Posts Tagged robotics
[ARTICLE] Pilot Study of a Powered Exoskeleton for Upper Limb Rehabilitation Based on the Wheelchair – Full Text
To help hemiplegic patients with stroke to restore impaired or lost upper extremity functionalities efficiently, the design of upper limb rehabilitation robotics which can substitute human practice becomes more important. The aim of this work is to propose a powered exoskeleton for upper limb rehabilitation based on a wheelchair in order to increase the frequency of training and reduce the preparing time per training. This paper firstly analyzes the range of motion (ROM) of the flexion/extension, adduction/abduction, and internal/external of the shoulder joint, the flexion/extension of the elbow joint, the pronation/supination of the forearm, the flexion/extension and ulnar/radial of the wrist joint by measuring the normal people who are sitting on a wheelchair. Then, a six-degree-of-freedom exoskeleton based on a wheelchair is designed according to the defined range of motion. The kinematics model and workspace are analyzed to understand the position of the exoskeleton. In the end, the test of ROM of each joint has been done. The maximum error of measured and desired shoulder flexion and extension joint angle is 14.98%. The maximum error of measured and desired elbow flexion and extension joint angle is 14.56%. It is acceptable for rehabilitation training. Meanwhile, the movement of drinking water can be realized in accordance with the range of motion. It demonstrates that the proposed upper limb exoskeleton can also assist people with upper limb disorder to deal with activities of daily living. The feasibility of the proposed powered exoskeleton for upper limb rehabilitation training and function compensating based on a wheelchair is proved.
Upper extremity motor function disorder is one of the most common rehabilitation problems of hemiplegic patients with stroke . The upper extremity motor function plays a key role in self-care and social activities. The upper extremity motor function disorder significantly lowers the life quality of hemiplegic patients with stroke [2, 3]. Due to the complex structure and functional requirement of the upper limb, the rehabilitation process of the impaired upper extremity functionality is a long and slow process. Because of the specificity of hemiplegic patients in diagnosis, treatment, and rehabilitation, it brings a series of severe psychological and financial stress for patients . The outcome of upper limb motor rehabilitation depends on duration, intensity and task orientation of the training. The therapists assisting patients have to bear a significant burden. As a result, the duration of primary upper limb rehabilitation is becoming shorter . To deal with these problems, robotic rehabilitation devices with the ability to conduct repetitive tasks and provide assistive force have been proposed.
The upper limb rehabilitation robots can be divided into two types according to the service environment. One is mainly used in the hospital and shared by several patients. The upper limb rehabilitation robots used in the hospital are often designed for rehabilitation training and difficult to move. Loris et al. introduced a dual exoskeleton robot called automatic recovery arm motility integrated system. The system was developed to enable therapists to define and apply patient-specific rehabilitation exercises with multidisciplinary support by neurologist, engineers, ICT specialists and designers . Farshid et al. presented the GENTLE/S system for upper limb rehabilitation. The system comprised a 3-degree-of-freedom (DOF) robot manipulator with an extra 3 DOFs passive gimbal mechanism, an exercise table, computer screen, overhead frame, and chair . Dongjin Lee et al. proposed a clinically relevant upper-limb exoskeleton that met the clinical requirements. The pilot test showed that the safety for robot-aided passive training of patients with spasticity could be guaranteed . The other is mainly used in the home to assist a single patient in activities of daily living. A lightweight and ergonomic upper-limb rehabilitation exoskeleton named CLEVER ARM was proposed by Zeiaee et al. The wearable upper limb exoskeleton was to provide automated therapy to stroke patients . Feiyun et al. presented a seven DOFs cable-driven upper limb exoskeleton for post-stroke patients. The experimental results showed that the activation levels of corresponding muscles were reduced by using the 7 DOFs cable-driven upper limb exoskeleton in the course of rehabilitation . In fact, the main function of upper extremity rehabilitation devices is to provide the physical training and assist the patients with hemiplegia to perform the activities of daily living. However, hospital or home used rehabilitation robot research has just focused on one respect. Indeed, the research on the upper extremity rehabilitation devices would focus on both aspects of assisting and training. Therefore, it is important for the design of upper limb rehabilitation robot to combine the rehabilitation training and assisting function.
The stationary upper extremity rehabilitation robot cannot solve the movability problem and perform the activities of daily living (ADL). The wearable exoskeleton devices are limited by the weight. In addition, whether the range of motion is in line with the physiological joints directly determines the rehabilitation effect. Therefore, the key questions can be summarized as follows. Can we transform the weight of the upper limb exoskeleton to another movable device instead of wearing by patients? How to guarantee the design of upper limb exoskeleton joint axis in line with the human joint movement axis?
To deal with the above questions, some researchers have made useful explorations. Kiguchi et al. proposed a mechanism and control method of a mobile exoskeleton robot based on a wheelchair for 3 DOFs upper-limb motion assist . The first problem of transforming weight can be solved by design based on a wheelchair. The physical rehabilitation training can be realized on a wheelchair instead of a stationary place. The ADL can be assisted by the powered upper limb exoskeleton on a moving platform. However, the rotation axis of each joint (shoulder joint and elbow joint) is moving with the movement of the upper limb. The gap between the exoskeleton and human arm is also changing by following their movement. It does not consider the problem about the movement consistency of the exoskeleton joint rotation axis and the human joint. As for this problem, Vitiello et al. proposed an elbow exoskeleton with double-shelled links to allow an ergonomic physical human-robot interface and a four-degree-of-freedom passive mechanism to allow the user’s elbow and robot axes to be constantly aligned during movement . However, it focused on the elbow. The whole upper limb rehabilitation was not considered. In this work, we present a novel solution for the two mentioned problems. The range of motion of the upper extremity exoskeleton based on a wheelchair is defined through the normal people test. The 6 DOFs exoskeleton based on a wheelchair is designed according to the defined range of motion. The pursuit movement experiment and the assistive movement of drinking water of the prototype are done to verify the feasibility of the design.
2. Materials and Methods
2.1. Definition of ROM of Each Joint for the Specific Upper Limb Exoskeleton on a Wheelchair
To ensure the safety of using an upper limb exoskeleton on a wheelchair, it is necessary to know the ROM of the human upper limb on the wheelchair.
The parts of the upper limb taken into account in the design of an exoskeleton are shoulder, arm, elbow, wrist, and hand. Hand is excluded in an entire upper extremity exoskeleton design because of its complexity and dexterous characteristic. Therefore, this work only analyzes the ROM of the shoulder joint, elbow joint, and wrist joint. And then the upper limb exoskeleton designed in this paper must conform to the ROM of these joints.
The apparatus consists of a wheelchair and a motion analysis system. The motion analysis system can transmit data in real time. It was made in JIANGSU NEUCOGNIC MEDICAL CO., LTD. The system can measure the ROM of the shoulder joint, elbow joint and wrist joint of a person who sits on a common wheelchair. In Figure 1, there are two inertial sensors located at the upside and downside of backbone, and ten inertial sensors located at the upper limb (shoulder, upper arm, forearm, palm, and hand), respectively. All of the sensors in this system can measure the angles in x-, y– and z-axis. Sensor 1 and Sensor 4 are utilized to measure the ROM of the rear waist as the referring data. Sensor 4 and Sensor 6 are utilized to measure the ROM of the shoulder joint as the referring data. Sensor 6 and Sensor 7 are utilized to measure the ROM of the elbow joint as the referring data. Sensor 7 and hand sensor are utilized to measure the ROM of wrist joint as the referring data.[…]
Background and Purpose: After stroke, only 12% of survivors obtain complete upper limb (UL) functional recovery, while in 30% to 60% UL deficits persist. Despite the complexity of the UL, prior robot-mediated therapy research has used only one robot in comparisons to conventional therapy. We evaluated the efficacy of robotic UL treatment using a set of 4 devices, compared with conventional therapy.
Methods: In a multicenter, randomized controlled trial, 247 subjects with subacute stroke were assigned either to robotic (using a set of 4 devices) or to conventional treatment, each consisting of 30 sessions. Subjects were evaluated before and after treatment, with follow-up assessment after 3 months. The primary outcome measure was change from baseline in the Fugl-Meyer Assessment (FMA) score. Secondary outcome measures were selected to assess motor function, activities, and participation.
Results: One hundred ninety subjects completed the posttreatment assessment, with a subset (n = 122) returning for follow-up evaluation. Mean FMA score improvement in the robotic group was 8.50 (confidence interval: 6.82 to 10.17), versus 8.57 (confidence interval: 6.97 to 10.18) in the conventional group, with no significant between-groups difference (adjusted mean difference −0.08, P = 0.948). Both groups also had similar change in secondary measures, except for the Motricity Index, with better results for the robotic group (adjusted mean difference 4.42, P = 0.037). At follow-up, subjects continued to improve with no between-groups differences.
Discussion and Conclusions: Robotic treatment using a set of 4 devices significantly improved UL motor function, activities, and participation in subjects with subacute stroke to the same extent as a similar amount of conventional therapy. Video Abstract is available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A291).
Only 12% of stroke survivors obtain complete upper limb (UL) functional recovery after 6 months from stroke.1 In the remaining 88%, UL motor deficits persist with a negative impact on their level of activities2–4 and participation,5 according to the International Classification of Functioning, Disability and Health (ICF).6
Robotic therapy has been proposed as a viable approach for the rehabilitation of the UL, as a way to increase the amount and intensity of the therapy,7 and to standardize the treatment,8 by providing complex but controlled multisensory stimulation.7 Moreover, because of their built-in technology in terms of sensors and actuators, robotic devices can provide quantitative measure about the user’s dexterity.9 A large number of scientific articles on robot-assisted rehabilitation after stroke have been published, analyzing the effects of robotics alone,10–18 or in conjunction with conventional therapy.19–24 Nowadays, the use of robotic rehabilitation in addition to conventional therapy is recommended in some of the current stroke guidelines.25
Regarding the efficacy of robotic rehabilitation when compared with other treatments, the available scientific data are not conclusive. In comparing robotic and conventional treatment, some studies did not find an overall significant effect in favor of robotic therapy11,26,27: others showed a greater effect of robotic therapy than conventional therapy.28 However, in the latter case, the results must be interpreted with caution because the quality of the evidence was low or very low, owing to the variations between the trials in intensity, duration, and amount of training, type of treatment, participant characteristics, and measurements used. Finally, according to the most recent meta-analysis,29 it is not clear whether the difference between robotic therapy and other interventions (as conventional therapy) is clinically meaningful for the persons with stroke.
Almost all studies of robotic therapy have focused on the effects of the use of 1 device, compared with a conventional therapy approach. However, despite the complexity of the anatomy and the motor function of whole UL, especially the hand, almost all commercial devices act on a limited number of joints and a limited workspace. Conversely, during conventional therapy, the whole UL is routinely treated and the 3-dimensional space explored. Because of this, it is very difficult to compare the effects of 1 robotic device with conventional approaches. Therefore, it would be desirable to use devices that allow treatment of the entire UL (from shoulder to hand), in a workspace similar to that required in daily activities. Moreover, using more than 1 device new personnel organizational models can be adopted, wherein 1 physical therapist supervises more than 1 patient, thereby increasing the sustainability of the treatment.15,21,30
The aim of the current study was to evaluate, in subjects with subacute stroke, the efficacy of standardized UL robotic rehabilitation (using an organizational model in which 1 physical therapist supervises 3 subjects, each treated using a set of 4 robots and sensor-based devices), compared with UL conventional therapy. Outcomes of interest were selected to reflect effects on function, activities, and participation (per the ICF) […]
[Abstract] Movement kinematics and proprioception in post-stroke spasticity: assessment using the Kinarm robotic exoskeleton – Full Text PDF
Motor impairment after stroke interferes with performance of everyday activities. Upper limb spasticity may further disrupt the movement patterns that enable optimal function; however, the specific features of these altered movement patterns, which differentiate individuals with and without spasticity, have not been fully identified. This study aimed to characterize the kinematic and proprioceptive deficits of individuals with upper limb spasticity after stroke using the Kinarm robotic exoskeleton.
Upper limb function was characterized using two tasks: Visually Guided Reaching, in which participants moved the limb from a central target to 1 of 4 or 1 of 8 outer targets when cued (measuring reaching function) and Arm Position Matching, in which participants moved the less-affected arm to mirror match the position of the affected arm (measuring proprioception), which was passively moved to 1 of 4 or 1 of 9 different positions. Comparisons were made between individuals with (n = 35) and without (n = 35) upper limb post-stroke spasticity.
Statistically significant differences in affected limb performance between groups were observed in reaching-specific measures characterizing movement time and movement speed, as well as an overall metric for the Visually Guided Reaching task. While both groups demonstrated deficits in proprioception compared to normative values, no differences were observed between groups. Modified Ashworth Scale score was significantly correlated with these same measures.
The findings indicate that individuals with spasticity experience greater deficits in temporal features of movement while reaching, but not in proprioception in comparison to individuals with post-stroke motor impairment without spasticity. Temporal features of movement can be potential targets for rehabilitation in individuals with upper limb spasticity after stroke.
[Abstract] A Method for Self-Service Rehabilitation Training of Human Lower Limbs – IEEE Conference Publication
[Abstract] The effects of a robot-assisted arm training plus hand functional electrical stimulation on recovery after stroke: a randomized clinical trial
Having a stroke can be a scary experience, but the long road to recovery might be getting shorter, thanks to research out of ECU.
Imagine suddenly losing control of a limb or your ability to communicate.
And while this happens, excruciating pain spreads across your head.
This was Joanna’s experience when she had a stroke at the age of 44.
“I was sick three days up to having my stroke,” Joanna explains. “I had vomiting, headaches and was not making much sense when talking.”
“Three days later, I was sitting down and then it felt like my head was being squeezed between two vices. Excruciating pain.”
In Australia, strokes affect around 55,000 people a year and are the third most common cause of death and a leading cause of disability.
There’s a range of factors that increase the risk of strokes, including diet, exercise and high blood pressure.
But one of the most telling risk factors is, simply, age.
From the age of 45, the risk of a stroke in men is one in four, and for women, it’s one in five.
Fortunately, our knowledge of strokes and how to combat them has improved a lot in the past few decades.
A big part of the solution is getting help quickly, according to Edith Cowan University (ECU) Professor Dylan Edwards.
“If it’s the blockage of a blood vessel, it can be treated very well by anti-coagulant therapy that will break up the blood clot and restore the blood flow to the brain,” Dylan says.
“Typically, you notice somebody is having a stroke by them having issues with their speech or they have a weakness or funny sensation in one side of their body.”
But surviving a stroke is only part of the journey, and with 65% of stroke survivors suffering from some form of disability, restoring motor skills is a critical part of rehabilitation.
Road to recovery
Recovery from stroke can be a long and frustrating road for even the smallest paralysation.
For stroke survivor Joanna, the frustration she felt not being able to move normally made the recovery process even more challenging.
“The emotional side of having the stroke has affected me more than anything else,” Joanna says.
“You slowly get used to the fact that you can’t move your left side, and you know that you’ll get therapy. But when I had people come visit, when they left, I was in tears [out of frustration].”
Joanna eventually started to get some feeling back in her left side, just to her thumb at first.
“It was still a shock that I had lost all of that, so just a little bit of movement was enough to keep me going and stay motivated.”
Fighting back with technology
At ECU’s Lab for NeuroRehabilitation and Robotics, Dylan and his team have been researching how to help people recover their motor control after a brain or spinal cord injury.
Part of their research focuses on understanding the recovery of stroke survivors, using a robotic sensory platform called the Kinarm Exoskeleton Lab.
“The Kinarm looks like a fancy piece of gym equipment,” Dylan explains. “You sit inside the device and position your arms on top of movable handles, and you’re wheeled into this virtual reality environment.”
For the user in the chair, it feels like you’re playing a series of games, moving the chair’s arms to get a response on the screen—such as bouncing balls off paddles.
But the real work is happening behind the scenes.
“All of this information is acquired by these high-powered computers and analysed for how the person is performing,” Dylan says. “This [helps] identify the precise proprioceptive issue with an individual stroke survivor so we can prescribe therapy more effectively.”
In simplest terms, the Kinarm helps identify issues where the user is telling their arm to move but the resulting movement is not what they were trying to do.
This could be an arm not extending the full distance or slower reaction times.
With strokes usually affecting one side of the body more than the other, the unaffected side can provide a good baseline for what their normal reactions should be.
But what if both sides of the body have been affected? The Kinarm can pick up on that too, detecting deficits in what would be considered the unaffected side and showing this in the test results.
R&R—Robotics and Recovery
For Joanna, using the Kinarm has been a challenging experience, even three years after her stroke.
“It actually made you concentrate more in the game to hit the balls coming down,” she explains.
“I think that made you use the brain to try and keep up with your eye, which it didn’t, but I gave it my best shot. I also noticed my peripheral vision has gone.”
“It highlighted for me the improvements I have got since my stroke, which is nice for me three years on to see how it was then to what I could actually achieve on the Kinarm now.”
The data collected helps doctors prescribe the most beneficial treatment for their patients, based on the results of the tests.
Whether it’s heading towards recovering the function in a limb or something as simple as the mobility of a single joint, Dylan believes even small changes are worth pursuing.
“Some degree of independence—even though it might be apparent to an onlooker or a carer—can be very meaningful for a patient.”
“Small changes that we have made in the past through prescribing therapies effectively are things like being able to stabilise yourself on the train and send a text message.”
Recovering movement and lives
While full recovery from a stroke is not guaranteed, any improvement to quality of life can mean everything for survivors. Restoring simple movements can help patients build up their self-confidence to return to their everyday lives.
“Often stroke patients are in the older age bracket, and many of them are working,” Dylan says. “It’s very depressing to be disengaged from a functional work life, and going back to work might just be having the confidence of turning over a page of paper at your desk.”
As we learn more about how the body and brain recover after these traumatic events, there’s hope we can find ways to better support those who have experienced extensive motor damage.
While there’s medication and training regimes to follow, at its core, it comes down to the drive to actively engage in recovering.
And even if it’s just through small victories, a spark from ECU’s Lab for NeuroRehabilitation and Robotics could help light the fire of determination in stroke survivors.
[Abstract] A game changer: the use of digital technologies in the management of upper limb rehabilitation – BOOK
Hemiparesis is a symptom of residual weakness in half of the body, including the upper extremity, which affects the majority of post stroke survivors. Upper limb function is essential for daily life and reduction in movements can lead to tremendous decline in quality of life and independence. Current treatments, such as physiotherapy, aim to improve motor functions, however due to increasing NHS pressure, growing recognition on mental health, and close scrutiny on disease spending there is an urgent need for new approaches to be developed rapidly and sufficient resources devoted to stroke disease. Fortunately, a range of digital technologies has led to revived rehabilitation techniques in captivating and stimulating environments. To gain further insight, a meta-analysis literature search was carried out using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Articles were categorized and pooled into the following groups; pro/anti/neutral for the use of digital technology. Additionally, most literature is rationalised by quantitative and qualitative findings. Findings displayed, the majority of the inclusive literature is supportive of the use of digital technologies in the rehabilitation of upper extremity following stroke. Overall, the review highlights a wide understanding and promise directed into introducing devices into a clinical setting. Analysis of all four categories; (1) Digital Technology, (2) Virtual Reality, (3) Robotics and (4) Leap Motion displayed varying qualities both—pro and negative across each device. Prevailing developments on use of these technologies highlights an evolutionary and revolutionary step into utilizing digital technologies for rehabilitation purposes due to the vast functional gains and engagement levels experienced by patients. The influx of more commercialised and accessible devices could alter stroke recovery further with initial recommendations for combination therapy utilizing conventional and digital resources.
[Abstract] Cognitive Reserve as a useful variable to address robotic or conventional upper limb rehabilitation treatment after stroke. A multicenter study of the Fondazione Don Carlo Gnocchi
Rehabilitation plays a central role in stroke recovery. Besides conventional therapy, technological treatments have become available. About technological rehabilitation, its effectiveness and appropriateness are not yet well defined, hence researches focused on different variables impacting the recovery are needed. Results from literature identified the Cognitive Reserve (CR) as a variable impacting on the cognitive outcome. In this paper we aim to evaluate whether the CR influences the motor outcome in patients after stroke treated with conventional or robotic therapy and if it may address towards one treatment rather than another.
Seventy‐five stroke patients were enrolled in five Italian neurological rehabilitation centres. Patients were assigned either to a Robotic Group, rehabilitation by means of robotic devices, or to a Conventional Group, where a traditional approach was used. Patients were evaluated at baseline and after rehabilitation treatment of 6 weeks through Action Research Arm Test (ARAT), Motricity Index (MI) and Barthel Index (BI). CR was assessed at baseline using the Cognitive Reserve Index (CRI) questionnaire.
Considering all patients, a weak correlation was found between the CRI related to leisure time and MI evolution (r:0.276; p=0.02). Among the patients who performed a robotic rehabilitation a moderate correlation emerged between the CRI related to working activities and the MI evolution (r:0.422; p=0.02).
Our results suggest that CR may influence the motor outcome. For each patient, the CR and its subcategories should be considered in the choice between conventional and robotic treatment.
via Cognitive Reserve as a useful variable to address robotic or conventional upper limb rehabilitation treatment after stroke. A multicenter study of the Fondazione Don Carlo Gnocchi – Padua – – European Journal of Neurology – Wiley Online Library
[Abstract] Robotic Techniques Used for Increasing Improvement Rate In The Rehabilitation Process Of Upper Limb Stroke Patients – Full Text PDF
The rate of stroke patients in Pakistan is increasing, resulting in the decrease mobility of the patients. The movement of upper limb stoke patient is decreased due to the weakness and loss of joint control in his upper body. To improve the coordination of movement of the upper limb stroke patients, many methods e.g. passive and active modes for improving the disrupted mobility are introduced. The objectives of this paper are to first review the studies on upper limb stroke patients and the techniques used for increasing the improvement rate through physical therapy by exoskeleton and evaluation of the performance of the patient using methods such as quantification and graphical representations so that it can be shown to the patient for his motivation to improve further. The paper introduces a mechanical design of exoskeleton with 1 degree of freedom for elbow and 2 degrees of freedom for shoulder movement for rehabilitation of joints of stoke patients. It also mentions the safety that will be taken in the process so that the exoskeleton is safe to use when it is in contact with human. The model of the exoskeleton has the characteristic of being modular and easily operable and use admittance control strategy. Control strategy of the exoskeleton is discussed to maintain the position and orientation of the device and also is able to cater the gravitational attraction which plays an important part in the movement of the actuators. The mathematical model of motion attained due to the degrees of freedom of the exoskeleton is then evaluated and the lastly areas where the future work of exoskeleton can be done are discussed.
Key take home messages
- Clinically meaningful improvements are possible in chronic stroke patients
- The dose of rehabilitation treatment needs to be larger than currently delivered
- Rehabilitation is a complex intervention that cannot be reduced to a single element
Somewhere between 50-80% of stroke survivors have upper limb symptoms after acute stroke1 and persistent difficulty in using the upper limb is a major contributor to ongoing physical disability.2 A commonly held view is that most recovery from stroke occurs over the first three to six months after which little improvement is possible, especially at the level of impairment.3-6 We argue that this may be a self-fulfilling prophecy resulting in lack of provision of potentially helpful rehabilitation.
What is the best way to promote upper limb recovery after stroke? Most studies of behavioural interventions have investigated forms of constraint induced movement therapy (CIMT),7,8 repetitive task training (RTT)9 or robotics,10 each of which focuses on increasing the activity of the affected limb. Kwakkel et al8suggested that motor function, arm-hand activities and self-reported arm-hand functioning in daily life, improved immediately after CIMT and at long-term follow-up, but the comparison was often with usual care. It is worth noting that CIMT approaches were said to be more likely to be successful in promoting long term benefits if the protocol included shaping, massed practice and a behavioural transfer package, whereas simple forced use therapy was ineffective.8 RTT also has some evidence to support benefits over what is described as usual care, but the evidence for benefits over ‘matched therapy’ is less strong.9 The use of robotics can increase the number of movement repetitions, but has failed to produce clinically meaningful effects.10 Indeed, the recent RATULS study showed that compared with usual care, approximately 23 hours of robot-assisted training and matched dose ‘upper limb therapy’ did not improve upper limb function.11Overall, it would appear that asking patients to make simple repetitions of movement, however meaningful the task, is relatively ineffective without some way of actively translating any improvements into activities of daily living. Simply increasing the number of repetitions does not appear to be effective,12 and this in itself should give us pause for thought.
A few studies have tested more complex therapies incorporating a number of different elements. The ICARE study13 of upper limb treatment after stroke went beyond simple repetitions, using a structured, task-oriented motor training programme that was impairment focused, task specific, intense, engaging, collaborative, self-directed, and patient centred, starting about six weeks post-stroke. Outcomes were not improved by this approach, but on reflection it is likely that, as with many of the studies, the dose of 30 hours over ten weeks was too low (the usual care group received 11.2 hours over ten weeks). Despite scepticism that stroke patients would be able to ‘tolerate’ much higher doses,12 one study managed to deliver 300 hours of upper limb therapy to chronic stroke patients over twelve weeks and reported changes in measures of both impairment and activity that were far greater than those in lower dose studies,14 and in fact the findings of this study have recently been replicated by the same group.15 We recently reported the findings of the Queen Square Upper Limb (QSUL) Neurorehabilitation programme,16 a single centre clinical service that provides 90 hours of treatment focusing on the post-stroke upper limb. Most patients entering the programme were in the chronic stage (> 6 months post-stroke), but were able to complete the 90 hours of the programme, even though they exhibited a wide range of impairments and fatigue levels. Despite the time since stroke (median = 18 months) we observed (i) large clinically meaningful improvements in upper limb impairment and activity (of a magnitude similar to those reported by McCabe et al.), and importantly (ii) that these changes were maintained, or even improved upon, six months after treatment.
The first lesson to take from these studies is that post-stroke rehabilitation programmes and clinical trials are almost certainly under dosing patients. In future, clinical trials must investigate the effects of much higher doses than are currently being used. The second question to be raised is what are the key ‘active ingredients’ of an upper limb rehabilitation treatment? Whilst it is not clear what the optimal behavioural approach for promoting upper limb recovery should be, it is clear that simple protocol driven approaches have not led to large or sustained effects,17 both of which are necessary to produce a step change in stroke recovery. Successful post-stroke neurorehabilitation is likely to require a combination of complimentary approaches. If we accept this premise, then we are unlikely to determine the optimal combination of active ingredients simply by studying each approach in isolation, because the interactions between these elements will also have to be considered.
So how do we work out what the ‘active ingredients’ of upper limb rehabilitation are? A more sensible way forward is to look at interventions that have already demonstrated a high level of efficacy and then begin to work out their key components. Here, it is important to say that we need to start with treatments that have a high chance of achieving minimum clinically important differences (MCID) rather than small changes that might be statistically significant. Both McCabe et al14 and Daly et al,15 as well as the QSUL programme,16 produced large improvements on both impairment and activity limitation and both involved more complex treatment approaches, not restricted to one element. It is worth considering these in more detail.
- Analysis of movement and performance in activities of daily living. The initial assessment is crucial. The question, ‘why does this person’s hand and arm not work’ should never be answered with ‘because they have had a stroke’. There needs to be an appreciation of the range of potential contributory impairments (patterns of weakness, spasticity, loss of joint range, shoulder restriction and pain, sensory loss, apraxia, cognitive deficits, depression, apathy, fatigue etc.) because each of these becomes a therapeutic target. Our view is that without informed clinical reasoning based on the presence or absence of specific impairments, the correct treatment approach is unlikely to be selected.
- Identify and treat barriers. Avoid complications that will prevent participation in an active rehabilitation programme. We commonly see loss of passive joint range preventing people accessing finger or thumb movement, due to either spasticity or non-neural shortening. This can happen at most joints, but particularly in the hand. As well as increased finger flexion, be alert to loss of flexion at MCP joints which makes it difficult to shape the hand properly. Treatment involves splinting and optimal spasticity management. We also see pain and restriction of range in the shoulder. Restriction of external rotation in particular should raise the possibility of adhesive capsulitis. Despite the lack of a clear evidence base for treating post-stroke adhesive capsulitis, anecdotally we have had success with capsular hydrodilatation followed by physiotherapy.
- Preparation. Manual techniques are used to optimise and improve baseline at an impairment level, for example mobilising joints to improve range, lengthening and strengthening muscles to ensure they are at a biomechanical advantage to generate force, training sensory discrimination and improving postural control and balance.
- Reduction of impairment and re-education of quality and control of movement within activities of daily living. Individualised meaningful tasks are practiced repeatedly in order to facilitate task mastery with a focus on quality of movement. This is achieved through (i) adaptation of the task, e.g. decomposing tasks into individual components to be practiced; (ii) adaptation of the environment, e.g. fabrication of functional splints and adaptation of tools such as cutlery or screwdrivers, to enable integration of the affected hand in meaningful activities; (iii) assistance, e.g. de-weighting the arm to allow strengthening and training of movement quality and control through increased range.
- Coaching (involving instruction, supervision, reinforcement) was considered a key component of the QSUL programme, used throughout to embed new skills and knowledge into individual daily routines. Consequently, individuals increase participation and confidence in their desired goals, enhancing self-efficacy and motivation to sustain behavioural change beyond the end of the active treatment period.
- Sustaining change. Our view is that the approach described, delivered at a high dose is most likely to achieve clinically meaningful improvement together with improved self-efficacy and behaviour change that results in retention of gains or further improvement (something not routinely seen with many upper limb interventions that have been investigated).
Rehabilitation is often criticised for not following standardised approaches that lend themselves to investigation through clinical trials. However, when single elements are then studied in isolation the results are often not clinically meaningful and are not sustained.18,19 Looking at the difference between these approaches and those taken by McCabe et al14, Daly et al15 and QSUL16 should be informative, with a view to formally describing the key elements of a successful treatment. Whilst approaches at the activity and participation level will vary as they are tailored to an individual’s specific meaningful goals, the overall therapeutic approach taken towards specific impairments should be the same across all patients. Ideally, it should be possible to describe the principles of an optimal intervention using a format such as the TIDIER guidelines.18,19
There is a way to go before we can really say we understand both the treatment itself and the effects of the treatment on individuals. This will require careful assessment of both the ‘input’ (the nature of the behavioural intervention) and of the ‘output’ (the resulting behavioural change) at a level of fine-grained detail that is not currently achieved on a regular basis, for example using kinematic20 or neurophysiological21 assessment. In addition, this input-output relationship will be modulated by a number of patient characteristics, which could relate to behavioural characteristics (e.g. severity, presence of multiple impairments) or to biological characteristics (e.g. the nature and extent of brain damage, time since stroke, age, medication).
Overall, our experience suggests that much higher doses and intensity of upper limb neurorehabilitation can be delivered with beneficial effects. We have highlighted the need to consider the dose and the nature of the intervention as well as appropriate patient stratification in informing future clinical trial design.
- Lawrence ES et al. Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 2001;32:1279–1284.
- Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ. The long-term outcome of arm function after stroke: results of a follow-up study. Disabil Rehabil. 1999;21:357–364.
- Kwakkel G, Kollen BJ, van der Grond J, Prevo AJH. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003;34:2181–2186.
- Nakayama H, Jørgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994;75:394–398.
- Sunderland A et al. Enhanced physical therapy for arm function after stroke: a one year follow up study. J. Neurol. Neurosurg. Psychiatr. 1994;57:856–858.
- Wade DT, Langton-Hewer R, Wood VA, Skilbeck CE, Ismail HM. The hemiplegic arm after stroke: measurement and recovery. J. Neurol. Neurosurg. Psychiatr. 1983;46:521–524 .
- Corbetta D, Sirtori V, Castellini G, Moja L, Gatti R. Constraint-induced movement therapy for upper extremities in people with stroke. Cochrane Database Syst Rev CD004433 (2015). doi:10.1002/14651858.CD004433.pub3
- Kwakkel G, Veerbeek J, van Wegen EEH, Wolf SL. Constraint-induced movement therapy after stroke. Lancet Neurol. 2015;14:224–234.
- French B et al. Repetitive task training for improving functional ability after stroke. Cochrane Database Syst Rev. 2016;11:CD006073.
- Veerbeek JM, Langbroek-Amersfoort AC, van Wegen, EEH, Meskers CGM, Kwakkel G. Effects of Robot-Assisted Therapy for the Upper Limb After Stroke. Neurorehabil Neural Repair. 2017;31: 107–121.
- Rodgers H et al. Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial. Lancet (2019). doi:10.1016/S0140-6736(19)31055-4.
- Lang CE et al. Dose response of task-specific upper limb training in people at least 6 months poststroke: A phase II, single-blind, randomized, controlled trial. Ann. Neurol. 2016;80:342–354.
- Winstein CJ et al. Effect of a Task-Oriented Rehabilitation Program on Upper Extremity Recovery Following Motor Stroke: The ICARE Randomized Clinical Trial. JAMA. 2016;315:571–581.
- McCabe J, Monkiewicz M, Holcomb J, Pundik S, Daly JJ. Comparison of robotics, functional electrical stimulation, and motor learning methods for treatment of persistent upper extremity dysfunction after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2015; 96:981–990.
- Daly JJ et al. Long-Dose Intensive Therapy Is Necessary for Strong, Clinically Significant, Upper Limb Functional Gains and Retained Gains in Severe/Moderate Chronic Stroke. Neurorehabil Neural Repair. 1545968319846120 (2019). doi:10.1177/1545968319846120.
- Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry jnnp-2018-319954 (2019). doi:10.1136/jnnp-2018-319954
- Pollock A et al. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. CD010820 (2014). doi:10.1002/14651858.CD010820.pub2
- Hoffmann TC et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348;g1687.
- Walker MF et al. Improving the Development, Monitoring and Reporting of Stroke Rehabilitation Research: Consensus-Based Core Recommendations from the Stroke Recovery and Rehabilitation Roundtable. Neurorehabil Neural Repair. 2017;31:877–884.
- Balasubramanian S, Colombo R, Sterpi I, Sanguineti V, Burdet E. Robotic assessment of upper limb motor function after stroke. Am J Phys Med Rehabil. 2012;91:S255-269.
- Cheung VCK et al. Muscle synergy patterns as physiological markers of motor cortical damage. Proc. Natl. Acad. Sci. U.S.A. 2012;109:14652–14656.
Correspondence to: Nick Ward, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG.
Conflict of interest statement: None declared.
Provenance and peer review: Submitted and externally reviewed.
Date first submitted: 15/4/19
Date resubmitted after peer review: 10/6/19
Acceptance date: 11/6/19
To cite: Ward NS, Kelly K, Brander F. ACNR 2019;18(4):20-22
Published online: 1/8/19