We express gratitude to the patients and medical staff of the Second Hospital of Jiaxing for their support and cooperation during the research process.

This study (Approval No. JXEY-2020SW038) was approved by the Medical Ethics Committee of the Second Hospital of Jiaxing, with all participants providing informed consent. It aimed to assess the feasibility and effectiveness of a protocol through a randomized, single-blind, controlled trial. Between January and December 2021, 60 stroke patients admitted to the Second Hospital of Jiaxing were enrolled.
NOTE: Inclusion criteria comprised: 1) confirmed diagnosis of cerebral infarction or hemorrhage via computed tomography (CT) or magnetic resonance imaging (MRI), 2) first-onset and unilateral lesion with a disease duration of 2 weeks to 3 months and a stable condition, 3) age 25-75 years, 4) absence of hemianopsia or unilateral spatial neglect, as well as no visual or auditory deficits, 5) conscious, compliant, and able to participate in rehabilitation treatment, 6) clear unilateral upper limb dysfunction with a modified Ashworth scale (MAS) grade &#8804; 216. Exclusion criteria included: 1) previous craniocerebral injury or other intracranial diseases, 2) severe myocardial infarction, angina pectoris, liver, kidney, lung, or other important organ diseases, malignant tumors, etc., 3) previous history of psychiatric disorders and epilepsy, 4) severe pain, numbness, or other sensory deficits on the hemiplegic side of the limbs, 5) significant limitation of movement in the bilateral upper limbs.
1. Study design
<ol>
	<li>Randomly divide patients (n = 60) who met the specified criteria into two groups: an experimental group (n = 30) and a control group (n = 30).</li>
	<li>Have a skilled occupational therapist complete the following functional assessments, who was unaware of the group assignments before and after a 6-week treatment period.
	<ol>
		<li>Motor evoked potential (MEP):
		<ol>
			<li>Elicit MEPs in patients using a magnetic stimulation therapy system following the guidelines established by Groppa et al.17.</li>
			<li>During the test, position the patient in front of the device in a stable and comfortable manner and place the recording electrode pads on the abductor pollicis brevis and wrist joint osseous process.</li>
			<li>Then, center the magnetic stimulation coil above the motor cortex on the injured side of the brain, with the coil handle positioned at a 45&#176; angle to the sagittal plane.</li>
			<li>Carry out stimulation of the motor cortex area 10 times at 100% intensity and record the presence or absence of motor-evoked potentials, along with their latency and amplitude. 
			NOTE: Due to the inability to detect motor evoked potentials in all patients, a thorough comparison and analysis of the latency and amplitude of the evoked potentials between the two patient groups was not feasible. Therefore, the study aimed to determine the presence or absence of MEPs and compare the percentage of detectable MEPs between two groups of patients. A higher percentage of detectable MEPs indicates a greater potential for enhancing corticospinal pathways in stroke patients.</li>
		</ol>
		</li>
		<li>Perform functional test for the hemiplegic upper extremity-Hong Kong (FTHUE-HK).
		<ol>
			<li>Utilize the scale to assess the patient&#39;s upper limb functionality, which includes 12 tasks, such as placing the hand on the knee and wringing a rag. 
			NOTE: Each task must be completed within 3 min and can only be attempted up to 3 times. The scale comprises 7 levels, with higher levels indicating better upper limb functionality18.</li>
		</ol>
		</li>
		<li>Use the Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE).
		<ol>
			<li>Utilize this scale to evaluate the motor function of the shoulder, elbow, forearm, wrist, and hand. 
			NOTE: A score of 0 indicates inability to perform the specified movement, a score of 1 indicates partial completion, and a score of 2 indicates full completion. The scale has a maximum score of 66 points, with higher scores indicating better upper limb motor function19.</li>
		</ol>
		</li>
		<li>Calculate the Modified Barthel index (MBI).
		<ol>
			<li>Utilize this scale to assess the patient&#39;s performance in activities of daily living. 
			NOTE: The scale consists of 10 items, including eating, dressing, bathing, etc., with a maximum score of 100 points. A higher score indicates greater independence in the patient&#39;s daily life20.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Ensure that all patients are prescribed conventional medications, including anti-hypertensives, anti-diabetics, lipid regulators, etc., tailored to their individual conditions. 
	NOTE: The medication selection for stroke patients is based on their unique circumstances and may differ from one patient to another.</li>
	<li>Confirm that all patients received routine physical therapy, occupational therapy for the forearm and hand, and activities of daily living training for 6 weeks.</li>
	<li>Ensure that patients in the control group received routine occupational therapy targeting upper limb function for 1 h per day for 6 weeks. 
	NOTE: The routine occupational therapy targeting upper limb function includes motor control training for the shoulder and elbow joints, roller training, hoop training, and reaching for objects training.</li>
	<li>Confirm that patients in the experimental group received routine occupational therapy targeting upper limb function for 30 min per day, in addition to dual upper limb task-oriented robotic system training for 30 min per day for 6 weeks.</li>
</ol>
2. Dual upper limb task-oriented robotic system training session
NOTE: Only the stroke patients in the experimental group received these training sessions.
<ol>
	<li>Start the robotic system equipment, turn on the system&#39;s computer screen, open the ULCOT Rehab application, and enter the main interface of the system.</li>
	<li>During the initial training session, click Register to establish a personal file for each patient, mainly including name, gender, age, case number, diagnosis, affected side, and other relevant medical contents.</li>
	<li>Click Login on the main interface of the system, select the patient who needs training from the list, and enter the interface of the training system for that patient.</li>
	<li>Assist the patient in positioning themselves in front of the robotic device, ensuring a safe and comfortable distance.</li>
	<li>Click Adjustment on the interface of the patient training system to enter the interface of equipment parameter adjustment and set the appropriate parameters for the patient. 
	NOTE: It is not necessary to set parameters for each training session. Upon logging into the patient&#39;s training system interface, the system automatically adjusts to the parameters established during the patient&#39;s previous training session. The therapist can then modify the corresponding parameters in accordance with the therapeutic goals. If no changes to the parameters are needed, the user can click Training in the training system interface to access the training program setting interface.
	<ol>
		<li>Click on + or - to increase or decrease the height of the platform in the Platform Height Adjustment module. Adjust the height of the equipment platform based on the patient&#39;s height.</li>
		<li>Click + or - to increase or decrease the tilt angle of the system&#39;s robot arm in the Arm Tilt Angle Adjustment module. Adjust the tilt angle of the robotic arm according to the patient&#39;s shoulder flexion and extension training goals (the higher the target, the greater the angle).</li>
		<li>Click + or - to increase or decrease the angle between the two robot arms in the Arm Angle Adjustment module. Adjust the angle between the robotic arms according to the patient&#39;s upper limb adduction and abduction training goals (the higher the goal, the greater the angle).</li>
	</ol>
	</li>
	<li>Click Training in the patient training system interface to enter the training program setting interface.
	<ol>
		<li>Select an appropriate training program based on the patient&#39;s upper limb functional status. When the upper limb on the hemiplegic side is unable to actively manipulate the mechanical handle through the full range of motion, opt for the assisted training program.</li>
		<li>Conversely, if the upper limb on the hemiplegic side is capable of actively manipulating the mechanical handle to complete the full range of motion, choose the resistance training program.</li>
	</ol>
	</li>
	<li>Explain and demonstrate the training methods of the selected items and inform relevant precautions to ensure that patients know how to perform the training session safely and accurately.</li>
	<li>Help the patient to fix their hands on the handles at the end of the two robotic arms (Figure 1).</li>
	<li>Conduct dual upper limb task-oriented robot system training.
	<ol>
		<li>For patients who are unable to actively manipulate the mechanical handle to achieve a full range of motion on the hemiplegic side of the upper limb, click Assistance in the training program setting interface to enter the assisted training mode interface. 
		NOTE: The therapist may select Air Flying game or Ping-Pong game for the patient in assisted training mode. It should be noted that patients may only select one game per training session.
		<ol>
			<li>Set the time to 30 min in the Training Time module, and select the level set for the patient in the Assisted Level module. 
			NOTE: This mode offers 6 levels of assistance, with level 6 involving the affected upper limb being driven by both the robot and the healthy upper limb during bilateral upper limb training. On the other hand, level 1 entails the affected upper limb participating in bilateral upper limb training directly without external force. The training session commences at level 6, and the patient can progress to the next level after achieving a full score at each level. Once the patient attains a full training score at assistance level 1, they are deemed ready for resistance mode training.</li>
			<li>Click Air Flying or Ping-Pong, then click Start to enter the game interface.</li>
			<li>Air Flying game: Instruct the patient to control a virtual airplane displayed on the computer screen by maneuvering the affected upper limb through the healthy side with the assistance of a robotic device, enabling the patient to optimize their efforts in guiding the virtual airplane along the designated flight trajectory while simultaneously capturing virtual gold coins (Figure 2).</li>
			<li>Ping-Pong game: With the assistance of the robot, instruct the patient to use the unaffected side to drive the affected side upper limb to control the virtual table tennis racket and move the racket to catch the flying ping-pong (Figure 3).</li>
		</ol>
		</li>
		<li>For patients who are able to actively manipulate the mechanical handle to achieve a full range of motion on the hemiplegic side of the upper limb, click Resistance in the training program settings interface to access the resistance training mode interface. 
		NOTE: In the resistance training mode, participants can choose from five available games: Air Flying, Ping-Pong, Bridge &#38; Road, Weight-Lifting, and Pop Matching. Only one game may be selected for each training session.
		<ol>
			<li>Set the time to 30 min in the Training Time module, and select the resistance levels of the healthy side and the affected side, respectively, in the Healthy Level and Affected Level modules. 
			NOTE: In the resistance training mode, resistance levels can be individually set for the patient&#39;s healthy and affected sides based on upper limb muscle strength. Levels range from 1 (lowest resistance) to 10 (highest resistance). The initial treatment involved the selection of Level 1 resistance, with patients permitted to progress to the subsequent level upon achieving a perfect score on each level of training.</li>
			<li>In the Healthy Side Resistance Direction and Affected Side Resistance Direction modules, select the resistance direction indicated by the system for the patient&#39;s healthy side and the affected side of the upper limb during resistance training, respectively. 
			NOTE: The direction of resistance is selected for the patient according to the purpose of the exercise, including push and pull.</li>
			<li>Select the amount of time the target needs to be held in the Holding Time module. 
			NOTE: The time is determined based on the patient&#39;s upper limb function, ranging from 1 to 10 s. The longer the time, the more challenging it becomes. If the set holding time is 10 s and the training score is perfect, the resistance level will be increased for the next session. The Air Flying and Ping-Pong games do not include this step.</li>
			<li>Click to select one of the following games: Air Flying, Ping-Pong, Bridge &#38; Road, Weight-Lifting, and Pop Matching. Click Start to enter the game interface.</li>
			<li>Air Flying game: Instruct the patient to control the virtual airplane by resisting the resistance given by the robotic arm on both the healthy and affected upper limbs, enabling the patient to optimize their efforts in guiding the virtual airplane along the designated flight trajectory while simultaneously capturing virtual gold coins.</li>
			<li>Ping-Pong game: Instruct the patient to control the virtual table tennis racket by resisting the resistance given by the robotic arm on both the healthy and affected upper limbs and move the racket to catch the flying ping-pong.</li>
			<li>Bridge &#38; Road game: Have&#160;the patient control both ends of a wooden&#160;bridge on the screen by resisting the resistance&#160;given by the robotic arm on both the healthy&#160;and affected upper limbs, move two ladder platforms of different heights, and hold them&#160;for a certain time to allow the virtual character&#160;to pass (Figure 4).</li>
			<li>Weight-Lifting game: Have&#160;the patient control the ends of a weight-lifting&#160;barbell displayed on a screen by resisting the&#160;resistance given by the robotic arm on both the healthy 
			and affected upper limbs,&#160;adjusting its position to reach a target location&#160;by varying the distance and maintaining that&#160;position for a specified duration&#160;(Figure 5).</li>
			<li>Pop Matching game:&#160;Have the patient control two virtual 
			fingers located at the left and right ends&#160;of the screen by resisting the resistance given&#160;by the robotic arm on both the healthy and&#160;affected upper limbs, select identical items from the left and right columns of pictures&#160;through the virtual fingers and maintain this position for a 
			designated duration (Figure 6). 
			NOTE: The system verifies whether the selected pictures on both sides are the same; if they are, the selected pictures are eliminated. If they do not match, the patient is prompted to re-select.</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>
3. Follow-up procedure
<ol>
	<li>Utilize statistical software to analyze the assessment data collected, determining appropriate analysis methods based on the data type.</li>
	<li>Elucidate the significance of the data results and evaluate the impact of dual upper limb task-oriented robot system training on upper limb function in stroke patients.</li>
</ol>

Dual Upper Limb Robotic Training in Stroke Rehabilitation

<ol>
	<li>Feigin, V. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=World+Stroke+Organization+(WSO):+Global+stroke+fact+sheet+2022.">World Stroke Organization (WSO): Global stroke fact sheet 2022.</a> Int J Stroke. 17 (1), 18-29 (2022).</li><li>Kiper, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+immersive+virtual+reality+on+upper-extremity+stroke+rehabilitation:+A+systematic+review+with+meta-analysis.">Effects of immersive virtual reality on upper-extremity stroke rehabilitation: A systematic review with meta-analysis.</a> J Clin Med. 13 (1), 146 (2023).</li><li>Yao, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cognitive+function+and+upper+limb+rehabilitation+training+post-stroke+using+a+digital+occupational+training+system.">Cognitive function and upper limb rehabilitation training post-stroke using a digital occupational training system.</a> J Vis Exp. (202), e65994 (2023).</li><li>Tang, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bilateral+upper+limb+robot-assisted+rehabilitation+improves+upper+limb+motor+function+in+stroke+patients:+a+study+based+on+quantitative+EEG.">Bilateral upper limb robot-assisted rehabilitation improves upper limb motor function in stroke patients: a study based on quantitative EEG.</a> Eur J Med Res. 28 (1), 603 (2023).</li><li>Yang, S. -. W., Ma, S. -. R., Choi, J. -. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+3-dimensional+robotic+therapy+combined+with+electromyography-triggered+neuromuscular+electrical+stimulation+on+upper+limb+function+and+cerebral+cortex+activation+in+stroke+patients:+A+randomized+controlled+trial.">Effect of 3-dimensional robotic therapy combined with electromyography-triggered neuromuscular electrical stimulation on upper limb function and cerebral cortex activation in stroke patients: A randomized controlled trial.</a> Bioengineering. 11 (1), 12 (2023).</li><li>Chen, P. M., Kwong, P. W. H., Lai, C. K. Y., Ng, S. S. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+bilateral+and+unilateral+upper+limb+training+in+people+with+stroke:+A+systematic+review+and+meta-analysis.">Comparison of bilateral and unilateral upper limb training in people with stroke: A systematic review and meta-analysis.</a> PLoS One. 14 (5), e0216357 (2019).</li><li>Dhakate, D., Bhattad, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Study+the+effectiveness+of+bilateral+arm+training+on+upper+extremity+motor+function+and+activity+level+in+patients+with+sub-acute+stroke.">Study the effectiveness of bilateral arm training on upper extremity motor function and activity level in patients with sub-acute stroke.</a> Int J Cur Res Rev. 12 (20), 2987 (2020).</li><li>Ahn, S. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Benefits+of+robot-assisted+upper-limb+rehabilitation+from+the+subacute+stage+after+a+stroke+of+varying+severity:+A+multicenter+randomized+controlled+trial.">Benefits of robot-assisted upper-limb rehabilitation from the subacute stage after a stroke of varying severity: A multicenter randomized controlled trial.</a> J Clin Med. 13 (3), 808 (2024).</li><li>Li, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dual-tDCS+combined+with+sensorimotor+training+promotes+upper+limb+function+in+subacute+stroke+patients:+A+randomized,+double-blinded,+sham-controlled+study.">Dual-tDCS combined with sensorimotor training promotes upper limb function in subacute stroke patients: A randomized, double-blinded, sham-controlled study.</a> CNS Neurosci Ther. 30 (4), e14530 (2023).</li><li>Yuan, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+uni-+vs.+bilateral+upper+limb+robot-assisted+rehabilitation+on+motor+function,+activities+of+daily+living,+and+electromyography+in+hemiplegic+stroke:+A+single-blinded+three-arm+randomized+controlled+trial.">Effects of uni- vs. bilateral upper limb robot-assisted rehabilitation on motor function, activities of daily living, and electromyography in hemiplegic stroke: A single-blinded three-arm randomized controlled trial.</a> J Clin Med. 12 (8), 2950 (2023).</li><li>Song, Y. -. H., Lee, H. -. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effect+of+immersive+virtual+reality-based+bilateral+arm+training+in+patients+with+chronic+stroke.">Effect of immersive virtual reality-based bilateral arm training in patients with chronic stroke.</a> Brain Sci. 11 (8), 1032 (2021).</li><li>Dembele, J., Triccas, L. T., Amanzonw&#233;, L. E. R., Kossi, O., Spooren, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Bilateral+versus+unilateral+upper+limb+training+in+(sub)acute+stroke:+A+systematic+and+meta-analysis.">Bilateral versus unilateral upper limb training in (sub)acute stroke: A systematic and meta-analysis.</a> S Afr J Physiother. 80 (1), 1985 (2024).</li><li>Wu, J. Y., Cheng, H., Zhang, J. Q., Bai, Z. F., Cai, S. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+modulatory+effects+of+bilateral+arm+training+(BAT)+on+the+brain+in+stroke+patients:+a+systematic+review.">The modulatory effects of bilateral arm training (BAT) on the brain in stroke patients: a systematic review.</a> Neurol Sci. 42 (2), 501-511 (2021).</li><li>Yang, X. W., Shi, X. B., Xue, X. L., Deng, Z. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+robot-assisted+training+on+rehabilitation+of+upper+limb+function+in+patients+with+stroke:+A+systematic+review+and+meta-analysis.">Efficacy of robot-assisted training on rehabilitation of upper limb function in patients with stroke: A systematic review and meta-analysis.</a> Arch Phys Med Rehabil. 104 (9), 1498-1513 (2023).</li><li>Wu, J. Y., Cheng, H., Zhang, J. Q., Yang, S. L., Cai, S. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robot-assisted+therapy+for+upper+extremity+motor+impairment+after+stroke:+A+systematic+review+and+meta-analysis.">Robot-assisted therapy for upper extremity motor impairment after stroke: A systematic review and meta-analysis.</a> Phys Ther. 101 (4), pzab010 (2021).</li><li>Meseguer-Henarejos, A. B., S&#225;nchez-Meca, J., L&#243;pez-Pina, J. A., Carles-Hern&#225;ndez, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Inter-+and+intra-rater+reliability+of+the+Modified+Ashworth+Scale:+a+systematic+review+and+meta-analysis.">Inter- and intra-rater reliability of the Modified Ashworth Scale: a systematic review and meta-analysis.</a> Eur J Phys Rehabil Med. 54 (4), 576-590 (2018).</li><li>Groppa, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+practical+guide+to+diagnostic+transcranial+magnetic+stimulation:+report+of+an+IFCN+committee.">A practical guide to diagnostic transcranial magnetic stimulation: report of an IFCN committee.</a> Clin Neurophysiol. 123 (5), 858-882 (2012).</li><li>Fong, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+the+Hong+Kong+version+of+the+functional+test+for+the+hemiplegic+upper+extremity+(FTHUE-HK).">Development of the Hong Kong version of the functional test for the hemiplegic upper extremity (FTHUE-HK).</a> Hong Kong J Occup Th. 14 (1), 21-29 (2004).</li><li>Hern&#225;ndez, E. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intra-+and+inter-rater+reliability+of+Fugl-Meyer+Assessment+of+Upper+Extremity+in+stroke.">Intra- and inter-rater reliability of Fugl-Meyer Assessment of Upper Extremity in stroke.</a> J Rehabil Med. 51 (9), 652-659 (2019).</li><li>Ohura, T., Hase, K., Nakajima, Y., Nakayama, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Validity+and+reliability+of+a+performance+evaluation+tool+based+on+the+modified+Barthel+Index+for+stroke+patients.">Validity and reliability of a performance evaluation tool based on the modified Barthel Index for stroke patients.</a> BMC Med Res Methodol. 17 (1), 131 (2017).</li><li>Wu, J., Cheng, H., Zhang, J., Bai, Z., Cai, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+modulatory+effects+of+bilateral+arm+training+(BAT)+on+the+brain+in+stroke+patients:+a+systematic+review.">The modulatory effects of bilateral arm training (BAT) on the brain in stroke patients: a systematic review.</a> Neurol Sci. 42 (2), 501-511 (2021).</li><li>Hsu, H. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Robotic-assisted+therapy+with+bilateral+practice+improves+task+and+motor+performance+in+the+upper+extremities+of+chronic+stroke+patients:+A+randomised+controlled+trial.">Robotic-assisted therapy with bilateral practice improves task and motor performance in the upper extremities of chronic stroke patients: A randomised controlled trial.</a> Aust Occup Ther J. 66 (5), 637-647 (2019).</li><li>Kitsos, G. H., Hubbard, I. J., Kitsos, A. R., Parsons, M. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+ipsilesional+upper+limb+can+be+affected+following+stroke.">The ipsilesional upper limb can be affected following stroke.</a> ScientificWorldJournal. 2013, 684860 (2013).</li><li>Bustr&#233;n, E. L., Sunnerhagen, K. S., Alt Murphy, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Movement+kinematics+of+the+ipsilesional+upper+extremity+in+persons+with+moderate+or+mild+stroke.">Movement kinematics of the ipsilesional upper extremity in persons with moderate or mild stroke.</a> Neurorehabil Neural Repair. 31 (4), 376-386 (2017).</li><li>da Silva, E. S. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+priming+on+outcomes+of+task-oriented+training+for+the+upper+extremity+in+chronic+stroke:+A+systematic+review+and+meta-analysis.">The effect of priming on outcomes of task-oriented training for the upper extremity in chronic stroke: A systematic review and meta-analysis.</a> Neurorehabil Neural Repair. 34 (6), 479-504 (2020).</li><li>Lee, C. Y., Howe, T. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+activity-based+task-oriented+training+on+upper+extremity+recovery+for+adults+with+stroke:+A+systematic+review.">Effectiveness of activity-based task-oriented training on upper extremity recovery for adults with stroke: A systematic review.</a> Am J Occup Ther. 78 (2), 7802180070 (2024).</li></ol>

The authors declare no conflicts of interest or financial disclosures in this study.

Bilateral training has been shown to normalize intercortical inhibition in stroke patients, facilitate brain functional network reorganization, and ultimately enhance upper limb function21. This study presents a program for upper limb functional training in stroke patients utilizing a dual upper limb task-oriented robotic system. The program integrates bilateral upper limb movement, task-oriented activities, and robot-assisted training to enhance the rehabilitation of upper limb function in stroke...

Stroke is one of the major causes of disability and the second leading cause of death globally1,2. Stroke patients often face various challenges, such as motor, sensory, and cognitive deficits3. Upper limb dysfunction is a common problem after stroke, characterized by muscle weakness, spasticity, and reduced motor ability of the upper limb on the hemiplegic side4. It is reported to be present in more than 70% of stroke patients, and only around 5% recover to normal, while 20% regain some upper limb capabilities5. More than half of human life requires the participation of the upper limbs6, and upper limb dysfunction after a stroke severely affects patients' activities of daily living7, significantly decreasing their quality of life8 and increasing their financial burden9. Therefore, it is particularly important to explore effective methods of upper limb functional rehabilitation.
Various clinical upper limb rehabilitation treatments, such as mirror therapy, constraint-induced movement therapy, functional electrical stimulation, and other active or passive training, are commonly utilized for stroke patients3,10. In recent years, bilateral arm training has garnered increased attention6,11,12. It has been demonstrated to enhance neural connectivity between the sensorimotor areas of both ipsilateral and contralateral hemispheres12. This type of training helps correct abnormalities in interhemispheric inhibition, facilitates reorganization of brain functional networks, and ultimately leads to improvements in upper limb function12,13. Furthermore, robot-assisted training has also been shown to assist patients in consistently executing accurate limb movements and engaging in task-specific training14. This process provides the brain with substantial feedback stimulation, ultimately boosting neuroplasticity and aiding in the restoration of upper limb function in individuals with hemiplegia14,15. There is currently limited research on strategies utilizing robot-assisted dual upper limb training for stroke patients. This study employed a dual upper limb task-oriented robotic system to combine robot-assisted training with bilateral upper limb training. The robotic device was utilized to aid stroke patients in conducting dual upper limb task-oriented training with high repetitions in a proper movement pattern. The objective of the research was to evaluate the effects of this method on the corticospinal pathway, upper-limb function, and activities of daily living in stroke survivors, with the aim of discovering innovative strategies for upper limb functional rehabilitation.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Dual upper limb task-oriented robotic system</td>
			<td>Auckland Tongji Rehabilitation Medical Equipment Research Center, Tongji Zhejiang College</td>
			<td>N/A</td>
			<td>The dual upper limb task-oriented robotic system can aid stroke patients in bilateral upper limb virtual game training by regulating force transmission between the healthy and affected upper limbs.</td>
		</tr>
		<tr>
			<td>Magnetic stimulation therapy system</td>
			<td>Sichuan Junjian Wanfeng Medical Equipment Co.,Ltd.</td>
			<td>http://www.jjwf-med.com</td>
			<td> 
			This system can be used to measure the Motor evoked potential (MEP)</td>
		</tr>
		<tr>
			<td>SPSS 25.0</td>
			<td>IBM</td>
			<td>Version 25.0</td>
			<td>https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-25</td>
		</tr>
	</tbody>
</table>

application of a dual upper limb task-oriented robotic system for the functional recovery of the upper limb in stroke patients

Highly repetitive and task-oriented training has been shown to promote the recovery of limb function in stroke patients. Additionally, bilateral arm training can help stroke survivors regain their upper limb function and improve their daily activities. The dual upper limb task-oriented robotic system is designed to assist the healthy side of the stroke patient in driving the affected side to perform bilateral arm training through the use of a robotic device. It can also guide the patient in carrying out dual upper limb coordinated movements and engage them in a task-oriented virtual game using force feedback and human-computer interaction technology. This study aimed to assess the efficacy of the system in enhancing upper limb function and activities of daily living in stroke patients. The assessment methods used included motor evoked potential (MEP), functional test for the hemiplegic upper extremity-Hong Kong (FTHUE-HK), Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE), and modified Barthel index (MBI). The results of the study indicate that the dual upper limb task-oriented robotic system can significantly improve the corticospinal pathway, upper limb function, and activities of daily living in stroke patients after 6 weeks of treatment. This system can serve as an effective adjunct to upper limb functional rehabilitation in stroke survivors, reducing the dependence on rehabilitation therapists. In conclusion, the dual upper limb task-oriented robotic system provides a new strategy for post-stroke limb functional rehabilitation and holds great potential for application, as it offers certain social and financial benefits.

A total of 60 stroke patients were divided into a control group (n = 30) and an experimental group (n = 30) for this study. Upon comparing age, gender, stroke type, disease duration, side of hemiplegia, and other general information between the two groups, no statistically significant differences were found (P &#62; 0.05), indicating their comparability (Table 1). Patients in the experimental group, who underwent training with a dual upper limb task-oriented robotic system, showed greater improvements in...

Author Spotlight: Enhancing Upper Limb Rehabilitation in Stroke Patients Through Advanced Robotic and Neuromodulation Technologies

This experimental protocol outlines the use of a dual upper limb task-oriented robotic system for stroke patients with upper limb dysfunction. The findings indicate that this system can significantly improve stroke patients' upper limb function and daily living activities.

Application of a Dual Upper Limb Task-Oriented Robotic System for the Functional Recovery of the Upper Limb in Stroke Patients

Highly repetitive and task-oriented training has been shown to promote the recovery of limb function in stroke patients. Additionally, bilateral arm ...

Our research is focused on the rehabilitation of patients who have suffered a stroke or traumatic brain injury, and we're trying to investigate the impact of our robot-assisted to upper limb training strategy on the recovery of upper limb function in stroke patients. Our protocol integrates bilateral upper limb training, task-oriented activities, and robot-assisted training to enhance the rehabilitation of upper limb function in stroke patients. We will focus on the impact of neuromodulation technology, virtual reality technology, and artificial intelligence robotic assistants on post-stroke limb function rehabilitation.

application-dual-upper-limb-task-oriented-robotic-system-for

Microsoft Bing

Without Section

Research

JoVE Journal

Medicine

317 Views.  Graduate School of Zhejiang Chinese Medical University. Our research is focused on the rehabilitation of patients who have suffered a stroke or traumatic brain injury, and we're trying to investigate the impact of our robot-assisted to upper limb training strategy on the recovery of upper limb function in stroke patients. Our protocol integrates bilateral upper limb training, task-oriented activities, and robot-assisted training to enhance the rehabilitation of upper limb function in stroke patients. We will focus on the impact of neuromodulation ...

Video: Author Spotlight: Enhancing Upper Limb Rehabilitation in Stroke Patients Through Advanced Robotic and Neuromodulation Technologies

Orthotopic Hind Limb Transplantation in the Mouse

In vivo animal model systems, and in particular mouse models, have evolved into powerful and versatile scientific tools indispensable to basic and translational research in the field of transplantation medicine. A vast array of reagents is available exclusively in this setting, including mono- and polyclonal antibodies for both diagnostic and interventional applications. In addition, a vast number of genotyped, inbred, transgenic, and knock out strains allow detailed investigation of the individual contributions of humoral and cellular components to the complex interplay of an immune response and make the mouse the gold standard for immunological research. 
Vascularized Composite Allotransplantation (VCA) delineates a novel field of transplantation using allografts to replace "like with like" in patients suffering traumatic or congenital tissue loss. This surgical methodological protocol shows the use of a non-suture cuff technique for super-microvascular anastomosis in an orthotopic mouse hind limb transplantation model. The model specifically allows for comparison between established paradigms in solid organ transplantation with a novel form of transplants consisting of various different tissue components. Uniquely, this model allows for the transplantation of a viable vascularized bone marrow compartment and niche that have the potential to exert a beneficial effect on the balance of immune acceptance and rejection. This technique provides a tool to investigate alloantigen recognition and allograft rejection and acceptance, as well as enables the pursuit of functional nerve regeneration studies to further advance this novel field of transplantation.

This novel model for orthotopic hind limb transplantation in the mouse, applying a non-suture cuff technique for super-microvascular anastomosis, provides a powerful tool for in&#160;vivo mechanistic immunological research related to vascularized composite allotransplantation (VCA).

In vivo animal model systems, and in particular mouse models, have evolved into powerful and versatile scientific tools indispensable to basic and ...

A Method for Quantifying Upper Limb Performance in Daily Life Using Accelerometers

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.

This protocol describes a method to quantify upper limb performance in daily life using wrist-worn accelerometers.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. ...

Taking the Next Step: a Neural Coaptation Orthotopic Hind Limb Transplant Model to Maximize Functional Recovery in Rat

Limb transplant in particular and vascularized composite allotransplant (VCA) in general have wide therapeutic promise that have been stymied by current limitations in immunosuppression and functional neuromotor recovery. Many animal models have been developed for studying unique features of VCA, but here we present a robust reproducible model of orthotopic hind limb transplant in rats designed to simultaneously investigate both aspects of current VCA limitation: immunosuppression strategies and functional neuromotor recovery. At the core of the model rests a commitment to meticulous, time-tested microsurgical techniques such as hand sewn vascular anastomoses and hand sewn neural coaptation of the femoral nerve and the sciatic nerve. This approach yields durable limb reconstructions that allow for longer lived animals capable of rehabilitation, resumption of daily activities, and functional testing. With short-term treatment of conventional immunosuppressive agents, allotransplanted animals survived up to 70 days post-transplant, and isotransplanted animals provide long lived controls beyond 200 days post-operatively. Evidence of neurologic functional recovery is present by 30 days post operatively. This model not only provides a useful platform for interrogating immunological questions unique to VCA and nerve regeneration, but also allows for in vivo testing of new therapeutic strategies specifically tailored for VCA.

This protocol presents a robust, reproducible model of vascularized composite allotransplant (VCA) geared toward simultaneous study of immunology and functional recovery. The time invested in meticulous technique in a right mid-thigh hind limb orthotopic transplant with hand sewn vascular anastomoses and neural coaptation yields the ability to study functional recovery.

Limb transplant in particular and vascularized composite allotransplant (VCA) in general have wide therapeutic promise that have been stymied by current ...

Development of a Novel Task-oriented Rehabilitation Program using a Bimanual Exoskeleton Robotic Hand

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor control. However, it is unclear how conventional occupational training strategies can be applied to the use of rehabilitation robots. Novel robotic technologies and occupational therapy concepts are used to develop a protocol that allows patients with impaired upper limb function to grasp objects using their affected hand through a variety of pinching and grasping functions. To conduct this appropriately, we used five types of objects: a peg, a rectangular cube, a cube, a ball, and a cylindrical bar. We also equipped the patients with a robotic hand, the Mirror Hand, an exoskeleton&#160;hand that is fitted to the subject&#8217;s affected hand and follows the movement of the sensor glove fitted to their unaffected hand (bimanual movement training (BMT)). This study had two stages. Three healthy subjects were first recruited to test the feasibility and acceptability of the training program. Three patients with hand dysfunction caused by stroke were then recruited to confirm the feasibility and acceptability of the training program, which was conducted on 3 consecutive days. On each day, the patient was monitored during 5 min of movement in a passive range of motion, 5 min of robot-assisted bimanual movement, and task-oriented training using the five objects. The results showed that both healthy subjects and subjects who had suffered a stroke in conjunction with the robotic hand could successfully grasp the objects. Both healthy subjects and those who had suffered a stroke performed well with the robot-assisted task-oriented training program in terms of feasibility and acceptability.

This study reports the development of a novel robot-assisted task-oriented program for hand rehabilitation. The developmental process consists of experiments using both healthy subjects and subjects who have had a stroke and suffered from subsequent motor control dysfunction.

A robot-assisted hand is used for the rehabilitation of patients with impaired upper limb function, particularly for stroke patients with a loss of motor ...

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

Enhancing Stroke Rehabilitation with Virtual Reality-Based Occupational Training

Cognitive Function and Upper Limb Rehabilitation Training Post-Stroke Using a Digital Occupational Training System

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the potential to meet these demands by providing engaging and motivating therapy options. The digital occupational training system is a VR application that utilizes cutting-edge technologies, including multi-touch screens, virtual reality, and human-computer interaction, to offer diverse training techniques for advanced cognitive capacity and hand-eye coordination abilities. The objective of this study was to assess the effectiveness of this program in enhancing cognitive function and upper extremity rehabilitation in stroke patients. The training and assessment consist of five cognitive modules covering perception, attention, memory, logical reasoning, and calculation, along with hand-eye coordination training. This research indicates that after eight weeks of training, the digital occupational training system can significantly improve cognitive function, daily living skills, attention, and self-care abilities in stroke patients. This software can be employed as a time-saving and clinically effective rehabilitation aid to complement traditional one-on-one occupational therapy sessions. In summary, the digital occupational training system shows promise and offers potential financial benefits as a tool to support the functional recovery of stroke patients.

Author Spotlight: Rehabilitation of Stroke Patients With a Digital Occupational Training System

The current protocol outlines how the VR-based digital occupational training system enhances the rehabilitation of patients with cognitive impairment and upper limb dysfunction following a stroke.

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the ...

Functional OT and Near-IR Spectroscopy to Study Brain Function Remodeling

Investigating the Effect of Different Types of Exercise on Upper Limb Functional Recovery in Patients with Right Hemisphere Damage Based on fNIRS

To investigate the effects of functional occupational therapy (FOT) combined with different types of exercise on upper limb motor function recovery and brain function remodeling in patients with right hemisphere damage (RHD) by analyzing functional near-infrared spectroscopy (fNIRS). Patients (n = 32) with RHD at Beijing Bo'ai Hospital were recruited and randomly allocated to receive either FOT combined with passive motion (N=16) or FOT combined with assisted active movement (N=16). The passive motion group (FOT-PM) received functional occupational therapy for 20 min and passive exercise for 10 min in each session, while the assisted active movement group (FOT-AAM) received functional occupational therapy for 20 min and assisted active exercise for 10 min. Both groups received conventional drug therapy and other rehabilitation therapy. Treatment was performed once a day, 5 times a week for 4 weeks. The recovery of motor function and activities of daily living (ADL) was assessed using Fugl-Meyer Assessment upper extremity (FMA-UE) and modified Barthel index (MBI) before and after treatment, and brain activation of the bilateral motor area was analyzed with fNIRS. The findings suggested that FOT combined with AAM was more effective than FOT combined with PM in improving the motor function of RHD patients' upper limbs and fingers, improving their ability to perform activities of daily living, and facilitating brain function remodeling of the motor area.

Author Spotlight: Advancing Upper Limb Rehabilitation in Patients with Right Hemisphere Damage Using Assisted Active Exercise

Here, we investigate the effect of functional occupational therapy combined with assisted active or passive motion on the upper limb function of patients with right hemisphere damage and explore the effect of functional near-infrared spectroscopy on brain function remodeling.

To investigate the effects of functional occupational therapy (FOT) combined with different types of exercise on upper limb motor function recovery and ...

Rehabilitation Treatment Plan for ACLR Patients

Early Weight-Bearing Rehabilitation Protocol After Anterior Cruciate Ligament Reconstruction

Anterior cruciate ligament (ACL) injury is one of the common sports injuries. Anterior cruciate ligament reconstruction (ACLR) is the mainstream treatment for ACL injury, aiming to regain normal anatomical structure and stability of the knee joint and promote the patient's return to sports. Under the guidance of the concept of enhanced recovery after surgery, early weight-bearing rehabilitation (EWB) is an important factor affecting patient function and quality of life. However, there is no consensus on whether EWB rehabilitation can be performed after ACL surgery. 
This study aims to explore the safety and feasibility of EWB after ACL surgery. The study implemented a gradual EWB rehabilitation program in the experimental group, including weight-shifting training, balance training, and gait training on the affected lower limb, and assessed wound healing and stability of the knee joint. The study found that EWB after ACLR is safe and feasible. EWB rehabilitation not only does not pose a negative effect on the patient's knee pain, swelling, wound healing, and stability, but also helps to improve knee active flexion and quality of life faster and better. The EWB program in this study is simple, safe, and effective, and it provides strong theoretical guidance and practical demonstration for accelerated rehabilitation after ACLR.

Author Spotlight: Implementing the Enhanced Recovery After Surgery Concept in Rehabilitation Following Anterior Cruciate Ligament Reconstruction

Based on the safety and feasibility, this article presents an early weight-bearing rehabilitation protocol after anterior cruciate ligament reconstruction. The protocol is clear and easy to operate, which is helpful to promote its use in clinical practice and accelerate the functional recovery of patients.

Anterior cruciate ligament (ACL) injury is one of the common sports injuries. Anterior cruciate ligament reconstruction (ACLR) is the mainstream treatment ...

Integrated Robotic and Conventional Therapy for Post-Stroke Upper Limb Recovery

Enhancing Upper Limb Function and Motor Skills Post-Stroke Through an Upper Limb Rehabilitation Robot

Cerebrovascular accidents, commonly known as strokes, represent a prevalent neurological event leading to significant upper limb disabilities, thereby profoundly affecting individuals' activities of daily living and diminishing their quality of life. Traditional rehabilitation methods for upper limb recovery post-stroke are often hindered by limitations, including therapist and patient fatigue, reliance on singular training methodologies, and lack of sustained motivation. Addressing these challenges, this study introduces an upper limb rehabilitation robot, which uses intelligent feedback motion control to improve therapeutic outcomes. The system is distinguished by its capability to adjust the direction and magnitude of force feedback dynamically, based on the detection of spastic movements during exercises, thereby offering a tailored therapeutic experience. This system is equipped with four distinct training modes, intelligent assessment of joint range of motion, and the ability to personalize training programs. Moreover, it provides an immersive interactive gaming experience coupled with comprehensive safety measures. This multifaceted approach not only elevates the engagement and interest of participants beyond traditional rehabilitation protocols but also demonstrates significant improvements in upper limb functionality and the activities of daily living among hemiplegic patients. The system exemplifies an advanced tool in upper limb rehabilitation, offering a synergistic blend of precision, personalization, and interactive engagement, thereby broadening the therapeutic options available to stroke survivors.

Author Spotlight: Enhancing Post-Stroke Upper Limb Rehabilitation with Robotic Technologies for Improved Motor Recovery and Functional Outcomes

This protocol describes an upper limb rehabilitation robot that provides intelligent feedback through four modes. These modes enhance upper limb function and flexibility, thereby improving patients' quality of life.

Cerebrovascular accidents, commonly known as strokes, represent a prevalent neurological event leading to significant upper limb disabilities, thereby ...