Effects of Robotic Rehabilitation in Post-Stroke Patients

Study Overview
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Brief Summary
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This study aims to evaluate the effect of robotic rehabilitation through training on a robot-assisted orthostatic board and neuromuscular electrical stimulation (NMES) on functionality in post-stroke patients. In this randomized controlled trial the patients will be allocated to a control group (which will receive conventional physiotherapy) or or to intervention group (which will receive conventional physiotherapy and robotic rehabilitation). Interventions will occur every day in the hospital phase and three times/week after discharge, totaling 18 sessions.The groups will be evaluated prior to any physiotherapy intervention, in the 10h session and at the end of six weeks of treatment (or 18 sessions).The following outcomes will be measured: functionality, peripheral muscle strength, muscle architecture and echogenicity, spasticity, cardiorespiratory repercussions, mobility, disability and dependence, quality of life and time of hospital stay.

Official Title
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Effects of Robotic Rehabilitation in Post-Stroke Patients: A Randomized Controlled Trial

Conditions
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Stroke

Intervention / Treatment
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* Device: Intervention group (Robotic rehabilitation)
* Other: Control group (Conventional physiotherapy)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Medical diagnosis of ischemic stroke, in the subacute phase (after 48 hours); To present hemiparesis or muscle weakness defined by the Medical Research Council (MRC) score; To understand simple commands and being able to report signs of discomfort. Exclusion Criteria: Severe psychomotor agitation; Recent acute myocardial infarction (24 hours) and/or uncontrolled arrhythmias; Intracranial hypertension (PIC> 20mmHg); Uncontrolled hypertension (PAS> 230 mmHg and PAD> 120 mmHg) or PAM <60 mmHg; Decompensated heart failure; To present important hemodynamic changes during training; Peripheral vascular disease in the lower limb such as untreated deep vein thrombosis; Unconsolidated fractures or severe joint pain; Feverish state; Smokers; Epidermal lesions on the thighs that make it impossible to place self-adhesive electrodes for electrical stimulation; Pre-existing neuromuscular disease; Signs of rhabdomyolysis; Pregnancy.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Robotic rehabilitation<br>Robotic rehabilitation with Erigo® equipment (Hocoma, Volketswil, Switzerland). | Device: Intervention group (Robotic rehabilitation)<br>* Robotic rehabilitation with Erigo® equipment (Hocoma, Volketswil, Switzerland). The training protocol has a progression of the board inclination up to 90º associated with flexion/extension movements of the knees and hips, with time evolution of up to 40 minutes. Such equipment is associated with electrostimulation of the quadriceps, hamstrings, sural triceps and anterior tibialis.<br>* Other names: Erigo®;|
| Active Comparator: Conventional physiotherapy<br>The protocol will be based on lower limb exercises, aiming at maintaining and gaining muscle strength through passive, assisted or active mobilization, when possible, on the affected side. | Other: Control group (Conventional physiotherapy)<br>* Knee and hip flexion and extension movements, hip adduction, and abduction, respecting the articular physiology of each joint. Weight transfer will also be performed in the sitting and standing position, mini squat, and gait training. All exercises will have a total of 10 repetitions in three sets. In the end, stretching of the upper and lower limbs will be performed.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Functionality | The change in functionality will be assessed using the Fugl-Meyer Scale. This scale consists of six domains: range of motion, pain, sensitivity, motor function of the upper and lower extremities, balance, coordination and speed. The score for each item ranges from 0 to 2, where 0 = cannot be performed; 1 = partially accomplished; 2 = completely accomplished. The total score ranges from 0 to 266 points and the higher the score the better the functionality. | Baseline, after 3 weeks and after 6 weeks | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Muscle strength | The change in muscle strength will be assessed by the Medical Research Council (MRC) scale and by test of maximum repetition (1RM) | Baseline, after 3 weeks and after 6 weeks. | 
| Quadriceps muscle thickness | The change in quadriceps muscle thickness will be evaluated for the acquisition of ultrasound images using a high resolution ultrasound device (Vivid-i, GE, USA). In order to verify the thickness of the muscle, the distance between the superficial and deep aponeurosis is measured.The thickness is given in centimeters. | Baseline and after 6 weeks | 
| Echogenicity of the rectus femoris muscle | The change in echogenicity will be evaluated for the acquisition of ultrasound images of the rectus femoris muscle using a high resolution ultrasound device (Vivid-i, GE, USA). To check the echogenicity of the rectus femoris an image of the cross-sectional area of the muscle will be taken. The echogenicity measurement is given in an arbitrary unit. | Baseline and after 6 weeks | 
| Spasticity | The change in spasticity will be assessed by the Modified Ashworth Scale. This scale consists of an ordinal classification of 5 points for grading the resistance found during passive stretching, with 0 indicating normal muscle tone and 4 severe increase in tone. The higher the score, the greater the spasticity. | Baseline, after after 3 weeks and after 6 weeks | 
| Mobility | The change in mobility will be assessed using the Timed Up and Go test (TUG), which will be associated with an inertial sensor | After 3 weeks and after 6 weeks | 
| Disability and dependence | The change in disability and dependency will be assessed using the Modified Rankin Scale. This instrument has 6 scores, where: 0 = asymptomatic; 1 = symptoms without disabilities; 2 = mild disability; 3 = moderate disability; 4 = moderate to severe disability; 5 = severe disability and 6 = death. The higher the score, the greater the degree of disability and dependence. | Baseline and after 6 weeks | 
| Quality of life indicator | The change in quality of life will be assessed using the EuroQol-5D questionnaire. This is a generic instrument that assesses mobility, personal care, usual activities, pain and anxiety/depression. It allows to generate a global index of the value of an individual's health status. The number 1 indicates the best state of health (perfect health) and 0 the worst state of health (death). | Baseline and after 6 weeks | 
| Heart rate | Heart rate will be assessed by pulse oximetry | From the 1st to the 18th day/session | 
| Peripheral arterial oxygen saturation | Peripheral arterial oxygen saturation will be assessed by pulse oximetry | From the 1st to the 18th day/session | 
| Systolic blood pressure | Systolic blood pressure will be assessed through sphygmomanometer | From the 1st to the 18th day/session | 
| Diastolic blood pressure | Diastolic blood pressure will be assessed through sphygmomanometer | From the 1st to the 18th day/session | 
| Muscle pain | Pain perception will be assessed using the Visual Analog Scale. This scale ranges from 0 to 10, where 0 indicates no pain and 10 maximum pain. | From the 1st to the 18th day/session | 
| Lower limb fatigue | Lower limb fatigue will be assessed by Borg effort subjective perception scale. This scale ranges from 0 to 10, where 0 indicates no effort or fatigue and 10 indicates maximum effort. | From the 1st to the 18th day/session | 
| Time of hospital stay | The days between admission and hospital discharge will be counted | From the 1st to the last day of hospitalization | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Stroke, Robotics, Electric stimulation