Date Presented 4/19/2018
Evidence for improved upper limb function after robot-assisted therapy is limited. The purpose of this pilot study was to develop and refine a stroke therapy protocol that combines robot-assisted therapy with a home program based on task-oriented training and motor learning principles.
Primary Author and Speaker: Susan Fasoli
PURPOSE: The purpose of this pilot study was to develop and refine a stroke therapy protocol that infuses robot-assisted therapy with a structured program based on motor learning theory that includes a patient-targeted home action plan and task-oriented training for the paretic arm and hand. The intent of this protocol was to teach stroke survivors ways to better use their weaker arm after stroke during daily activities.
METHOD: For this randomized controlled trial, we recruited 10 adults aged 18–82 diagnosed with unilateral stroke >6 mo before study enrollment. Stroke type included both ischemic and hemorrhagic stroke. Potential participants were recruited through printed flyers provided to rehabilitation departments of local hospitals, physician referral, and contact by study staff if they previously had given permission to be contacted about research opportunities. Eligible participants were screened and enrolled if they met the following inclusion criteria: moderate upper extremity (UE) hemiparesis (i.e., some ability to move shoulder, elbow, and hand and initial score on the Fugl-Meyer Assessment [FMA] between 21 and 50 of 66); intact cognitive function (Montreal Cognitive Assessment score ≥26/30) during initial evaluation visit to understand and actively engage in the Active Learning Program for Stroke robotic therapy procedures; and no more than moderate impairments in paretic UE sensation, passive range of motion, tone and spasticity, and pain that would limit ability to engage in therapy. All participants provided informed consent before study participation.
Participants were randomly assigned to receive 18 1-hr sessions of robot-assisted therapy, with or without task-oriented training, in conjunction with an individualized home program to facilitate carryover of targeted upper limb motions to the home and community. Principles of motor learning and experience-dependent neuroplasticity guided selection of training activities. Home programs were reviewed and updated weekly and focused on self-management and problem-solving strategies to optimize paretic upper limb use.
The Motor Activity Log (MAL) served as the primary measure of perceived changes in upper limb use in the home and community. Secondary measures included the FMA, the Wolf Motor Function Test (WMFT), the Stroke Impact Scale, the Confidence in Arm and Hand Movement (CAHM) scale, and data collected from wrist-worn accelerometers during 72-hr periods at home before and after intervention. Outcome measures were administered pre- and posttreatment and at 1-mo follow-up.
RESULTS: Moderate to large gains were evident on the MAL, FMA, and WMFT in both treatment groups. Preliminary results indicate that participants with greater distal function at baseline were more likely to follow through with home program activities for the paretic arm and hand and reported greater ability to independently apply problem-solving strategies to optimize upper limb functioning. Associations between amount of paretic arm use and ratings on the CAHM scale will be examined.
CONCLUSION: Results indicate that this hybrid approach has the potential to improve the effectiveness of robot-assisted therapy by facilitating UE self-management through active problem identification and problem solving and by specifically addressing the transfer of acquired skills (e.g., UE motor capacity) to the performance of UE tasks during activities of daily living. Previous studies of robot-assisted therapy after stroke have not well addressed the transfer of robot-trained movements to functional use of the paretic upper limb during daily activities. These pilot results indicate the need for an integrated approach to robotic training that uses theory-based motor learning strategies to optimize home programming and carryover of upper limb function to the home and community. This hybrid treatment approach, focused on principles of motor learning and recovery, holds promise for improving function of the paretic upper limb across domains of the International Classification of Functioning, Disability and Health (World Health Organization, 2001) and for optimizing occupational performance after stroke.
References
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Winstein, C. J., & Wolf, S. L. (2009). Task-oriented training to promote upper extremity recovery. In J. Stein, R. L. Harvey, R. F. Macko, C. J. Winstein, & R. D. Zorowitz (Eds.), Stroke recovery and rehabilitation (pp. 267–290). New York: Demos Medical Publishing.
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