Abstract
This presentation will describe pilot findings of a novel protocol, the Active Learning Program for Stroke, in which cognitive strategy training is used to facilitate the transfer of robot-trained motor skills to upper limb performance in the home and community. This protocol is relevant to clinical practice with and without robotic technology because it provides clinicians with a structured, client-centered motor learning approach to optimize functional use of the paretic arm and hand after stroke.
Primary Author and Speaker: Susan E. Fasoli
Contributing Authors: Sarah L. Smith
Rehabilitation robots have provided researchers and clinicians with new treatment options to improve UE motor capacity and performance after stroke. While systematic reviews of robot-assisted therapies confirm gains in motor capacity after stroke, they provide little evidence for the transfer of trained motor skills to paretic UE performance during ADLs. This disparity between improved UE motor capacity (i.e. what a person can do in a standardized, controlled setting) and daily use of the paretic arm and hand is a significant clinical issue and critical barrier to the integration of robotic technology into clinical practice. These findings may be partly attributed to a primary focus on intensity of practice with little regard for other principles of motor learning and experience-dependent neuroplasticity, such as the salience and transfer of robot therapy tasks. In this development-of-concept pilot trial, the Active Learning Program for Stroke (ALPS) aimed to facilitate the transfer of robot-trained UE motor skills to functional use of the paretic arm and hand during daily activities. ALPS incorporates motor learning principles during robot-assisted therapy and client-centered home action plans to facilitate UE performance in the home and community. ALPS instructions to engage in active problem solving, performance analysis and use of general cognitive strategies (STOP, THINK, DO, CHECK) are modeled after the Cognitive Orientation for daily Occupational Performance. We enrolled ten individuals (53.2 ± 19.8 years of age) more than 6 months post stroke onset with moderate UE impairments as measured by the Fugl-Meyer Assessment (FMA-UE). All participants were administered the ALPS protocol and received 18 one-hour sessions of robot-assisted therapy, 3x week for 6 weeks via the Armeo®Spring (Hocoma AG, Switzerland) and AmadeoTM (Tyromotion, Graz, AT) devices. The ALPS protocol was feasible and well-tolerated, as every participant completed all assessment and intervention sessions, described use of ALPS cognitive strategies during their HAP, and reported high satisfaction with the therapy process. Friedman tests and post-hoc Wilcoxon analyses to evaluate effects of the ALPS protocol combined with robot-assisted therapy revealed statistically significant improvements, with moderate to large effect sizes at the one-month follow-up for the FMA-UE, Wolf Motor Function Test, Motor Activity Log, and the hand portion of the Stroke Impact Scale (effect size range d = 0.54 to 1.09). Clinically significant improvements in FMA-UE scores at follow up (n = 10, mean = 7.3/66 points) were promising and exceeded gains reported in larger studies that focused primarily on delivering highly repetitive movement therapy for the paretic arm and hand after stroke. The Rehabilitation Treatment Specification System, developed by Whyte and colleagues to specify and study the effects of rehabilitation treatments, is useful for describing the treatment outcomes or targets as well as the many treatment ingredients that comprise robot-assisted therapy interventions and their potential mechanisms of action. In the current ALPS protocol, treatment ingredients included guided discovery and instruction in cognitive strategies to enhance problem solving during UE activities, and a home action plan that facilitated carry-over of robot-trained motor skills to daily activities.
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