Stroke is a leading cause of long-term disability, with more than half of survivors experiencing persistent upper limb impairments. Despite clear evidence that high-dose, repetitive, task-specific training is essential for motor recovery, many stroke survivors do not receive a sufficiently high therapy dose - particularly in the outpatient phase. Limited therapist availability, high care costs, and travel burdens remain key barriers to accessing rehabilitation training. While technology-assisted rehabilitation has emerged as a promising solution, most existing studies are limited to single-device interventions, are conducted in clinical settings, and/or require constant supervision, thereby restricting their scalability and impact. This study protocol presents the Technology-Assisted Rehabilitation Gym for at-home Training (TARGeT) trial (ClinicalTrials.gov: NCT06406569), which aims to evaluate the feasibility, safety, usability, clinical benefits, and economic potential of a novel, unsupervised, high-dose home-based therapy program that integrates multiple complementary technologies for upper limb stroke rehabilitation. In this single-centre, pilot feasibility trial, up to 30 subacute and chronic stroke survivors will complete six weeks of daily home-based therapy using three complementary rehabilitation technologies that enable self-administered training without therapist supervision. The training will be remotely monitored by clinicians via an online platform that reports data on the training progress. Assessments will be conducted at five timepoints, measuring clinical outcomes (e.g., FMA, ARAT), quality of life, healthcare utilization, and technologies' perceived usability (SUS, RawTLX). The study will assess whether unsupervised, home-based multi-technology rehabilitation is feasible and safe, provides high usability and satisfying user experience, whether it yields clinical outcomes comparable to conventional therapy based on data from previous studies (own data and literature data), and determines the associated costs relative to conventional therapy. The TARGeT program addresses the critical gap in therapy access and intensity by delivering scalable, high-dose rehabilitation directly into patients' homes. Results will inform future trials and support broader adoption of decentralized, technology-enabled stroke rehabilitation.

In recent years, the growing demand for cost-effective rehabilitation after stroke has motivated the development of novel technologies to support high-intensity rehabilitation. However, available knowledge on the economic benefits of stroke technology-assisted rehabilitation (TAR) is relatively scarce and fragmented. Therefore, this scoping review aimed to review evidence on the economic benefits of TAR in laboratory, clinical, and home settings, as well as the methodologies used to evaluate these outcomes. A systematic search of four electronic bibliographic databases and two additional grey literature/ economic evidence sources (until 03 June 2026) identified 6469 records. Following predefined inclusion and exclusion criteria, 44 records were considered for further analysis. Additionally, 21 records were identified through a citation search. In total, 65 articles reporting TAR-related costs were included, but only a few of these studies reported cost analyses (mostly cost comparisons). Firstly, of the 38 studies conducted in laboratory settings, only one reported a formal TAR-related cost analysis. Secondly, out of 16 studies reporting costs, 11 studies performed cost analysis for TAR in clinical settings. Of these, the majority (six) estimated TAR to be equally effective or even superior (one) and cheaper than conventional therapy (CT) in the clinic, but only when TAR enabled the therapist to treat several stroke survivors in parallel. This was captured using the relative therapist-to-patient ratio (rT/P), indicating that staffing and supervision models were more important than device cost. Lastly, seven of 13 studies conducted TAR-related cost analysis in a home setting. Three studies suggested that TAR may be economically beneficial compared with CT in the clinic. Empirical findings suggest that TAR may generate cost savings compared to CT in the clinic, particularly when rT/P is < 0.5. However, the current evidence is sparse, with limited comparability and generalisability due to heterogeneous TAR modalities, comparators and cost-calculation methods. Not applicable.

This paper establishes analytical stability boundaries for robot-mediated human-human (dyadic) interaction systems, subject to haptic communication under network-induced time delays. Bypassing conservative approximations, we employ a frequency-domain zero-crossing methodology to extract explicit stability limits based on the robotic hardware dynamics and coupling stiffness. To demonstrate the scalability of this mathematical framework, we extend the analysis from an elastic coupling to a highly complex, asymmetric virtual proxy topology. The theoretical analysis reveals how interaction stiffness non-linearly constrains the system's stability margin, heightening its vulnerability to delay. Furthermore, we validate these theoretical boundaries through experimental trials, highlighting the correlation between analytical stability margins and empirical motor performance. The proposed framework provides rigorous design guidelines for stable remote dyadic systems and suggests the prerequisites for effective delay-compensation strategies.

Wearable sensors, such as inertial measurement units (IMUs), can objectively measure upper limb performance outside clinical settings, providing complementary outcomes to support the rehabilitation of neurological patients. Measuring performance, and thus quantifying functional movements in daily life, is a necessary step towards the implementation of more personalized goal-adjusted therapy. However, it remains challenging to accurately and reliably separate functional from non-functional movements based on IMU data. Existing digital health metrics are typically too sensitive, classifying nonfunctional movements as functional or too specific. Additionally, these metrics rely on empirical thresholds, and their dependence on the individual has not been explored. This paper explores methods to optimize the thresholds used to compute IMU-based metrics (activity count, gross movement score, and GMAC) measuring functional upper limb movements on a group level and per individual. To this end, a preliminary study was conducted on 10 non-impaired subjects wearing IMUs on both wrists while performing predefined daily life activities. The optimized thresholds were found with cross-validation by maximizing the Youden index. At the group level, the most effective metric was the optimized GMAC, with a Youden index of 0.58 +/- 0.05, achieved by combining thresholds on the magnitude of the arm's acceleration and the angular rotation of the arm. Notably, the individualized optimized thresholds on arm acceleration varied widely, ranging from 2 to 59 counts for the non-dominant hand. These findings suggest that personalized thresholds might be necessary to improve the detection of functional movements in daily life.

Research on robot-mediated dyadic interactions has shown benefits in understanding cooperation between individuals with different skill levels, such as rehabilitation between a therapist and a patient. The need for remote rehabilitation arises in response to overcoming physical distance. However, setting up remote connections between individuals remains a challenge considering network delay. This study explored how haptic delay between humans influences their motor performance. A real-time impedance controller, where time delay can be explicitly introduced, has been developed to mediate intervention. Twelve healthy participants were divided into six dyads, each comprising one Expert and one Novice. Experts were assigned to track a given target point evolving along a pre-determined random trajectory, whereas Novices were tasked with tracking a cloud of points centered around the same target point presented to Experts, thus implementing a form of visual disturbance. Each dyadic interaction started with a Familiarization condition, followed by a Solo condition, and then activating the connection introduced different haptic delays. Preliminary results reveal a negative impact on the motor performance of both Experts and Novices attributable to the haptic delay. Future work needs to expand upon these results.

Soft robotics is gaining interest in rehabilitation applications, bringing new opportunities to offset the loss of upper limb motor function following neurological, neuromuscular, or traumatic injuries. Unlike conventional rigid robotics, the added softness in linkages or joints promises to make rehabilitation robots compliant, which translates into higher levels of safety, comfort, usability, and portability, opening the door for these rehabilitation technologies to be used in daily life. While several reviews documented the different technical implementations of soft rehabilitation robots, it is essential to discuss the growing clinical evidence on the feasibility and effectiveness of using this technology for rehabilitative and assistive purposes, whether softness brings the expected advantages from the perspective of end users, and how we should proceed in the future of this field. In this perspective article, we present recent clinical evidence on how 13 different upper limb devices were used in both controlled (clinical) and uncontrolled (at home) settings in more than 37 clinical studies. From these findings and our own experience, we derive recommendations for future developers and end users regarding the design, application, and evaluation of soft robotics for upper limb rehabilitation and assistance.

This study describes a pipeline designed to address post-stroke compensatory movements that hinder long-term motor recovery. To achieve this goal, a markerless body tracking approach is employed to track trunk flexion during a robotic reaching task and multi-modal feedback is provided-comprising visual, audio, and haptic elements-when excessive trunk flexion occurs. Our aim is to improve the quality of robotic training targeting motor recovery. To evaluate the feasibility of this pipeline, three different phases of robotic training (Baseline, Training, and Test) are performed, with only the Training phase including the multi-modal compensatory movement feedback. The preliminary findings from a single stroke patient show the initial feasibility of the proposed pipeline, demonstrating the potential of postural adaptations facilitated by feedback. While the current report is limited to a single participant, validation with a diverse sample to test the overall feasibility and applicability across a wider range of patients is essential.

We evaluated the feasibility, safety, and efficacy of a 2D-planar robot for minimally supervised home-based upper-limb therapy for post-stroke hemiparesis. The H-Man, end effector robot, combined with web-based software application for remote tele-monitoring were evaluated at homes of participants. Inclusion criteria were: strokes > 28 days, Fugl-Meyer Motor Assessment (FMA) > 10-60/66, presence of a carer and absence of medical contraindications. Participants performed self-directed, minimally supervised robotics-assisted therapy (RAT) at home for 30 consecutive days, after 2 therapist-supervised clinic on-boarding sessions. Web-based compliance measures were: accessed sessions of > 20 min/day, training minutes/day and active training hours/30 days. Clinical outcomes at weeks 0, 5 (post-training), 12 and 24 (follow-up) consisted of FMA, Action Research Arm Test (ARAT) and WHO-Stroke Specific Quality of Life (SSQOL). To estimate immediate economic benefits of the home-based robotic therapy, we performed cost-effectiveness analysis (CEA), followed by budget impact analysis (BIA). Altogether, all 12 participants completed Home-RAT without adverse events; 9 (75.0 https://clinicaltrials.gov ).

Background:Stroke is a leading cause of lifelong disability worldwide, partially driven by a reduced ability to use the upper limb in daily life causing increased dependence on caregivers. However, post-stroke functional impairments have only been investigated using limited clinical scores, during short-term longitudinal studies in relatively small patient cohorts. With the addition of technology-based assessments, we propose to complement clinical assessments with more sensitive and objective measures that could more holistically inform on upper limb impairment recovery after stroke, its impact on upper limb use in daily life, and on overall quality of life. This paper describes a pragmatic, longitudinal, observational study protocol aiming to gather a uniquely rich multimodal database to comprehensively describe the time course of upper limb recovery in a representative cohort of 400 Asian adults after stroke. Particularly, we will characterize the longitudinal relationship between upper limb recovery, common post-stroke impairments, functional independence and quality of life. Methods:Participants with stroke will be tested at up to eight time points, from within a month to 3 years post-stroke, to capture the influence of transitioning from hospital to community settings. We will perform a battery of established clinical assessments to describe the factors most likely to influence upper limb recovery. Further, we will gather digital health biomarkers from robotic or wearable sensing technology-assisted assessments to sensitively characterize motor and somatosensory impairments and upper limb use in daily life. We will also use both quantitative and qualitative measures to understand health-related quality of life. Lastly, we will describe neurophysiological motor status using transcranial magnetic stimulation. Statistics:Descriptive analyses will be first performed to understand post-stroke upper limb impairments and recovery at various time points. The relationships between digital biomarkers and various domains will be explored to inform key aspects of upper limb recovery and its dynamics using correlation matrices. Multiple statistical models will be constructed to characterize the time course of upper limb recovery post-stroke. Subgroups of stroke survivors exhibiting distinct recovery profiles will be identified. Conclusion:This is the first study complementing clinical assessments with technology-assisted digital biomarkers to investigate upper limb sensorimotor recovery in Asian stroke survivors. Overall, this study will yield a multimodal data set that longitudinally characterizes post-stroke upper limb recovery in functional impairments, daily-life upper limb use, and health-related quality of life in a large cohort of Asian stroke survivors. This data set generates valuable information on post-stroke upper limb recovery and potentially allows researchers to identify different recovery profiles of subgroups of Asian stroke survivors. This enables the comparisons between the characteristics and recovery profiles of stroke survivors in different regions. Thus, this study lays out the basis to identify early predictors for upper limb recovery, inform clinical decision-making in Asian stroke survivors and establish tailored therapy programs. Clinical trial registration:ClinicalTrials.gov, identifier: NCT05322837.

Assessment and rehabilitation of the upper limb after stroke have focused primarily on the contralesional arm. However, increasing evidence highlights functional sensorimotor alterations also in the ipsilesional arm. This study aims to evaluate the position sense of both arms after stroke using a passive position matching task. We hypothesized that the ipsilesional arm would have higher accuracy and precision than the contralesional arm but lower than the dominant arm in unimpaired participants. Additionally, we hypothesized a correlation in performance between the two arms in stroke survivors. The study included 40 stroke survivors who performed the proprioceptive test with both arms and 24 unimpaired participants who performed it with their dominant arm. During each trial, a planar robot moved their hand to a target and back. In the Participants had to indicate when their hand reached the target position in the second phase. We evaluated performance by computing the matching accuracy and precision. We found that the ipsilesional arm had similar matching accuracy but higher precision than the contralesional arm. Furthermore, only the matching accuracy of the two arms was correlated in the left and central regions of the workspace. When comparing stroke survivors to unimpaired participants, the ipsilesional arm exhibited significantly lower accuracy, yet not different precision. These findings support the notion that the ipsilesional arm is not ‘unaffected’ by stroke but rather ‘less-affected’, suggesting that stroke does not impact ipsilesional position sense precision. Additionally, the results suggest a dissociation between accuracy and precision in passive multi-joint position matching tasks.

Post stroke upper limb rehabilitation is a challenging problem with poor outcomes as 40% of survivors have functionally useless upper limbs. Robot-aided therapy (RAT) is a potential method to alleviate the effort of intensive, task-specific, repetitive upper limb exercises for both patients and therapists. The present study aims to investigate how a time matched combinatory training scheme that incorporates conventional and RAT, using H-Man, compares with conventional training toward reducing workforce demands. In a randomized control trial (NCT02188628, www.clinicaltrials.gov), 44 subacute to chronic stroke survivors with first-ever clinical stroke and predominant arm motor function deficits were recruited and randomized into two groups of 22 subjects: Robotic Therapy (RT) and Conventional Therapy (CT). Both groups received 18 sessions of 90 min; three sessions per week over 6 weeks. In each session, participants of the CT group received 90 min of 1:1 therapist-supervised conventional therapy while participants of the RT group underwent combinatory training which consisted of 60 min of minimally-supervised H-Man therapy followed by 30 min of conventional therapy. The clinical outcomes [Fugl-Meyer (FMA), Action Research Arm Test and, Grip Strength] and the quantitative measures (smoothness, time efficiency, and task error, derived from two robotic assessment tasks) were independently evaluated prior to therapy intervention (week 0), at mid-training (week 3), at the end of training (week 6), and post therapy (week 12 and 24). Significant differences within group were observed at the end of training for all clinical scales compared with baseline [mean and standard deviation of FMA score changes between baseline and week 6; RT: Δ4.41 (3.46) and CT: Δ3.0 (4.0); p < 0.01]. FMA gains were retained 18 weeks post-training [week 24; RT: Δ5.38 (4.67) and week 24 CT: Δ4.50 (5.35); p < 0.01]. The RT group clinical scores improved similarly when compared to CT group with no significant inter-group at all time points although the conventional therapy time was reduced to one third in RT group. There were no training-related adverse side effects. In conclusion, time matched combinatory training incorporating H-Man RAT produced similar outcomes compared to conventional therapy alone. Hence, this study supports a combinatory approach to improve motor function in post-stroke arm paresis. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02188628.

INTRODUCTION:Studies in robotic therapy which applied the performance enhancement approach report improvements in motor performance during training, though these improvements do not always transfer to motor learning. OBJECTIVES:We postulate that there exists an assistance threshold for which performance saturates. Above this threshold, the robot's input outweighs the patient's input and likely learning is not fostered. This study investigated the relationship between assistance and performance changes in stroke patients to find the assistance threshold for performance saturation. METHODS:Twelve subacute and chronic stroke patients engaged in five sessions (over two weeks, each 60 min) in which they performed a reaching task with the rehabilitation robot H-Man in presence of varying levels of haptic assistance (50 N/m to 290 N/m, randomized order). In two additional sessions, a therapist manually tuned the assistance to promote maximal motor learning. RESULTS:Higher levels of assistance resulted in smoother and faster performance that saturated at assistance levels with K ≥ 110 N/m. Also, the therapist selected assistance levels of K = 175 N/m or below. CONCLUSION:The findings of the study indicate that low levels of assistance (K ≤ 175 N/m) can sufficiently induce a significant change in performance.

Although motor and sensory impairments of the upper limb after stroke have been widely studied, the relationship between sensory deficits and motor functions has been less thoroughly explored. In this ongoing study, we investigated the relationship between proprioceptive impairments and motor functions with 20 chronic stroke survivors. Their proprioceptive abilities were assessed with a passive joint position matching test using H-Man and their motor functions were assessed with ARAT (Action Research Arm Test) and FMA (Fugl Meyer Upper Extremity Assessment) clinical scores. The assessments were conducted before, during and after the therapy. Results indicated a significant difference between the proprioceptive outcomes of healthy and stroke participants (at baseline) in both matching accuracy (absolute error, p=0.02) and precision (variability of the signed error, p=0.03). Significant correlations were found between the proprioceptive assessment outcomes (assessed before the beginning of the motor rehabilitation) of stroke participants with impaired proprioception and their ARAT clinical scores assessed at the first follow-up (week 12) (rho =- 0.74 and p=0.047 for the absolute error; rho =-0.78 and p= 0.03 for the variability of the signed error). The results from this preliminary study indicated a significant relationship between proprioceptive impairments and motor function performances in proprioceptively impaired chronic stroke participants.

Dyadic interaction between humans has gained great research interest in the last years. The effects of factors that influence the interaction, as e.g. roles or skill level matching, are still not well understood. In this paper, we further investigated the effect of skill level matching between partners on learning of a visuo-motor task. Understanding the effect of skill level matching is crucial for applications in collaborative rehabilitation. Fifteen healthy participants were asked to trace a path while being subjected to a visuo-motor rotation (Novice). The Novices were paired with a partner, forming one of the three Dyad Types: a) haptic connection to another Novice, b) haptic connection to an Expert (no visuo-motor rotation), or c) no haptic. The intervention consisted of a Familiarization phase, followed by a Training phase, in which the Novices were learning the task in the respective Dyad Type, and a Test phase in which the learning was assessed (haptic connection removed, if any). Results suggest that learning of the task with a haptic connection to an Expert was least beneficial. However, during the Training phase the dyads comprising an Expert clearly outperformed the dyads with matched skill levels. The results point towards the same direction as previous findings in literature and can be explained by current motor-learning theories. Future work needs to corroborate these preliminary results.

The H-Man robot, a table-top, portable, 2D planar, end-effector with virtual reality feedback was designed to deliver self-paced, repetitive reaching arm movements. Preliminary results of a randomized clinical trial of 26/44 strokes with hemiparetic arm weakness are presented. Inclusion criteria included first-stroke, > 4 months duration with Fugl Meyer Assessment Scale (FMA) 20–50/66) without contraindications to robot-aided therapy. Following informed consent, subjects were randomized into 2 groups: H-Man-conventional (HCT) group received 18 sessions over 6 weeks of 60 minutes of H-man training then 30 minutes of conventional therapy (CT), while control group (CG) received a similar intensity of 90 minutes of CT. Blinded outcome assessments at weeks 0 (baseline), 3, 6 (end-training), 12 and 24 (follow-up). The primary outcome measure was FMA change at week 6. Parametric analysis was used and level of significance was P < 0.05. Altogether, data from 26 out of 44 subjects were analyzed. (13 HCT, 13 CG). Mean age was 54.0 years (SD 10.9), 14/26 were male, 15/26 had hemorrhagic strokes, mean stroke duration 227.2 days (SD 207.2), and mean baseline FMA 38.6 (SD 11.1). The HCT group achieved significantly better FMA gains compared to CG (4.15 HCT vs. 1.69 CG, P = 0.03) at week 6 (post-training), and at week 24 (5.77 HCT vs 2.61 CG, P = 0.03). There were no adverse side effects or drop outs. Robotic kinematic measures of line and circle temporal tracing correlated with FMA scores at Week 0. Combinatory arm rehabilitation with H-Man robot was superior to CT and well tolerated.

This chapter presents a systematic interaction control framework for robot-assisted training in neurologically impaired individuals. The human-robot relationship is considered as the interaction of two agents with respective control described by a cost function, which enables us to express and implement various interaction strategies. Implementation of this method for training arm reaching in chronic stroke survivors exhibits smooth motion guidance, neither disrupting movement nor preventing the intertrial variability critical to learning. The human-robot interaction is further analyzed by using differential game theory with an algorithm to identify the human user's behavior, providing stable, reactive, and adaptive movement assistance demonstrated in simulations.

Proprioception is a critical component for motor functions and directly affects motor learning after neurological injuries. Conventional methods for its assessment are generally ordinal in nature and hence lack sensitivity. Robotic devices designed to promote sensorimotor learning can potentially provide quantitative precise, accurate, and reliable assessments of sensory impairments. In this paper, we investigate the clinical applicability and validity of using a planar 2 degrees of freedom robot to quantitatively assess proprioceptive deficits in post-stroke participants. Nine stroke survivors and nine healthy subjects participated in the study. Participants' hand was passively moved to the target position guided by the H-Man robot (Criterion movement) and were asked to indicate during a second passive movement towards the same target (Matching movement) when they felt that they matched the target position. The assessment was carried out on a planar surface for movements in the forward and oblique directions in the contralateral and ipsilateral sides of the tested arm. The matching performance was evaluated in terms of error magnitude (absolute and signed) and its variability. Stroke patients showed higher variability in the estimation of the target position compared to the healthy participants. Further, an effect of target was found, with lower absolute errors in the contralateral side. Pairwise comparison between individual stroke participant and control participants showed significant proprioceptive deficits in two patients. The proposed assessment of passive joint position sense was inherently simple and all participants, regardless of motor impairment level, could complete it in less than 10 minutes. Therefore, the method can potentially be carried out to detect changes in proprioceptive deficits in clinical settings.

Technology aided measures offer a sensitive, accurate and time-efflcient approach for the assessment of sensorimotor function after neurological impairment compared to standard clinical assessments. This preliminary study investigated the relationship between task definition and its effect on robotic measures using a planar, two degree of freedom, robotic-manipulator (H-Man). Four chronic stroke participants (49.5±11.95 years, 2 Female, FMA: 37.5±13.96) and eight healthy control participants (26.25± 4.70 years, 2 Female) participated in the study. Motor functions were evaluated using line tracing and circle tracing tasks with dominant and nondominant hand of healthy and affected vs. non affected hand of stroke participants. The results show significant dependence of quantitative measures on investigated tasks.

Due to the aging population and increase in the number of neurological injuries, the demand for physical therapy has increased. As a result, in recent years robotic devices have been introduced to address the neuro-rehabilitation needs and have been proved to augment the recovery process. Results from a preliminary assessment study on a planar reaching task are presented in this paper. H-Man, a novel upper limb rehabilitation planar robot is employed for the study with ten healthy control subjects - divided into young and aged adults (to understand the effect of aging) and two chronic stroke patients with motor impairment. The assessment of performance was made through kinematic task parameters (smoothness of movement and time to peak velocity) and EMG signal measure (Integrated Average Value) from the upper limb muscles. This revealed significant differences between the groups. The results of the study indicated the potential use of EMG-based metric as a complementary measure to generally-used end effector robotic metrics to track the recovery process.

In the past few years, rehabilitation technology has been one of the emerging fields in the robotics area. H-Man, a 2D planar robot, was developed for upper extremities neurorehabilitation. The current design allows elbow and shoulder motor function recovery. To further expand its use to distal components of upper limb physiotherapy, a modular end-effector capable of measuring grip force and vertical displacement is developed to be implemented on the manipulandum. The grip force measurement yields results with less than 1N (3%) mean error and 0.6N (2%) standard deviation, demonstrating the feasibility of the end effector.