J Neurol. 2014 May;261(5):1037-45. doi: 10.1007/s00415-014-7345-4.

Sequential combination of robot-assisted therapy and constraint-induced therapy in stroke rehabilitation: a randomized controlled trial.

Hsieh YW, Lin KC, Horng YS, Wu CY, Wu TC, Ku FL.

Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, 259 Wen-hwa 1st Road, Taoyuan, Taiwan.



Robot-assisted therapy (RT) and constraint-induced therapy (CIT) both show great promise to improve stroke rehabilitation outcomes. Although the respective treatment efficacy of RT and CIT has been validated, the additive effects of RT combined with CIT remain unknown. This study investigated the treatment effects of RT in sequential combination with a distributed form of CIT (RT + dCIT) compared with RT and conventional rehabilitation (CR). Forty-eight patients with stroke were enrolled and randomized to receive one of the three interventions for 4 weeks. Primary outcomes assessed the changes of motor impairment and motor function on the Fugl-Meyer Assessment (FMA) and Wolf Motor Function Test (WMFT). Secondary outcomes, including the Motor Activity Log (MAL) and accelerometers, examined functional performance during daily activities. The three treatment groups improved significantly on most primary and secondary outcomes over time. The combined RT + dCIT group exhibited significantly greater improvement on the FMA and functional ability subscale of the WMFT than the RT and CR groups. The improvements on the MAL and accelerometers were not significantly different among the three groups. RT in sequential combination with CIT led to additive effects on participants’ motor ability and functional ability to perform motor tasks after stroke, which support that combined therapy can be an effective means to intensify outcomes. Further research investigating the potential long-term effects of combination therapy, especially on real-life performance, would be valuable.

PMID: 24748465



Upper-limb paresis and its associated disability are common problems for people after stroke. Robot-assisted therapy and constraint-induced therapy bring scientific concepts into day-to-day clinical practice and show great promise in promoting recovery for individuals with stroke. Robot-assisted therapy in stroke rehabilitation has developed remarkably in the past decade that provides high intensive, repetitive, reproducible, and interactive treatment. Constraint-induced therapy was originally developed by Dr. Edward Taub at the University of Alabama in the 1990s to overcome the learned non-used phenomena after stroke. To date, constraint-induced therapy family has had a significant impact on stroke rehabilitation. Cumulative evidence supports that stroke patients exhibited great improvement in motor function and functional use of the affected arm in their daily life after constraint-induced therapy.

This study was the first to investigate the efficacy of sequential combination of the 2 prominent neurorehabilitation interventions in stroke survivors. A total of 48 patients with stroke were recruited to participate in this clinical trial. Each participant received 20 treatment sessions of 1.5 hours per session for 4 weeks. The participants who were randomized to the combination treatment group received 2 weeks of robot-assisted therapy, followed by 2 weeks of constraint-induced therapy (Figure 1). Outcome measures were administered to each participant before and after rehabilitation. Outcomes included Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Motor Activity Log (MAL) and wrist accelerometers (Figure 2) to evaluate motor function and daily performance of the patients. We found that robot-assisted therapy in sequential combination with constraint-induced therapy had better effects on improving the participants’ motor ability and functional ability to perform motor tasks, as compared with control interventions.

The importance of this study: This study provides evidence of the beneficial effects of robot-assisted therapy combined with constraint-induced therapy on motor and functional outcomes in patients with stroke. The findings support that combined therapy may be an effective means to intensify stroke outcome which makes contribution to expand the scientific basis of stroke rehabilitation and facilitate develop innovative combined interventions to maximize stroke recovery.

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