Effects of Robot-Assisted Rehabilitation On Hand Function of People With Stroke: A Randomized, Crossover-Controlled, Assessor-Blinded Study

Research Article
Effects of Robot-Assisted Rehabilitation

on Hand Function of People With Stroke:
A Randomized, Crossover-Controlled,
Assessor-Blinded Study
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Hsin-Chieh Lee, Fen-Ling Kuo, Yen-Nung Lin, Tsan-Hon Liou, Jui-Chi Lin, Shih-Wei Huang
Importance: The effects of robot-assisted task-oriented training with tangible objects among patients with stroke remain unknown.
Objective: To investigate the effects of robot-assisted therapy (RT) with a Gloreha device on sensorimotor and hand function and
ability to perform activities of daily living (ADLs) among patients with stroke.
Design: Randomized, crossover-controlled, assessor-blinded study.
Setting: Rehabilitation clinic.
Participants: Patients (N = 24) with moderate motor and sensory deficits.
Intervention: Patients participated in 12 RT sessions and 12 conventional therapy (CT) sessions, with order counterbalanced, for
6 wk, with a 1-mo washout period.
Outcomes and Measures: Performance was assessed four times: before and after RT and before and after CT. Outcomes
were measured using the Fugl-Meyer Assessment–Upper Extremity (FMA–UE), Box and Block Test, electromyography of the
extensor digitorum communis (EDC) and brachioradialis, and a grip dynamometer for motor function; Semmes–Weinstein hand
monofilament and the Revised Nottingham Sensory Assessment for sensory function; and the Modified Barthel Index (MBI) for ADL
ability.
Results: RT resulted in significantly improved FMA–UE proximal (p = .038) and total (p = .046) and MBI (p = .030) scores.
Participants’ EDC muscles exhibited higher efficacy during the small-block grasping task of the Box and Block Test after RT than
after CT (p = .050).
Conclusions and Relevance: RT with the Gloreha device can facilitate whole-limb function, leading to beneficial effects on arm
motor function, EDC muscle recruitment efficacy, and ADL ability for people with subacute and chronic stroke.
What This Article Adds: The evidence suggests that a task-oriented approach combined with the Gloreha device can facilitate
engagement in whole-limb active movement and efficiently promote functional recovery.
fter stroke, both sensory and motor functions are impaired, and they recover together (Doyle et al., 2014).
A Functional impairment of the upper extremity after stroke, including hemiplegia, synergistic movement, muscle
hypertonicity, and somatosensory impairment, results in inefficient and inaccurate movement (Nordin et al., 2014).
Moreover, in the subacute and chronic stages of stroke, voluntary motor skill in the paretic arm is insufficient (Hwang
et al., 2012). Somatosensory deficits have a negative effect on the functional outcomes of people with hemiplegia and
prolong rehabilitative treatment (Meyer et al., 2014; Smania et al., 2003; Tyson et al., 2007; Zeman & Yiannikas, 1989).
The identification and assessment of poststroke sensory problems remain underexplored.
Integration of sensory abilities is crucial for recovery of motor control and learning (Bolognini et al., 2016). Robot-
assisted rehabilitation is an intensive training approach that has been found to be effective in promoting the recovery of
Citation: Lee, H.-C., Kuo, F.-L., Lin, Y.-N., Liou, T.-H., Lin, J.-C., & Huang, S.-W. (2021). Effects of robot-assisted rehabilitation on hand function of people
with stroke: A randomized, crossover-controlled, assessor-blinded study. American Journal of Occupational Therapy, 75, 7501205020. https://doi.org/
10.5014/ajot.2021.038232
The American Journal of Occupational Therapy, January/February 2021, Vol. 75, No. 1 7501205020p1
Research Article
sensorimotor and hand function (Veerbeek et al., 2017). Most previous studies investigated only shoulder or elbow
robotics (Veerbeek et al., 2017). A few studies have suggested that when combined with distal upper extremity training,
robotic therapy can be effective in improving hand function and ability to perform activities of daily living (ADLs;
Balasubramanian et al., 2010; Susanto et al., 2015). However, these studies had small sample sizes, no control group,
and uncertainty regarding spontaneous recovery of patients with acute stroke (Pětioký, 2020). Moreover, the effects of
robot-assisted task-oriented training with tangible objects in people with stroke remain unknown.
In the current study, we investigated the effect of robot-assisted therapy (RT) performed with the Gloreha Sinfonia
robotic device (Indrogent, Lumezzane, Italy) on the sensorimotor and hand function and ADL ability of patients with
subacute to chronic stroke. The device benefits people with stroke by improving sensorimotor function, muscle tone
and strength, and hand function (Varalta et al., 2014). We hypothesized that 12 intervention sessions of RT would lead
to improvements in sensorimotor and hand function and ADL independence in patients with subacute or chronic stroke.
Method
Design
This study had a randomized, crossover-controlled, assessor-blinded design. Participants were recruited from the
Department of Physical Medicine and Rehabilitation of a medical university hospital with the approval of the ethics
committee. All participants provided written informed consent.
Participants
Participants were recruited between February 1, 2018, and June 30, 2018. A total of 25 (17 men, 8 women) community-
dwelling patients with subacute or chronic stroke were divided into two groups and participated in two phases of
treatment: RT and conventional therapy (CT; Lins et al., 2018). Patients were included in the study if they had had a first
stroke with hemiplegia, had subacute (3–6 mo) or chronic (>6 mo) stroke, could understand instructions, were in
Brunnstrom Stages II–V of recovery, had sensory impairment (revised Nottingham Sensory Assessment [rNSA] Tactile
score <2 and Kinesthetic score <3), and had muscle tone allowing movement (Modified Ashworth Scale score <3).
Patients who were ages <20 or >75 yr, who were unable to clearly see or hear the feedback from the device, or who had
other medical symptoms affecting movement were excluded.
Procedure
The following baseline data were collected from all participants (Table 1): gender, age, education level, affected side,
etiology, site of stroke, poststroke duration, tactile and kinesthetic sensation function, Brunnstrom stage, muscle tone of
the upper extremity, and cognitive level (Montreal Cognitive Assessment; Carson et al., 2018). Participants were
randomly sorted into two treatment groups using a computer program with simple randomization. The groups received
60 min of RT or CT twice per week for 6 wk, with order of treatment counterbalanced after a 1-mo washout period.
Participants’ performance was assessed at four time points: RT pretest, RT posttest, CT pretest, and CT posttest
(Figure 1). The occupational therapist assessors were blinded to treatment assignment; they did not screen participants
or provide intervention and went to the clinics only to conduct the four assessments. All participants continued regular
therapy, including speech and physical therapy.
Robot-Assisted Therapy
The RT condition was conducted using a Gloreha Sinfonia device. The device consists of a glove that detects individual
finger movement and, on the basis of residual motor skills, partially or completely supports people in practicing finger
movement. The Gloreha device focuses on the distal part of the upper limb and uses a dynamic support system to
support the proximal part of the limb against gravity. It simulates ADL function through task-oriented exercises involving
Research Article
Table 1. Participant Characteristics at Baseline reaching, grasping, and transporting objects in a

n (%) or M (SD) 3D space. Patients are encouraged to train on
RT-First Group CT-First Group the components of a skill (e.g., the skill of drinking
Characteristic (n = 14) (n = 10) p
from a bottle includes the components of reaching
Gender .770
out toward a bottle, grasping the bottle, lifting the
Male 9 (64.3) 7 (70.0)
Female 5 (35.7) 3 (30.0)
bottle, bringing the bottle to the mouth, and
Age (yr) 59.56 (8.29) 53.50 (12.33) .235 placing the bottle on the table). Each motor ex-
Education level .531 ercise is enriched by multisensory stimulation
<High school 5 (35.7) 3 (30.0)
and the simultaneous display of 3D animation on
High school 4 (28.6) 5 (50.0)
>High school 5 (35.7) 2 (20.0)
a screen to amplify cortical stimulation.
Affected side .404 A registered occupational therapist who had
Left 9 (64.3) 8 (80.0) completed training sessions provided by Gloreha
Right 5 (35.7) 2 (20.0)
Sinfonia technical staff conducted individual in-
Etiology .239
Infarction 9 (64.3) 4 (40.0)
terventions in an occupational therapy room in a
Hemorrhage 5 (35.7) 6 (60.0) clinical setting. Each training session lasted
Site of stroke .269 60 min and included a 20-min warm-up program
Cerebral 10 (71.4) 9 (90.0)
and a 40-min RT program. The warm-up program
Cerebellum 0 (0.0) 0 (0.0)
Brain stem 4 (28.6) 1 (10.0)
included weight-bearing and rhythm activities to
Poststroke duration (days) 882.00 (957.67) 883.30 (1,020.49) .931 inhibit spasticity. The RT program consisted of
Poststroke phase 10 min of continuous whole-hand and individual-
Subacute 4 (28.6) 1 (10.0) .307
finger passive range of motion exercises with vi-
Chronic 10 (71.4) 9 (90.0)
rNSA score
sual cues displayed on the Gloreha device’s
Tactile sensation screen and 30 min of active-assist activities with
Forearm 0.86 (0.95) 0.50 (0.85) .403 settings adjusted according to participants’ ability.
Hand 0.57 (0.76) 0.60 (0.70) .886
The active-assist part of the program included
Kinesthetic sensation
Elbow 2.14 (0.95) 1.70 (1.06) .312
task-oriented bimanual activities, active-assist
Wrist 1.29 (1.14) 1.00 (0.94) .585 activities, and games. Participants practiced the
Hand 1.14 (1.03) 1.00 (0.94) .841 task-oriented exercises by using objects—for
Brunnstrom stage of UE
example, grasping a box. In the games mode,
Proximal 3.36 (1.15) 3.00 (0.82) .585
Distal 3.29 (1.20) 2.90 (0.88) .546
participants were required to grasp objects and
MAS score of UE open their hands to actively control interactive
Proximal 1.36 (0.75) 1.50 (0.53) .796 games, which included flying a spaceship, filling a
Distal 1.29 (0.91) 1.80 (0.63) .212
shopping cart, and playing a Breakout clone.
MoCA score 23.21 (4.90) 22.00 (7.06) .841
Note. p values were calculated according to the Mann–Whitney U or x test. CT =
2
Conventional Therapy
conventional therapy; MAS = Modified Ashworth Scale; MoCA = Montreal Cognitive
Assessment; rNSA = revised Nottingham Sensory Assessment; RT = robot-assisted The CT condition included a 20-min warm-up
therapy; UE = upper extremity. program and a 40-min conventional occupational
rehabilitation program. The warm-up was the
same as that used in RT to inhibit spasticity. The CT program included task-oriented bilateral hand, grasp-and-release,
and pinch activities, which were the same as those used in the RT program but without the use of the Gloreha device.
Outcome Measures
Upper Extremity Motor Outcomes
The primary outcome measure was the Fugl-Meyer Assessment–Upper Extremity (FMA–UE; Duncan et al., 1983),
which measures upper extremity motor impairment. The FMA–UE consists of 33 items, including items assessing
Research Article
Figure 1. Flowchart showing flow of participants through the study.
Enrollment
Assessed for eligibility (N = 32)
Excluded (n = 7)
Did not meet inclusion criteria (n = 6)
Declined participation (n = 1)
Randomized (n = 25)
Allocation
Allocated to Group 1 (n = 15) Allocated to Group 2 (n = 10)
Received allocated intervention (n = 14) Received allocated intervention (n = 10)
Did not receive allocated intervention (medical Did not receive allocated intervention (n = 0)
reason; n = 1)
Robot-assisted therapy (n = 14) Conventional therapy (n = 10)
1-month break
Conventional therapy (n = 14) Robot-assisted therapy (n = 10)
Received allocated intervention (n = 13)
Did not complete allocated intervention (moved
house; n = 1)
Analysis
Pretest–posttest outcome data (n = 14) Pretest–posttest outcome data (n = 10)
movement, reflex, grasp, and coordination, and has a maximum score of 66. The FMA–UE has an intraclass cor-
relation coefficient (ICC) of .99, interrater reliability of .96, and construct validity of .92 (Platz et al., 2005).
Surface electromyography (EMG; Vinstrup et al., 2018) was used to assess muscle activity. Electrodes were
connected directly to the signal (gain 1000) and transmitted data in real time to a nearby two-channel notebook interface
receiver (Myotrace 400; Noraxon, Scottsdale, AZ). Participants sat in an adjustable chair and placed their forearm on a
table to allow the affected hand to move comfortably. We measured the EMG signal of grip movement in the middle
position without compensatory movement to prevent spasticity. We selected the superficial outer layer finger flexor and
extensor muscles on the forearm. EMG signals were recorded from the brachioradialis and extensor digitorum
communis (EDC) muscles during three tasks: (1) maximal voluntary contraction of grasp-and-release movement
(fisting and opening the hand), (2) grasping a 2-in. (5.08-cm) block in a whole-hand grasp and holding it for 5 s, and (3)
grasping a 1-in. (2.54-cm) small block in a three-jaw chuck and holding it for 5 s. All task movements were performed 3
times. We analyzed the data using the Noraxon software. The data were ratified, smoothed, and normalized to the peak
amplitude value of the maximal voluntary grasp-and-release contraction. The area of the maximal voluntary grasp-and-
release contraction and the mean and peak value of grasping the two blocks were analyzed.
Upper Extremity Sensory Outcomes

To measure light touch, we used a 3.61-mm Semmes–Weinstein hand monofilament (test–retest and interrater re-
liabilities are .71–.79; Arakawa et al., 2012; Bell-Krotoski & Tomancik, 1987). The number of correct responses among
10 trials for each participant was recorded for analysis.
Research Article
Proprioception was assessed with the rNSA Kinesthetic subtest. Using standard procedures, we tested the position
sense of the fingers, wrist, and elbow 3 times each. The interrater reliability for the rNSA ranges from .32 to .57 (Lincoln
et al., 1998). The sum of the scores for each joint for the three trials was recorded.
Hand Function Outcomes

A grip dynamometer (Jamar dynamometer; Asimow Engineering, Santa Monica, CA) was used to measure the
maximum isometric strength of the hand and forearm muscles. The correlation coefficient of the dynamometer is .85,
and the within-instrument reliability is .82 (Hamilton et al., 1992). The mean score of three trials was calculated.
The Box and Block Test (BBT; Chen et al., 2009) was used to measure unilateral gross manual dexterity. The ICC
for the BBT ranges from .85 to .98, and the construct validity is .921 (Platz et al., 2005).
Activities of Daily Living Outcomes

Performance of ADLs was measured with the Modified Barthel Index (MBI). With patients with stroke, its test–retest
reliability (Cronbach’s a) is .84, and its construct validity is high (rs > .92, ICC > .74; Hsueh et al., 2002).
Data Analysis
A power calculation performed for a previous study indicated that 23 participants per group would provide 80%
power with an a of .05 to detect a within-groups difference in FMA–UE scores (Hsieh et al., 2018). The data were
analyzed using IBM SPSS Statistics (Version 20.0; IBM Corp., Armonk, NY). The significance level was set at .05.
Demographic and baseline characteristics were evaluated using a x2 or Mann–Whitney U test.
The sequence and period effects of the clinical data were evaluated first. A Mann–Whitney U test was performed to
evaluate the sequence effect between groups for the RT and CT posttest measures. A Wilcoxon signed-rank test was
performed to evaluate the period effect within groups for the RT and CT posttest measures. A Mann–Whitney U test
was performed between groups for RT and CT treatments, and a Wilcoxon signed-rank test was performed for within
RT and CT treatments if the data did not exhibit a significant period or sequence effect. If the data exhibited a significant
period or sequence effect, we performed a mixed linear model analysis to investigate differences between treatments
at the endpoint. In the intention-to-treat analysis, the last score was used only for the participant who withdrew (see
Figure 1).
Results
Participants
A total of 25 participants were recruited. Two participants in the RT-first group withdrew from the study. One withdrew
during the initial phase for medical reasons; thus, we excluded this participant’s data. The other participant withdrew
before the CT phase as a result of a move; thus, we included this participant’s data and conducted an intention-to-treat
analysis. The final number of participants was 24. No safety concerns or adverse events were related to study
participation. Before treatment, there were no significant between-group differences in demographic, clinical, or EMG
data.
Upper Extremity Sensorimotor Effectiveness

With the exception of EMG data, analysis of the clinical data identified no sequence or period effects. With respect to
motor function, a significant time effect was observed in the RT-first group for proximal (p = .030) and total (p = .046)
FMA–UE scores. Although both groups exhibited partial improvement in scores, nonsignificant time effects were ob-
served for other outcomes, and nonsignificant group effects were observed for all measures (Table 2). With respect to
sensory function, no significant improvement was observed in the light touch assessment for either group. Although
improvement in proprioception was noted, no significant time or group effect was observed (see Table 2).
Research Article
Table 2. Intragroup and Intergroup Comparisons of Pretest and Posttest Clinical Assessment Scores
RT (n = 24) CT (n = 24) p
Outcome Measure M (SD) Intragroup Effect M (SD) Intragroup Effect Intergroup Effect Sequence Effect Period Effect
FMA–UE
Pretest
Proximal 16.54 (9.90) .030* 17.21 (9.74) .965 .757 .796 .871
Distal 3.92 (6.48) .381 4.46 (6.80) .630 .726 .096 .114
Total 20.46 (15.83) .046* 21.67 (15.85) .895 .718 .666 .624
Posttest
Proximal 17.75 (10.05) 17.17 (9.81) .959
Distal 4.29 (6.59) 4.42 (7.26) .849
Total 22.04 (16.22) 21.58 (16.41) .959
BBT
Pretest 2.33 (6.70) .102 2.50 (6.83) .279 .739 .666 .498
Posttest 3.21 (7.85) 2.88 (7.73) .790
Grip strength
Pretest 3.32 (5.76) .550 3.78 (5.03) .753 .676 .259 .286
Posttest 3.58 (5.02) 3.98 (5.27) .598
Light touch
Forearm
Pretest 3.38 (3.13) .231 3.29 (3.43) .697 .916 .403 .439
Posttest 3.08 (3.39) 2.29 (3.22) .313
Hand
Pretest 2.88 (2.77) .793 2.83 (3.27) .614 .729 .841 .317
Posttest 3.04 (3.22) 2.38 (2.98) .429
Proprioception
Elbow
Pretest 6.38 (2.60) .151 5.79 (3.22) .335 .682 .585 .273
Posttest 6.92 (2.28) 6.38 (2.79) .555
Wrist
Pretest 4.33 (3.07) .984 4.00 (3.30) .424 .787 .172 .313
Posttest 4.17 (2.70) 4.38 (3.00) .654
Hand
Pretest 3.08 (2.99) .316 2.96 (2.35) .831 .826 .841 .380
Posttest 3.25 (2.92) 2.75 (2.54) .645
MBI
Pretest 80.63 (15.06) .038* 81.67 (14.04) .071 .925 .096 1.000
Posttest 82.92 (14.59) 83.33 (14.72) .867
Note. p values were calculated according to the Mann–Whitney U or Wilcoxon signed-rank test. BBT = Box and Block Test; CT = conventional therapy; FMA–UE =
Fugl-Meyer Assessment–Upper Extremity; MBI = Modified Barthel Index; RT = robot-assisted therapy.
*p < .05.
The EMG results for both treatment conditions are presented in Table 3. A mixed linear model analysis was
performed to avoid period and sequence effects. A significant group effect was observed for the peak value of the EDC
during Task 3 (the small-block grasping task; p = .05). No significant group effect was observed for the other EMG data.
Hand Function Effectiveness

The mean change in BBT score for the RT-first group was .88, and no significant effect in intragroup (p = .102) or
intergroup (p = .790) comparison was observed. Analysis of grasp strength also did not show a significant intragroup
(p = .550) or intergroup (p = .598) effect (see Table 2).
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Table 3. Intergroup Comparisons of Electromyography Results, by Treatment Condition Activities of Daily

Outcome Period Sequence
M (SD) Living Effectiveness
Measure Effect Effect RT (n = 24) CT (n = 24) p Regarding ADL function, a significant
Task 1 time effect was observed in the MBI
BR .43 .15 481.70 (178.24) 231.77 (130.01) .35 scores of the RT-first group (p =
EDC .25 .68 443.24 (269.92) 172.30 (205.72) .48
.038). No significant time effects were
Task 2
M observed in the CT-first group (p =
BR .15 .45 253.17 (115.40) 109.79 (84.23) .41 .071) or between the groups (p =
EDC .24 .25 68.17 (13.77) 77.68 (10.12) .65 .867; see Table 2). In the RT-first
Peak
group, the items on which participants
BR .90 .61 111.08 (28.24) 99.38 (21.07) .78
EDC .39 .33 48.63 (69.66) 153.49 (51.50) .31 improved the most were stairs (n =
Task 3 8), dressing (n = 5), mobility (n = 3),
M and transfer (n = 3). In the CT-first
BR .29 .76 56.69 (17.01) 74.03 (12.41) .50
group, the items on which partici-
EDC .30 .56 79.45 (32.40) 93.92 (23.71) .09
Peak pants improved the most were
BR .76 .84 111.11 (34.93) 114.73 (25.48) .95 dressing (n = 3), stairs (n = 3), feeding
EDC .14 .73 44.80 (35.57) 150.42 (26.19) .05* (n = 2), and bladder mobility (n = 2).
Note. p values are calculated according to mixed model analysis. Task 1 = maximal voluntary contraction
of grasp-and-release movement; Task 2 = grasping a 2-in. (5.08-cm) block in a whole-hand grasp and
holding it for 5 s; Task 3 = grasping a 1-in. (2.54-cm) small block in a three-jaw chuck and holding it for 5 Discussion
s. BR = brachioradialis; CT = conventional therapy; EDC = extensor digitorum communis; RT = robot- The results of the current study reveal
assisted therapy.
*p < .05. that RT with a Gloreha glove for 12
sessions produced significant im-
provements in upper extremity motor control and ADL ability. Compared with CT-first participants, RT-first participants
had more efficient hand extensor muscles during the small-block grasping task.
Upper Extremity Motor Effectiveness

The FMA–UE results for the RT condition revealed significant improvements in the proximal (shoulder and elbow) and
total scores, consistent with the results of previous studies (Balasubramanian et al., 2010; Hsieh et al., 2018; Hu et al.,
2015; Hu, Tong, Song, Zheng, Lui, et al., 2009; Hu, Tong, Song, Zheng, & Leung, 2009; Lambercy et al., 2011;
Veerbeek et al., 2017). Recovery is more difficult in the distal (hand) than in the proximal part of the UE. Moreover,
participants in this study had severe sensory impairment and low FMA–UE scores. Early finger extension and intact
finger proprioception predict better motor recovery (Rowe et al., 2017; Stinear, 2010). Intensive training to move the
proximal part of the UE in the early stages after a stroke is common; perhaps for this reason, the function of the
participants’ proximal UE was more efficient than that of the distal part. The proximal parts of the upper extremities are
mainly used for stability and transport, and the distal parts are used for object manipulation (Hsieh et al., 2018). Even in
distal hand training, the muscle activity of the proximal UE and coordination between proximal and distal movements
remain necessary (Chae et al., 2000; Dewald et al., 2001; Takeuchi & Izumi, 2012).
Motor Improvement Evaluated Using Electromyography

Compared with the CT condition, results for the RT condition demonstrated a significantly smaller peak (p = .05) and
mean (p = .09) amplitude of the EDC value during the small-block grasping task, which may indicate that grasping
blocks was relatively easy (Sawada et al., 2017). The hand extensor muscle was more efficient in the RT condition
during the small-block grasping task.
Research Article
On the basis of a systematic review, Nordin et al. (2014) reported that kinematic and kinetic measurements are
critical and widely used to provide an objective movement evaluation and to identify reduced dynamic behavior
according to synergy patterns and interjoint (intralimb) coordination. Nordin et al. found that after RT, patients with
stroke showed increased mean and peak speed, thus reducing the additional effort required to perform movements.
These results were associated with the FMA–UE, muscle power, and Motor Status Scale scores.
Hu et al. (2015) conducted 20 robot-assisted wrist rehabilitation sessions, using sensory cues and guidance for
correct muscle use during training. The extensor and flexor muscles were coordinated and movement smoothness was
achieved after robot-assisted rehabilitation (Blank et al., 2014; Hu et al., 2015; Nordin et al., 2014). Thus, improving
hand extensor muscle control could effectively reduce synergistic patterns in people with subacute to chronic stroke
after RT.
Upper Extremity Sensory Effectiveness

Light touch and proprioception were not significantly different between the RT and CT conditions after 12 sessions.
However, proprioception of the elbow improved after RT. Nordin et al.’s (2014) review demonstrated that position sense
improved, but not significantly, among people with subacute to chronic stroke. This finding is consistent with our
results.
The loss of somatosensation affects movement planning and interlimb coordination. Movement planning is at-
tributed to feed-forward sensorimotor control, which influences target attainment strategies including initiation of
movement and initial speed with which a person moves to reach the endpoint. Sensorimotor function has been found to
be significantly correlated with FMA–UE scores (Nordin et al., 2014). This finding is consistent with our results, which
showed that participants’ proprioception of the elbow and FMA–UE scores improved. Interlimb coordination affects the
accuracy of limb positioning during movement and enables functional tasks, such as drinking, to be performed
satisfactorily. Our results also demonstrated that after RT, participants achieved high efficiency during the small-block
grasping task.
Hand Function Effectiveness

We found no significant differences in BBT scores and dynamometer grip strength between the conditions, results that
are inconsistent with those of previous studies (Masiero et al., 2011; Takahashi et al., 2008). The mean total FMA–UE
scores were 20.46 for the RT participants and 21.67 for the CT participants. According to Woytowicz et al. (2017),
scores <28 indicate severe impairment. In that study, 75%, 16.7%, and 8.3% of participants had severe, moderate, and
mild motor impairment, respectively. Our study participants had more severe impairment, which may have influenced
their distal dexterity recovery.
Baseline BBT scores between 20 and 30 are 2–6 times more likely to be followed by clinically significant im-
provements in outcome measures compared with baseline BBT scores of <10 (Hsieh et al., 2014). Only 6 participants in
our study could perform the small-block grasping task, and only 2 had a baseline BBT score of >10. The BBT requires
grasping, transporting, and releasing objects, which require a combination of proximal and distal functional movements
(Kontson et al., 2017). Although the motion of the proximal UE improved among participants in our study, insufficient
distal function made the BBT task difficult.
In other studies (Fischer et al., 2007; Veerbeek et al., 2017), shoulder and elbow robotics exerted small but sig-
nificant effects on muscle strength. Most studies used evaluation tools, such as the Medical Research Council Scale for
Muscle Strength, Motricity Index Arm subscale, and Motor Power Scale (Veerbeek et al., 2017), that are different from
those used in our study. Fischer et al. (2007) reported that improvement may have resulted primarily from developing
new movement strategies or improving proximal arm control rather than from improving finger extension or strength,
consistent with our results.
Research Article
Activities of Daily Living Effectiveness

Participants’ ADL ability improved more after RT than after CT, especially on the Dressing, Mobility, Stair Climbing, and
Chair/Bed Transfer indexes of the MBI. These results are consistent with those of a study of people who received 25 hr
of robot exercise with MIT-MANUS; they experienced positive functional outcomes including increased proximal arm
strength, reduced motor impairment in the shoulder and elbow, and improved ADL function (Volpe et al., 2000).
Proximal hand improvement could transfer to ADL function, and training the arms may improve walking rehabilitation
because of the activation of interneuronal patterning networks after a stroke (Kaupp et al., 2018). However, our results
are inconsistent with those of Norouzi-Gheidari et al. (2012), who used the proximal part of upper extremity robotic
devices. The intervention regions they used for RT (proximal UE) were different from those used in our study (distal UE).
A Cochrane Review by Veerbeek et al. (2017) found that ADL improvement varies by the duration and amount of
training, type of treatment, and differences in patient characteristics. Moreover, after RT, patients with stroke have
shown improved quality of movement as assessed with scales related to ADLs such as the Motor Activity Log and
Stroke Impact Scale (Balasubramanian et al., 2010; Hsieh et al., 2014, 2018). Further study is warranted.
Limitations
This study has several limitations. First, although RT is feasible for people with a broad range of impairments, its
effectiveness appears to be limited for those with the most severe impairments. In one study, the treatment dose ranged
from 13.6 to 26.3 hr (Gassert & Dietz, 2018); ours used only 12 hr. Additional studies are required to determine
whether, depending on the severity of initial motor deficits, more intensive or prolonged RT is required to achieve more
motor improvement. Second, we used a crossover design because of the small sample size, but this design made
clarifying longitudinal effectiveness difficult. Third, our results may have been influenced by the heterogeneity of our
participants, and future studies would benefit from larger samples and cluster analysis.
Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:
n A task-oriented approach combined with use of the Gloreha device can facilitate whole-limb active movement and
efficiently improve functional recovery for people with stroke.
n Improving hand extensor muscle control could effectively reduce synergistic patterns in people with subacute to
chronic stroke after RT.
Conclusion
RT with the Gloreha device can simultaneously facilitate whole-limb UE function and ADL function by means of task-
oriented exercises with tangible objects. This approach can lead to beneficial effects on arm motor function, ability to
perform ADLs, and EDC recruitment efficacy among people with subacute and chronic stroke. Further research based
on intensive and prolonged rehabilitation for patients with severe motor deficits should be considered.
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Hsin-Chieh Lee, MS, is Occupational Therapist, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical
University, Taipei, Taiwan.
Fen-Ling Kuo, MS, is Occupational Therapist, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University,
Taipei, Taiwan.
Yen-Nung Lin, MD, MS, is Physiatrist, Department of Physical Medicine and Rehabilitation, Wan Fang Hospital, and Graduate Institute of Injury
Prevention and Control, Taipei Medical University, Taipei City, Taiwan.
Tsan-Hon Liou, MD, PhD, is Physiatrist, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, and Department of Physical
Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
Jui-Chi Lin, MS, is Occupational Therapist, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University,
Taipei, Taiwan; 08175@s.tmu.edu.tw
Shih-Wei Huang, MD, is Physiatrist, Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, and Department of Physical Medicine
and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
Acknowledgment
Hsin-Chieh Lee, Fen-Ling Kuo, Shih-Wei Huang, and Jui-Chi Lin contributed equally to this study. This research was supported by
the study projects of Taipei Medical University Shuang Ho Hospital (106 SHH HCP-11). The authors thank their colleagues from the
Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, who provided insights and
expertise that greatly assisted the research. The authors thank Wallace Academic Editing for editing the manuscript of this article.

Effects of Robot-Assisted Rehabilitation On Hand Function of People With Stroke: A Randomized, Crossover-Controlled, Assessor-Blinded Study

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Effects of Robot-Assisted Rehabilitation On Hand Function of People With Stroke: A Randomized, Crossover-Controlled, Assessor-Blinded Study

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Research Article

Effects of Robot-Assisted Rehabilitation

Table 1. Participant Characteristics at Baseline reaching, grasping, and transporting objects in a

Figure 1. Flowchart showing ﬂow of participants through the study.

Robot-assisted therapy (n = 14) Conventional therapy (n = 10)

Pretest–posttest outcome data (n = 14) Pretest–posttest outcome data (n = 10)

Upper Extremity Sensory Outcomes

Hand Function Outcomes

Activities of Daily Living Outcomes

Upper Extremity Sensorimotor Effectiveness

Hand Function Effectiveness

Table 3. Intergroup Comparisons of Electromyography Results, by Treatment Condition Activities of Daily

Upper Extremity Motor Effectiveness

Motor Improvement Evaluated Using Electromyography

Upper Extremity Sensory Effectiveness

Hand Function Effectiveness

Activities of Daily Living Effectiveness

Implications for Occupational Therapy Practice

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