Robotic Versus Conventional Therapy For Post-Stroke Hand Motoric Recovery

Comparison Of Robotic And Conventional Mirror Therapy On Hand Motoric Recovery And Functional Outcomes For Rehabilitation Of Post-Stroke Patients

This clinical trial aims to compare the effectiveness of Robotic versus conventional mirror therapy among post-stroke patients. The main questions it aims to answer are:

• Effectiveness of both interventions in hand motoric recovery across time
• Effectiveness of both interventions in functional outcomes across time
• Clinical outcome difference between both interventions Participants will be allocated into either a robotic group as the main intervention or a mirror therapy group as the active comparator. A serial follow-up will be conducted to assess the selected clinical outcome and differences in outcome

Study Overview

• Status: Not yet recruiting
• Conditions: Stroke; Physical Disability; Upper Extremity Paresis
• Intervention / Treatment: Procedure: SYREBO; Procedure: Conventional Mirror Method

Detailed Description

1. Research design This research is an experimental study with a randomized controlled trial research design.
2. Study Setting The research will be carried out among post-stroke patients at two teaching hospitals and one physical rehabilitation centre in Makassar

3. Procedure

   1. Robotic Procedure an exoskeletal robot (Syrebo) will help and stimulate the movement of the paralyzed extremity. One set of training covering Activity Daily Living (ADL) set will be conducted. A mirror will reflect the movement of the healthy extremities
   2. Conventional Method the difference from the robotic procedure was, the movement and stimulation will be provided by the physical therapist.
4. Time frame the procedure will be conducted in parallel three times per week for a total of six weeks

5. Outcomes

   1. motoric ability of upper extremity using Fugl-Meyer Assessment for Upper Extremities (FMA-UE)
   2. Dexterity, coordination and response of finger using the Nine Hole Peg Test (NHPT)

6. Covariates and potential confounders

   1. type of stroke determined by radiology imaging
   2. phase of stroke (acute, sub-acute or chronic)
   3. cognitive ability measured using mini-mental state examination (MMSE)
   4. Spasticity measured by the Modified Ashworth Scale (MAS)

7. Procedure The data collected is primary data obtained in accordance with the inclusion criteria.

   Samples who are willing to become research subjects will undergo interviews, physical examinations, FMA-UE-Hand Motor Domain and NHPT examinations. The interview questionnaire in this study will contain a list of patient identities including name, age, marital status, address, educational history, employment history, history of stroke, cognitive examination (MMSE), and self-reported visual ability.

   The FMA-UE-Hand Motor Domain scoring system is used to evaluate upper extremity motor function in patients with neurological disorders, such as stroke. The scoring system ranges from 0-14, with higher scores indicating better motor function. The FMA-UE-Hand Motor domain assessment system is broken down into several subscales, namely Mass Flexion and Extension movements, followed by functional movements of grasping (Grasp), including Hook Grasp, Thumb Adduction, Pincer Grasp, Cylinder Grasp, and Spherical Grasp. The assessment will get a score of 0 = None or no movement, 1 = Partial or limited movement, and 2 = Full or perfect movement.

   The NHPT assessment consists of a square board with 9 pegs. At one end of the board, there is a hole for the peg, and at the other end, there is a shallow round plate for holding the peg. NHPT is performed by having the patient take pegs from a container, one at a time, and place them into the holes in a board, as quickly as possible. The patient must then remove the pegs from the holes, one at a time, and reinsert them into the housing. To practice and register initial scores, the test must be started with the unaffected upper limb. The board should be placed in the centre of the patient's body with the housing holding the pegs oriented toward the hand being tested. Only the hand being evaluated should perform the test. The non-evaluated hand is allowed to grip the edge of the board to provide stability. Patients are scored based on the time required to complete the test activity, recorded in seconds. The stopwatch must start from the moment the participant touches the first peg until the last peg touches the container. This assessment requires a board, of wood or plastic, with 9 holes (10 mm diameter, 15 mm depth), spaced 32 mm or 50 mm apart and a stopwatch.

8. Sample Size Based on previous research, the value of the standard deviation of the selected outcome = 11.5 and the value of x1-x2 = 9.1 (Lin, 2020). The Zα value = 1.96 with a confidence interval of 95% and the Zβ value = 0.84 with a power of 80%, two arms and a dropout rate of 30% at least 40 participants should be recruited. A consecutive sampling will be applied and allocated randomly using the simple randomization technique.
9. Proposed Statistical Analysis Data on the effect of robotic mirror therapy compared to conventional mirror therapy will be assessed using the independent t-test. Data from the FMA-UE and NHPT assessments before and after the intervention will be analyzed using the paired t-test. Next, the relationship between the FMA-UE and NHPT values will be assessed using the Pearson correlation test (normally distributed data) or the Spearman test (data not normally distributed) to determine how big the correlation is between these variables.

• Study Type: Interventional
• Enrollment (Estimated): 40
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Steven Kurniawan, MD; Phone Number: +6281319912162; Email: stvn.aupp@gmail.com

Study Locations

• Indonesia
  • South Sulawesi
    • Makassar, South Sulawesi, Indonesia, 90245
      • Hasanuddin University, Faculty of Medicine
      • Contact: Bumi Herman, MD; Phone Number: +62411591331; Email: bumiherman@med.unhas.ac.id
      • Principal Investigator: Steven Kurniawan, MD
      • Principal Investigator: Yose Waluyo, MD, PhD
      • Principal Investigator: Husnul Mubarak, MD, PhD
      • Principal Investigator: Nuralam Sam, MD, PhD
    • Makassar, South Sulawesi, Indonesia, 90245
      • Wahidin Sudirohusodo General Hospital
      • Principal Investigator: Steven Kurniawan, MD
      • Principal Investigator: Yose Waluyo, MD, PhD
      • Contact: Bumi Herman, Ph.D.; Phone Number: +62 411 583333; Email: bumiherman@med.unhas.ac.id
      • Principal Investigator: Nuralam Sam, MD. PhD
      • Principal Investigator: Husnul Mubarak, MD
      • Sub-Investigator: Andi A Zainuddin, MD, PhD
      • Sub-Investigator: Andi A Mochtar, Dr, Eng
    • Makassar, South Sulawesi, Indonesia, 90231
      • Cerebellum Clinic
      • Contact: Yose Waluyo, MD.PhD; Phone Number: +62 411 427184; Email: pelayanancerebellumclinic@gmail.com
      • Principal Investigator: Yose Waluyo
      • Principal Investigator: Steven Kurniawan

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion criteria:

1. Patients aged 20 - 85 years.
2. Non-haemorrhagic stroke/infarction with onset more than 3 months from the onset of the attack.
3. Patients with unilateral upper limb hemiparesis.
4. Modified Ashworth Scale (MAS) on fingers and hands <3
5. The patient has not undergone mirror therapy treatment before.
6. Patients who are able to understand informed consent to participate in research.
7. The patient had a Radiology imaging of the head at the time of stroke onset.

Exclusion criteria:

1. Patients with severe spasticity or contractures of the upper extremities.
2. Patients with infarction/bleeding with extensive lesions covering 2 hemispheres.
3. The patient has severe cognitive impairment that will interfere with the research objectives (MMSE score >24).
4. Patients post Digital Subtraction Angiography (DSA) procedures in the last 2 months.
5. Patients with a history of seizures or epilepsy.
6. Patients with visual field deficits or severe visual impairment.
7. Patients who are unable to sit upright without assistance.
8. Other uncontrolled medical conditions (musculoskeletal, neuromuscular, cardiorespiratory) that may interfere with the ability to exercise.

Dropout criteria:

Patients were excluded from the study if:

1. Participant dies.
2. Participants take part in the exercise <3 times for 2 consecutive weeks.
3. The participant refuses to continue the training session.
4. Participants experience hemodynamic disorders during the training program phase.
5. Participants experience neurological disorders during the training program phase.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Robotic Mirror Therapy; Serial training with the help of exoskeletal robot therapy	Procedure: SYREBO; Serial ADL training of upper extremities with robotic aid
Active Comparator: Conventional Mirror Therapy; Serial training with the help of physical therapist	Procedure: Conventional Mirror Method; Serial ADL training of upper extremities assisted by physical therapist

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
FMA-UE Score	a motoric assessment with each score range from 0-2 with a total score range from 0-66. Higher score indicates better and free movement	changes of FMA-UE score from pre-intervention to six weeks after intervention
NHPT value	an assessment for finger dexterity and coordination where the time of the subject to accomplish task will be recorded. Average healthy adult male completed the NHPT in 19.0 seconds (SD 3.2) with the right hand, and in 20.6 seconds (SD 3.9) with the left hand. For healthy adult women, the NHPT was completed in 17.9 seconds (SD 2.8) and 19.6 seconds (SD 3.4) with the right and left hands, respectively.	changes of NHPT values from pre-intervention to six weeks after intervention

Collaborators and Investigators

• Sponsor: Hasanuddin University
• Investigators: Principal Investigator: Steven Kurniawan, MD, Hasanuddin University; Principal Investigator: Nuralam Sam, MD. Ph.D, Hasanuddin University; Principal Investigator: Husnul Mubarak, MD, Hasanuddin University; Principal Investigator: Yose Waluyo, MD. PhD, Hasanuddin University; Principal Investigator: Andi A Zainuddin, MD.Phd, Hasanuddin University; Principal Investigator: Andi A Mochtar, Dr. Eng, Hasanuddin University

Publications and helpful links

General Publications

• Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther. 1987 Feb;67(2):206-7. doi: 10.1093/ptj/67.2.206.
• Rothgangel AS, Braun SM, Beurskens AJ, Seitz RJ, Wade DT. The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature. Int J Rehabil Res. 2011 Mar;34(1):1-13. doi: 10.1097/MRR.0b013e3283441e98.
• Beom J, Koh S, Nam HS, Kim W, Kim Y, Seo HG, Oh BM, Chung SG, Kim S. Robotic Mirror Therapy System for Functional Recovery of Hemiplegic Arms. J Vis Exp. 2016 Aug 15;(114):54521. doi: 10.3791/54521.
• Chowdhury, Z., 2018. Effectiveness of Mirror Therapy on hand function improvement among patients with chronic stroke. IOSR Journal of Nursing and Health Science (IOSR-JNHS) e-ISSN: 2320-1959.p- ISSN: 2320-1940 Volume 4, Issue 6 Ver. V (Nov. - Dec. 2015), PP 01-04
• Hijikata N, Kawakami M, Ishii R, Tsuzuki K, Nakamura T, Okuyama K, Liu M. Item Difficulty of Fugl-Meyer Assessment for Upper Extremity in Persons With Chronic Stroke With Moderate-to-Severe Upper Limb Impairment. Front Neurol. 2020 Nov 16;11:577855. doi: 10.3389/fneur.2020.577855. eCollection 2020.
• Lee MM, Cho HY, Song CH. The mirror therapy program enhances upper-limb motor recovery and motor function in acute stroke patients. Am J Phys Med Rehabil. 2012 Aug;91(8):689-96, quiz 697-700. doi: 10.1097/PHM.0b013e31824fa86d.
• Nogueira NGHM, Parma JO, Leao SESA, Sales IS, Macedo LC, Galvao ACDR, de Oliveira DC, Murca TM, Fernandes LA, Junqueira C, Lage GM, Ferreira BP. Mirror therapy in upper limb motor recovery and activities of daily living, and its neural correlates in stroke individuals: A systematic review and meta-analysis. Brain Res Bull. 2021 Dec;177:217-238. doi: 10.1016/j.brainresbull.2021.10.003. Epub 2021 Oct 7.
• Schrader M, Sterr A, Kettlitz R, Wohlmeiner A, Buschfort R, Dohle C, Bamborschke S. The effect of mirror therapy can be improved by simultaneous robotic assistance. Restor Neurol Neurosci. 2022;40(3):185-194. doi: 10.3233/RNN-221263.

Study record dates

Study Major Dates

• Study Start (Estimated): December 1, 2023
• Primary Completion (Estimated): February 28, 2024
• Study Completion (Estimated): March 30, 2024

Study Registration Dates

• First Submitted: November 24, 2023
• First Submitted That Met QC Criteria: November 24, 2023
• First Posted (Actual): December 4, 2023

Study Record Updates

• Last Update Posted (Actual): December 4, 2023
• Last Update Submitted That Met QC Criteria: November 24, 2023
• Last Verified: November 1, 2023

More Information

Terms related to this study

• Keywords: Functional Outcome; Mirror Therapy; Post-Stroke; Robotic Therapy; Upper Extremities; Motoric Function
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurologic Manifestations; Stroke; Paresis
• Other Study ID Numbers: 2411232122

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: To protect the confidentiality, should the data need to share, any de-identified data will be shared for peer-review

Drug and device information, study documents

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