Getting the Best Out of Advanced Rehabilitation Technology for the Lower Limbs: Minding Motor Learning Principles

Advanced technology, including gait-training devices, is increasingly being integrated into neurorehabilitation. However, to use gait-training devices to their optimal potential, it is important that they are applied in accordance with motor learning and locomotor training principles. In this article, we outline the most important principles and explain how advanced gait-training devices are best used to improve therapy outcome.

Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies

Background

The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.

Methods

ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.

Results

At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.

Conclusions

The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.

A comprehensive person-centered approach to adult spastic paresis: a consensus-based framework

Spastic paresis is a common feature of an upper motor neuron impairment caused by stroke, brain injury, multiple sclerosis and other central nervous system (CNS) disorders. Existing national and international guidelines for the treatment of adult spastic paresis tend to focus on the treatment of muscle overactivity rather than the comprehensive approach to care, which may require life-long management. Person-centered care is increasingly adopted by healthcare systems in a shift of focus from "disease-oriented" towards "person-centered" medicine. The challenge is to apply this principle to the complex management of spastic paresis and to include an educative process that engages care providers and patients and encourages them to participate actively in the long-term management of their own disease. To address this issue, a group of 13 international clinicians and researchers used a pragmatic top-down methodology to evaluate the evidence and to formulate and grade the strength of recommendations for applying the principles of person-centered care to the management of spastic paresis. There is a distinct lack of clinical trial evidence regarding the application of person-centered medicine to the rehabilitation setting. However, the current evidence base supports the need to ensure that treatment interventions for spastic paresis should be centered on as far as reasonable on the patient's own priorities for treatment. Goal setting, negotiation and formal recording of agreed SMART goals should be an integral part of all spasticity management programs, and goal attainment scaling should be recorded alongside other standardized measures in the evaluation of outcome. When planning interventions for spastic paresis, the team should consider the patient and their family's capacity for self-rehabilitation, as well as ways to enhance this approach. Finally, the proposed intervention and treatment goals should consider the impact of any neuropsychological, cognitive and behavioral deficits on rehabilitation. These recommendations support a person-centric focus in the management of spastic paresis.

Efficacy and safety of abobotulinumtoxinA in spastic lower limb: Randomized trial and extension

OBJECTIVE

To demonstrate single abobotulinumtoxinA injection efficacy in lower limb vs placebo for adults with chronic hemiparesis and assess long-term safety and efficacy of repeated injections.

METHODS

In a multicenter, double-blind, randomized, placebo-controlled, single-cycle study followed by a 1-year open-label, multiple-cycle extension, adults ≥6 months after stroke/brain injury received one lower limb injection (abobotulinumtoxinA 1,000 U, abobotulinumtoxinA 1,500 U, placebo) followed by ≤4 open-label cycles (1,000, 1,500 U) at ≥12-week intervals. Efficacy measures included Modified Ashworth Scale (MAS) in gastrocnemius-soleus complex (GSC; double-blind primary endpoint), physician global assessment (PGA), and comfortable barefoot walking speed. Safety was the open-label primary endpoint.

RESULTS

After a single injection, mean (95% confidence interval) MAS GSC changes from baseline at week 4 (double-blind, n = 381) were as follows: -0.5 (-0.7 to -0.4) (placebo, n = 128), -0.6 (-0.8 to -0.5) (abobotulinumtoxinA 1,000 U, n = 125; p = 0.28 vs placebo), and -0.8 (-0.9 to -0.7) (abobotulinumtoxinA 1,500 U, n = 128; p = 0.009 vs placebo). Mean week 4 PGA scores were as follows: 0.7 (0.5, 0.9) (placebo), 0.9 (0.7, 1.1) (1,000 U; p = 0.067 vs placebo), and 0.9 (0.7, 1.1) (1,500 U; p = 0.067); walking speed was not significantly improved vs placebo. At cycle 4, week 4 (open-label), mean MAS GSC change reached -1.0. Incremental improvements in PGA and walking speed occurred across open-label cycles; by cycle 4, week 4, mean PGA was 1.9, and walking speed increased +25.3% (17.5, 33.2), with 16% of participants walking >0.8 m/s (associated with community mobility; 0% at baseline). Tolerability was good and consistent with the known abobotulinumtoxinA safety profile.

CONCLUSIONS

In chronic hemiparesis, single abobotulinumtoxinA (Dysport Ipsen) administration reduced muscle tone. Repeated administration over a year was well-tolerated and improved walking speed and likelihood of achieving community ambulation.

CLINICALTRIALGOV IDENTIFIERS

NCT01249404, NCT01251367.

CLASSIFICATION OF EVIDENCE

The double-blind phase of this study provides Class I evidence that for adults with chronic spastic hemiparesis, a single abobotulinumtoxinA injection reduces lower extremity muscle tone.

A Comparison of Locomotor Therapy Interventions: Partial-Body Weight-Supported Treadmill, Lokomat, and G-EO Training in People With Traumatic Brain Injury

BACKGROUND

Literature in the application of gait training techniques in persons with traumatic brain injury (TBI) is limited. Current techniques require multiple staff and are physically demanding. The use of a robotic locomotor training may provide improved training capacity for this population.

OBJECTIVE

To examine the impact of 3 different modes of locomotor therapy on gait velocity and spatiotemporal symmetry using an end effector robot (G-EO); a robotic exoskeleton (Lokomat), and manual assisted partial-body weight-supported treadmill training (PBWSTT) in participants with traumatic brain injury.

DESIGN

Randomized, prospective study.

SETTING

Tertiary rehabilitation hospital.

PARTICIPANTS

A total of 22 individuals with ≥12 months chronic TBI with hemiparetic pattern able to walk overground without assistance at velocities between 0.2 and 0.6 m/s.

INTERVENTION

Eighteen sessions of 45 minutes of assigned locomotor training.

OUTCOME MEASURES

Overground walking self-selected velocity (SSV), maximal velocity (MV), spatiotemporal asymmetry ratio, 6-Minute Walk Test (6MWT), and mobility domain of Stroke Impact Scale (MSIS).

RESULTS

Severity in walking dysfunction was similar across groups as determined by walking velocity data. At baseline, participants in the Lokomat group had a baseline velocity that was slightly slower compared with the other groups. Training elicited a statistically significant median increase in SSV for all groups compared with pretraining (Lokomat, P = .04; G-EO, P = .03; and PBWSTT, P = .02) and MV excluding the G-EO group (Lokomat, P = .04; PBWSTT, P = .03 and G-EO, P = .15). There were no pre-post significant differences in swing time, stance time, and step length asymmetry ratios at SSV or MV for any of the interventions. Mean rank in the change of SSV and MV was not statistically significantly different between groups. Participants in the G-EO and PBWSTT groups significantly improved their 6MWT posttraining (P = .04 and .03, respectively). The MSIS significantly improved only for the Lokomat group (P = .04 and .03). The data did not elicit between-groups significant differences for 6MWT and MSIS. There was less use of staff for Lokomat than G-EO.

CONCLUSIONS

Locomotor therapy using G-EO, Lokomat, or PBWSTT in individuals with chronic TBI increased SSV and MV without significant changes in gait symmetry. Staffing needed for therapy provision was the least for the Lokomat. A larger study may further elucidate changes in gait symmetry and other training parameters.

LEVEL OF EVIDENCE

II.