Intensive Sensorimotor Arm Training Mediated by Therapist or Robot Improves Hemiparesis in Patients With Chronic Stroke

Abstract

Investigators have demonstrated that a variety of intensive movement training protocols for persistent upper limb paralysis in patients with chronic stroke (6 months or more after stroke) improve motor outcome. This randomized controlled study determined in patients with upper limb motor impairment after chronic stroke whether movement therapy delivered by a robot or by a therapist using an intensive training protocol was superior. Robotic training (n = 11) and an intensive movement protocol (n = 10) improved the impairment measures of motor outcome significantly and comparably; there were no significant changes in disability measures. Motor gains were maintained at the 3-month evaluation after training. These data contribute to the growing awareness that persistent impairments in those with chronic stroke may not reflect exhausted capacity for improvement. These new protocols, rendered by either therapist or robot, can be standardized, tested, and replicated, and potentially will contribute to rational activity-based programs.Key Words: Stroke-Recovery of function-Rehabilitation. S troke causes permanent disability that is dependent in large part on motor impairment, and although most patients walk independently, often with a device or orthosis, recovery of arm and hand function occurs less often.1-3 Despite the tendency to focus restorative treatments in the weeks soon after the stroke inasmuch as motor improvements, in general, plateau 3 to 6 months later, 4,5 a new convergence of animal and human studies has focused on the treatment efficacy of repetitive exercise of the paralyzed upper limb to alter motor performance in patients with chronic stroke.5-13 These emerging data have stimulated the clinical development of activity-based techniques based on a combination of the control of guidance and speed of the movements and intensive practice.14-19 In patients with chronic stroke referred to an outpatient clinic, we have attempted to establish a standard therapistdelivered intensive physical therapy program, and then to compare it to a treatment with a robotic-driven protocol that has been demonstrated to alter motor performance significantly in patients with chronic stroke. 15 METHODS Study Population and DesignWe screened 55 patients with stroke referred to the outpatient clinic and who had impaired arm and hand mobility for at least 6 months. Twenty-one patients who met the inclusion criteria were randomized to robotic training that was identical to a past robotic trial 15 or to an intensive upper extremity movement-based treatment from a therapist. The therapist's protocol was designed by a group of senior therapists working in the stroke recovery program, and represented a combination of common practice treatments that, for the purpose of this experiment, matched the session duration, number, and timing of robot treatments. Patients were measured monthly for 3 months to test whether there was spontaneous improvement. Measurements of motor impairment were also obtained at the mid-point and the end of trai...

Changes in passive ankle stiffness and its effects on gait function in people with chronic stroke

“…In light of prior findings on passive ankle stretching [20][21][22][23] as well as our experience in upper-limb rehabilitation in stroke [26][27][28][29][30][31][32][33], we hypothesized that after 6 wk of anklebot training, the paretic PAS would change in the trained sagittal plane, i.e., DF-PF, but not in the untrained frontal plane, i.e., INV-EV. Moreover, we expected that, to be functionally meaningful, a robotic treatment protocol must emphasize a sequence and timing of sensorimotor stimuli similar to those naturally occurring during gait.…”

Potential of robots as next-generation technology for clinical assessment of neurological disorders and upper-limb therapy

“…This plateau is determined by the same problematic clinical tools already discussed. Some authors have suggested that this plateau may actually be the patients consolidating their poststroke practice experience rather than optimal biological recovery [85][86][87] and this, in itself, has important implications in the timing of how we deliver treatment after a stroke.…”

“…Some studies have been criticized for lacking appropriate control groups, because control groups were not present or did not receive an equivalent amount of therapy as the treatment group [104,[112][113]. Other more recent studies have given control subjects an equivalent amount of traditional rehabilitation treatment [85] to control for the confound of differing intensity between control and robotic treatment groups. While we agree that an increased amount of therapy to robotic intervention groups represents a confound in terms of study design, it may actually represent a more real-world scenario then some previous critics have recognized.…”

Invasive Neurostimulation in Stroke Rehabilitation

“…Disability adds to the costs of disease management that total $74 billion/ year [4]. Developing methods to effectively alleviate residual deficits will reduce health and economic burden of stroke.Several evidence-based rehabilitative approaches have been developed with prominent ones, including neuromuscular electrical stimulation [5], motor learning [6], robotic training [7] constraint-induced movement therapy [8], and bilateral arm training [9], etc. In spite of extensive therapy, recovery is frequently incomplete [10].…”

“…Several evidence-based rehabilitative approaches have been developed with prominent ones, including neuromuscular electrical stimulation [5], motor learning [6], robotic training [7] constraint-induced movement therapy [8], and bilateral arm training [9], etc. In spite of extensive therapy, recovery is frequently incomplete [10].…”