Hand Functional Recovery in Sub-acute Brain Injury Stage Patients
using AMADEO® Robotic-assisted Therapy
A Pilot Clinical Study with Apraxic and Neglect Patients
Pedro A. Serrano López-Terradas,
1
Diana Moya Rosendo
1
and Marcos Ríos Lago
1,2,3
1
Unidad de Daño Cerebral, Hospital Beata María Ana de Jesús, Madrid, Spain
2
Dpto. Psicología Básica II, UNED, Madrid, Spain
3
Fundación Reina Sofía-Fundación CIEN, Madrid, Spain
Keywords: Amadeo Robot, Brain Injury, Hand Functional Rehabilitation, Robot-assisted Therapy, Stroke.
Abstract: INTRODUCTION: Repeated and intensive exercise with AMADEO® Robot-Assisted Therapies (RAT) has
been found useful in restoring functions of hand paresis in some brain-injured patients. OBJECTIVES:
Evaluate the effects of RAT using AMADEO® device in combination with Conventional Neuro-
rehabilitation Therapy (CNT) for the hand functional recovery in post-acute phase patients and to identify
differences in the hand outcome trends among infants and adults with different recovery potential.
METHODS: 12 adults and 3 infants with neglect or apraxia and hemi-paresis of the upper limb were
enrolled in this prospective randomized pre-post pilot clinical study. They were assigned a priori to positive
(PF+) or negative (PF-) prognostic factor groups. All subjects followed the same standardized protocol with
AMADEO® and CNT. The outcome measures selected were: ARAT, MAS, COTNAB (subtest III), RASP,
RPAB, and AMADEO® ROM and Strength Assessment Tools. RESULTS: Statistical analysis showed
important differences between PF+ and PF- groups in hand function outcome measurements. Similar
improved trends were found between PF+ and the group of infants. Both groups improved in extension
variables, total score, level of difficulty, and speed in performing robot-graded tasks. They also showed
more strength and motor control. Patients in the PF- group showed only hand recovery in flexion and ROM
variables after using the robotic device. Positive intra- and intersession effects were found in all patients.
DISCUSSION: The results suggest that finger motor activation and less somato-sensorial impairments in
pre-test could be a better sign for the prognosis of hand recovery and for the decision to apply Amadeo® in
opposite to the presence or absence of apraxic or neglect symptoms, which have been referred as
contraindications. Amadeo® was a valuable tool, easy to use, safe and useful to monitor hand recovery and
improve grip and finger motor function in spite of the presence of other cognitive impairments.
1 INTRODUCTION
Nowadays, improving hand hemiparesis after brain
injury is a main objective in neuro-rehabilitation in
order to decrease disability in post- brain-injured
survivors. Chronic hand paresis deficits are
prevalent in the distal upper extremities in over 40 %
of individuals, especially regarding arm and hand
motor function (Wang, 2012). Most studies have
found that proximal improvements do not migrate to
the distal arm or vice versa (Takahashi, 2008).
Unfortunately, some of these patients with potential
for partial hand recovery could be excluded from
using robotic devices such as AMADEO® due to
interference with other cognitive impairments, as
apraxia or neglect. These symptoms have been
referred in the instruction Tyromotion manual of
AMADEO® as contraindications. Repeated and
intensive exercise with robot-assisted therapies has
been found useful in restoring functions of upper
extremities by their ability to deliver well-defined
repetitive exercises consistently. Furthermore, the
highly frequent afferent stimulation combined with
increments in efferent activity can stimulate the
mirror neurons and can lead to a shift in the
contribution of the Sensory-Motor Cortex (SMC)
activation of the unlesioned and lesioned
hemispheres (Enzinger, 2012).
Serrano López-Terradas P., Moya Rosendo D. and Ríos Lago M..
Hand Functional Recovery in Sub-acute Brain Injury Stage Patients using AMADEO
R
Robotic-assisted Therapy - A Pilot Clinical Study with Apraxic
and Neglect Patients.
Copyright
c
2013 SCITEPRESS (Science and Technology Publications, Lda.)
2 OBJECTIVES
The first aim was to evaluate the effects of robotic-
assisted therapy (RAT) using AMADEO® hand
device in combination with occupational and
physiotherapy conventional neuro-rehabilitation
(CNT) for the hand functional recovery in post-acute
phase (Figure 1).
The second aim was to identify differences in the
hand outcome trends among infants and adults with
different recovery potential. Finally, safety
contraindications of the standardized guidelines of
the AMADEO® Tyromotion manual, version R5
(2010 - 2011), will be discussed.
Figure 1: Use of the AMADEO® hand robot device.
3 METHODS
A sample of 12 adults and 3 infants with moderate to
high grade of hemi-paresis of the upper limb, an
Asworth Scale score of spasticity minor than 3 and
an evolution time inferior to 6 months (Table 1)
were enrolled in this prospective randomized pre-
post pilot clinical study.
On one side, all patients with any extension or
flexion hand activity and less somato-sensorial
disability (moderate impairment in the upper limb)
were assigned a priori to group 1, with a positive
prognostic factor (PF+). On the other side, patients
without voluntary finger activation and high somato-
sensorial disability (severe impairment in the upper
limb) were assigned to group 2, with a negative
prognosis factor (PF-). Apraxic or neglect
impairments were not kept in mind for patient
grouping. The 3 children were included on a third
independent group.
All subjects followed the same standardized
protocol (45 min per session, 2-3 times a week, 12
weeks maximum) with the hand robot, i.e., passive
(CPM), active-assisted (AAT) or active task-
oriented (AT) repetitive hand/finger trainings.
Throughout the 3 months of treatment, all patients
received similar conventional multidisciplinary
neuro-rehabilitation and specific occupational and
physiotherapy sessions to optimize hand functional
sensory-motor performance.
Table 1: Demographic variables of sample groups. CVA:
cerebrovascular accident; Infants: Infants group; L: left;
PF+: Positive prognosis factor group; PF-: Negative
prognosis factor group; R: right; TBI: traumatic brain
injury.
PF+ PF- Infants
Age (years) 63 ± 11 56 ± 12 12 ± 3
Etiology
1 TBI
5 CVA
6 CVA 3TBI
Hemi-paresis
1 R
5 L
3 R
3 L
1 R
2 L
Hand dominance
5 R
1 L
5 R
1 L
3 R
0 L
The following primary and secondary hand
function outcome measures (Sivan, 2011) were
selected: Action Research Arm Test (ARAT) to
assess activities, and Motor Assessment Scale
(MAS), along with Chessington Occupational
Therapy Sensory-motor Assessment (COTNAB-
subtest III) and Rivermead Assessment of
Somatosensory Performance (RASP), to assess body
function. AMADEO® Range of Motion (ROM) and
Strength Assessment (SA) tools were also used as
pre-post outcome measures. Rivermead Perceptual
Assessment Battery (RPAB) and Rivermead
Assessment of Somatosensory Performance (RASP)
were used prior to the use of this robotic device to
diagnose apraxic or neglect symptoms in all patients.
4 RESULTS
Assuming normality, homocedasticity and sphericity
in all variables, preliminary data analysis by
ANOVA of repeated measurements followed by
post-hoc tests showed not statistically significant
differences between PF+ and the group of infants in
any of the variables analysed. Moreover, similar
improved trends of recovery were found in these two
groups.
In most of the variables analyzed, statistical
significant differences were found for the effect of
treatment between PF+ and PF- groups (p < 0.05).
However, the statistical analysis of the
interaction among groups showed, with a high
contrast potency, that only PF+ and the group of
infants improved in the extension variables such as
total extension SA score, individual II-III-IV-V
finger activation in extension SA and extension
trend of recovery (p < 0.05).
With a moderate contrast potency, there were no
differences among both groups in quantity of
improvements associated to flexion variables (p >
0.05) such as flexion SA total score, flexion SA pre-
test, individual I-II-III-IV-V finger activation in
flexion SA, and flexion trend of recovery. Also, the
effect of the interaction within and between subjects
was significant in those variables.
Further post hoc analyses showed a more
significant improvement in the PF+ group than PF-
group in pre-post measurements. The PF- group also
showed hand recovery although less significantly in
variables such as flexion SA total score, ROM and
flexion recovery trends after using robotic-device
(Figure 2). Additionally, in 3 out of 6 PF- cases we
found progressively lower hand tone intra- and inter-
sessions. Besides, the PF+ group improved in the
score, level of difficulty and speed in performing
robot-graded tasks (Figure 3). It also showed more
strength and motor control (Norouzi-Gheidari,
2012).
Positive intra- and inter-session effects were
found in all patients, particularly good tolerance,
motivation and absence of pain.
Patients in the PF+ group with contraindications
to apply AMADEO® (e.g., apraxia and symptoms of
neglect) improved hand motor function and
increased the use of affected hand in the post-tests.
In contrast, patients with lowest somato-sensory
performance showed worse hand outcomes. Some
patients with PF- a priori and apraxia or neglect
symptoms demonstrated smaller but positive
outcomes.
Figure 2: Hand function assessment with AMADEO®.
Em: mean Extension; Fm: mean Flexion; PF+: Positive
prognosis group; PF-: Negative prognosis group.
Important differences between both groups in
hand function outcome measurements were found
for COTNAB-III (p = 0.000), MAS (p = 0.000) and
ARAT (p = 0,000) tools at post-tests (Figure 4).
Figure 3: Pre-post hand function improvements with
AMADEO® tool. ROM: Range of motion. *Statistically
significant differences (p < 0.05).
Figure 4: Main hand outcome measurements. Please, see
Methods for abbreviations on the variables used. Pre: pre-
test; Pos: post-test. *Statistically significant differences (p
< 0.05).
5 DISCUSSION
The findings of this pilot study seem to reveal that
the safety contraindications to apply clinically this
robot device (page 6, version R5, 2010 - 2011)
should be revised. The results suggest that minimal
finger activation motor skills and less somato-
sensorial impairments, such as baseline in pre-test,
could be a better sign for the prognosis of hand
recovery and the decision to apply Amadeo® in
opposite to the presence or absence of apraxia or
neglect symptoms. For this group of patients with
cognitive impairments, Amadeo® was a valuable
tool with a complex intervention design (Hwang,
2012), easy to use, safe and useful to monitor hand
recovery and improve hand grip and finger motor
function.
Our pilot results evidence a better recovery
prognosis for children or patients with motor finger
activation in the hand and less somatosensorial
deficiency, contrary to patients with severe sensitive
damage and serious hand paresis. Apraxic and
neglect symptoms can interfere and complicate the
recovery of the paretic hand, but it is not decisive.
Patients with neglect could benefit from the AT
program facilitated by the adjustments of the
AMADEO® software, whereas patients with apraxia
could improve their motor control due to the
combination of AAT and AT programs.
The combined use of CNT, RAT and splinting
has allowed to regulate and reduce the flexor tone of
hand in 3/12 adult cases.
The presence of other concomitant variables and
their potential positive or negative contribution to
hand function recovery, such as cranioplasty, cancer
radiotherapy or pneumonia due to dysphagia, has
been observed although not analyzed during this
pilot study.
Despite lacking finger opposition and ADD-
ABD of thumb and lumbrical and interosea
movements, the appropriate visual, auditory and
somatosensorial feedback of motor execution, along
with the possibility of working the finger
discrimination of movements and the feedforward at
the higher levels of the device, transforms
AMADEO in a good tool to improve the hand
function in combination with CNT.
The total or partial improvements of one or
several study groups (PF+, PF- and infants) in the
main variables of motor function analyzed (ROM,
flexion or extension SA, finger activation, activities,
and body functions) justifies the necessity of new
studies. More studies will be needed to assess impact
of our results on the activities of daily living (ADL).
Specifically, the small sample size and the absence
of a control group in this study did not allow us to
verify whether this treatment is valid in terms of
effectiveness and universality (Sale, 2012). In future
studies, more statistical analysis will be needed to:
(1) further estimate the impact of these results on
larger samples, (2) to compare with a control group
the outcomes between RAT and CNT with a broader
variety of time and intensity regimens (MacClelland,
2012), and (3) to assess the generalization of
outcomes on ADL with a repetitive, functional and
specific task-oriented rehabilitation in order to
ensure hand function improvements in brain-injured
patients. The good outcomes found in this pilot
clinical study encourage us to design a larger
prospective study.
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