Date Presented 4/18/2015
Stroke survivors in rural areas lack access to the specialized occupational therapy needed for functional gains in the upper extremity (UE). The Home Arm Assistance Progression Initiative (HAAPI) trial demonstrates robotic-assisted telerehabilitation as a viable means to deliver occupational therapy remotely, maintain a client-centered relationship, improve quality of life (QoL), and promote UE neuromotor recovery.
SIGNIFICANCE: Financial and logistical barriers limit access to quality rehabilitation, which may affect potential for functional recovery of stroke survivors in rural and underserved locations. The objective of this study was to determine the benefits of providing a home-based, robotic-assisted therapy for upper extremity (UE) motor recovery to improve quality of life (QoL). Robotic-assisted telerehabilitation is a novel approach providing both access and remote oversight to UE stroke rehabilitation guided by a skilled occupational therapist (OT) or physical therapist (PT).
INNOVATION: A portable robotic device incorporating motor learning principles of graded repetitive practice, high repetitions, engagement, and feedback to illicit neuromotor recovery in the wrist and hand was combined with an individualized home exercise program (HEP), weekly phone calls, and remote telemonitoring by either an OT or PT. This is an innovative approach to reach underserved stroke survivors.
METHOD: We hypothesized that the home-based robotics intervention + HEP would produce greater results than a HEP-only group. An additional aim was to analyze the impact of this intervention on the QoL and depression of stroke survivors. This was a prospective, single-blinded, multisite (Emory University in Atlanta, GA, and the Cleveland Clinic in Cleveland, OH), randomized controlled trial, completed by 99 subjects who met the following inclusion criteria: age ≥ 18 yr, within 6 mo of stroke, limited access to formal therapy, unilateral ischemic or hemorrhagic stroke, a Fugl–Myer Assessment (FMA) score of 11 to 55, and preserved cognitive function. Subjects were randomized into either (1) HEP or (2) robotic-assisted therapy + HEP groups for an 8-wk home intervention. The primary outcome measure was the Action Research Arm Test. Secondary outcome measures were the Wolf Motor Function Test (WMFT), Stroke Impact Scale, FMA, and Centers for Epidemiologic Studies—Depression Scale (CES–D); all of which were administered at the beginning and end of the interventions. Data were double-entered into a customized Microsoft Access database, checked, and validated. We analyzed changes in functional outcome scores from baseline to posttreatment using a mixed-model approach with intent-to-treat analysis and no ad-hoc imputation. The estimate of primary interest was the Time (baseline, posttreatment) × Treatment (HEP, robotic) interaction. Outcome scores, except the FMA, were adjusted for subjects’ age at enrollment, time between stroke and enrollment, baseline CES–D score, and baseline FMA score. Analyses of the FMA scores were adjusted for participants’ age at enrollment, time between stroke and enrollment, and the baseline CES–D score. A p value of .05 was used as the criterion for statistical significance, and no adjustments were made for multiplicity. We performed analyses using SPSS Version 22.
RESULTS: Both groups improved significantly in the motor and nonmotor outcomes. Contrary to our hypothesis, the robotic + HEP group did not produce superior results to the HEP-only group, and there was no significant interaction between the groups.
CONCLUSION: Robotic-assisted telerehabilitation home therapy augmented with a HEP is an efficacious intervention applicable to underserved stroke survivors.
