Robotic Assisted Upper Limb Training Post Stroke: A Randomized Control Trial Using Combinatory Approach Toward Reducing Workforce Demands.

Post stroke upper limb rehabilitation is a challenging problem with poor outcomes as 40% of survivors have functionally useless upper limbs. Robot-aided therapy (RAT) is a potential method to alleviate the effort of intensive, task-specific, repetitive upper limb exercises for both patients and therapists. The present study aims to investigate how a time matched combinatory training scheme that incorporates conventional and RAT, using H-Man, compares with conventional training toward reducing workforce demands. In a randomized control trial (NCT02188628, www.clinicaltrials.gov), 44 subacute to chronic stroke survivors with first-ever clinical stroke and predominant arm motor function deficits were recruited and randomized into two groups of 22 subjects: Robotic Therapy (RT) and Conventional Therapy (CT). Both groups received 18 sessions of 90 min; three sessions per week over 6 weeks. In each session, participants of the CT group received 90 min of 1:1 therapist-supervised conventional therapy while participants of the RT group underwent combinatory training which consisted of 60 min of minimally-supervised H-Man therapy followed by 30 min of conventional therapy. The clinical outcomes [Fugl-Meyer (FMA), Action Research Arm Test and, Grip Strength] and the quantitative measures (smoothness, time efficiency, and task error, derived from two robotic assessment tasks) were independently evaluated prior to therapy intervention (week 0), at mid-training (week 3), at the end of training (week 6), and post therapy (week 12 and 24). Significant differences within group were observed at the end of training for all clinical scales compared with baseline [mean and standard deviation of FMA score changes between baseline and week 6; RT: Δ4.41 (3.46) and CT: Δ3.0 (4.0); p < 0.01]. FMA gains were retained 18 weeks post-training [week 24; RT: Δ5.38 (4.67) and week 24 CT: Δ4.50 (5.35); p < 0.01]. The RT group clinical scores improved similarly when compared to CT group with no significant inter-group at all time points although the conventional therapy time was reduced to one third in RT group. There were no training-related adverse side effects. In conclusion, time matched combinatory training incorporating H-Man RAT produced similar outcomes compared to conventional therapy alone. Hence, this study supports a combinatory approach to improve motor function in post-stroke arm paresis. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02188628.

A preliminary study on the relationship between proprioceptive deficits and motor functions in chronic stroke patients.

Although motor and sensory impairments of the upper limb after stroke have been widely studied, the relationship between sensory deficits and motor functions has been less thoroughly explored. In this ongoing study, we investigated the relationship between proprioceptive impairments and motor functions with 20 chronic stroke survivors. Their proprioceptive abilities were assessed with a passive joint position matching test using H-Man and their motor functions were assessed with ARAT (Action Research Arm Test) and FMA (Fugl Meyer Upper Extremity Assessment) clinical scores. The assessments were conducted before, during and after the therapy. Results indicated a significant difference between the proprioceptive outcomes of healthy and stroke participants (at baseline) in both matching accuracy (absolute error, p=0.02) and precision (variability of the signed error, p=0.03). Significant correlations were found between the proprioceptive assessment outcomes (assessed before the beginning of the motor rehabilitation) of stroke participants with impaired proprioception and their ARAT clinical scores assessed at the first follow-up (week 12) (rho =- 0.74 and p=0.047 for the absolute error; rho =-0.78 and p= 0.03 for the variability of the signed error). The results from this preliminary study indicated a significant relationship between proprioceptive impairments and motor function performances in proprioceptively impaired chronic stroke participants.

Quantitative assessment of motor functions post-stroke: Responsiveness of upper-extremity robotic measures and its task dependence.

Technology aided measures offer a sensitive, accurate and time-efflcient approach for the assessment of sensorimotor function after neurological impairment compared to standard clinical assessments. This preliminary study investigated the relationship between task definition and its effect on robotic measures using a planar, two degree of freedom, robotic-manipulator (H-Man). Four chronic stroke participants (49.5±11.95 years, 2 Female, FMA: 37.5±13.96) and eight healthy control participants (26.25± 4.70 years, 2 Female) participated in the study. Motor functions were evaluated using line tracing and circle tracing tasks with dominant and nondominant hand of healthy and affected vs. non affected hand of stroke participants. The results show significant dependence of quantitative measures on investigated tasks.

Self-Paced Reaching after Stroke: A Quantitative Assessment of Longitudinal and Directional Sensitivity Using the H-Man Planar Robot for Upper Limb Neurorehabilitation.

Technology aided measures offer a sensitive, accurate and time-efficient approach for the assessment of sensorimotor function after neurological insult compared to standard clinical assessments. This study investigated the sensitivity of robotic measures to capture differences in planar reaching movements as a function of neurological status (stroke, healthy), direction (front, ipsilateral, contralateral), movement segment (outbound, inbound), and time (baseline, post-training, 2-week follow-up) using a planar, two-degrees of freedom, robotic-manipulator (H-Man). Twelve chronic stroke (age: 55 ± 10.0 years, 5 female, 7 male, time since stroke: 11.2 ± 6.0 months) and nine aged-matched healthy participants (age: 53 ± 4.3 years, 5 female, 4 male) participated in this study. Both healthy and stroke participants performed planar reaching movements in contralateral, ipsilateral and front directions with the H-Man, and the robotic measures, spectral arc length (SAL), normalized time to peak velocities (TpeakN ), and root-mean square error (RMSE) were evaluated. Healthy participants went through a one-off session of assessment to investigate the baseline. Stroke participants completed a 2-week intensive robotic training plus standard arm therapy (8 × 90 min sessions). Motor function for stroke participants was evaluated prior to training (baseline, week-0), immediately following training (post-training, week-2), and 2-weeks after training (follow-up, week-4) using robotic assessment and the clinical measures Fugl-Meyer Assessment (FMA), Activity-Research-Arm Test (ARAT), and grip-strength. Robotic assessments were able to capture differences due to neurological status, movement direction, and movement segment. Movements performed by stroke participants were less-smooth, featured longer TpeakN , and larger RMSE values, compared to healthy controls. Significant movement direction differences were observed, with improved reaching performance for the front, compared to ipsilateral and contralateral movement directions. There were group differences depending on movement segment. Outbound reaching movements were smoother and featured longer TpeakN values than inbound movements for control participants, whereas SAL, TpeakN , and RMSE values were similar regardless of movement segment for stroke patients. Significant change in performance was observed between initial and post-assessments using H-Man in stroke participants, compared to conventional scales which showed no significant difference. Results of the study indicate the potential of H-Man as a sensitive tool for tracking changes in performance compared to ordinal scales (i.e., FM, ARAT).