# Exercise as it relates to Disease/Robot-assisted training in comparison to conventional training methods in post stroke patients
## Background
### Stroke: Definition

Strokes occur when blood flow is stopped or interrupted to a certain part of the brain. Without the required supply of oxygen and nutrients the cells in that region begin to die. Depending on the region of the brain affected, a stroke can cause paralysis, loss of memory and reasoning ability, speech difficulties, coma’s and even death.
There are two different types of strokes:
* Ischemic Stroke - When a blood clot from a distant blood vessel in the body breaks off, and travels to the brain and blocks a small blood vessel (embolic). There is also a Thrombotic stroke which is caused by atherosclerosis or the blood vessel becomes so narrow that blood cannot pass through it.
* Haemorrhagic Stroke – An intracerebral stroke is caused by the thinning of blood vessel lining causing a blood vessel in the brain to burst. Alternatively there is a subarachnoid stroke which occurs when there is bleeding surrounding the brain (not in the brain tissue).

### Risk Factors

A stroke often occurs secondary to a primary health issue. There are risk factors that can increase likelihood of a stroke occurring as well as non-preventable factors. These are the different risk factors associated with strokes:
| Preventable Factors | Non-Preventable Factors |
| * Obesity and physical inactivity * Poor diet * Alcohol consumption and Smoking * Diabetes | * Age * Race and gender * Family History |

### Prevalence: Importance of improved rehabilitation techniques.

Stroke is the largest cause of severe disability and considered to be the leading cause of serious, long-term disability. In the referenced study, it found that stroke is are twice as disabling as musculoskeletal disorders. There is an increasing effort towards developing rehabilitation methods that decrease the length of stay of inpatients and the burden on public health care. There is a current emphasis on the development of robot assisted training programs to help rehabilitate stroke patients and decrease prospective length of stay.

## Rehabilitation: Conventional Rehabilitation vs. Robot-assisted training
### Comparison

Current rehab methods include resistance based strength programs with an emphasis on repeated movement patterns to assist in re-educating the patients brain. The researched study has a specific focus on upper limb therapy techniques. The validity of using a robot-assisted training program is evident as other studies have shown highly repeated and stereotyped movements are effective in rehab when external forces or neuromuscular stimulation are applied to the effected limb to help facilitate movement patterns.

### Testing measures

* Function: This was assessed using a Fugl-Meyer test which is a valid and reliable test using light touch and proprioception at the arm, hand, and wrist.
* Strength: A strength designed force platform was used to assess elbow flexion and extension, shoulder flexion and extension, shoulder abduction and adduction, and shoulder internal and external rotation. Considerations such as anthropometry were taken into account and there was a comparison to the non-effected arm to help assess overall power.
* Reach: Patients in both groups were given target to reach to which assessed their overall reach. Targets were placed at locations that corresponded to a tabletop, shoulder level and the reaching directions used in the robot training. the target were placed far enough away so that the test did assess the total reach capacity of each patient.

### Robot assisted training vs. Conventional rehabilitation

Compared with conventional treatment of equal intensity and duration, the robot-assisted movements program had significantly better increases in all parameters after 2 months of treatment in terms of decreasing impairment, improving strength, and increasing reach. The immediate increase in function, strength and reach was evident in the robot-assisted program however after 6 months both groups achieved similar test results. There is a direct correlation between a robot-assisted therapy approach and decreasing prospective length of stay for patients in the healthcare system.
A comparison of the measures used in the two test groups can be found in the link on page 5:
* Strength Comparison Graph http://www.archives-pmr.org/article/S0003-9993(02)00011-4/pdf

## Evidence for implementation

There is evidence to suggest that the robot-assisted training will help to decrease prospective length of stay. The robot-assisted training group increased in all aspects (Strength, Reach & Function) which further supports the implementation of these programs into the health care systems.

## References

* ↑ R. Sacco, S Kasner, et, al. (2013), An Updated Definition of Stroke for the 21st Century, American Association of Neurological Surgeons and Congress of Neurological Surgeons, Pg 2.
* 1 2 3 World Health Organization (2005). WHO STEPS Stroke Manual: The WHO STEPwise approach to stroke surveillance. Geneva, World Health Organization.
* ↑ J. Adamson, A. Beswick, S. Ebrahim, (2004). Is Stroke the Most Common Cause of Disability? Journal of Stroke and Cerebrovascular Diseases, Vol. 13, No. 4. Pg 174.
* 1 2 3 4 5 6 7 8 9 P. Lum, C. B. (2002). Robot-Assisted Movement Training Compared With Conventional Therapy Techniques for the Rehabilitation of Upper-Limb Motor Function After Stroke. Arch Phys Med Rehabil Vol 83
* ↑ H. Feys, W. De Weerdt, et, al. (1998), Effect of a Therapeutic Intervention for the Hemiplegic Upper Limb in the Acute Phase After Stroke, American Heart Association, Inc. Pg 785-788.
* ↑ J. Powell, D. Pandyan,(1999), Electrical Stimulation of Wrist Extensors in Post-stroke Hemiplegia, American Heart Association, Inc. Pg 1384-1388.
* ↑ AR. Fugl-Meyer , L. Jaasko, I. Leyman, S. Olsson, S. Steglind,(1975), The post-stroke hemiplegic patient, A method for evaluation of physical performance, Scand J Rehabilitation Med. Pg 13-31.