The Translation of Mobile-Exoneuromusculoskeleton-Assisted Wrist-Hand Poststroke Telerehabilitation from Laboratory to Clinical Service

Abstract

Rehabilitation robots are helpful in poststroke telerehabilitation; however, their feasibility and rehabilitation effectiveness in clinical settings have not been sufficiently investigated. A non-randomized controlled trial was conducted to investigate the feasibility of translating a telerehabilitation program assisted by a mobile wrist/hand exoneuromusculoskeleton (WH-ENMS) into routine clinical services and to compare the rehabilitative effects achieved in the hospital-service-based group (n = 12, clinic group) with the laboratory-research-based group (n = 12, lab group). Both groups showed significant improvements (p ≤ 0.05) in clinical assessments of behavioral motor functions and in muscular coordination and kinematic evaluations after the training and at the 3-month follow-up, with the lab group demonstrating better motor gains than the clinic group (p ≤ 0.05). The results indicated that the WH-ENMS-assisted tele-program was feasible and effective for upper limb rehabilitation when integrated into routine practice, and the quality of patient-operator interactions physically and remotely affected the rehabilitative outcomes.

Keywords: rehabilitation; robot; stroke; telerehabilitation; upper limb.

Figure 1

Evolution of ENMS from laboratory development to market availability. (a) The laboratory prototype of the ENMS developed in the lab; (b) the commercially available ENMS; (c) the wrist–hand module of ENMS for self-help telerehabilitation.

Figure 2

The Consolidated Standards of Reporting Trials flowchart of the study.

Figure 3

Timeline and training setup of the 20-session training program. (a) Timeline of the 20-session training program; (b) guided sessions assisted by an OT or OTA at the CRSSC; (c) guided sessions assisted by a researcher in the lab. During each training session, participants were required to perform repetitive limb tasks, including (d) a 30 min horizontal task and (e) a 30 min vertical task in both groups, and (f) an optional 30 min forward task at the CRSSC.

Figure 4

Behavioral improvements. Clinical scores by group before, after, and 3 months after the training represented by means and SDs. Significant levels are indicated by * (p ≤ 0.05), ** (p ≤ 0.01), and *** (p ≤ 0.001) for one-way repeated measures ANOVA intragroup tests or Friedman intragroup tests; # (p ≤ 0.05) for Quade’s ANCOVA intergroup tests on the time point with the mean value of three pre-training evaluations as the covariate.

Figure 5

Improved muscular coordination. (a) Normalized EMG activation levels and (b) normalized co-contraction index by group before and after the training represented by means and SDs. Significant levels are indicated by * (p ≤ 0.05), ** (p ≤ 0.01), and *** (p ≤ 0.001) for paired t-test or Wilcoxon signed rank intragroup tests; # (p ≤ 0.05), ## (p ≤ 0.01), and ### (p ≤ 0.001) for independent t-test or Mann–Whitney U intergroup tests.

Figure 6

Improved kinematic performance. (a) NMUs and (b) MTD by group before and after the training represented by means and SDs. Significant levels are indicated by * (p ≤ 0.05), ** (p ≤ 0.01) for paired t-test or Wilcoxon signed rank intragroup tests; ### (p ≤ 0.001) for intergroup independent t-test. (c) Representative measured trajectory of the hand marker during the transport phases in the horizontal task for a participant and the related velocity profiles of the trial. (d) Representative measured trajectory of the thorax marker over the entire trial for the horizontal task for a participant and the related displacement profiles in the trial.

Figure 7

Normalized scores of (a) USE and (b) IMI by group represented by means (mean%) and SD (SD%). Significant levels are indicated by * (p ≤ 0.05) for intergroup independent t-test.