Evidence reviews for robot-assisted arm training

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Evidence reviews for robot-assisted arm training

Stroke rehabilitation in adults (update)

Evidence review M

NICE Guideline, No. 236

London: National Institute for Health and Care Excellence (NICE); 2023 Oct.

ISBN-13: 978-1-4731-5462-9

1. Robot-assisted arm training

1.1. Review question

In people after stroke, what is the clinical and cost effectiveness of robot-assisted arm training in improving function and reducing disability?

1.1.1. Introduction

Robot assisted arm training is an intervention which allows people with arm weakness following stroke to perform repetitive functional tasks with the aim of improving strength and function. Repetitive functional task practice is known to help recovery following stroke and robot assisted arm training is a potential mechanism to increase the intensity and frequency of rehabilitation. In previous guidance, robot assisted arm training could only be recommended in the context of a clinical trial and it is important to understand whether recent evidence might support its use as an intervention or adjunct to improve arm recovery.

In current clinical practice, robot assisted arm training is not widely available. New technologies are being developed which are potentially more accessible to both in hospital and community services. It is not yet understood the extent to which robot assisted arm training could benefit arm recovery, or indeed whether use of robots may potentially cause harm to the weaker arm following stroke. In addition, there are discrepancies around the use of this technology regarding whether it can be used independently or requires supervision by health care professionals.

Implementation of robot assisted arm training will require investment in training and equipment in the majority of services and review of evidence is necessary to understand both the effectiveness and cost effectiveness of its implementation within stroke rehabilitation services.

1.1.2. Summary of the protocol

Table 1

PICO characteristics of review question.

For full details see the review protocol in Appendix A.

1.1.3. Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in Appendix A and the methods document.

Declarations of interest were recorded according to NICE’s conflicts of interest policy.

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

One systematic review⁷⁹ and in total eighty-one randomised controlled trial studies (one hundred and five papers) were included in the review¹^–⁵^, ⁸^–¹¹^, ¹⁴^–²⁰^, ²³^, ²⁴^, ²⁶^, ²⁷^, ³⁰^, ³³^–³⁶^, ³⁸^–⁴¹^, ⁴³^–⁵⁰^, ⁵³^–⁵⁸^, ⁶¹^, ⁶²^, ⁶⁴^–⁶⁸^, ⁷²^–⁷⁴^, ⁷⁷^, ⁸²^, ⁸⁴^–⁸⁸^, ⁹⁰^, ⁹²^–¹⁰⁶^, ¹⁰⁹^–¹¹²; these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 3).

This review updated a previous Cochrane review, Mehrholz 2018⁷⁹. This review included forty-five trials from up to January 2018. A search from January 2018 was completed and an additional thirty trials were added to the review¹^, ⁵^, ¹⁰^, ¹⁴^–¹⁹^, ²⁶^, ²⁷^, ³⁴^, ³⁶^, ⁴⁵^, ⁴⁶^, ⁴⁹^, ⁵⁰^, ⁵⁴^, ⁵⁵^, ⁵⁸^, ⁸⁴^, ⁸⁶^–⁸⁸^, ⁹²^, ⁹³^, ⁹⁷^, ¹⁰³^, ¹¹⁰^, ¹¹². This included six cross-over trials (of which only the first phase was included in the analysis as per the Cochrane review protocol)³^, ⁹^, ¹⁶^, ⁴⁰^, ⁴⁹^, ⁷⁴.

Trials included comparisons of robot assisted arm therapy to any other intervention (including usual care/conventional rehabilitation, no treatment and other interventions. All comparisons have been pooled for the analysis as in Mehrholz 2018⁷⁹.

Robot assisted arm training was usually offered alongside conventional rehabilitation exercises or in two studies as a combination with other therapies (including botulinum toxin A injection and functional electrical stimulation).

Studies included a range of robotic devices which performed different movement types (including active, active/assisted, passive or a combination) and which targeted different parts of the joint (for example: proximal or distal). The type of movement and the region of the limb trained was poorly reported in many studies, but the majority of the robotic devices provided a combination of passive and active assisted movements and trained both the proximal and distal limb to perform tasks such as reaching and grasping. Nearly all of the trials reported supervised robot assisted arm training and the healthcare professional delivering the therapy was most commonly an occupational therapist or physiotherapist.

The people included in the studies were from a mixture of time periods after stroke, being split between subacute and chronic periods. However, the majority of studies included people in the subacute phase post stroke.

Indirectness

7 outcomes were downgraded for indirectness due to outcome indirectness arising from a short follow up duration. Specifically, any outcomes reported after the post intervention follow up were included in the ≥6 month follow up category and if these were reported at less than 6 months they were downgraded.

Inconsistency

A number of outcomes showed significant heterogeneity. In each case, this was not resolved by sensitivity or subgroup analyses and so random effects models were used, and the outcomes were downgraded for inconsistency.

See also the study selection flow chart in Appendix C, study evidence tables in Appendix D, forest plots in Appendix E and GRADE tables in Appendix F.

1.1.4.2. Excluded studies

See the excluded studies list in Appendix J.

1.1.5. Summary of studies included in the effectiveness evidence

Table 2

Summary of studies included in the evidence review.

See Appendix D for full evidence tables.

1.1.6. Summary of the effectiveness evidence

Table 3

Clinical evidence summary: Robot-assisted arm training compared to any other intervention.

See Appendix F for full GRADE tables.

1.1.7. Economic evidence

1.1.7.1. Included studies

Two health economic studies with the relevant comparison were included in this review.³¹^,⁴⁹ These are summarised in the health economic evidence profile below (Table 4) and the health economic evidence tables in Appendix H. Note that one study,³¹ as well as the RCT⁸⁸ that formed the basis of the analysis are also included as part of the evidence review for this guideline that assessed the clinical and cost-effectiveness of more intensive rehabilitation.

1.1.7.2. Excluded studies

No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in Appendix G.

1.1.8. Summary of included economic evidence

Table 4

Health economic evidence profile: Robot-assisted arm training versus usual care.

1.1.9. Economic model

This area was not prioritised for new cost-effectiveness analysis.

1.1.10. Unit costs

Relevant unit costs are provided below to aid consideration of cost effectiveness.

The main additional resource use of robot-assisted arm training is the cost of the robotic device. The studies included in the clinical review used different robots. The RATULS RCT (Rodgers 2019⁸⁸), conducted as part of the Health Technology Assessment (HTA) programme, provided UK costs associated with the MIT-Manus robotic gym. This included the initial capital investment and maintenance fees. Costs associated with a trial centre’s estate and facilities were included in the salary costs of the staff delivering the therapy, and so are not incorporated in the robotic device costing below (staff costs were incorporated in the cost effectiveness analysis above however). No additional storage facilities were identified as the robotic gyms were installed in the therapy room. The allocation of these capital costs was conducted following the ‘equivalent annual cost’ methodology by Drummond 2005²⁸. This method allowed for the initial capital cost to be converted into an annual sum that equals the resources invested plus their opportunity cost.

The equivalent annual cost of each robot session was calculated under the following assumptions:

Robot usage: 35 average number of sessions per week (seven sessions held on an 8-hour day). Weeks per year that the MIT-Manus robotic gym system is in use: 52 weeks.
Useful lifespan of the MIT-Manus robotic gym system is 5 years.
Training costs are not included as they are not considered to drive any differences in costs between randomisation groups.
The capital cost of the robotic gym was spread over its lifespan (5 years).
A discount factor of 3.5% was applied to account for the individual’s time preference for costs to be incurred later rather than sooner. This follows guidance for best practice.

Tables 5 and 6 illustrate this method, incorporating the initial purchasing cost of £1,000,000 for the MIT-Manus robotic gym and £15,000 annual fees.

Table 5

Equivalent annual cost or equivalent annuity from Rodgers 2019.

Table 6

Illustrative cost of the MIT-Manus robotic gym per session from Rodgers 2019.

Resource use varied across studies included in the clinical review due to the following factors:

Variation in the frequency and duration of training time with the robot-assisted device, with sessions ranging from 20 minutes to 60 minutes, not including time spent receiving conventional rehabilitation therapy. In some instances, robot-assisted arm training added more intervention time, and, in these cases, there would be additional staff time costs. Sessions mostly occurred 3-5 days per week. In the included clinical studies, the interventions were delivered for between 2 weeks and 9 weeks and had follow-up periods from 3 weeks up to 8 months.
A small number of studies included other interventions being given with robot-assisted training (such as neuromuscular, transcranial and functional electrical stimulation) which would also be an additional cost.
Training was primarily supervised by a member of the rehabilitation team, such as occupational therapists and physiotherapists. However, one study from the clinical review (Budhota 2021^10xxx) reported that the training was minimally supervised by occupational therapists as well as bioengineers. Rodgers 2019⁸⁸ reported that therapists and therapy assistants delivered interventions.
The level of supervision differed across studies as well. Most studies were reported to have participants supervised by therapists, however, Hesse 2005³⁹ reported that while patients were left unsupervised during the training, a therapist remained ‘within shouting distance’ in case of problems and Housman 2009⁴¹ reported mixed supervision, where the first three sessions were supervised before offering intermittent supervision for the remaining sessions. Remy-Neris 2021⁴⁹ assessed a similar approach, where a therapist was present during the first 4 sessions but for the remaining sessions, the therapist set the patient up in the device, adjusted the device parameters, and programmed the exercises, but the participant then trained independently.
Additional resource use required as part of the intervention, such as staff-training costs.

Table 7

Unit costs of health care professionals who may be involved in delivering robot-assisted arm training interventions.

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

One cost-utility analysis found that robot-assisted arm training plus usual care was dominated (higher costs and lower QALYs) by usual care alone for people following a stroke. This analysis was assessed as directly applicable with potentially serious limitations.
One cost-utility analysis suggested that for people following stroke, usual rehabilitation plus an additional hour of games-based self-rehabilitation using an exoskeleton incurred lower costs and higher QALYs compared to usual rehabilitation alone, however total costs and QALY gains were not statistically significant between groups. This analysis was assessed as partially applicable with potentially serious limitations.

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

The committee included the following outcomes: person/participant generic health-related quality of life, carer generic health-related quality of life, activities of daily living, arm function, arm muscle strength, spasticity, stroke-specific Patient-Reported Outcome Measures, withdrawal for any reason and adverse events (including cardiovascular events, injuries and pain and other reported adverse events). All outcomes were considered equally important for decision making and therefore have all been rated as critical.

This review updated a published Cochrane review⁷⁸. Therefore, the outcomes used in this review are the same as those reported in the Cochrane review with the inclusion of four additional outcomes which were agreed by the guideline committee: person/participant and carer generic health-related quality of life, stroke-specific Patient-Reported Outcome Measures and spasticity. Person/participant and carer generic health-related quality of life outcomes were added to this review as they are important outcomes for understanding the holistic impact of the treatment and to further understanding of the economic considerations. Similarly, stroke-specific Patient-Reported Outcome Measures were added as these provide insight into how the interventions affect the persons functional abilities or quality of life. The spasticity outcome was added as the committee deemed it important given the nature of the intervention and as previous research has highlighted increases in spasticity as a potential adverse effect of robot assisted therapy.

The committee chose to investigate these outcomes at post intervention and at more than and equal to 6 months follow up period as they considered that there could be a difference in the short-term and long-term effects of the intervention.

There was a large amount of evidence available for the majority of the outcomes at both follow up time points with the number of studies reporting each outcome ranged from 2 to 66. Evidence was more limited for person/participant health-related quality of life and cardiovascular adverse events, but there was sufficient evidence available for the committee to make a recommendation.

1.1.12.2. The quality of the evidence

Seventy-five randomised controlled trial studies were included in the review including six crossover RCTs (in which only the first phase was analysed as a parallel trial). Evidence was available for robot assisted arm training compared to any other intervention (including usual care, placebo and no treatment) at post-intervention and after 6 months follow up periods. Results from studies that compared robot assisted arm training to any of the above interventions were pooled together in the analysis as this was the method employed by the Cochrane review.

The evidence varied from high to very low quality, with the majority being of very low quality. Outcomes were commonly downgraded for risk of bias, inconsistency, indirectness and imprecision. Risk of bias was rated as a concern in the majority of the studies. This was generally due to bias in the randomisation procedure, bias arising due to deviations from the intended interventions, bias in the measurement of the reported result and bias arising from missing outcome data.

Inconsistency was present in many of the outcomes due to the large number of studies and the heterogeneity in the included evidence which reported different time periods post-stroke, doses of the intervention and sample sizes. Heterogeneity was investigated with sensitivity analyses and the pre-specified subgroup analyses. None of the analyses resolved the heterogeneity so these outcomes were downgraded for inconsistency. In several cases the heterogeneity was deemed to be due to differences in the study sample sizes (specifically Rodgers 2019 had a much larger population than any others in the review). Therefore, to avoid over emphasising the effects of the smaller unblinded studies in the analysis a fixed effects analysis was employed for these outcomes rather than using a random effects model.

Seven outcomes were downgraded due to outcome indirectness arising from a short follow up duration. As detailed in the protocol, any outcome reported after the post intervention follow up (and at the longest available follow up time point) was included in the more than and equal to 6 months follow up category. However, if these outcomes were reported at less than 6 months they were downgraded for indirectness. Imprecision was seen in several outcomes due to small sample sizes and uncertainty around the effect estimate.

The committee concluded that the evidence was of a sufficient quality to make recommendations. The committee noted that studies took place in a wide range of countries worldwide which in some of cases may limit applicability to the NHS. One lay member also voiced their concern that a number of studies have been funded by the manufacturers which may introduce further bias in these studies. However, a large multi-site NIHR funded study (⁸⁸) recently took place in the UK which included a health economic analysis. This study reported many of the outcomes included in this review and was of low risk of bias. Therefore, the committee gave this study greater consideration in their decision making.

1.1.12.3. Benefits and harms

The results showed that when robot assisted arm training was compared to any other intervention an inconsistent effect was seen. There was a clinically important benefit in some outcomes and no clinically important difference in other outcomes in arm function at more than and equal to 6 months and arm muscle strength at end of intervention and more than and equal to 6 months. An unclear effect where some outcomes showed a clinically important benefit, some no clinically important difference and one a clinically important harm was also seen in stroke-specific Patient-Reported Outcome Measures at end of intervention.

No clinically important difference was seen in person/participant generic health-related quality of life at end of intervention, arm function at end of intervention, spasticity at end of intervention and more than and equal to 6 months, stroke-specific Patient-Reported Outcome Measures at more than and equal to 6 months, withdrawal for any reason at end of intervention and more than and equal to 6 months and adverse events (including cardiovascular events, injuries and pain and other reported adverse events) at end of intervention and more than and equal to 6 months.

An inconsistent effect where some outcomes showed no clinically important difference and some showed a clinically important harm was seen in person/participant generic health-related quality of life at more than and equal to 6 months. The committee acknowledged that where there was evidence that robot arm therapy was worse than any other intervention at improving quality of life, this was based on evidence from the Rodgers 2019⁸⁸ study, which was a large RCT in which the 2 comparison groups (an enhanced upper limb therapy intervention and usual care) were combined for the analysis. The committee considered the fact that the enhanced therapy group received regular one on one, face-to-face physiotherapy treatment which seemed to be more intensive than the usual care provided in other studies. Hence, the committee suggested this may explain the benefit for the other interventions arm for this outcome. Furthermore, when the robot assisted arm training arm was compared to the usual care arm alone the results showed a small benefit for robot therapy in the post-intervention follow-up and no difference at more than and equal to 6 months.

The committee acknowledged the benefits reported for several of the arm muscle strength outcomes and concluded that robot assisted arm training may be appropriate for improving muscle strength alone. However, this does not appear to translate to functional gains, improvements in activities of daily living and ultimately in the person’s quality of life. These outcomes may be more important to the holistic wellbeing of the person and was considered in their deliberation. However, the committee agreed that improving upper limb strength may reduce pain and improve joint stability. Therefore, they suggested that these devices may be appropriate for strength training in a specific subset of patients who present with a motor deficit and in whom upper limb strengthening is the main goal of treatment. These findings were echoed in the experiences of one lay member who had used a robotic device during his rehabilitation and suggested that although it may have helped improve his strength in the short term it did not seem to have any lasting positive effects on his function.

The committee also discussed the results of the Rodgers 2019⁸⁸, study which found greater improvements in the enhanced upper limb therapy group when compared to the robot-assisted arm training group for many outcomes. This enhanced therapy arm included face-to-face functional task training delivered by a physiotherapist which was matched for time with the robot therapy arm. Based on these findings the committee argued that more intensive physiotherapy for the upper limb seems to be more effective than additional therapy delivered by the robot device. This view was supported by the lay members who preferred therapy sessions delivered by physiotherapists rather than ‘being left alone with a machine’. One lay member suggested that the personal relationships formed with the physiotherapist are crucial for building trust and increasing motivation to engage in therapy sessions. They also noted that technical issues with the devices along with time spent explaining and setting up the devices wasted valuable therapy time.

On reviewing the evidence, the committee considered the balance of benefits and harms and the large amount of evidence reporting no clinically important difference. Ultimately, they agreed that the evidence did not support a recommendation for the use of robot-assisted arm training. The committee were satisfied by the amount of evidence available and noted that the evidence encompassed a wide range of robotic devices performing different types of movement at different doses and in subacute/chronic time periods post stroke. Therefore, they did not feel that a research recommendation was necessary.

Despite the lack of evidence in support of robot assisted arm training there was also no evidence reporting a harm of the device. Therefore, the committee agreed that if services already have access to a robot device there is no clinical reason why they should avoid using it in specific circumstances (for example: people after stroke who present with upper limb motor problems in whom the main treatment goal is to improve upper limb strength). However, the overall clinical benefit of a sole improvement in muscle strength was unclear as there was no evidence to suggest that overarching outcomes which may be more important to people after stroke, such as quality of life, would be improved and there would be resource use implications. This time could also be used by a therapist for other therapy that may be able to achieve greater benefits in other areas that may impact quality of life more. Taking into account these factors, and the cost effectiveness evidence, the committee concluded that robot-assisted arm training should not be offered as part of an upper limb rehabilitation program.

1.1.12.4. Cost effectiveness and resource use

Two health economic analyses were identified for this review. The first study included in the review was a within-trial cost-utility analysis of an RCT included in the clinical review, which compared usual rehabilitation (1 hours, 5 days per week for 4 weeks) plus an additional daily hour of self-rehabilitation , consisting of basic stretching and active exercises for the control group versus usual rehabilitation plus an additional daily hour of self-rehabilitation consisting of gravity-supported, games-based training using an exoskeleton (Armeo®Spring). The results suggested that the Exo group intervention dominates usual care (lower costs and higher QALYs), however total costs and QALY gains were not statistically significant between groups. The study conclusions were shown to be robust following a probabilistic sensitivity analysis. The analysis was assessed as partially applicable as the study was set in the French healthcare system which may not reflect the current UK NHS context. In addition, the French population valuation tariff was used to estimate QALYs, but NICE reference case specifies that the UK tariff is preferred. Potentially serious limitations were identified as the study was a within-trial analysis of a single RCT which meant the results only reflect this study and not the wider evidence based identified in the clinical review. References for unit costs were not reported either which further limits the interpretation of the results for a UK context.

The second study was also a within-trial cost-utility analysis of a UK RCT included in the clinical review, where participants were randomised to one of three programmes over a 12-week period: usual care (45 minutes with a physiotherapist or occupational therapist, 5 days a week); robot-assisted training (45 minutes per day, 3 times per week) plus usual care or the EULT programme (45 minutes with a physiotherapist, 3 times per week) plus usual care. The results found that robot-assisted arm training was not cost-effective, as it incurred higher overall costs than both usual care and EULT, primarily due to having higher intervention costs. In addition, robot-assisted training was not associated with higher QALYs than usual care and resulted in lower QALYs than EULT.

There was low uncertainty in this conclusion. Note the conclusions about the EULT intervention are discussed in the intensity of rehabilitation evidence report. The analysis was assessed as directly applicable with minor limitations. Although it is a within-RCT analysis and so only reflects the results of this study, the RCT was a large, recent, NIHR funded, UK-based study that was considered highly applicable by the committee. In addition, while it had a limited follow-up period, sensitivity analyses that extrapolated the trial data to a 12-month time horizon did not change the study conclusions regarding robot arm training.

The committee were also presented with intervention costs from the NIHR study, which incorporated capital and maintenance costs for the robot as well as physiotherapy time to supervise the training. The estimated cost per session of the robot was £41 (assuming the robot is used for an average of 35 session per week for 52 weeks per year with capital costs spread over 5 years). This incorporated an initial purchase cost of £1,000,000 and £15,000 annual fees. Physiotherapy time with robot-assisted training was the same as for EULT and higher than usual care. The committee noted that they were unsure if people would receive supervision from a physiotherapist for the entire duration of robot-training if this was provided in clinical practice. Less staff supervision would suggest lower intervention costs than what is reported in the analysis but given that there wasn’t an increase in QALYs with robot-arm training it would still not be cost-effective in this case. It is also unknown if less supervision would affect clinical outcomes. The committee also highlighted that storage and space to use the devices in an NHS setting would likely be an issue. Costs related to this were not captured in the NIHR study as it was possible to install the robot in existing therapy rooms, however the committee did not think this would always be possible.

The committee stated that robot arm training is not commonly used in current practice, however it was noted that a few UK hospitals currently own a robot-training machine. They discussed that even where machines were already available there would be ongoing maintenance costs and use would require staff time for supervision of the intervention (and machines would ultimately need replacing if use continued). In addition, it was noted that if machines were only used in a small subset of patients and so could not be used to full capacity this may increase the cost per use and so overall intervention costs. The committee also highlighted that time was also required for setting-up the machine for each use and to teach the person how to use it. Staff training costs to use the machine may also be incurred. For these reasons the committee agreed that there would be a significant resource impact associated with robot arm training and alongside the limited clinical evidence the committee concluded the robot arm training was not cost-effective for the NHS and made a ‘do not offer’ recommendation.

1.1.13. Recommendations supported by this evidence review

This evidence review supports recommendation 1.13.18.

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Appendices

Appendix I. Health economic model

Health economic modelling was not undertaken for this review.

Appendix J. Excluded studies

Clinical studies

Table 11Studies excluded from the clinical review

Study	Code [Reason]
(2020) Correction…McCabe J, Monkiewicz M, Holcomb J, et al. Comparison of Robotics, Functional Electrical Stimulation, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction After Stroke: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation. 2015;96(6):981-990. Archives of Physical Medicine & Rehabilitation 101(4): 730–730 [PubMed: 25461822]	- Correction only
(2019) Does emg-driven robotic treatment have effect for the recovery of the hand 9 years after stroke?. Gait & Posture 73: 362–363	- Full text paper not available
Adamovich, S. V. (2018) Robot assisted virtual rehabilitation for the hand post stroke (RAVR).	- Full text paper not available
Adomaviciene, A., Daunoraviciene, K., Kubilius, R. et al. (2019) Influence of New Technologies on Post-Stroke Rehabilitation: A Comparison of Armeo Spring to the Kinect System. Medicina 55(4): 09 [PMC free article: PMC6524064] [PubMed: 30970655]	- Comparator in study does not match that specified in this review protocol
Aguiar, L. T., Nadeau, S., Martins, J. C. et al. (2020) Efficacy of interventions aimed at improving physical activity in individuals with stroke: a systematic review. Disability & Rehabilitation 42(7): 902–917 [PubMed: 30451539]	- Systematic review used as source of primary studies
Akcay, S, Karagozoglu, Coskunsu D, Erkan, Ogul O et al. (2020) The effect of robotic rehabilitation for recovery of hand functions in patients with acute stroke: Pilot study. Gait and Posture 81(s1): 6–7.	- Conference abstract
Ambrosini, E., Gasperini, G., Zajc, J. et al. (2021) A Robotic System with EMG-Triggered Functional Eletrical Stimulation for Restoring Arm Functions in Stroke Survivors. Neurorehabilitation & Neural Repair 35(4): 334–345 [PubMed: 33655789]	- Study does not contain an intervention relevant to this review protocol
Anonymous (2020) Correction: Comparison of Robotics, Functional Electrical Stimulation, and Motor Learning Methods for Treatment of Persistent Upper Extremity Dysfunction After Stroke: A Randomized Controlled Trial (Archives of Physical Medicine and Rehabilitation (2015) 96(6) (981-990), (S0003999314012283), (10.1016/j.apmr.2014.10.022)). Archives of Physical Medicine and Rehabilitation 101(4): 730	- Correction only
Arya, K. N.; Pandian, S.; Puri, V. (2018) Rehabilitation methods for reducing shoulder subluxation in post-stroke hemiparesis: a systematic review. Topics in Stroke Rehabilitation 25(1): 68–81 [PubMed: 29017429]	- Systematic review used as source of primary studies
Bajaj, P. and Contractor, A. (2022) EFFICACY OF UPPER EXTREMITY ROBOTIC REHABILITATION IN ADDITION TO CONVENTIONAL REHABILITATION IN FUNCTIONAL IMPROVEMENT IN CHRONIC STROKE IN A TERTIARY CARE HOSPITAL IN INDIA. International Journal of Stroke 17(3supplement): 127	- Conference abstract
Baniqued, P. D. E., Stanyer, E. C., Awais, M. et al. (2021) Brain-computer interface robotics for hand rehabilitation after stroke: a systematic review. Journal of Neuroengineering & Rehabilitation 18(1): 15 [PMC free article: PMC7825186] [PubMed: 33485365]	- Systematic review used as source of primary studies
Bayindir, O; Akyuz, G; Sekban, N (2022) The effect of adding robot-assisted hand rehabilitation to conventional rehabilitation program following stroke: a randomized-controlled study. Turkish journal of physical medicine and rehabilitation 68(2): 254–261 [PMC free article: PMC9366479] [PubMed: 35989963]	- Data not reported in an extractable format or a format that can be analysed Medians and interquartile ranges
Bernhardt, J and Mehrholz, J (2019) Robotic-assisted training after stroke: RATULS advances science. Lancet 394(10192): 6–8. [PubMed: 31128923]	- Conference abstract
Bressi, F., Bravi, M., Campagnola, B. et al. (2020) Robotic treatment of the upper limb in chronic stroke and cerebral neuroplasticity: a systematic review. Journal of Biological Regulators & Homeostatic Agents 34(5suppl3): 11–44. Technology in Medicine [PubMed: 33386032]	- Systematic review used as source of primary studies
Bumin, G.; Colak, F.D.; Yasar, E. (2022) THE EFFECT OF UPPER EXTREMITY ROBOTIC REHABILITATION ON ACTIVITY PERFORMANCE IN INDIVIDUALS WITH STROKE. International Journal of Stroke 17(3supplement): 252–253	- Conference abstract
Burridge, Jane and Hughes, Ann-Marie (2020) Robot-assisted training offers little improvement in severe arm weakness and functions after stroke. Frontline (20454910) 26(1): 42–43	- Conference abstract
Cantillo-Negrete, J., Carino-Escobar, R. I., Carrillo-Mora, P. et al. (2021) Brain-Computer Interface Coupled to a Robotic Hand Orthosis for Stroke Patients’ Neurorehabilitation: A Crossover Feasibility Study. Frontiers in Human Neuroscience 15 (no pagination) [PMC free article: PMC8215105] [PubMed: 34163342]	- Study design not relevant to this review protocol
Carpinella, I, Lencioni, T, Bowman, T et al. (2019) Planar robotic training versus arm-specific physiotherapy: effects on arm function and motor strategies in post-stroke subjects. Gait and Posture 74(s): 7	- Full text paper not available
Cecchi, F., Germanotta, M., Macchi, C. et al. (2021) Age is negatively associated with upper limb recovery after conventional but not robotic rehabilitation in patients with stroke: a secondary analysis of a randomized-controlled trial. Journal of Neurology 268(2): 474–483 [PubMed: 32844309]	- Secondary publication of an included study that does not provide any additional relevant information
Chen, Z., Wang, C., Fan, W. et al. (2020) Robot-Assisted Arm Training versus Therapist-Mediated Training after Stroke: A Systematic Review and Meta-Analysis. Journal of Healthcare Engineering 2020: 8810867 [PMC free article: PMC7641296] [PubMed: 33194159]	- Systematic review used as source of primary studies
Chen, Z., Xia, N., He, C. et al. (2021) Action observation treatment-based exoskeleton (AOT-EXO) for upper extremity after stroke: study protocol for a randomized controlled trial. Trials [Electronic Resource] 22(1): 222 [PMC free article: PMC7981809] [PubMed: 33743788]	- Study design not relevant to this review protocol
Chien, W. T., Chong, Y. Y., Tse, M. K. et al. (2020) Robot-assisted therapy for upper-limb rehabilitation in subacute stroke patients: A systematic review and meta-analysis. Brain and Behavior 10(8): e01742 [PMC free article: PMC7428503] [PubMed: 32592282]	- Systematic review used as source of primary studies
Chinembiri, B. (2019) Comparing the effects of Fourier M2 robotic rehabilitation machine combined with conventional occupational therapy on hand function and quality of life in patients whose arms have been affected by a recent first stroke.	- Full text paper not available
Chua, K., Kuah, C., Ng, C. et al. (2018) Clinical and kinematic evaluation of the H-Man arm robot for post-stroke upper limb rehabilitation: preliminary findings of a randomised controlled trial. Annals of physical and rehabilitation medicine	- Full text paper not available
Comino-Suarez, N., Moreno, J. C., Gomez-Soriano, J. et al. (2021) Transcranial direct current stimulation combined with robotic therapy for upper and lower limb function after stroke: a systematic review and meta-analysis of randomized control trials. Journal of Neuroengineering & Rehabilitation 18(1): 148 [PMC free article: PMC8474736] [PubMed: 34565399]	- Systematic review used as source of primary studies
D’Anci, K. E., Uhl, S., Oristaglio, J. et al. (2019) Treatments for Poststroke Motor Deficits and Mood Disorders: A Systematic Review for the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Guidelines for Stroke Rehabilitation. Annals of Internal Medicine 171(12): 906–915 [PubMed: 31739315]	- Systematic review used as source of primary studies
Da-Silva, R. H.; Moore, S. A.; Price, C. I. (2018) Self-directed therapy programmes for arm rehabilitation after stroke: a systematic review. Clinical Rehabilitation 32(8): 1022–1036 [PubMed: 29756513]	- Systematic review used as source of primary studies
de Sousa, D. G., Harvey, L. A., Dorsch, S. et al. (2018) Interventions involving repetitive practice improve strength after stroke: a systematic review. Journal of Physiotherapy 64(4): 210–221 [PubMed: 30245180]	- Systematic review used as source of primary studies
de-la-Torre, R., Ona, E. D., Balaguer, C. et al. (2020) Robot-Aided Systems for Improving the Assessment of Upper Limb Spasticity: A Systematic Review. Sensors 20(18): 14 [PMC free article: PMC7570987] [PubMed: 32937973]	- Systematic review used as source of primary studies
Dehem, S., Gilliaux, M., Stoquart, G. et al. (2018) Effectiveness of upper limb robotic-assisted therapy in the early phase of stroke rehabilitation: a single-blind, randomised, controlled trial. Annals of physical and rehabilitation medicine [PubMed: 31028900]	- Duplicate reference
Dixit, S. and Tedla, J. S. (2019) Effectiveness of robotics in improving upper extremity functions among people with neurological dysfunction: a systematic review. International Journal of Neuroscience 129(4): 369–383 [PubMed: 30311823]	- Systematic review used as source of primary studies
Duret, C. (2018) Robotic rehabilitation of the upper limb after a stroke (ROBOASSIST).	- Full text paper not available
Ellis, M. D., Carmona, C., Drogos, J. et al. (2018) Progressive Abduction Loading Therapy with Horizontal-Plane Viscous Resistance Targeting Weakness and Flexion Synergy to Treat Upper Limb Function in Chronic Hemiparetic Stroke: A Randomized Clinical Trial. Frontiers in neurology [electronic resource]. 9: 71 [PMC free article: PMC5825888] [PubMed: 29515514]	- Study does not contain an intervention relevant to this review protocol
Esquenazi, A., Lee, S., Watanabe, T. et al. (2018) Abstract edited–Supplemental therapeutic conventional vs. robotic upper limb exercise in acute stroke rehabilitation: a randomized, blinded assessor study. Annals of physical and rehabilitation medicine 61(suppl1): e95	- Full text paper not available
Ferreira, Fmrm, Chaves, M. E. A., Oliveira, V. C. et al. (2018) Effectiveness of robot therapy on body function and structure in people with limited upper limb function: A systematic review and meta-analysis. PLoS ONE [Electronic Resource] 13(7): e0200330 [PMC free article: PMC6042733] [PubMed: 30001417]	- Systematic review used as source of primary studies
Fonte, C., Varalta, V., Rocco, A. et al. (2021) Combined transcranial Direct Current Stimulation and robot-assisted arm training in patients with stroke: a systematic review. Restorative Neurology & Neuroscience 39(6): 435–446 [PubMed: 34974446]	- Systematic review used as source of primary studies
García-Rudolph, A.; Bernabeu-Guitart, M.; Opisso, E. (2020) [Intensities in the application of robotic technologies in upper extremity rehabilitation after a stroke: a systematic review of randomised controlled clinical trials]. Revista de neurologia 70(12): 434–443 [PubMed: 32500522]	- Full text paper not available
Gasperini, G., Rossini, M., Proserpio, D. et al. (2018) Hybrid robotic system combining passive exoskeleton and functional electrical stimulation for upper limb stroke rehabilitation: preliminary results of the retrainer multi-center randomized controlled trial. Annals of physical and rehabilitation medicine	- Conference abstract
Germanotta, M, Pecchioli, C, Cruciani, A et al. (2019) Efficacy of upper limb robot-assisted therapy compared with conventional therapy in stroke patients: preliminary results on a daily task assessed by means of motion analysis. Gait and Posture 74(s): 18	- Full text paper not available
Hameed, Husamuldeen K., Hassan, Wan Zuha Wan, Shafie, Suhaidi et al. (2020) A Review on Surface Electromyography-Controlled Hand Robotic Devices Used for Rehabilitation and Assistance in Activities of Daily Living. Journal of Prosthetics & Orthotics (JPO) 32(1): 3–13	- Review article but not a systematic review
Hayward, K. S., Kramer, S. F., Thijs, V. et al. (2019) A systematic review protocol of timing, efficacy and cost effectiveness of upper limb therapy for motor recovery post-stroke. Systematic Reviews 8(1): 187 [PMC free article: PMC6657039] [PubMed: 31345263]	- Study design not relevant to this review protocol
Hsieh, Y. W., Lin, K. C., Wu, C. Y. et al. (2018) Comparison of proximal versus distal upper-limb robotic rehabilitation on motor performance after stroke: a cluster controlled trial. Scientific Reports 8(1): 2091 [PMC free article: PMC5794971] [PubMed: 29391492]	- Study design not relevant to this review protocol
Hu, X. (2020) Upper limb rehabilitation after stroke assisted with a hybrid electrical stimulation (ES)-robot system.	- Full text paper not available
Hung, C. S., Hsieh, Y. W., Wu, C. Y. et al. (2019) Comparative Assessment of Two Robot-Assisted Therapies for the Upper Extremity in People With Chronic Stroke. American Journal of Occupational Therapy 73(1): 7301205010p1–7301205010p9 [PubMed: 30839256]	- Data not reported in an extractable format or a format that can be analysed Reports median and interquartile ranges only
Hung, J. W., Chen, Y. W., Chen, Y. J. et al. (2021) The Effects of Distributed vs. Condensed Schedule for Robot-Assisted Training with Botulinum Toxin A Injection for Spastic Upper Limbs in Chronic Post-Stroke Subjects. Toxins 13(8): 01 [PMC free article: PMC8402581] [PubMed: 34437410]	- Comparator in study does not match that specified in this review protocol
Hung, J. W., Wu, C. Y., Chang, K. C. et al. (2018) Comparative hybrid effects of combining botulinum toxin A injection with bilateral robot-assisted, mirror or task-oriented therapy for upper extremity spasticity in patients with chronic stroke. Annals of physical and rehabilitation medicine	- Conference abstract
Iamsirikij, C. (2018) Effects of upper limb rehabilitation robot EnMotion® in subacute stroke patients: a single blind randomized controlled trial (robotic rehab, stroke, subacute).	- Full text paper not available
Kagiyama, T. and Mukae, N. (2020) Clinical research for efficacy and safety of hand-finger rehabilitation robot SMOVE in the goods operation training for the patients with upper limb paresis after recovery stage stroke patients: a pilot study under single center, open-label, randomized, standard therapy controlled trial - (SMOVE pilot study_02).	- Full text paper not available
Kang, T. W., Oh, D. W., Lee, J. H. et al. (2018) Effects of integrating rhythmic arm swing into robot-assisted walking in patients with subacute stroke: a randomized controlled pilot study. International Journal of Rehabilitation Research 41(1): 57–62 [PubMed: 29140826]	- Study does not contain an intervention relevant to this review protocol
Keeling, A. B., Piitz, M., Semrau, J. A. et al. (2021) Robot enhanced stroke therapy optimizes rehabilitation (RESTORE): a pilot study. Journal of NeuroEngineering and Rehabilitation 18(1) [PMC free article: PMC7819212] [PubMed: 33478563]	- Study design not relevant to this review protocol Non-randomised study with sufficient randomised evidence included in the review
Khalid, S., Alnajjar, F., Gochoo, M. et al. (2021) Robotic assistive and rehabilitation devices leading to motor recovery in upper limb: a systematic review. Disability & Rehabilitation Assistive Technology: 1–15 [PubMed: 33861684]	- Systematic review used as source of primary studies
Kim, S. B., Lee, K. W., Lee, J. H. et al. (2018) Effect of Combined Therapy of Robot and Low-Frequency Repetitive Transcranial Magnetic Stimulation on Hemispatial Neglect in Stroke Patients. Annals of Rehabilitation Medicine 42(6): 788–797 [PMC free article: PMC6325312] [PubMed: 30613071]	- Comparator in study does not match that specified in this review protocol
Kim, W. S. (2018) Anodal tDCS over the contralesional hemisphere with robotic arm training in subacute stroke patients with severe upper limb hemiparesis.	- Full text paper not available
Kuo, L-C, Yang, K-C, Lin, Y-C et al. (2022) Internet of Things (IoT) Enables Robot-Assisted Therapy as a Home Program for Training Upper Limb Functions in Chronic Stroke: a Randomized Control Crossover Study. Archives of physical medicine and rehabilitation [PubMed: 36122608]	- Study design not relevant to this review protocol Crossover trial that only reports results for all of the participants together (does not report results for the first trial period only) - therefore it is not possible to extract results by the methods described in the Cochrane review and so the study is excluded
Lee, H. C., Kuo, F. L., Lin, Y. N. et al. (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(1): 7501205020p1–7501205020p11 [PubMed: 33399050]	- Study design not relevant to this review protocol
Lee, S. H., Kim, W. S., Park, J. et al. (2020) Effects of anodal transcranial direct current stimulation over the contralesional hemisphere on motor recovery in subacute stroke patients with severe upper extremity hemiparesis: Study protocol for a randomized controlled trial. Medicine 99(14): e19495 [PMC free article: PMC7220659] [PubMed: 32243365]	- Study design not relevant to this review protocol
Leem, Min Jeong, Kim, Gyu Seong, Kim, Kee Hoon et al. (2019) Predictors of functional and motor outcomes following upper limb robot-assisted therapy after stroke. International Journal of Rehabilitation Research 42(3): 223–228 [PubMed: 30932930]	- Study design not relevant to this review protocol
Lin, I. H., Tsai, H. T., Wang, C. Y. et al. (2019) Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review. Archives of Physical Medicine & Rehabilitation 100(2): 366–378 [PubMed: 30686327]	- Systematic review used as source of primary studies
Lin, J. C. (2018) Robot-assisted hand rehabilitation for patients with stroke.	- Full text paper not available
Lin, K. C. (2018) Synergistic bilateral upper-limb stroke rehabilitation based on robotic priming technique.	- Full text paper not available
Liu, L. Y.; Li, Y.; Lamontagne, A. (2018) The effects of error-augmentation versus error-reduction paradigms in robotic therapy to enhance upper extremity performance and recovery post-stroke: a systematic review. Journal of Neuroengineering & Rehabilitation 15(1): 65 [PMC free article: PMC6033222] [PubMed: 29973250]	- Systematic review used as source of primary studies
Lo, K.; Stephenson, M.; Lockwood, C. (2019) The economic cost of robotic rehabilitation for adult stroke patients: a systematic review. JBI Database Of Systematic Reviews And Implementation Reports 17(4): 520–547 [PubMed: 30973526]	- Systematic review used as source of primary studies
Marotta, N., Demeco, A., Moggio, L. et al. (2021) The adjunct of transcranial direct current stimulation to Robot-assisted therapy in upper limb post-stroke treatment. Journal of Medical Engineering & Technology 45(6): 494–501 [PubMed: 34038313]	- Systematic review used as source of primary studies
Mashizume, Y; Zenba, Y; Takahashi, K (2020) Novel Mechanism of Action: Efficacy of Upper Extremity Robotic Therapy For Chronic Stroke Patients in Occupational Therapy. Archives of Physical Medicine and Rehabilitation 101(11): e98	- Conference abstract
Mehrholz, J., Pollock, A., Pohl, M. et al. (2020) Systematic review with network meta-analysis of randomized controlled trials of robotic-assisted arm training for improving activities of daily living and upper limb function after stroke. Journal of Neuroengineering & Rehabilitation 17(1): 83 [PMC free article: PMC7325016] [PubMed: 32605587]	- Systematic review used as source of primary studies
Merians, A. S., Fluet, G. G., Qiu, Q. et al. (2020) Hand Focused Upper Extremity Rehabilitation in the Subacute Phase Post-stroke Using Interactive Virtual Environments. Frontiers in Neurology 11 (no pagination) [PMC free article: PMC7726202] [PubMed: 33324323]	- Study design not relevant to this review protocol
Meyer, S., Verheyden, G., Kempeneers, K. et al. (2021) Arm-Hand Boost Therapy During Inpatient Stroke Rehabilitation: A Pilot Randomized Controlled Trial. Frontiers in Neurology 12 (no pagination) [PMC free article: PMC7952763] [PubMed: 33716948]	- Comparator in study does not match that specified in this review protocol
Moggio, L., de Sire, A., Marotta, N. et al. (2021) Exoskeleton versus end-effector robot-assisted therapy for finger-hand motor recovery in stroke survivors: systematic review and meta-analysis. Topics in Stroke Rehabilitation: 1–12 [PubMed: 34420498]	- Systematic review used as source of primary studies
Morone, G., Palomba, A., Martino Cinnera, A. et al. (2021) Systematic review of guidelines to identify recommendations for upper limb robotic rehabilitation after stroke. European journal of physical & rehabilitation medicine. 57(2): 238–245 [PubMed: 33491943]	- Review article but not a systematic review
Mubin, O., Alnajjar, F., Jishtu, N. et al. (2019) Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients’ Rehabilitation: Systematic Review. JMIR Rehabilitation And Assistive Technologies 6(2): e12010 [PMC free article: PMC6779025] [PubMed: 31586360]	- Systematic review used as source of primary studies
Park, S. W.; Kim, J. H.; Yang, Y. J. (2018) Mental practice for upper limb rehabilitation after stroke: a systematic review and meta-analysis. International Journal of Rehabilitation Research 41(3): 197–203 [PubMed: 29912022]	- Systematic review used as source of primary studies
Patel, J., Fluet, G., Qiu, Q. et al. (2019) Intensive virtual reality and robotic based upper limb training compared to usual care, and associated cortical reorganization, in the acute and early sub-acute periods post-stroke: a feasibility study. Journal of Neuroengineering & Rehabilitation 16(1): 92 [PMC free article: PMC6637633] [PubMed: 31315612]	- Study design not relevant to this review protocol
Perini, G., Bertoni, R., Thorsen, R. et al. (2021) Sequentially applied myoelectrically controlled FES in a task-oriented approach and robotic therapy for the recovery of upper limb in post-stroke patients: A randomized controlled pilot study. Technology & Health Care 29(3): 419–429 [PubMed: 33386831]	- Study does not contain an intervention relevant to this review protocol
Perini, G, Lencioni, T, Bertoni, R et al. (2019) Rehabilitation of upper limb in chronic stroke patients: pilot study of functional and neuromotor outcome of a task oriented approach including MeCFES and robotic treatment. Gait and Posture 74(s): 29–30.	- Full text paper not available
Quaglia, D., Gasperi, M., Coser, R. et al. (2018) Robotic rehabilitation effect on upper limb recovery in post-acute stroke. Gait & Posture 66: S31–S32	- Conference abstract
Reis, S. B., Bernardo, W. M., Oshiro, C. A. et al. (2021) Effects of Robotic Therapy Associated With Noninvasive Brain Stimulation on Upper-Limb Rehabilitation After Stroke: Systematic Review and Meta-analysis of Randomized Clinical Trials. Neurorehabilitation & Neural Repair 35(3): 256–266 [PubMed: 33522417]	- Systematic review used as source of primary studies
Remy-Neris, O., Medee, B., Bensmail, D. et al. (2018) Rehabilitation robotics of the upper limb after stroke. The REM_AVC trial. Annals of physical and rehabilitation medicine	- Conference abstract
Rintala, A, Paivarinne, V, Hakala, S et al. (2019) Effectiveness of Technology-Based Distance Physical Rehabilitation Interventions for Improving Physical Functioning in Stroke: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Archives of Physical Medicine and Rehabilitation 100(7): 1339–1358. [PubMed: 30529323]	- Systematic review used as source of primary studies
Rosenthal, O. (2018) Performance-based selective training for robot-mediated upper limb rehabilitation after stroke.	- Full text paper not available
Rosenthal, O., Wing, A. M., Wyatt, J. L. et al. (2019) Boosting robot-assisted rehabilitation of stroke hemiparesis by individualized selection of upper limb movements - A pilot study. Journal of NeuroEngineering and Rehabilitation 16(1) [PMC free article: PMC6425657] [PubMed: 30894192]	- Comparator in study does not match that specified in this review protocol
Rosenthal, Orna, Wing, Alan M., Wyatt, Jeremy L. et al. (2019) Correction to: Boosting robot-assisted rehabilitation of stroke hemiparesis by individualized selection of upper limb movements - a pilot study. 16: N.PAG-N.PAG [PMC free article: PMC6466732] [PubMed: 30987648]	- Correction only
Rozevink, S. G., Hijmans, J. M., Horstink, K. A. et al. (2021) Effectiveness of task-specific training using assistive devices and task-specific usual care on upper limb performance after stroke: a systematic review and meta-analysis. Disability & Rehabilitation Assistive Technology: 1–14 [PubMed: 34788166]	- Systematic review used as source of primary studies
Serrezuela, R. R., Quezada, M. T., Zayas, M. H. et al. (2020) Robotic therapy for the hemiplegic shoulder pain: a pilot study. Journal of Neuroengineering & Rehabilitation 17(1): 54 [PMC free article: PMC7178610] [PubMed: 32321536]	- Data not reported in an extractable format or a format that can be analysed
Shin, J. H. (2019) Effects of upper extremity rehabilitation robot and transcranial direct current stimulation in chronic stroke.	- Full text paper not available
Suarez-Escobar, M. and Rendon-Velez, E. (2018) An overview of robotic/mechanical devices for post-stroke thumb rehabilitation. Disability & Rehabilitation Assistive Technology 13(7): 683–703 [PubMed: 29334274]	- Review article but not a systematic review
Takebayashi, T., Takahashi, K., Amano, S. et al. (2018) Assessment of the Efficacy of ReoGo-J Robotic Training Against Other Rehabilitation Therapies for Upper-Limb Hemiplegia After Stroke: Protocol for a Randomized Controlled Trial. Frontiers in neurology [electronic resource]. 9: 730 [PMC free article: PMC6121101] [PubMed: 30210446]	- Study design not relevant to this review protocol
Takebayashi, T., Takahashi, K., Domen, K. et al. (2020) Impact of initial flexor synergy pattern scores on improving upper extremity function in stroke patients treated with adjunct robotic rehabilitation: A randomized clinical trial. Topics in Stroke Rehabilitation 27(7): 516–524 [PubMed: 32151236]	- Secondary publication of an included study that does not provide any additional relevant information
Terranova, T. T., Simis, M., Santos, A. C. A. et al. (2021) Robot-Assisted Therapy and Constraint-Induced Movement Therapy for Motor Recovery in Stroke: Results From a Randomized Clinical Trial. Frontiers in Neurorobotics 15: 684019 [PMC free article: PMC8335542] [PubMed: 34366819]	- Comparator in study does not match that specified in this review protocol
Terranova, T., Simis, M., Santos, A. et al. (2018) Comparing effects of constraint-induced movement therapy and robotic therapy: randomized clinical trial. Annals of physical and rehabilitation medicine	- Conference abstract
Tramontano, M., Morone, G., Palomba, A. et al. (2020) Effectiveness of a sensor-based technology in upper limb motor recovery in post-acute stroke neurorehabilitation: a randomized controlled trial. Journal of Biological Regulators & Homeostatic Agents 34(5suppl3): 165–174. Technology in Medicine [PubMed: 33386046]	- Full text paper not available
Tsuchimoto, S., Shindo, K., Hotta, F. et al. (2019) Sensorimotor Connectivity after Motor Exercise with Neurofeedback in Post-Stroke Patients with Hemiplegia. Neuroscience 416: 109–125 [PubMed: 31356896]	- Data not reported in an extractable format or a format that can be analysed
Valdes, B. A. and Van der Loos, H. F. M. (2018) Biofeedback vs. game scores for reducing trunk compensation after stroke: a randomized crossover trial. Topics in Stroke Rehabilitation 25(2): 96–113 [PubMed: 29078743]	- Comparator in study does not match that specified in this review protocol
Valkenborghs, Sarah R., Callister, Robin, Visser, Milanka M. et al. (2019) Interventions combined with task-specific training to improve upper limb motor recovery following stroke: a systematic review with meta-analyses. Physical Therapy Reviews 24(34): 100–117	- Systematic review used as source of primary studies
Wright, Zachary A., Majeed, Yazan A., Patton, James L. et al. (2020) Key components of mechanical work predict outcomes in robotic stroke therapy. Journal of NeuroEngineering & Rehabilitation (JNER) 17(1): 1–12 [PMC free article: PMC7175566] [PubMed: 32316977]	- Data not reported in an extractable format or a format that can be analysed
Wu, C. Y. (2020) Robot-assisted therapy combined with mirror priming in upper limb training in stroke.	- Full text paper not available
Wu, J., Cheng, H., Zhang, J. et al. (2021) Robot-Assisted Therapy for Upper Extremity Motor Impairment After Stroke: A Systematic Review and Meta-Analysis. Physical Therapy 101(4): 04 [PubMed: 33454787]	- Systematic review used as source of primary studies
Xu, Q., Li, C., Pan, Y. et al. (2020) Impact of smart force feedback rehabilitation robot training on upper limb motor function in subacute stage of stroke. NeuroRehabilitation [PubMed: 32741790]	- Full text paper not available
Yuan, R. and Wang, H. (2022) TU-173. The effect of upper limb rehabilitation robot training on the motor function and neuroelectrophysiology of stroke patients. Clinical Neurophysiology 141(supplement): 29	- Conference abstract
Yáñez-Sánchez, A. and Cuesta-Gómez, A. (2020) [Effectiveness of the Armeo ® device in the rehabilitation of the upper limb of stroke’s patients. A review of the literature]. Revista de neurologia 70(3): 93–102 [PubMed: 31994166]	- Full text paper not available

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Final

Evidence reviews underpinning recommendation 1.13.18 in the NICE guideline

These evidence reviews were developed by NICE

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

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Evidence reviews for robot-assisted arm training: Stroke rehabilitation in adults (update): Evidence review M. London: National Institute for Health and Care Excellence (NICE); 2023 Oct. (NICE Guideline, No. 236.)
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Evidence reviews for robot-assisted arm training

1. Robot-assisted arm training

1.1. Review question

1.1.1. Introduction

1.1.2. Summary of the protocol

1.1.3. Methods and process

1.1.4. Effectiveness evidence

1.1.4.1. Included studies

Indirectness

Inconsistency

1.1.4.2. Excluded studies

1.1.5. Summary of studies included in the effectiveness evidence

1.1.6. Summary of the effectiveness evidence

1.1.7. Economic evidence

1.1.7.1. Included studies

1.1.7.2. Excluded studies

1.1.8. Summary of included economic evidence

1.1.9. Economic model

1.1.10. Unit costs

1.1.11. Evidence statements

Effectiveness/Qualitative

Economic

1.1.12. The committee’s discussion and interpretation of the evidence

1.1.12.1. The outcomes that matter most

1.1.12.2. The quality of the evidence

1.1.12.3. Benefits and harms

1.1.12.4. Cost effectiveness and resource use

1.1.13. Recommendations supported by this evidence review

1.1.14. References

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

Appendix C. Effectiveness evidence study selection

Appendix D. Effectiveness evidence

Appendix E. Forest plots

Appendix F. GRADE tables

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

Appendix I. Health economic model

Appendix J. Excluded studies

Clinical studies

Table 11Studies excluded from the clinical review

Health Economic studies

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