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Title: Distal versus proximal - an investigation on different supportive strategies by robots for upper limb rehabilitation after stroke : a randomized controlled trial
Authors: Qian, QY 
Nam, CY 
Guo, ZQ 
Huang, YH 
Hu, XL 
Ng, SC
Zheng, YP 
Poon, W
Issue Date: 2019
Source: Journal of neuroEngineering and rehabilitation, 5 June 2019, v. 16, 64, p. 1-16
Abstract: Background Different mechanical supporting strategies to the joints in the upper extremity (UE) may lead to varied rehabilitative effects after stroke. This study compared the rehabilitation effectiveness achieved by electromyography (EMG)-driven neuromuscular electrical stimulation (NMES)-robotic systems when supporting to the distal fingers and to the proximal (wrist-elbow) joints.
Methods Thirty subjects with chronic stroke were randomly assigned to receive motor trainings with NMES-robotic support to the finger joints (hand group, n=15) and with support to the wrist-elbow joints (sleeve group, n=15). The training effects were evaluated by the clinical scores of Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), and Modified Ashworth Scale (MAS) before and after the trainings, as well as 3months later. The cross-session EMG monitoring of EMG activation level and co-contraction index (CI) were also applied to investigate the recovery progress of muscle activations and muscle coordination patterns through the training sessions.
Results Significant improvements (P<0.05) in FMA full score, FMA shoulder/elbow (FMA-SE) and ARAT scores were found in both groups, whereas significant improvements (P<0.05) in FMA wrist/hand (FMA-WH) and MAS scores were only observed in the hand group. Significant decrease of EMG activation levels (P<0.05) of UE flexors was observed in both groups. Significant decrease in CI values (P<0.05) was observed in both groups in the muscle pairs of biceps brachii and triceps brachii (BIC&TRI) and the wrist-finger flexors (flexor carpi radialis-flexor digitorum) and TRI (FCR-FD&TRI). The EMG activation levels and CIs of the hand group exhibited faster reductions across the training sessions than the sleeve group (P<0.05).
Conclusions Robotic supports to either the distal fingers or the proximal elbow-wrist could achieve motor improvements in UE. The robotic support directly to the distal fingers was more effective than to the proximal parts in improving finger motor functions and in releasing muscle spasticity in the whole UE.
Clinical trial registration:, identifier NCT02117089; date of registration: April 10, 2014.
Keywords: Stroke rehabilitation
Upper extremity
Supporting strategy
Publisher: BioMed Central
Journal: Journal of neuroEngineering and rehabilitation 
EISSN: 1743-0003
DOI: 10.1186/s12984-019-0537-5
Rights: © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.
The following publication Qian, Q. Y., Nam, C. Y., Guo, Z. Q., Huang, Y. H., Hu, X. L., Ng, S. C., … & Poon, W. (2019). Distal versus proximal - an investigation on different supportive strategies by robots for upper limb rehabilitation after stroke : a randomized controlled trial. Journal of neuroEngineering and rehabilitation, 16, 64, 1-16 is available at
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