Clinical Scenario:

The patient is a 72 year old female diagnosed with a left CVA 8 months prior.  Initially at diagnosis, patient spent 4 days within an acute care hospital and 2 weeks within an acute rehabilitation setting before being discharged to her own home. Following discharge, patient participated in 8 weeks of outpatient physical and occupational therapy to continue to improve independence around her home. Since that time, she has not participated in any further rehabilitation program.

On examination, patient displayed abnormal synergistic patterns with right AROM movements and noted difficulty isolating movements without decreasing speed of movement. With right shoulder flexion AROM, patient displayed flexion synergy pattern (shoulder elevation, shoulder flexion and abduction in conjunction with elbow flexion) to the level of her shoulder. When patient was asked to demonstrate extending her arm in front of her to reach for a cup, patient demonstrated decreased speed in movement, slight dyscoordination of movement, and forward trunk flexion in order to obtain the object.  Patient states her goals are to improve overall arm function, such as being able to reach into a cabinet without difficulty, as well as hand function for activities such as cooking.

PICO:

In adults presenting with moderate to severe upper extremity impairments (Fugl-Meyer assessment score <50) following chronic stroke (>6 months), is robotic therapy more effective than conventional therapy in improving upper extremity function?

Search Strategy:

Databases Searched: PubMed, CINAHL, and Web of Science

Inclusion Criteria: participants experienced a single CVA at least 6 months ago, participants presented with moderate (if not severe) deficits in upper extremity function meaning Fugl-Meyer scores were no greater than 50, participant age range was 40-70 years old, robotic system provided hepatic feedback but allowed for active movement by participant, English was the main language, all articles were published in the past 10 years

Exclusion criteria: severe spasticity in involved limb (Modified Ashworth Scale 3 or higher), minor deficits in involved limb (Fugl-Meyer score 55 or higher), age <40 years old, and a robotic system that was EMG driven and therefore controlling all aspects of patient’s arm movement (ie patient only performing passive movements).

Search terms used for all 3 databases: upper extremity function, chronic stroke, and robotic therapy

Results:

Limitations:

• Small sample sizes
• Robotic system’s not compared to one another; hard to determine which features of the system are leading to improvements in motor recovery
• Conventional therapy not clearly defined in all studies
• Statistically significant differences between groups very minimal

Clinical Bottom Line:

• There is both Level I and II evidence demonstrating minor but present change in upper extremity motor recovery with the use of robotic and conventional therapy for individuals with chronic deficits in UE function as a result of CVA
• Greater improvements in scores were noted with robotic therapy immediately after intervention however at follow up robotic therapy was not superior to conventional therapy in most studies
• Two studies found significance when robotic therapy was applied in addition to conventional therapy

Application to Clinical Case Scenario:

• Two factors to take into consideration: Cost effectiveness knowing that a robotic exoskeleton is rather expensive, however robotic systems allow repetitive task movements at a higher intensity and with greater precision (more so than what a therapist may be able to provide over extended period of time).
• If arm exoskeleton is available in clinic, robotic therapy could be combined with traditional therapeutic interventions for maximal upper extremity motor recovery
• Treatment:  First couple of weeks utilizing robotic exoskeleton alone: robotic system should provide hepatic feedback to maximize motor learning.  Remaining weeks: conventional therapy with emphasis on functional tasks such as reach and grasp or fine motor movements such as pinch.
• Goal: Gross motor movements are refined with robotic exoskeleton during those first initial weeks with progression to gross motor movements against gravity without the exoskeleton as well as fine motor movements or any other movement the patient wanted to achieve during final weeks prior to discharge.

References:

1. Brokaw E, Nichols D, Holley R, Lum P. Robotic therapy provides a stimulus for upper limb motor recovery after stroke that is complementary to and distinct from conventional therapy. Neurorehabil Neural Repair. 2014;28(4):367-376.
2. Klamroth-Marganska V, Blanco J, Campen K, et al. Three-dimensional, task-specific robot therapy of the arm after stroke: A multicentre, parallel-group randomised trial. The Lancet Neurology. 2014;13(2):159-166. doi: http://dx.doi.org.libproxy.temple.edu/10.1016/S1474-4422(13)70305-3.
3. Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: Systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479–96. http://dx.doi.org/10.1682/JRRD.2010.10.0210
4. Reinkensmeyer DJ, Wolbrecht ET, Chan V, Chou C, Cramer SC, Bobrow JE. Comparison of 3D, Assist-as-Needed Robotic Arm/Hand Movement Training Provided with Pneu-WREX to Conventional Table Top Therapy Following Chronic Stroke. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2012;91(11 0 3):S232-S241. doi:10.1097/PHM.0b013e31826bce79.
5. Susanto EA, Tong RKY, Ockenfeld C, Ho NSK. Efficacy of robot-assisted fingers training in chronic stroke survivors: A pilot randomized-controlled trial. Journal of NeuroEngineering and Rehabilitation. 2015;12:42. http://go.galegroup.com.libproxy.temple.edu/ps/i.do?p=AONE&sw=w&u=temple_main&v=2.1&it=r&id=GALE%7CA412502874&sid=summon&asid=e6e160c574c1931cbce913c8d1827e73.