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Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke.

ABSTRACT: BACKGROUND:Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke. OBJECTIVES:To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy. SEARCH METHODS:We searched the Cochrane Stroke Group's Trials Register (last searched January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2018, Issue 1), MEDLINE (1950 to January 2018), Embase (1980 to January 2018), CINAHL (1982 to January 2018), AMED (1985 to January 2018), SPORTDiscus (1949 to January 2018), PEDro (searched February 2018), Compendex (1972 to January 2018), and Inspec (1969 to January 2018). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as manufacturers of commercial devices. SELECTION CRITERIA:Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for people after stroke. DATA COLLECTION AND ANALYSIS:Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, used the GRADE approach to assess the quality of the body of evidence, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables. MAIN RESULTS:We included 45 trials (involving 1619 participants) in this update of our review. Electromechanical and robot-assisted arm training improved activities of daily living scores (SMD 0.31, 95% confidence interval (CI) 0.09 to 0.52, P = 0.0005; I² = 59%; 24 studies, 957 participants, high-quality evidence), arm function (SMD 0.32, 95% CI 0.18 to 0.46, P < 0.0001, I² = 36%, 41 studies, 1452 participants, high-quality evidence), and arm muscle strength (SMD 0.46, 95% CI 0.16 to 0.77, P = 0.003, I² = 76%, 23 studies, 826 participants, high-quality evidence). Electromechanical and robot-assisted arm training did not increase the risk of participant dropout (RD 0.00, 95% CI -0.02 to 0.02, P = 0.93, I² = 0%, 45 studies, 1619 participants, high-quality evidence), and adverse events were rare. AUTHORS' CONCLUSIONS:People who receive electromechanical and robot-assisted arm training after stroke might improve their activities of daily living, arm function, and arm muscle strength. However, the results must be interpreted with caution although the quality of the evidence was high, because there were variations between the trials in: the intensity, duration, and amount of training; type of treatment; participant characteristics; and measurements used.

SUBMITTER: Mehrholz J

PROVIDER: S-EPMC6513114 | biostudies-literature | 2018 Sep

REPOSITORIES: biostudies-literature

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Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke.

Mehrholz Jan J Pohl Marcus M Platz Thomas T Kugler Joachim J Elsner Bernhard B

The Cochrane database of systematic reviews 20180903

<h4>Background</h4>Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke.<h4>Objectives</h4>To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.<h4>Search methods</h4>We searched the Cochrane Stroke Group's Trials Register ( ...[more]

PMID: 30175845

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Project description:BackgroundUpper limb recovery is one of the main goals of post-stroke rehabilitation due to its importance for autonomy in Activities of Daily Living (ADL). Although the efficacy of upper limb Robot-assisted Therapy (RT) is well established in literature, the impact of the initial status of the patient on the effects of RT is still understudied. This paper aims to identify whether demographic, clinical and motor characteristics of stroke patients may influence the ability to independently perform ADL after RT.MethodsA retrospective study was conducted on sixty stroke patients who conducted planar upper limb goal-directed tasks with the InMotion 2.0 robot. The RT was administered 5 days/week for 4 weeks and each session lasted 45 minutes. The primary outcome measure was the Modified Barthel Index (BI), dichotomized into favourable (BI ≥75) and unfavourable (BI<75) outcomes. The potential predictors were the demographic and clinical records, and the following clinical assessment scores: Modified Ashworth Scale-Shoulder (MAS-S); Modified Ashworth Scale-Elbow (MAS-E); Fugl-Meyer Assessment Upper Extremity (FMA-UE); upper limb section of the Motricity Index (MIul); total passive Range Of Motion (pROM); and Box and Block Test (BBT).ResultsStatistical analysis showed that the BBT, FMA-UE and MIul scores were significant predictors of a favourable outcome in ADL. The cut-off scores of the independent variables were calculated (FMA-UE = 32; MIul = 48; BBT = 3) with respect to the dichotomic BI outcome. Their robustness was assessed with the Fragility Index (FMA-UE = 2; MIul = 3; BBT = 7), showing that BBT is the most robust predictor of favourable BI outcome. Moreover, subjects with all predictors higher than the cut-off scores had higher probability to increase their independence in ADL at the end of the therapy. Demographic records, spasticity and pROM were not identified as predictors.ConclusionStroke patients with greater manual dexterity and less impairment appear to have a higher probability of achieving clinically significant ADL outcomes after upper limb RT. The obtained results can help to optimise the management of RT treatment planning. Further studies on a larger number of patients with a long-term follow up are recommended in order to evaluate other potential predictors and to validate the results.

Project description:BackgroundAdvanced prostheses can restore function and improve quality of life for individuals with amputations. Unfortunately, most commercial control strategies do not fully utilize the rich control information from residual nerves and musculature. Continuous decoders can provide more intuitive prosthesis control using multi-channel neural or electromyographic recordings. Three components influence continuous decoder performance: the data used to train the algorithm, the algorithm, and smoothing filters on the algorithm's output. Individual groups often focus on a single decoder, so very few studies compare different decoders using otherwise similar experimental conditions.MethodsWe completed a two-phase, head-to-head comparison of 12 continuous decoders using activities of daily living. In phase one, we compared two training types and a smoothing filter with three algorithms (modified Kalman filter, multi-layer perceptron, and convolutional neural network) in a clothespin relocation task. We compared training types that included only individual digit and wrist movements vs. combination movements (e.g., simultaneous grasp and wrist flexion). We also compared raw vs. nonlinearly smoothed algorithm outputs. In phase two, we compared the three algorithms in fragile egg, zipping, pouring, and folding tasks using the combination training and smoothing found beneficial in phase one. In both phases, we collected objective, performance-based (e.g., success rate), and subjective, user-focused (e.g., preference) measures.ResultsPhase one showed that combination training improved prosthesis control accuracy and speed, and that the nonlinear smoothing improved accuracy but generally reduced speed. Phase one importantly showed simultaneous movements were used in the task, and that the modified Kalman filter and multi-layer perceptron predicted more simultaneous movements than the convolutional neural network. In phase two, user-focused metrics favored the convolutional neural network and modified Kalman filter, whereas performance-based metrics were generally similar among all algorithms.ConclusionsThese results confirm that state-of-the-art algorithms, whether linear or nonlinear in nature, functionally benefit from training on more complex data and from output smoothing. These studies will be used to select a decoder for a long-term take-home trial with implanted neuromyoelectric devices. Overall, clinical considerations may favor the mKF as it is similar in performance, faster to train, and computationally less expensive than neural networks.

Project description:BackgroundRehabilitation robotics is progressing towards developing robots that can be used as advanced tools to augment the role of a therapist. These robots are capable of not only offering more frequent and more accessible therapies but also providing new insights into treatment effectiveness based on their ability to measure interaction parameters. A requirement for having more advanced therapies is to identify how robots can 'adapt' to each individual's needs at different stages of recovery. Hence, our research focused on developing an adaptive interface for the GENTLE/A rehabilitation system. The interface was based on a lead-lag performance model utilising the interaction between the human and the robot. The goal of the present study was to test the adaptability of the GENTLE/A system to the performance of the user.MethodsPoint-to-point movements were executed using the HapticMaster (HM) robotic arm, the main component of the GENTLE/A rehabilitation system. The points were displayed as balls on the screen and some of the points also had a real object, providing a test-bed for the human-robot interaction (HRI) experiment. The HM was operated in various modes to test the adaptability of the GENTLE/A system based on the leading/lagging performance of the user. Thirty-two healthy participants took part in the experiment comprising of a training phase followed by the actual-performance phase.ResultsThe leading or lagging role of the participant could be used successfully to adjust the duration required by that participant to execute point-to-point movements, in various modes of robot operation and under various conditions. The adaptability of the GENTLE/A system was clearly evident from the durations recorded. The regression results showed that the participants required lower execution times with the help from a real object when compared to just a virtual object. The 'reaching away' movements were longer to execute when compared to the 'returning towards' movements irrespective of the influence of the gravity on the direction of the movement.ConclusionsThe GENTLE/A system was able to adapt so that the duration required to execute point-to-point movement was according to the leading or lagging performance of the user with respect to the robot. This adaptability could be useful in the clinical settings when stroke subjects interact with the system and could also serve as an assessment parameter across various interaction sessions. As the system adapts to user input, and as the task becomes easier through practice, the robot would auto-tune for more demanding and challenging interactions. The improvement in performance of the participants in an embedded environment when compared to a virtual environment also shows promise for clinical applicability, to be tested in due time. Studying the physiology of upper arm to understand the muscle groups involved, and their influence on various movements executed during this study forms a key part of our future work.

Project description:ObjectiveTo evaluate if bilateral or unilateral upper limb robot-assisted rehabilitation training using a new three-dimensional end-effector robot that targets shoulder and elbow flexion and abduction is superior to conventional therapy with regard to upper extremity motor function recovery and neuromuscular improvement in stroke patients.DesignRandomized, controlled, parallel, assessor-blinded, three-arm clinical trial.SettingSoutheast University Zhongda Hospital Nanjing, Jiangsu, China.MethodsSeventy patients with hemiplegic stroke were randomly assigned to conventional training (Control, n = 23) or unilateral (URT, n = 23), or bilateral robotic training (BRT, n = 24). The conventional group received routine rehabilitation, 60 min/day, 6 days/week, for 3 weeks. For URT and BRT upper limb robot-assisted rehabilitation training was added. This was 60 min/day, 6 days/week, for 3 weeks. The primary outcome was upper limb motor function assessed with Fugl-Meyer-Upper Extremity Scale (FMA-UE). Secondary outcomes were activities of daily living (ADL) assessed with the Modified Barthel Index (MBI), Motor Evoked Potential (MEP) to assess corticospinal tract connectivity, Root Mean Square (RMS) value, and integrate Electromyography (iEMG) value recorded by surface electromyography to evaluate muscle contraction function.ResultsThe primary outcome indicator FMA-UE (least square mean (LSMEAN): 31.40, 95% confidence interval (95% CI): 27.74-35.07) and the secondary outcome indicator MBI (LSMEAN: 69.95, 95% CI: 66.69-73.21) were significantly improved in BRT as opposed to control (FMA-UE, LSMEAN: 24.79, 95% CI: 22.23-27.35; MBI, LSMEAN: 62.75, 95% CI: 59.42-66.09); and unilateral (FMA-UE, LSMEAN: 25.97, 95% CI: 23.57-28.36; MBI, LSMEAN: 64.34, 95% CI: 61.01-67.68). BRT also showed greater improvement in the anterior deltoid bundle with regard to muscle contraction function indicated by RMS (LSMEAN: 257.79, 95% CI: 211.45-304.12) and iEMG (LSMEAN: 202.01, 95% CI: 167.09-236.94), as compared to the controls (RMS, LSMEAN: 170.77, 95% CI: 148.97-192.58; iEMG, LSMEAN: 132.09, 95% CI: 114.51-149.68), and URT (RMS, LSMEAN: 179.05, 95% CI: 156.03-202.07; iEMG, LSMEAN: 130.38, 95% CI: 107.50-153.26). There was no statistically significant difference between URT and conventional training for any outcome. There was no significant difference in MEP extraction rate after treatment between groups (p = 0.54 for URT, p = 0.08 for BRT).ConclusionsA 60 min daily training for upper extremities using a three-dimensional end-effector targeting elbow and shoulder adding conventional rehabilitation appears to promote upper limb function and ADL in stroke patients only if delivered bilaterally. URT does not seem to result in better outcomes than conventional rehabilitation. Electrophysiological results suggest that training using a bilateral upper limb robot increases the recruitment of motor neurons rather than improving the conduction function of the corticospinal tract.

Project description:BackgroundElectromechanical and robotic-assisted gait training devices are used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane Review first published in 2007.ObjectivesTo investigate the effects of automated electromechanical and robotic-assisted gait training devices for improving walking after stroke.Search methodsWe searched the Cochrane Stroke Group Trials Register (last searched April 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 2), MEDLINE (1966 to November 2012), EMBASE (1980 to November 2012), CINAHL (1982 to November 2012), AMED (1985 to November 2012), SPORTDiscus (1949 to September 2012), the Physiotherapy Evidence Database (PEDro, searched November 2012) and the engineering databases COMPENDEX (1972 to November 2012) and INSPEC (1969 to November 2012). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists and contacted authors in an effort to identify further published, unpublished and ongoing trials.Selection criteriaWe included all randomised and randomised cross-over trials consisting of people over 18 years old diagnosed with stroke of any severity, at any stage, or in any setting, evaluating electromechanical and robotic-assisted gait training versus normal care.Data collection and analysisTwo review authors independently selected trials for inclusion, assessed methodological quality and extracted the data. The primary outcome was the proportion of participants walking independently at follow-up.Main resultsIn this update of our review, we included 23 trials involving 999 participants. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (OR) (random effects) 2.39, 95% confidence interval (CI) 1.67 to 3.43; P < 0.00001; I² = 0%) but did not significantly increase walking velocity (mean difference (MD) = 0.04 metres/s, 95% CI -0.03 to 0.11; P = 0.26; I² = 73%) or walking capacity (MD = 3 metres walked in six minutes, 95% CI -29 to 35; P = 0.86; I² = 70%). The results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study, (2) we found variations between the trials with respect to devices used and duration and frequency of treatment, and (3) some trials included devices with functional electrical stimulation. Our planned subgroup analysis suggests that people in the acute phase may benefit but people in the chronic phase may not benefit from electromechanical-assisted gait training. Post hoc analysis showed that people who are non-ambulatory at intervention onset may benefit but ambulatory people may not benefit from this type of training. Post hoc analysis showed no differences between the types of devices used in studies regarding ability to walk, but significant differences were found between devices in terms of walking velocity.Authors' conclusionsPeople who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices. Specifically, people in the first three months after stroke and those who are not able to walk seem to benefit most from this type of intervention. The role of the type of device is still not clear. Further research should consist of a large definitive, pragmatic, phase III trial undertaken to address specific questions such as the following: What frequency or duration of electromechanical-assisted gait training might be most effective? How long does the benefit last?

Project description:Background Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are essential for independent living and are predictors of morbidity and mortality in older populations. Older adults who are dependent in ADLs and IADLs are also more likely to have poor muscle measures defined as low muscle mass, muscle strength, and physical performance, which further limit their ability to perform activities. The aim of this systematic review and meta-analysis was to determine if muscle measures are predictive of ADL and IADL in older populations. Methods A systematic search was conducted using four databases (MEDLINE, EMBASE, Cochrane, and CINAHL) from date of inception to 7 June 2018. Longitudinal cohorts were included that reported baseline muscle measures defined by muscle mass, muscle strength, and physical performance in conjunction with prospective ADL or IADL in participants aged 65 years and older at follow-up. Meta-analyses were conducted using a random effect model. Results Of the 7760 articles screened, 83 articles were included for the systematic review and involved a total of 108 428 (54.8% female) participants with a follow-up duration ranging from 11 days to 25 years. Low muscle mass was positively associated with ADL dependency in 5/9 articles and 5/5 for IADL dependency. Low muscle strength was associated with ADL dependency in 22/34 articles and IADL dependency in 8/9 articles. Low physical performance was associated with ADL dependency in 37/49 articles and with IADL dependency in 9/11 articles. Forty-five articles were pooled into the meta-analyses, 36 reported ADL, 11 reported IADL, and 2 reported ADL and IADL as a composite outcome. Low muscle mass was associated with worsening ADL (pooled odds ratio (95% confidence interval) 3.19 (1.29-7.92)) and worsening IADL (1.28 (1.02-1.61)). Low handgrip strength was associated with both worsening ADL and IADL (1.51 (1.34-1.70); 1.59 (1.04-2.31) respectively). Low scores on the short physical performance battery and gait speed were associated with worsening ADL (3.49 (2.47-4.92); 2.33 (1.58-3.44) respectively) and IADL (3.09 (1.06-8.98); 1.93 (1.69-2.21) respectively). Low one leg balance (2.74 (1.31-5.72)), timed up and go (3.41 (1.86-6.28)), and chair stand test time (1.90 (1.63-2.21)) were associated with worsening ADL. Conclusions Muscle measures at baseline are predictors of future ADL and IADL dependence in the older adult population.

Dataset Information

Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke.

Publications

Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke.

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