ROBOTIC UPPER EXTREMITY TRAINING WITH INTENSIVE HOME PRACTICE IN CHRONIC

STROKE: A CASE STUDY

Susan S. Conroy*1, Toye Jenkins1,2, George F. Wittenberg1,2, Christopher T. Bever1,3

1. VA Maryland Health Care Systems; 2. Physical Therapy and Rehabilitation Science, University of Maryland
School of Medicine; 3. University of Maryland School of Medicine

PURPOSE: The purpose of this case study is to present the exceptional outcome measures for a 51 year old
individual with a chronic stroke who participated in a robotic rehabilitation study. Study intervention included
protocol multi-planar robotic reaching activities and the participant’s non-protocol self-guided home weight
training program. This case study reinforces prior notions of benefit for 1) training repetition and intensity, 2)
individual motivation and 3) use of a combined therapeutic approach to promote motor recovery and reduce
functional impairment in persons with chronic stroke. Physiologic improvements within the motor system related
to the intervention were tested by transcranial magnetic stimulation (TMS).
BACKGROUNDS/SIGNIFICANCE: Stroke is the primary cause of long-term disability in the United States
with 780,000 new or recurrent strokes occurring each year. 80% of stroke survivors experience acute paresis of
the upper extremity, and only approximately one-third achieve full functional recovery. Weakness and spasticity
of the upper extremity is a major cause of disability, and contributes to a related loss of quality of life. Although
physical rehabilitation for post stroke recovery positively influences outcome, no one treatment strategy or
protocol has demonstrated superiority.
SUBJECTS: 51 year old African-American male with a 16 month history of upper extremity hemiparesis due to
a stroke. He sustained a left ischemic subcortical cerebral vascular accident with resulting right hemiparesis. His
status in the acute phase of recovery included: moderate assist for bathing and dressing his upper body, maximal
assist for his lower body, moderate assist for all functional mobility and minimal assist to ambulate 15 feet with a
quad cane. He also had mild to moderate cognitive and linguistic deficits, including receptive and expressive
aphasia. Upon enrollment in the robotic study, he had significant recovery in many areas except continued
chronic right upper extremity hemiparesis, necessitating compensatory techniques for independence in his home
setting. He was independent ambulating without a device in the community and driving to all study visits.
METHODS AND MATERIALS: Informed consent was obtained in the IRB approved protocol. Quantitative
measures included a series of baseline tests on three separate occasions; each one week apart. Tests of interest
include the upper extremity portion of the Fugl-Meyer Assessment of Motor Recovery (F-M), the Wolf Motor
Function Test (WMFT), dynamometry of the involved upper extremity, and TMS motor evoked potentials
(MEP) in two upper extremity muscles (biceps and extensor digitorum communis.) These tests were repeated at
the midpoint, final intervention, and upon a 12 week follow-up. The subject participated in a 6 week long
protocol of 60 minute interventions 3 times a week. The intervention utilized two separate robotic devices
(Interactive Motion Technologies planar and antigravity robots) for goal directed reaching toward visual targets.
A summary of performance feedback graphs were presented at the completion of every 80 repetitions. Each
session include 30 minutes of planar reaching across a table toward visually evoked targets in a star-like pattern
beginning from the center out to eight different locations. The subject performed approximately 640 of these
robot assist-as-needed movements. The next 30 minutes involved goal directed elevation and lowering of the arm
toward 3 separate targets. The subject performed approximately 320 movements with his hemiparetic arm in a
position of shoulder flexion and slight abduction. This individual added his own home exercise program outside
of the protocol intervention for his hemiparetic arm which included lifting a 15 pound weight 10 to 20 repetitions
daily for modified bicep curls and shoulder abduction.
ANALYSES: The upper extremity portion of the F-M score improved from a baseline 35 out of a 66 to a final
score of 41 and a 12 week follow-up score of 40. The WMFT mean time improved from 20 seconds at baseline
to a final score of 13 seconds and a 12 week follow-up score of 3 seconds. Dynamometry of his involved right
upper extremity at the final evaluation demonstrated improvements in wrist extension, elbow flexion, and
shoulder flexion. Two baseline TMS sessions were conducted and at each session there were no MEP in the
biceps or extensor digitorum communis (EDC). Post-intervention TMS revealed reliable MEP in the EDC with
thresholds of 82% maximum stimulator output and this finding was sustained at the 12 week follow-up visit.
RESULTS: Following intervention a significant improvement was seen in the reduction of the patient’s right
upper extremity impairment level as well as an improvement in his ability to perform functional tasks. He also
maintained strength gains for his wrist and elbow, however, he returned to baseline levels for his shoulder
strength during the follow-up phase. The appearance of a forearm MEP suggests that the intervention affected
excitability and/or effectiveness of the corticospinal tract on the affected side.
CONCLUSIONS: A varied therapeutic approach that maintains a high level of intensity and repetitive task
training in a highly motivated individual who carries out a home exercise program can produce measurable
improvements of motor functional ability and even physiology at the chronic stage of recovery. Outcomes of this
case study support continued research into interventions for individuals even after the acute stages of motor
recovery.
FUNDING SOURCE: Veterans Affairs, Maryland Health Care System.
KEYWORDS: rehabilitation, robotics, stroke