Systematic review with network meta-analysis of randomized controlled trials of robotic-assisted arm training for improving activities of daily living and upper limb function after stroke

Background: The aim of the present study was to to assess the relative effectiveness of the various types of electromechanical-assisted arm devices and approaches after stroke. Method: This is a systematic review of randomized controlled trials with network meta-analysis. Our primary endpoints were activities of daily living (measured e.g. with Barthel-Index) and hand-arm function (measured e.g. with the Fugl-Meyer Scale for the upper limb), our secondary endpoints were hand-arm strength (measured e.g. with the Motricity Index) and safety. We used conventional arm training as our reference category and compared it with different intervention categories of electromechanical-assisted arm training depending on the therapy approach. We did indirect comparisons between the type of robotic device. We considered the heterogeneity of the studies by means of confidence and prediction intervals. Results: Fifty five randomized controlled trials, including 2654 patients with stroke, met our inclusion criteria. For the primary endpoints activities of daily living and hand-arm function and the secondary endpoint hand-arm strength, none of the interventions achieved statistically significant improvements, taking into account the heterogeneity of the studies. Safety did not differ with regard to the individual interventions of arm rehabilitation after stroke. Conclusion: The outcomes of robotic-assisted arm training were comparable with conventional therapy. Indirect comparisons suggest that no one type of robotic device is any better or worse than any other device, providing no clear evidence to support the selection of specific types of robotic device to promote hand-arm recovery. Trial registration: PROSPERO 2017 CRD42017075411.