BACKGROUND: Robotic rehabilitation, which provides a high-intensity, high-frequency therapy to improve neuroplasticity, is gaining traction. However, its effectiveness for upper extremity stroke rehabilitation remains uncertain. This study comprehensively reviewed meta-analyses on the effectiveness of upper extremity robot-assisted therapy in patients with stroke. METHODS: We combined results from 396 randomized controlled trials (RCTs) in 16 meta-analyses and conducted a new meta-analysis using nonoverlapping RCTs and 6 additional RCTs published after 2024. Duplicate studies were removed, all data were from RCTs, and a random-effects model resolved heterogeneity. Effects were analyzed by comparing robot-assisted therapy with conventional therapy at the same dose and as an add-on to conventional therapy. RESULTS: Compared with conventional therapy, the effect of robot-assisted therapy on the Fugl-Meyer assessment was summarized as a significant standardized mean difference (SMD) of 0.29 (95% CI, 0.14–0.44; number of individual RCTs reanalyzed, 100 RCTs), and the additional effect of robot-assisted therapy was an SMD of 0.42 (95% CI, 0.23–0.61; 16 RCTs). However, these Fugl-Meyer assessment improvements did not meet the minimum clinically important difference thresholds identified in previous studies: 12.4 for subacute and 3.5 for chronic stroke. For activities of daily living, only the additional effect was significant by SMD of 0.35 (95% CI, 0.17–0.54; 26 RCTs), muscle strength was significant by SMD of 0.46 (95% CI, 0.22–0.70; 31 RCTs), and spasticity was not significant by SMD of −0.25 (95% CI, −0.55 to 0.06; 25 RCTs). CONCLUSIONS: Robot-assisted therapy shows statistically significant improvements in motor recovery as measured by the Fugl-Meyer assessment in patients with stroke, both at the same dose and as an add-on to conventional therapy; however, these improvements do not meet the minimum clinically important difference. These benefits are consistent across different stages of stroke recovery, different types of robotic devices, duration of intervention, and training sites. However, the heterogeneity of included studies in patient population, stroke severity, intervention protocol, and robot type limits generalizability. High-quality trials are needed to better define the value of robot-assisted therapy across various devices and strategies.

As a first-line treatment for lateral elbow tendinopathy (LET), eccentric exercise has been suggested as a conservative treatment method. This study aimed to investigate the impact of eccentric exercise on LET with regard to pain reduction, and strength and functional improvement. The PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched, and studies up to May 2021 were included if (1) randomization was used for patient allocation, (2) the study comprised patients with LET, (3) the intervention was eccentric exercise, and (4) the primary outcomes included improvement in pain intensity, muscle strength, or function. The meta-analysis comprised of six studies, totaling 429 participants. Additional eccentric exercise with underlying adjuvant therapy significantly improved the visual analog scale (VAS) scores (standardized mean difference [SMD], −0.63; 95% confidence interval [CI], −0.90–−0.36) and muscle strength (SMD, 1.05; 95% CI, 0.78–1.33) compared with adjuvant therapy alone. Compared with the concentric or isotonic exercise group, the eccentric exercise group showed significantly improved VAS scores (SMD, −0.30; 95% CI, −0.58–−0.02). However, no differences in muscle strength and function were observed between the two groups. Eccentric exercise can improve pain and muscle strength in patients with LET. The limited number of included studies and heterogeneous exercise parameters are important when interpreting these findings.

Background: Extracorporeal shock wave therapy (ESWT) has been used in various musculoskeletal disorders, including lateral epicondylitis. However, in 2005, a meta-analysis of randomized controlled trials showed that ESWT provides minimal or no benefit in terms of pain and function in patients with lateral epicondylitis. Since the review, several randomized controlled trials including different types of ESWT such as radial type for lateral epicondylitis have been published. Investigations of the effect modifiers such as symptom and follow-up duration on the effects of ESWT on lateral epicondylitis have not been performed. Questions/purposes: (1) Does ESWT reduce pain and improve grip strength in patients with lateral epicondylitis? (2) Which type of ESWT, radial or focused, is more effective? (3) Is the duration of symptoms associated with the efficacy of ESWT for lateral epicondylitis? (4) Do improvements in pain scores remain in patients with longer follow-up? Methods: The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched up to July 2019 for articles published in English or Korean. Studies were included if patient allocation was randomized, the sample was composed of patients with lateral epicondylitis, interventions were ESWT (focused or radial), comparison group only received sham stimulation or no additional treatment, and the study outcome was pain intensity or grip strength. The quality of the evidence was assessed using the Cochrane risk of bias tool. Twelve studies including 1104 participants fulfilled the inclusion criteria and were included in the meta-analysis. The mean difference for pain reduction and improvement in grip strength was calculated. Results: The meta-analysis showed no clinically important difference in the VAS score (2.48 ± 7.55 versus 3.17 ± 9.78, mean difference -0.68 [95% confidence interval -1.17 to -0.19]; p = 0.006) and grip strength (38.02 ± 70.56 versus 34.85 ± 108.26, mean difference 3.33 [95% CI 0.93 to 5.73]; p = 0.007) after ESWT relative to the comparison group’s score. Even though radial ESWT showed more improvement than focused, the mean difference for VAS did not exceed the minimal clinically important differences threshold. There were no clinically important effects on the VAS scores of patients with lateral epicondylitis (2.78 ± 5.57 versus 3.92 ± 6.29, mean difference -1.13 [95% CI -1.84 to -0.42]; p = 0.002) and focused ESWT did not improve pain in patients with lateral epicondylitis. In the subgroup analysis, ESWT was effective in patients with a symptom duration of more than 6 months (2.28 ± 8.48 versus 3.31 ± 11.81, mean difference -0.95 [95% CI -1.75 to -0.15]; p = 0.02) but not for those with shorter symptom duration. The effects did not last beyond 24 weeks (2.52 ± 9.19 versus 3.34 ± 5.93, mean difference -0.82 [95% CI -2.57 to 0.93]; p = 0.36). Conclusions: ESWT did not show clinically important improvement in pain reduction and grip strength. Radial ESWT, symptom duration of longer than 6 months, and short follow-up duration (less than 24 weeks) were related to better effects. Further studies are needed to determine the appropriate protocol and elucidate the effects according to the intervention type and specific disease condition. Level of Evidence: Level I, therapeutic study.

Shin HJ, et al. Yonsei Med J. 2014 May;55(3):792-799. http://dx.doi.org/10.3349/ymj.2014.55.3.792

Objective. The aim of this study was to investigate regenerative effects of ultrasound- (US-) guided injection with human umbilical cord blood-derived mesenchymal stem cells (UCB-MSCs) and/or polydeoxyribonucleotide (PDRN) injection in a chronic traumatic full-thickness rotator cuff tendon tear (FTRCTT) in a rabbit model. Methods. Rabbits (n=32) were allocated into 4 groups. After a 5 mm sized FTRCTT just proximal to the insertion site on the subscapularis tendon was created by excision, the wound was immediately covered by a silicone tube to prevent natural healing. After 6 weeks, 4 injectants (0.2 mL normal saline, G1-SAL; 0.2 mL PDRN, G2-PDRN; 0.2 mL UCB-MSCs, G3-MSC; and 0.2 mL UCB-MSCs with 0.2 ml PDRN, G4-MSC + PDRN) were injected into the FTRCTT under US guidance. We evaluated gross morphologic changes on all rabbits after sacrifice. Masson’s trichrome, anti-type 1 collagen antibody, bromodeoxyuridine, proliferating cell nuclear antigen, vascular endothelial growth factor, and platelet endothelial cell adhesion molecule stain were performed to evaluate histological changes. Motion analysis was also performed. Results. The gross morphologic mean tendon tear size in G3-MSC and G4-MSC + PDRN was significantly smaller than that in G1-SAL and G2-PDRN (p<0.05). However, there were no significant differences in the tendon tear size between G3-MSC and G4-MSC + PDRN. In G4-MSC + PDRN, newly regenerated collagen type 1 fibers, proliferating cell activity, angiogenesis, walking distance, fast walking time, and mean walking speed were greater than those in the other three groups on histological examination and motion analysis. Conclusions. Coinjection of UCB-MSCs and PDRN was more effective than UCB-MSC injection alone in histological and motion analysis in a rabbit model of chronic traumatic FTRCTT. However, there was no significant difference in gross morphologic change of tendon tear between UCB-MSCs with/without PDRN injection. The results of this study regarding the combination of UCB-MSCs and PDRN are worth additional investigations.