according to the sEMG signals from the contralateral intact limb. A BPNN model using a novel multi-features input vector was employed for establishing the relationship between the sEMG signals and the motion intention. To verify the intention prediction performance, the comparison experiments involving both the offline phase and online phase were carried out using three different kinds of feature input vectors of sEMG. Furthermore, the real-time bilateral control experiments were conducted to verify the feasibility and effectiveness of the proposed bilateral rehabilitation system, in terms of motion synchronization tracking and the real-time characteristics.

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[ARTICLE] Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial – Full Text



Our group developed a rehabilitation robot to assist with repetitive, active reaching movement of a paretic upper extremity. The robot is equipped with a servo motor-controlled arm-weight support and works in conjunction with neuromuscular electrical stimulation and vibratory stimulation to facilitate agonist-muscle contraction. In this before-and-after pilot study, we assessed the feasibility of applying the robot to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.


We enrolled 6 patients with chronic stroke and hemiparesis who, while sitting and without assistance, could reach 10 cm both sagitally and vertically (from a starting position located 10 cm forward from the patient’s navel level) with the affected upper extremity. The patients were assigned to receive reaching exercise intervention with the robot (Yaskawa Electric Co., Ltd. Fukuoka, Japan) for 2 weeks at 15 min/day in addition to regular occupational therapy for 40 min/day. Outcomes assessed before and after 2 weeks of intervention included the upper extremity component of the Fugl-Meyer Assessment (UE-FMA), the Action Research Arm Test (ARAT), and, during reaching movement, kinematic analysis.


None of the patients experienced adverse events. The mean score of UE-FMA increased from 44.8 [SD 14.4] to 48.0 [SD 14.4] (p = 0.026, r = 0.91), and both the shoulder–elbow and wrist–hand scores increased after 2-week intervention. An increase was also observed in ARAT score, from mean 29.8 [SD 16.3] to 36.2 [SD 18.1] (p = 0.042, r = 0.83). Kinematic analysis during the reaching movement revealed a significant increase in active range of motion (AROM) at the elbow, and movement time tended to decrease. Furthermore, trajectory length for the wrist (“hand path”) and the acromion (“trunk compensatory movement”) showed a decreasing trend.


This robot-assisted modality is feasible and our preliminary findings suggest it improved motor control and motor function of the hemiparetic upper extremity in patients with chronic stroke. Training with this robot might induce greater AROM for the elbow and decrease compensatory trunk movement, thus contributing to movement efficacy and efficiency.


Stroke is a leading cause of death and disability. In 2017, the number of patients treated for stroke in Japan was 1,115,000, with 109,844 deaths [12]. Many survivors of stroke require nursing care to some extent; in fact, patients with stroke account for the largest percentage of claims under the Japanese Long-term Care Insurance System [3]. In a previous review, about 90% of patients with stroke had hemiparesis on admission, and less than 15% of them experienced complete motor recovery [4]. In stroke rehabilitation, some principles are well accepted: high-intensity, task-specific, goal-setting, and multidisciplinary-team care are needed to be effective [5]. Among these principles, “task-specific” might be controversial, because some theories of motor control suggest that, on the contrary, motor learning improves, and acquires greater generalizability, when a training program offers variability [67]. The appropriate approach probably depends on the aim of rehabilitation (which can be subject-dependent): for example, a reaching movement with the arm is frequently needed in activities of daily living.

Robotic rehabilitation is a novel intervention method, and several reviews have noted that it leads to improved muscle strength and motor control of the affected upper extremity [89]. A recent Cochrane review suggests that electromechanical and robot-assisted arm training might improve arm function, muscle strength of the upper extremity, and even activity of daily living after stroke [10]. Robotic devices can enable patients to perform task-specific, high-intensity rehabilitation due to increased repetition or amount of training.

At the same time, neuromuscular electrical stimulation (NMES) is widely employed as a rehabilitation technique. According to a previous study, NMES is effective at improving motor control and motor function of affected arms of patients with acute stroke [11], and the NMES system was more efficient when applied with a high-voltage pulsed current [12]. Although few studies have investigated untriggered NMES for the hemiparetic upper limb, continuous electrical stimulation with robotic training improved active range of motion and motor control [13], and we employed the NMES system without triggered electromyography (EMG) [14]. Continuous stimulation with NMES has been considered to be effective in facilitating contraction of paretic muscles [14]. Furthermore, the latest meta-analysis showed that electrical stimulation was effective for arm function and activity regardless of the stimulation type (NMES, EMG triggered, or sensory) [15].

Functional vibratory stimulation (FVS) is known to produce a favorable effect on spasticity, motor control, and gait after stroke [16]. Regarding hemiparetic upper extremities, previous studies have shown that focal vibration applied to paretic muscles is effective at decreasing spasticity with an amplitude of 91 Hz [17], and that it probably improves motor control with an amplitude of 120 Hz, especially in terms of smoothness of movement [18]. For the lower extremity, a previous study revealed that focal vibration improved gait by promoting contraction of the target muscle [19]. Moreover, not only did it promote contraction of the agonist muscle, low amplitude vibratory stimulation (80 Hz) also facilitated focused motorcortical activation [2021]. In addition, tendon or muscle vibration produces a tonic vibration reflex through both spinal and supraspinal pathways via repetitive activation of Ia afferent fibers [2223]. It is possible to artificially elicit the illusion of movement by vibrating the tendons or the muscles through the skin [24]; the illusion is probably mediated by the activation of muscle spindles [25]. This phenomenon indicates that vibration induces a strong proprioceptive feedback. On the other hand, it has been reported that the vastus lateralis muscle demonstrates a shift toward more appropriate muscle timing when vibration is applied during stance phase and transition to stance of the gait cycle in patients with spinal cord injury [26]. This indicates that strong sensory feedback from quadriceps vibration caused increased muscle excitation [26]. Thus, the combination of muscle vibration with NMES might help to recruit Ia afferent fibers and increase muscle force production. This phenomenon has already been demonstrated in healthy people in the plantar flexors [27]. To the best of our knowledge, however, the use of a robotic device equipped with electrical stimulation and vibration has not been reported.

Considering these facts, our group undertook to develop a rehabilitation robot to assist with repetitive, active reaching movement of the paretic upper extremity; patent acquisitions [28,29,30] and product development were accomplished with a medical–engineering collaboration within Kagoshima University and collaboration between industry (Yaskawa Electric Co., Ltd., Fukuoka, Japan) and academia (Kagoshima university). The robot is equipped with a servo motor-controlled arm-weight support via a wire—the system is programmed to assist the patient’s paretic arm to move between two switches (sensors) located at various three-dimensional positions, which provide a variety of reaching tasks—and works in conjunction with NMES and vibratory stimulation to facilitate agonist-muscle contraction, because the combination might strengthen proprioceptive feedback and tonic vibration reflex. Indeed, this device was applicable and beneficial for a patient with incomplete spinal cord injury [31]. In the before-and-after pilot study reported here, we assessed the feasibility of our novel approach of applying the robot equipped with electrical stimulation and vibration to improve motor control and function of the hemiparetic upper extremity in patients who suffered chronic stroke.[…]

Continue —-> Reaching exercise for chronic paretic upper extremity after stroke using a novel rehabilitation robot with arm-weight support and concomitant electrical stimulation and vibration: before-and-after feasibility trial | SpringerLink

Fig. 5

Fig.5 Setting for training with the robot. A wire (a) connecting the device to the forearm cuff adjusts the amount of arm-weight support. The patient repeats a reaching movement from the start button (b) to the target button (c), accompanied with the arm-weight support, electrical stimulation (d), and vibratory stimulation (e). Two video cameras (f) on the upper frame of the device record the reaching movement for kinematic analysis

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[Abstract] The effectiveness of extracorporeal shock wave therapy to reduce lower limb spasticity in stroke patients: a systematic review and meta-analysis

Objective: To assess the effectiveness of Extracorporeal Shock Wave Therapy (ESWT) to reduce lower limb spasticity in adult stroke survivors.

Data Sources: A systematic review of Medline/Pubmed, CENTRAL, CINAHL, PEDro database, REHABDATA, Scielo, Scopus, Web of Science, Trip Database, and Epistemonikos from 1980 to December 2018 was carried out.

Review Methods: The bibliography was screened to identify clinical trials (controlled and before-after) that used ESWT to reduce spasticity in stroke survivors. Two reviewers independently screened references, selected relevant studies, extracted data, and assessed risk of bias by PEDro scale. The primary outcome was spasticity.

Results: A total of 12 studies (278 participants) were included (5 randomized controlled trials, 1 controlled trial, and 6 before-after studies). A meta-analysis was performed by randomized controlled trials. A beneficial effect on spasticity was found. The mean difference (MD) was 0.58; 95% confidence interval (CI) 0.30 to 0.86 and also in subgroup analysis (short, medium, and long term). The MD for range of motion was 1.81; CI −0.20 to 3.82 and for lower limb function the standard mean difference (SMD) was 0.34; 95% CI −0.09 to 0.77. Sensitivity analysis demonstrated a better beneficial effect for myotendinous junction. MD was 1.5; 95% CI −2.44 to 5.44 at long-term (9 weeks).

Conclusion: The ESWT (radial/focused) would be a good non-invasive rehabilitation strategy in chronic stroke survivors to reduce lower limb spasticity, increase ankle range of motion, and improve lower limb function. It does not show any adverse events and it is a safe and effective method.

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[REVIEW ARTICLE ] Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach – Full Text

Robot-mediated therapy is an innovative form of rehabilitation that enables highly repetitive, intensive, adaptive, and quantifiable physical training. It has been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis. Multiple studies collated in a growing number of review articles showed the positive effects on motor impairment, less clearly on functional limitations. After describing the current status of robotic therapy after upper limb paresis due to stroke, this overview addresses basic principles related to robotic therapy applied to upper limb paresis. We demonstrate how this innovation is an evidence-based approach in that it meets both the improved clinical and more fundamental knowledge-base about regaining effective motor function after stroke and the need of more objective, flexible and controlled therapeutic paradigms.


Robot-mediated rehabilitation is an innovative exercise-based therapy using robotic devices that enable the implementation of highly repetitive, intensive, adaptive, and quantifiable physical training. Since the first clinical studies with the MIT-Manus robot (1), robotic applications have been increasingly used to restore loss of motor function, mainly in stroke survivors suffering from an upper limb paresis but also in cerebral palsy (2), multiple sclerosis (3), spinal cord injury (4), and other disease types. Thus, multiple studies suggested that robot-assisted training, integrated into a multidisciplinary program, resulted in an additional reduction of motor impairments in comparison to usual care alone in different stages of stroke recovery: namely, acute (57), subacute (18), and chronic phases after the stroke onset (911). Typically, patients engaged in the robotic therapy showed an impairment reduction of 5 points or more in the Fugl-Meyer assessment as compared to usual care. Of notice, rehabilitation studies conducted during the chronic stroke phase suggest that a 5-point differential represents the minimum clinically important difference (MCID), i.e., the magnitude of change that is necessary to produce real-world benefits for patients (12). These results were collated in multiple review articles and meta-analyses (1317). In contrast, the advantage of robotic training over usual care in terms of functional benefit is less clear, but there are recent results that suggest how best to organize training to achieve superior results in terms of both impairment and function (18). Indeed, the use of the robotic tool has allowed us the parse and study the ingredients that should form an efficacious and efficient rehabilitation program. The aim of this paper is to provide a general overview of the current state of robotic training in upper limb rehabilitation after stroke, to analyze the rationale behind its use, and to discuss our working model on how to more effectively employ robotics to promote motor recovery after stroke.

Upper Extremity Robotic Therapy: Current Status

Robotic systems used in the field of neurorehabilitation can be organized under two basic categories: exoskeleton and end-effector type robots. Exoskeleton robotic systems allow us to accurately determine the kinematic configuration of human joints, while end-effector type robots exert forces only in the most distal part of the affected limb. A growing number of commercial robotic devices have been developed employing either configuration. Examples of exoskeleton type include the Armeo®Spring, Armeo®Power, and Myomo® and of end-effector type include the InMotion™, Burt®, Kinarm™ and REAplan®. Both categories enable the implementation of intensive training and there are many other devices in different stages of development or commercialization (1920).

The last decade has seen an exponential growth in both the number of devices as well as clinical trials. The results coalesced in a set of systematic reviews, meta-analyses (1317) and guidelines such as those published by the American Heart Association and the Veterans Administration (AHA and VA) (21). There is a clear consensus that upper limb therapy using robotic devices over 30–60-min sessions, is safe despite the larger number of movement repetitions (14).

This technic is feasible and showed a high rate of eligibility; in the VA ROBOTICS (911) study, nearly two thirds of interviewed stroke survivors were enrolled in the study. As a comparison the EXCITE cohort of constraint-induced movement therapy enrolled only 6% of the screened patients participated (22). On that issue, it is relevant to notice the admission criteria of both chronic stroke studies. ROBOTICS enrolled subjects with Fugl-Meyer assessment (FMA) of 38 or lower (out of 66) while EXCITE typically enrolled subjects with an FMA of 42 or higher. Duret and colleagues demonstrated that the target population, based on motor impairments, seems to be broader in the robotic intervention which includes patients with severe motor impairments, a group that typically has not seen much benefit from usual care (23). Indeed, Duret found that more severely impaired patients benefited more from robot-assisted training and that co-factors such as age, aphasia, and neglect had no impact on the amount of repetitive movements performed and were not contraindicated. Furthermore, all patients enrolled in robotic training were satisfied with the intervention. This result is consistent with the literature (24).

The main outcome result is that robotic therapy led to significantly more improvement in impairment as compared to conventional usual care, but only slightly more on motor function of the limb segments targeted by the robotic device (16). For example, Bertani et al. (15) and Zhang et al. (17) found that robotic training was more effective in reducing motor impairment than conventional usual care therapy in patients with chronic stroke, and further meta-analyses suggested that using robotic therapy as an adjunct to conventional usual care treatment is more effective than robotic training alone (1317). Other examples of disproven beliefs: many rehabilitation professionals mistakenly expected significant increase of muscle hyperactivity and shoulder pain due to the intensive training. Most studies showed just the opposite, i.e., that intensive robotic training was associated with tone reduction as compared to the usual care groups (92526). These results are shattering the resistance to the widespread adoption of robotic therapy as a therapeutic modality post-stroke.

That said, not all is rosy. Superior changes in functional outcomes were more controversial until the very last years as most studies and reviews concluded that robotic therapy did not improve activities of daily living beyond traditional care. One first step was reached in 2015 with Mehrholz et al. (14), who found that robotic therapy can provide more functional benefits when compared to other interventions however with a quality of evidence low to very low. 2018 may have seen a decisive step in favor of robotic as the latest meta-analysis conducted by Mehrholz et al. (27) concluded that robot-assisted arm training may improve activities of daily living in the acute phase after stroke with a high quality of evidence However, the results must be interpreted with caution because of the high variability in trial designs as evidenced by the multicenter study (28) in which robotic rehabilitation using the Armeo®Spring, a non-motorized device, was compared to self-management with negative results on motor impairments and potential functional benefits in the robotic group.

The Robot Assisted Training for the Upper Limb after Stroke (RATULS) study (29) might clarify things and put everyone in agreement on the topic. Of notice, RATULS goes beyond the Veterans Administration ROBOTICS with chronic stroke or the French REM_AVC study with subacute stroke. RATULS included 770 stroke patients and covered all stroke phases, from acute to chronic, and it included a positive meaningful control in addition to usual care.[…]


Continue —-> Frontiers | Robot-Assisted Therapy in Upper Extremity Hemiparesis: Overview of an Evidence-Based Approach | Neurology

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