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Stroke Patients: Effects of Intensive Robotic Therapy

Introduction

Stroke, which is scientifically referred to as ‘cerebral vascular accident, ’ is a sudden impairment in neurological function that is not associated with convulsions resulting from a hemorrhagic or ischemic event in the cranium. It currently ranks third as a killer in the UK behind cardiac disease and cancer. In most instances, chronic stroke patients have a limited motion of the upper and lower limbs on the affected side. Stroke is a suspect in most impairments of daily living. Several studies have been done to demonstrate various methods that can be used to regain functional movement of the affected parts. One such study is the use of robotic therapy. There is a significant success reported with the use of this method. Intensive robotic therapy is currently being investigated in its role in augmenting exercise training for stroke patients.

It is reported that intensive robotic therapy improves the functioning ability of the affected part by enhancing the attention of the individuals since they have to independently perform the exercises. The reinforcement feedback characteristic of the therapy also accelerates the recovery of the subject by encouraging his involvement in the whole process of rehabilitation. Robotic therapy has some advantages over supervised standard physiotherapy. In clinical practice, it is relatively cheap as it does not incorporate the frequent charges for routine physiotherapy. It is reportedly easy for most patients to use since it encourages faster recovery. It also encourages the patient to increase input towards personal recovery, which is associated with minimal fatigue, improved specificity, and increased intensity.

Robotic therapy works in the same principle upon which traditional physiotherapy is built. Through repeated motion, there is an activation in the brain of the side opposite the affected part. The activation develops new neurological links with different areas of the brain being trained to perform new things. With the reported increase in neurological impairment that is not necessarily associated with stroke, robotic therapy is increasing in demand all over the world. This promising therapy will improve the clinical management of neurologically impaired patients.

In fact, there are researches and clinical trials being tried in the major hospitals and research organizations in the world. Fasoli et al investigated the use of robotic therapy in reducing motor impairment in stroke-induced hemiparesis. Their study targeted the affected upper limb (2003, p.447). They concluded that this therapy may serve as an adjunct to other modes of physiotherapy for mild or moderate motor impairment (FasoIi et al., 2003, p. 479). Other researchers elsewhere have complemented these findings. The literature supports the use of therapy in hemiparesis rehabilitation (Kutner et al., 2010, p.493). The topic is therefore an important one to consider by combining the research findings that have been forthcoming. The paper, therefore, evaluates the existing evidence on the effects of intensive robotic therapy on functional movements of the upper limb of chronic stroke patients.

Context

In most areas of the world, stroke is increasingly becoming a major cause of disability that is described to be limiting the normal functioning of thousands of people. The loss of neurological function associated with it causes upper limb impairment, lower limb impairment, or a combination of both. It is reported that over 65 percent of patients will not be able to use their upper limbs effectively six months after a stroke (Kutner et al., 2010, p.493). This outcome limits the quality of life of the affected individuals. Rehabilitation is the scientific method of attempting to adapt them to their conditions by eliciting improvement in motor function. Studies on the limitation to quality of life in stroke patients have not been forthcoming (Kutner et al., 2010, p.493). Some of the strategies developed in their rehabilitation include Repetitive Task Practice (RTP), which is used in constraint-induced movement therapy (CIMT) (Kutner et al., 2010, p.493). They are geared towards improving limb function and patients’ perception of their “health-related quality of life (HRQOL)” (Wolf et al., 2006, p. 2100).

In the past, RTP-based interventions have proved to be labor-intensive. In fact, with the development of robotic therapy in rehabilitation, a solution to effective rehabilitation is in the offing. Over the decades, these devices have improved in performance and design besides reducing in size and weight. There is evidence that they reduce the time taken in rehabilitation and in physiotherapy consultations. Their use has also been tested in various randomized control trials with improvement being noted in a large percentage. The studies have led to the development of “sophisticated upper extremity robotic systems such as the ‘MIT-Manus” (Kutner et al., 2010, p.493).

According to Kutner et al, “a meta-analysis of robot-assisted therapy effects on upper-limb function in patients with stroke concluded that robotic therapy typically improves proximal limb control” (2010, p.494). The main challenge to the use of robot-assisted therapy currently is the rejection that most clinical institutions have accorded to it. This means that the recorded advantages are not in use by most stroke patients who require the therapy. Albert et al (2010, p.1773) stated that, with the advancement in robotics and increased number of stroke patients with long-term upper-limb impairment, there is a need to shift from the traditional usual care or conventionally used techniques in rehabilitation. The advantages that robotic therapy has are the reproducibility of results and the absence of fatigue associated with routine physiotherapy practice. It also enables patients to take charge of their own management thereby encouraging faster recovery and improved perception of their standard of living.

The focus of the upper limbs for rehabilitation is because the resumption to the normal functioning of the lower limbs is often spontaneous. However, as Hsieh et al state, patients recovering from stroke still suffer from mild to severe forms of hemiparesis of the upper limbs (2011, p. 112). Arguments emerge whether robotic therapy improves the daily functioning of stroke patients “the lack of appropriate scales to measure activities of daily living (ADLs)” (Kwakkel et al., 2008, p.119). The existing methods of evaluating the effects on the quality of life of the patients are subjective with most of them relying on reports of the patients without consideration of the real-life functioning of the patient. Studies have also demonstrated that hemiparesis patients tend to use normal arms. Often, they have therefore developed and learned non-use in the affected hand (Hsieh et al., 2011, p. 112). Nevertheless, robotic therapy continues to provide a good alternative to conventional physiotherapy in stroke patients.

A new method for measuring arm activity has reignited studies demonstrating the efficacy of robotic therapy over conventional therapy and hence the so-called accelerometer (Hsieh et al., 2011, p. 112). These devices provide an objective way of assessing limb function. They do this by measuring and recording the physical activity in terms of acceleration. They can continuously “record arm activity over time in the patient’s natural living environment” (Hsieh et al., 2011, p. 112). This information is then used to assess the physical activity level of the affected arm. Accelerometers, therefore, provide a means of demonstrating the efficacy of robotic therapy in the rehabilitation of hemiparesis patients.

The use of robotic therapy is possible in both in-patient and outpatient settings. In their study on the use of robotic therapy in in-patients suffering from stroke-induced hemiparesis, Abdullah et al concluded that it can be used as sole therapy in the rehabilitation of stroke patients (2011, p. 47). They recorded a significant amount of success in reducing the time taken to recover by stroke patients to regain the function of the affected arm (Abdullah et al., 2011, p. 47). These studies demonstrate the application of robotic therapy in clinical practice and rehabilitation of stroke-induced hemiparesis. There is still room for more research in this field as sophisticated methods of measuring physical activities emerge.

Critical Appraisal

The subject of the use of robotics in the rehabilitation of upper limb impairment in stroke has elicited a number of researches in this field. This has led to the production of literature supporting and refuting opposing claims. One such study by Kutner et al sought to investigate the “quality-of-life change associated with robotic-assisted therapy to improve hand motor function in patients with sub-acute stroke” (2010, p.496). This randomized clinical trial concluded, “Robotic-assisted therapy may be an effective alternative or adjunct to the delivery of intensive task practice interventions to enhance hand function recovery in patients with stroke” (Kutner et al., 2010, p.501). The build-up to this study involved another study that found out that patients who had been affected by a stroke for less than seven months experienced impairment in handling common items such as newspapers, envelopes, and hanging clothes in the wardrobe. This effort reportedly reduced their perception of their quality of life (Clarke, & Black, 2005, p. 433). Stroke is associated with expensive medical interventions, which are not guaranteed to reinstate function to the affected limbs. It is reported that patients undergoing rehabilitation after stroke do not necessarily recover with most of them reporting a significant residual loss of function on the affected hand (Lai, Studenski, Duncan, & Perera, 2002, p.1842). The research by Kutner et al, however, demonstrates that the use of robotic therapy in combination with other standard rehabilitation therapies after stroke results in increased perception of improved quality of life (Kutner et al., 2010, p.522)

An explanation that was reached for improvement in motor functioning of an affected upper limb was that the increased range of motion of the fingers and the wrist coupled with reduced spasticity of the affected limb caused the improved perception of recovered hand function (Kutner et al., 2010, p.501). This resulted in the participants recording an improved quality of life since they regarded their functioning highly. Robotic therapy is therefore supported by this study. On the contrary, research done by Albert et al concluded that robotic-assisted therapy has no significant benefit over the usual care for patients with moderate-to-severe upper-limb impairment six months or more after a stroke (2012, p.1779).

Their research showed that patients with stroke-induced upper-limb impairment had the same outcome at 12 months after the incidence with the only improvement noted in the Stroke Impact Scale (SIS) score (Albert et al., 2010, p. 1779). They also noted improvement in motor recovery to function in the 36-week study though they say this was not different from that observed in the comparison therapy (Albert et al., 2010, p. 1779). The factors considered in the study were broad thus increasing the generalisability of the results in stroke patients. This was contrary to other studies, which studied the various rehabilitation strategies in acute-to-sub-acute periods after stroke in patients having less impairment (Dromerick et al., 2009, p.199). However, their findings, “robot-assisted therapy at12 weeks did not provide any benefit with respect to the primary outcome” (Albert et al 2010, p. 1780) are refuted by several other studies as discussed above.

The research however demonstrated an important quality of stroke recovery that had been a subject of debate for a long time. Scientists and medical practitioners have held for long the belief that there is little possibility for long-term stroke survivors to regain motor function (Jørgensen et al., 2000, p.410). They managed to demonstrate that an improvement in motor function was likely possible due to the rehabilitation services. This possibility resulted in the suggestion that should stroke patients receive incremental motor activity in their daily routine, the motor function could easily be regained (Albert et al., 2010, p. 1781: Krebs et al., 2002, p.67). This research is therefore significant as it shows the advantageous use of robotic technology in stroke patient rehabilitation. It also shows that robotic-assisted therapy has the “potential long-term benefits of intensive rehabilitation in patients with moderate-to-severe impairment even years after a stroke” (Albert et al 2010, p. 1781).

As previously discussed, accelerometers provide a means of measuring and recording the effects of robot-assisted therapy in the real world. In their randomized control trial, Hsieh et al used accelerometers and ‘the ABILHAND measure’ to investigate the outcomes of using robot-assisted therapy in the upper limbs that were affected by a stroke (2011, p. 116). Their study, which was conducted in Taiwan, involved 20 patients attending rehabilitation services in one of the centers in the country. The patients had satisfied the inclusion criteria of radiological evidence of a stroke with “an initial upper limb Fugl-Meyer Motor Assessment score of 28–56(range 0–66) and no-severe cognitive deficit as demonstrated by their Mini-Mental State Examination Score” (Hsieh et al., 2011, p. 116). The patients did not have any other comorbidity spasticity of the wrist joints, and the lesion had to be in the brain (Hsieh et al., 2011, p. 116).

They observed an improvement in the functioning of the affected arm though this was contrary to the previous studies showing no advantage of using robotic-assisted therapy (Mehrholz, Platz, Kugler, & Pohl, 2009, p.393). They found a remarkable functional improvement in patients receiving robotic-assisted therapy in upper limb impairment after stroke, which complimented studies that got the same results when using the Bi-Manu-Track (Hesse et al., 2005, p.1969). This was supported by the p- values of the experiment, which included “Fugl-Meyer Assessment Scale: 51.20_8.82, P¼0.002; mean arm activity ratio: 0.76_0.10, P¼0.026; ABILHAND questionnaire: 1.24_0.28, P¼0.043” (Hsieh et al., 2011, p. 116). This observation supports the existing evidence that robotic-assisted therapy is important in rehabilitating the impairment of the upper limbs after acute and chronic stroke incidents. The study also concluded that, if combined with a specific time of functional activity training in a day, robotic-assisted therapy has a “superior benefit on real-world arm activity, quality of movement, and bimanual arm activity in the affected arm than dose-matched active control treatment in chronic stroke individuals” (Hsieh et al., 2011, p. 118).

Abdullah et al used a Canadian measure, the Chedoke McMaster Stroke Assessment of the Arm, and Hand (CMSA) to measure the severity of upper limb impairment as opposed to the common measure of Fugal Myer that most studies utilized (Abdullah et al., 2011, p. 9: Coote, Murphy, Harwin, & Stoke, 2008, p.401). They, therefore, offered a different means of interpreting and comparing the effects of robotic therapy in the rehabilitation of the upper limbs in post-stroke patients. The measure used allows the researcher a greater degree of comparison and categorization of patients into the seven groups. This makes it easy to assess any change from one category to the other (Abdullah et al., 2011, p. 9). The results were significant. According to Abdullah et al, “Individuals in the robotic therapy group, on average, improved by 62% (95% CI: 26% to 107%) while those in the conventional therapy group changed by 30% (95% CI: 4% to 61%)” (2011, p.5). The study criticized the use of robotic-assisted therapy in in-patient based on the argument that most stroke patients are elderly and without adequate computer skills required to operate the robots (Abdullah et al., 2011, p. 9). They however found that this population enjoyed and adapted to the use of the robotic technology with time. In fact, “None indicated that he or she was intimidated by the robot in any way” (Abdullah et al., 2011, p. 10).

The study also involved finding out which gender enjoyed the therapy more in relation to the other. The female gender had an equal preference for the methods of rehabilitation assessed with their male counterparts preferring and enjoying robotic-assisted therapy more (Abdullah et al., 2011, p. 10). They explained their findings of the improved hand function by stating that it could have resulted from a number of factors (Abdullah et al., 2011, p. 10). The findings include activation of spared corticospinal pathway neurons by the improved motor control, increased shoulder and elbow strength in the extension of the arm, simulated handgrip and release, and increased motivation from the activity (Abdullah et al., 2011, p. 10).

The research conclusions were that robotic-assisted therapy has important beneficial effects in the rehabilitation of patients with upper limb impairment after stroke (Abdullah et al., 2011, p. 10). They found that robotic arm therapy without adjunctive physiotherapy is significant in the rehabilitation of these patients. Recovery following a stroke is therefore possible using robotic therapy. It should be used in combination with other physiotherapy procedures to facilitate recovery. Other studies discussed above, and others that used different measurements to demonstrate this exposition (Erlandson, 2005, p.33).

Other studies conducted on the use of robotic-assisted therapy in rehabilitation of the upper limb in patients with stroke have found different results. In their randomized control trial, Fasoli et al utilized 20 volunteer patients presenting with hemiparesis who had been diagnosed with “a single unilateral stroke within the past one to five years of the study” (2003, p. 483). They provided the theory to these patients three times a week for a period of six weeks. The exercise performed included the reaching of objects at a set distance by the use of the robotic arm while exercising the hemiparetic shoulder and elbow in the process (Fasoli et al., 2003, p. 483). The criteria used to measure the outcomes were “The Modified Ashworth Scale, Fugl-Meyer test of upper-extremity function, Motor Status Scale (MSS) score, and Medical Research Council motor power score” (Fasoli et al., 2003, p. 477).

Their results were similar to those of previous studies utilizing the same principles mainly for persons in the acute phase of recovery after a stroke (Volpe et al., 2000, p.19440). As for the p-value, “evaluations by a single-blinded therapist revealed statistically significant gains from admission to discharge (P<.05) on the Fugl-Meyer test” (Fasoli et al., 2003, p. 477). The chi-squared test proved the significance of the result since the p-value was less than the cut-off. This research, therefore, advocates for the use of “focused, repetitive movement therapy to enhance motor recovery after stroke” (Fasoli et al., 2003, p. 483: Mater Health and Wellness, 2011, Para. 8). They suggested that the recovery in motor function was related to motor learning. They invoked the theory of motor learning in children where “learning of skilled reach in children has been characterized by a plateau of little or no change interspersed between periods of substantial improvement in reaching smoothness and quality of grasp” (Georgopoulos, 2000, p.148).

This study provided a statistical conclusion in favor of the use of robotic therapy in the rehabilitation of patients with impaired upper limb function because of a stroke. The therapy should be goal-directed and repetitive to achieve significant results in rehabilitation (Fasoli et al., 2003, p. 482). However, the research was specific to the shoulder and elbow joint movement. The fine motor skills of the smaller joints are not significantly affected. This, therefore, leaves some room for more research on the use of sophisticated robots to improve the functioning of the smaller joints in the upper limbs in stroke patients having hemiparesis. Though most of the studies and experiments were done on the use of robotic-assisted therapy in the rehabilitation of hemiparesis patients demonstrate the application of the technology, some hold a contrary opinion by stating that the technology is not beneficial in comparison to the existing physiotherapy measures.

Application to Practice

In the United States, the United Kingdom, and elsewhere in the world, stroke is a significant cause of mortality with the associated morbidity robbing economies of billions of shillings. Conventional methods of attempting to recover lost function in the affected upper limbs in the event of a stroke are expensive and time-consuming. They have also been associated with poor outcomes, as the patients are still perceived to have a low quality of life even after therapy. Researchers and clinical practitioners have also suggested that chronic stroke patients with long-term effects do not recover from their hemiparesis.

Through the combination of the conventional methods of rehabilitation and robot-assisted therapy, there is a demonstrated improvement in the quality of life of these patients. The time taken is also reduced thus enabling patients to be independent in their management. This improves the outcome of physiotherapy. In fact, it may significantly change the mode of management of stroke patients. As discussed above, various applications to the findings of the research in clinical practice are possible.

The therapy could be employed in the management of in-patients and outpatients with stroke. By increasing the contact between the instruments and the patient, the routine visit to the physiotherapy departments could be reduced. This effort will in return save the institutions the money required to rehabilitate patients in a bid to contribute towards improving the quality of life of the millions of patients affected by stroke the world over. This therapy, therefore, targets to revolutionize the management practice of stroke patients.

Traditional rehabilitation services had the assumption that motor recovery for stroke patients is only significant in the first year after the episode, and that subsequent years have little or no improvements associated with them. Researches that have been reviewed above demonstrate that the use of robot-aided therapy in the rehabilitation of these patients can be used to achieve significant motor function even a year after a stroke. This means that the management period for stroke patients could be extended thus resulting in better performance of the affected upper limbs. With the use of robotics in the management of patients, the therapy could be standardized making it easy for the physiotherapy personnel. Less training could also be employed in physiotherapy, as the trade would become easier.

This therapy could also provide a way for clinicians to keep track of their patients in a bid to assess their recovery. Since most of the robotics could be fitted with means of recording activity, clinical practitioners and physiotherapists may interpret the progress of their patients by looking at the readings obtained from the robotic arms (Burgar, Lum, Shor & Van der Loos, 2000, p.667). This step in the forward direction could make the work for physiotherapists easier and more effective. In most counties, health is expensive to maintain since it constitutes a large proportion of government expenditure. With the use of robotic-assisted therapy for stroke patients, the resources could be saved with the resulting improvement in the patients contributing to their economic survival.

Another application of robot-assisted therapy in the rehabilitation of patients with stroke is the return of motor function through supporting other therapies. With the combination of this therapy with other traditional therapies, the outcome in the management of stroke patients could be improved. This will contribute towards reducing stroke-associated morbidity. The researches above demonstrate the use of this technology in clinical and other settings. However, they suggest areas that need to be studied more including the use of robotics to aid in the return of fine motor functions using devices adapted for smaller joints in the hands smaller joints.

Conclusion

In conclusion, stroke is among the leading causes of morbidity in the world only being surpassed by cancer and cardiac disease. It is therefore a cause of concern both in society and in clinical practice. The most common result of a stroke is hemiparesis where one side of the body opposite to the lesion in the brain becomes weak. Return of motor activity in the lower limbs is observed in most instances though this is not to the original strength. However, the upper limbs do not regain function-ability in most patients. They require active movement for this to occur. In the past, physiotherapy has utilized various methods to accomplish this activity. However, these only achieve a portion of the original functioning of the limb.

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