Introduction: A scoping review provides a means to synthesize and present a large body of literature on a broad topic, such as methods for various upper extremity activity-based therapy (ABT) interventions.
Objectives: To describe our scoping review protocol to evaluate peer-reviewed articles focused on ABT interventions for individuals with neurologically impaired upper extremities.
Methods: At Jefferson College of Health Professions and Sidney Kimmel Medical College at Jefferson, Philadelphia, the authors will follow this protocol to conduct a scoping review by establishing a research question and conducting a search of bibliographic databases to identify relevant studies. Using specific inclusion and exclusion criteria, abstracts will be screened and full-text articles will be reviewed for inclusion in charting, summarizing, and reporting results of appropriate studies.
Conclusion: This protocol will guide the scoping review process to develop a framework for establishing a noninvasive ABT intervention informed by evidence for individuals with neurologically impaired upper extremities.
Although published literature and evidence to support medical practice is becoming more abundant, it is not known how well available evidence supports the full spectrum of hand therapy practice.
The aim of this mapping review was to identify strengths and/or gaps in the available literature as compared with the hand therapy scope of practice to guide future research.
A systematic search and screening was conducted to identify evidence published from 2006 to 2015. Descriptive data from 191 studies were extracted, and the diagnoses, interventions, and outcomes used in the literature were compared with the hand therapy scope of practice.
Osteoarthritis, tendon surgeries, and carpal tunnel syndrome were most frequently studied. Exercise, education, and orthotic interventions were most common, each used in more than 100 studies; only 12 studies used activity-based interventions. Primary outcome measures included range of motion, pain/symptoms, strength, and functional status.
Abundant high-quality research exists for a portion of the hand therapy scope of practice; however, there is a paucity of evidence for numerous diagnoses and interventions.
More evidence is needed for complex diagnoses and activity-based interventions as well as behavioral and quality-of-care outcomes.
Powered robotic exoskeletons are a potential intervention for gait rehabilitation in stroke to enable repetitive walking practice to maximize neural recovery. As this is a relatively new technology for stroke, a scoping review can help guide current research and propose recommendations for advancing the research development.
The aim of this scoping review was to map the current literature surrounding the use of robotic exoskeletons for gait rehabilitation in adults post-stroke. Five databases (Pubmed, OVID MEDLINE, CINAHL, Embase, Cochrane Central Register of Clinical Trials) were searched for articles from inception to October 2015. Reference lists of included articles were reviewed to identify additional studies. Articles were included if they utilized a robotic exoskeleton as a gait training intervention for adult stroke survivors and reported walking outcome measures.
Of 441 records identified, 11 studies, all published within the last five years, involving 216 participants met the inclusion criteria. The study designs ranged from pre-post clinical studies (n = 7) to controlled trials (n = 4); five of the studies utilized a robotic exoskeleton device unilaterally, while six used a bilateral design. Participants ranged from sub-acute (<7 weeks) to chronic (>6 months) stroke. Training periods ranged from single-session to 8-week interventions. Main walking outcome measures were gait speed, Timed Up and Go, 6-min Walk Test, and the Functional Ambulation Category.
Meaningful improvement with exoskeleton-based gait training was more apparent in sub-acute stroke compared to chronic stroke. Two of the four controlled trials showed no greater improvement in any walking outcomes compared to a control group in chronic stroke.
In conclusion, clinical trials demonstrate that powered robotic exoskeletons can be used safely as a gait training intervention for stroke. Preliminary findings suggest that exoskeletal gait training is equivalent to traditional therapy for chronic stroke patients, while sub-acute patients may experience added benefit from exoskeletal gait training. Efforts should be invested in designing rigorous, appropriately powered controlled trials before powered exoskeletons can be translated into a clinical tool for gait rehabilitation post-stroke.
Stroke is a leading cause of acquired disability in the world, with increasing survival rates as medical care and treatment techniques improve . This equates to an increasing population with stroke-related disability [1, 2], who experience limitations in communication, activities of daily living, and mobility . A majority of this population ranks recovering the ability to walk or improving walking ability among their top rehabilitation goals [4, 5]; furthermore, the ability to walk is a determining factor as to whether an individual is able to return home after their stroke . However, 30 – 40 % of stroke survivors have limited or no walking ability even after rehabilitation [7, 8] and so there is an ongoing need to advance the efficacy of gait rehabilitation for stroke survivors.
Powered robotic exoskeletons are a recently developed technology that allows individuals with lower extremity weakness to walk . These wearable robots strap to the legs and have electrically actuated motors that control joint motion to automate overground walking. Powered exoskeletons were originally designed to be used as an assistive device to allow individuals with complete spinal cord injury to walk . However, because they allow for walking without overhead body weight support or a treadmill, they have gained attention as an alternate intervention for gait rehabilitation in other populations such as stroke where repetitive gait training has been shown to yield improvements in walking function [11, 12]. Several powered exoskeletons are already commercially available, such as the Ekso (Ekso Bionics, USA), Rewalk (Rewalk Robotics, Israel), and Indego (Parker Hannifin, USA) exoskeletons, with more being developed.
There have been many forms of gait retraining proposed for stroke survivors. Conventional physical therapy gait rehabilitation leads to improvements in speed and endurance , particularly when conducted early post-stroke . However, conventional gait retraining using hands-on assistance can be taxing on therapists; the number of steps actually taken in a session reflects this and has been shown to be low in sub-acute hospital rehabilitation . Many of the proposed technology-based gait intervention strategies have focused on reducing the physical strain to therapists while increasing the amount of walking repetition that individuals undergo. For example, body weight-supported treadmill training (BWSTT) allows therapists to manually move the hemiparetic limb in a cyclical motion while the patient’s trunk and weight are partially supported by an overhead harness system; this has shown improvements in stroke survivors’ gait speed and endurance compared to conventional gait training , yet still places a high physical demand on therapists. Advances in technology have led to treadmill-based robotics, such as the Lokomat (Hocoma, Switzerland), LOPES (University of Twente, Netherlands), and G-EO (Reha-Technology, Switzerland), which have bracing that attaches to the patient’s legs to take them through a walking motion on the treadmill. The appeal of this technology is that it can provide substantially higher repetitions for walking practice than BWSTT without placing strain on therapists; however, there is conflicting evidence regarding the efficacy of treadmill-based robotics for gait training compared to conventional therapy or BWSTT. Some studies have shown that treadmill robotics improve walking independence in stroke [17, 18] but do not improve speed or endurance [18, 19]. There has been some sentiment that such technology has not lived up to the expectations originally predicted based on theory and practice . One argument is that these treadmill robotics with a pre-set belt speed, combined with body weight support, create an environment where the patient has less control over the initiation of each step ; another argument against treadmill-based gait training is the lack of variability in visuospatial flow, which is an essential challenge of overground walking . Powered robotic exoskeletons, though similar in structure to treadmill-based robotics, differ in that they require active participation from the user for both swing initiation and foot placement; for example, some exoskeletons have control strategies which will only assist the stepping motion when it detects adequate lateral weight-shifting . Furthermore, because the powered exoskeletons are used for overground walking, it requires the user to be responsible for maintaining trunk and balance control, as well as navigating their path over varying surfaces.
While these powered exoskeletons hold promise, the literature surrounding their use for gait training is only just beginning to gather, with the majority focusing on spinal cord injury [22, 23, 24]. Several [25, 26, 27] systematic reviews have shown safe usage, positive effects as an assistive device, and exercise benefits for individuals with spinal cord injury. Only one systematic review  specifically focusing on powered exoskeletons has included studies involving stroke participants, though studies in spinal cord injury and other conditions were also included. This review focused exclusively on the Hybrid Assistive Limb (HAL) exoskeleton (Cyberdyne, Japan), (which currently is not approved for clinical use outside of Japan), and found beneficial effects on gait function and walking independence; however, the results were combined generally across all included patient populations and not specifically for stroke.
Given that this is a relatively new intervention for stroke, the objective of this scoping review was to map the current literature surrounding the use of powered robotic exoskeletons for gait rehabilitation in post-stroke individuals and to identify gaps in the research. The second objective of this scoping review was to preliminarily explore the efficacy of exoskeleton-based gait rehabilitation in stroke. As this is a relatively new technology for stroke, a scoping review can help guide current research and propose recommendations for advancing the technology.
Individuals with motor impairments may be limited in the realization of their activities of daily living, their leisure activities or their work activities. To overcome these limitations, the involvement of a caregiver and/or the acquisition of assistive devices are often necessary. In the last few years, more and more assistance robots have been developed and the interest they generate is growing. Among these, there are robotic arms aiming to improve the functional autonomy of people living with upper limb motor impairment.
Since the effects and impacts of the use of a robotic arm by these individuals are not well documented, this study aims at obtaining an overview of what has been reported until now in the scientific literature.
To achieve this, we undertook a scoping review. Four databases were searched: PubMed, Embase, Compendex and Scopus. Following a selection process involving different steps, 36 papers were retained. Relevant data, the same for each paper, were recorded. The quality of the selected papers was evaluated using the Critical Review Form for Quantitative Studies (McMaster University). The papers were also classified according to the Canadian Model of Occupational Performance and Engagement (CMOP-E). The CMOP-E allowed us to identify the occupational domains addressed in the retained studies.
Twenty-four papers presented results related to basic activities of daily living, 18 to instrumental activities of daily living, 9 to work activities, 8 to leisure activities, 2 to school and 2 to games. The quality assessment revealed a mean score of 8.8/15, demonstrating that the effects and impacts of robotic arms have to establish in a more rigorous way. The utilisation of a robotic arm has more positive than negative effects and impacts on the various occupational domains.
These assistive devices have the potential to be successfully integrated into the users’ life, but some improvements are desirable to increase the satisfaction related to their utilization.