Although the name of T-WREX presumes a robotic device, both T-WREX and Armeo Spring are passive arm orthoses based on springs which contain several sensors to measure movements of the arm and hand. The Therapy Wilmington Robotic Exoskeleton (T-WREX) and its commercially available version Armeo Spring are the most investigated non-robotic devices that were successful in improving the arm function. In comparison to the large amount of robotic devices that are studied, only a few studies investigated non-robotic devices. Unactuated devices could be a cheaper alternative, safer to use at home and may have the same training effect. However, these devices are often expensive and therefore not suitable to be used at home and supervision is needed due to safety issues. Robot-assisted training devices, containing an actuator or motor, have shown to be effective in improving the upper limb function in stroke patients. Serious games and telerehabilitation can be combined with training devices to even further increase the effectiveness of therapy. A positive dose–response relation between the amount of training and upper limb improvement emphasizes the need for intensive training. By providing various serious games with different levels of difficulty, the patient may be more motivated to continue the training program, which may lead to more improvement in arm function. Keeping patients motivated is of utmost importance because patients express that performing the same exercises may lead to boredom and inhibits continuation of training. Serious games are computer games used for training or educational purposes. Telerehabilitation combined with serious games may increase the engagement of the patient with the therapy. Using telerehabilitation (providing rehabilitation via online communication), the patient can train at home, and the therapist is able to provide assistance from a distance using online communication. Home rehabilitation could fill the gap of insufficient amount of training for patients in the chronic phase of stroke. More affordable ways of providing intensive, task specific therapy in the chronic phase of stroke are needed. However, this is not yet generally available in practice for patients in the chronic phase of stroke, possibly due to the high costs of individual sessions with a therapist. Therefore, training has to involve a few key parameters that are important for motor learning such as high intensity training, many repetitions and a task specific approach. However, more evidence is emerging that patients in the chronic phase of stroke are able to improve the upper limb function significantly. It is generally believed that after six months, a plateau in functional motor recovery is reached. Upper limb function is often undertreated according to patients, and consequently many return home from a hospital or rehabilitation center with remaining disabilities. During recovery, patients and therapists have to focus on many rehabilitation goals such as improving balance and gait, and reducing spasticity. After stroke, almost 77% of the patients have a paretic upper limb with loss of function, leading to a lower quality of life. Stroke is common in the general population, with annually 1.1 million people in Europe suffering from stroke. Trial registration This study is registered at the Netherlands Trial Register (NL7535). Patients in the chronic phase of stroke significantly improved their upper limb function with the MERLIN training at home. Comfort and the robustness of the system need further improvements. Patients were overall satisfied with the usability of the device. No significant changes in quality of life were observed. From start of the intervention to six weeks follow up, WMFT improved significantly with 3.8 points (p = .006), which is also clinically relevant. Twelve patients were included, ten completed the training. Secondary outcomes were other arm function tests, quality of life, user satisfaction and motivation. Primary outcome was the Wolf Motor Function Test (WMFT). Measurements were performed six weeks pre-intervention (T0), at the start (T1), end (T2) and six weeks post-intervention (T3). Progress was monitored and game settings were tailored through telerehabilitation. Patients trained task specific serious games for three hours per week during six weeks using an unactuated version of a robotic device. The aim of this study is to investigate the effect of MERLIN training on the upper limb function of patients with unilateral upper limb paresis in the chronic phase of stroke (> 6 months post stroke). Stroke patients are able to train the upper limb function using serious games at home. HoMEcare aRm rehabiLItatioN (MERLIN) is an unactuated version of the robotic device ArmAssist combined with a telecare platform.
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