Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke: Cochrane systematic review

Abstract

Background

Electromechanical and robot-assisted arm training devices are used in rehabilitation, and may help to improve arm function after stroke.

Objectives

To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.

Search methods

We searched the Cochrane Stroke Group's Trials Register (last searched January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2018, Issue 1), MEDLINE (1950 to January 2018), Embase (1980 to January 2018), CINAHL (1982 to January 2018), AMED (1985 to January 2018), SPORTDiscus (1949 to January 2018), PEDro (searched February 2018), Compendex (1972 to January 2018), and Inspec (1969 to January 2018). We also handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as manufacturers of commercial devices.

Selection criteria

Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other rehabilitation or placebo interventions, or no treatment, for people after stroke.

Data collection and analysis

Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, used the GRADE approach to assess the quality of the body of evidence, and extracted data. We contacted trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk differences (RDs) for dichotomous variables.

Main results

We included 45 trials (involving 1619 participants) in this update of our review. Electromechanical and robot-assisted arm training improved activities of daily living scores (SMD 0.31, 95% confidence interval (CI) 0.09 to 0.52, P = 0.0005; I² = 59%; 24 studies, 957 participants, high-quality evidence), arm function (SMD 0.32, 95% CI 0.18 to 0.46, P < 0.0001, I² = 36%, 41 studies, 1452 participants, high-quality evidence), and arm muscle strength (SMD 0.46, 95% CI 0.16 to 0.77, P = 0.003, I² = 76%, 23 studies, 826 participants, high-quality evidence). Electromechanical and robot-assisted arm training did not increase the risk of participant dropout (RD 0.00, 95% CI -0.02 to 0.02, P = 0.93, I² = 0%, 45 studies, 1619 participants, high-quality evidence), and adverse events were rare.

Authors' conclusions

People who receive electromechanical and robot-assisted arm training after stroke might improve their activities of daily living, arm function, and arm muscle strength. However, the results must be interpreted with caution although the quality of the evidence was high, because there were variations between the trials in: the intensity, duration, and amount of training; type of treatment; participant characteristics; and measurements used.

Author(s)

Mehrholz Jan, Pohl Marcus, Platz Thomas, Kugler Joachim, Elsner Bernhard

Summary

Electromechanical-assisted training for improving arm function and disability after stroke

Review question

To assess the effects of electromechanical and robot-assisted arm training for improving arm function in people who have had a stroke.

Background

More than two-thirds of people who have had a stroke have difficulties with reduced arm function, which can restrict a person's ability to perform everyday activities, reduce productivity, limit social activities, and lead to economic burden. Electromechanical and robot-assisted arm training uses specialised machines to assist rehabilitation in supporting shoulder, elbow, or hand movements. However, the role of electromechanical and robot-assisted arm training for improving arm function after stroke is unclear.

Study characteristics

We identified 45 trials (involving 1619 participants) up to January 2018 and included them in our review. Twenty-four different electromechanical devices were described in the trials, which compared electromechanical and robot-assisted arm training with a variety of other interventions. Participants were between 21 to 80 years of age, the duration of the trials ranged from two to 12 weeks, the size of the trials was between eight and 127 participants, and the primary outcome (activities of daily living: the most important target variable measured) differed between the included trials.

Key results

Electromechanical and robot-assisted arm training improved activities of daily living in people after stroke, and function and muscle strength of the affected arm. As adverse events, such as injuries and pain, were seldom described, these devices can be applied as a rehabilitation tool, but we still do not know when or how often they should be used.

Quality of the evidence

The quality of the evidence was high.

Reviewer's Conclusions

Implications for practice

We found that people after stroke who receive electromechanical or robot-assisted arm training are more likely to show improvement in their activities of daily living, arm function, and muscle strength of the paretic arm, and we rated the quality of evidence as high.

In practice, electromechanical or robot-assisted arm training could increase the intensity of arm therapy. Perhaps more repetitions during the same therapy time can be achieved if electromechanical and robot-assisted therapy is given. Electromechanical devices could, therefore, be used as an adjunct to conventional therapies.

However, it is still not clear if the difference between electromechanical or robot-assisted arm training and other interventions is clinically meaningful for most people after stroke. Perhaps one main difference between electromechanical or robot-assisted arm training and other interventions could be an improvement in motivation due to the feedback of the device, or the novelty of a robotic device, or both. However, we can only speculate about this.

Implications for research

There is still a need for well-designed, large-scale, multicentre studies to evaluate benefits and harms of electromechanical-assisted arm training after stroke. Further research should count the number of repetitions in time and address specific questions about the type, timing, frequency, and duration of electromechanical and robot-assisted arm training. Further research should also investigate whether or not there is any benefit over and above the amount of practice, for example, if it would be useful or not if a robot prevents 'incorrect learning or movements'. Additionally, improved reporting of trial methods and the use of published reporting guidelines for trials are essential.

It may be useful if future studies could use arm function-specific outcome measures and measures of repetitions during training to gain a better understanding of the explicit effects of this special form of training.

Future studies should better report the interventions and should therefore adhere to the TiDIER guidelines when describing content, frequency and dose of therapy, and the personnel supervising participants during training.

Future studies should investigate the effects on participation and should also investigate the most severely affected people and groups, who are not reflected so far in the existing trials.

We found a dropout rate of often less than 5%. Future studies could determine their sample size calculations based on this dropout rate.

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