Effect of Robot-assisted Rehabilitation to Botulinum Toxin A Injection for Upper Limb Disability in Patients with Chronic Stroke: A Case Series and Systematic Review

Combining single-joint hybrid assistive limb (HAL-SJ) with botulinum toxin A (BTX-A) therapy is novel and has great therapeutic potential for the rehabilitation of stroke patients with upper limb paralysis. The purpose of this observational case series study was to evaluate the effect of BTX-A and HAL-SJ combination therapy on different exoskeleton robots used for treating upper limb paralysis. The HAL-SJ combination received a BTX-A injection followed by HAL-SJ-assisted rehabilitation for 60 min per session, 10 times per week, during 2 weeks of hospitalization. Clinical evaluations to assess motor function, limb functions used during daily activities, and spasticity were performed prior to injection, at 2-week post-treatment intervention, and at the 4-month follow-up visit. The total Fugl-Meyer assessment-upper limb (FMA-UE), proximal FMA-UE, action research arm test (ARAT), Motor Activity Log (MAL), and Disability Assessment Scale (DAS) showed a statistically significant difference, and a large effect size. However, the FMA distal assessment at 2-week post-treatment intervention showed no significant difference and a moderate effect size. The FMA-UE scores of the extracted systematic review articles showed that our design improved upper limb function. The change in the total FMA-UE score in this study showed that, compared to previous reports in the exoskeletal robotic therapy group, our combination therapy had a higher score than five of the seven references. Our results suggest that BTX-A therapy and HAL-SJ combination therapy may improve upper limb function, similar to other treatment methods in the literature.