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Robot Therapy Improves Mobility After Stroke

Japanese researchers have found that patients with stroke-paralyzed arms and shoulders responded better to robot-assisted exercises (in addition to standard rehabilitation in the sub-acute period) better, as compared with self-training.

Patients with hemiplegia showed significant gains in their ability to move their upper extremities with robotic rehabilitation over six weeks (P<0.001), whereas those on standard therapy did not (P¡Ü0.05 between groups) in a randomized trial reported by Kayoko Takahashi, ScD, OTR, of Kitasato University East Hospital in Kanagawa, Japan. Takahashi's study followed patients for just six weeks.

It randomized 56 hemiplegia patients on an average of 47 days after stroke onset to daily rehabilitation consisting of standard therapist-assisted upper extremity work for 40 minutes, plus another 40 minutes of either robotic therapy or self-training (stretches and passive-to-active exercises of the affected arm).

The robo-rehab group gained an average of 4.8 points on the 36-point Fugl-Meyer scale reflecting recovery of motor function in the shoulder, elbow, and forearm compared with a change of 1.9 points in the control group (P<0.05).

Recovery of voluntary arm movements also showed an advantage in the robot-assisted group, with a gain of 2.1 points on the 12-point Fugl-Meyer flexor synergy score scale compared with a decline of 0.1 points in the control group over the six-week study (P<0.01).

Patients with a baseline Fugl-Meyer total score of at least 30 on the 66-point scale improved significantly regardless of treatment group, without a significant difference between groups.

More severely paralyzed patients got maximum advantage from robotic guidance, Takahashi reported here at the American Stroke Association's International Stroke Conference.

"This may be because the patients with lower function have difficulty performing self-training correctly and therefore they are more likely to benefit from the robot, which can carry out repetitive exercise with exactly the right movement pattern at the right amount of assistance," Takahashi told reporters at a press conference. Another possibility is that the structured self-training exercises weren't hard enough for those with higher function, she suggested.

The Reo Therapy System has been developed by Motorika Ltd. in Israel was used in the study. Initially the patient's arm is moved while giving feedback on a monitor -- re-educating the brain on how the arm works -- then gives diminishing amounts of support as the patient is able to initiate and then carry through movement. The patient's forearm, either resting on or strapped to a platform, is moved in multiple directions based on pre-programmed exercise movements.

Researchers selected five such pre-programmed movements. For instance, in one of the movements, "forward reach," the robot helps patients extend their arms forward as if reaching for something in front of them.

Therapists also selected from five levels of robotic assistance according to what was most appropriate for the patient, from movement entirely guided by the robot and passive on the patient's part, to movement actively performed by the patient.

Some similar devices have proven as effective as human physical therapist-guided exercises in restoring motor function after a stroke.

But robots are no replacement for self-training or therapists, Takahashi said."Self-training is still very important," she told MedPage Today. "I believe the combination is key to success of [the] intervention."

She suggested that the device could take care of menial exercises, freeing up physical therapists and patients to focus on retraining in skills needed for activities of daily living.

Daniel Lackland, DrPH, of the Medical University of South Carolina in Charleston, likened it to the situation in the orthopaedic community where machines that mobilize knees or shoulders after surgery have taken the place of what physical therapists would have done at one time.

While the ReoGo and other robotic rehabilitation devices are available in the U.S., they have been adopted by relatively few centres. Though expensive, the rehabilitation robot is considered cost-saving because of the reduced human involvement over time is less expensive, explained press conference moderator Robert J. Adams, MD, of the Medical University of South Carolina Stroke Center in Charleston.

Aside from cost, the concern is whether the short-term advantages shown with robotic rehabilitation actually translate to long-term functional outcome, which hasn't been shown, commented Larry B. Goldstein, MD, of Duke University Medical Center in Durham, N.C.

But the advantage of robotic therapy was substantial for those with lower function at baseline, with triple the gain in score compared with controls (change 6.6 versus 2.2, P<0.05).

Most studies have focused on the chronic stage after a stroke to test the benefit of robotic rehabilitation, Takahashi noted at the press conference.

"Sub-acute rehab is not a common stage to test robotic therapy," she acknowledged. "But since the health insurance system in Japan is mainly focused on sub-acute care, what we tried to do is to increase their function as much as possible during that phase."

Lackland, a spokesperson for the American Stroke Association, saw the early approach as an advantage.

"If you can get rehab as quickly as possible, then there's less you have to teach," he noted. "It's been shown that if you get it quickly, recovery is better."

With a recent trend in helping patients function with one arm, "many post-stroke patients have given up hope of recovery of their affected arms." Takahashi said. "Participating in such robotic exercise is therefore expected to give patients insights about their future ability and a more positive image regarding their affected arm, increasing their self-efficacy and motivation toward rehabilitation."

"Further research using larger groups of patients is necessary to investigate the efficacy of such robotic exercise in more detail," Takahashi said.

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