Multi-segmental Robotic and Technological Upper Limb Rehabilitation in Stroke
NCT ID: NCT02879279
Last Updated: 2018-12-13
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
Get a concise snapshot of the trial, including recruitment status, study phase, enrollment targets, and key timeline milestones.
COMPLETED
NA
247 participants
INTERVENTIONAL
2016-05-31
2018-03-31
Brief Summary
Review the sponsor-provided synopsis that highlights what the study is about and why it is being conducted.
Detailed Description
Dive into the extended narrative that explains the scientific background, objectives, and procedures in greater depth.
Robot-mediated therapy (RT) has been proposed in the literature as a viable approach for the rehabilitation of the upper limb. A first meta-analysis of 262 subjects showed that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy, no difference exists between the two groups in terms of motor recovery, activities of daily living, strength or motor control; instead, when the RT is added to CT, a greater effectiveness can be observed, when compared with regular CT alone (5). A subsequent meta-analysis by Mehrholz et al., including 19 trials (involving 666 subjects), showed that RT was more effective than other interventions in improving patients' activities of daily living (SMD 0.43, 95% confidence interval (CI) 0.11 to 0.75, P = 0.009, I2 = 67%). In the same sample, stratified by time since disease onset, the analysis confirmed that RT was more effective in improving the activities of daily living in the 224 acute and sub-acute patients (within 3 months of stroke onset) (SMD 0.64, 95% CI 0.14 to 1.15, P=0.01, I2 =69%). The same findings were not confirmed in 334 chronic patients (more than 3 months after stroke) (SMD 0.85, 95% CI -0.27 to 1.97, P=0.14, I2 =94%). As for the other outcomes, robotic therapy was more effective in improving upper extremity function (SMD 0.45, 95% CI 0.20 to 0.69, P = 0.0004, I2 = 45%), but not muscular strength (SMD 0.48, 95% CI -0.06 to 1.03, P = 0.08, I2 = 79%). Finally, RT was well accepted by patients, there was no marked increase in the number of drop-outs, and serious adverse events were rare and unrelated to the robotic treatment (6).
In an update of their meta-analysis, published in 2015, the same research team confirmed that RT was more effective than other therapies in improving activities of daily living (SMD 0.37, 95% confidence interval (CI) 0.11 to 0.64, P = 0.005, I² = 62%), motor function (SMD 0.35, 95% CI 0.18 to 0.51, P \< 0.0001, I² = 36%) and strength (SMD 0.36, 95% CI 0.01 to 0.70, P = 0.04, I² = 72%) of the upper limb. RT was well accepted by patients, there was no marked increase in the number of drop-outs (RD 0.00, 95% CI -0.02 to 0.03, P = 0.84, I² = 0%), and serious adverse events were rare and unrelated to the robotic treatment. However, the authors concluded that the evidence quality was low, highlighting the need for more rigorous studies.
It should be noted that the authors of the review highlighted the fact that the studies reviewed were heterogeneous in terms of study design (two arms, four arms, parallel groups or cross-over, duration of follow-up and selection criteria), of the devices used for the therapeutic treatment, of the patients' characteristics (time since disease onset), of the methodological protocols (methods of randomization, of the blindness of the outcome assessors to group allocation, and of the presence or absence of an intention to treat analysis).
However, the authors emphasized that limitations such as the inability to blind the therapist and participants, i.e. the so-called contamination (provision of the intervention to the control group), and co-intervention (when the same therapist unintentionally provides additional care to either treatment or comparison group) has often been present in rehabilitation studies. Moreover, they pointed out that sometimes the sample is selected according to comorbidities, age, spasticity or pain; instead, in clinical practice patients are often older, and the prevalence of comorbidity, pain, spasticity and/or limitations of articular function is higher than that reported in the studies analyzed. Therefore, inclusion criteria that allow the effects of a robotic treatment to be evaluated on a larger sample of patients with stroke, with clinical characteristics as close as possible to the real-world clinical setting, are desirable.
Many authors have highlighted the impact on costs and the greater sustainability of the RT when compared with the CT. The latter requires a ratio of one therapist to one patient, while RT, after adequate training of the therapist, allows a ratio of one therapist to every three or four patients, depending on the technology used.
RT allows patients' improvements to be assessed even after a single treatment session, to constantly monitor the rehabilitation program and therefore to better define the best rehabilitation strategies. In fact, thanks to the possibility the systems available, it is possible to customize the treatment based on the patients' clinical characteristics. Last but not least, robotic devices involve and motivate patients, providing them with visual and auditory feedback through virtual reality programs in the form of games. Training progresses through increasingly difficult stages that can be linked by patients to their own progress. This becomes an important stimulus to increase the active participation of patients in the rehabilitation program.
Almost all scientific papers in the literature have focused on the effects of the use of one or, at most, two robotic devices, compared with a conventional approach.
However, even though the anatomy and the motor function of the upper limbs, especially the hand, is extremely complex, all but a very few commercial devices act on a limited number of joints and limit the workspace on a plane. By contrast, during conventional therapy the whole upper limb is routinely treated and the three-dimensional space, in which the upper limb is normally required to move to accomplish daily activities, is normally explored. In the light of the above, it is very difficult to compare the effects of robotic and traditional approaches.
This results in the need for a multi-set of robots and electromechanical systems, each of which acts on a different joint and/or on a different plane, in upper limb rehabilitation in stroke patients. To the best of our knowledge, the effects of a similar approach, i.e. the use of a multi-set of robotic devices to restore motor function in patients with stroke, have never been compared with those of a conventional approach. Moreover, the effects should ideally be explored on a large sample of subjects that are representative of clinical practice.
Hypothesis. The rationale behind the study is that a multi-set of robotic devices used to treat the whole upper limb may be more effective than conventional treatments in improving upper limb motor performance, since they raise the degree of motivation and participation among patients, and provide a more intensive, standardized and individualized treatment.
Therefore, the investigators wish to verify this hypothesis on a large sample of subjects, within a multicenter study using the same multi-set of robotic devices and the same outcome measures, to obtain better-quality scientific evidence than that currently available in the literature.
Aim: to assess, using evidence-based criteria (RCT), the effectiveness of a rehabilitation program targeting all the upper limb joints in stroke patients, using a multi-set of robotic and technological systems, by comparing it with that of a conventional approach.
Conditions
See the medical conditions and disease areas that this research is targeting or investigating.
Keywords
Explore important study keywords that can help with search, categorization, and topic discovery.
Study Design
Understand how the trial is structured, including allocation methods, masking strategies, primary purpose, and other design elements.
RANDOMIZED
PARALLEL
TREATMENT
SINGLE
Study Groups
Review each arm or cohort in the study, along with the interventions and objectives associated with them.
Robotic rehabilitation
In the robotic rehabilitation group, both the distal and the proximal parts of the patients' upper arm will be treated by means of a multi-set of robotic and technological devices, i.e, Amadeo, Pablo, Diego and Motore. The aforementioned systems can be used to perform three-dimensional movements of the shoulder, planar movements of the shoulder and elbow, prono-supination movements of the forearm, flexion-extension movements of the wrist, bimanual movements, and flexion/extension movements of the fingers. A vibratory treatment will be applied, using the Amadeo, to increase the proprioception of the hand. Motor and cognitive tasks, comprising active, passive and active-assistive, will be performed during the treatment. Visual and auditory feedback will be provided to help the patients.
Amadeo, Pablo, Diego and Motore.
In the robotic rehabilitation group, patients will be treated with the following systems: Amadeo, Pablo and Diego (Tyromotion GmbH, Austria), and Motore (Humanware, Italy). A ratio of one therapist to every 3 or 4 patients will be used, depending on the patient's severity. The rehabilitation treatment will be performed daily for 45 minutes, for 5 days per week, for 6 weeks. A total of 30 sessions will be performed.
Conventional rehabilitation
In the conventional rehabilitation group, patients will undergo a conventional treatment. The therapeutic tasks will focus on sensorimotor reprogramming, hypertonus inhibition, functional improvement, including task-oriented exercises. Specifically, patients will perform passive, active and active assisted exercises on the three upper limb joints, to improve joint function, to prevent contractures, to inhibit hypertonus and to improve trophism and motor function.
Conventional rehabilitation
In the conventional rehabilitation group, patients will undergo a conventional treatment with a ratio of one therapist to one patient. The rehabilitation treatment will be performed daily for 45 minutes, for 5 days per week, for 6 weeks. A total of 30 sessions will be performed.
Interventions
Learn about the drugs, procedures, or behavioral strategies being tested and how they are applied within this trial.
Amadeo, Pablo, Diego and Motore.
In the robotic rehabilitation group, patients will be treated with the following systems: Amadeo, Pablo and Diego (Tyromotion GmbH, Austria), and Motore (Humanware, Italy). A ratio of one therapist to every 3 or 4 patients will be used, depending on the patient's severity. The rehabilitation treatment will be performed daily for 45 minutes, for 5 days per week, for 6 weeks. A total of 30 sessions will be performed.
Conventional rehabilitation
In the conventional rehabilitation group, patients will undergo a conventional treatment with a ratio of one therapist to one patient. The rehabilitation treatment will be performed daily for 45 minutes, for 5 days per week, for 6 weeks. A total of 30 sessions will be performed.
Eligibility Criteria
Check the participation requirements, including inclusion and exclusion rules, age limits, and whether healthy volunteers are accepted.
Inclusion Criteria
2. Age between 40 and 80 years;
3. Time latency since stroke ranging from two weeks to six months
4. Cognitive and language abilities that are sufficient to understand the experiments and follow instructions
Exclusion Criteria
2. Fixed contraction deformity in the affected limb that would interfere with active therapy (ankylosis, Modified Ashworth Scale = 4);
3. Severe deficits in visual acuity;
4. Upper extremity Fugl-Meyer score \>58.
40 Years
80 Years
ALL
No
Sponsors
Meet the organizations funding or collaborating on the study and learn about their roles.
Fondazione Don Carlo Gnocchi Onlus
OTHER
Responsible Party
Identify the individual or organization who holds primary responsibility for the study information submitted to regulators.
Irene Giovanna Aprile
M.D., PhD
Principal Investigators
Learn about the lead researchers overseeing the trial and their institutional affiliations.
Irene Aprile, MD, PhD
Role: PRINCIPAL_INVESTIGATOR
Don Gnocchi Foundation
Locations
Explore where the study is taking place and check the recruitment status at each participating site.
Don Gnocchi Foundation
Rome, , Italy
Countries
Review the countries where the study has at least one active or historical site.
References
Explore related publications, articles, or registry entries linked to this study.
Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev. 2015 Nov 7;2015(11):CD006876. doi: 10.1002/14651858.CD006876.pub4.
Kwakkel G, Kollen BJ, Krebs HI. Effects of robot-assisted therapy on upper limb recovery after stroke: a systematic review. Neurorehabil Neural Repair. 2008 Mar-Apr;22(2):111-21. doi: 10.1177/1545968307305457. Epub 2007 Sep 17.
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke. Cochrane Database Syst Rev. 2014 Nov 12;2014(11):CD010820. doi: 10.1002/14651858.CD010820.pub2.
Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012;49(4):479-96. doi: 10.1682/jrrd.2010.10.0210.
Cecchi F, Germanotta M, Macchi C, Montesano A, Galeri S, Diverio M, Falsini C, Martini M, Mosca R, Langone E, Papadopoulou D, Carrozza MC, Aprile I. Age is negatively associated with upper limb recovery after conventional but not robotic rehabilitation in patients with stroke: a secondary analysis of a randomized-controlled trial. J Neurol. 2021 Feb;268(2):474-483. doi: 10.1007/s00415-020-10143-8. Epub 2020 Aug 25.
Aprile I, Germanotta M, Cruciani A, Loreti S, Pecchioli C, Cecchi F, Montesano A, Galeri S, Diverio M, Falsini C, Speranza G, Langone E, Papadopoulou D, Padua L, Carrozza MC; FDG Robotic Rehabilitation Group. Upper Limb Robotic Rehabilitation After Stroke: A Multicenter, Randomized Clinical Trial. J Neurol Phys Ther. 2020 Jan;44(1):3-14. doi: 10.1097/NPT.0000000000000295.
Germanotta M, Cruciani A, Pecchioli C, Loreti S, Spedicato A, Meotti M, Mosca R, Speranza G, Cecchi F, Giannarelli G, Padua L, Aprile I. Reliability, validity and discriminant ability of the instrumental indices provided by a novel planar robotic device for upper limb rehabilitation. J Neuroeng Rehabil. 2018 May 16;15(1):39. doi: 10.1186/s12984-018-0385-8.
Other Identifiers
Review additional registry numbers or institutional identifiers associated with this trial.
FDG_MUR
Identifier Type: -
Identifier Source: org_study_id