Skip to main content

Advertisement

SpringerLink
Log in

Sequential combination of robot-assisted therapy and constraint-induced therapy in stroke rehabilitation: a randomized controlled trial

  • Techniques in Clinical Science
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Robot-assisted therapy (RT) and constraint-induced therapy (CIT) both show great promise to improve stroke rehabilitation outcomes. Although the respective treatment efficacy of RT and CIT has been validated, the additive effects of RT combined with CIT remain unknown. This study investigated the treatment effects of RT in sequential combination with a distributed form of CIT (RT + dCIT) compared with RT and conventional rehabilitation (CR). Forty-eight patients with stroke were enrolled and randomized to receive one of the three interventions for 4 weeks. Primary outcomes assessed the changes of motor impairment and motor function on the Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT). Secondary outcomes, including the Motor Activity Log (MAL) and accelerometers, examined functional performance during daily activities. The three treatment groups improved significantly on most primary and secondary outcomes over time. The combined RT + dCIT group exhibited significantly greater improvement on the FMA and functional ability subscale of the WMFT than the RT and CR groups. The improvements on the MAL and accelerometers were not significantly different among the three groups. RT in sequential combination with CIT led to additive effects on participants’ motor ability and functional ability to perform motor tasks after stroke, which support that combined therapy can be an effective means to intensify outcomes. Further research investigating the potential long-term effects of combination therapy, especially on real-life performance, would be valuable.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Broeks JG, Lankhorst GJ, Rumping K, Prevo AJ (1999) The long-term outcome of arm function after stroke: results of a follow-up study. Disabil Rehabil 21:357–364

    Article  CAS  PubMed  Google Scholar 

  2. Cramer SC (2004) Changes in motor system function and recovery after stroke. Restor Neurol Neurosci 22:231–238

    PubMed  Google Scholar 

  3. Kwakkel G, Kollen BJ, van der Grond J, Prevo AJ (2003) Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke 34:2181–2186

    Article  PubMed  Google Scholar 

  4. Hesse S, Werner C, Pohl M, Rueckriem S, Mehrholz J, Lingnau ML (2005) Computerized arm training improves the motor control of the severely affected arm after stroke: a single-blinded randomized trial in two centers. Stroke 36:1960–1966

    Article  CAS  PubMed  Google Scholar 

  5. Lin KC, Wu CY, Liu JS, Chen YT, Hsu CJ (2009) Constraint-induced therapy versus dose-matched control intervention to improve motor ability, basic/extended daily functions, and quality of life in stroke. Neurorehabil Neural Repair 23:160–165

    Article  PubMed  Google Scholar 

  6. Lo AC, Guarino PD, Richards LG et al (2010) Robot-assisted therapy for long-term upper-limb impairment after stroke. N Engl J Med 362:1772–1783

    Article  CAS  PubMed  Google Scholar 

  7. Wolf SL, Winstein CJ, Miller JP et al (2006) Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA 296:2095–2104

    Article  CAS  PubMed  Google Scholar 

  8. Birkenmeier RL, Prager EM, Lang CE (2010) Translating animal doses of task-specific training to people with chronic stroke in 1-hour therapy sessions: a proof-of-concept study. Neurorehabil Neural Repair 24:620–635

    Article  PubMed Central  PubMed  Google Scholar 

  9. Brochard S, Robertson J, Medee B, Remy-Neris O (2010) What’s new in new technologies for upper extremity rehabilitation? Curr Opin Neurol 23:683–687

    Article  PubMed  Google Scholar 

  10. Volpe BT, Lynch D, Rykman-Berland A et al (2008) Intensive sensorimotor arm training mediated by therapist or robot improves hemiparesis in patients with chronic stroke. Neurorehabil Neural Repair 22:305–310

    Article  PubMed  Google Scholar 

  11. Hsieh YW, Wu CY, Liao WW, Lin KC, Wu KY, Lee CY (2011) Effects of treatment intensity in upper limb robot-assisted therapy for chronic stroke: a pilot randomized controlled trial. Neurorehabil Neural Repair 25:503–511

    Article  PubMed  Google Scholar 

  12. Hsieh YW, Wu CY, Lin KC, Yao G, Wu KY, Chang YJ (2012) Dose-response relationship of robot-assisted stroke motor rehabilitation: the impact of initial motor status. Stroke 43:2729–2734

    Article  PubMed  Google Scholar 

  13. Lum PS, Burgar CG, Shor PC, Majmundar M, Van der Loos M (2002) Robot-assisted movement training compared with conventional therapy techniques for the rehabilitation of upper-limb motor function after stroke. Arch Phys Med Rehabil 83:952–959

    Article  PubMed  Google Scholar 

  14. Kwakkel G, Kollen BJ, Krebs HI (2008) Effects of robot-assisted therapy on upper limb recovery after stroke: a systematic review. Neurorehabil Neural Repair 22:111–121

    Article  PubMed Central  PubMed  Google Scholar 

  15. Mehrholz J, Hadrich A, Platz T, Kugler J, Pohl M (2012) Electromechanical and robot-assisted arm training for improving generic activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev 6:CD006876

    PubMed  Google Scholar 

  16. Prange GB, Jannink MJ, Groothuis-Oudshoorn CG, Hermens HJ, Ijzerman MJ (2006) Systematic review of the effect of robot-aided therapy on recovery of the hemiparetic arm after stroke. J Rehabil Res Dev 43:171–184

    Article  PubMed  Google Scholar 

  17. Taub E, Miller NE, Novack TA et al (1993) Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil 74:347–354

    CAS  PubMed  Google Scholar 

  18. Page SJ, Levine P, Leonard A, Szaflarski JP, Kissela BM (2008) Modified constraint-induced therapy in chronic stroke: results of a single-blinded randomized controlled trial. Phys Ther 88:333–340

    Article  PubMed  Google Scholar 

  19. Smania N, Gandolfi M, Paolucci S et al (2012) Reduced-intensity modified constraint-induced movement therapy versus conventional therapy for upper extremity rehabilitation after stroke: a multicenter trial. Neurorehabil Neural Repair 26:1035–1045

    Article  PubMed  Google Scholar 

  20. Wu CY, Chen CL, Tang SF, Lin KC, Huang YY (2007) Kinematic and clinical analyses of upper-extremity movements after constraint-induced movement therapy in patients with stroke: a randomized controlled trial. Arch Phys Med Rehabil 88:964–970

    Article  PubMed  Google Scholar 

  21. Kutner NG, Zhang R, Butler AJ, Wolf SL, Alberts JL (2010) Quality-of-life change associated with robotic-assisted therapy to improve hand motor function in patients with subacute stroke: a randomized clinical trial. Phys Ther 90:493–504

    Article  PubMed Central  PubMed  Google Scholar 

  22. Page SJ, Levine P, Khoury JC (2009) Modified constraint-induced therapy combined with mental practice: thinking through better motor outcomes. Stroke 40:551–554

    Article  PubMed  Google Scholar 

  23. Reinkensmeyer DJ, Boninger ML (2012) Technologies and combination therapies for enhancing movement training for people with a disability. J Neuroeng Rehabil 9:17

    Article  PubMed Central  PubMed  Google Scholar 

  24. Taub E, Uswatte G, Bowman MH et al (2013) Constraint-induced movement therapy combined with conventional neurorehabilitation techniques in chronic stroke patients with plegic hands: a case series. Arch Phys Med Rehabil 94:86–94

    Article  PubMed Central  PubMed  Google Scholar 

  25. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S (1975) The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 7:13–31

    CAS  PubMed  Google Scholar 

  26. Taub E, Uswatte G, Pidikiti R (1999) Constraint-induced movement therapy: a new family of techniques with broad application to physical rehabilitation: a clinical review. J Rehabil Res Dev 36:237–251

    CAS  PubMed  Google Scholar 

  27. Dobkin BH (2009) Progressive staging of pilot studies to improve phase III trials for motor interventions. Neurorehabil Neural Repair 23:197–206

    Article  PubMed Central  PubMed  Google Scholar 

  28. Hsieh YW, Wu CY, Lin KC, Chang YF, Chen CL, Liu JS (2009) Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation. Stroke 40:1386–1391

    Article  PubMed  Google Scholar 

  29. Page SJ, Fulk GD, Boyne P (2012) Clinically important differences for the upper-extremity Fugl-Meyer Scale in people with minimal to moderate impairment due to chronic stroke. Phys Ther 92:791–798

    Article  PubMed  Google Scholar 

  30. Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C (1993) Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Phys Ther 73:447–454

    CAS  PubMed  Google Scholar 

  31. Wolf SL, Catlin PA, Ellis M, Archer AL, Morgan B, Piacentino A (2001) Assessing Wolf motor function test as outcome measure for research in patients after stroke. Stroke 32:1635–1639

    Article  CAS  PubMed  Google Scholar 

  32. Wolf SL, Lecraw DE, Barton LA, Jann BB (1989) Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Exp Neurol 104:125–132

    Article  CAS  PubMed  Google Scholar 

  33. van der Lee JH, Beckerman H, Knol DL, de Vet HC, Bouter LM (2004) Clinimetric properties of the Motor Activity Log for the assessment of arm use in hemiparetic patients. Stroke 35:1410–1414

    Article  PubMed  Google Scholar 

  34. Liao WW, Wu CY, Hsieh YW, Lin KC, Chang WY (2012) Effects of robot-assisted upper limb rehabilitation on daily function and real-world arm activity in patients with chronic stroke: a randomized controlled trial. Clin Rehabil 26:111–120

    Article  PubMed  Google Scholar 

  35. Uswatte G, Giuliani C, Winstein C, Zeringue A, Hobbs L, Wolf SL (2006) Validity of accelerometry for monitoring real-world arm activity in patients with subacute stroke: evidence from the extremity constraint-induced therapy evaluation trial. Arch Phys Med Rehabil 87:1340–1345

    Article  PubMed  Google Scholar 

  36. Cohen J (1988) Statistical power analysis for the behavior sciences, 2nd edn. Erlbaum, Hillsdale, NJ

    Google Scholar 

  37. Teasell RW, Kalra L (2004) What’s new in stroke rehabilitation. Stroke 35:383–385

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This study was supported in part by the National Health Research Institutes (NHRI-EX103-10010PI, and NHRI-EX102-9920PI), the National Science Council (NSC-102-2314-B-182-001, NSC-100-2314-B-002-008-MY3, NSC-102-2314-B-002-154-MY2, and NSC-102-2628-B-182-005-MY3), Chang Gung Memorial Hospital (CMRPD 1C0402), and the Healthy Ageing Research Center at Chang Gung University (EMRPD1D0291 and CMRPD1B0331) in Taiwan.

Conflicts of interest

The authors have no conflicts of interest.

Author information

Authors and Affiliations

  1. Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, 259 Wen-hwa 1st Road, Taoyuan, Taiwan

    Yu-wei Hsieh & Ching-yi Wu

  2. Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan

    Yu-wei Hsieh & Ching-yi Wu

  3. School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan

    Keh-chung Lin

  4. Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan

    Keh-chung Lin

  5. Department of Physical Medicine and Rehabilitation, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan

    Yi-shiung Horng

  6. Department of Medicine, Tzu Chi University, Hualien, Taiwan

    Yi-shiung Horng

  7. Division of Occupational Therapy, Department of Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan

    Tai-chieh Wu

  8. Department of Physical Medicine and Rehabilitation, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan

    Fang-ling Ku

Authors
  1. Yu-wei Hsieh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Keh-chung Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yi-shiung Horng
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ching-yi Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tai-chieh Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fang-ling Ku
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ching-yi Wu.

Additional information

Clinical Trial Registration—URL: http://clinicaltrials.gov. Unique identifier: NCT01727648.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hsieh, Yw., Lin, Kc., Horng, Ys. et al. Sequential combination of robot-assisted therapy and constraint-induced therapy in stroke rehabilitation: a randomized controlled trial. J Neurol 261, 1037–1045 (2014). https://doi.org/10.1007/s00415-014-7345-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-014-7345-4

Keywords

Search

Navigation