Topics in Stroke Rehabilitation

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ytsr20

Effects of two different robot-assisted arm training

on upper limb motor function and kinematics in
chronic stroke survivors: A randomized controlled
trial

Ki-Hun Cho & Won-Kyung Song

To cite this article: Ki-Hun Cho & Won-Kyung Song (2021) Effects of two different robot-
assisted arm training on upper limb motor function and kinematics in chronic stroke
survivors: A randomized controlled trial, Topics in Stroke Rehabilitation, 28:4, 241-250, DOI:
10.1080/10749357.2020.1804699

To link to this article: https://doi.org/10.1080/10749357.2020.1804699

Published online: 13 Aug 2020.

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TOPICS IN STROKE REHABILITATION
2021, VOL. 28, NO. 4, 241–250
https://doi.org/10.1080/10749357.2020.1804699

ARTICLE

Effects of two different robot-assisted arm training on upper limb motor function
and kinematics in chronic stroke survivors: A randomized controlled trial
a b
Ki-Hun Cho and Won-Kyung Song
a
Department of Physical Therapy, Korea National University of Transportation, Chungbuk, Republic of Korea; bDepartment of Rehabilitative &
Assistive Technology, National Rehabilitation Research Institute, National Rehabilitation Center, Seoul, Republic of Korea

ABSTRACT ARTICLE HISTORY

Background: Comparative studies of different robotic types are warranted to tailor robot-assisted Received 3 March 2020
upper limb training to patient’s functional level. Accepted 29 July 2020
Objectives: This study aimed to directly compare the effects of high inertia robot arm (whole arm KEYWORDS
manipulator, WAM) and low inertia robot arm (Proficio) on upper limb motor function in chronic Inertia; motor function; robot
stroke patients. arm; stroke; upper extremity
Methods: In this randomized controlled trial, 40 chronic stroke survivors were randomized into
robot-assisted arm training with WAM (RAT-WAM) and robot-assisted arm training with Proficio
(RAT-P) groups. The RAT-WAM and RAT-P groups participated in the robot-assisted arm training
with WAM and robot-assisted arm training with Proficio, respectively, for 40 min daily, three times
weekly over a four week. Upper limb motor function was measured before and after the interven­
tion using the Fugl–Meyer assessment (FMA), action research arm test, and box and block test (BBT).
Curvilinearity ratio (the length ratio of a straight line from the start to the target) was also measured
as an index for upper limb kinematic performance.
Results: The RAT-WAM and RAT-P groups showed significant improvements in FMA-total and -
proximal (shoulder/elbow units), BBT, and ARAT after the intervention (P < .05). Also, the RAT-P
group showed significantly more improvement than the RAT-WAM group in FMA-distal (hand/wrist
units) (P < .05).
Conclusions: Improvements of upper limb motor function occurred during robot-assisted arm
training with robotic systems. Low inertia robot arm was more effective in improving the motor
function of the hand and wrist. The results may be useful for robot-assisted training for upper limb
impairment.

Introduction arm and provide assistance or resistance forces to

the user during training.5 In particular, the robotic
Impairment of upper limb function commonly
system improves functional movements by varying
occurs after a stroke, and it leads to difficulties
the force, reducing assistance, increasing the resis­
with most activities of daily living.1 Only a small
tance, and expanding the movement amplitude.6 In
proportion of people achieve a complete functional
addition, the robotic system for upper limb stroke
recovery after a stroke, with 55% to 75% of survi­
rehabilitation enables intensive, repetitive, and
vors left with persistent impairment of the upper
motivational therapy paradigms.7,8 These advan­
extremity as well as restriction of activity of daily
tages, consistent with therapy principles, can max­
living and community participation at 6 months
imize the effectiveness of the training.6 Various
after onset.2 Thus, improving upper limb capacity
types of robotic systems have been applied in
of stroke survivors is one of the most important
upper extremity rehabilitation of stroke survivors
challenges for clinicians and researchers.3
based on these advantages.9
In the last decade, many stroke rehabilitation
Several studies have reported that training intensity
robotic systems have emerged to enhance upper
is an important factor in improving upper extremity
limb motor function and activities of daily living
motor function.7,9,10 The training intensity in robot-
performance in stroke survivors.4 Some robotic
assisted rehabilitation may vary depending on the
systems provide passive movement of the user’s
number of repetitions, the degree of subject

CONTACT Won-Kyung Song wonksong@gmail.com Department of Rehabilitative & Assistive Technology, National Rehabilitation Research Institute,
National Rehabilitation Center, Seoul 01022, Republic of Korea
© 2020 Taylor & Francis Group, LLC
242 K. H. CHO AND W.-K. SONG
participation, or the degree of assistance of the
robot.10 According to previous studies, brain plastic
change can be induced by over 300 repetitive move­
ments per day11,12 and over 100 active participations
per session.13 On this basis, many previous studies on
robot-assisted rehabilitation attempted to compare
the effects of robot-assisted rehabilitation on upper
limb according to exercise intensity. Hwang et al.14
reported that robot-assisted intervention with active-
assisted mode is more effective in improving hand
function compared with robot-assisted intervention
with passive mode in stroke patients. Another study
demonstrated that high-intensity robot training may
lead to greater improvement in motor ability and
functional performance of forearm and wrist move­
ments in stroke patients.15
Although the association between training inten­
sity and robot-assisted rehabilitation in upper limb
motor function of stroke patients has been noted,
disparate effects and heterogeneities exist depend­
ing on the types of robotic system.4,16 To compare
the effects of different types of robots, comparative
studies of different robotic types (e.g. high inertia
versus low inertia) are warranted to tailor robot-
assisted upper limb training to patient’s functional
level. Moment of inertia is the resistance to the
rotation of the robot arm, and the inertia of the
robot arm is an important factor in determining the
back-driveability required to react smoothly and
quickly according to the user’s movement.17
Because depending on the degree of inertia, the
user’s naturalness, comfort, and soft-touch may
change during robot arm rehabilitation which
may affect the possibility of secondary damage for
the musculoskeletal system, the influence of inertia
during rehabilitation using robot arm system
should be considered.18 Thus, the purpose of this
study was to investigate and compare the effects of
two types of robot inertia on upper limb motor
function in chronic stroke survivors. This study
mainly compared the 4 weeks of training effects of
the high inertia robotic system (whole arm manip­
ulator, WAM) versus the low inertia robotic system
(Proficio). Proficio (low inertia robotic system) is
easy to manipulate the robot arm and responds
immediately to the user’s movement, while WAM
(high inertia robotic system) is relatively difficult to
manipulate the robot arm and responds slowly to
the user’s movement.
Materials and methods
Study design
This randomized controlled trial was conducted at
a rehabilitation institute. All participants were ran­
domized into two groups: a robot-assisted arm
training with WAM group (RAT-WAM group)
and a robot-assisted arm training with Proficio
group (RAT-P group). Randomization was con­
ducted using a computer-generated permuted four-
block allocation scheme by an individual who was
not involved in this study. The randomization was
concealed until the posttest was performed. The
study was approved by the ethics committee of
the (NRC-2017-01-01) and was conducted in
accordance with the approved guidelines. Written
informed consent was provided by all participants.
In addition, this study protocol was registered with
the (KCT0002596). In addition, this study con­
formed to the CONSORT (Consolidated
Standards of Reporting Trials) Guidelines to pre­
pare reports of trial findings, facilitating their com­
plete and transparent reporting, and aiding their
critical appraisal and interpretation.
Subjects
Forty-five subjects with chronic stroke who were
living in the community were included in this
study. Inclusion criteria were (1) first-ever unilat­
eral stroke and chronic stroke survivors at least
6 months after the onset of stroke, (2) able to follow
the study instructions (≥24 points on the Korean
version of the mini-mental state examination
score), and (3) absence of any musculoskeletal con­
dition that could affect the ability to sit safely.
Exclusion criteria were (1) shoulder subluxation
or obvious joint pain of the upper limb, or (2)
spasticity (modified Ashworth scale score > 2).
After screening, three subjects were excluded, and
the remaining 42 were included. The sample size
was determined after a calculation based on the
results of the G-power 3.1.9.3 software. The power
and alpha were set at 0.80 and 0.05, respectively,
and the effect size was set at 0.92 in accordance to
prior analysis, requiring at least 20 participants in
each group. Therefore, 21 subjects in each group
were enrolled with the consideration for potential
drop outs.
 TOPICS IN STROKE REHABILITATION 243

Intervention compensation and triggered assistance force (4 N)

based on the subjects’ reaching performance.
All subjects underwent the training program three
A triggered assistance force occurred temporarily
times a week for 4 weeks. A single training session
to assist the lack of reaching movement. When
lasted 40 minutes, and it was supervised by the
a subject could not move the arm toward the target
same occupational therapist. The RAT-WAM
during robot-assisted arm training, they were pro­
group underwent robot-assisted arm training with
vided assistance force to reach the desired targets.
high inertia robotic system (WAM), and the RAT-P
group underwent robot-assisted arm training with
RAT-WAM protocol
low inertia robotic system (Proficio). The robot-
Robot-assisted arm training with WAM (RAT-
assisted arm training with robotic systems (WAM
WAM) was conducted on a testbed using a WAM
and Proficio) was conducted on a testbed. The
system (Barrett Technology, Inc., Newton, MA,
setting of the testbed followed previous studies.19–
21 USA). WAM was set at five degrees of freedom of
The testbed comprised a robotic arm with a set of
a motorized function for the shoulder, elbow, and
gimbals, a visual display, and two PCs (Figure 1).
wrist joints during the training sessions. WAM has
PC #l (for the robotic arm) and PC #2 (for the 3D
seven degrees of freedom, and two degrees of free­
display) communicated via the user datagram pro­
dom is fixed to regulate the overall pose of a robotic
tocol. PC #1 sent position and force data periodi­
arm. The WAM provides a back-drivable motion
cally to PC #2, and PC #2 generated visual
that helps the user reach the desired sphere using
information from these data via Virtools.
point-to-point movements.22 The total system
The subjects performed robot-assisted arm train­
mass, maximal control stiffness, and the estimated
ing while sitting on a chair wearing the robotic
mass moment of inertia of the WAM are 25 kg,
system. A 120-inch projection display placed in
5,000 N/m, and 0.1–0.5 kg m2.23 During RAT-
front of the testbed was used to provide suitable
WAM, subjects performed reaching movements
visual and auditory feedback to the user. Once the
toward targets for six directions in the projection
training began, yellow and gray balls appeared on
screen. In addition, WAM provided gravity com­
the projection display, and the subjects performed
pensation and triggered assistance force based on
reaching movements toward targets in three-
the subjects’ reaching performance (Figure 2(a)).
dimensional space in six directions (i.e. targets
1–6). The yellow ball was linked to the reaching
RAT-P protocol
movements of the subject, and an auditory feed­
Robot-assisted arm training with Proficio (RAT-P)
back (ding-dong sound) was provided when the
was conducted on a testbed using a Proficio system
yellow and gray balls matched. The reaching move­
(Barrett Medical, Newton, MA, USA). Proficio was
ments consisted of three phases (moving toward
set at three degrees of freedom of a motorized func­
the target, manipulating the target, and returning
tion for the shoulder, elbow, and wrist joints during
from the target to hand point), and the upper limb
the training sessions. The handle of a Proficio
kinematic data (curvilinearity ratio, CR) during the
includes a gimbal-type two degrees of freedom with­
reaching movements were recorded. In addition,
out a motorized function. Proficio is a robotic arm
during the robot-assisted arm training, robotic sys­
designed to help people who had suffered a stroke to
tems (WAM and Proficio) provided gravity
regain upper limb functionality with low inertia and
high fidelity such as the reproduction of a force that
is very faithful to the original. Proficio encourages
the user to explore and carry out range tasks in 3D
freely. The total system mass, maximal control stiff­
ness, and the estimated mass moment of inertia of
the Proficio are 11.5 kg, 2,500 N/m, and
0.025–0.12 kg m2.23 During RAT-P, subjects per­
Figure 1. System block diagram of the testbed. formed reaching movements toward targets for six
244 K. H. CHO AND W.-K. SONG

Figure 2. Robot-assisted arm training using WAM (a) and Proficio (b) in the testbed. Subjects performed reaching movements toward
targets in three-dimensional space in six directions (i.e. targets (T) 1–6).

directions in the projection screen. In addition,
Proficio provided gravity compensation and trig­
gered assistance force based on the subjects’ reaching
performance (Figure 2(b)).
Outcome measures
Upper limb motor function and kinematic assess­
ments were performed at baseline (before the inter­
vention period) and after 4 weeks of intervention
period. Upper limb motor function assessment was
conducted using the Fugl-Meyer Assessment
(FMA) for the upper extremity, box and block test
(BBT), and action research arm test (ARAT).
The FMA is an index used to assess the sensor­
imotor impairment in individuals who have had
a stroke. It has been tested several times and has
excellent consistency and responsivity and good
accuracy.24 The FMA-upper limb subscale consists
of 33 items, and the total score ranges from 0 to 66,
 TOPICS IN STROKE REHABILITATION 245

with higher scores indicating better motor func­ Statistical analysis

tion. This subscale can also be separated into sub­
Data analysis was performed using SPSS (version
scores of a proximal unit of shoulder/elbow (0 to
21.0; IBM Corp., Armonk, NY). Mann–Whitney
42) and a distal unit of hand/wrist (0 to 24) to
U-test was used for comparison of the baseline
represent proximal and distal upper limb scores,
characteristics and dependent variables of the par­
respectively.4
ticipants in both groups. For dependent variable
The BBT measures unilateral gross manual dex­
measures, Wilcoxon signed-rank test and Mann–
terity. It is a quick, simple, and inexpensive test. It
Whitney U-test were used respectively to compare
can be used with a wide range of populations,
dependent variables within and between groups
including patients with stroke. The test consists of
after interventions. A significance level of 0.05 was
a box with a partition in the middle. Blocks are
used for all tests.
placed on one side of the partition, and the box is
placed on a table. The test user is seated facing the
box. During the tests, the test user is given 60 sec­ Results
onds to move as many blocks as possible from one
Forty-two subjects were randomly allocated to the
side to the other, by using only the hand being
RAT-WAM or RAT-P group. However, one parti­
tested. The test hand can be either the user’s own
cipant who did not complete the intervention ses­
hand or a prosthetic device operated by the user.
sion in each group was excluded from the analysis.
The number of displaced blocks is a measure of the
Thus, 20 subjects were finally included in each
gross manual dexterity. A greater number of dis­
group (Figure 3). No significant differences were
placed blocks indicate a better gross dexterity. The
found in baseline characteristics and dependent
results can be compared to the reference values of
variables between the RAT-WAM and RAT-P
a healthy test user or the reference values of tests
groups (Table 1).
performed with prosthesis.25
Changes in the upper limb motor function and
The ARAT is designed to assess upper limb dis­
kinematics after robot-assisted arm training are
ability by assessing four basic movements: primary
shown in Table 2. In the upper limb motor func­
grasp, grip, pinch, and gross movements of flexion
tion, both the RAT-WAM and RAT-P groups
and extension at the elbow and shoulder. Each test
showed significant improvements in FMA-total
is graded on a 4-point scale from 0 (unable to
and -proximal, BBT, and ARAT after 4 weeks of
complete any part of the hand or arm movement)
robot-assisted arm training (P < .05). However,
to 3 (normal performance), yielding a maximum
only the RAT-P group showed significant improve­
score of 57.26
ments in the FMA-distal (P < .05). In addition, the
Upper extremity kinematics was measured using
RAT-P group showed significantly more improve­
CR for upper limb reaching during robot-assisted
ment than the RAT-WAM group in FMA-distal
arm training. CR represented the length ratio of
(P < .05). In the kinematics, improvements were
a straight line from the start to the target to the
observed in both groups but were not statistically
actual displacement of the hand. CR close to 1
significant.
indicates that the actual displacement between the
starting and target points was close to a straight
line. CR was recorded using robotic systems. CR Discussion
was calculated via MATLAB software (Mathworks
This study showed that both the RAT-WAM and
Inc., Natick, MA) for further analysis.
RAT-P groups had significant improvements in
upper limb motor function (FMA-total and -
Curvilinearity Ratio ðCRÞ
proximal, BBT, and ARAT) after 4 weeks of robot-
length of a straight line from the start assisted arm training.
point to the target point The development and clinical trials of robotic
¼
actual displacement of the hand devices have grown exponentially over the last
246 K. H. CHO AND W.-K. SONG

scores: 2.05 and 3.30 points). Although the magni­

tude of FMA change required to bring patient real-
world benefits (minimum clinically important dif­
ference) is at least 5 points,33 we believe that this
result is meaningful considering the included
chronic stroke subjects survived for over 11 to
12 years after onset of stroke.

Table 1. Homogeneity test for general characteristics and depen­

dent variables of the subjects (N = 40).
RAT-WAM group RAT-P group
(n = 20) (n = 20)
P-values
General
Figure 3. Study flowchart. characteristics
Gender (Male/ 13/7 (65/35) 14/6 (70/30)
Female, %)
Paretic side 15/5 (75/25) 11/9 (55/45)
decade. Through the results of previous systematic (Right/Left, %)
Etiology 7/13 (35/65) 10/10 (50/50)
reviews, meta-analyses,27–29 and guidelines such as (Infarction/
the American Heart Association,30 the need of the Hemorrhage,
%)
assist-as-needed paradigm for the effective inter­ MRC 2/16/2 1/17/2
vention of the robotic system in stroke upper limb scale_shoulder
F (3/4/5)
rehabilitation has been emphasized. Subjects’ active MRC scale_elbow 1/17/2 0/18/2
E (3/4/5)
attempts during robot training can promote synap­ MAS_U/E (1/1 10/9/1 7/13/0
togenesis or reinforcement of weakened pathways +/2)
Age, years 63.55 ± 7.66 60.25 ± 9.42 .342
through sensory feedback on actual movement Height, cm 163.25 ± 8.32 166.35 ± 10.76 .401
execution.10 In this study, during robot-assisted Weight, kg 68.96 ± 10.94 68.02 ± 9.76 .745
Post stroke 12.65 ± 5.45 11.75 ± 8.32 .448
arm training with WAM and Proficio, subjects duration, years
were provided triggered assistance force when MMSE, points 26.90 ± 2.26 26.90 ± 2.33 .956
MBI, points 95.70 ± 3.67 94.15 ± 4.20 .167
they could not move the arm toward the target for Dependent
more than 2 seconds. Because triggered assistance variables
FMA-total (range: 45.45 ± 13.31 46.55 ± 11.23 .799
force was applied only when the subjects could not 0–66)
FMA-proximal 31.00 ± 3.15 30.50 ± 7.28 .820
move the arm, they were able to participate as (range: 0–42)
active as possible in the training. Thus, we think FMA-distal 14.30 ± 7.78 16.35 ± 6.19 .495
(range: 0–24)
that promoting active participation of subjects BBT 9.40 ± 9.01 13.65 ± 7.96 .114
through robot assistance provided only when ARAT (range: 30.25 ± 22.09 35.85 ± 18.56 .383
0–57)
necessary may led to improvement in upper limb CR 1 0.56 ± 0.41 0.81 ± 0.39 .512
motor function. CR 2 0.38 ± 0.38 0.54 ± 0.25 .495
CR 3 0.36 ± 0.37 0.51 ± 0.23 .529
The most notable finding of our study was the CR 4 0.49 ± 0.45 0.67 ± 0.31 .301
changes in FMA scores. In a previous study target­ CR 5 0.39 ± 0.41 0.42 ± 0.20 .314
CR 6 0.33 ± 0.39 0.40 ± 0.15 .640
ing chronic stroke patients by Conroy et al., robot- Values are expressed as Mean±SD
assisted planar reaching training showed RAT-WAM: Robot-Assisted arm Training with Whole Arm Manipulator, RAT-P:
Robot-Assisted arm Training with Proficio, MRC scale_shoulder F: Medical
a significant positive change in total FMA change Research Council Scale for muscle strength on shoulder flexion, MRC
scores (2.94 points).31 In addition, another study on scale_elbow E: Medical Research Council Scale for muscle strength on
elbow extension, MAS_U/E: Modified Ashworth Scale for Upper
12 weeks of robot-assisted therapy reported the Extremity, MMSE: Mini-Mental State Examination, MBI: Modified Barthel
improvement of upper limb motor function (total Index, FMA-total: Fugl-Meyer Assessment for Upper Extremity, FMA-
proximal: Fugl-Meyer Assessment Upper Extremity subscale (shoulder/
FMA change scores: 3.87 points).32 The amount of elbow units), FMA-distal: Fugl-Meyer Assessment Upper Extremity subscale
(wrist/hand units), BBT: Box and Block Test, ARAT: Action Research Arm
improvement in the total FMA score in previous Test,
studies was similar to the gains reported in our CR : curvilinearity ratio ¼ length of a straight line from the start point to the target point
actual displacement of the hand
result from WAM and Proficio (total FMA change
 TOPICS IN STROKE REHABILITATION 247

Table 2. Comparison of upper limb motor function and kinematics (N = 40).

RAT-WAM group (n = 20) RAT-P group (n = 20)
parameters Pretest Posttest Δ values Pretest Posttest Δ values Z P
Motor function
FMA-total (range: 0–66) 45.45 ± 13.31 47.50 ± 13.23 2.05 ± 3.06* 46.55 ± 11.23 49.85 ± 11.08 3.30 ± 4.79* 0.951 .355
FMA-proximal (range: 0–42) 31.00 ± 3.15 32.65 ± 6.14 1.65 ± 1.66* 30.50 ± 7.28 32.45 ± 6.87 1.95 ± 2.91* 0.056 .968
FMA-distal (range: 0–24) 14.30 ± 7.78 13.95 ± 7.54 −0.35 ± 1.18 16.35 ± 6.19 17.70 ± 5.97 1.35 ± 2.73*+ 3.899 <.000
BBT 9.40 ± 9.01 10.85 ± 10.50 1.45 ± 1.87* 13.65 ± 7.96 15.00 ± 8.73 1.35 ± 1.98* 0.097 .925
ARAT (range: 0–57) 30.25 ± 22.09 31.45 ± 22.64 1.20 ± 2.62* 35.85 ± 18.56 37.23 ± 18.58 1.40 ± 3.26* 0.150 .904
Kinematics
CR 1 0.56 ± 0.41 0.56 ± 0.45 0.00 ± 0.27 0.81 ± 0.39 0.82 ± 0.28 0.01 ± 0.29 0.474 .860
CR 2 0.38 ± 0.38 0.40 ± 0.39 0.01 ± 0.20 0.54 ± 0.25 0.59 ± 0.26 0.05 ± 0.18 0.352 .591
CR 3 0.36 ± 0.37 0.39 ± 0.39 0.02 ± 0.23 0.51 ± 0.23 0.55 ± 0.26 0.04 ± 0.19 0.203 .787
CR 4 0.49 ± 0.45 0.41 ± 0.39 0.07 ± 0.25 0.67 ± 0.31 0.69 ± 0.28 0.01 ± 0.22 0.717 .222
CR 5 0.39 ± 0.41 0.42 ± 0.47 0.02 ± 0.31 0.42 ± 0.20 0.48 ± 0.22 0.06 ± 0.15 0.907 .636
CR 6 0.33 ± 0.39 0.40 ± 0.41 0.07 ± 0.26 0.40 ± 0.15 0.50 ± 0.19 0.10 ± 0.08* 0.542 .558
Values are expressed as Mean±SD
RAT-WAM: Robot-Assisted arm Training with Whole Arm Manipulator, RAT-P: Robot-Assisted arm Training with Proficio
FMA-total: Fugl-Meyer Assessment for Upper Extremity, FMA-proximal: Fugl-Meyer Assessment Upper Extremity subscale (shoulder/elbow units), FMA-distal:
Fugl-Meyer Assessment Upper Extremity subscale (wrist/hand units), BBT: Box and Block Test, ARAT: Action Research Arm Test,
CR : curvilinearity ratio ¼ length of a straight line from the start point to the target point
actual displacement of the hand
*: significant differences between pre and posttest, p < 0.05
+
: significant differences for change value between two groups, p < 0.05

Another important result of this study is the
changes in FMA subscores. Interestingly, total FMA
scores increased in both the RAT-WAM and RAT-P
groups, but differences were found in the FMA sub­
scores. In particular, the RAT-P group showed more
improvement than the RAT-WAM group in FMA-
distal unit. This result suggests that the robot-assisted
arm training using Proficio is more effective in
improving the motor function of the hand and wrist
than the robot-assisted arm training using WAM.
This difference is probably due to the mechanical
characteristics of the robot arm. The high inertia of
WAM interferes with the subject’s manipulation dur­
ing training, and it can increase the burden on the
subject by rigorous physical human-robot interaction.
Because the distal segment of upper extremity move­
ments is crucial for performing functional tasks and
training for upper extremity distal segment can led to
improvement of distal motor function, muscle
strength, and quality of movement during functional
activities,4 this finding is clinically meaningful. Thus,
we believe that this information may help guide clin­
ical decision-making in stroke rehabilitation and may
be useful for robot-assisted training for upper limb
impairment.
Recent advanced robotic systems include sensors
that derive indicators and movement features for
measuring and recording kinematics while per­
forming upper limb movement.10 Many previous
studies suggested that kinematic indicators may be
valid measures to assess upper limb motor impair­
ments, and kinematic measures may help clarify the
observed changes after robotic rehabilitation.10,34,35
Moreover, other studies suggested that kinematic
analysis is useful for evaluating upper limb function
recovery after stroke, and it could provide more
accurate indicators of motor recovery when com­
bined with clinical evaluation tools.36 On the other
hand, despite the suggestion that kinematic mea­
surements may be a reliable indicator of motor
recovery, one study reported that it is only moder­
ately correlated with the proximal part of the FMA
upper extremity scores.35
Kinematics measured in our study showed that
some improvements were observed in both the
RAT-WAM and RAT-P groups but were not sta­
tistically significant. In this study, we mainly
observed the ∆degree of linearity (CR) of the
upper limb reaching movement to target to evalu­
ate the kinematic performance during robot-
assisted arm training. CR represented the length
ratio of a straight line from the start to the target
to the actual displacement of the hand during
robot-assisted arm training. In other words, CR
indicates the degree to which the arm moves in
a straight line. This study focused on the efficient
movement via CR to compare the influence of two
robotic arms with different inertia. Interestingly,
the robot arm with low inertia showed better
improvement of CR than high inertia. Although it
does not make a statistically significant difference,
we think that this finding means that the movement
efficiency during robot-assisted arm training can
change depending on the inertia of the robot arm.
248 K. H. CHO AND W.-K. SONG
Although straightness of the arm movement has
a significant correlation with the severity of clinical
symptoms as an index of movement accuracy, the
influence of the target position during point-to-
point reaching movement and gravity must be con­
sidered for an accurate evaluation of the movement
accuracy of the arm.18,37 Therefore, many research­
ers are considering various factors such as the
movement velocity, time, and trajectory of the
arm for kinematic movement evaluation of the
upper limb.18 In future studies, different kinematic
measurements, such as arm movement velocity,
time, and smoothness of movement should be per­
formed for more proper evaluation. Also, further
studies that include kinematic measures along with
clinical scales to help clarify the observed changes
after robotic rehabilitation are necessary. We
expect that measurement of various indicators of
kinematic and kinetic analyses during robot-
assisted arm movements may lead to a better
understanding of changes in kinematic perfor­
mance according to robot-assisted arm movements.
Several limitations of this study need to be con­
sidered. First, long-term follow-up evaluations
were not conducted in this study; thus, beneficial
carry-over effects could not be determined. Further
studies, including long-term follow-up assessment,
are warranted to evaluate the beneficial carry-over
effects of the two different robot-assisted arm train­
ing. Second, this study included only high-
functioning stroke survivors. Thus, the results
from this study cannot be generalized to all stroke
survivors. Third, the study participants were stroke
survivors living in the community. Although we
confirmed that they did not participate in regular
treatments, such as physical and occupational
therapies, we did not limit their individual exercise
in daily living. Future studies should consider the
limitation of personal exercise in daily living.
To our knowledge, this is the first clinical trial to
directly compare the effects of robot inertia on
motor function of stroke survivors. In conclusion,
robot-assisted arm training with robotic systems
led to an improvement in upper limb motor func­
tion of chronic stroke survivors. In particular, low
inertia robot arm, Proficio, was more effective in
improving the motor function of the hand and
wrist. The obtained findings may help guide clinical
decision-making in stroke rehabilitation and may
be useful for robot-assisted training for upper limb
impairment.
Disclosure of interest
The authors report no conflict of interest.
Funding
This study was supported by the Research Program (NRCTR-
IN17006, NRCTR-IN18006, NRCTR-IN19006) of the
National Rehabilitation Center, Ministry of Health and
Welfare, Republic of Korea.
ORCID
Ki-Hun Cho http://orcid.org/0000-0001-6248-1768
Won-Kyung Song http://orcid.org/0000-0002-9884-0467
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