Experimental study
Beyond motor recovery after stroke: The role of hand robotic rehabilitation plus virtual reality in improving cognitive function

https://doi.org/10.1016/j.jocn.2021.07.053Get rights and content

Highlights

  • Stroke represents the leading cause of disability in the industrialized world.

  • Post-stroke impairment interferes with the QoL of the patient and caregiver.

  • Robot-assisted hand training allow to perform practical tasks with a VR setting.

  • Hand robotic plus VR-based training may amplify the functional outcome achievement.

Abstract

Robot-assisted hand training adopting end-effector devices results in an additional reduction of motor impairment in comparison to usual care alone in different stages of stroke recovery. These devices often allow the patient to perform practical, attentive, and visual-spatial tasks in a semi-virtual reality (VR) setting. We aimed to investigate whether the hand end-effector robotic device AmadeoTM could improve cognitive performance, beyond the motor deficit, as compared to the same amount of occupational treatment focused on the hand. Forty-eight patients (aged 54.3 ± 10.5 years, 62.5% female) affected by either ischemic or hemorrhagic stroke in the chronic phase were enrolled in the study. The experimental group (EG) underwent AmadeoTM robotic training, while the control group (CG) performed occupational therapy involving the upper limb. Patients were assessed at the beginning and at the end of the rehabilitation protocol using a specific neuropsychological battery, as well as motor function tests. The EG showed greater improvements in different cognitive domains, including attentive abilities and executive functions, as well as in hand motor function, as compared to CG. Our study showed that task-oriented VR-based robotic rehabilitation enhanced not only motor function in the paretic arm but also global and specific cognitive abilities in post-stroke patients. We may argue that the hand robotic plus VR-based training may provide patients with an integration of cognitive and motor skill rehabilitation, thus amplifying the functional outcome achievement.

Introduction

Stroke represents the leading cause of disability in the industrialized world [1]. Motor and cognitive impairment resulting from stroke interferes significantly with the quality of life of the patient and his/her family [2], [3], [4], [5]. In particular, the recovery of hand function is a challenging task in rehabilitation. Actually, hand paresis usually determines poor motor control and function with consequential, often severe, limitations in the activities of daily living [6], [7]. It is therefore essential to apply promptly the correct rehabilitation strategy. In fact, treatments carried out in the early phase following stroke are more likely to be effective [8]. Recent clinical trials have shown significant improvements in motor recovery of upper and lower limbs through repetitive, intensive, assisted-as-needed, and task-oriented motor training [9], [10], [11]. In this regard, robotic devices are promisingly useful to carry out such motor tasks. Actually, robotic rehab implies less effort by the therapists and may furnish a more objective and quantitative assessment of the disability, which can be monitored over time. In particular, several studies suggested that robot-assisted training, integrated into a multidisciplinary program, can result in an additional reduction of motor impairments in comparison to usual care alone in different stages of stroke recovery [9], [10], [11]. In this regard, the effectiveness of a motor-rehabilitation using the hand end-effector robotic device AmadeoTM has been proven in a previous study [12]. The main advantage of this device relies on the fact that the patient is committed to perform practical, attentive, and visual-spatial tasks in a semi-virtual setting. This fosters sensorimotor retrain, and thus functional recovery, by conjugating repetitive motor practice and cognitive entertainment, which are both inspired by the principles of motor learning [12], [13], [14].

Noteworthy, the recovery of hand function in post-stroke patients is a challenging task in rehabilitation also owing to the cognitive sequelae of stroke, beyond the above mentioned motor ones. In fact, cognitive function impairment in post-stroke prominently involves executive and attentive domains, which has relevant consequences on hand function [15], [16], [17], [18]. However, the cognitive function-related hand recovery is still understudied. In this regard, we wondered if the use of AmadeoTM could also involve an improvement in cognitive performance, beyond the motor one.

Our study was aimed at evaluating the effects of cognitive recovery in post-stroke patients induced by robotic hand therapy (using Amadeo™ device, AHT), as compared to conventional hand therapy (CHT), in the context of a conventional, comprehensive rehabilitation approach.

Section snippets

Study design and population

This is an assessor-blind randomized trial conducted according to the Declaration of Helsinki. Our Institutional Ethics Committee approved the study protocol (IRCCSME 7/2018). All of the patients provided written informed consent before entering the study.

Forty-eight patients (aged 54.3 ± 10.5 years, 62.5% female), attending the Behavioral and Neurorobotic Rehabilitation Unit of the IRCCS Centro Neurolesi Bonino Pulejo - Piemonte (Messina, Italy), from March 2018 to March 2019, were enrolled in

Results

There were not significant baseline differences between the groups concerning both clinical-demographic characteristics and outcome measures. Particularly, no statistically significant difference was found in age between EG and CG (p = 0.6), and the two groups were homogenous for gender proportion.

All the patients completed the training without significant side effects. Results showed that the type of treatment influenced specific cognitive domains (Table 2, Table 3). Indeed, we found that the

Discussion

AHT had superior effects on cognitive impairment and hand function following stroke, with particular regard to attentive, executive and visual-spatial abilities, as compared to the CHT based on the Cognitive Orientation to Daily Occupational Performance principles. Previous studies reported on the positive, non-motor effects of robot-assisted training, such as quality of life, psychological well-being and global cognitive level in patients following stroke [19], [24], [25], [26], [27], [28],

Conclusions

With the increasing numbers of stroke patients, which creates an unbalance in the healthcare systems (primarily due to the lack of caregivers or physiotherapists), robots could be proposed as a possible solution for neurorehabilitation, given that evidence indicates that robotic rehab is at least as effective as conventional training [51].

Our study suggests that robot-aided and VR-based hand therapy could be useful in the rahab setting of post-stroke patients, also in the chronic phase, to

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

The authors wish to thank Dr. Antonina Donato for English editing.

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