Highlights
- •Exoskeleton-assisted anthropomorphic movement training generated reaching movements of the upper extremity under human-like postures and trajectories.
- •EAMT therapy provided a novel and feasible method of upper limb robot-assisted training after stroke.
- •Participants may have improved their upper limb motor function, activities of daily living, and kinematics after engaging in the 4-week therapy.
- •There were no differences in motor capacity between the exoskeleton and conventional therapy.
- •The therapy might be effective for moderate to severe motor impairments only in specific training segments as the exoskeleton is focused on the proximal arm.
Abstract
Objective
To investigate the feasibility of exoskeleton-assisted anthropomorphic movement training
(EAMT) and its effects on upper extremity motor impairment, function, and kinematics
after stroke.
Design
A single-blind pilot randomized controlled trial.
Setting
Stroke rehabilitation inpatient unit.
Participants
Participants with a hemiplegia (N=20) due to a first-ever, unilateral, subacute stroke
who had a score of 8-47 on the Fugl-Meyer Assessment for Upper Extremity (FMA-UE).
Interventions
The exoskeleton group received EAMT therapy that provided task-specific training under
anthropomorphic trajectories and postures. The control group received conventional
upper limb therapy. For both groups, therapy was delivered at the same intensity,
frequency, and duration: 45 minutes daily, 5 days per week, for 4 weeks.
Main Outcome Measures
Primary outcome: feasibility analysis. Secondary outcomes: FMA-UE, Action Research
Arm Test (ARAT), modified Barthel Index (MBI), and kinematic metrics during exoskeleton
therapy.
Results
Twenty participants with subacute stroke were recruited and completed all therapy
sessions. EAMT therapy was feasible and acceptable for the participants. The recruitment
rate, retention rate, and number of therapists required for EAMT therapy were acceptable
compared with other robotic trials. EAMT was determined to be safe, as no adverse
event occurred except tolerable muscle fatigue in 2 participants. There were significant
between-group differences in the change scores of FMA-UE (difference, 4.30 points;
P=.04) and MBI (difference, 8.70 points; P=.03) in favor of EAMT therapy. No significant between-group difference was demonstrated
for the change scores of ARAT (P=.18). Participants receiving EAMT showed significant improvements in kinematic metrics
after treatment (P<.01).
Conclusions
Our results indicate that EAMT is a feasible approach and may improve upper extremity
motor impairment, activities of daily living, and kinematics after stroke. However,
fully powered randomized controlled trials are warranted to confirm the results of
this pilot study and explore the underlying mechanisms by which EAMT therapy might
work.
Key Words
List of abbreviations:
ADL (activities of daily living), ARAT (Action Research Arm Test), DOF (degree of freedom), EAMT (exoskeleton-assisted anthropomorphic movement training), FMA-UA (Fugl-Meyer Assessment for Upper Arm), FMA-UE (Fugl-Meyer Assessment for Upper Extremity), FMA-WH (Fugl-Meyer Assessment for Wrist/Hand), MBI (modified Barthel Index), MCID (minimal clinically important difference), PCA (principal component analysis), PE (postural error)To read this article in full you will need to make a payment
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References
- Global, regional, and national burden of stroke, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet Neurol. 2019; 18: 439-458
- Generalizability of the proportional recovery model for the upper extremity after an ischemic stroke.Neurorehabil Neural Repair. 2015; 29: 614-622
- The proportional recovery rule for stroke revisited.Ann Neurol. 2015; 78: 845-847
- Motor recovery after stroke: a systematic review.Lancet Neurol. 2009; 8: 741-754
- Early prediction of outcome of activities of daily living after stroke: a systematic review.Stroke. 2011; 42: 1482-1488
- Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke. 2016; 47: e98-169
- Repetitive task training for improving functional ability after stroke.Cochrane Database Syst Rev. 2016; 11CD006073
- What is the evidence for physical therapy poststroke? A systematic review and meta-analysis.PLoS One. 2014; 9: e87987
- Robot-assisted therapy in upper extremity hemiparesis: overview of an evidence-based approach.Front Neurol. 2019; 10: 412
- Stroke rehabilitation.Lancet. 2011; 377: 1693-1702
- Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke.Cochrane Database Syst Rev. 2018; 9CD006876
- A survey on robotic devices for upper limb rehabilitation.J Neuroeng Rehabil. 2014; 11: 3
- Combining upper limb robotic rehabilitation with other therapeutic approaches after stroke: current status, rationale, and challenges.Behav Neurol. 2017; 20178905637
- Comparisons between end-effector and exoskeleton rehabilitation robots regarding upper extremity function among chronic stroke patients with moderate-to-severe upper limb impairment.Sci Rep. 2020; 10: 1806
- Robotics in neuro-rehabilitation.J Rehabil Med. 2009; 41: 955-960
- Effects of robot-assisted therapy for the upper limb after stroke.Neurorehabil Neural Repair. 2017; 31: 107-121
- Training modalities in robot-mediated upper limb rehabilitation in stroke: a framework for classification based on a systematic review.J Neuroeng Rehabil. 2014; 11: 111
- Robotic therapy and the paradox of the diminishing number of degrees of freedom.Phys Med Rehabil Clin N Am. 2015; 26: 691-702
- Robot-based hand motor therapy after stroke.Brain. 2008; 131: 425-437
- Effects of robot-assisted upper limb rehabilitation in stroke patients: a systematic review with meta-analysis.Neurol Sci. 2017; 38: 1561-1569
- Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial.Lancet. 2019; 394: 51-62
- Gains in upper extremity function after stroke via recovery or compensation: potential differential effects on amount of real-world limb use.Top Stroke Rehabil. 2009; 16: 237-253
- A taxonomy of functional upper extremity motion.Front Neurol. 2019; 10: 857
- Modifying upper-limb inter-joint coordination in healthy subjects by training with a robotic exoskeleton.J Neuroeng Rehabil. 2017; 14: 55
- Postural synergy based design of exoskeleton robot replicating human arm reaching movements.Robot Auton Syst. 2018; 99: 84-96
- Mechatronic design of a synergetic upper limb exoskeletal robot and wrench-based assistive control.J Bionic Eng. 2018; 15: 247-259
- Three-dimensional, task-specific robot therapy of the arm after stroke: a multicentre, parallel-group randomised trial.Lancet Neurol. 2014; 13: 159-166
- Robot-assisted therapy for long-term upper-limb impairment after stroke.N Engl J Med. 2010; 362: 1772-1783
- Feasibility of ballistic strength training in subacute stroke: a randomized, controlled, assessor-blinded pilot study.Arch Phys Med Rehabil. 2018; 99: 2430-2446
- A standardized approach to the Fugl-Meyer assessment and its implications for clinical trials.Neurorehabil Neural Repair. 2013; 27: 732-741
- The Fugl-Meyer assessment of the upper extremity: reliability, responsiveness and validity of the Danish version.Disabil Rehabil. 2017; 39: 934-939
- Clinically important differences for the upper-extremity Fugl-Meyer Scale in people with minimal to moderate impairment due to chronic stroke.Phys Ther. 2012; 92: 791-798
- The responsiveness of the Action Research Arm test and the Fugl-Meyer Assessment scale in chronic stroke patients.J Rehabil Med. 2001; 33: 110-113
- Development of a Chinese version of the Modified Barthel Index– validity and reliability.Clin Rehabil. 2007; 21: 912-922
- Establishing the minimal clinically important difference of the Barthel Index in stroke patients.Neurorehabil Neural Repair. 2007; 21: 233-238
- The contribution of kinematics in the assessment of upper limb motor recovery early after stroke.Neurorehabil Neural Repair. 2014; 28: 4-12
- Kinematic measures for upper limb robot-assisted therapy following stroke and correlations with clinical outcome measures: a review.Med Eng Phys. 2018; 53: 13-31
- Upper limb coordination in individuals with stroke: poorly defined and poorly quantified.Neurorehabil Neural Repair. 2017; 31: 885-897
- Does the finger-to-nose test measure upper limb coordination in chronic stroke?.J Neuroeng Rehabil. 2017; 14: 6
- Movement smoothness changes during stroke recovery.J Neurosci. 2002; 22: 8297-8304
- Three-dimensional analysis of performance of an upper limb functional task among adults with dyskinetic cerebral palsy.Gait Posture. 2014; 39: 875-881
- Testing proprioception in intrinsic and extrinsic coordinate systems: is there a difference?.Conf Proc IEEE Eng Med Biol Soc. 2014; 2014: 6961-6964
- Agreed definitions and a shared vision for new standards in stroke recovery research: The Stroke Recovery and Rehabilitation Roundtable taskforce.Int J Stroke. 2017; 12: 444-450
- Synergy repetition training versus task repetition training in acquiring new skill.Front Bioeng Biotechnol. 2017; 5: 9
- Efficacy of robot-assisted rehabilitation for the functional recovery of the upper limb in post-stroke patients: a randomized controlled study.Eur J Phys Rehabil Med. 2016; 52: 767-773
- The effects of combination of robot-assisted therapy with task-specific or impairment-oriented training on motor function and quality of life in chronic Stroke.PM R. 2016; 8: 721-729
- Robot-assisted arm training in chronic stroke: addition of transition-to-task practice.Neurorehabil Neural Repair. 2019; 33: 751-761
- Efficacy of occupational therapy task-oriented approach in upper extremity post-stroke rehabilitation.Occup Ther Int. 2016; 23: 444-456
- Providing low-dimensional feedback of a high-dimensional movement allows for improved performance of a skilled walking task.Sci Rep. 2019; 9: 19814
- A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments.J Neuroeng Rehabil. 2014; 11: 32
- Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis?.Top Stroke Rehabil. 2015; 22: 176-184
- Post-stroke spasticity: predictors of early development and considerations for therapeutic intervention.PM R. 2015; 7: 60-67
- Spasticity may obscure motor learning ability after stroke.J Neurophysiol. 2018; 119: 5-20
- The Canadian occupational performance measure: an outcome measure for occupational therapy.Can J Occup Ther. 1990; 57: 82-87
Article info
Publication history
Published online: June 23, 2021
Accepted:
June 9,
2021
Received in revised form:
June 8,
2021
Received:
November 25,
2020
Footnotes
Supported by the National Natural Science Foundation of China (grant nos. U 1913601, 91648203).
Disclosures: none.
Clinical Trial Registration No.: ChiCTR1900026656.
Identification
Copyright
© 2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
