Do people with multiple sclerosis perceive upper limb improvements from robotic-mediated therapy? A mixed methods study

Published:September 05, 2022DOI:


      • Experiences of rehabilitation technology using mixed methods have been rarely explored in people with multiple sclerosis.
      • Robot-mediated upper limb therapy resulted in positive experiences on upper limb impairments for people with multiple sclerosis.
      • Expectations of participants were rather low at baseline but increased with observed functional benefits.
      • Long-term rehabilitation programs involving rehabilitation technology should be considered for people with multiple sclerosis.



      Robot-mediated training is increasingly considered as a rehabilitation intervention targeting upper limb disability. However, experiences of such an intervention have been rarely explored in the multiple sclerosis population. This mixed methods study sought to explore the impact of an eight week upper limb robotic intervention on experiences of people with multiple sclerosis.


      Eleven participants (Median EDSS- score: 6.5) with moderate to severe upper limb impairment, performed eight week robot- mediated training of the most affected arm. The training involved a virtual learning platform called I-TRAVLE with duration of 30 min per training session, twice to three times per week. Two subjective questionnaires with items from the Intrinsic Motivation Inventory (IMI) and Credibility and Expectancy Questionnaire (CEQ) were collected bi-weekly during the intervention. Approximately one month after completing the training, three focus groups were conducted. Main themes were identified using thematic analysis.


      Results from the IMI and CEQ indicated high patient satisfaction and expectation that the intervention will be beneficial for them. Two main themes were identified: (1) Effect of the intervention on impairment and activity in that participants felt that there was a positive impact of the training on strength, endurance and during activities of daily living and that it met their expectations; (2) Experiences based on system usage from the system in that participants expressed feelings of motivation and self-improvement. The participants also perceived the training as enjoyable and concluded that the use of games instigated a competitive spirit between the participants.


      Robot-mediated training could have a motivating effect and induce a general positive experience while reducing disabilities of people with multiple sclerosis.


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        • Barker R.N.
        • Brauer S.G.
        Upper limb recovery after stroke: the stroke survivors' perspective.
        Disabil. Rehabil. 2005; 27: 1213-1223
        • Bastiaens H.
        • et al.
        Facilitating robot-assisted training in MS patients with arm paresis: a procedure to individually determine gravity compensation.
        IEEE Int. Conf. Rehabil. Robot. 2011; 20115975507
        • Bertoni R.
        • et al.
        Unilateral and bilateral upper limb dysfunction at body functions, activity and participation levels in people with multiple sclerosis.
        Mult. Scler. 2015; 21: 1566-1574
        • Calsius J.
        • et al.
        How to conquer a mountain with multiple sclerosis". How a climbing expedition to Machu Picchu affects the way people with multiple sclerosis experience their body and identity: a phenomenological analysis.
        Disabil. Rehabil. 2015; : 1-7
        • Carpinella I.
        • et al.
        Robot-based rehabilitation of the upper limbs in multiple sclerosis: feasibility and preliminary results.
        J. Rehabil. Med. 2009; 41: 966-970
        • Carpinella I.
        • et al.
        Robot training of upper limb in multiple sclerosis: comparing protocols with or without manipulative task components.
        IEEE Trans. Neural Syst. Rehabil. Eng. 2012; 20: 351-360
        • Conradsson D.
        • et al.
        Activity limitations and participation restrictions in people with multiple sclerosis: a detailed 10-year perspective.
        Disabil. Rehabil. 2019; : 1-8
        • Creswell J.W.
        • Hirose M.
        Mixed methods and survey research in family medicine and community health.
        Fam. Med. Community Health. 2019; 7
        • Cuesta-Gómez A.
        • et al.
        Effects of virtual reality associated with serious games for upper limb rehabilitation inpatients with multiple sclerosis: randomized controlled trial.
        J. NeuroEng. Rehabil. 2020; 17: 1-10
        • Curry L.
        • Nunez-Smith M.
        Assessing quality in mixed methods studies.
        Mixed Methods in Health Sciences Research: A Practical Primer. SAGE Publications, Inc, New Haven2015: 169-200
        • Devilly G.J.
        • Borkovec T.D.
        Psychometric properties of the credibility/expectancy questionnaire.
        J. Behav. Ther. Exp. Psychiatry. 2000; 31: 73-86
        • Feys P.
        • et al.
        Robot-supported upper limb training in a virtual learning environment: a pilot randomized controlled trial in persons with MS.
        J. Neuroeng. Rehabil. 2015; 12: 1-12
        • Gandolfi M.
        • et al.
        Effects of high-intensity robot-assisted hand training on upper limb recovery and muscle activity in individuals with multiple sclerosis: a randomized, controlled, single-blinded trial.
        Front. Neurol. 2018; 9: 905
        • Gavin H.
        Thematic Analysis. Understanding Research Methods and Statistics in Psycho$logy.
        2008: 273-282
        • Gijbels D.
        • et al.
        The Armeo Spring as training tool to improve upper limb functionality in multiple sclerosis: a pilot study.
        J. Neuroeng. Rehabil. 2011; 8: 5
        • Giunti G.
        • et al.
        Exploring the specific needs of persons with multiple sclerosis for mHealth solutions for physical activity: mixed-methods study.
        JMIR Mhealth Uhealth. 2018; 6: e37
        • Kasser S.
        Exercising with multiple sclerosis- insights into meaning and motivation.
        Adapt. Phys. Act. Q. 2009; : 16
        • Kitzinger J.
        The methodology of focus groups: the importance of interaction between research participants.
        Sociol. Health Illn. 1994; 16: 103-121
        • Knippenberg E.
        • et al.
        Motivation, usability, and credibility of an intelligent activity-based client-centred training system to improve functional performance in neurological rehabilitation: an exploratory cohort study.
        Int. J. Environ. Res. Public Health. 2021; 18: 7641
        • Kuper A.
        • Reeves S.
        • Levinson W.
        An introduction to reading and appraising qualitative research.
        BMJ. 2008; 337: a288
        • Lamers I.
        • et al.
        Associations of upper limb disability measures on different levels of the international classification of functioning, disability and health in people with multiple sclerosis.
        Phys. Ther. 2015; 95: 65-75
        • Lamers I.
        • et al.
        Upper limb rehabilitation in people with multiple sclerosis: a systematic review.
        Neurorehabilit. Neural Repair. 2016; 30: 773-793
        • Laparidou D.
        • et al.
        Patient, carer, and staff perceptions of robotics in motor rehabilitation: a systematic review and qualitative meta-synthesis.
        J. Neuroeng. Rehabil. 2021; 18: 1-24
        • Louie D.R.
        • et al.
        Patients’ and therapists’ experience and perception of exoskeleton-based physiotherapy during subacute stroke rehabilitation: a qualitative analysis.
        Disabil. Rehabil. 2021; : 1-9
        • Maggio M.G.
        • et al.
        Virtual reality in multiple sclerosis rehabilitation: A review on cognitive and motor outcomes.
        J. Clin. Neurosci. 2019; 65: 106-111
        • Manuli A.
        • et al.
        Patients' perspective and usability of innovation technology in a new rehabilitation pathway: An exploratory study in patients with multiple sclerosis.
        Mult. Scler. Relat. Disord. 2020; 44102312
        • Maris A.
        • et al.
        The impact of robot-mediated adaptive I-TRAVLE training on impaired upper limb function in chronic stroke and multiple sclerosis.
        Disabil. Rehabil. 2018; 13: 1-9
        • Massetti T.
        • et al.
        Virtual reality in multiple sclerosis–a systematic review.
        Mult. Scler. Relat. Disord. 2016; 8: 107-112
        • McAuley E.
        • Duncan T.
        • Tammen V.V.
        Psychometric properties of the Intrinsic Motivation Inventory in a competitive sport setting: a confirmatory factor analysis.
        Res. Q. Exerc. Sport. 1989; 60: 48-58
        • Meadmore K.L.
        • et al.
        Functional electrical stimulation mediated by iterative learning control and 3D robotics reduces motor impairment in chronic stroke.
        J. Neuroeng. Rehabil. 2012; 9: 1-11
        • Merians A.S.
        • et al.
        Virtual reality–augmented rehabilitation for patients following stroke.
        Phys. Ther. 2002; 82: 898-915
        • Morgan D.L.
        Focus groups.
        Annu. Rev. Sociol. 1996; 22: 129-152
        • Noseworthy J.H.
        • et al.
        Multiple sclerosis.
        N. Engl. J. Med. 2000; 343: 938-952
        • Nyumba O.
        • et al.
        The use of focus group discussion methodology: Insights from two decades of application in conservation.
        Methods Ecol. Evol. 2018; 9: 20-32
        • Octavia J.R.
        • Coninx K.
        Adaptive personalized training games for individual and collaborative rehabilitation of people with multiple sclerosis.
        Biomed. Res. Int. 2014; 2014
        • Penner I.-K.
        • et al.
        Exploring the impact of fatigue in progressive multiple sclerosis: a mixed-methods analysis.
        Mult. Scler. Relat. Disord. 2020; 43102207
        • Sabini R.C.
        • Dijkers M.P.
        • Raghavan P.
        Stroke survivors talk while doing: development of a therapeutic framework for continued rehabilitation of hand function post stroke.
        J. Hand Ther. 2013; 26 (quiz 131): 124-130
        • Simacek K.F.
        • et al.
        The impact of disease-modifying therapy access barriers on people with multiple sclerosis: mixed-methods study.
        J. Med. Internet Res. 2018; 20: e11168
        • Spooren A.I.
        • Timmermans A.A.
        • Seelen H.A.
        Motor training programs of arm and hand in patients with MS according to different levels of the ICF: a systematic review.
        BMC Neurol. 2012; 12: 49
        • Spooren A.I.
        • Timmermans A.A.
        • Seelen H.A.
        Motor training programs of arm and hand in patients with MS according to different levels of the ICF: a systematic review.
        BMC Neurol. 2012; 12: 1-11
        • Tedesco Triccas L.
        • et al.
        A qualitative study exploring views and experiences of people with stroke undergoing transcranial direct current stimulation and upper limb robot therapy.
        Top. Stroke Rehabil. 2018; 25: 480-488
        • Tedesco Triccas L.
        • et al.
        A nation-wide survey exploring the views of current and future use of functional electrical stimulation in spinal cord injury.
        Disabil. Rehabil. 2021; : 1-11
        • Yozbatıran N.
        • et al.
        Motor assessment of upper extremity function and its relation with fatigue, cognitive function and quality of life in multiple sclerosis patients.
        J. Neurol. Sci. 2006; 246: 117-122