Posts Tagged stroke rehabilitation

[Abstract] Comparison of the effects of and usability of active and active-assistive rehabilitation robots for the upper extremity function among patients with stroke: a single-blinded randomized controlled pilot study – Full Text PDF


Background: Robotic rehabilitation of stroke survivors with upper extremity dysfunction yields different outcomes depending on the robot type. Considering that excessive dependence on assistive force provided by robots may interfere with the patient’s active learning and participation, we hypothesized that the use of an active-assistive robot does not lead to a more meaningful difference with respect to upper extremity rehabilitation than the use of an active robot. Accordingly, we aimed to evaluate the differences in the clinical and kinematic outcomes between active and active-assistive robotic rehabilitation among stroke survivors.

Methods: In this single-blinded randomized controlled trial, we assigned 20 stroke survivors with upper extremity dysfunction (Medical Research Council scale score, 3 or 4) to the active (ACT) and active-assistive (ACAS) robotic rehabilitation groups in a 1:1 ratio and administered 20 sessions of 30-minute robotic intervention (5 days/week, 4 weeks). The primary (Wolf Motor Function Test [WMFT]-score and -time: measures activity), and secondary (Fugl-Meyer Assessment [FMA] and Stroke Impact Scale [SIS] scores: measure impairment and participation, respectively; kinematic outcomes) outcome measures were determined at baseline, after 2 and 4 weeks of the intervention, and 4 weeks after the end of the intervention. Furthermore, we evaluated the usability of the robotic devices by conducting interviews with the patients, therapists, and physiatrists.

Results: In both the groups, the WMFT-score and -time improved over the course of the intervention. Time had a significant effect on the WMFT-score and -time, FMA-UE, FMA-prox, and SIS-strength; group × time interaction had a significant effect on SIS-function and SIS-social participation (all, p <0.05). The ACT group showed better improvement in participation and smoothness than the ACAS group. In contrast, the ACAS group exhibited better improvement in mean speed.

Conclusions: There were no differences between the two groups regarding the impairment and activity domains. However, the ACT robots were more beneficial than ACAS robots regarding participation and smoothness. Considering the high cost and complexity of ACAS robots, ACT robots may be more suitable for robotic rehabilitation in stroke survivors who can perform voluntary movement.


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[Abstract] The Use of Virtual Reality Applications in Stroke Rehabilitation for Older Adults : Technology Enhanced Relearning


After stroke rehabilitation is a long-term relearning process that can be divided into cognitive relearning, speech relearning and motoric relearning. Today with an aging population it it interesting to look at technology enhanced and game-based solutions that can facilitate independent living for older adults. The aim of the study was to identify and categorise recently conducted research in the field of virtual reality applications for older adults’ relearning after stroke. This study was conducted as a systematic literature review with results categorised in a pre-defined framework. Findings indicate that virtual reality-based stroke rehabilitation is an emerging field that can renew after stroke rehabilitation. Most found studies were on stroke patients’ motoric and game-based relearning, and with less studies on speech rehabilitation. The conclusion is that virtual reality systems should not replace the existing stroke rehabilitation, but rather to have the idea of combining and extending the traditional relearning process where human-to-human interaction is essential. Finally, there are no virtual reality applications that can fit all stroke patients’ needs, but a thoughtful selection of exercises that matches each individual user would have a potential to enhance the current relearning therapy for older adults after stroke.

via The Use of Virtual Reality Applications in Stroke Rehabilitation for Older Adults : Technology Enhanced Relearning

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[ARTICLE] Self-Support Biofeedback Training for Recovery From Motor Impairment After Stroke – Full Text


Unilateral arm paralysis is a common symptom of stroke. In stroke patients, we observed that self-guided biomechanical support by the nonparetic arm unexpectedly triggered electromyographic activity with normal muscle synergies in the paretic arm. The muscle activities on the paretic arm became similar to the muscle activities on the nonparetic arm with self-supported exercises that were quantified by the similarity index (SI). Electromyogram (EMG) signals and functional near-infrared spectroscopy (fNIRS) of the patients (n=54) showed that self-supported exercise can have an immediate effect of improving the muscle activities by 40–80% according to SI quantification, and the muscle activities became much more similar to the muscle activities of the age-matched healthy subjects. Using this self-supported exercise, we investigated whether the recruitment of a patient’s contralesional nervous system could reactivate their ipsilesional neural circuits and stimulate functional recovery. We proposed biofeedback training with self-supported exercise where the muscle activities were visualized to encourage the appropriate neural pathways for activating the muscles of the paretic arm. We developed the biofeedback system and tested the recovery speed with the patients (n=27) for 2 months. The clinical tests showed that self-support-based biofeedback training improved SI approximately by 40%, Stroke Impairment Assessment Set (SIAS) by 35%, and Functional Independence Measure (FIM) by 20%.


Stroke is the leading cause of long-term disability worldwide. Of more than 750,000 stroke victims in the United States each year [1], approximately two-thirds survive and require immediate rehabilitation to recover lost brain functions [2]. These stroke rehabilitation programs, of which direct and indirect costs were estimated to be 73.7 billion dollars in 2010 [3], aim to help survivors gain physical independence and better quality of life.

Stroke damage typically interrupts blood flow within one brain hemisphere, resulting in unilateral motor deficits, sensory deficits, or both. The preservation of long-term neural and synaptic plasticity is essential for the functional reorganization and recovery of neural pathways disrupted by stroke [4]–[5][6]. Stroke survivors typically require long-term, intensive rehabilitation training due to the length of time required for these recovery processes [7], [8]. The typical time course for partial recovery of arm movement after mild to moderate unilateral stroke damage is 2 to 6 months, depending on the severity of tissue damage and the latency of treatment initiation [9], [10]; however, patients with severe damage require additional months to years of rehabilitation. Given the economic burden on patients’ families and the medical system, novel rehabilitation methods that promote rapid and complete functional recovery are needed, along with a better understanding of the functional mechanisms and neural circuits that can participate in potential therapeutic processes. The identification of rehabilitation methods that can more effectively recover brain functions in the damaged hemisphere by re-engaging dormant motor functions should be a major global objective, from both economic and societal perspectives. Such an objective would require the interface of biology, medical research, and clinical practice [4].

Recently, candidate brain areas that become activated during stroke recovery have been identified in patients and animal models [7]. Brain imaging studies during stroke recovery suggest that the extent of functional motor recovery is associated with an increase in neuronal activity in the sensorimotor cortex of the ipsilesional hemisphere [10]–[11][12]. Other work has suggested that repetitive sensorimotor tasks may promote cortical reorganization and functional recovery in the ipsilesional area by increasing bilateral cortical activity to enhance neuroplasticity [13]. Activation in the contralesional hemisphere is also observed in the early stages of post-stroke patients. This activation has been explained by the emergence of communication in corticospinal projections that are silent in the healthy state [11], and it may also contribute to movement-related neural activity on the ipsilesional limb [14], [15]. Functional brain imaging studies show that activity of the contralesional hemisphere is increased early after stroke and gradually declines as recovery progresses [16]. The functional relevance of contralesional recruitment remains unclear [17], [18]. Some reported studies have linked high abnormal activity to a high inhibitory signaling drive onto the ipsilesional cortex [19], which may be a major contributor to motor impairment [6], [20]. Recent studies have also investigated the benefits of activating the contralesional and/or ipsilesional hemispheres in functional motor recovery using brain-computer interface (BCI) and transcranial magnetic stimulation (TMS) therapies [21], [22].

Current stroke rehabilitation approaches have largely focused on paretic limb rehabilitation interventions such as muscle strengthening and endurance training [23], forced-use therapy [24], constraint-induced exercise [25], robot therapy with biofeedback [26], nonparetic limb interventions (e.g., mirror-therapy [27], [28]), or bilateral/bimanual training [29], [30]. However, to date, none have clearly investigated how the use of a patient’s unaffected neural circuits in the healthy cortical hemisphere, or in the local peripheral circuit, affect the impaired limb in terms of functional rehabilitation of the bilateral cortical sensorimotor network [31].

In this study, we investigated a motor recovery approach for post-stroke unilateral arm impairment that combined sensory feedback, motor control, and motor intention. While observing a patient cohort with unilateral stroke damage and arm movement impairment, we found that a specific self-guided motion, which we termed self-supported exercise, surprisingly reactivated a healthy muscles pattern in the paretic arm. The key of the self-supported exercise is use of the nonparetic arm as a support to help move the paretic arm. First, we will show the observation of appropriate muscle recruitment and reduction of abnormal muscle synergies for post-stroke patients during the self-supported exercise, which are a common problem in stroke recovery [32]. Then, we conduct the experiments of functional imaging and electromyography recordings and characterized the neurobiology and physiology of this self-supported exercise. Based on this mechanism, we designed a rehabilitation program involving biofeedback-aided self-supported exercises that employ a patients’ self-initiated motor intention. The results of the comparative experiments between the feedback training cohorts and the control cohorts show that this method results in efficient recovery from post-stroke motion paralysis. Finally, we discuss the significance of our findings for the design of biologically-based stroke rehabilitation.[…]

via Self-Support Biofeedback Training for Recovery From Motor Impairment After Stroke – IEEE Journals & Magazine

FIGURE 2. - The four types of exercises.

FIGURE 2.The four types of exercises.




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[Abstract] Developments and clinical evaluations of robotic exoskeleton technology for human upper-limb rehabilitation

The development of upper limb and lower extremity robotic exoskeletons has emerged as a way to improve the quality of life as well as act as a primary rehabilitation device for individuals suffering from stroke or spinal cord injury. This paper contains extractions from the database of robotic exoskeleton for human upper limb rehabilitation and prime factors behind the burden of stroke. Various studies on stroke-induced deficiency from different countries were included in the review. The data were extracted from both clinical tests and surveys. Though there have been splendid advancements in this field, they still present enormous challenges. This paper provides the current developments, progress and research challenges in exoskeleton technology along with future research directions associated with the field of exoskeletons and orthosis. Robot-assisted training (RT) was found to be more effective than conventional training (CT) sessions. The present research articles in this field have many weaknesses as they do not cover the systematic review including the clinical studies and various surveys that lay a foundation for the requirement of robotic assistive devices. This review paper also discusses various exoskeleton devices that have been clinically evaluated.


via Developments and clinical evaluations of robotic exoskeleton technology for human upper-limb rehabilitation: Advanced Robotics: Vol 0, No 0

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Recently, the functional near-infrared spectroscopy (600–900nm electromagnetic wave) (ff-NIRS)-based rehabilitation researches have been studied for understanding the human brain. Although ff-NIRS can successfully measure the relative blood concentration changes of oxy-hemoglobin (HbO) and deoxy-hemoglobin (HbR) as an assessment tool to identify significant clinical intervention during pre- and post-rehabilitation therapy for stroke survivors, there is insufficient information particularly on the use of ff-NIRS as a clinical translation in upper extremity function rehabilitation. In order to widely utilize the ff-NIRS for upper extremity rehabilitation, device information, experiment design, measurement procedure, and analyzing method are described for clinician aspect in this study. In addition, further research trend was introduced from previous studies for stroke survivor rehabilitation. The authors believed that the information provided in this study can be a useful guideline to encourage future researchers to focus on upper extremity function rehabilitation of stroke survivors.




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[Abstract] Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials

Background: Stroke is a major cause of life-long disability in adults, associated with poor quality of life. Virtual reality (VR)-based therapy systems are known to be helpful in improving motor functions following stroke, but recent clinical findings have not been included in the previous publications of meta-analysis studies.

Aims: This meta-analysis was based on the available literature to evaluate the therapeutic potential of VR as compared to dose-matched conventional therapies (CT) in patients with stroke.

Methods: We retrieved relevant articles in EMBASE, MEDLINE, PubMed, and Web of Science published between 2010 and February 2019. Peer-reviewed randomized controlled trials that compared VR with CT were included.

Results: A total of 27 studies met the inclusion criteria. The analysis indicated that the VR group showed statistically significant improvement in the recovery of UL function (Fugl-Meyer Upper Extremity [FM-UE]: n = 20 studies, Mean Difference [MD] = 3.84, P = .01), activity (Box and Block Test [BBT]: n = 13, MD = 3.82, P = .04), and participation (Motor Activity Log [MAL]: n = 6, MD = 0.8, P = .0001) versus the control group.

Conclusion: VR appears to be a promising therapeutic technology for UL motor rehabilitation in patients with stroke.


via Virtual reality therapy for upper limb rehabilitation in patients with stroke: a meta-analysis of randomized clinical trials: Brain Injury: Vol 0, No 0

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[Abstract] The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis

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.


via The Role of Robotic Path Assistance and Weight Support in Facilitating 3D Movements in Individuals With Poststroke Hemiparesis – Preeti Raghavan, Seda Bilaloglu, Syed Zain Ali, Xin Jin, Viswanath Aluru, Megan C. Buckley, Alvin Tang, Arash Yousefi, Jennifer Stone, Sunil K. Agrawal, Ying Lu, 2020

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[Abstract] Cable driven exoskeleton for upper-limb rehabilitation: A design review


One of the primary reasons for long-term disabilities in the world is strokes. The causes of these cerebrovascular diseases are various, i.e., high blood pressure, heart disease, etc. For those who survive strokes, this affectation causes lose in mobility of extremities, requiring the intervention of long session with a therapeutic professional to recover the movement of the impair limb. Hence, the investment to threat this condition is usually high. Those devices permit the user a mean to conduct the therapies without the constant supervision of a professional. Furthermore, exoskeletons are capable of maintaining a detailed recording of the forces and movements developed for the patients throughout the session. However, the construction of an exoskeleton is not cheap principally for the actuation systems, especially if the exoskeleton requires the actuator to be placed at the joints of the user; thus, the actuator at a joint would have to withstand the load of the actuator of the following joint and so on.

Researchers have addressed this drawback by applying cable transmission systems that allow the exoskeleton to place their actuator at a base, reducing the weight of their design and decreasing their cost. Thus, this paper reviews the principal models of cable-driven exoskeleton for stroke rehabilitation focusing on the upper-limb. The analysis departs from the study of the anatomy of the arm in all its extension, including the shoulder, elbow, wrist, fingers, and the thumb. Besides, it also includes the mechanical consideration the researchers have to take in mind to design a proper exoskeleton. Then, the article presents a compendium of the different transmission systems found in the literature, addressing their advantages, disadvantages and their requirements for the design. Lastly, the paper reviews the cable-driven exoskeleton for stroke rehabilitation of the upper limb. Again, for this analysis, it is included the design consideration of each prototype focusing on their advantages in terms of anatomical mechanics.


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[Abstract] Effects of the multisensory rehabilitation product for home-based hand training after stroke on cortical activation by using NIRS methods


  • NIRS was designed to detect effect of stimulation on cortical activation response.
  • Multisensory environment can induce cortical activation in most brain regions.
  • Multisensory stimuli are more beneficial to neural activities and cognitive control.
  • Activation of the motor cortex is closely related to the cognitive performance.



This study aimed to assess the effects of the multisensory rehabilitation product for stroke patients on cortical activation response through near-infrared spectroscopy (NIRS).


The music rehabilitation glove (MRG), multisensory rehabilitation product, was developed with a user-centered design concept. The 40-channel NIRS system monitored the cortical activation changes in the motor cortex (MC), prefrontal cortex (PFC), temporal lobe (TL) and occipital lobe (OL) of 22 young subjects during “sequential finger-to-thumb opposition movements (SFTOM)” phase of traditional training and “musical finger-to-thumb opposition movements (MFTOM)” phase of MRG training.


The two phases of training showed significant activation (P < 0.05) in the cerebral cortex compared with baseline, with more activation during MFTOM in the MC, PFC and TL. Compared with SFTOM, there were 22 channels of cortical activation in MFTOM that had significant enhancements (P < 0.05). There was also a significant positive correlation between the prefrontal cortex and motor cortex in the cortical activation.


According to these results, MFTOM-induced cortical activation in the MC, PFC and TL with visual, auditory and tactile stimuli was stronger than SFTOM, providing evidence that the multisensory stimulation is more beneficial to cortical activation and cognitive control to promote neurological recovery.

via Effects of the multisensory rehabilitation product for home-based hand training after stroke on cortical activation by using NIRS methods – ScienceDirect

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[Abstract] Fugl-Meyer Assessment Scores Are Related With Kinematic Measures in People with Chronic Hemiparesis after Stroke


Background: Stroke often results in motor impairment and limited functional capacity. This study aimed to verify the relationship between widely used clinical scales and instrumented measurements to evaluate poststroke individuals with mild, moderate, and severe motor impairment.

Methods: This cross-sectional study included 34 participants with chronic hemiparesis after stroke. Fugl-Meyer Assessment and Modified Ashworth Scale were used to quantify upper and lower limb motor impairment and the resistance to passive movement (i.e., spasticity), respectively. Upper limb Motor performance (movement time and velocities) and movement quality (range of motion, smoothness and trunk displacement) were analyzed during a reaching forward task using an optoelectronic system (instrumented measurement). Lower limb motor performance (gait and functional mobility parameters) was assessed by using an inertial measurement unit system.

Findings: Fugl-Meyer Assessment correlated with motor performance (upper and lower limbs) and with movement quality (upper limb). Modified Ashworth scale correlated with movement quality (upper limb). Cutoff values of 9.0 cm in trunk anterior displacement and .57 m/s in gait velocity were estimated to differentiate participants with mild/moderate and severe compromise according to the Fugl-Meyer Assessment.

Conclusions: These results suggest that the Fugl-Meyer Assessment can be used to infer about motor performance and movement quality in chronic poststroke individuals with different levels of impairment.


via Fugl-Meyer Assessment Scores Are Related With Kinematic Measures in People with Chronic Hemiparesis after Stroke – ScienceDirect

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