Vol 55, No 1 (2021)
Research Paper
Published online: 2020-12-14

open access

Page views 9616
Article views/downloads 6223
Get Citation

Connect on Social Media

Connect on Social Media

Early post-stroke rehabilitation for upper limb motor function using virtual reality and exoskeleton: equally efficient in older patients

Tereza Gueye123, Miriama Dedkova1, Vladimir Rogalewicz2, Marcela Grunerova-Lippertova1, Yvona Angerova2
Pubmed: 33314016
Neurol Neurochir Pol 2021;55(1):91-96.


Aim of the study. To evaluate the effectiveness of virtual reality therapy (VRT) Armeo Spring® upper limb exoskeleton (Armeo), in early post-stroke rehabilitation with a focus on the elderly.

Clinical rationale for the study.
Convalescence from a stroke is a complex process driven by a spontaneous recovery supported by multifactorial activation. Novel technology-based rehabilitation methods are being introduced to support brain plasticity.

Materials and methods. Using a randomised controlled study design, participants within 30 days after stroke with arm paresis were, in addition to a daily rehabilitation programme, assigned to an intervention group (45 minutes Armeo IG n = 25; mean age 66.5 years) performing VRT, or to a conventional physiotherapy (45 minutes) control group (Armeo CG, n = 25, mean age 68.1 years). Montreal Cognitive Assessment (MoCA), Functional Independence Measure (FIM) and Fugl Mayer Assessment Upper Extremity Scale (FMA-UE) were performed before and after the three-week therapy with 12 therapeutic sessions. Results of participants < 65 and ≥ 65 years old were compared.

Results. Paretic upper arm function improved significantly in both the IG and CG groups, the improvement in FMA-UE was significantly higher in the IG compared to the CG (p = 0.02), and patients ≥ 65 years old presented an equal magnitude of improvement in paretic arm function compared to younger patients.

Conclusions and clinical implications. Early post-stroke rehabilitation strategies using, in addition to the daily rehabilitation programme, VRT with visual biofeedback is more effective on upper extremity motor performance than conventional physiotherapy, and the effectiveness does not diminish with patient age. This may be a promising addition to conventional physiotherapy in older stroke patients as well as in younger.

Article available in PDF format

View PDF Download PDF file


  1. Lin MP. Time matters greatly in acute stroke care. Neurol Neurochir Pol. 2020; 54(2): 104–105.
  2. Nowak K, Derbisz J, Jagiełła J, et al. Time from stroke onset to groin puncture affects rate of recanalisation after mechanical thrombectomy: a real-life single centre experience. Neurol Neurochir Pol. 2020; 54(2): 156–160.
  3. Winters C, van Wegen EEH, Daffertshofer A, et al. Generalizability of the Proportional Recovery Model for the Upper Extremity After an Ischemic Stroke. Neurorehabil Neural Repair. 2015; 29(7): 614–622.
  4. Zarahn E, Alon L, Ryan SL, et al. Prediction of motor recovery using initial impairment and fMRI 48 h poststroke. Cereb Cortex. 2011; 21(12): 2712–2721.
  5. Biernaskie J, Chernenko G, Corbett D. Efficacy of rehabilitative experience declines with time after focal ischemic brain injury. J Neurosci. 2004; 24(5): 1245–1254.
  6. Kwakkel G, van Peppen R, Wagenaar RC, et al. Effects of augmented exercise therapy time after stroke: a meta-analysis. Stroke. 2004; 35(11): 2529–2539.
  7. Murphy TH, Corbett D. Plasticity during stroke recovery: from synapse to behaviour. Nat Rev Neurosci. 2009; 10(12): 861–872.
  8. Kitago T, Krakauer JW. Motor learning principles for neurorehabilitation. Handb Clin Neurol. 2013; 110: 93–103.
  9. Bertani R, Melegari C, De Cola MC, et al. Effects of robot-assisted upper limb rehabilitation in stroke patients: a systematic review with meta-analysis. Neurol Sci. 2017; 38(9): 1561–1569.
  10. Veerbeek JM, Langbroek-Amersfoort AC, van Wegen EEH, et al. Effects of Robot-Assisted Therapy for the Upper Limb After Stroke. Neurorehabil Neural Repair. 2017; 31(2): 107–121.
  11. Norouzi-Gheidari N, Archambault PS, Fung J. Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J Rehabil Res Dev. 2012; 49(4): 479–496.
  12. Masiero S, Celia A, Rosati G, et al. Robotic-assisted rehabilitation of the upper limb after acute stroke. Arch Phys Med Rehabil. 2007; 88(2): 142–149.
  13. Chong J, Sacco R. Risk factors for stroke, assessing risk, and the mass and high-risk approaches for stroke prevention. Continuum: Lifelong Learning in Neurology. 2005; 11: 18–34.
  14. Ovbiagele B, Nguyen-Huynh MN. Stroke epidemiology: advancing our understanding of disease mechanism and therapy. Neurotherapeutics. 2011; 8(3): 319–329.
  15. Thrift AG, Thayabaranathan T, Howard G, et al. Global stroke statistics. Int J Stroke. 2017; 12(1): 13–32.
  16. Chen P, Hreha K, Fortis P, et al. Functional assessment of spatial neglect: a review of the Catherine Bergego scale and an introduction of the Kessler foundation neglect assessment process. Top Stroke Rehabil. 2012; 19(5): 423–435.
  17. Fugl-Meyer AR, Jääskö L, Leyman I, et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975; 7(1): 13–31.
  18. Gladstone DJ, Danells CJ, Black SE. The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair. 2002; 16(3): 232–240.
  19. Thompson-Butel AG, Lin G, Shiner CT, et al. Comparison of three tools to measure improvements in upper-limb function with poststroke therapy. Neurorehabil Neural Repair. 2015; 29(4): 341–348.
  20. Ottenbacher KJ, Hsu Y, Granger CV, et al. The reliability of the functional independence measure: a quantitative review. Arch Phys Med Rehabil. 1996; 77(12): 1226–1232.
  21. Choo SX, Stratford P, Richardson J, et al. Comparison of the sensitivity to change of the Functional Independence Measure with the Assessment of Motor and Process Skills within different rehabilitation populations. Disabil Rehabil. 2018; 40(26): 3177–3184.
  22. MoCA test. https://www.mocatest (February 25, 2020).
  23. Dong Y, Lee WY, Basri NA, et al. The Montreal Cognitive Assessment is superior to the Mini-Mental State Examination in detecting patients at higher risk of dementia. Int Psychogeriatr. 2012; 24(11): 1749–1755.
  24. Armeo Spring Hocoma. https://www.hocoma.com/solutions/armeo-spring/ (February 25, 2020).
  25. Gijbels D, Lamers I, Kerkhofs L, et al. The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study. J Neuroeng Rehabil. 2011; 8: 5.
  26. Laver KE, Lange B, George S, et al. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017; 11: CD008349.
  27. Angerova Y, Marsalek P, Chmelova I, et al. , Cost and cost-effectiveness of early inpatient rehabilitation after stroke varies with initial disability, International Journal of Rehabilitation Research: September 24. 2020; 43(4): 376–382.
  28. Parton A, Malhotra P, Husain M. Parton A, Malhotra P, Husain M, Hemispatial neglect, Journal of Neurology, Neurosurgery & Psychiatry. 2004; 75: 13–21.
  29. Di Monaco M, Schintu S, Dotta M, et al. Severity of unilateral spatial neglect is an independent predictor of functional outcome after acute inpatient rehabilitation in individuals with right hemispheric stroke. Arch Phys Med Rehabil. 2011; 92(8): 1250–1256.
  30. Taveggia G, Borboni A, Salvi L. at al. Efficacy of robot-assisted rehabilitation for the functional recovery of the upper limb in post-stroke patients: a randomized controlled study. Eur J Phys Rehabil Med. 2016; 52(6): 767–773.
  31. Colomer C, Baldoví A, Torromé S, et al. Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis. Neurologia. 2013; 28(5): 261–267.
  32. Bartolo M, De Nunzio AM, Sebastiano F, et al. Arm weight support training improves functional motor outcome and movement smoothness after stroke. Funct Neurol. 2014; 29(1): 15–21.
  33. Rodgers H, Bosomworth H, Krebs H, et al. Robot assisted training for the upper limb after stroke (RATULS): a multicentre randomised controlled trial. The Lancet. 2019; 394(10192): 51–62.
  34. Gueye T, Dedkova M. Outcome of the Armeo Therapy with the Patients Developing Spastic Paresis of the Upper Limb, IV. Kladruby Symposium on Interdisciplinary Neurorehabilitation, book of abstracts, 2017, ISBN: 978-80-270-2951-8.
  35. Schinwelski MJ, Sitek EJ, Wąż P, et al. Prevalence and predictors of post-stroke spasticity and its impact on daily living and quality of life. Neurol Neurochir Pol. 2019; 53(6): 449–457.
  36. Wissel J, Ward AB, Erztgaard P, et al. European consensus table on the use of botulinum toxin type A in adult spasticity. J Rehabil Med. 2009; 41(1): 13–25.
  37. Gracies JM. Pathophysiology of spastic paresis. I: Paresis and soft tissue changes. Muscle Nerve. 2005; 31(5): 535–551.
  38. Gracies JM, Bayle N, Vinti M, et al. Five-step clinical assessment in spastic paresis. Eur J Phys Rehabil Med. 2010; 46(3): 411–421.
  39. Gracies JM. Pathophysiology of Impairment in Patients with Spasticity and Use of Stretch as a Treatment of Spastic Hypertonia. Physical Medicine and Rehabilitation Clinics of North America. 2001; 12(4): 747–768.
  40. Calabrò RS, Russo M, Naro A, et al. Who May Benefit From Armeo Power Treatment? A Neurophysiological Approach to Predict Neurorehabilitation Outcomes. PM R. 2016; 8(10): 971–978.
  41. Zeng N, Pope Z, Lee J, et al. A systematic review of active video games on rehabilitative outcomes among older patients. Journal of Sport and Health Science. 2017; 6(1): 33–43.