title: Technology-assisted stroke rehabilitation in Mexico: a pilot randomized trial comparing traditional therapy to circuit training in a Robot/technology-assisted therapy gym.
abstract: Stroke rehabilitation in low- and middle-income countries, such as Mexico, is often hampered by lack of clinical resources and funding. To provide a cost-effective solution for comprehensive post-stroke rehabilitation that can alleviate the need for one-on-one physical or occupational therapy, in lower and upper extremities, we proposed and implemented a technology-assisted rehabilitation gymnasium in Chihuahua, Mexico. The Gymnasium for Robotic Rehabilitation (Robot Gym) consisted of low- and high-tech systems for upper and lower limb rehabilitation. Our hypothesis is that the Robot Gym can provide a cost- and labor-efficient alternative for post-stroke rehabilitation, while being more or as effective as traditional physical and occupational therapy approaches.
  
  
  
  A typical group of stroke patients was randomly allocated to an intervention (n = 10) or a control group (n = 10). The intervention group received rehabilitation using the devices in the Robot Gym, whereas the control group (n = 10) received time-matched standard care. All of the study subjects were subjected to 24 two-hour therapy sessions over a period of 6 to 8 weeks. Several clinical assessments tests for upper and lower extremities were used to evaluate motor function pre- and post-intervention. A cost analysis was done to compare the cost effectiveness for both therapies.
  
  
  
  No significant differences were observed when comparing the results of the pre-intervention Mini-mental, Brunnstrom Test, and Geriatric Depression Scale Test, showing that both groups were functionally similar prior to the intervention. Although, both training groups were functionally equivalent, they had a significant age difference. The results of all of the upper extremity tests showed an improvement in function in both groups with no statistically significant differences between the groups. The Fugl-Meyer and the 10 Meters Walk lower extremity tests showed greater improvement in the intervention group compared to the control group. On the Time Up and Go Test, no statistically significant differences were observed pre- and post-intervention when comparing the control and the intervention groups. For the 6 Minute Walk Test, both groups presented a statistically significant difference pre- and post-intervention, showing progress in their performance. The robot gym therapy was more cost-effective than the traditional one-to-one therapy used during this study in that it enabled therapist to train up to 1.5 to 6 times more patients for the approximately same cost in the long term.
  
  
  
  The results of this study showed that the patients that received therapy using the Robot Gym had enhanced functionality in the upper extremity tests similar to patients in the control group. In the lower extremity tests, the intervention patients showed more improvement than those subjected to traditional therapy. These results support that the Robot Gym can be as effective as traditional therapy for stroke patients, presenting a more cost- and labor-efficient option for countries with scarce clinical resources and funding.
  
  
  
  ISRCTN98578807 .
authors.affiliation: Orthopaedic and Rehabilitation Engineering Center (OREC), Marquette University, Milwaukee, WI, USA.|Biomedical Engineering, ITESM, Campus Chihuahua, Chihuahua, Chihuahua, Mexico.
authors.forename: Karla
authors.initials: K
authors.lastname: Bustamante Valles
authors.affiliation: Biomedical Engineering, ITESM, Campus Chihuahua, Chihuahua, Chihuahua, Mexico.
authors.forename: Sandra
authors.initials: S
authors.lastname: Montes
authors.affiliation: Centro de Rehabilitacion y Educacion Especial, DIF, Chihuahua, Chihuahua, Mexico.
authors.forename: Maria de Jesus
authors.initials: Mde J
authors.lastname: Madrigal
authors.affiliation: Centro de Rehabilitacion y Educacion Especial, DIF, Chihuahua, Chihuahua, Mexico.
authors.forename: Adan
authors.initials: A
authors.lastname: Burciaga
authors.affiliation: Biomedical Engineering, ITESM, Campus Chihuahua, Chihuahua, Chihuahua, Mexico.
authors.forename: María Elena
authors.initials: ME
authors.lastname: Martínez
authors.affiliation: Department of Physical Medicine and Rehabilitation, University of Pennsylvania, Philadelphia, PA, USA. johnmic@mail.med.upenn.edu.|Department of Biomedical Engineering, University of Pennsylvania, Philadelphia, PA, USA. johnmic@mail.med.upenn.edu.|Orthopaedic and Rehabilitation Engineering Center (OREC), Marquette University, Milwaukee, WI, USA. johnmic@mail.med.upenn.edu.
authors.forename: Michelle J
authors.identifier: 0000-0002-7964-0304
authors.initials: MJ
authors.lastname: Johnson
mesh_terms: D000328:Adult; D000368:Aged; D065327:Circuit-Based Exercise / Q000191:economics; D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D035002:Lower Extremity; D008297:Male; D008800:Mexico; D008875:Middle Aged; D009788:Occupational Therapy; D026741:Physical Therapy Modalities; D010865:Pilot Projects; D012371:Robotics / Q000191:economics; D000071939:Stroke Rehabilitation / Q000191:economics / Q000295:instrumentation*; D034941:Upper Extremity; D016138:Walking
keywords: Affordable; Global Health; Low-and-Middle Income Countries (LMIC); Lower limb; Rehabilitation; Robot therapy; Stroke; Upper limb