Robot-assisted reaching exercise promotes arm movement recovery in chronic hemiparetic stroke: a randomized controlled pilot study
Leonard E Kahn, Michele L Zygman, W Zev Rymer, David J Reinkensmeyer, Leonard E Kahn, Michele L Zygman, W Zev Rymer, David J Reinkensmeyer
Abstract
Background and purpose: Providing active assistance to complete desired arm movements is a common technique in upper extremity rehabilitation after stroke. Such active assistance may improve recovery by affecting somatosensory input, motor planning, spasticity or soft tissue properties, but it is labor intensive and has not been validated in controlled trials. The purpose of this study was to investigate the effects of robotically administered active-assistive exercise and compare those with free reaching voluntary exercise in improving arm movement ability after chronic stroke.
Methods: Nineteen individuals at least one year post-stroke were randomized into one of two groups. One group performed 24 sessions of active-assistive reaching exercise with a simple robotic device, while a second group performed a task-matched amount of unassisted reaching. The main outcome measures were range and speed of supported arm movement, range, straightness and smoothness of unsupported reaching, and the Rancho Los Amigos Functional Test of Upper Extremity Function.
Results and discussion: There were significant improvements with training for range of motion and velocity of supported reaching, straightness of unsupported reaching, and functional movement ability. These improvements were not significantly different between the two training groups. The group that performed unassisted reaching exercise improved the smoothness of their reaching movements more than the robot-assisted group.
Conclusion: Improvements with both forms of exercise confirmed that repeated, task-related voluntary activation of the damaged motor system is a key stimulus to motor recovery following chronic stroke. Robotically assisting in reaching successfully improved arm movement ability, although it did not provide any detectable, additional value beyond the movement practice that occurred concurrently with it. The inability to detect any additional value of robot-assisted reaching may have been due to this pilot study's limited sample size, the specific diagnoses of the participants, or the inclusion of only individuals with chronic stroke.
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References
- Carr JH, Shepherd RB. Neurological Rehabilitation: Optimizing Motor Performance. Oxford: Butterworth Heinemann; 1998.
- Krebs HI, Hogan N, Aisen ML, Volpe BT. Robot-aided neurorehabilitation. IEEE Transactions in Rehabilitation Engineering. 1998;6:75–87. doi: 10.1109/86.662623.
- Lum PS, Burgar CG, Shor PC, Majmundar M, Van der Loos M. Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Archives of Physical Medicine & Rehabilitation. 2002;83:952–959. doi: 10.1053/apmr.2001.33101.
- Tremblay F, Malouin F, Richards CL, Dumas F. Effects of prolonged muscle stretch on reflex and voluntary muscle activations in children with spastic cerebral palsy. Scand J Rehabil Med. 1990;22:171–180.
- Odeen I. Reduction of muscular hypertonus by long-term muscle stretch. Scand J Rehabil Med. 1981;13:93–99.
- Carey JR. Manual stretch: effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles. Archives of Physical Medicine & Rehabilitation. 1990;71:888–894.
- Williams PE. Use of intermittent stretch in the prevention of serial sarcomere loss in immobilised muscle. Ann Rheum Dis. 1990;49:316–317.
- Mima T, Sadato N, Yazawa S, Hanakawa T, Fukuyama H, Yonekura Y, Shibasaki H. Brain structures related to active and passive finger movements in man. Brain. 1999;122:1989–1997. doi: 10.1093/brain/122.10.1989.
- Weiller C, Jueptner M, Fellows S, Rijntjes M, Leonhardt G, Kiebel S, Muller S, Diener H, Thilmann AF. Brain representation of active and passive movements. Neuroimage. 1996;4:105–110. doi: 10.1006/nimg.1996.0034.
- Carel C, Loubinoux I, Boulanouar K, Manelfe C, Rascol O, Celsis P, Chollet F. Neural substrate for the effects of passive training on sensorimotor cortical representation: a study with functional magnetic resonance imaging in healthy subjects. J Cereb Blood Flow Metab. 2000;20:478–484.
- Woldag H, Hummelsheim H. Evidence-based physiotherapeutic concepts for improving arm and hand function in stroke patients: a review. J Neurol. 2002;249:518–528. doi: 10.1007/s004150200058.
- van der Lee J, Snels I, Beckerman H, Lankhorst G, Wagenaar R, Bouter L. Exercise therapy for arm function in stroke patients: a systematic review of randomized controlled trials. Clin Rehabil. 2001;15:20–31. doi: 10.1191/026921501677557755.
- Aisen ML, Krebs HI, Hogan N, McDowell F, Volpe BT. The effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke. Arch Neurol. 1997;54:443–446.
- Volpe BT, Krebs HI, Hogan N. Is robot-aided sensorimotor training in stroke rehabilitation a realistic option? Curr Opin Neurol. 2001;14:745–752. doi: 10.1097/00019052-200112000-00011.
- Ferraro M, Palazzolo JJ, Krol J, Krebs HI, Hogan N, Volpe BT. Robot-aided sensorimotor arm training improves outcome in patients with chronic stroke. Neurology. 2003;61:1604–1607.
- Amirabdollahian F, Gradwell E, Loureiro R, Harwin W. Effects of the GENTLE/S robot mediated therapy on the outcome of upper limb rehabilitation post-stroke: Analysis of the Battle Hospital data. Proceedings of the 8th International Conference on Rehabilitation Robotics: 2003; Daejeon, Korea. 2003. pp. 55–58.
- Hesse S, Schulte-Tigges G, Konrad M, Bardeleben A, Werner C. Robot-assisted arm trainer for the passive and active practice of bilateral forearm and wrist movements in hemiparetic subjects. Archives of Physical Medicine & Rehabilitation. 2003;84:915–920. doi: 10.1016/S0003-9993(02)04954-7.
- Reinkensmeyer DJ, Emken JL, Cramer SC. Robotics, motor learning, and neurological recovery. Annual Review of Biomedical Engineering. 2004;6:497–525. doi: 10.1146/annurev.bioeng.6.040803.140223.
- Cohen J. Statistical power analysis for the behavioral sciences. 2. Hillsdale, N.J.: L. Erlbaum Associates; 1988.
- Gowland C, Stratford P, Ward M, Moreland J, Torresin W, Van Hullenaar S, Sanford J, Barreca S, Vanspall B, Plews N. Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke. 1993;24:58–63.
- Reinkensmeyer DJ, Takahashi CD, Timoszyk WK, Reinkensmeyer AN, Kahn LE. Design of robot assistance for arm movement therapy following stroke. Advanced Robotics. 2000;14:625–637. doi: 10.1163/156855301742058.
- Reinkensmeyer DJ, Schmit BD, Rymer WZ. Assessment of active and passive restraint during guided reaching after chronic brain injury. Ann Biomed Eng. 1999;27:805–814. doi: 10.1114/1.233.
- Reinkensmeyer DJ, Dewald JP, Rymer WZ. Guidance-based quantification of arm impairment following brain injury: a pilot study. IEEE Trans Rehabil Eng. 1999;7:1–11. doi: 10.1109/86.750543.
- Reinkensmeyer DJ, Kahn LE, Averbuch M, McKenna-Cole A, Schmit BD, Rymer WZ. Understanding and treating arm movement impairment after chronic brain injury: Progress with the ARM Guide. J Rehabil Res Dev. 2000;37:653–662.
- Flash T, Hogan N. The coordination of arm movements: an experimentally confirmed mathematical model. J Neurosci. 1985;5:1688–1703.
- Kamper DG, McKenna-Cole AN, Kahn LE, Reinkensmeyer DJ. Alterations in reaching after stroke and their relation to movement direction and impairment severity. Arch Phys Med Rehabil. 2002;83:702–707. doi: 10.1053/apmr.2002.32446.
- Levin MF. Interjoint coordination during pointing movements is disrupted in spastic hemiparesis. Brain. 1996;119:281–293.
- Trombly CA. Deficits of reaching in subjects with left hemiparesis: a pilot study. Am J Occup Ther. 1992;46:887–897.
- Rohrer B, Fasoli S, Krebs HI, Hughes R, Volpe B, Frontera WR, Stein J, Hogan N. Movement smoothness changes during stroke recovery. J Neurosci. 2002;22:8297–8304.
- Wilson DJ, Baker LL, Craddock JA. Functional test for the hemiparetic upper extremity. Am J Occup Ther. 1984;38:159–164.
- Schutz RW, Gessaroli ME. The analysis of repeated measures designs involving multiple dependent variables. Res Q Exerc Sport. 1987;58:132–149.
- Patton JL, Stoykov ME, Kovic M, Mussa-Ivaldi FA. Evaluation of robotic training forces that either enhance or reduce error in chronic hemiparetic stroke survivors. Exp Brain Res. 2006;168:368–383. doi: 10.1007/s00221-005-0097-8.
- Volpe B, Krebs H, Hogan N, Edelsteinn L, Diels C, Aisen M. Robot training enhanced motor outcome in patients with stroke maintained over 3 years. Neurology. 1999;53:1874–1876.
- Kwakkel G, Kollen BJ, Wagenaar RC. Long term effects of intensity of upper and lower limb training after stroke: a randomised trial.[see comment] Journal of Neurology, Neurosurgery & Psychiatry. 2002;72:473–479.
- Diggle P. Analysis of longitudinal data. 2. Oxford ; New York: Oxford University Press; 2002.
- Platz T, van Kaick S, Moller L, Freund S, Winter T, Kim I-H. Impairment-oriented training and adaptive motor cortex reorganisation after stroke: a fTMS study. J Neurol. 2005;252:1363–1371. doi: 10.1007/s00415-005-0868-y.
- Kahn LE, Lum PS, Rymer WZ, Reinkensmeyer DJ. Robot-assisted movement training for the stroke-impaired arm: Does it matter what the robot does? J Rehabil Res Dev in press. 2006.
- Winstein CJ, Pohl PS, Lewthwaite R. Effects of physical guidance and knowledge of results on motor learning: support for the guidance hypothesis. Res Q Exerc Sport. 1994;65:316–323.
- Emken JL, Bobrow JE, Reinkensmeyer DJ. Robotic movement training as an optimization problem: Designing a controller that assists only as needed. Proceedings of the 2005 IEEE 9th International Conference on Rehabilitation Robotics: June 28 – July 1 2005; Chicago, IL, USA. 2005. pp. 307–312.
- Kwakkel G, Wagenaar RC, Koelman TW, Lankhorst GJ, Koetsier JC. Effects of intensity of rehabilitation after stroke. A research synthesis. Stroke. 1997;28:1550–1556.
- Krebs HI, Palazzolo JJ, Dipietro L, Ferraro M, Krol J, Rannekleiv K, Volpe BT, Hogan N. Rehabilitation robotics: Performance-based progressive robot-assisted therapy. Autonomous Robots. 2003;15:7–20. doi: 10.1023/A:1024494031121.
Source: PubMed