Objective. The aim of the study was to present a systematic review of studies that investigate the effects of robot-assisted therapy on motor and functional recovery in patients with stroke. Methods. A database of articles published up to October 2006 was compiled using the following Medline key words: cerebral vascular accident, cerebral vascular disorders, stroke, paresis, hemiplegia, upper extremity, arm, and robot. References listed in relevant publications were also screened. Studies that satisfied the following selection criteria were included: (1) patients were diagnosed with cerebral vascular accident; (2) effects of robot-assisted therapy for the upper limb were investigated; (3) the outcome was measured in terms of motor and/or functional recovery of the upper paretic limb; and (4) the study was a randomized clinical trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for motor recovery and functional ability (activities of daily living [ADLs]) using fixed and random effect models. Ten studies, involving 218 patients, were included in the synthesis. Their methodological quality ranged from 4 to 8 on a (maximum) 10-point scale. Results. Meta-analysis showed a nonsignificant heterogeneous SES in terms of upper limb motor recovery. Sensitivity analysis of studies involving only shoulder-elbow robotics subsequently demonstrated a significant homogeneous SES for motor recovery of the upper paretic limb. No significant SES was observed for functional ability (ADL). Conclusion. As a result of marked heterogeneity in studies between distal and proximal arm robotics, no overall significant effect in favor of robot-assisted therapy was found in the present meta-analysis. However, subsequent sensitivity analysis showed a significant improvement in upper limb motor function after stroke for upper arm robotics. No significant improvement was found in ADL function. However, the administered ADL scales in the reviewed studies fail to adequately reflect recovery of the paretic upper limb, whereas valid instruments that measure outcome of dexterity of the paretic arm and hand are mostly absent in selected studies. Future research into the effects of robot-assisted therapy should therefore distinguish between upper and lower robotics arm training and concentrate on kinematical analysis to differentiate between genuine upper limb motor recovery and functional recovery due to compensation strategies by proximal control of the trunk and upper limb.
Muntner P., Garrett E., Klag MJ, Coresh J.Trends in stroke prevalence between 1973 and 1991 in the US population 25 to 74 years of age. Stroke. 2002;33:1209-1213.
2.
Kwakkel G., Kollen BJ, van der Grond J., Prevo AJProbability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003;34: 2181-2186.
3.
Van Peppen RP , Kwakkel G., Wood-Dauphinee S., Hendriks HJ, Van der Wees PJ, Dekker J.The impact of physical therapy on functional outcomes after stroke: what's the evidence? Clin Rehabil. 2004;18:833-862.
4.
Kwakkel G., Kollen BJ, Lindeman E.Understanding the pattern of functional recovery after stroke: facts and theories . Restor Neurol Neurosci. 2004 ;22:281-299.
Krebs HI, Volpe BT, Aisen ML, Hogan N.Increasing productivity and quality of care: robotic-aided neurorehabilitation . J Rehabil Res Dev. 2000;37:639-652.
7.
Reinkensmeyer DJ, Kahn LE, Averbuch M., McKenna-Cole AN, Schmit BD, Rymer WZUnderstanding and treating arm movement impairment after chronic brain injury: progress with the ARM Guide. J Rehabil Res Dev. 2000;37:653-662.
8.
Burgar CG, Lum PS, Shor PC, Van der Loos HFM.Development of robots for rehabilitation therapy: the Palo Alto VA/Stanford experience. J Rehabil Res Dev. 2000;37:663-673.
9.
Lum PS, Burgar CG, Shor PCEvidence for improved muscle activation patterns after retraining of reaching movements with the MIME robotic system in subjects with post-stroke hemiparesis . IEEE Trans Neural Syst Rehabil Eng. 2004 ;12:186-194.
10.
Daly JJ, Hogan N., Perepezko EM, et al. Response to upper-limb robotics and functional neuromuscular stimulation following stroke. J Rehabil Res Dev. 2005;42(6):723-736.
11.
Basmajian JV , Gowland CA, Finlayson AJ, Hall AL, Swanson LR, Stratford PWStroke treatment: comparison of integrated behavioural physical therapy vs. traditional physical therapy programs. Arch Phys Med Rehabil.1987;68:276-272.
12.
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 . Arch. Phys Med Rehabil. 2002;83(7):952-959.
13.
Logigian MK , Samuels MA, Falconer J., Zagar R.Clinical exercise trial for stroke subjects . Arch Phys Med Rehabil. 1983;64:364-367.
14.
Wagenaar RC , Meijer OG, van Wieringen P., Kuik DJ, Hazenberg GL, Lindeboom J.The functional recovery of stroke: a comparison between neuro-developmental treatment and the Brunnstrom method. Scand J Rehabil Med. 1990;22:1-8.
15.
Wolf SL, LeCraw DE, Barton LAComparison of motor copy and targeted biofeedback training techniques for restitution of upper extremity function among subjects with neurologic disorders . Phys Ther. 1989;69(9):719-735.
16.
Butefisch C. , Humelsheim H., Denzler P., Mauritz KHRepetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand . J Neurol Sci. 1995 ;130:56-68.
17.
Foley NC, Bhogal SK, Teasell RW, Bureau Y., Speechley MREstimates of quality and reliability with the physiotherapy evidence-based database scale to assess the methodology of randomized controlled trials of pharmacological and nonpharmacological interventions. Phys Ther. 2006;86(6):817-824.
18.
Dobkin BHStrategies for stroke rehabilitation. Lancet Neurol . 2004;3:528-526.
19.
Hesse S., Schmidt H., Werner C., Bardeleben A.Upper and lower extremity robotic devices for rehabilitation and for studying motor control. Curr Opin Neurol. 2003;16:705-710.
20.
Hidler J., Nichols D., Pelliccio M., Brady K.Advances in the understanding and treatment of stroke impairment using robotic devices. Top Stroke Rehabil. 2005;12:22-33.
Lum P., Reinkensmeyer D., Mahoney R., Rymer WZ, Burgar C.Robot devices for movement therapy after stroke: current status and challenge to clinical acceptance. Top Stroke Rehabil. 2002;8:40-53.
23.
Platz T.Evidence-based arm rehabilitation. Nervenarzt. 2003;74: 841-849.
24.
Riener R., Nef T., Colombo G.Robot-aided neurorehabilitation of the upper extremities. Med. Biol. Eng. Comput. 2005;43:2-10.
25.
Volpe BT, Krebs HI, Hogan N.Is robot-aided sensorimotor training in stroke rehabilitation a realistic option? Curr Opin. Neurol. 2001;14:745-752.
26.
Brewer BR, Fagan M., Klatzky RL, Matsuoka Y.Perceptual limits for a robotic rehabilitation environment using visual feedback distortion. IEEE Trans Neural Syst Rehabil Eng. 2005;13(1):1-11.
27.
Colombo R., Pisano M., Micere S., et al. Robotic techniques for upper limb evaluation and rehabilitation of stroke patients. IEEE Trans Neural Syst Rehabil Eng. 2005;13(3):311-324.
28.
Cozens JARobotic assistance of an active upper limb exercise in neurologically impaired patiens.IEEETrans Rehabil Eng. 1999 ;7:254-256.
29.
Dipietro L. , Ferraro M., Palazzolo JJ, Krebs HI, Volpe BT, Hogan N.Customized interactive robotic treatment for stroke: EMG-triggered therapy. IEEE Trans Neura1 Syst Rehabil Eng. 2005;13:325-334.
30.
Fasoli SE, Krebs HI, Stein J., Frontera WR, Hogan N.Effects of robotic therapy on motor impairment and recovery in chronic stroke . Arch Phys Med Rehabil. 2003;84:477-482.
31.
Fasoli SE, Krebs HI, Stein J., Frontera WR, Hughes R., Hogan N.Robotic therapy for chronic motor impairments after stroke: follow-up results . Arch Phys Med Rehabil. 2004;85:1106-1111.
32.
Ferraro M., Palazzolo JJ, Krol J., Krebs HI, Hogan N., Volpe BTRobot-aided sensorimotor arm training improves outcome in patients with chronic stroke. Neurology. 2003;61:1604-1607.
33.
Finley MA, Fasoli SE, Dipietro L., et al. Short-duration robotic therapy in stroke patients with severe upper-limb motor impairment. J Rehabil Res Dev. 2005;42:683-692.
34.
Johnson MJ, Van der Loos HF, Burgar CG, Shor P., Leifer LJExperimental results using force-feedback cueing in robot-assisted stroke therapy. IEEE Trans Neural Syst Rehabil Eng. 2005;13:335-348.
35.
Krebs HI, Ferraro M., Buerger SP, et al. Rehabilitation robotics: pilot trial of a spatial extension for MIT-Manus. Journal of Neuroengineering Rehabilitation . 2004;1:5.
36.
Krebs HI, Aisen ML, Volpe BT, Hogan N.Quantization of continuous arm movements in humans with brain injury . Proc Natl Acad Sci USA. 1999;99:4645-4649.
37.
Krebs HI, Palazzolo JJ, Dipietro L., et al. Rehabilitation robotic: performance-based progressive robot-assisted therapy. Auton Robot. 2003;15:7-20.
38.
MacClellan LR, Bradham DD, Whitall J., et al. Robotic upper-limb neurorehabilitation in chronic stroke patients. J Rehabil Res Dev. 2005;42:717-722.
39.
Matsuoka Y. , Allin SJ, Klatzky RLThe tolerance for visual feedback distortions in a virtal environment. Physiol Behav . 2002 ;77:651-655.
40.
Micera S., Carozza MC, Guglielmelli E., et al. A simple robotic system for neurorehabilitation. Auton Robot. 2005;19:271-284.
41.
Patton JL, Stoykov M., Kovic M.Evaluation of robotic training forces that either enhance or reduce error in chronic hemiparetic stroke survivors. Exp Brain Res . 2005;168:368-383.
42.
Reikensmeyer DJ, Schmit BD, Rymer WZAssessment of active and passive restraint during guided reaching after chronic brain injury. Ann Biomed Eng. 1999;27:805-814.
43.
Reinkensmeyer DJ, Pang CT, Nessler JA, Painter CCWeb-based telerehabilitation for the upper extremity after stroke. IEEE Trans Neural Syst Rehabil Eng . 2002;10:102-108.
44.
Rohrer B., Fasoli S., Krebs HI, et al. Movement smoothness changes during stroke recovery. J Neurosci. 2002;22:8297-8304.
45.
Stein J., Krebs HI, Frontera WR, Fasoli SE, Hughes R., Hogan N.Comparison of two techniques of robot-aided upper limb exercise training after stroke. Am J Phys Med Rehabil. 2004;85:1106-1111.
46.
Takahashi CD , Reinkensmeyer DJHemiparetic stroke impairs anticipatory control of arm movement. Exp Brain Res. 2003 ;149: 131-140.
47.
Volpe BT, Krebs HI, Hogan N., Edelsteinn L., Diels CM, Aisen MLRobot training enhanced motor outcome in patients with stroke maintained over 3 years. Neurology. 1999;53:1874-1876.
48.
Aisen ML, Krebs HI, Hogan N., McDowel F., Volpe BTThe effect of robot-assisted therapy and rehabilitative training on motor recovery following stroke. Arch Neurol. 1997 ;54:443-446.
49.
Fasoli SE, Krebs HI, Ferraro M., Hogan N., Volpe BTDoes shorter rehabilitation limit potential recovery poststroke? Neurorehabil Neural Repair. 2004;18:88-94.
50.
Hesse S., Werner C., Pohl M., Rueckriem S., Mehrhoz J., Lingnau MLComputerized arm training improves the motor control of the severely affected arm after stoke. Stroke. 2005;36:1960-1966.
51.
Kahn LE, Averbuch M., Rymer WZ, Reinkensmeyer J.Comparison of robot-assisted reaching to free reaching in promoting recovery from chronic stroke. In: Mokhtari M, ed. Integration of Assistive Technology in the Information Age. Amsterdam, The Netherlands: IOS Press; 2001:39-44.
52.
Kahn LE, Zygman ML, Rymer WZ, Reinkensmeyer D.J.Robot-assisted reaching exercise promotes arm movement recovery in chronic hemiparetic stroke: a randomized controlled pilot study. Journal of NeuroEngineering and Rehabilitation.2006;3;1-13.
53.
Lum PS, Burgar CG, Van der Loos M., Shor PC, Majmumdar M., Yap R.MIME robotic device for upper-limb neurorehabilitation in subacute stroke subjects: a follow-up study. J Rehabil Res Dev. 2006;43:631-642.
Sanford J., Moreland J., Swanson LR, Stratford PW, Gowland C.Reliability of Fugl-Meyer assessment for testing motor performance in patients following stroke. Phys Ther. 1993 ;73:447-454.
56.
Rohrer B., Fasoli S., Krebs HI, et al. Movement smoothness changes during stroke recovery. J Neurosci. 2002;22:18:8297-8304.
57.
Cirstea MC, Levin MFCompensatory strategies for reaching in stroke. Brain . 2000;123:940-953.
58.
Kwakkel G., Kollen B., Twisk J.Impact of time on improvement of outcome after stroke. Stroke . 2006;37:2348-2353.
59.
van der Lee JH, Beckerman H., Lankhorst GJ, Bouter LMThe responsiveness of the Action Research Arm test and the Fugl-Meyer Assessment scale in chronic stroke patients. J Rehab Med. 2001;33:110—113.
60.
Wolf SL, Winstein CJ, Miller JP, et al; EXCITE Investigators. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA.2006;296:2095-2104.
61.
Gowland C., Stratford P., Ward M., et al. Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke. 1993;24:58-63.
