Technology-Related Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012

Abstract

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association’s Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for technology-related interventions to improve performance in activities of daily living for adults with stroke, such as virtual reality/gaming, biofeedback, robotics, electrical stimulation, and telerehabilitation.

Full Systematic Review Question

This systematic review addressed the question “What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to improve performance and participation in activities of daily living (ADL) for adult stroke survivors?”

Current Theme Reported

The main theme of the studies included in this systematic review brief is interventions involving the use of technology to improve performance in ADL (i.e., virtual reality [VR] and gaming, robotics, biofeedback, electrical stimulation [e-stim], and telerehabilitation).

Clinical Scenario

There are more than 7 million stroke survivors, with stroke as the leading cause of adult disability in the United States (Tsao et al., 2022). Stroke often leaves survivors with limitations in ADL (Gadidi et al., 2011), which is correlated with overall life dissatisfaction (Hartman-Maeir et al., 2007). VR and technology-based interventions can create an immersive experience for the user (Wolf & Nilsen, 2015). The systematic review theme presented here addresses VR and gaming, robotics, biofeedback, e-stim, and telerehabilitation for adults who had a stroke and the effectiveness of these technology- related interventions for improved performance in ADL including basic ADL (i.e., functional independence measure [Ottenbacher et al., 1996], Barthel Index [Mahoney & Barthel, 1965], Canadian Occupational Performance Measure [Law et at., 2016], Stroke Impact Scale [Duncan et al., 1999], Abilhand [Penta et al., 1998], Functional Reach Test [Duncan et al., 1990], Modified Motor Assessment Scale [Carr et al., 1985]) and functional mobility (i.e., Forward Reach Test [Duncan et al., 1990], Berg Balance Scale [Stevenson, 2001], Timed Up and Go [Podsiadlo & Richardson, 2015], and Motor Activity Log [Taub et al., 2011]).

Summary of Key Findings

Four Level 1A (systematic reviews) and 16 Level 1B (randomized control trials [RCT]) studies met the criteria for inclusion and provided evidence for the effectiveness of technology interventions to improve ADL performance (Table 1). The risk of bias for a majority of the studies was low, but two studies had moderate risk of bias. The studies in this theme involved several types of technology interventions such as VR/gaming, biofeedback, robotics, e-stim, and telerehabilitation. The levels of evidence used in this review are from Oxford Centre for Evidence-Based Medicine (2009). The strength-of-evidence designations are based on the guidelines of the U.S. Preventive Services Task Force (2018).

Table 1.

Evidence Table for Technology-Related Interventions to Improve Performance in ADL for Adults with Stroke

AuthorYearLevel of EvidenceRisk of Bias (RoB)CountrySetting	Intervention	Statistically SignificantImprovement ResultingFrom Intervention
VR/Gaming
One Level 1A and Eight level 1B studies provided moderate strength of evidence, due to inconsistent findings, supporting the use of VR/gaming after stroke to improve performance in ADL. Although the interventions themselves were quite diverse, all studies included use of a video game or a virtual reality. environment to provide intervention.
Laver et al. (2018) Level 1A—Systematic Review with Meta-Analysis RoB Low Country United States and Canada Setting Varies per study	Population (Varies by study) N = 2470 (across 72 trials). Stroke patients in a variety of settings, at a variety of stages poststroke, participating in VR intervention. Intervention (Varies by study) Five intervention approaches using VR were used: activity retraining (n = 4), upper limb training (n = 35), lower limb, balance, & gait training (n = 23), global motor function training (n = 10), and cognitive/perceptual training (n = 1); 22 studies used commercially available gaming consoles (e.g., Playstation EyeToy, Nintendo Wii, Microsoft Kinetic); 8 used Gesture Tek IREX; 1 study used the Armeo; 1 study used the CAREN system; 1 study used the Lokomat; remaining studies used customized VR programs. Delivery Method (Varies per study) Dose (Varies by study) total hours of treatment: <5 hr (n = 13); 6–10 hr (n = 25); 11–20 hr (n = 26); >21(n = 7); 1 study had a low intensity group (4 hr) and a high intensity group (10 hr).	ADL Pooled analysis from 10 trials with 466 participants found statistically significant findings favoring VR on ADL performance. Functional Mobility No significant findings.
Adie et al. (2016) Level 1B—RCT RoB Low Country United Kingdom Setting In-home	Population N = 240. 24–90 yr old stroke within the past 6 mo with arm weakness, and able to manipulate Wii remote. Intervention Wii gaming system with participants able to select any of the Wii sports games. Delivery Method Individualized Dose Instructed to perform exercises for up to 45 min daily for six weeks in a seated position.	ADL No significant findings. Functional Mobility No significant findings.
Brunner et al. (2017) Level 1B—RCT RoB Low Country Norway Setting Outpatient	Population N = 120. Adults with subacute stroke, with residual upper extremity motor impairments. Intervention Usual care + VR training with the YouGrabber system (consists of data gloves with sensors, an infrared camera and software in combination with a personal computer and screen. Delivery Method Individual Dose 4–5 training sessions per week of up to 60 min duration.	ADL No significant findings.
Cannell et al. (2017) Level 1B—RCT RoB Low Country Australia Setting Subacute	Population N = 73. Stroke patients with a clinician-assessed capacity for improvement in mobility, any level of mobility. Intervention Game-based activities with an individualized prescription of repetitive exercises using software from the Jintronix Rehabilitation System^TM. Delivery Method Individualized care Dose 2 sessions per day, first individualized PT and the second session either the intervention or control. Intervention lasting up to 1 hr, 5×/week, depending on the endurance of the participant.	ADL No significant findings. Functional Mobility No significant findings.
Henrique et al. (2019) Level 1B—RCT RoB Moderate Country Brazil Setting Physiotherapy School Clinic	Population N = 31. Chronic ischemic stroke, over 6 mo post stroke. Intervention Exergame rehabilitation using Motion Rehab AVE 3D, which simulates six activities where user must move hands, limbs, and torso to collect objects and score points. Delivery Method Individualized Dose Twice a week for 30 min each over a 12-wk period.	Functional Mobility No significant findings.
Kong et al. (2016) Level 1B—RCT RoB Low Country Singapore Setting Inpatient Stroke Rehabilitation	Population N = 105. Aged 21–80 yr, less than 6 wk after stroke onset. Intervention Wii gaming system with Wiimote held in the stroke-affected hand. Delivery Method Individualized Dose 12 sessions, 4×/week over 3 wk, with each session lasting about 60 min.	ADL No significant findings.
Laffont et al. (2020) Level 1B—RCT RoB Low Country France Setting Inpatient Rehabilitation	Population N = 51. Adults with greater than 3 mo post stroke. Intervention Video games played with the affected upper extremity. The first half of the session were games that were configurable by the therapist and the second half of the session consisted of online games previously selected by a group of therapists. Delivery Method Individualized Dose Usual rehab programs with an additional session of intervention or control for 45 min 5 days/week for 6 wk.	ADL No significant findings.
Lin et al. (2015) Level 1B—RCT RoB Moderate Country Taipei Setting Inpatient Rehabilitation	Population N = 33. At least 3 mo poststroke, with the ability to flex and extend the paretic arm and hand. Intervention Bilateral isometric handgrip force training while seated at an LCD screen in which the individual gradually increased or decreased their grip to track the trajectory of the targeted force. Delivery Method Individualized Dose 30 min a day, 3 days a week, for 4 wk.	ADL Statistically significant improvements in favor of the intervention both on the BI and the MAS.
Şimşek & Çekok (2015) Level 1B—RCT RoB Moderate Country Turkey Setting Inpatient Rehabilitation	Population N = 42. Stroke survivors with hemiplegia with no conventional physical therapy treatment received in the early period after stroke. Intervention Use of the Wii sports and Wii Fit packages for upper limb and balance training. Delivery Method Individualized Dose 45–60 min per day, 3 days a week for 10 wk.	ADL No significant findings.
Biofeedback
Three Level 1B studies provided low strength of evidence, due to inconsistent findings, in favor of the use of passive range of motion to increase performance of ADL.
Ambrosini et al. (2020) Level 1B—RCT RoB Low Country Italy Setting Inpatient Rehabilitation	Population N = 68. Subacute stroke, less than 6 mo previous, with hemiparesis. Intervention Biofeedback training of voluntary cycling and FES followed by platform-based balance training, both supported by visual feedback. Delivery Method Individualized Dose 20 min of each session which was added to 70 min of usual care, 5×/week	ADL No significant findings.
Kutlay et al. (2018) Level 1B—RCT RoB Moderate Country Turkey Setting Inpatient Rehabilitation	Population N = 64. First stroke, with unilateral neglect and can stand for 5 min. Intervention KAT which is a balance training program performed on a movable platform with visual feedback. Delivery Method Individualized Dose 20–30 min, 5×/week for 4 wk in addition to usual care.	ADL No significant findings.
Najafi et al. (2018) Level 1B—RCT RoB Moderate Country Iran Setting Physiotherapy Center	Population N = 60. Mean age 60 and 58% female. Stroke patients between 3 mo and 3 yr poststroke, and able to walk for 10 meters without assistive devices. Intervention Biofeedback to improve motor function was performed. Delivery Method Individualized Dose 20-min sessions, twice weekly for 8 wk.	ADL Intervention group improved significantly better than the control in terms of balance.
Robotics
Two Level 1A studies and three Level 1B studies provided low strength of evidence, due to no significant findings, for the use of robotic-assisted therapy to improve ADL performance.
Lo et al. (2017) Level 1A—Systematic Review RoB Low Country Australia Setting Varies by study	Population N = 1798 (51 studies included). Adult stroke patients. Intervention (Varies by study) Interactive automated electromechanical equipment (i.e., robotics) both with and without conventional therapy. Delivery Method Individual, (Varies by study) Inpatient and outpatient settings Dose (Varies by study)	ADL No significant findings.
Veerbeek et al. (2017) Level 1A—Systematic Review with Meta-Analysis RoB Low Country Netherlands Setting Varies by study	Population N = 1206 (across 38 trials included in quantitative analysis). Stroke patients with use of robotics therapy for the upper limb. Intervention (Varies by study) Five most common devices included: MIME robot, BiManu Track, NeReBo, MIT MANUS, InMotion Shold Elbow Robot. Delivery Method (Varies by study) Dose (Varies by study) The duration of the intervention ranged from 2 to 12 wk; total therapy time ranged from a low of 0.5 hr to a high of 90 hr; number of repetitions per session ranged from a low of 50 to a high of 2700 to 3600.	ADL No significant findings. Functional Mobility No significant findings.
Hsieh et al. (2016) Level 1B—RCT RoB Low Country Taiwan Setting Outpatient Home	Population N = 34. Chronic unilateral stroke, greater than 6 mo poststroke. Intervention Robot-assisted therapy followed by mCIT or functional activities. Delivery Method Individual Dose Average of 90–105 min/day, 5 days a week for 4 wks. 2 wk of 600–800 repetitions of the passive-passive and active-passive modes for 15–20 min and 150–200 repetitions of the active-active mode for 3–5 min; followed by 2 wk of mCIT for 6 hrs a day in the intervention group; or 15–20 min of functional-based activities in the control group.	ADL No significant findings.
Lee et al. (2018) Level 1B—RCT RoB Low Country Korea Setting Inpatient Rehabilitation	Population N = 30. Patients with stroke-induced hemiplegia occurring at least 6 mo before study enrollment. Intervention Robot-assisted therapy. A total of five functional movement programs were applied, namely, “shooting targets,” “catching falling objects with different grasps and twists,” “boxing,” “weeding a garden,” and “stack attack.” Delivery Method Individualized Dose 30 min, 5×/week, for 8 wk	ADL No significant findings.
Straudi et al. (2020) Level 1B—RCT RoB Low Country Italy Setting Inpatient Rehabilitation	Population N = 40. Adults aged 18–80, with first single unilateral stroke. Intervention Functional electric stimulation + Robot Assisted Hand Therapy (Reo Therapy system). Delivery Method Individualized Dose 1 hr and 40 min, 5×/week for 6 wk.	ADL No significant findings.
Electrical Muscle Stimulation (E-Stim)
Two Level 1B studies provided low strength of evidence, due to no significant findings, for the use of e-stim in improving ADL outcomes.
Carrico et al. (2018) Level 1B—RCT RoB Low Country United States Setting Lab	Population N = 55. Single hemorrhagic stroke during the 3–12 mo preceding enrollment, with inability to demonstrate active extension of the fingers. Intervention Stimulation set to evoke compound muscle action potentials in the deltoid, triceps, and opponens pollicis brevis. Delivery Method In person Dose 3× wk for 6 wks: 18 sessions total, 2-hr somatosensory stimulation followed by 4 hr of intensive task-oriented UE training.	ADL No significant findings.
Zhou et al. (2018) Level 1B—RCT RoB Low Country China Setting Rehabilitation Hospital	Population N = 81. Adults with hemiplegia in the unilateral limb and shoulder pain poststroke. Intervention Two arms. Intervention 1: NMES to supraspinatus and deltoids. Intervention 2: TENS applied to same area as NMES group. Delivery Method Individualized Dose 20 sessions of 1-hr stimulation, daily for 4 wk.	ADL No significant findings.
Telerehabilitation
One Level 1A study provided low strength of evidence, due to no significant findings and lack of additional evidence, supporting the use of telerehabilitation to support ADL outcomes after stroke.
Tchero et al. (2018) Level 1A–Systematic Review with Meta-Analysis RoB Low Country France Setting Virtual Telerehabilitation	Population N = 1339 (across 15 studies). Telerehabilitation used with post stroke population. Intervention (Varied by study) Models included telephone calls, video conferencing, educational videos, Web-based chats, and virtual reality systems to provide standard care or home exercises programs. Delivery Method via telerehabilitation Dose Not reported.	ADL No significant findings. Functional Mobility No significant findings.

Note: ADL = activities of daily living; RCT = randomized control trial; MAS = Modified Motor Assessment Scale; BI = Barthel Index; FES = functional E-Stim; KAT = Kinesthetic Ability Trainer; mCIT = modified constraint induced therapy; VR = virtual reality; e-stim = electrical muscle stimulation; NMES = neuromuscular e-stim.

Bottom Line for Occupational Therapy Practice

Overall, evidence to support the use of technology- related interventions to improve ADL outcome after stroke is limited by the diverse nature of the interventions within this theme. In addition, within each of the themes, evidence was limited in that many studies demonstrated no statistical significance in favor of interventions. There is strong strength of evidence supporting the use of VR/gaming for ADL outcomes after stroke (Laver et al., 2018; Lin et al., 2015), although additional studies demonstrate low strength of evidence (Adie et al., 2016; Brunner et al., 2017; Cannell et al., 2017; Henrique et al., 2019; Kong et al., 2016; Laffont et al., 2020; Şimşek & Çekok, 2015). Gaming interventions used both commercially available systems, such as Nintendo Wii (Adie et al., 2017; Kong et al., 2016; Laver et al., 2018; Şimşek & Çekok, 2015), as well as rehab-specific intervention programs, such as Jintronix (Cannell et al., 2017). Practitioners should consider adding these interventions to rehabilitation of stroke patients. One study did show moderate strength of evidence in favor of biofeedback in the improvement of ADL outcome (Najafi et al., 2018), although other studies demonstrated no significant findings (Ambrosini et al., 2020; Kutlay et al., 2018). Although biofeedback may be used for other purposes, there is not sufficient evidence to support the use of biofeedback in improvement of ADL outcomes. The themes of robotics, e-stim and telerehabilitation all provided low strength of evidence in support of use to improve ADL outcomes, as none of the included studies demonstrated any significant findings. While this review was limited to studies that met criteria for 1A/1B levels of evidence, it is possible that smaller trials with significant findings were not represented in this review. Further investigation is also needed to look at more specific comparisons of intervention, with attention to the type of technology used as well as the dosage provided to best improve ADL outcomes after stroke.

Footnotes

*

Indicates studies included in the systematic review.

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Technology-Related Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012–2019)