Fisioterapia asistida por robot, en caso de Hemorragia cerebral

1. Yu-wei Hsieh, Ching-yi Wu, Keh-chung Lin, Grace Yao, Kuen-yuh Wu and Ya-ju Chang
of Initial Motor Status
Response Relationship of Robot-Assisted Stroke Motor Rehabilitation: The Impact−Dose
Print ISSN: 0039-2499. Online ISSN: 1524-4628
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is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Stroke
doi: 10.1161/STROKEAHA.112.658807
2012;43:2729-2734; originally published online August 14, 2012;Stroke.
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2. Dose–Response Relationship of Robot-Assisted Stroke
Motor Rehabilitation
The Impact of Initial Motor Status
Yu-wei Hsieh, PhD; Ching-yi Wu, ScD; Keh-chung Lin, ScD; Grace Yao, PhD;
Kuen-yuh Wu, PhD; Ya-ju Chang, PhD
Background and Purpose—The increasing availability of robot-assisted therapy (RT), which provides quantifiable,
reproducible, interactive, and intensive practice, holds promise for stroke rehabilitation, but data on its dose–response
relation are scanty. This study used 2 different intensities of RT to examine the treatment effects of RT and the effect
on outcomes of the severity of initial motor deficits.
Methods—Fifty-four patients with stroke were randomized to a 4-week intervention of higher-intensity RT, lower-intensity
RT, or control treatment. The primary outcome, the Fugl-Meyer Assessment, was administered at baseline, midterm, and
posttreatment. Secondary outcomes included the Medical Research Council scale, the Motor Activity Log, and the
physical domains of the Stroke Impact Scale.
Results—The higher-intensity RT group showed significantly greater improvements on the Fugl-Meyer Assessment than
the lower-intensity RT and control treatment groups at midterm (Pϭ0.003 and Pϭ0.02) and at posttreatment (Pϭ0.04
and Pϭ0.02). Within-group gains on the secondary outcomes were significant, but the differences among the 3 groups
did not reach significance. Recovery rates of the higher-intensity RT group were higher than those of the lower-intensity
RT group, particularly on the Fugl-Meyer Assessment. Scatterplots with curve fitting showed that patients with
moderate motor deficits gained more improvements than those with severe or mild deficits after the higher-
intensity RT.
Conclusions—This study demonstrated the higher treatment intensity provided by RT was associated with better motor
outcome for patients with stroke, which may shape further stroke rehabilitation.
Clinical Trial Registration—URL: http://clinicaltrials.gov. Unique identifier: NCT00917605.
(Stroke. 2012;43:2729-2734.)
Key Words: randomized controlled trial Ⅲ robot-aided neurorehabilitation Ⅲ stroke Ⅲ treatment dosage
Stroke remains a common cause of acquired adult disabil-
ity worldwide.1,2 Motor deficits of the upper limb are
often a devastating disability for stroke survivors3 and thus,
the search for effective and efficient rehabilitation to promote
motor recovery becomes urgent. Robot-assisted therapy (RT)
is an innovative approach to stroke rehabilitation that uses
intensive, repetitive, interactive, and individualized practice
as an optimal strategy to enhance motor learning.4,5
The optimal dosage for specific rehabilitation regimens to
induce improvement is unclear from current evidence.6 Be-
cause the research suggests that intensive therapy has a
positive influence on stroke recovery,7,8 RT may offer a good
way to close the gap between limited rehabilitation resources
and a greater amount of therapy.9 RT also provides precise
and quantifiable control of therapy, allowing better research
into treatment dosage.10 This critical factor—how the inten-
sity of therapy influences the effects of RT—should be
addressed to inform the dose–response relation and to seek
proper treatment intensity for patients.
Another emerging concern is which intervention is most
beneficial for which type of patient under specific circum-
stances.11 Identifying the factors affecting successful out-
comes and the patients most likely to respond to the therapy
would be informative for clinical guidelines. Although the
initial motor status of patients with stroke is viewed as an
important factor that influences recovery,12,13 whether this
factor affects the outcomes of RT remains unknown. We
therefore investigated the effects of RT on clinical outcomes
in patients with chronic stroke by using higher-intensity and
lower-intensity RT relative to a duration-matched control
Received March 27, 2012; final revision received July 15, 2012; accepted July 18, 2012.
From the School of Occupational Therapy (K.C.L.), College of Medicine, the Department of Psychology (G.Y.), and the Institute of Occupational
Medicine and Industrial Hygiene (K.Y.W.), National Taiwan University, Taipei, Taiwan; the Departments of Occupational Therapy and Graduate Institute
of Behavioral Science (Y.W.H., C.Y.W.) and Physical Therapy (Y.J.C.), Chang Gung University, Taoyuan, Taiwan; and the Division of Occupational
Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan (K.C.L.).
Correspondence to Keh-chung Lin, ScD, School of Occupational Therapy, College of Medicine, National Taiwan University, 17, F4, Xu Zhou Road,
Taipei, Taiwan 100. E-mail kehchunglin@ntu.edu.tw
© 2012 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.112.658807
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3. treatment (CT) and also examined whether the initial severity
of motor deficits and the treatment intensities of RT interact
to influence the primary outcome.
Methods
Participants
Criteria for study participants were (1) more than 6 months’ onset
from a unilateral stroke; (2) baseline upper extremity score on the
Fugl-Meyer Assessment (FMA) of 26 to 56; (3) no excessive
spasticity in forearm and wrist joints (modified Ashworth scale Ͻ3);
(4) able to follow study instructions and perform study tasks
(Mini-Mental Status Examination Ն22); (5) no upper limb fracture
within 3 months or painful arthritis of the joints; and (6) no severe
neuropsychologic impairments (eg, global aphasia or severe atten-
tion deficits). The Institutional Review Boards of the participating
hospitals approved the study, and all participants provided
informed consent.
Study Procedures
This was a randomized-block controlled trial with pretest, midterm,
and posttest evaluations. Eligible participants were stratified accord-
ing to side of lesion and level of motor deficits and individually
randomized to receive one of the 3 interventions. A random number
table was used to generate randomization assignments, and a
research assistant allocated the patients to an intervention group
accordingly. All clinical measures were administered to the patients
at baseline and immediately after the intervention by the same
blinded rater. The primary outcome measure was also administered
2 weeks after treatment began (midterm).
Interventions
All participants received a duration-matched intervention for 90 to
105 minutes/day, 5 days/week for 4 weeks. The patients in the 2 RT
groups practiced with the Bi-Manu-Track (Reha-Stim Co, Berlin,
Germany; Figure 1), which allows 2 movement patterns: forearm
pronation–supination and wrist flexion–extension.14 Each move-
ment pattern is enabled by 3 computer-controlled modes: passive–
passive (mode 1), active–passive (mode 2), and active–active
mode (mode 3). The parameters of movement and resistance can
be adjusted individually. The robot was equipped with a computer
game to provide instant visual movement feedback and to
increase participation.
Within one training session, the patients in the higher-intensity RT
group practiced 600 to 800 repetitions of modes 1 and 2 for 15 to 20
minutes and 150 to 200 repetitions of mode 3 for 3 to 5 minutes for
bilateral forearm and wrist movements. One repetition indicated one
movement direction. Patients in the higher-intensity RT received
Figure 1. Bi-Manu-Track.
326 Patients with stroke were
assessed for eligibility
54 Underwent randomization
272 Were excluded
232 Did not meet inclusion
criteria
40 Refused to participate
18 Were assigned to
lower-intensity
robot-assisted therapy
18 Were assigned to
control treatment
18 Were assigned to
higher-intensity
robot-assisted therapy
18 Completed study
and 18 were analyzed
18 Completed study
and 18 were analyzed
17 Completed study and
18 were analyzed
1 Drop out
(due to
hydronephrosis)
Figure 2. Flow chart of participant enrollment.
2730 Stroke October 2012
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4. twice the number of the repetitions per unit of time than patients in
the lower-intensity RT group.15
Before the RT training, 5 minutes of mobilization warm-up were
provided. After the training, the patients received 15 to 20 minutes of
functional activities practice to help them transfer the acquired motor
ability to their performance of daily activities.
The CT group received an intensive therapist-administered control
therapy matched in duration with the RT groups. Occupational
therapy techniques used in the treatment protocols included neuro-
developmental treatment, muscle strengthening, fine-motor training,
and functional task training.
Outcome Measures
The primary outcome was a change in the FMA. The 33 upper
extremity items of the FMA, with scores ranging from 0 to 66, were
used to assess motor impairment.16 The reliability, validity, and
responsiveness of the FMA in patients with stroke have been well
established.16–18
Secondary outcomes included the following assessments: (1) the
Medical Research Council scale, a reliable measurement ranging
from 0 (no contraction) to 5 (normal power), examines muscle power
of the affected arm19; (2) the Motor Activity Log consists of a
30-question interview in which patients rate the amount of use and
quality of movements at the time of using their affected arm to
accomplish daily activities20; and (3) the Stroke Impact Scale (SIS)
3.0 has 4 physical domains—strength, activities of daily living/
instrumental activities of daily living, mobility, and hand function—
that use patient report to evaluate function and quality of life.21
Two common complications after stroke, pain and fatigue,22 were
measured to investigate if intensive rehabilitation causes adverse
effects. The therapist asked the patient to rate the severity of his or
her pain and fatigue during the intervention on a scale of 0 (no pain
and no fatigue) to 10 (unbearable pain and exhaustion).
Statistical Analysis
An intention-to-treat analysis was applied. Two-way repeated-
measures analysis of covariance was used to evaluate efficacy of the
primary outcome among the 3 groups followed by a post hoc analysis
using the Bonferroni test for a significant effect. Analysis of
covariance was used to evaluate treatment efficacy for the secondary
outcomes with baseline scores as the covariates. The t test was used
to examine recovery rates of each week on each outcome (ie,
improved score divided by the number of weeks) between the 2 RT
groups. We also examined whether the initial severity of motor
impairments affected the primary outcome (ie, FMA). Scatterplots
with quadratic curves were used to illustrate the relationship between
the baseline scores and the change scores.
Results
The study enrolled 54 patients. One patient in the CT group
dropped out due to a medical problem unrelated to the study
treatment (Figure 2). The 3 groups did not differ significantly
in baseline characteristics (Pϭ0.40–0.93; Table 1). As de-
termined by the obtained effect size of the primary outcome,
post hoc power was calculated to be 0.80.
Primary Outcome
On the FMA total score, there was a significant groupϫtime
interaction effect (F3.4,83.8ϭ3.95, Pϭ0.01). All 3 groups
showed significant within-group gains on the FMA total
score from baseline to midterm and from baseline to post-
treatment (all PϽ0.05; Table 2). Analysis of covariance
revealed significant differences among the 3 groups at mid-
term (F2,50ϭ6.97, Pϭ0.002) and at posttreatment
(F2,50ϭ4.80, Pϭ0.01). Post hoc analyses showed that the
higher-intensity RT group had significantly greater improve-
ments on the FMA total score than the lower-intensity RT and
CT groups at midterm (Pϭ0.003 and Pϭ0.02) and at post-
treatment (Pϭ0.04 and Pϭ0.02; respectively; Table 2). No
significant differences were found between the lower-
intensity RT and CT groups at midterm and at posttreatment.
A similar effect was also found on the FMA distal score
(Table 2).
Table 1. Baseline Characteristics of the Study Participants by
Group (N‫)45؍‬
Characteristics*
Higher-
Intensity RT
(nϭ18)
Lower-
Intensity RT
(nϭ18)
Control
Treatment
(nϭ18) P Value
Age, y 56.51 (10.03) 52.21 (12.20) 54.83 (9.84) 0.49
Time after
stroke, mo
28.67 (13.67) 23.28 (15.37) 22.44 (15.34) 0.40
Sex, no.
Male 11 13 12 0.78
Female 7 5 6
Stroke subtype, no.
Ischemic 12 11 9 0.73
Hemorrhagic 6 7 8
Subarachnoid 0 0 1
Side of stroke, no.
Right 9 9 8 0.93
Left 9 9 10
MMSE score 28.50 (1.98) 28.00 (2.50) 28.28 (2.08) 0.79
FMA score 42.78 (8.86) 43.11 (9.18) 44.61 (11.06) 0.84
RT indicates robot-assisted therapy; MMSE, Mini-Mental State Examination;
FMA, Fugl-Meyer Assessment.
*Continuous data are presented as the mean (SD); categoric data are
presented as indicated.
Table 2. Descriptive Statistics and Group Comparisons on the
Primary Outcome
Outcome
Higher-
Intensity RT
Mean (SD)
Lower-
Intensity RT
Mean (SD)
Control
Treatment
Mean (SD)
FMA total score
Baseline 42.78 (8.86) 43.11 (9.18) 44.61 (11.06)
Midterm 46.06 (8.50)*†‡ 44.50 (9.69)* 46.33 (10.50)*
Posttreatment 48.00 (8.22)*†‡ 46.33 (10.27)* 47.56 (10.50)*
FMA distal score
Baseline 12.56 (6.17) 11.44 (6.81) 13.39 (7.65)
Midterm 14.00 (5.99)*‡ 12.22 (7.14)* 14.06 (7.67)*
Posttreatment 15.17 (5.93)*‡ 13.06 (7.53)* 14.72 (7.51)*
FMA proximal score
Baseline 30.22 (4.01) 31.67 (3.96) 31.22 (4.60)
Midterm 32.06 (3.76)* 32.28 (4.17) 32.28 (4.07)*
Posttreatment 32.83 (3.62)* 33.28 (3.72)* 32.83 (4.25)*
RT indicates robot-assisted therapy; FMA, Fugl-Meyer Assessment.
With-group comparison: *PϽ0.05 when compared with baseline scores.
Between-group comparison: †PϽ0.05 when the higher-intensity RT group
score was greater than the lower-intensity RT group.
‡PϽ0.05, when the higher-intensity RT group score was greater than the
control treatment group.
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5. Secondary Outcomes and Adverse Responses
The 3 groups made significant within-group improvements
over time (all PϽ0.05) on the Medical Research Council and
Motor Activity Log; however, the improvements were not
significantly different among the 3 groups on the Medical
Research Council (F2,50ϭ1.41, Pϭ0.25), the Motor Activity
Log quality of movements (F2,50ϭ2.38, Pϭ0.10), or the
Motor Activity Log amount of use (F2,50ϭ1.61, Pϭ0.21).
The higher-intensity RT group reported significant within-
group improvements on the SIS–strength (Pϭ0.002) and SIS
– activities of daily living/instrumental activities of daily
living (Pϭ0.02) assessments. The lower-intensity RT group
had significant within-group improvements on the SIS–
strength assessment (Pϭ0.02). The CT group, however, did
not report significant improvements on the 4 SIS physical
domains (Pϭ0.07–0.29). The between-group comparison did
not show a significant difference among the 3 groups for
gains on the 4 SIS physical domains (F2,50ϭ0.40–1.38,
Pϭ0.26–0.67). The 3 groups showed mild ratings for fatigue
and pain (mean score of Ͻ3 of 10 possible).
Recovery Rates
Recovery rates of the higher-intensity RT group on the FMA
total and distal scores were significantly higher than those of
the lower-intensity RT group at midterm and posttreatment
(all PՅ0.05; Table 3). On the secondary outcomes, differ-
ences in recovery rates between the 2 RT groups were not
significant (Pϭ 0.10–0.86; Table 3); however, the recovery
rate values for the higher-intensity RT group were generally
higher than those for the lower-intensity RT group.
Interaction Between Initial Motor Status and
Treatment Intensity
Figure 3 shows the relationships between patients’ baseline
scores and change scores on the FMA. The data fit a quadratic
function, and the critical point of the fitted curve in the
higher-intensity RT group at posttreatment was calculated to
be 38.41 by differentiating the equation of the curve (Figure
3); that is, patients with an FMA baseline score of approxi-
mately 40 showed the most gains after the higher-intensity
RT. In the lower-intensity RT group, patients with fewer
motor deficits gained more benefits on the FMA; however,
the general gains of this group were lower than the gains in
the higher-intensity RT group. To summarize, the patients
with motor deficits in the middle range (FMA score of
approximately 40) had more improvement in motor ability
after the higher-intensity RT than those with severe or mild
motor deficits.
Discussion
The 3 treatment groups in this trial had significant within-
group gains on the FMA, Medical Research Council, and
Motor Activity Log, indicating that the patients benefited
from the intervention in motor ability, muscle power, and
self-perceived performance in daily activities. The 2 RT
groups also reported significant improvements in the strength
domain of the SIS over time. Between-group comparisons
showed that the patients who received the higher-intensity RT
had significant improvements in primary motor ability at
midterm and posttreatment compared with those who re-
ceived the lower-intensity RT or CT; however, the 2 RT
protocols and the CT demonstrated comparable effects on
improving the secondary outcomes.
When these results were compared with those in the trial
by Hesse et al,14 which used the same robotic device, the
effects on the primary outcome (ie, FMA) were different. The
treatment intensity of RT used in their study was similar to
the lower-intensity RT used in this study. The RT group in the
Hesse et al study, however, had significant benefits compared
with the control group, whereas we did not find a significant
difference between the lower-intensity RT and the CT. The
differing results may be attributable to differences in treat-
ment protocols of the control groups (electric stimulation
versus conventional occupational therapy), stroke phases
(subacute versus chronic), and baseline motor deficits of
patients (severe versus mild to moderate). Moreover, the
higher-intensity RT (twice as many repetitions as in the
lower-intensity RT) of this study led to significant gains in
motor ability compared with the other 2 groups. Our findings
suggest that for patients with chronic stroke with mild to
moderate motor deficits, the treatment intensity of RT using
the Bi-Manu-Track can be higher than the original protocol14
to reach superior effects on motor recovery.
Table 3. Recovery Rates of Each Week at Midterm and
Posttreatment on the Outcomes
Outcome
Higher-
Intensity RT
Mean (SD)
Lower-
Intensity RT
Mean (SD)
P
Value
FMA total score
Midterm 1.64 (1.12) 0.69 (0.52) 0.003
Posttreatment 1.31 (0.65) 0.81 (0.50) 0.01
FMA distal score
Midterm 0.72 (0.43) 0.39 (0.40) 0.02
Posttreatment 0.65 (0.39) 0.40 (0.33) 0.05
FMA proximal score
Midterm 0.92 (0.94) 0.31 (0.52) 0.02
Posttreatment 0.65 (0.46) 0.40 (0.46) 0.11
MRC
Posttreatment 0.07 (0.09) 0.03 (0.05) 0.14
MAL-QOM
Posttreatment 0.11 (0.12) 0.05 (0.09) 0.10
MAL-AOU
Posttreatment 0.10 (0.09) 0.05 (0.09) 0.11
SIS–strength
Posttreatment 2.00 (2.26) 2.17 (3.40) 0.86
SIS–ADL/IADL
Posttreatment 1.17 (1.93) 0.43 (2.45) 0.32
SIS–mobility
Posttreatment 0.62 (2.25) 0.26 (2.29) 0.63
SIS–hand function
Posttreatment 2.67 (5.95) 1.07 (5.29) 0.40
RT indicates robot-assisted therapy; FMA, Fugl-Meyer Assessment; MRC,
Medical Research Council scale; MAL-QOM, Motor Activity Log quality of
movement; AOU, amount of use; SIS, Stroke Impact Scale; ADL/IADL, activities
of daily living/instrumental ADL.
2732 Stroke October 2012
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6. The study results for the functional-based or disability
outcomes are concordant with previous RT studies23,24 that
did not find significant differences between RT and control
groups. Within-group analyses, however, showed that the 2
RT groups had significant gains in self-perceived amount of
use and quality of movement of the affected hand in daily
activities and in the strength domain of the SIS evaluation.
These gains may be attributed to the additional 15 to 20
minutes of functional training per session in our RT proto-
cols. The supplementary functional practice may be necessary
to enhance functional performance but may not be sufficient
for significant between-group differences compared with the
CT. Most robotic devices are designed for the practice of
relatively simple movements, and patients who train on them
have some difficulty in transferring the gained motor ability
to the performance of functional activities.25 Further ap-
proaches may consider the combination of RT and task-
oriented training (eg, constraint-induced therapy) in stroke
rehabilitation to promote motor recovery and functional
improvement.
The recovery rate data suggest a trend for better motor
outcome with the higher-intensity RT at midterm and post-
treatment, indicating a dose–response relationship such that
providing more intense RT may accelerate motor improve-
ment for chronic stroke. Current findings support that highly
intensive therapy tends to accelerate recovery.26 The midterm
evaluation can provide more information about the dynamic
response of patients during the treatment course; however,
whether the intensity effect occurs mainly in the first half or
throughout the entire period of the treatment course needs
further research. For patients who have already reached a
functional plateau at midterm, incorporating or receiving
other interventions after midterm (eg, RT in sequential
combination with constraint-induced therapy) might promote
further improvement.
The initial severity levels of the patients may influence the
treatment effects on the primary outcome. The FMA is
commonly used to identify the severity levels of patients with
stroke.27–29 The relation of FMA baseline scores and change
scores in this study was dependent on the intensity of RT
treatment. As seen in the graph (Figure 3), patients with
moderate motor deficits (ie, FMA score of approximately 40)
showed more motor improvement after the higher-intensity
RT than those with severe or mild deficits. However, there
was a trend that the patients with fewer motor deficits in the
lower-intensity RT group gained more benefits on the FMA.
Further studies may examine the usefulness of the FMA
cutoff score to more accurately stratify patients in RT trials.
Some limitations of the study warrant consideration. Only
one intermediate assessment was conducted during the study
period. To more clearly define dose–response curves of RT,
further investigation of the efficacy of RT on multiple
intermediate data points is warranted. This study did not
evaluate sensory function. Patients with sensory deficits who
receive interactive RT with sensory inputs and feedback may
benefit from RT.30 Further trials should assess the role of
sensory function as a treatment outcome and potential mod-
erator of the outcomes. Another study limitation is that the
participants and the intervention providers were not blinded
to the treatment group, which might have led to some bias.
In conclusion, our study results support that treatment
outcomes, especially in motor improvements, were better
after the higher-intensity RT than after the other 2 interven-
tions. Higher-intensity RT may be feasible in patients with
Figure 3. The relationships of initial values and change scores on the Fugl-Meyer Assessment (FMA) for the 2 robot-assisted therapy
groups. Scatterplots show the distribution of pretreatment and change scores on the FMA. Quadratic function was applied for curve
fitting. The dotted lines show the critical point (38.41) of the fitted curve in the higher-intensity robot-assisted therapy (RT) group at
posttreatment.
Hsieh et al Dose–Response of Robot-Assisted Stroke Rehabilitation 2733
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7. chronic stroke to accelerate the rate of motor recovery.
Patients with moderate motor deficits tended to have more
motor improvements after the higher-intensity RT than those
with severe or mild motor deficits. The patient’s level of
motor impairment should be considered when planning for
robot-assisted stroke rehabilitation.
Sources of Funding
This project was supported in part by the National Health Research
Institutes (NHRI-EX101-9920PI and NHRI-EX101-10010PI), the
National Science Council (NSC-100-2314-B-002-008-MY3 and
NSC 99-2314-B-182-014-MY3), and the Healthy Ageing Research
Center at Chang Gung University (EMRPD1A0891) in Taiwan.
Disclosures
None.
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