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Donders' Mental Chronometry, introduced by Dutch scientist Franciscus Cornelis Donders, measures the time it takes for mental processes to occur. His experiments, particularly on reaction time, laid the foundation for cognitive psychology, influencing our understanding of human cognition and behavior.

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When I first heard about hemispatial neglect condition, I found it to be very interesting and this is why I dug deeper into this and came acoss an interesting study. This recent study by Park (2020) looked into how using a robotic device to train the left hand could help elderly stroke patients with hemispatial neglect. They found that after the training sessions, these patients showed improvements in recognizing and interacting with objects on their neglected side. This finding is significant because it offers a potential way to help people regain some awareness of their neglected space.Overall, this research offers hope for better treatments for hemispatial neglect, which could greatly improve the lives of individuals affected by this condition.

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A pilot and randomized controlled trial

Monitoring Editor: Manal Kamel Youssef.

Background:

Even though a variety of rehabilitative technique have been implemented to ameliorate neglect symptoms of patients with stoke, the effects of limb activation using a robotic device are still unknown. The purpose of this study was to investigate the effects of the robot-assisted hand training on hemispatial neglect of older patients with chronic stroke.

Methods:

The participants were randomly allocated to the experimental group (EG) receiving robot-assisted left-hand training (n = 12) or the control group (CG) receiving conventional treatments for neglect symptoms (n = 12). All participants received 20 sessions for 4-week. To examine the effects on hemispatial neglect, the line bisection test (LBT), the Albert test, and the Catherine Bergego Scale (CBS) were utilized. The outcome measures were analyzed before and after the 20 training sessions.

Results:

After the intervention, improvements in the LBT, the Albert test, and the CBS were found in the EG whereas there were significant improvements in the LBT and the CBS but not the Albert test in the CG. In addition, the EG showed a significantly greater gain in all outcome measures compared to the CG ( p  < .05).

Conclusions:

These results indicate that robot-assisted hand training was beneficial to improving the hemispatial neglect of elderly person with chronic stroke compared to the conventional treatments. Robot-assisted limb activation might be useful to ameliorate hemispatial neglect of the elderly with chronic stroke.

Keywords: attention, hemispatial neglect, limbs, stroke

2.1. Design

This study was a pilot and a randomized controlled trial design. All participants were randomly assigned to the experimental group (EG) or the control group (CG) by using random numbers generated by an occupational therapist blinded to the allocation using a computer software (Excel, Microsoft), which is called simple randomization. To avoid unequal allocation, a randomization list made an occupational therapist who was not aware of participants and not participated in this study was used. The EG received robot-assisted hand training and the CG participated in conventional neglect treatments including both remedial approaches, such as visual scanning training and vibration on the left neck extensors and compensatory approaches. Outcome measures were examined at pre- and post-intervention by an assessor, an occupational therapist with more than five years of clinical experience, who was blinded to the group allocation. The intervention consisted of 20 sessions conducted five times a week for four weeks. This study was approved by the local Institutional Review Board and registered at the Thai Clinical Trials ( https://www.clinicaltrials.in.th, ID: TCTR20200222005). All participants provided written informed consent before the study according to the code of ethics of the World Medical Association (Declaration of Helsinki, version 2004).

2.2. Participants

Since there is no sufficient prior information to calculate the sample size, a sample size of 12 per group would be appropriate as a pilot study. Therefore, a total of 24 chronic stroke patients with hemispatial neglect were recruited by the author from a rehabilitation hospital in South Korea. The inclusion criteria derived from a previous study were:

right hemisphere stroke confirmed by a computed tomography scan or magnetic resonance imaging,

first-ever ischemic or hemorrhage stroke,

intact global cognitive function confirmed by the Korean version of Mini-Mental State Examination score ≥ 24,

time since stroke onset ≥ 6 months, and

the presence of hemispatial neglect diagnosed by performance on the Line Bisection Test and the Korean version of the Motor-free Visual Perception Test-Third Edition (MVPT-3).

The MVPT-3 is a tool to assess visual perception ability consisting of spatial relationship, visual discrimination, figure-ground discrimination, visual closure, and visual memory. In this study, the number of neglected responses in the MVPT-3 was counted. Hemispatial neglect was diagnosed by these two tests just before subjects participated in this study.

The exclusion criteria were:

any additional treatment for hemispatial neglect,

left upper limb sensory deficit or impairment,

the modified Ashworth scale score for left-hand muscle tone ≥ 2,

below second-grade left hand muscle strength in a manual muscle test,

orthopedic conditions involving the left upper limb, and

2.3. Intervention

The EG performed 20 sessions (five days a week for four weeks) of robot-assisted hand training using the Amadeo Robotic device (Trymotion GmbH, Graz, Austria) (Figure ). The end-effector-based Amadeo Robot has five degrees of freedom and provides the motion of one or all five fingers through a passive rotational joint placed between the fingertip and an entity moves laterally (the thumb has two passive rotational joints). All five translational degrees of freedom are independent and almost entirely cover the fingers' workspace. The interface between the human hand and the machine is achieved via elastic bands or plasters and the wrist is restrained from movement by a Velcro strap.

Each session lasted 30 minutes. The exercises were carried out according to a previous study as follow: (1) grasp and release training (digital joint flexion/extension exercise from the thumb to the fifth finger) for 15 minutes; and (2) count training (count a number sequence from one to five) for 15 minutes. The participant's hand motion was assisted by the robot and adjusted to the individual's level of function through the assistive therapy mode of the Amadeo robot. During the training, the participants in the EG received visual feedback of their hand movements via video animation presented on a monitor.

The control group received the 20 sessions of the conventional treatments that lasted 30 minutes each session for hemispatial neglect symptoms. These treatments included visual scanning training using a prism and vibration stimulation applied on the left neck extensors and a middle part of the left forearm. In addition, the participants in the CG learned the compensatory approach for ameliorating hemispatial neglect symptoms involving turning a head or trunk. Two dependent occupational therapists who had more than five years of experience conducted all sessions.

2.4. Outcome measures

Hemispatial neglect was diagnosed by the Line Bisection Test (LBT), the Star Cancellation test (SCT), and the MVPT-3. Among these tests, the LBT was also used to investigate training effectiveness. In the SCT, the number of neglected stars on a left side of a test sheet was counted.

The training effects were investigated by using the line bisection test (LBT), the Albert's Test, and the Catherine Bergego Scale (CBS). In the LBT, the distance of deviation from the objective midline of 18 lines was measured. The participant was instructed to point to the estimated center position using either a pencil or a stick. An average deviation distance less than 6.3 mm was normal, more than 6.33 mm indicated mild hemispatial neglect, and more than 12.5 mm indicated severe hemispatial neglect. In the Albert's Test, the participant was asked to mark 40 lines randomly located on a test sheet. Four lines located in the middle were marked by the assessor's demonstration. The number of missing lines of 36 lines was taken as the result.

The Catherine Bergego Scale (CBS) is a checklist designed to examine neglect symptoms by observing and interviewing the participant's daily function in 10 real life situations with a total score of 30. Each item is rated on a 4-point scale. A participant with a total score of 0 is considered to have no effect of neglect syndrome in performing the daily living. Higher scores mean more severe neglect symptom impact on daily life. Unlike the LBT and the Albert's test, the CBS is a tool that assesses not only hemispatial neglect symptoms but also the degree of disease recognition by comparing scores.

2.5. Statistical analyses

All data were analyzed using SPSS 22.0 version. All measures were described as the mean ± standard deviation. The Shapiro-Wilk test was used to determine normal distribution of outcome measures. To compare the general characteristics of the participants between both groups, the Chi-square test and independent t-test were conducted. After the training sessions, Wilcoxon-signed rank test was used to investigate changes within each group and the differences in changes between the groups were analyzed by using the Mann-Whitney U test. The effect size of each intervention group was calculated using the partial η ² value. A partial η ² ≥ 0.14 was considered a large effect; between ≥ 0.06 and <0.14, a moderate effect; and an between ≥ 0.01 and < 0.06, a small effect. The statistical significance level was set at P  < . 05.

3.1. General characteristics of the participants

A total of 24 participants were selected from 32 stroke patients. All participants completed the 20 training sessions. No dropouts were recorded during the intervention and all participants fulfilled the intervention protocol (Fig. ). There were no significant differences in the general characteristics between both groups (Table ).

Table 1

3.2. Performance on hemispatial neglect tasks

After intervention, the EG showed significant improvements in the LBT ( P < .001) and the Albert test ( P < .01) whereas there were significant improvements in the LBT ( P < .01) but not in the Albert test ( P > .05) in the CG. On the other hand, there were statistically significant differences in changes in the LBT ( P < .001; η ² = 0.507) and the Albert test ( P < .05; η ²  = 0.205), suggesting that robot-assisted hand training showed a greater improvement in ameliorating hemispatial neglect symptoms compared to the conventional treatment (Table ).

Table 2

3.3. Hemispatial neglect symptoms in activities of daily living

After intervention, both group showed a significant improvement in the CBS (EG: P < .001; CG: P < .05). On the other hand, there was a statistically significant difference in changes in the CBS ( P < .001; η ²  = 0.569). This finding indicated that robot-assisted hand training was more clinically beneficial in reducing hemispatial neglect symptoms in the participants' activities of daily living (Table ).

Conceptualization: Jin-Hyuck Park.

Data curation: Jin-Hyuck Park.

Formal analysis: Jin-Hyuck Park.

Funding acquisition: Jin-Hyuck Park.

Investigation: Jinhyuck Park.

Methodology: Jin-Hyuck Park.

Resources: Jinhyuck Park.

Supervision: Jinhyuck Park.

Validation: Jinhyuck Park.

Visualization: Jinhyuck Park.

Abbreviations: CBS = catherine bergego scale, CG = control group, EG = experimental group, LBT = line bisection test.

How to cite this article: Park JH. The effects of robot-assisted left-hand training on hemispatial neglect in older patients with chronic stroke: a pilot and randomized controlled trial. Medicine. 2021;100:9(e24781).

This work was supported by the Soonchunhyang University Research Fund.

This work was supported by the Korea Institute for Advancement of Technology(KIAT) grant funded by the Korea Government(MOTIE) (P0012724, The Competency Development Program for Industry Specialist).

Role of the funding source: This work was supported by the Soonchunhyang University Research Fund and the Korea Institute for Advancement of Technology(KIAT) grant funded by the Korea Government(MOTIE) (P0012724, The Competency Development Program for Industry Specialist). The proofreading of this manuscript were conducted by these funding sources. In addition, these funding sources were used to rent places and meals when having several meetings.

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Data are shown as mean ± standard deviations. K-MBI = Korean version of Modified Barthel Index, LBT = Line Bisection Test, MVPT = Motor-free Visual Perception Test.

Data are shown as mean ± standard errors and mean (95% confidence interval) for within and between-group changes. CBS = Catherine Bergego Scale, LBT = Line Bisection Test. †comparison within both groups, †P < .05, ††P < .01, †††P < .001. ∗Comparison between both groups, ∗P < .05, ∗∗∗P  < .001.

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The effects of robot-assisted left-hand training on hemispatial neglect in older patients with chronic stroke: A pilot and randomized controlled trial

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Even though a variety of rehabilitative technique have been implemented to ameliorate neglect symptoms of patients with stoke, the effects of limb activation using a robotic device are still unknown. The purpose of this study was to investigate the effects ...

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