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Upper extremities limitation is a common functional impairment in patients with Multiple Sclerosis (PwMS). Novel technological devices are increasingly used in neurorehabilitation to support motor function improvement and the quantitative assessment of motor performance during training in patients with neurological diseases. In this review, we systematically report the evidence on clinical applications and robotic-assisted arm training (RAT) in functional recovery in PwMS. PubMed/MEDLINE, the Cochrane Library, and the Physiotherapy Evidence Database (PEDro) databases were systematically searched from inception to March 2021. The 10-item PEDro scale assessed the study quality for the RCT, and the AMSTAR-2 was used to assess the quality of the systematic review. The 5-item Oxford CEBM scale was used to rate the level of evidence. A total of 10 studies (161 subjects) were included. The selected studies included one systematic review, four RCTs, one randomized crossover, and four case series. The RCTs were scored as high-quality studies, while the systematic review was determined to be of low quality. Shoulder range of motion, handgrip strength, and proximal arm impairment improved after RAT. Manual dexterity, arm function, and use in daily life also ameliorated arm function. The high clinical heterogeneity of treatment programs and the variety of robot devices affects the generalizability of the study results; therefore, we emphasize the need to standardize the intervention type in future studies that evaluate the role of robotic-assisted training in PwMS. Robot-assisted treatment seems safe and useful to increase manual dexterity and the quality of movement execution in PwMS with moderate to severe disability. Additional studies with an adequate sample size and methodological rigour are warranted to drive definite conclusions.

The upper extremities limitation represents one of the essential functional impairments in patients with cervical spinal cord injury. Electromechanics assisted devices and robots are increasingly used in neurorehabilitation to help functional improvement in patients with neurological diseases. This review aimed to systematically report the evidence-based, state-of-art on clinical applications and robotic-assisted arm training (RAT) in motor and functional recovery in subjects affected by cervical spinal cord injury. The present study has been carried out within the framework of the Italian Consensus Conference on “Rehabilitation assisted by robotic and electromechanical devices for persons with disability of neurological origin” (CICERONE). PubMed/MEDLINE, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases were systematically searched from inception to September 2021. The 10-item PEDro scale assessed the study quality for the RCT and the AMSTAR-2 for the systematic review. Two different authors rated the studies included in this review. If consensus was not achieved after discussion, a third reviewer was interrogated. The five-item Oxford CEBM scale was used to rate the level of evidence. A total of 11 studies were included. The selected studies were: two systematic reviews, two RCTs, one parallel-group controlled trial, one longitudinal intervention study and five case series. One RCT was scored as a high-quality study, while the systematic review was of low quality. RAT was reported as feasible and safe. Initial positive effects of RAT were found for arm function and quality of movement in addition to conventional therapy. The high clinical heterogeneity of treatment programs and the variety of robot devices could severely affect the generalizability of the study results. Therefore, future studies are warranted to standardize the type of intervention and evaluate the role of robotic-assisted training in subjects affected by cervical spinal cord injury.

Spasticity is one of the major complications after stroke. Botulinum toxin type A (BoNT-A) injection is commonly used to manage focal spasticity. However, it is uncertain whether BoNT-A can improve activities of daily living function of paretic arm. The recovery of functions of the affected arm is also the aim of robotic upper limb (UL) therapy. The motorized exoskeleton assists the patient in a large 3D work environment by promoting movement for the UL (shoulder, elbow, wrist, hand). The combination of the BoNT-A injection and the robotic therapy might enhance functional recovery after stroke. We reported the case of a chronic stroke patient in which the injection of BoNT-A was combined with multi-joint exoskeleton training. The patient showed improvement in the motor control of the UL, supporting the feasibility of this approach.

Stroke patients have reduced balance and postural control that limits their activities of daily living and participation in social life. Recently, many exergaming systems based on video-biofeedback have been developed for balance training in neurological conditions, however their efficacy remains to be proven. The aim of this study was to investigate the effects on balance skills and patient compliance of biofeedback training based on inertial measurement units and exergaming in subacute stroke. The enrolled subjects were randomized into two groups: subjects allocated to the experimental group performed 10 sessions of biofeedback balance training using inertial sensors, whereas subjects allocated to the control group performed 10 sessions of conventional balance training. All subjects were assessed at T0 (pre-treatment), T1 (posttreatment) and T2 (1-month follow-up). The Berg Balance Scale, Rivermead Mobility Index and modified Barthel Index were used to assess balance, mobility and global disability, respectively. To assess the severity of the stroke and its effects on the patient we used the National Institutes of Health Stroke Scale and the Canadian Neurological Scale. Finally, a static force platform evaluating stabilometric paparameters was used to assess balance skills. Fifteen subjects with subacute stroke (4F; age 57.80 ± 13.7) completed the experimental protocol. The analysis showed a significant improvement in balance skills and in the overall clinical outcomes in the experimental group compared with the control group; the experimental group also showed better compliance with the training. The biofeedback system of the device used in this study probably enhances neuroplasticity mechanisms of postural and balance skills in subacute stroke patients. Stroke patients have reduced balance and postural control that limits their activities of daily living and participation in social life. Recently, many exergaming systems based on video-biofeedback have been developed for balance training in neurological conditions, however their efficacy remains to be proven. The aim of this study was to investigate the effects on balance skills and patient compliance of biofeedback training based on inertial measurement units and exergaming in subacute stroke. The enrolled subjects were randomized into two groups: subjects allocated to the experimental group performed 10 sessions of biofeedback balance training using inertial sensors, whereas subjects allocated to the control group performed 10 sessions of conventional balance training. All subjects were assessed at T0 (pre-treatment), T1 (posttreatment) and T2 (1-month follow-up). The Berg Balance Scale, Rivermead Mobility Index and modified Barthel Index were used to assess balance, mobility and global disability, respectively. To assess the severity of the stroke and its effects on the patient we used the National Institutes of Health Stroke Scale and the Canadian Neurological Scale. Finally, a static force platform evaluating stabilometric parameters was used to assess balance skills. Fifteen subjects with subacute stroke (4F; age 57.80 ± 13.7) completed the experimental protocol. The analysis showed a significant improvement in balance skills and in the overall clinical outcomes in the experimental group compared with the control group; the experimental group also showed better compliance with the training. The biofeedback system of the device used in this study probably enhances neuroplasticity mechanisms of postural and balance skills in subacute stroke patients.