Various national guidelines recommend using VR and robotic devices for stroke rehabilitation

Stroke is the leading cause of disability1 worldwide. Half of all stroke survivors are left with a degree of physical impairment2. Stroke rehabilitation can be a slow process and begins at the hospital. Stroke recovery time3 varies by individual, severity of the stroke, and type of stroke.4 Slow recovery can result in a longer hospital stay and an increase in complications. Even after the hospital stay, a substantial amount of support for daily activities may be required by the stroke survivor. This loss of independence can become a burden for the stroke survivor and their loved ones.

How to start with stroke recovery?

Both early and post-hospitalization rehabilitation, are critical components of recovery. Timely rehabilitation reduces the risk of complications that come from immobility, loss of autonomy, and independence. With the increasing age of our population, demand for physical therapists is not keeping up with supply5. As a result, there is less rehabilitation time for stroke survivors. Filling this gap requires optimizing rehabilitation6. Effective rehabilitation options, such as virtual reality7 (VR) and robotic devices8, have been made possible9 by recent scientific breakthroughs10 and can allow stroke survivors to regain their sense of independence and improve their quality of life. Guidelines from multiple different countries now recommend the use of robotic therapy as a treatment for stroke survivors.

Timely rehabilitation reduces the risk of complications that come from immobility, loss of autonomy, and independence.

Robotic therapy is as effective as conventional therapy

Clinical trials11 have documented that, in some instances, robotic therapy is as effective as conventional therapy and has many benefits. The success of robotic therapy12 may stem from its ability to increase the intensity and duration13 of exercise therapy— crucial elements for functional recovery from stroke. Other benefits of robotic rehab also exist14. Robotic devices can collect recovery data and measurements that are normally not obtainable by a human examiner. This feature allows for better monitoring of recovery from stroke and empowers patients to have more control over their rehabilitation progress. Technology-assisted rehabilitation allows stroke survivors to use telemedicine to connect with doctors from the comfort of home and continue rehab after leaving the hospital. Further, VR for rehab, which allows patients to participate in specific task practice within a computer-generated visual setting, “gamifies” the rehab process. Gamifying rehab motivates the stroke survivor to comply with the rehab practice.

Given the amount of evidence supporting the benefits of robotic rehabilitation, the U.S. guidelines for healthcare professionals include now robotic rehabilitation as an option for therapy during rehabilitative care of a stroke survivor. Italy15, Canada16, and the Netherlands17 have also adopted similar guidelines.

What do national guidelines say?

  • U.S. guidelines18 were proposed by the American Heart Association/American Stroke Association and state that in combination with conventional therapy, robot-assisted movement training can be used to increase mobility and motor function after stroke. The guidelines also propose the consideration of robotic therapy for the delivery of more intensive exercise for stroke survivors with moderate to severe upper limb partial paralysis.
  • In the Netherlands, the KNGF Guidelines17 are intended to increase the quality, uniformity, and transparency of physical therapy that is provided to stroke survivors. These guidelines were based on the findings that robot-assisted rehab was as effective as conventional exercise therapy.
  • Guidelines in Italy15 strongly favor robotic-assisted functional recovery and reconditioning in all phases of stroke rehabilitation.
  • Canadian best practice recommendations for stroke16 encourage the integration of robotic therapies for children with traditional function-oriented therapy. These guidelines also recommend VR as an adjunct tool for rehab.

Stroke recovery with robotic devices

Robot-assisted movement training: Leg exercises for recovery after stroke

About 35% of stroke survivors with leg paralysis do not regain functional use of their leg19, and 25% of survivors will require full physical assistance to walk again. Chances of walking after a stroke are greatly improved by rehabilitation20.

Physical therapy exercises21 to walk again have been used for many years. However, recent clinical research has shown that robotic-assisted walking22 was more effective than overground walking for non-ambulatory stroke survivors. Likewise, robotic gait trainers23 have improved balance in stroke survivors. In fact, robotic training produced better rehabilitation outcomes24 in patients with severe lower extremity impairment than conventional therapy. This evidence has led to many countries adopting guidelines to optimize treatment of stroke survivors who require walking assistance.

What do national guidelines say about robot-assisted gait training?

  • The U.S. has adopted guidelines18 encouraging robotic-assisted walking with body weight support for stroke survivors who cannot walk or have low walking ability after stroke.
  • The Netherlands17 suggests the use of robot-assisted gait training for patients with inability to walk after stroke. Reports show that this treatment allows patients to walk independently, improved walking ability, walking distance, speed, maximum speed, heart rate, standing and sitting balance, and performance of daily living activities when compared to conventional therapy. Likewise, patients undergoing combined robot-assisted gait training and functional electrostimulation of the stroke-affected leg had improved standing and sitting balance, and walking abilities when compared to conventional therapy.
  • Italy15 recommends using robotic tools to regain walking ability within the first 30 days and no later than 3 months, even in patients with severe walking deficits.
  • To help quickly build endurance for stroke survivors who are able to walk with or without assistance, the UK guidelines25 recommends offering robotic-assisted treadmill training (with or without body weight support) to stroke survivors.
  • In France26, robotic-assisted gait training is recommended 3-11 weeks post-stroke if a patient cannot walk with the help of a therapist.
  • Canadian16 stroke best practice recommendations state that for patients who could not otherwise practice walking, robotic-assisted gait training could be considered, but should not replace conventional gait therapy.
Leg exercises for stroke patients

Technology for upper extremity movement practice: Arm and hands exercises for stroke survivors

Upper limb training, such as hand and arm exercises for stroke patients, is crucial to recovering control of the affected extremity. Recently, it has been shown that upper extremity function19 can be improved with the use of robotic therapy. Guidelines from several countries have proposed robotic-assisted rehabilitation for upper extremity movement practice.

What do national guidelines say about robot-assisted upper limb training?

  • In the US18, guidelines propose the consideration of robotic-assisted therapy to deliver more intensive practice for stroke survivors with moderate to severe upper limb paralysis. Also, VR is recommended as a method for upper extremity movement practice in stroke survivors.
  • In the Netherlands17, robot-assisted training reduced atypical pain and improved selective movements and muscle strength of the paretic arm. However, the guidelines point out that it is still unclear if robot-assisted training, involving simultaneous training of the arm and hand, is more effective for stroke survivors in recovery of muscle strength and selective movements than other interventions.
  • In Italy15, recommendations are in favor of early robotic-assisted rehabilitation of paretic upper limb to recover the highest degree of functionality, muscle strength, and motor control. VR is also recommended to improve paretic upper limb motor performance.
  • To improve motor skills, France26 recommends the combination of conventional treatment and robotic-assisted rehab for sub-acute and chronic phases of stroke.
  • Germany27 recommends robotic-assisted therapy for patients in the subacute stroke or chronic phase to increase selective mobility of severe arm paresis. The guidelines also support the use of VR for the treatment of mild to moderate arm palsy in patients in the subacute and chronic stroke phases.
Arm exercises for stroke patients
Arm exercises for stroke patients


Robotic and VR rehabilitation can provide consistent and engaging feedback to help stroke survivors comply with rehabilitation therapy. With robotic assistance, rehab time is optimized for faster recovery, which increases the quality of life for stroke survivors. Hocoma rehabilitation solutions for arm and hand, gait and balance, strength, and endurance can empower individuals to regain independence faster.