Author Names
Massimiliano Gobbo, Paolo Gaffurini, Laura Vacchi, Sara Lazzarini, Jorge Villafane, Claudio Orizio, Stefano Negrini, and Luciano Bissolotti
Reviewer Name
Jessica Fritson, SPT, ATC
Reviewer Affiliation(s)
Duke University School of Medicine, Doctor of Physical Therapy Division
Paper Abstract
This single arm pre-post study aimed at evaluating the acute effects induced by a single session of robot-assisted passive hand mobilization on local perfusion and upper limb (UL) function in poststroke hemiparetic participants. Twenty-three patients with subacute or chronic stroke received 20 min passive mobilization of the paretic hand with robotic assistance. Near-infrared spectroscopy (NIRS) was used to detect changes in forearm tissue perfusion. Muscle tone of the paretic UL was assessed by the Modified Ashworth Scale (MAS). Symptoms concerning UL heaviness, joint stiffness, and pain were evaluated as secondary outcomes by self-reporting. Significant (p = 0.014) improvements were found in forearm perfusion when all fingers were mobilized simultaneously. After the intervention, MAS scores decreased globally, being the changes statistically significant for the wrist (from 1.6 ± 1.0 to 1.1 ± 1.0; p = 0.001) and fingers (1.2 ± 1.1 to 0.7 ± 0.9; p = 0.004). Subjects reported decreased UL heaviness and stiffness after treatment, especially for the hand, as well as diminished pain when present. This study supports novel evidence that hand robotic assistance promotes local UL circulation changes, may help in the management of spasticity, and acutely alleviates reported symptoms of heaviness, stiffness, and pain in subjects with poststroke hemiparesis. This opens new scenarios for the implications in everyday clinical practice. Clinical Trial Registration Number is NCT03243123.
NIH Risk of Bias Tool
Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group
- Was the study question or objective clearly stated?
- Yes
- Were eligibility/selection criteria for the study population prespecified and clearly described?
- Yes
- Were the participants in the study representative of those who would be eligible for the test/service/intervention in the general or clinical population of interest?
- Yes
- Were all eligible participants that met the prespecified entry criteria enrolled?
- Yes
- Was the sample size sufficiently large to provide confidence in the findings?
- Cannot Determine, Not Reported, Not Applicable
- Was the test/service/intervention clearly described and delivered consistently across the study population?
- Yes
- Were the outcome measures prespecified, clearly defined, valid, reliable, and assessed consistently across all study participants?
- Yes
- Were the people assessing the outcomes blinded to the participants’ exposures/interventions?
- No
- Was the loss to follow-up after baseline 20% or less? Were those lost to follow-up accounted for in the analysis?
- Yes
- Did the statistical methods examine changes in outcome measures from before to after the intervention? Were statistical tests done that provided p values for the pre-to-post changes?
- Yes
- Were outcome measures of interest taken multiple times before the intervention and multiple times after the intervention (i.e., did they use an interrupted time-series design)?
- Cannot Determine, Not Reported, Not Applicable
- If the intervention was conducted at a group level (e.g., a whole hospital, a community, etc.) did the statistical analysis take into account the use of individual-level data to determine effects at the group level?
- Cannot Determine, Not Reported, Not Applicable
Key Finding #1
Passive mobilization within stroke recovery is an important component to a comprehensive rehabilitation program to aid in the treatment of spasticity, joint stiffness, and pain as well as promote activity.
Key Finding #2
This study suggests a single session of robotic-assisted hand PROM can improve forearm profusion when all fingers were moved simultaneously in subacute and chronic stroke patients with hemiparesis.
Key Finding #3
Spasticity ratings decreased globally within the wrist and fingers using the MAS from the single session of robotic-assisted PROM.
Key Finding #4
Secondary outcomes of self-reported UL heaviness, stiffness, and pain decreased with the single session of robotic-assisted PROM.
Please provide your summary of the paper
This study looked at the acute effects of a single passive hand mobilization performed by robotic assistance in subacute and chronic stroke patients with hemiparesis. Participants must be participating in the study post first event of cerebrovascular stroke, have unilateral paresis, and still be able to remain in a sitting position. Patients were excluded if they had bilateral impairment, cognitive or behavioral dysfunction, finger flexion contractures, DeQuervian’s tenosynovitis, or neurologic conditions where pain perception could be altered. The Gloreha (Idrogenet, Italy) robotic system was used to implement a 20-minute repetitive passive joint mobilization intervention including isolated, pinch, and synchronous movements for twenty-three patients who met the criteria. The outcome measure used to observe perfusion of the UE was near-infrared spectroscopy (NIRS). The functional assessment in the study included self-reported measures of heaviness, joint stiffness, and pain for all joints in the UE using a scale from zero to one hundred with zero being the absence of symptoms. The MAS objectively defined spasticity in motions of shoulder abduction, elbow extension, supination, wrist extension, and fingers extension movements with the patient in resting position. All these measures were performed before the intervention and five to fifteen minutes after the robotic-assisted treatment was completed. The results of this study showed improvement in forearm profusion, global UE spasticity, and reported secondary outcomes of heaviness, stiffness, and pain. The study was limited by the lack of control group to compare the improvements as well a lack of ability to control the treatment time of day which may impact the activity prior to the session or be impacted by the natural circadian patterns within the patients.
Please provide your clinical interpretation of this paper. Include how this study may impact clinical practice and how the results can be implemented.
This study further supports motion, specifically passive motion for stroke patients to address joint stiffness, pain, and increase circulation. Stroke is the most common cause of UE motor impairments in adults. Knowing the high impact stroke may have on UE function and the importance of mobilization within stroke rehabilitation, it is necessary to continue researching and evolving technology to give the best, most efficient care. Further research is needed on robotic-assisted therapy, but it could be something that becomes implemented in rehabilitation settings or at home for patients who don’t have access to so someone who can perform the manual therapy techniques. As discussed in the article, there are both a professional version and a low-cost home-based version that may be implemented more independently for the patient. When in clinical practice, it is important to take into consideration what is most appropriate for the individualized patient when considering which modality of intervention. Robotic-assisted passive motion may be a technology that will benefit some patients.
