Robot Mediated Therapy-Upper Limb Outcomes in Stroke

Effects of Robot-mediated Impairment-Oriented and Task-Specific Training on Upper Limb Outcomes Post Stroke (RMT-Stroke Outcomes)

This study aims to determine the clinical outcomes of stroke patients who are provided with adjunctive robot-mediated task specific therapy(RMTT) and robot-mediated impairment training (RMIT) as compared to those who are provided with adjunctive RMIT.

Study Overview

• Status: Not yet recruiting
• Conditions: Stroke, Acute
• Intervention / Treatment: Device: Robot mediated upper limb therapy

Detailed Description

Stroke is among the top 10 causes of hospitalisation in Singapore1. Approximately 630 stroke patients were transferred to our inpatient rehabilitation unit in 2021. Upper limb impairments are common after stroke2 and may result in loss of function, including self-care activities. Intensity of therapy is thus important for post-stroke recovery. A Cochrane overview of systematic reviews suggested that arm function can be improved by providing at least 20 hours of additional repetitive task training to patients3. However, providing sufficient therapy remains a challenge due to various reasons4, including manpower shortages. Robotic-mediated rehabilitation is an innovative exercise-based therapy using robotic devices that enables the implementation of highly repetitive, intensive, adaptive, and quantifiable physical training.

The RATULS trial5 showed that neither robot-assisted training using the MIT-Manus robotic gym nor an enhanced upper limb therapy (EULT) programme based on repetitive functional task practice improved upper limb function after stroke, as compared to usual care, for patients with moderate-to-severe upper limb functional limitations. It was suggested that further research was needed to find ways to translate the improvements in upper limb impairments seen with robot-assisted therapy into upper limb function and their activities of daily living (ADLs).

In a systematic review and meta-analysis on the effects of robot-assisted therapy on the upper limb, it was found that although there were improvements in strength, this was not translated to improvements in activities of daily living6. Additional transition to task training (facilitated by therapists) had been added to robot-mediated impairment training (RMIT) in various studies7,8. In a study by Hung8, robot-assisted therapy combined with occupational therapist (OT)-facilitated task specific training was found to be superior to robot-assisted therapy combined with OT-facilitated impairment-oriented training. Task-specific training consists of repetitively practising the tasks that are most relevant to the patient and their personal context, whereas impairment-oriented therapy emphasises remediation of motor deficits with a focus on single joint movements at a time.

A study that investigated Reharob, a robotic device used to assist patients living with chronic stroke in performing 5 ADLs, showed that patients had significant improvements on the Fugl-Meyer Assessment - Upper Extremity (FMA-UE), Action Research Arm Test (ARAT) and Functional Independence Measure (FIM)9. This is the only study that has been found addressing robot-mediated task-specific training thus far (RMTT).

This study aims to determine the clinical outcomes of stroke patients who are provided with both RMTT and robot-mediated impairment training (RMIT) in addition to conventional therapy, as compared to those who are provided with only adjunctive RMIT. From a review of the prevalent literature, there has been no study on the comparison of RMTT + RMIT against RMIT alone. A search for RMTT only yielded the study on Reharob, but the robot only administered RMTT and not RMIT.

The target patients would be those with acute stroke undergoing rehabilitation in an acute inpatient rehabilitation unit. Robotic therapy can continue when they are discharged, in the outpatient setting.

• Study Type: Interventional
• Enrollment (Anticipated): 96
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: San San Tay, MBBS; Phone Number: 69366455; Email: tay.san.san@singhealth.com.sg
• Study Contact Backup: Name: Edmund Neo, MBBS; Phone Number: 69366462; Email: neo.jin.rui.edmund@singhealth.com.sg

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 21 years to 99 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Diagnosis of stroke as evidenced by CT/MRI findings
2. First-ever stroke (ischaemic or haemorrhagic)
3. Upper limb weakness and an FMA-UE score of 16-53 (severe to moderate: 16-34. moderate to mild: 35-53)12,13
4. Cognitively intact to follow instructions
5. Medically stable to participate
6. Consent given
7. Age 21 and above

Exclusion Criteria:

1. Fractures or other musculoskeletal issues that render the use of the robotic device unsuitable 2. Involvement in another concurrent upper limb study 3. Wounds that do not allow donning of the device 4. Severe spasticity 5. Cognitive impairment (MMSE ≤20) 6. Inability to follow instructions 7. Severe osteoporosis 8. Infectious diseases that require the patient to be isolated in a single room eg airborne diseases

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Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Robot mediated Impairment-oriented training(RMIT); Participant receives 20 hours of robot mediated impairment-oriented training applied via the Optimo Regen	Device: Robot mediated upper limb therapy; The OR is classified as a Class A device with the Health Sciences Authority. The OR is capable of delivering RMIT as well as RMTT. It can provide zero, partial or full assistance to the patient to complete the movement or task. Its teach-and-follow mode allows a movement to be performed by the therapist, with the device then "replaying" the movement at either zero, partial or full assistance for the patient. Impairment oriented training will focus on the following movements: Diagonal movement; Shoulder abduction; Shoulder adduction; Shoulder flexion; Shoulder extension; Elbow flexion; Elbow extension Task-specific training will focus on the following activities: Picking up a cup/glass by the side and drink; Brushing hair; Cleaning unaffected upper limb (hand to arm); Wiping table; Wiping wall; Sliding card on table to a designated location; Clipping a clothe peg
Experimental: Robot mediated impairment-oriented and task-specific training (RMIT+RMTT); Participant receives a total of 20 hours of robotic therapy. 10 hours will be in the form of RMIT and 10 hours in the form of RMTT	Device: Robot mediated upper limb therapy; The OR is classified as a Class A device with the Health Sciences Authority. The OR is capable of delivering RMIT as well as RMTT. It can provide zero, partial or full assistance to the patient to complete the movement or task. Its teach-and-follow mode allows a movement to be performed by the therapist, with the device then "replaying" the movement at either zero, partial or full assistance for the patient. Impairment oriented training will focus on the following movements: Diagonal movement; Shoulder abduction; Shoulder adduction; Shoulder flexion; Shoulder extension; Elbow flexion; Elbow extension Task-specific training will focus on the following activities: Picking up a cup/glass by the side and drink; Brushing hair; Cleaning unaffected upper limb (hand to arm); Wiping table; Wiping wall; Sliding card on table to a designated location; Clipping a clothe peg

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of FMA-UE(Fugl Meyer Assessment for Upper Extremity) from baseline	30 items assessing motor function and 3 items assessing reflex function (0-66, higher scores indicates better outcomes)	baseline, 1 month and 3 months post commencement of intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change of FMA-UA( Fugl Meyer Assessment-Upper Arm) from baseline	subset of FMA-UE( 0-36, higher score indicates better outcomes)	baseline, 1 month and 3 months post commencement of intervention
Change of FMA-W/H (Fugl Meyer Assessment- Wrist/Hand) from baseline	subset of FMA-UE (0-30, higher scores indicates better outcomes)	baseline, 1 month and 3 months post commencement of intervention
Change of FAT( Frenchay Arm Test) from baseline	Upper limb functional assessment (0-5, higher score indicates better outcomes)	baseline, 1 month and 3 months post baseline
Change of FIM (Functional Independence Measure) from baseline	Functional outcome measure, mainly used in inpatient setting (18-126, higher score indicates better outcomes)	baseline, 1 month, 3 months post baseline
Change of MMT( manual muscle testing) from baseline	Using the Medical Research Council scale (0-5, higher indicates better outcomes)	baseline, 1 month and 3 months post baseline
Change of MAS (Modified Ashworth Scale) from baseline	spasticity assessment scale (0-4, lower indicates better outcomes)	baseline, 1 month and 3 months post baseline
Change of EQ5D from baseline	Quality of Life Questionaire (0-100, higher score indicates better outcomes)	baseline, 1 month and 3 months post baseline
Change of HADS (Hospital Anxiety and Depression Scale) from baseline	Masurement of mood (0-42, more than 8 points in each subcategory indicates considerable symptoms of anxiety or depression)	baseline, 1 month and 3 months post baseline
Change of patient satisfaction survey from baseline	Patient satisfaction survey (8-40), higher score denotes good outcome)	baseline, 1 month and 3 months post baseline
Difference in the presence of adverse effects	fatigue, pain, injuries (present or absent. Absent denotes better outcome)	baseline, 1 month and 3 months post baseline

Collaborators and Investigators

• Sponsor: Changi General Hospital

Publications and helpful links

General Publications

• Conroy SS, Wittenberg GF, Krebs HI, Zhan M, Bever CT, Whitall J. Robot-Assisted Arm Training in Chronic Stroke: Addition of Transition-to-Task Practice. Neurorehabil Neural Repair. 2019 Sep;33(9):751-761. doi: 10.1177/1545968319862558. Epub 2019 Jul 22.
• Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. 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 Sep 3;9(9):CD006876. doi: 10.1002/14651858.CD006876.pub5.
• Hung CS, Hsieh YW, Wu CY, Lin KC, Lin JC, Yeh LM, Yin HP. Comparative Assessment of Two Robot-Assisted Therapies for the Upper Extremity in People With Chronic Stroke. Am J Occup Ther. 2019 Jan/Feb;73(1):7301205010p1-7301205010p9. doi: 10.5014/ajot.2019.022368.

Study record dates

Study Major Dates

• Study Start (Anticipated): June 1, 2023
• Primary Completion (Anticipated): May 31, 2025
• Study Completion (Anticipated): December 31, 2025

Study Registration Dates

• First Submitted: March 28, 2023
• First Submitted That Met QC Criteria: March 28, 2023
• First Posted (Actual): April 10, 2023

Study Record Updates

• Last Update Posted (Actual): April 10, 2023
• Last Update Submitted That Met QC Criteria: March 28, 2023
• Last Verified: March 1, 2023

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Stroke
• Other Study ID Numbers: ChangiGH1

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No