Robotic Rehabilitation: An Opportunity to Improve Cognitive Functions in Subjects With Stroke. An Explorative Study

Irene Aprile, Giulia Guardati, Valeria Cipollini, Dionysia Papadopoulou, Alessia Mastrorosa, Letizia Castelli, Serena Monteleone, Alessandra Redolfi, Silvia Galeri, Marco Germanotta, Irene Aprile, Giulia Guardati, Valeria Cipollini, Dionysia Papadopoulou, Alessia Mastrorosa, Letizia Castelli, Serena Monteleone, Alessandra Redolfi, Silvia Galeri, Marco Germanotta

Abstract

Background: After a stroke, up to three-quarters of acute and subacute stroke survivors exhibit cognitive impairment, with a significant impact on functional recovery, quality of life, and social engagement. Robotic therapy has shown its effectiveness on motor recovery, but its effectiveness on cognitive recovery has not fully investigated. Objective: This study aims to assess the impact of a technological rehabilitation intervention on cognitive functions in patients with stroke, using a set of three robots and one sensor-based device for upper limb rehabilitation. Methods: This is a pilot study in which 51 patients were enrolled. An upper limb rehabilitation program was performed using three robots and one sensor-based device. The intervention comprised motor/cognitive exercises, especially selected among the available ones to train also cognitive functions. Patients underwent 30 rehabilitation sessions, each session lasting 45 minutes, 5 days a week. Patients were assessed before and after the treatment with several cognitive tests (Oxford Cognitive Scale, Symbol Digit Modalities Test, Digit Span, Rey-Osterrieth Complex Figure, Tower of London, and Stroop test). In addition, motor (Fugl-Meyer Assessment and Motricity Index) and disability (modified Barthel Index) scales were used. Results: According to the Oxford Cognitive Scale domains, a significant percentage of patients exhibited cognitive deficits. Excluding perception (with only one patient impaired), the domain with the lowest percentage of patients showing a pathological score was praxis (about 25%), while the highest percentage of impaired patients was found in calculation (about 70%). After the treatment, patients improved in all the investigated cognitive domains, as measured by the selected cognitive assessment scales. Moreover, motor and disability scales confirmed the efficacy of robotics on upper limb rehabilitation in patients with stroke. Conclusions: This explorative study suggests that robotic technology can be used to combine motor and cognitive exercises in a unique treatment session. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04164381.

Keywords: attention; executive function; memory; rehabilitation; robotics; stroke.

Copyright © 2020 Aprile, Guardati, Cipollini, Papadopoulou, Mastrorosa, Castelli, Monteleone, Redolfi, Galeri and Germanotta.

Figures

Figure 1
Figure 1
The robotic set: Pablo (upper left), Amadeo (lower left), and Diego (lower right) from Tyromotion and Motore (upper right) from Humanware.
Figure 2
Figure 2
List of motor/cognitive exercises performed with the devices.
Figure 3
Figure 3
Flow chart of the study.
Figure 4
Figure 4
Percentage of patients obtaining a pathological score in the Oxford Cognitive Screen (OCS) in our sample before (T0) and after (T1) the rehabilitation treatment. The asterisk indicates a statistically significant difference between T0 and T1 in our sample.
Figure 5
Figure 5
Box-plot diagrams showing the scores obtained before (T0) and after (T1) the robotic treatment in the cognitive tests assessing attention and processing speed (Symbol Digit Modalities Test), visuospatial abilities and visual memory (Rey–Osterrieth Complex Figure), memory (Digit Span), and executive functions (Stroop and Tower of London tests). The boxes show the interquartile range (IQR, from the 25th to the 75th percentile). The horizontal line within each box indicates the median. The vertical bars (whiskers) indicate the range of observations excluding outliers. Dots represent outliers, i.e., observations higher than the 75th percentile plus 1.5 times IQR or lower than the 25th percentile minus 1.5 times IQR. P values refer to the Wilcoxon signed-rank test and are marked in bold when a statistically significant difference at p < 0.05 level between T0 and T1 was detected.

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