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 (5–7), subacute (1, 8), and chronic phases after the stroke onset (9–11). 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 (13–17). 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 (19, 20).
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 (13–17) 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 (9, 11) 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 (13–17). 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 (9, 25, 26). 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.[…]
Stroke remains a leading cause of long-term disability in the United States. While significant medical advances have led to decreased stroke mortality rates, incidence of stroke has remained roughly the same. This has resulted in an increased number of stroke survivors living with upper extremity (UE) hemiparesis requiring occupational therapy (OT). Despite a significant increase in the number of stroke rehabilitation trials over the past decade, a recent systematic review and meta-analysis found insufficient evidence that any experimental interventions were superior to conventional rehabilitation for improving UE motor function post-stroke. While it may be true that novel interventions are no more effective than conventional rehabilitation, an equally probable reason is the large disparities in dosage, frequency, and interventions used across control groups in clinical trials.
In the stroke rehabilitation literature, control interventions are often referred to as standard care or conventional rehabilitation. Concerningly, the majority of stroke rehabilitation trials lack an empirically based rationale for how control interventions are comparable to standard care rehabilitation. Inadequate descriptions of, and rationales for, control interventions across stroke rehabilitation trials are significant barriers to the advancement of evidence-based practice. Without a true understanding of `standard care’ in real-world practice, there is no way to know if the control intervention is truly comparable. There is an urgent need to characterize `standard care’ rehabilitation to inform control intervention development and improve interpretability of clinical trial results. The purpose of this study was to investigate current practices of occupational therapy practitioners in outpatient rehabilitation settings to address upper extremity hemiparesis in adult stroke survivors.
In Chapter 2, a cross-sectional e-mail survey was sent to OT practitioners across the United States to determine current practice patterns of therapists working in outpatient stroke rehabilitation nationwide. The results of this study (n=269) revealed that stretching, bilateral upper extremity training, strength training, weightbearing, manual therapy and task-oriented training were used by more than 85% of OT practitioners in our sample. Poor patient compliance (84%), medical complexity (64%), and spasticity (63%) were the most commonly reported barriers to patients meeting their OT goals in outpatient rehabilitation.
Chapters 3 and 4 present the results of a video-based observational study of outpatient OT sessions at an academic medical center. The Rehabilitation Treatment Specification System (RTSS) was used to analyze 30 OT treatment sessions. The average total session time was 52 ± 4.7 minutes with 36.2 ± 7.4 minutes of active time and 15.8 ± 7.1 minutes of inactive time per session. Interventions in the RTSS categories of `Skills and Habits’ (e.g., task-oriented activities) and `Organ Function’ (e.g., stretching, weightbearing) were used in the majority of OT sessions with `Skills and Habits’ activities accounting for 59% of active time and `Organ Function’ activities accounting for 35% of active time. After removing outliers, an average of 150.2 ± 85.2 UE repetitions occurred per session. Functional electrical stimulation (FES) was commonly used as an adjuvant to task-oriented activities and knowledge of performance was provided often during treatment.
Taken together, these results suggest that task-oriented training is commonly used by OT practitioners to address UE hemiparesis and musculoskeletal interventions are often used to mitigate spasticity in preparation for task-oriented activities. Future research will include video observation and analysis of OT practice sessions across multiple practice settings, as well as analyzing our remaining survey data across multiple practice settings (e.g., inpatient rehabilitation, skilled nursing facilities) to describe similarities and differences with the current findings.
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[Purpose] Recent studies have reported the effectiveness of robotic rehabilitation of paralyzed upper limbs in stroke patients. For example, the Single-Joint Hybrid Assistive Limb has been shown to improve upper limb impairments. However, limited data are available on the effectiveness of robotic rehabilitation of the upper limb with regards to daily living. In this case study, an accelerometer was adopted to examine whether rehabilitation using the Single-Joint Hybrid Assistive Limb improved upper limb activity during daily living in a stroke patient.
[Participant and Methods] The participant was a 69-year-old male diagnosed with stroke and left hemiparesis. The Single-Joint Hybrid Assistive Limb was applied to the participant’s elbow on the paralyzed side. The participant wore an accelerometer on each wrist to measure the activities of the upper limbs. Clinical tests of the paralyzed upper limb were also performed.
[Results] The activity of the paralytic limb was significantly higher after Single-Joint Hybrid Assistive Limb intervention than before the intervention. On the other hand, none of the results of the clinical tests changed beyond a clinically important difference.
[Conclusion] The Single-Joint Hybrid Assistive Limb could be useful for promoting active use of a paralyzed upper limb in daily living. In addition, an accelerometer could be especially useful for evaluating the effects of robotic rehabilitation.
Hemiparesis is a sequela that can substantially influence the lives of patients with stroke. For these patients, exercise therapy can improve not only the impairment but also the patients’ daily activities and quality of life1, 2). Recent studies have reported the effectiveness of robotic rehabilitation of paralyzed upper limbs in patients with stroke37). For example, Saita et al. demonstrated that the Single-Joint Hybrid Assistive Limb (HAL-SJ; HAL-FS01, CYBERDYNE, Inc., Tsukuba, Japan) improved upper limb impairment in stroke patients7) . However, these studies evaluated the upper limb function in a testing situation, such as by using Fugl-Meyer assessment or the Action Research Arm Test. Few data are available about the effectiveness of robotic rehabilitation for the upper limb for activities of daily living.
Recently, some studies reported that an accelerometer provides an effective method for assessing arm activity in daily living for patients with stroke8) . Thus, accelerometer may be useful for evaluating the effectiveness of robotic rehabilitation for daily activities. In this case study, accelerometer was used to examine whether robotic rehabilitation using the HAL-SJ improved upper limb activity in daily living in a patient with stroke.
Background. High-intensity repetitive training is challenging to provide poststroke. Robotic approaches can facilitate such training by unweighting the limb and/or by improving trajectory control, but the extent to which these types of assistance are necessary is not known.
Objective. The purpose of this study was to examine the extent to which robotic path assistance and/or weight support facilitate repetitive 3D movements in high functioning and low functioning subjects with poststroke arm motor impairment relative to healthy controls.
Methods. Seven healthy controls and 18 subjects with chronic poststroke right-sided hemiparesis performed 300 repetitions of a 3D circle-drawing task using a 3D Cable-driven Arm Exoskeleton (CAREX) robot. Subjects performed 100 repetitions each with path assistance alone, weight support alone, and path assistance plus weight support in a random order over a single session. Kinematic data from the task were used to compute the normalized error and speed as well as the speed-error relationship.
Results. Low functioning stroke subjects (Fugl-Meyer Scale score = 16.6 ± 6.5) showed the lowest error with path assistance plus weight support, whereas high functioning stroke subjects (Fugl-Meyer Scale score = 59.6 ± 6.8) moved faster with path assistance alone. When both speed and error were considered together, low functioning subjects significantly reduced their error and increased their speed but showed no difference across the robotic conditions.
Conclusions. Robotic assistance can facilitate repetitive task performance in individuals with severe arm motor impairment, but path assistance provides little advantage over weight support alone. Future studies focusing on antigravity arm movement control are warranted poststroke.
Purpose: For stroke survivors, abnormal gait patterns lead to a significant risk of falls. We have recently developed an IoT-based Upper and Lower Extremity Rehabilitation Medical Device (RoBoGat) that enables continuous passive motion (CPM) training, squat training (ST), and gait training (GT). The purpose of this study was to test the effectiveness of RoBoGat on gait in a chronic stroke survivor.
Methods: In this study, an individual with right-side chronic hemiparesis post-stroke participated. The participant underwent 14 days of RoBoGat training that involved continuous passive motion training, squat training, and gait training. During the training, knee and hip joint angles were adjusted within the range where the subject felt no pain. We assessed gait, timed up and go test, and visual analog scale at baseline and after first and final interventions.
Results: After the intervention, positive changes were observed such as stride, gait velocity, and loading phase. Improvements were also observed in timed up and go tests. However, there was no significant change in VAS, which assessed pain in training and daily life.
Conclusion: The main finding of this case-control study is that robot-based upper and lower extremity training may be a feasible approach in the neurorehabilitation field. It can be concluded that repetitive and continuous robot rehabilitation exercises have a positive effect on improving the physical function of chronic stroke survivors.
Background. Severe poststroke arm impairment is associated with greater activation of the nonlesioned hemisphere during movement of the affected arm. The circumstances under which this activation may be adaptive or maladaptive remain unclear.
Objective. To identify the functional relevance of key lesioned and nonlesioned hemisphere motor areas to reaching performance in patients with mild versus severe arm impairment.
Methods. A total of 20 participants with chronic stroke performed a reaching response time task with their affected arm. During the reaction time period, a transient magnetic stimulus was applied over the primary (M1) or dorsal premotor cortex (PMd) of either hemisphere, and the effect of the perturbation on movement time (MT) was calculated.
Results. For perturbation of the nonlesioned hemisphere, there was a significant interaction effect of Site of perturbation (PMd vs M1) by Group (mild vs severe; P < .001). Perturbation of PMd had a greater effect on MT in the severe versus the mild group. This effect was not observed with perturbation of M1. For perturbation of the lesioned hemisphere, there was a main effect of site of perturbation (P < .05), with perturbation of M1 having a greater effect on MT than PMd.
Conclusions. These results demonstrate that, in the context of reaching movements, the role of the nonlesioned hemisphere depends on both impairment severity and the specific site that is targeted. A deeper understanding of these individual-, task-, and site-specific factors is essential for advancing the potential usefulness of neuromodulation to enhance poststroke motor recovery.
Constraint-induced movement therapy (CI therapy) produces, on average, large and clinically meaningful improvements in the daily use of a more affected upper extremity in individuals with hemiparesis. However, individual responses vary widely.
The study objective was to investigate the extent to which individual characteristics before treatment predict improved use of the more affected arm following CI therapy.
This study was a retrospective analysis of 47 people who had chronic (> 6 months) mild to moderate upper extremity hemiparesis and were consecutively enrolled in 2 CI therapy randomized controlled trials.
An enhanced probabilistic neural network model predicted whether individuals showed a low, medium, or high response to CI therapy, as measured with the Motor Activity Log, on the basis of the following baseline assessments: Wolf Motor Function Test, Semmes-Weinstein Monofilament Test of touch threshold, Motor Activity Log, and Montreal Cognitive Assessment. Then, a neural dynamic classification algorithm was applied to improve prognostic accuracy using the most accurate combination obtained in the previous step.
Motor ability and tactile sense predicted improvement in arm use for daily activities following intensive upper extremity rehabilitation with an accuracy of nearly 100%. Complex patterns of interaction among these predictors were observed.
The fact that this study was a retrospective analysis with a moderate sample size was a limitation.
Advanced machine learning/classification algorithms produce more accurate personalized predictions of rehabilitation outcomes than commonly used general linear models.
For individuals with hand hemiparesis following a stroke, rehabilitation strategies are predominantly founded on the principles of neuroplasticity and automaticity  to regain optimal hand-related functional abilities and facilitate participation in everyday activities. Such an approach requires to engage these individuals into meaningful activity-specific exercises and to repeat those intensively on a daily basis. Adhering to these principles  remains challenging in clinical practice for rehabilitation professionals, especially given various time and productivity constraints. To overcome this challenge, the development of soft robotic gloves to facilitate hand rehabilitation have progressed substantially in the last decade. Moreover, these soft robotic gloves are foreseen as promising rehabilitation intervention to potentiate the effects of conventional rehabilitation interventions and are now about to transition into clinical practice, although their effects remain uncertain given the paucity of evidence. In this context, this review aims to map evidence on the effects of the different rehabilitation interventions using a soft robotic device for sensorimotor hand impairments and, whenever possible, the satisfaction related to their use.
Eligibility Criteria, Information Sources, And Search
This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . A review of the literature published in English and French from 2000 to October 2018 using a combination of search terms was conducted in Medline, EMBASE, and CINAHL. The search strategy included a combination of search terms related to three key domains: technology attributes (robotics, bionics, exoskeleton device, robot*, exoskelet*, motorized, motor-driven, motor assisted), anatomy of the hand (hand, hands, wrist*, finger*, prehension, dexterity), and rehabilitation domains (rehabilitation, exercise*, exercise therapy, physical therapy modalities, physical therapy speciality, physical therapists, occupational therapy, occupational therapist, therap*, physiothrap*). Search terms related to amputation, surgery, computer-assisted device, and teleoperation were excluded. From this initial search, 1870 articles were found and only 1206 articles remained after eliminating all duplicates. To narrow down the number of articles, a new domain was added (i.e., technology= glove, soft, wearable) and the search among the keywords, title, and abstracts was continued in EndNote. Thereafter, 181 articles remained and were imported into the web-based software platform Covidence where 9 additional duplicates were found.
SELECTION OF SOURCES OF EVIDENCE
The articles title, abstract and full text of 172 articles were screened by two rehabilitation professionals to identify the articles qualifying for a subsequent full review. To be considered for full review the article has to target 1) the effects or effectiveness of rehabilitation interventions using soft robotic gloves to optimize hand-related functional abilities and facilitate participation in everyday activities in people with sensorimotor disorders via randomized controlled trials (RCTs), non-randomized controlled trials (non-RCT), and other types of research designs (cohort studies, pre- and post-case interventions, case series, case-control studies and case reports) and 2) the users satisfaction and stakeholder views on the use of soft robotic gloves. For this review, in order to be considered a soft robotic glove, the technology had to generate assisted pinching or gripping movements soliciting multiple joints involving at least the thumb and the index finger and middle fingers. Interventions using a soft robotic glove could be performed in a hospital, rehabilitation center or at home with the direct or indirect supervision of a rehabilitation professional. The use of the soft robotic glove could also be combined with other technologies (e.g., virtual reality). Research protocols or manuscripts that did not include participants with sensorimotor impairment were excluded. All scientific manuscripts and conference abstracts focusing on upper limb exoskeleton including the elbow or shoulder joint were excluded.
Data Extraction And Charting Process
Studies that met the inclusion and exclusion criteria were read by a single rehabilitation professional and the following information were extracted on project-specific forms data extraction tables organized within an excel file: author-related information’s, journals and publication year, soft robotic glove attributes, study design, population and sample size, intervention, measurement instruments, results and interpretations, and user’s satisfaction. At the end, to establish if the use of a soft robotic glove yield to positive, neutral or negative effect, the p-value and effect size of each outcome measures from each article were determined.
Characteristics Of Sources Of Evidence
Ten articles included in this study originated from European or American countries; USA (5/10) [4-8], Italy (2/10) [9,10], United Kingdom (2/10) [11,12], and Netherlands (1/10) . The majority of these studies were published in 2017 (6/10) [6,8-12] or 2018 (3/10) [5,7,13]. Only one study was published in 2011 .
Study Designs And Populations
Both experimental (3/10) [8,10,12] and quasi-experimental studies (7/10) [4-7,9,11,13] were selected with mean sample sizes of 12,4 participants and ranging from 2 to 27. Most studies investigated individuals with hemiparesis following a stroke (9/10) [4-6,8-13] whereas one article investigated individuals with of a traumatic spinal cord injury .
Synthesis Of Findings
Soft robotic gloves
Eight different soft robotic gloves (i.e., HandSOME [4,6], FES Hand Glove , Gloreha Light Glove , Gloreha Professional , VAEDA , HandinMind [12,13] and two others without names) with different types of assistance (i.e., motor [7,8,9,10,12,13], elastic [4,6], and pneumatic [5,11]) were identified.
Four studies [4,5,11,13] used a transversal design to compare hand function with and without the use of a soft robotic device glove whereas three studies used an experimental design [8,10,12] and three used a quasi-experimental design [6,7,9] to compare hand sensorimotor integrity and functional abilities before and after an intervention with the soft robotic glove. No concomitant therapy was used in all of the studies. The intervention protocols of the experimental and quasi-experimental design studies varied in length from 4 to 8 weeks, in frequency from 3 to 6 times a week and training sessions duration from 40 to 90 minutes.
The outcome measures included: Ashworth Spasticity Index  or Ashworth modified scale , edema , Hand pain VAS , Barthel , Motricity index [9,10], Nine hole peg test (NHPT) [9,10], grip strength [4,6,8-10], active range of motion (AROM) , Velocity of movements , Box and blocks test , Fugl-Meyer Assessment of Upper Extremity (FMA-UE) [6,8], Fugl-Meyer Hand (FMH) , The Action Research Arm Test (ARAT) [6,8], The Motor Activity Log , time to execute tasks , Toronto Rehabilitation Institute Hand Function Test (TRI-HFT) , pinch strength [8,10,12], JTFHT , Activity of Daily Living (ADL) , Functional Independence Measure (FIM) , Wolf Motor Function Test (WMFT) , Chedoke McMaster Stroke Assessment Hand (CMSAH)  and the Quick-DASH . Then, each outcomes measure have been classified according to the International Classification of Functioning, Disability and Health (ICF)  (Figure. 1).
Effects and effectiveness
The results in terms of effects and effectiveness of the interventions are listed in the Figure 1. Mostly, the use of robotic gloves increased joint mobility and functional capacity of the upper limb in terms of performance rapidity. According to muscular strength, functional capacity of the upper limb assessed by questionnaire, and global functional capacity, the results are heterogeneous and do not allow conclusion on the effectiveness of intervention using this technology.
Usability, feasibility and satisfaction
Four studies also assessed the usability, feasibility or satisfaction of the users after trying the soft robotic glove [10-13] using the Usefulness-Satisfaction-and-Ease-of-Use questionnaire , observations [4,10], System Usability Scale [12,13], Intrinsic Motivation Inventory , cost analysis . Studies concluded that the use of soft robotic gloves is foreseen as being feasible and acceptable by participants and rehabilitation professionals [10-13] and as increasing engagement in rehabilitation program [11,13]. Most of the studies support the fact that the soft robotic gloves are easy to use [10, 1,13]. However, the robotic glove was found to be more useful when performing gross motor tasks when compared to fine motor tasks , the presence of a zipper on the glove made it difficult to put on , and the choice of material, especially its thickness, was found to interfere with hand and finger sensations . A preference for the rental of these devices has been demonstrated . The most important features highlighted in the studies included: easy to clean, comfortable, easy to put on and take off. Last, a decreased in rehabilitation cost linked to the use of a soft robotic device at home may be anticipated .
This systematic review of the literature confirms an increased interest over the last decade in the development and use of soft robotic gloves for rehabilitation of individuals with hand hemiparesis following a neurological event. Overall, the use of soft robotics devices in rehabilitation treatment is feasible, safe, and acceptable by patients while its effects and effectiveness appear promising. However, the strength of the currently available evidence remains limited and given the wide variety of soft robotic glove attributes, study designs and interventions, and outcomes measures alongside the small sample sizes tested, it is impossible to highlight which soft robotic glove or intervention protocol would be the most appropriate to obtain the best clinical results. Stronger evidence linked to the effects or effectiveness, in addition to comprehensive stakeholder perspectives (e.g., patients, rehabilitation professionals), especially on the usability, are needed to ensure a successful transition from the laboratory to clinical practice.
This systematic review maps currently available evidence on the use of soft robotic gloves as a rehabilitation intervention while considering effectiveness and usability. This technology is a promising solution to optimize sensorimotor capabilities, hand-related functional abilities and facilitate participation in everyday activities while overcoming some clinical constraints. Additional research in this area should be encouraged to strengthen current evidence.
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Supported by the Initiative for the Development of New Technologies and Innovative Practices in Rehabilitation and by the Université de Montréal (Direction des affaires internationales).
Background: Stroke is the leading cause of disability in adults, producing a major personal and economic impact on those affected. The scientific evidence regarding the use of Motor Imagery (MI) as a preparatory process for motor control reinforces the need to explore this method as a complement to physical therapy.
Objectives: The objectives of this systematic review were to determine the effectiveness of MI for functional recovery after stroke and to identify a possible intervention protocol, according to the level of existing scientific evidence.
Methods: A comprehensive literature search was performed using Medline, Cochrane Library and PEDro databases. Studies were limited to those published between 2007 and 2017, and restricted to English and/or Spanish language publications.
Results: Thirteen randomized clinical trials that met the inclusion criteria were included. The methodological quality of studies was determined using the Critical Review Form for Quantitative Studies, obtaining scores of 9-13 points out of 15. The level of evidence and strength of recommendations were assessed using the U.S. Preventive Services Task Force (USPSTF) assessment, obtaining levels IA and II-B1. Significant improvements were found in outcome measures evaluating upper limb functionality, balance and kinematic gait parameters.
Conclusions: The use of MI combined with conventional rehabilitation is an effective method for the recovery of functionality after stroke. Due to the great heterogeneity in the scientific literature available, new lines of research are necessary, in order to include well-designed studies of good methodological quality and to establish a consensus regarding the most appropriate protocols.
Stroke rehabilitation researchers test new electrical stimulation therapy for improving for hand function after stroke, as part of multi-site study headed by the MetroHealth System and Case Western Reserve University
East Hanover, NJ. November 26, 2019. Kessler Foundation is participating in a phase II multi-site study of an innovative treatment to improve hand function in stroke survivors. Olga Boukrina, PhD, research scientist in the Center for Stroke Rehabilitation Research, is the site’s principal investigator. The study is funded through a five-year $3.2 million grant from the National Institutes of Health awarded to the principal investigator, Jayme S. Knutson, PhD, director of Research and associate professor of Physical Medicine and Rehabilitation at the MetroHealth System and Case Western Reserve University.
This is the first multi-site clinical trial of contralaterally controlled functional electrical stimulation (CCFES), a new rehabilitation intervention for hand recovery following stroke developed by Knutson and colleagues. With CCFES, electrical stimulation is applied to the muscles of the weak hand through surface electrodes, causing the weak hand to open, a function that is often lost in stroke survivors. The patient controls the stimulation to their weak hand through a glove with sensors worn on their opposite, unaffected hand. Opening their unaffected hand delivers a proportional intensity of electrical stimulation that opens their weak hand, and enables them to practice using their hand in therapy. Researchers will enroll 129 patients who are 6 to 24 months post stroke who have upper extremity hemiparesis and limited hand movement.
The effectiveness of CCFES will be compared with two other treatments — cyclic neuromuscular electrical stimulation (CNMES), which has pre-set duration and intensity of stimulation and operates independent of patient control, and traditional task-based training without stimulation. Participants will be randomly assigned to one of the three treatment options for 12 weeks. The research teams will administer the treatments and conduct blinded outcome assessments. The durability of functional improvements will be evaluated at 6-month follow-up. Study sites include the MetroHealth System (Jayme Knutson, PhD), the Cleveland Clinic (Ela Plow, PT, PhD), Emory University (A.M. Barrett, MD), and Johns Hopkins University (Preeti Raghavan, MD).
“Because hand function is integral to so many activities of daily living, advances that improve function can have significant effect on the lives of stroke survivors,” said Dr. Boukrina. “This study will help determine the optimal method for restoring hand function. We anticipate that putting the patients in control of stimulating their weak hand with CCFES may activate neuroplastic changes that lead to greater and longer lasting functional gains.”