Robotics and Autonomous Systems 91 (2017) 169–178

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Robotics and Autonomous Systems

journal homepage: www.elsevier.com/locate/robot

Robotic wrist training after stroke: Adaptive modulation of assistance

in pediatric rehabilitation
Francesca Marini a , Charmayne M.L. Hughes b , Valentina Squeri a , Luca Doglio c ,
Paolo Moretti c , Pietro Morasso a , Lorenzo Masia d, *
a
Department of Robotics, Brain and Cognitive Sciences, Istituto Italiano di Tecnologia, Genova, Italy
b
Department of Kinesiology, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132, United States
c
Physical Medicine and Rehabilitation Institute G. Gaslini, Genova, Italy
d
Robotics Research Centre, School of Mechanical and Aerospace Engineering, Nanyang Technological University, 50 Nanyang Ave, Singapore 639798,
Singapore

highlights

• Pediatric stroke leads to limb hemiparesis, sensory impairments, and spasticity.

• A 14-year old stroke patient completed in a 3-month wrist robotic training program.
• The robot provided online adaptive modulation of assistance instantaneously during each trial.
• Robot therapy led to positive changes in upper limb motor coordination and function.
• In addition, the patient needed less robot assistance to complete each trial.

article info a b s t r a c t
Article history: In this paper we present a case study in which a 14-year-old, right-handed stroke patient with severe
Available online 25 January 2017 weakness, spasticity, and motor dysfunction of the left upper extremity participated in a three-month
distal robotic training program. The robotic device was compliant to the patient’s movements and
Keywords: was able to modulate the level of assistance continuously throughout the trial (i.e., online adaptive
Motor dysfunction
modulation). Standard clinical and robotic evaluations of upper extremity motor performance were
Robotic rehabilitation
conducted before and after robotic training. There were improvements in upper extremity spasticity and
Pediatric stroke
Wrist rehabilitation motor functions. In addition, robotic training lead to positive changes in wrist active range of motion
and kinematics: movements were smoother and there was a noticeable decrease in the level of robotic
intervention required to complete each trial. In sum, results of the present case study demonstrate
that distal upper extremity robotic rehabilitation that features the proposed adaptive control algorithm
promoted positive changes in upper limb motor coordination and function after pediatric stroke.
© 2017 Published by Elsevier B.V.

1. Introduction by muscle weakness, impaired motor coordination, and impair-

Stroke or cerebral vascular accident (CVA), caused by the oc-
clusion or rupture of cerebral blood vessels, is the leading cause
of neurological disability worldwide. It has been estimated that
among the children who survive, between 50% and 80% will exhibit
permanent upper extremity sensorimotor deficits [1]. The most
common long-term impairments are hemiparesis (weakness of the
entire left or right side of the body) or hemiplegia (total or partial
paralysis on one side of the body) [2], which is often accompanied
* Corresponding author.
E-mail address: lorenzo.masia@ntu.edu.sg (L. Masia).
ments to sensory mechanisms of the affected paretic arm [3,4].
Functional loss of mobility due to hemiplegia has a significantly
negative impact on the ability to perform activities of daily living,
such as reaching and grasping and object manipulation. In addition
to hemiplegia, stroke patients often present with spasticity and
contractures of the elbow, wrist, and finger muscles [5,6]. Upper
extremity spasticity can lead to pain, tendon retraction or muscle
weakness, which has negative effects on a patient’s quality of life
and rehabilitation outcomes [7,8].
Current conventional stroke rehabilitation therapies are a labor
intensive process that involve daily one-on-one interactions with
therapists that can last for several weeks. Fortunately, robotic
advancements in the last decade have provided researchers

http://dx.doi.org/10.1016/j.robot.2017.01.006
0921-8890/© 2017 Published by Elsevier B.V.
170 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178
with instruments that can reduce the burden on therapists and
healthcare systems [9]. Robot-aided rehabilitation affords several
potential advantages to conventional therapy, including high re-
peatability, accurate control of robotic assistance or resistance
levels, and objective measurement of patients’ kinematic and dy-
namic performance [10,11]. In addition, rehabilitation robotics
leverage virtual reality multi-dimensional non-immersive games
to increase patient engagement and provide additional motiva-
tional components across the rehabilitation lifespan [12].
One of the most important aspect of integrating robotic de-
vice in clinical rehabilitation has always been the choice of the
most effective control algorithm [13]. Early rehabilitation robotic
devices implemented control algorithms that attempted to mimic
the actions of the therapist by using a robot to help completing
the movement task if the patient is unable to [14]. Initial clinical
results indicated that these active assistance algorithms lead to an
increase in arm strength and a noticeable recovery of functional
independence [10] with benefits lasting more than 3 years [15].
Several groups proposed a different approach based on active mod-
ulation of robotic assistance indicated as adaptive control strat-
egy [12,16]. This assistance-as-needed control strategy evaluates
performance across trials using different variables collected during
the therapeutic protocol (e.g., elapsed time, force generated by the
patient, limb velocity) and provides the patient with the minimal
amount of robotic assistance necessary for to complete a task,
modulating the flow of control authority and avoiding the device
assistance is perceived too invasive or provides a drastic reduction
of voluntary action modulation.
Ideally, assistance should be adjusted with respect to the cur-
rent amount of voluntary control. As the latter is not readily
available, most schemes of regulation are driven by the observed
performance. Among the several ways to provide assistance, and
to continuously regulate it, optimal solutions have been proposed
for simple, specific tasks, like lifting a weight [17,18], or for lower
limb rehabilitation tasks, in which the robot adaptively takes into
account the patient’s intention rather than imposing an inflexible
control strategy. This adaptive law is an error-based strategy that
adjusts a control parameter from trial to trial based on measured
participant performance [19]. Another approach is to pose the
assistance-as-needed problem as one in which the goal is to mini-
mize a cost that is the sum of kinematic error (ensuring the task is
completed) and robotic assistance (ensuring that the robot assists
as little as possible) [20]. Recently, Wolbrecht and coll. [21] pro-
posed an adaptive control scheme in which a controller negotiates
an error-reducing and an effort-reducing component. This keeps
assistance to a minimum and to automatically adapt it to task
performance, while providing enough assistance to support task
completion. This technique does not explicitly aim to augment the
degree of voluntary control. Such an increase is assumed to result
from the ability to successfully complete the task.
In general, clinical studies in adult stroke populations have
demonstrated that assistance-as-needed algorithms lead to reduc-
tions in upper extremity spasticity and improvements in the ability
to perform functional movements [22,23].
However, there are limitations in the aforementioned control
approach. First, there is an evidence of a slacking response, in
which the patient triggers the robotic assistance by producing an
initial movement, but then decreases the level of muscular activa-
tion and voluntary movement so that the adaptive controller takes
over the task [24,25]. Second, although the assistance-as-needed
algorithms adapt the level of robotic assistance on a trial-to-trial
or session-by-session basis, assistance modulation is not updated
continuously within a single trial. This is unfortunate as one of the
important features of the robotic therapy is the possibility to tailor
exercises to the specific initial impairments of the patient and their
progress over the course of rehabilitation lifespan [26].
The present work provides a further contribution in this di-
rection by assessing the clinical effects of distal upper extremity
robotic training program that incorporates an adaptive modulation
of assistance each single instant of the movement during a trial.
In contrast to previous control algorithms, the proposed one was
designed in such a way that the robotic intervention provided
assistance along the target direction in a point to point task. The
magnitude of the assistive elastic component is online modulated,
on a moment-by-moment basis, so as to have a level of assistance
always tailored to the participant’s capabilities. Specifically, the
robotic device provides more assistance during the trial when the
patient requires it, and less intervention when the participant is
able to move toward the target.
In this case study we describe the potential benefit of our
control algorithm in the rehabilitation of a pediatric stroke patient
with severe weakness, spasticity, and motor dysfunction of the left
upper extremity who did not benefit from conventional therapy.
Improvements were assessed using clinical and robotic evaluations
of upper extremity motor performance. It was hypothesized that
robotic training with our distal control algorithm would be particu-
larly effective in improving upper extremity function in this patient
without increasing spasticity.
2. Methods
2.1. Case description
The patient was a 14-year-old, right-handed female with no
family history of vascular or hematologic disorders who had a
first-occurrence stroke , participated in robot-assisted distal upper
extremity training twice per week for a total of three months.
Neurological examination presented severe weakness and motor
impairment to the left upper extremity, more strongly affecting
distal than proximal limb function. Initial assessment revealed a
noticeable bias from the neutral configuration at the paretic wrist
joint at rest, which resulted in accentuated pathological flexion.
The patient presented with high levels of hypertonia in the paretic
wrist, and even when the patient was asked to relax her muscles
(i.e., adopt a neutral limb position) the configuration of the wrist
was characterized by exaggerated flexion indicating the presence
of hypertonia. This bias caused the wrist to freeze in an unnatural
posture, restricting the ability of the patient to use her hand and en-
tire upper extremity during the performance of functional actions
and skilled activities of daily life. Acute neurological assessment
indicated the presence of an intracranial hemorrhage of idiopathic
origin. Magnetic Resonance Imaging (MRI) revealed a low T2 sig-
nal intensity haemosiderin staining in the left cerebral peduncle,
left midbrain tegmentum, and left superior and middle cerebellar
peduncles, indicating that the patient suffered from a hemorrhagic
stroke affecting the midbrain and cerebellum. After hospitalization
the patient received intensive gait training and occupational ther-
apy for a period of sixteen weeks. Four months from the stroke
onset, the patient was enrolled in a robotic rehabilitation program,
as upper extremity spasticity and functional independence did
not improve during the sixteen weeks of conventional therapy.
Informed consent was obtained from the parents of the patient
prior to participation in the study. The experiment was approved
by the ethical committee, and was conducted in accordance with
local ethical guidelines.
2.2. Experimental setup
The experimental device (Fig. 1A) used in this study was a 3
degree of freedom (DoF) exoskeleton developed specifically for
the study of human motor control and neurorehabilitation. The
device allows full range of motion for the human wrist across its
 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178
three DoFs (Fig. 1B) and is fully backdrivable, thereby making it
suitable for use in the current experiment [27]. The range of motion
(RoM) for the three DoFs approximates that of a normal human
wrist (flexion/extension: human = 65◦ /70◦ , robot = 72◦ /72◦ ;
adduction/abduction (AA): human = 19◦ /30◦ , robot = 45◦ /27◦ ;
pronation/supination (PS): human = 90◦ /90◦ , robot = 80◦ /80◦ ).
The robot is powered by four brushless motors that enable accu-
rate haptic rendering, the weight and inertia compensation of the
device, and it can overcome muscular contraction and allow for the
manipulation of joints in case of hypertonia. One of the four motors
actuates the FE and one actuates the PS, while the remaining two
motors actuate the AA mechanism. They are symmetrically located
on each side of the robot and serve to balance and provide gravity
compensation of the FE element. The axis of rotation of both motors
is rotated by 90◦ thanks to conic couplings. They allow the axis
of rotation to coincide with each other with the human wrist’s
axis of rotation. The continuous torque range at the different wrist
joints is 1.53 N m, 1.63 N m, and 2.77 N m for FE, AA, and PS,
respectively [28].
The system was integrated into a virtual reality (VR) environ-
ment that provided visual feedback to the user during the task
(Fig. 1C). The patient controlled the position of an end-effector
(EE), represented on the screen as a gray dot. The configuration of
wrist joints for FE and AA motions were represented as a projection
on the screen on x and y axes of the virtual reality environment
respectively. The EE displacement along the two coordinate axes
(x, y) was linearly proportional to the rotation of the wrist around
the FE and AA axes. The scaling coefficient was chosen so that the
dimensions of the computer monitor matched the wrist RoM of
the patient. The targets in the virtual environment were selected
so that there were movements that required a single DoF as well
as movements that required the coordinated use of two DoFs.
The maximum angular span in the workspace was determined by
assessing the patient’s active FE and AA RoM prior to enrollment in
the robotic training program (5◦ for both DoFs).
2.3. Adaptive modulation of assistance control algorithm
The control algorithm was designed to accurately provide the
appropriate level of assistance and force during the task; the gains
were opportunely chosen and tuned by the controller depending
on the patient’s wrist movement ability and residual capacity of
motion. In particular, the robot offered assistance when the par-
ticipant was unable to reach targets without aid, (and thus would
not able to complete the trial) by providing active assistance as
needed [29]. In this way, the muscle activity of the patient was
increased and neural plasticity was encouraged [30,15].
The control architecture included three main components
(Fig. 2), a force field generator, a performance evaluator, and an
adaptive controller. The force field generator was online modu-
lated by means of elastic and viscous components using the fol-
lowing impedance control scheme (Eq. (1)):
F = K (θT − θW ) − Bθ̇W .
The viscous force Bθ̇W was proportional to the joint angular
speed and introduced a stabilizing effect during movement (i.e., fil-
tering possible muscular tremor that may arise during motion).
Damping values were set to which based on prior experimen-
tation [31,32], enabled simultaneous smooth and stable interac-
tions between the device and the patient. This value was constant
throughout sessions. The elastic force (K (θT − θW )) was the main
component of the force field generator (F ) and was directed from
the actual position of the EE to the target. As such, assistance
intensity is proportional to the distance between the EE and the
target and is online modulated (according to the motor abilities of
the patient) via EE speed monitoring.
171
We decided to use the speed to adjust the controller on the basis
of subject’s kind of impairment. Indeed, the subject was hemiplegic
with a high degree of anisotropy in the active range of motion of
the two DoFs (Flexion/Extension and Abduction/adduction). We
assumed that, when the speed was too low, or close to zero the
subject was unable to move and complete the task and the stiffness
k had therefore to be linearly increased. As soon as the assistance
was sufficient for the subject to start moving again (and conse-
quently for the speed to increase), the assistive force had to remain
constant since the subject was able to move by herself. When the
movement was performed with a high level of speed we assumed
that the movement could be easily accomplished and there was no
need for that level of assistance, that accordingly, was decreased.
The performance evaluator updated the magnitude of the stiff-
ness K after an instantaneous check of EE speed. A preset min-
imal speed threshold provided the means by which to decide if
the stiffness K of the controller must be increased or decreased
when patient’s movement was lower or higher to the threshold
respectively. When the speed of the EE was lower than 0.05 rad/s
the stiffness K of the assistive force field increased linearly with
a 0.1 [N m/rad/s] slope. Once the speed exceeded 0.3 rad/s the K
slope was reversed to a decreasing trend. K was kept constant if
the speed was in a 0.05–0.3 rad/s range.
v < vt1 K ↑
{
k = k(v ) = vt1 < v < vt2 K = cost (2)
v > vt2 K ↓
As such, the adaptive controller changes the value of K throughout
the trial and serves to provide to the force field generator the
amplitude of the proper amount of force that has to be delivered
to the participant.
2.4. Procedure
The patient sat comfortably in front of a screen with the torso
and forearm restrained to a rigid support by Velcro straps. This
ensured the biomechanical and robot rotation axes were approxi-
mately aligned. After the patient grasped the handle of the EE with
the impaired hand, clinic staff member used a neoprene glove and
Velcro strap to assure a correct and continuous contact between
hand and EE. The therapeutic team visually inspected forearm and
wrist placement every 5 min in order to ensure that the patients
grasp on the robotic handle was maintained throughout the ses-
sion.
The virtual environment was rendered in the form of a puzzle
game (e.g., an animal, television or movie actor, landscape) in
order to ensure patient motivation over the three-month training
program. The patient performed a series of nine point-to-point
reaching actions in which she used the robotic handle to move
the virtual EE (i.e., the gray circle) from the start position toward
a specified target (i.e., the red circle). Upon successfully reaching
the target a portion of the puzzle was unveiled, and after a 2 s
pause the next target was displayed on the computer monitor. The
complete puzzle was visible on the computer monitor after patient
successfully performed reaching movements to all nine targets.
(1) Visual feedback regarding the position of the virtual EE through-
out the duration of the trial (Fig. 1C). At the start of each session
the patient was informed that movement accuracy and comple-
tion time was of utmost importance, and these instructions were
repeated throughout each training session, as needed. To moti-
vate the patient throughout the three months training program
the Virtual Environment was rendered in the form of a puzzle
game (e.g., an animal, television or movie actor, landscape). After
completion of each reaching movement (i.e., trial) a portion of the
puzzle was unveiled. The robotic training sessions were carried
out at the pediatric hospital Gaslini of Genoa, Italy, under the
supervision of experienced clinical personnel and engineers. The
patient did not receive any other rehabilitative treatment or advice
regarding the use of the paretic hand during the experiment period.
172 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178

Fig. 1. (A) Wrist robotic device with associated representation of its three Degrees of freedom (B). (C) Workstation comprising the robotic device and a screen for the virtual
reality environment providing the visual feedback and ideal trajectories for 9 different targets during the pointing exercise.

Fig. 2. Assistive control algorithm consisting in three components: a performance evaluator, a force field generator and an adaptive controller.

2.5. Clinical and robotic measurements
Clinical and robotic evaluations of upper extremity motor per-
formance were carried out one week before (t1) and one week after
the robotic therapy (t2). Each evaluation session lasted between
60 and 90 min hours. Clinical measures included the Melbourne
Assessment of Unilateral Upper Limb Function, MAUULF [33], the
Assisting Hand Assessment, AHA, [34], and the Modified Ashworth
Scale, MAS [35].
We also evaluated performance using robot-based measures,
as these have been found to have high resolution and repeata-
bility, and provide complementary information regarding motor
function [15]. To this end wrist joint rotation was recorded from
the robot’s incremental encoders: the patient’s wrist joint angular
RoM was estimated before (t1) and after robot training (t2). For
each DoF (flexion/extension and abduction/abduction) the patient
freely moved the handle of the robot handle back and forth twenty
times, attempting to achieve the maximum excursion of articu-
lar joints. RoM was calculated as the maximum excursion value
reached by the patient. During this test the motors of the robot
were turned off, thus the patient moved the robotic handle without
any assistance.
Wrist motion was post-processed to evaluate potential dif-
ferences in motor recovery across the training program, and the
robotic data were calculated for each trial. Movement onset was
defined as the instant in which the wrist rotation speed exceeded
a threshold of 0.02 rad/s. Movement offset was defined as the
time at which the distance between EE and the target was less
than 0.02 rad with angular speed below 0.02 rad/s. The following
kinematic performance indicators were calculated:
• Execution time (s): The time period between movement on-
set and offset.
• Lateral deviation: mean distance between actual trajectory
by the patient and the ideal straight trajectory between
the center of two consecutive targets, calculated across the
entire trials.
• Linearity index: The ratio between the length of ideal tra-
jectory (the straight line connecting the starting point to
the target), and the trajectory covered by the end-effector.
A linearity index value of 1 (or 100%) indicates that the
movement path was identical to that of the ideal trajectory,
whereas values below 1 (or 100%) indicate that the patient
is unable to achieve the final end point. Values above 1 (or
100%) indicate that the movement path was longer than
the ideal trajectory and featured one or more corrective
movements.
• Smoothness index: The smoothness of the trajectory was
evaluated using Teuling’s jerk indicator [36]. This indicator
is calculated from each trajectory by obtaining the jerk J(t)
(the third time derivative of the trajectory) and computing
 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178
Table 1
Pre- and post-robotic training scores from the Melbourne Assessment of Unilateral
Upper Limb Function (MAUULF) and the Assisting Hand Assessment (AHA).
t1 t2
MAUULF (% scores) 11.89% 26.63%
AHA (raw score) 36/88 50/88
the square root of the averaged norm of Jerk, normalized
with respect to duration T and path length L (Eq. (3)):
√
T5
∫
1
jerk index = ∥J(t)∥2 dt .
2 L2
Teuling’s jerk is dimensionless and does not depend on
movement duration and trajectory length. Reduced coordi-
nation results in multiple acceleration peaks (i.e., increased
jerk levels) with lower values indicating smoother move-
ments and higher motor coordination and control
• The level of robotic assistance (i.e., amount of torque gener-
ated by the robot to help the patient complete the trial) was
also evaluated. Overall FE and AA torques were measured
to quantify the total amount of assistance provided to the
subject to perform the task, as well as separately in order to
determine the recovery trend for each wrist DoF.
• The stiffness (K ), modulated online by the control algorithm
has been quantified (Eq. (2)).
3. Results
The patient participated in robot therapy twice a week for a
period of three months, with a total of forty sessions completed. On
average, the patient completed between 3 and 6 puzzles (between
27 and 54 trials) per robotic therapy session. Each session lasted
between 30 and 60 min, with the length of individual sessions
depending on the level of collaboration, fatigue and psychological
status of the patient on that day.
3.1. Clinical measures
Outcome scores from clinical evaluation obtained before (t1)
and after robot therapy (t2) are shown in Tables 1 and 2. Prior to
robotic therapy the patient obtained a score of 11.9 in the MAUULF
scale, which improved to 26.6 after the three months training
period. MAUULF guidelines state a 14-point score change can be
considered clinically significant, and as such the 14.8 difference
obtained in the present study is indicative of a clinically significant
improvement in upper limb function. AHA scores also improved,
with a 15.9-points difference between pre- and post-assessment
(t2−t1). This improvement exceeds the minimum change of points
required to be considered clinically significant [37,38], indicating
that the patient had a noticeable reduction of motor impairments
during bimanual activities.
MAS scores of different upper extremity joints prior to (t1) and
after robot therapy (t2) are shown in Table 2. Prior to robot ther-
apy (t1) the patient exhibited considerable spasticity in the wrist
flexors (MAS score of 3), and mild spasticity in the wrist extensors,
elbow and finger flexors (MAS score of 2: more marked increase
in tone, but affected parts are easily moved) and shoulder muscles
(MAS score of 1+: slightly increased tone). After the robotic train-
ing program (t2), MAS score was reduced at all levels of the upper-
limb, with greater improvements in the wrist extensors, elbow,
wrist, and finger flexors (2-point change in score) compared to the
shoulder muscles, and elbow extensors (1-point change in score).
173
Table 2
Modified Ashworth Scale (MAS) scores of different joints of the upper extremity
prior to (t1) and after (t2) robotic training.
Difference t2–t1 Pre-training (t1) Post-training (t2)
14.75% Shoulder adduction 1+ 1
14 points Shoulder abduction 1+ 1
Elbow flexor 2 1
Elbow extensor 1+ 1
Wrist flexor 3 2
Wrist extensor 2 2
Finger flexor 2 2
(3)
3.2. Robot-based measures
To determine the effect size of the distal upper extremity
robotic rehabilitation program that featured an adaptive mod-
ulation of assistance, Tau-U was calculated separately for each
robot-based measure [39]. TAU-U is a non-parametric derivation of
Kendall’s rank correlation and the Mann–Whitney U test between
groups (trend index and nonoverlap index, respectively) com-
monly used in single case research that examines the percentage
of non-overlap of the data between phases (i.e., pre-training vs.
post-training [40]. Tau-U scores range from 0 to 1, with 0.93 to 1
considered a large effect, 0.66 to 0.92 a medium effect, and 0 to 0.65
a small effect [41]. Alpha was set at 1.0; a Bonferroni correction was
not applied as the measures tested were dependent.
Fig. 3A depicts mean values of wrist joint angular RoM before
(t1) and after robot training (t2), for the four motions (FL, EX,
ABB, ADD). Active flexion RoM was substantially greater after robot
training (∼68.5◦ ) was substantially greater than prior to robot
training (∼45.5◦ ), resulting in a ∼23◦ increase, Tau − U = 0.778,
90% CI = −0.06 to 1.0, p = 0.089. The improvements in wrist
extension (∼0.94◦ at t1 and ∼2◦ at t2) and wrist abduction RoM
(∼2◦ at t1 and ∼4.5◦ at t2) also reached statistical significance,
Tau − U = 0.889, 90% CI = 0.156 to 1.0, p = 0.809 and
Tau − U = 1.0, 90% CI = 0.162 to 1.0, p = 0.0495, respectively. The
improvement in wrist adduction RoM apparent after robot training
(∼24.5◦ at t1 and ∼38◦ at t2) failed to reach statistical significance,
Tau − U = 0.667, 90% CI = −0.067 to 1.0, p = 0.190.
3.2.1. Kinematic measures
Representative movement trajectories are depicted in Fig. 3B,
and mean values for all kinematic indicators before (t1) and after
robot training (t2) are shown in Fig. 4A. For targets 1–8, execu-
tion time values were significantly shorter during the last session
(mean = 7.43 s, SD = 2.8) compared to the first session (mean =
22.67 s, SD = 2.8), (Tau − Urange = 0.64–0.92, 90% CIrange = −1.00
to −0.37, all p’s < 1.0). For target 9, Tau − U analysis indicated that
execution time values were significantly shorter during the last
(7.55 s, SD = 3.2) compared to the first session (4.60 s, SD = 3.06),
Tau − U = 0.68, 90% CI = 0.05 to 1.0, p = 0.076).
Improvements in lateral deviation were also found, with the
maximum distance between the actual and the ideal trajectories
decreasing from 10.98◦ (SD = 7.8) at t1 to 2.92◦ (SD = 2.1)
at t2 (mean difference = 8.1◦ ), p < 0.001. Improvements
in lateral deviation was observed for all movement directions
(mean difference = 8.06◦ , SD = 7.31◦ , range = 1.68◦ –20.86◦ ),
indicating that the subject regained mobility and isotropic RoM
despite the high level of spasticity. Tau − U analysis revealed
significant differences in lateral deviation for targets 1–8 (Tau −
Urange = −0.60–1.0, 90% CIrange = −1.00 to −0.37, all p’s < 1.0),
but not target 9 (Tau − U = 0.02, 90% CI = −1.00 to −0.37,
p = 0.602).
The patient showed significant improvement (p < 0.001) in
linearity index, performing the movements with straighter trajec-
tories in the last session (mean = 1.32, SD = 0.5) than the first
174 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178

Fig. 3. (A) Mean active RoM values calculated prior (t1) and after robot training (t2) for the different tasks (FL, EX, AB, AD). Error bars indicate Standard Deviation evaluated
on the total number of trajectories requesting vertical or horizontal movements. (B) Representative trajectories during the first (left) and the last (right) training session.

Fig. 4. (A) Trend of performance’s indicators between first and last sessions. (B) Robotic assistance for the first five and the last five training sessions for flexion/extension (FE)
and abduction/adduction (AA), and trend line across sessions of total assistive torque and stiffness of the force field. Colors correspond to the different targets, as indicates
in Fig. 1C.

(mean = 6.31, SD = 4.5). Trajectories were found to be straighter
after robotic training for targets 1–8 (mean difference = 5.4,
SD = 4.5, range = 1.09–11.23), which was confirmed by Tau − U
analysis (Tau − Urange = −0.76–1.0, 90% CIrange = −1.00 to
−0.37, all p’s < 1.0). In contrast, linearity values did not differ
significantly between the first and last session for target 9 (2.92
and 1.60 respectively), Tau − U = 0.02, 90% CI = −0.43 to 0.83,
p = 0.602.
Movement smoothness significantly changed over the course
of therapy, such that trajectories in the last training session were
smoother (0.180e4, SD = 0.033e04) when compared to the first
training session (2.405e4, SD = 0.537e4). Tau−U analysis revealed
significant differences in lateral deviation for targets 1–3 and 5–8
(Tau − Urange = −0.68–1.0, 90% CIrange = 0.05 to 1.0, all p’s < 1.0),
but not target 4 (Tau − U = 0.52, 90% CI = −0.031 to 1.0,
p = 0.175).
3.2.2. Robot assistance measures
The level of assistance provided by the robotic device was also
evaluated (Figs. 4B and 5). In general, the amount of assistive force
was higher in the first training session than the last session for FE
(14.16 m N m vs 2.08 m N m, , Tau − U = −0.84, 90% I = −1.0
to −0.210 , p = 0.0283) and AA (29.35 m N m vs 5.45 m N m),
Tau − U = −1, 90% CI = −1.0 to −0.370 , p = 0.0090, both
p values < 0.001. As can be seen in Fig. 4B (third and fourth
panels), there was a decreasing trend in the total amount of re-
quired robotic assistance (exponential fit, r 2 = 0.52) and stiffness
(exponential fit, r 2 = 0.59), indicating that the patient needed less
robotic assistance after completing the robotic training program.
Important information can be gleaned by examining the unique
contributions of the separate FE and AA DoFs. The directional
representation of the assistance at the beginning (t1) and end (t2)
of the therapy is shown in the first and second panels of Fig. 4B. It
is clear that the amount of torque provided by the device is higher
in directions in which the subject was initially unable to move or
had a limited range of motion. Prior to robotic therapy the patient
required a greater amount of robotic assistance for wrist extension
and adduction than wrist flexion and abduction (Fig. 5). However,
the patient was not only able to perform the task with an overall
lower level of assistance after the three-month robotic training
 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178
Fig. 5. Representative maximum assistive force provided by the robot during the
first (light gray) and last training sessions (dark gray) for flexion/extension (FE,
horizontal axis) and abduction/adduction (AA, vertical axis) movements.
program, but the reduced robotic intervention was delivered in a
more isotropic way (Fig. 5).
4. Discussion
In this paper the effects of a three-month distal upper extremity
robotic training program that featured an online adaptive control
algorithm was evaluated on a 14-year-old patient affected by up-
per extremity hemiparesis and spasticity after stroke. In contrast
to previous control algorithms in which the level of assistance is
adjusted at the end of each trial or training session, the present on-
line adaptive control algorithm provided assistance continuously
throughout the trial, so that the level of assistance was always
tailored to the participant’s capabilities.
The use of our online adaptive control algorithm lead to a
reduction in upper extremity spasticity after the three-month
robotic training program that extended throughout the entire limb,
with greater improvements observed in the upper arm flexors,
forearm/wrist flexors and extensors, and finger flexors compared
to the shoulder and upper arm extensor muscles. In addition,
clinical scores of upper extremity unimanual and bimanual limb
function increased after the three-month robotic training program
(14.8-point and 15.9-point difference for the MAUULF and AHA,
respectively). The improvement in scores between the pre- and
post-test assessments exceeded the minimum change for both as-
sessments [42,43], suggesting a clinically significant improvement
in arm function during unimanual and bimanual activities.
There were also noticeable improvements in kinematic and
robot-based measures. Improvements in the quality of wrist
movement could be observed post-training: path lengths were
smoother, shorter, and featured fewer corrective movements in the
last training session than the first training session. Improvements
in wrist joint angular RoM as a consequence of robotic training
differed between DoFs. While there were no substantial changes
in wrist extension and abduction, active flexion RoM and adduc-
tion improved as a consequence of robotic training. In addition,
the amount of torque generated by the robot to help the patient
complete the trial (assistive torque) was significantly lower in the
last training session than the first session, indicating that the pa-
tient required less robotic assistance after completing the robotic
training program. We also found pre-training differences between
FE and AA DoFs, such that the amount of torque generated by the
robot to help the patient complete the trial (assistive torque) was
higher for wrist extension and adduction than for wrist flexion and
abduction. However, this anisotropy in impairment decreased after
the robotic training program, as the amount of assistance delivered
175
by the robotic device at the end of the robotic training program was
similar between the two DoFs.
Considering results from both the clinical and robotic assess-
ments, this case study provides preliminary evidence that partic-
ipation in intensive distal upper extremity robotic therapy that
features an adaptive control strategy can lead to positive changes
in active wrist RoM, wrist kinematics and dynamics. They also
show, for the first time, that distal upper extremity training can
lead to improvements in both the proximal and distal segments
of the upper limb in a pediatric stroke patient. This finding is
congruent with prior research in adult populations on robotic
rehabilitation of stroke [44,45] and incomplete spinal cord injury
in adult populations [46], and can be attributed to central and
peripheral mechanisms [43,47]. Examination of human upper ex-
tremity skeletal muscles [48] has revealed that distal movements
activate nerves and muscles that control the entire upper limb,
and as such wrist training results in muscle activity at the distal
as well as the proximal segments of the limb. The improvements
in spasticity and motor performance brought about by distal upper
extremity robotic rehabilitation in turn lead to profound changes
in neural plasticity within the cerebral cortex [49–51]. In contrast
to post-stroke proximal upper extremity robotic therapy, in which
improvements in function are limited to the elbow and shoul-
der [52], there is emerging evidence that rehabilitation of the distal
portion of the paretic limb leads to positive changes in the function
of the entire limb even in the non-exercised joints. As such, it is
recommended that bioengineering groups continue to focus their
efforts on the development of devices and control algorithms for
distal upper extremity rehabilitation.
The results reported in this case study demonstrate that the
proposed adaptive control strategy is robust (in terms of patient
response), is well accepted by the patient, and is able to smoothly
adapt to the specific impairments of the patient without fine ad-
justments of the controller gains. The robust control architecture
allows for the introduction of a haptic robotic rehabilitation system
that features tuneable assistance and a user friendly interface to
a clinical environment. Haptic robotic rehabilitation systems can
complement conventional physical therapy protocols by allowing
the patient to perform a greater number of trials per training
session, and providing kinematic and dynamic feedback to the
clinician and patient. The proposed controller strategy is an autom-
atized robotic version of the established wrist splinting technique,
which many clinicians are familiar with. It is hypothesized that
the similarities between the established manual technique and
the robotic device will assuage any concerns that medical staff
have regarding robotic rehabilitation, and consequently allow for
technological based solutions to become more accessible to neuro-
logical populations who require specialized rehabilitation.
In the future, it would be worthwhile comparing the effects
obtained using our adaptive control strategy to different adap-
tive control algorithms [20,53]. For example, Pehlivan et al., [54]
presented an assist-as-needed controller featuring a feedback
gain modification algorithm (which estimates only the position-
dependent elements) and a real-time trajectory generation algo-
rithm (used to modify the amount of permissible error based on
user performance). Results demonstrated that the AAN adapted to
the behavior of the (neurologically healthy) participants by provid-
ing varying levels of mechanical assistance and adapts the feedback
gains based on task performance. In a more recent study, the same
research group [55] developed a minimal assist-as-needed (mAAN)
controller that uses a Kalman filter and Lyapunov stability analysis
to accurately determine state estimation, a modification algorithm
that alters the degree of allowable error, and a disturbance re-
jection decay algorithm that decreases resistive forces when able
subject movement desirably exceeds some given trajectory. Re-
sults from ten neurologically healthy individuals indicate that error
176 F. Marini et al. / Robotics and Autonomous Systems 91 (2017) 169–178
bound modification is capable of responding to changes in partic-
ipant involvement, and that the disturbance rejection decay algo-
rithm encourages voluntary movement when end-effector forces
are directed at the target and are greater than the implemented
threshold for trajectory following. While these adaptive control al-
gorithms have only been validated in neurologically healthy adults,
we expect that it is only a matter of time before the effectiveness
of this algorithm is tested in stroke and SCI injury populations.
There are, however, several limitations to the current experi-
ment which should be acknowledged and used to inform future
studies. First, the generalization of results is limited as we exam-
ined the effectiveness of robotic therapy in a single pediatric stroke
patient with a specific neurological profile. Given the incidence and
impact of pediatric stroke [2] and other childhood movement dis-
orders (e.g., pediatric stroke, traumatic brain injury [56]), cerebral
palsy [57] on lifespan motor development, rehabilitation methods
that target motor function and concomitant symptoms (e.g., spas-
ticity, muscle weakness) would be highly beneficial. Nonetheless,
the results of the current study are encouraging, and we will
continue this line of research by conducting additional studies with
a larger number of pediatric stroke patients across a broader neu-
rological profile (e.g., cerebral, right and left hemispheres; lacunar
and brain stem) in order to fully evaluate the effectiveness of this
therapy in pediatric stroke patients.
In addition, given the emerging evidence indicating that func-
tional recovery is most effective during the early weeks after the
stroke incident [58] and that patients who receive organized health
care while they are still in the stroke unit are more likely to be alive,
independent, and living at home one year after the stroke [59]
it would be interesting to investigate the efficacy of distal upper
extremity rehabilitation in subacute phase. In future, researchers
could also examine whether gains in functional recovery are im-
proved if distal upper extremity rehabilitation is implemented in
the first few weeks after stroke compared to if it is delivered in the
chronic stage of stroke.
Second, we used a scale-based evaluation method to measure
tonal abnormality. While the MAS is a widely used method of
evaluating spasticity, there is some evidence that ordinal-level
data may not have the requisite sensitivity to track treatment
effects [60] or the progress of spasticity [61,62]. Given that post
stroke spasticity often leads to inappropriate co-activation of ag-
onist and antagonist muscles, it would be useful to employ elec-
tromyography (EMG) techniques in order to determine muscular
activity at rest (hypertonia) and to delineate changes in the con-
tribution and activation timing between agonist and antagonist
muscles during pre- and post-assessment.
Last, although we measured certain aspects of distal and prox-
imal upper extremity function, it would be beneficial to examine
impairments to the sensorimotor control of grasping [63]. For ex-
ample, stroke patients often have difficulty producing appropriate
finger forces required for object manipulation [63] and are slower
to modify fingertip forces even at low grasp force levels [64]. Given
the positive effects of robotic training on the upper limb, it would
certainly be worthwhile to investigate whether changes in grip
force (e.g., peak grip force and dynamic grip force scaling) may
also have occurred as a result of distal upper extremity robotic
rehabilitation.
In sum, results of the present case study demonstrate that distal
upper extremity robotic rehabilitation that features an adaptive
control algorithm can lead to positive changes in upper limb motor
coordination and function after pediatric stroke. Robotic devices
can more objectively quantify motor performance, and when used
in conjunction with clinical scales, provide the rehabilitation team
with a more complete picture of recovery and prognosis. This
information can be used to customize therapeutic protocols to
the specific needs of the patient, which should result in positive
recovery trajectories in a shorter amount of time than is presently
reported.
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Francesca Marini graduated in Biomedical Engineering
at the University of Rome. Since January 2014, she has
been following a Ph.D. program in Cognitive Robotics,
Interaction and Rehabilitation Technologies at the Italian I
nstitute of Technology. Her Ph.D. project is mainly focused
on robotic rehabilitation in children with neurological in-
juries.
Lorenzo Masia, Assistant Professor at the Nanyang Techn
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doctoral researcher at Italian Institute of Technology (IIT).
He graduated as Ph.D. in ‘‘Mechanical Measurement for
Dr Charmayne Hughes is now Associate Professor at the Engineering’’ at the University of Padua and was Ph.D. vis-
Department of Kinesiology of San Francisco State Univ iting student at the Massachusetts Institute of Technology
ersity and she was a senior post-doctoral fellow in the (MIT).
Robotics Research Centre in the Department of Mechanical
and Aerospace Engineering at Nanyang Technological Uni-
versity (NTU). Charmayne joined NTU in December 2013
following a Ph.D. in Motor Control at Purdue University,
and postdoctoral fellowships at Bielefeld University and
the Technical University of Munich.