Multicenter Randomized Clinical Trial Evaluating the Effectiveness of the Lokomat in Subacute Stroke

Neural Decoding of Robot-Assisted Gait During Rehabilitation After Stroke

OBJECTIVE

Advancements in robot-assisted gait rehabilitation and brain-machine interfaces may enhance stroke physiotherapy by engaging patients while providing information about robot-induced cortical adaptations. We investigate the feasibility of decoding walking from brain activity in stroke survivors during therapy using a powered exoskeleton integrated with an electroencephalography-based brain-machine interface.

DESIGN

The H2 powered exoskeleton was designed for overground gait training with actuated hip, knee, and ankle joints. It was integrated with active-electrode electroencephalography and evaluated in hemiparetic stroke survivors for 12 sessions per 4 wks. A continuous-time Kalman decoder operating on delta-band electroencephalography was designed to estimate gait kinematics.

RESULTS

Five chronic stroke patients completed the study with improvements in walking distance and speed training for 4 wks, correlating with increased offline decoding accuracy. Accuracies of predicted joint angles improved with session and gait speed, suggesting an improved neural representation for gait, and the feasibility to design an electroencephalography-based brain-machine interface to monitor brain activity or control a rehabilitative exoskeleton.

CONCLUSIONS

The Kalman decoder showed increased accuracies as the longitudinal training intervention progressed in the stroke participants. These results demonstrate the feasibility of studying changes in patterns of neuroelectric cortical activity during poststroke rehabilitation and represent the first step in developing a brain-machine interface for controlling powered exoskeletons.

Stroke Gait Rehabilitation: A Comparison of End-Effector, Overground Exoskeleton, and Conventional Gait Training

Gait recovery is one of the main goals of post-stroke rehabilitation and Robot-Assisted Gait Training (RAGT) has shown positive outcomes. However, there is a lack of studies in the literature comparing the effects of different devices. This paper aims to study the effects, in terms of clinical and gait outcomes, of treadmill-based and overground RAGT, compared to conventional gait training in stroke subjects. The results showed a significant improvement of clinical outcomes in both robotic treatments and in conventional therapy. The performance of locomotor tasks was clinically significant in the robotic groups only. The spatio-temporal gait parameters did not reveal any significant difference. Results suggest future multicentre studies on a larger number of subjects.

Spatiotemporal gait characteristic changes with gait training using the hybrid assistive limb for chronic stroke patients

BACKGROUND

Robotic rehabilitation has been attracting attention as a means to carry out "intensive", "repetitive", "task-specific", gait training. The newly developed robotic device, the Hybrid Assistive Limb (HAL), is thought to have the possibility of having an excellent effect on gait speed improvement over the conventional automatic programed assist robot. The purpose of this study was to investigate the spatiotemporal characteristics related to gait speed improvement using the HAL in chronic stroke patients.

RESEARCH QUESTION

To investigate the effects of robotic gait training on gait speed and gait parameters.

METHODS

An observational study with an intervention for single group was used. Intervention was conducted in University Hospital. Eleven chronic stroke patients were enrolled in this study. The patients performed 8 gait training sessions using the HAL, 2-5 sessions/week for 3 weeks. Gait speed, stride length, cadence, time of gait cycle (double-limb stance phases and single-limb stance phases) and time asymmetry index were measured before and after intervention.

RESULTS

After intervention, gait speed, stride length, and cadence were significantly improved (Effect size = 0.39, 0.29, and 0.29), the affected initial double-limb stance phase was significantly shortened (from 15.8 ± 3.46%-13.3 ± 4.20%, p =  .01), and the affected single-limb stance phase was significantly lengthened (from 21.8±7.02%-24.5±7.95%, p <  .01). The time asymmetry index showed a tendency to improve after intervention (from 22.9±11.8-17.6±9.62, p =  .06). There was a significant correlation between gait speed and the stride length increase rate (r = .72, p =  .01).

SIGNIFICANCE

This study showed that increasing stride length with lengthening of the affected single-stance phase by gait training using the HAL improved gait speed in chronic stroke patients. However, the actual contributions on HAL cannot be separated from gait training because this study is an observational research without a control group.

Analysis of heterogeneity in a systematic review using meta-regression technique

AIM

Heterogeneity is an important consideration in systematic reviews, as high heterogeneity may imply that it is not suitable to perform meta-analysis. The degree of variation could be caused by clinical or methodological differences among the studies, or it could be due to the randomness of chance. Methods of assessing heterogeneity are calculating a statistical test for heterogeneity (the I value), visual evaluations of forest plots, conducting subgroup analysis or meta-regression. We conducted meta-regression on data of our previous systematic review on the effectiveness of robotic rehabilitation, and in this article, we present the findings and discuss its implications.

METHOD

In our meta-regression plots, plotted on the x-axis was the trial covariate (duration of intervention group therapy), and plotted on the y-axis was the effect size measure (standardized mean differences), with positive effect sizes favouring robotic intervention. Analysis using random effects was applied, and each study symbol was sized in proportion to its precision (inverse-variance weighting).

RESULTS

Differences were observed in the meta-regression plots between the subgroups of therapy ratio = 0 and therapy ratio more than 0 for upper limb movement, lower limb walking and activities of daily living. For upper limb movement, positive linear relationships were found for both subgroups. However, in terms of the strength of the relationship, a stronger relationship was found for therapy ratio = 0. For lower limb walking, opposing linear relationships were found in both subgroups: therapy ratio = 0 had a negative linear relationship, whereas therapy ratio more than 0 had a positive linear relationship. For activities of daily living, positive linear relationships were found for both subgroups, but a stronger linear relationship was found for therapy ratio = 0.

CONCLUSION

From the meta-regression analysis, we found that differing levels of linear relationships and the varying spread of effect sizes across positive and negative ranges were the likely sources of heterogeneity. This was especially so in the meta-regression of lower limb walking, which showed opposing directions of linear relationships. The wider spread of effect sizes for therapy ratio = 0 could indicate that some robotic devices were more effective than others. In addition, for therapy ratio more than 0, the effect sizes were mainly found in the positive region, which implied that adding conventional training to robotic training was generally positive for robotic devices.

Robotics for Lower Limb Rehabilitation

Improving walking function is a desirable outcome in rehabilitation and of high importance for social and vocational reintegration for persons with neurologic-related gait impairment. Robots for lower limb gait rehabilitation are designed principally to help automate repetitive labor-intensive training during neurorehabilitation. These include tethered exoskeletons, end-effector devices, untethered exoskeletons, and patient-guided suspension systems. This article reviews the first 3 categories and briefly mentions the fourth. Research is needed to further define the therapeutic applications of these devices. Additional technical improvements are expected regarding device size, controls, and battery life for untethered devices.

Overground wearable powered exoskeleton for gait training in subacute stroke subjects: clinical and gait assessments

BACKGROUND

Wearable powered exoskeletons provide intensive overground gait training with patient's active participation: these features promote a successful active motor relearning of ambulation in stroke survivors.

AIM

The aim of this study was to investigate the feasibility and the clinical effects of an overground exoskeleton-assisted gait training (OEAGT) in subacute stroke patients.

DESIGN

Prospective, pilot pre-post, open label, non-randomized experimental study.

SETTING

Four Italian neurological rehabilitation centers.

POPULATION

Forty-eight subacute stroke patients were enrolled. Two patients dropped out because of medical problems. Data analysis was conducted on 46 subjects (56.84±14.29 years; 27 male; 29 ischemic; 24 left hemiparesis).

METHODS

Patients underwent 15±2 sessions (60 min/session, 3-5 times/week) of OEAGT. Clinical and gait assessments were performed at the beginning (T1) and at the end (T2) of the training period: modified Barthel Index (BI), modified Ashworth Scale at Hip (MAS-H), Knee (MAS-K), and Ankle (MAS-A) level, Motricity Index (MI), Trunk Control Test (TCT), Functional Ambulation Classification (FAC), Walking Handicap Scale (WHS), 10-Meter Walking Test (10MWT), 6-Minute Walking Test (6mWT), Timed Up-and-Go test (TUG). The Technology Acceptance Model (TAM) questionnaire evaluated the acceptance of OEAGT by patients. Data stratification was performed using the time post the acute event and the onset of rehabilitation treatment, and the MI at T1. Wilcoxon's test (P<0.05) was used.

RESULTS

All clinical scales significantly improved at T2; no statistically significant changes were reported for MAS-H, MAS-K, MAS-A. The 69.57% patients were able to walk at T1; 17.39% were not able to walk at T1 but regained ambulation at T2; and 13.04% were not able to walk at either T1 or T2. The ambulant patients showed a statistical improvement in speed measured during the 10MWT and in the distance covered over a time of 6 minutes (6mWT). The results from the TAM questionnaire showed that all subjects perceived the OEAGT positively. The data stratification analysis suggests that the OEAGT does not have any restriction of use.

CONCLUSIONS

The OEAGT improved the clinical and gait outcomes in subacute patients. Randomized studies on larger samples are needed to confirm these data and to assess the efficacy of OEAGT.

CLINICAL REHABILITATION IMPACT

Introduce innovative rehabilitation strategies based on customized OEAGT.

Short-burst interval treadmill training walking capacity and performance in cerebral palsy: a pilot study

PURPOSE

To examine the effect of short-burst interval locomotor treadmill training (SBLTT) on walking capacity and performance in cerebral palsy (CP).

METHODS

Twelve children with spastic diplegic CP (average 8.6 years) across Gross Motor Function Classification System levels II (8) and III (4) were randomized to 20 SBLTT sessions over 4 or 10 weeks. SBLTT consisted of alternating 30 seconds of slow and fast walking for 30 minutes/session. Outcomes included the 10 m walk test, one-minute walk test (1MWT), and timed-up-and go (TUG) (capacity) and StepWatch (performance) collected at baseline, post, and 6 weeks post.

RESULTS

Fast speed (+.11, p = .04; +.11 m/s, p = .006), 1MWT (+11.2; +11.7 m, p = .006) and TUG (-1.7; -1.9 seconds, p = .006) improved post SBLTT and 6 weeks, respectively. Walking performance increased: average strides/day (+948; +1712, p < .001) and percent time in high strides rates (+0.4, p = 0.07; +0.2, p = .008).

CONCLUSIONS

Pilot study suggests SBLTT may improve short-term walking capacity and performance.

Bibliometric analysis of global research on the rehabilitation of spinal cord injury in the past two decades

Purpose

We aimed to build a model to qualitatively and quantitatively evaluate publications of research of spinal cord injury rehabilitation from 1997 to 2016.

Methods

Data were obtained from the Web of Science Core Collection on October 6, 2017. We conducted a qualitative and quantitative analysis of publication outputs, journals, authors, institutions, countries, cited references, keywords, and terms by bibliometric methods and bibliometric software packages.

Results

We identified 5,607 publications on rehabilitation of spinal cord injury from 1997 to 2016, and found that the annual publication rate increased with time. The Archives of Physical Medicine and Rehabilitation published the largest number of literature, the most active country was USA, the most active institution was University of Washington, and Post MWM was the leading author. Keyword analysis indicated that life satisfaction, muscle strength, wheelchair training, walking, gait, and others were the hot spots of these research studies, whereas classification, exoskeleton, plasticity, and old adult were research frontiers.

Conclusion

This bibliometric study revealed that research on rehabilitation of spinal cord injury is a well-developed and promising research field. Global scientific research cooperation is close. However, higher quality research is needed. Our findings provide valuable information for researchers to identify better perspectives and develop the future research direction.

Robot-assisted gait training effectively improved lateropulsion in subacute stroke patients: a single-blinded randomized controlled trial

BACKGROUND

Some stroke patients are known to use nonparetic extremities to push toward the paretic side, a movement known as lateropulsion. Lateropulsion impairs postural balance and interferes with rehabilitation.

AIM

The aim of the present study was to investigate the effect of robot-assisted gait training (RAGT) on recovery from lateropulsion compared with conventional physical therapy (CPT).

DESIGN

This was a single-blinded, randomized controlled trial.

SETTING

Participants were recruited from a rehabilitation department of a tertiary hospital.

POPULATION

Patients diagnosed with lateropulsion after a stroke.

METHODS

Thirty-six subacute stroke patients with lateropulsion were recruited. RAGT was performed in the experimental group (N.=18), and CPT was performed in the control group (N.=18). The participants received treatment for 3 weeks, 30 minutes per day, 5 days per week. Outcomes were assessed before the intervention (T0), immediately after the intervention (T1), and 4 weeks after the intervention (T2). The Burke Lateropulsion Scale (BLS) was evaluated as a primary outcome to assess the severity of lateropulsion. The secondary outcome measures were the Berg Balance Scale (BBS), the Postural Assessment Scale for Stroke (PASS), and Somatosensory Evoked Potentials (SSEP).

RESULTS

After intervention, the experimental group showed greater improvement in the BLS score at T1 (experimental group: Δ=-1.9, control group: Δ=-1.1, P=0.032) and T2 (experimental group: Δ=-2.8, control group: Δ=-6.5, P<0.001) than the control group. In addition, the BBS was significantly improved in the experimental group at T1 (experimental group: Δ=+7.1, control group: Δ=+1.9, P<0.001) and T2 (experimental group: Δ=+13.0, control group: Δ=+6.1, P<0.001). There were significant between-group differences in the PASS at T1 (experimental group: Δ=+3.2, control group: Δ=+1.6, P=0.014) and T2 (experimental group: Δ=+8.8, control group: Δ=+4.3, P<0.001).

CONCLUSIONS

RAGT ameliorated lateropulsion and balance function more effectively than CPT in subacute stroke patients.

CLINICAL REHABILITATION IMPACT

Early RAGT may be recommended for patients with lateropulsion after stroke.

Effect of Stride Management Assist Gait Training for Poststroke Hemiplegia: A Single Center, Open-Label, Randomized Controlled Trial

BACKGROUND

Poststroke gait disorders negatively impact activities of daily living. Rehabilitation for stroke patients is aimed at improving their walking ability, balance, and quality of life. Robot-assisted gait training (RAGT) is associated with an increased number of task-specific exercises, which may benefit poststroke motor learning. We investigated the effects of RAGT using Stride Management Assist (SMA, which increases walk ratio by inducing hip-joint flexion and extension) in subacute stroke patients with hemiplegia.

METHODS

We conducted a single center, open-label randomized controlled trial in hemiplegia patients who experienced a first ever stroke and were admitted to the convalescent rehabilitation ward. A total of 41 were divided into the control (20 patients) and experimental group (21 patients). A 10-day, conventional gait training program was carried out for the control group; and RAGT with SMA was used for the experimental group. The maximum walking speed and other gait parameters were compared preintervention and postintervention. The intergroup differences in the improvement ratio were compared using an intention-to-treat analysis.

RESULTS

Ten-day intervention was completed by 36 patients. There was no difference between the 2 groups regarding gait parameters at intervention initiation. The improvement ratio of the maximum walking speed was significantly higher for the experimental group. Significant improvements were observed postintervention for maximum walking speed, paralysis-side step length, symmetry, and cadence in the experimental group. No adverse events attributable to the SMA were observed.

CONCLUSIONS

Ten days of RAGT with the SMA was effective for improving gait disorders of subacute stroke patients.

Error-augmented bimanual therapy for stroke survivors

BACKGROUND

Stroke recovery studies have shown the efficacy of bimanual training on upper limb functional recovery and others have shown the efficacy of feedback technology that augments error.

OBJECTIVE

In a double-blinded randomized controlled study (N = 26), we evaluated the short-term effects of bilateral arm training to foster functional recovery of a hemiparetic arm, with half of our subjects unknowingly also receiving error augmentation (where errors were visually and haptically enhanced by a robot).

METHODS

Twenty-six individuals with chronic stroke were randomly assigned to practice an equivalent amount of bimanual reaching either with or without error augmentation. Participants were instructed to coordinate both arms while reaching to two targets (one for each arm) in three 45-minute treatments per week for two weeks, with a follow-up visit after one week without treatment.

RESULTS

Subjects' 2-week gains in Fugl-Meyer score averaged 2.92, and we also observed improvements Wolf Motor Functional Ability Scale average 0.21, and Motor Activity Log of 0.58 for quantity and 0.63 for quality of life scores. The extra benefit of error augmentation over the three weeks became apparent in Fugl-Meyer score only after removing an outlier from consideration.

CONCLUSIONS

This modest advantage of error augmentation was detectable over a short interval encouraging further research in interactive self-rehabilitation systems that can enhance error motor recovery.

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.

Exoskeleton assistance symmetry matters: unilateral assistance reduces metabolic cost, but relatively less than bilateral assistance

BACKGROUND

Many gait impairments are characterized by asymmetry and result in reduced mobility. Exoskeletons could be useful for restoring gait symmetry by assisting only one leg. However, we still have limited understanding of the effects of unilateral exoskeleton assistance. Our aim was to compare the effects of unilateral and bilateral assistance using a within-subject study design.

METHODS

Eleven participants walked in different exoskeleton conditions. In the Unilateral conditions, only one leg was assisted. In Bilateral Matched Total Work, half of the assistance from the Unilateral conditions was applied to both legs such that the bilateral sum was equal to that of the Unilateral conditions. In Bilateral Matched Work Per Leg, the same assistance as in the Unilateral conditions was provided to both legs such that the bilateral sum was the double of that of the Unilateral conditions. In the Powered-Off condition, no assistance was provided. We measured metabolic energy consumption, exoskeleton mechanics and kinematics.

RESULTS

On average, the Unilateral, Bilateral Matched Total Work and Bilateral Matched Work Per Leg conditions reduced the metabolic rate by 7, 11 and 15%, respectively, compared with the Powered-Off condition. A possible explanation for why the Unilateral conditions effectively reduced the metabolic rate could be that they caused only very little asymmetry in gait biomechanics, except at the ankle and in the horizontal center-of-mass velocity. We found the highest ratio of metabolic rate reduction versus positive work assistance with bilateral assistance and low work per leg (Bilateral Matched Total Work). Statistical analysis indicated that assistance symmetry and assistance per leg are more important than the bilateral summed assistance for reducing the metabolic rate of walking.

CONCLUSIONS

These data bridge the gap between conclusions from studies with unilateral and bilateral exoskeletons and inform how unilateral assistance can be used to influence gait parameters, such as center-of-mass velocity.

Design and evaluation of a modular lower limb exoskeleton for rehabilitation

This paper deals with the evaluation of an exoskeleton designed for assisting individuals to rehabilitate compromised lower limb movements resulting from stroke or incomplete spinal cord injury. The exoskeleton is composed of lightweight tubular structures and six free joints that provide a modular feature to the system. This feature allows the exoskeleton to be adapted to assist the movement of one or more patient joints. The actuation of the exoskeleton is also modular, and can be performed passively, by means of springs and dampers, or actively through actuators. In addition, its telescopic tubular links, developed to adjust the size of the links in order to align the joints of the exoskeleton with patient joints, allows the exoskeleton to be adjustable to fit different patients. Experiments considering the interaction between a healthy subject and the exoskeleton are performed to evaluate the influence of the exoskeleton structure on kinematic and muscular activity profiles during walking.

Gait training using a stationary, one-leg gait exercise assist robot for chronic stroke hemiplegia: a case report

[Purpose] The Gait Exercise Assist Robot (GEAR) is a stationary, one-leg robot for gait training. The purpose of this case study was to evaluate the efficacy of rehabilitation using GEAR training for chronic stroke hemiplegia. [Participant and Methods] The participant was a 66-year-old male stroke survivor with left hemiparesis due to a right putaminal hemorrhage. He could walk slowly under supervision, although his gait had a constant forward trunk lean, with flexed knee, and a lack of hip extension movement on the affected side. Gait training using GEAR and physical therapy were performed for 14 days. Under both training conditions, the physical therapist made the participant conscious of extension movement of the hip joint in the affected-side stance phase. The robotic assistance was adjusted to maximize voluntary movement while observing gait. Physical function and gait ability parameters were evaluated before and after training. [Results] After training, extension motion of the hip joint increased in the affected-side stance phase, and body weight was transferred smoothly onto the affected-side limb, leading to an improvement in gait speed. [Conclusion] Gait training using GEAR and physical therapy may improve gait pattern and speed in patients with chronic stroke hemiplegia.

Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of robotic assistive devices in the rehabilitation of adult stroke patients for recovery of impairments in the upper and lower limbs. The secondary objective is to investigate the sustainability of treatment effects associated with use of robotic devices.The specific review question to be addressed is: can robotic assistive devices help adult stroke patients regain motor movement of their upper and lower limbs?

Robotically-driven orthoses exert proximal-to-distal differential recovery on the lower limbs in children with hemiplegia, early after acquired brain injury

Robotically-driven orthoses (RDO) are promising for treating gait impairment in children with hemiplegia after acquired brain injury (ABI). Despite this, existing literature on the employment of RDO in ABI is scanty, and cohorts' age spans throughout the adult age, with no specific focus on the developmental age. We aim to compare a treatment solely based on conventional physiotherapy (CP) with a program combining RDO training with CP, and to examine the effect of time following ABI on recovery. A prospective two-cohorts study was conducted in a rehabilitation hospital. Post-acute and chronic children with hemiplegia due to ABI underwent either: (i) 20 sessions of RDO plus 20 sessions of CP (n = 29), or (ii) 40 of CP (n = 12). Gross Motor Function Measures (GMFM), Functional Assessment Questionnaire (FAQ), 6 Minutes Walk Test and gait analysis (GA) parameters were recorded before and after training. Over all the patients in RDO + CP group, all GMFM domains and FAQ improved after RDO training (p < 0.05). The unaffected limb showed significantly decreased stance, increased step length and reduced anteroposterior center of pressure oscillation; the affected side increased the stride length. ROM hip and knee flex-extension increased bilaterally (p < 0.05 for all). RDO training during the acute/subacute post-injury phase increased motor functional abilities, cadence and velocity of gait (p < 0.05). We conclude that RDO imposes a proximal-to-distal differential effect on the lower limbs, with the hip joint being the most stimulated. RDO training fostered recovery, increasing the quality of gait on the unaffected side. Planning RDO early in the rehabilitation course of pediatric ABI is advantageous. RDO + CP may extend rehabilitation efficacy to the proximal segment of leg and to gait velocity.

Effects of forced movements on learning: Findings from a choice reaction time task in rats

To investigate how motor sensation facilitates learning, we used a sensory–motor association task to determine whether the sensation induced by forced movements contributes to performance improvements in rats. The rats were trained to respond to a tactile stimulus (an air puff) by releasing a lever pressed by the stimulated (compatible condition) or nonstimulated (incompatible condition) forepaw. When error rates fell below 15%, the compatibility condition was changed (reversal learning). An error trial was followed by a lever activation trial in which a lever on the correct or the incorrect response side was automatically elevated at a preset time of 120, 220, 320, or 420 ms after tactile stimulation. This lever activation induced forepaw movement similar to that in a voluntary lever release response, and also induced body movement that occasionally caused elevation of the other forepaw. The effects of lever activation may have produced a sensation similar to that of voluntary lever release by the forepaw on the nonactivated lever. We found that the performance improvement rate was increased by the lever activation procedure on the incorrect response side (i.e., with the nonactivated lever on the correct response side). Furthermore, the performance improvement rate changed depending on the timing of lever activation: Facilitative effects were largest with lever activation on the incorrect response side at 320 ms after tactile stimulation, whereas hindering effects were largest for lever activation on the correct response side at 220 ms after tactile stimulation. These findings suggest that forced movements, which provide tactile and proprioceptive stimulation, affect sensory–motor associative learning in a time-dependent manner.

A narrative review of gait training after stroke and a proposal for developing a novel gait training device that provides minimal assistance

BACKGROUND

Gait impairment is common in stroke survivors. Recovery of walking ability is one of the most pressing objectives in stroke rehabilitation.

OBJECTIVES

Of this report are to briefly review recent progress in gait training after stroke including the use of partial body weight-supported treadmill training (PBWSTT) and robot-assisted step training (RAST), and propose a minimal assistance strategy that may overcome some of limitations of current RAST.

METHODS

The literature review emphasizes a dilemma that recent randomized clinical trials did not support the use of RAST. The unsatisfactory results of current RAST clinical trials may be partially due to a lack of careful analysis of movement deficiencies and their relevance to gait training task specificity after stroke. Normal movement pattern is implied to be part of task specificity in the current RAST. Limitations of such task specificity are analyzed.

RESULTS

Based on the review, we redefine an alternative set of gait training task specificity that represents a minimal assistance strategy in terms of assisted body movements and amount of assistance. Specifically, assistances are applied only to hip flexion and ankle dorsiflexion of the affected lower limb during swing phase. Furthermore, we propose a conceptual design of a novel device that may overcome limitations of current RAST in gait training after stroke. The novel device uses a pulling cable, either manually operated by a therapist or automated by a servomotor, to provide assistive forces to help hip flexion and ankle dorsiflexion of the affected lower limb during gait training.

CONCLUSION

The proposed minimal assistance strategy may help to design better devices for gait or other motor training.

Shaping neuroplasticity by using powered exoskeletons in patients with stroke: a randomized clinical trial

BACKGROUND

The use of neurorobotic devices may improve gait recovery by entraining specific brain plasticity mechanisms, which may be a key issue for successful rehabilitation using such approach. We assessed whether the wearable exoskeleton, Ekso™, could get higher gait performance than conventional overground gait training (OGT) in patients with hemiparesis due to stroke in a chronic phase, and foster the recovery of specific brain plasticity mechanisms.

METHODS

We enrolled forty patients in a prospective, pre-post, randomized clinical study. Twenty patients underwent Ekso™ gait training (EGT) (45-min/session, five times/week), in addition to overground gait therapy, whilst 20 patients practiced an OGT of the same duration. All individuals were evaluated about gait performance (10 m walking test), gait cycle, muscle activation pattern (by recording surface electromyography from lower limb muscles), frontoparietal effective connectivity (FPEC) by using EEG, cortico-spinal excitability (CSE), and sensory-motor integration (SMI) from both primary motor areas by using Transcranial Magnetic Stimulation paradigm before and after the gait training.

RESULTS

A significant effect size was found in the EGT-induced improvement in the 10 m walking test (d = 0.9, p < 0.001), CSE in the affected side (d = 0.7, p = 0.001), SMI in the affected side (d = 0.5, p = 0.03), overall gait quality (d = 0.8, p = 0.001), hip and knee muscle activation (d = 0.8, p = 0.001), and FPEC (d = 0.8, p = 0.001). The strengthening of FPEC (r = 0.601, p < 0.001), the increase of SMI in the affected side (r = 0.554, p < 0.001), and the decrease of SMI in the unaffected side (r = - 0.540, p < 0.001) were the most important factors correlated with the clinical improvement.

CONCLUSIONS

Ekso™ gait training seems promising in gait rehabilitation for post-stroke patients, besides OGT. Our study proposes a putative neurophysiological basis supporting Ekso™ after-effects. This knowledge may be useful to plan highly patient-tailored gait rehabilitation protocols.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT03162263 .

A systematic review of game technologies for pediatric patients

Children in hospital are subjected to multiple negative stimuli that may hinder their development and social interactions. Although game technologies are thought to improve children's experience in hospital, there is a lack of information on how they can be used effectively. This paper presents a systematic review of the literature on the existing approaches in this context to identify gaps for future research. A total of 1305 studies were identified, of which 75 were thoroughly analyzed according to our review protocol. The results show that the most common approach is to design mono-user games with traditional computers or monitor-based video consoles, which serve as a distractor or a motivator for physical rehabilitation for primary school children undergoing fearful procedures such as venipuncture, or those suffering chronic, neurological, or traumatic diseases/injures. We conclude that, on the one hand, game technologies seem to present physical and psychological benefits to pediatric patients, but more research is needed on this. On the other hand, future designers of games for pediatric hospitalization should consider: 1. The development for kindergarten patients and adolescents, 2. Address the psychological impact caused by long-term hospitalization, 3. Use collaboration as an effective game strategy to reduce patient isolation, 4. Have purposes other than distraction, such as socialization, coping with emotions, or fostering physical mobility, 5. Include parents/caregivers and hospital staff in the game activities; and 6. Exploit new technological artifacts such as robots and tangible interactive elements to encourage intrinsic motivation.

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®.

Early robot-assisted gait retraining in non-ambulatory patients with stroke: a single blind randomized controlled trial

BACKGROUND

Restoration of walking function is a primary concern of neurorehabilitation with respect to the aspired social and vocational reintegration. To date, the best practice for improving gait early after stroke is still object of debate. On one hand, repetitive task-specific approaches with higher intensities of walking have been observed to result in greater improvements of gait after stroke. Conversely there is some evidence that conventional gait training would be more effective for facilitating walking ability after stroke.

AIM

To compare the effects of an early treatment protocol of add-on robot-assisted gait training with add-on conventional overground physiotherapy for improving locomotion in non-ambulatory adult stroke patients.

DESIGN

Single-blind randomized controlled trial.

SETTING

Neurorehabilitation hospital.

POPULATION

Seventy-four subacute patients with first-ever ischemic stroke.

METHODS

The patients were randomized into two groups. The training program consisted of forty, 2-hour sessions (including 45 minutes basic training, 45 minutes add-on training plus rest periods), 5 days a week, for 8 consecutive weeks. Patients allocated to the add-on robot-assisted gait training were treated by means of the Lokomat. Patients allocated to the add-on conventional overground gait training aimed at improving postural control during gait, body weight transfer, stability during the stance phase, free swing phase, adequate heel contact and gait pattern. Primary outcome was the modified Emory Functional Ambulation Profile. Secondary outcomes were the Rivermead Motor Index, the Mobility Milestones and the Hochzirl Walking Aids Profile.

RESULTS

No significant difference was observed between groups with regards to age (P=0.661), time from stroke onset (P=0.413) and the primary outcome (P=0.854) at baseline evaluation. As to the primary outcome, no significant differences were found between groups at the end of the study. As During the 8-week training, within-group comparisons showed significant improvements of mean modified Emory Functional Ambulation Profile in both groups (P<0.001).

CONCLUSIONS

Our results support the hypothesis that an early treatment protocol of robot-assisted gait retraining is not superior to add-on conventional gait training intervention for improving locomotion in non-ambulatory stroke patients.

CLINICAL REHABILITATION IMPACT

This study might help to better understand the role of robot-assisted gait training in early phase stroke rehabilitation.

A review in gait rehabilitation devices and applied control techniques

PURPOSE

The aim of this review is to analyse the different existing technologies for gait rehabilitation, focusing mainly in robotic devices. Those robots help the patient to recover a lost function due to neurological gait disorders, accidents or after injury. Besides, they facilitate the identification of normal and abnormal features by registering muscle activity providing the doctor important data where he can observe the evolution of the patient.

METHOD

A deep literature review was realized using selected keywords considering not only the most common medical and engineering databases, but also other available sources that provide information on commercial and scientific gait rehabilitation devices. The founded literature for this review corresponds to control techniques for gait rehabilitation robots, since the early seventies to the present year.

RESULTS

Different control strategies for gait analysis in rehabilitation devices have been developed and implemented such as position control, force and impedance control, haptic simulation, and control of EMG signals. These control techniques are used to analyze the force of the patient during therapy, compensating it with the force generated by the mechanism in the rehabilitation device. It is observed that the largest number of studies reported, focuses on the impedance control technique. Leading to include new control techniques and validate them using the necessary protocols with ill patients, obtaining reliable results that allows a progressive and active rehabilitation.

CONCLUSIONS

With this exhaustive review, we can conclude that the degree of complexity of the rehabilitation device influences in short and long-term therapeutic results since the movements become more controlled. However, there is still a lot of work in the sense of motion control in order to perform trajectories that are more alike the natural movements of humans. There are many control techniques in other areas, which seek to improve the performance of the process. These techniques may possibly be applicable in gait rehabilitation devices, obtaining controllers that are more efficient and that adapts to different people and the necessities that entail every disease. Implications for Rehabilitation Rehabilitation helps people to improve the activities of their daily life, allowing them to observe their progress in the functional abilities as the months pass by with intensive and repetitive therapies. There is a mobility issue when the patient needs to move to the hospital or to the laboratory, which is not always feasible. For overcoming it, patients use the equipment at home to perform their daily therapy. However, they need the sufficient knowledge about its operation, also about the therapeutic movements, the therapy duration and the movement speed. Besides, is necessary to place the equipment in a proper and lively environment that helps to forget or reduce pain while the patient moves his joints progressively. The purpose of robotic rehabilitation devices is to generate repetitive and progressive movements, according to the motor disability. There are training trajectories to follow, which motivate patients to generate active movements. The benefits of robotic rehabilitation depend on the ability of each patient to adapt to the speed and load variations generated by the device, improving and reinforcing motor functions in therapy, especially in patients with advanced disabilities in early rehabilitation. Multi-joint rehabilitation devices are more effective than single-joint rehabilitation devices because they involve a higher number of muscles in the therapy. The greater the number of degrees of freedom (DoF) of the device, it cushions its effect in the patient because the inertia is reduced and higher torques are generated. The assistive technological devices allows to explore different rehabilitation techniques that motivate the patient in therapy, increasing appropriately the energy and pressure in the blood which is reflected in gradually recovering his ability to walk.

Development of new rehabilitation robot device that can be attached to the conventional Knee-Ankle-Foot-Orthosis for controlling the knee in individuals after stroke

This research developed a device that can be attached to the conventional Knee-Ankle-Foot-Orthosis for controlling the knee in individuals after stroke. The device automatically assists the flexion and extension movements of the knee joint at the appropriate timing. We aimed to clarify the effect of this device on gait performance, kinematic pattern and muscle activation during gait. Seventeen participants after stroke were recruited in this study. They walked with this device for 3 minutes, and we measured the 10m gait time, number of steps, knee motion using electric goniometer and muscle activities of lower limbs during gait. The gait speed, number of steps, and range of knee joint improved by using the device with assist, and those changes remained without assist. For muscle activities measured by electromyography in the lower limbs, although the device only assists one side of the limb, it was able to alter EMG of both paretic and non-paretic limbs. By assisting only the paretic knee movements, the device was able to improve the performance, kinematic pattern and muscle activation during gait, which remained as an aftereffect.

A Comparative Study of Conventional Physiotherapy versus Robot-Assisted Gait Training Associated to Physiotherapy in Individuals with Ataxia after Stroke

OBJECTIVES

To assess the influence of RAGT on balance, coordination, and functional independence in activities of daily living of chronic stroke survivors with ataxia at least one year of injury.

METHODS

It was a randomized controlled trial. The patients were allocated to either therapist-assisted gait training (TAGT) or robotic-assisted gait training (RAGT). Both groups received 3 weekly sessions of physiotherapy with an estimated duration of 60 minutes each and prescribed home exercises. The following outcome measures were evaluated prior to and after the completion of the 5-month protocol treatment: BBS, TUG test, FIM, and SARA. For intragroup comparisons, the Wilcoxon test was used, and the Mann-Whitney test was used for between-group comparison.

RESULTS

Nineteen stroke survivors with ataxia sequel after one year of injury were recruited. Both groups showed statistically significant improvement (P < 0.05) in balance, functional independencein, and general ataxia symptoms. There were no statistically significant differences (P < 0.05) for between-group comparisons both at baseline and after completion of the protocol.

CONCLUSIONS

Chronic stroke patients with ataxia had significant improvements in balance and independence in activities of daily living after RAGT along with conventional therapy and home exercises. This trial was registered with trial registration number 39862414.6.0000.5505.

Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients

The purpose of this study was to critically evaluate the effects of robot-assisted gait training (RAGT) on gait-related function in patients with acute/subacute stroke. We conducted a systematic review of randomized controlled trials published between May 2012 and April 2016. This search included 334 articles (Cochrane, 51 articles; Embase, 175 articles; PubMed, 108 articles). Based on the inclusion and exclusion criteria, 7 studies were selected for this review. We performed a quality evaluation using the PEDro scale. In this review, 3 studies used an exoskeletal robot, and 4 studies used an end-effector robot as interventions. As a result, RAGT was found to be effective in improving walking ability in subacute stroke patients. Significant improvements in gait speed, functional ambulatory category, and Rivermead mobility index were found with RAGT compared with conventional physical therapy (p < 0.05). Therefore, aggressive weight support and gait training at an early stage using a robotic device are helpful, and robotic intervention should be applied according to the patient's functional level and onset time of stroke.

Influence of skill and exercise training parameters on locomotor recovery during stroke rehabilitation

PURPOSE OF REVIEW

Research findings from the fields of motor learning and exercise physiology suggest specific training parameters that can be manipulated during physical rehabilitation profoundly influence skilled task performance. This review details the rationale for some of these training variables and their application in selected intervention studies focused on improving walking function in patients poststroke.

RECENT FINDINGS

Basic and applied studies have shown that the amount, intensity, and variability of specific task practice applied during rehabilitation interventions can affect recovery of walking poststroke. Many studies detailing the effects of conventional, therapist, and mechanically assisted interventions may incorporate some of these training parameters but minimize others, and their relative contributions may influence walking outcomes. Specific patient factors, such as the stroke acuity and degree of impairments, appear to influence the relative contributions of these training variables, and different patient subgroups may benefit from greater emphasis on specific parameters.

SUMMARY

The present findings suggest these training parameters should be considered when evaluating or implementing physical interventions directed toward improving locomotor function poststroke. More work is needed to understand their optimal combinations to maximize walking outcomes in patients with different levels of impairment poststroke.

Underactuated Potential Energy Shaping with Contact Constraints: Application to a Powered Knee-Ankle Orthosis

Body-weight support (i.e., gravity compensation) is an effective clinical tool for gait rehabilitation after neurological impairment. Body-weight supported training systems have been developed to help patients regain mobility and confidence during walking, but conventional systems constrain the patient's treatment in clinical environments. We propose that this challenge could be addressed by virtually providing patients with bodyweight support through the actuators of a powered orthosis (or exoskeleton) utilizing potential energy shaping control. However, the changing contact conditions and degrees of underactuation encountered during human walking present significant challenges to consistently matching a desired potential energy for the human in closed loop. We therefore derive a generalized matching condition for shaping Lagrangian systems with holonomic contact constraints. By satisfying this matching condition for four phases of gait, we derive passivity-based control laws to achieve virtual body-weight support through a powered knee-ankle orthosis. We demonstrate beneficial effects of virtual body-weight support in simulations of a human-like biped model, indicating the potential clinical value of this proposed control approach.

What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis

BACKGROUND

Studies about electromechanical-assisted devices proved the validity and effectiveness of these tools in gait rehabilitation, especially if used in association with conventional physiotherapy in stroke patients.

OBJECTIVE

The aim of this study was to compare the effects of different robotic devices in improving post-stroke gait abnormalities.

METHODS

A computerized literature research of articles was conducted in the databases MEDLINE, PEDro, COCHRANE, besides a search for the same items in the Library System of the University of Parma (Italy). We selected 13 randomized controlled trials, and the results were divided into sub-acute stroke patients and chronic stroke patients. We selected studies including at least one of the following test: 10-Meter Walking Test, 6-Minute Walk Test, Timed-Up-and-Go, 5-Meter Walk Test, and Functional Ambulation Categories.

RESULTS

Stroke patients who received physiotherapy treatment in combination with robotic devices, such as Lokomat or Gait Trainer, were more likely to reach better results, compared to patients who receive conventional gait training alone. Moreover, electromechanical-assisted gait training in association with Functional Electrical Stimulations produced more benefits than the only robotic treatment (-0.80 [-1.14; -0.46], p > .05).

CONCLUSIONS

The evaluation of the results confirm that the use of robotics can positively affect the outcome of a gait rehabilitation in patients with stroke. The effects of different devices seems to be similar on the most commonly outcome evaluated by this review.

Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review

BACKGROUND

Stroke is a leading cause of long-term disability, and rehabilitation, involving repetitive, high intensity, task-specific exercises, is the pathway to restoring motor skills. Robotic assistive devices are increasingly being used and it is hoped that with robotic devices, rehabilitation progress can be achieved for patients.

OBJECTIVES

To examine the effectiveness of robotic devices in the rehabilitation of stroke patients for upper limb mobility, lower limb mobility, and activities of daily living. The sustainability of treatment effect was also examined.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult stroke patients 18 years and over.

TYPES OF INTERVENTION(S)

Rehabilitation of stroke patients using robotic devices with assistive automation, compared to conventional physiotherapy.

OUTCOMES

Motor movements of upper limbs, walking movement of lower limbs and activities of daily living, including follow-up measurements to examine the sustainability of treatment effect.

TYPES OF STUDIES

Randomized and controlled clinical trials.

SEARCH STRATEGY

Published and unpublished studies in English were searched.

METHODOLOGICAL QUALITY

All studies meeting the review inclusion criteria were independently assessed for methodological quality by two reviewers.

DATA EXTRACTION

Quantitative data were extracted using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

DATA SYNTHESIS

Quantitative data were pooled in statistical meta-analysis. Effect sizes expressed as standardized mean difference, 95% confidence intervals and levels of heterogeneity (I) were calculated. Where statistical pooling was not possible, the findings were presented in narrative form.

RESULTS

Fifty-one studies with 1798 patients were included in this review. Thirty studies examined upper limb interventions and 21 studies evaluated lower limb gait training. Non-significant results were found for upper limb (SMD 0.07, 95% CI -0.11 to 0.26, I = 41%, P = 0.45), lower limb (SMD 0.17, 95% CI -0.15 to 0.48, I = 75%, P = 0.31) and activities of daily living (SMD 0.11, 95% CI -0.11 to 0.33, I = 66%, P = 0.32). For patients with severely impaired lower limbs, a significant difference was observed in favor of robotics (SMD 0.41, 95% CI 0.19 to 0.63, I = 28%, P = 0.0003). P-value analysis did not show significant results for the sustainability of treatment effect post intervention.

CONCLUSIONS

Robotic training is just as effective as conventional training for upper limb motor movement, lower limb walking mobility and for activities of daily living. For lower limb patients with severe impairment, robotic training produces better outcomes than conventional training. The sufficient quantity of studies included and the reasonable quality of Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence support the findings.For treatment sustainability of upper and lower limbs, robotic training is just as effective as conventional training. However, the low quality of GRADE evidence and the lower number of studies included require caution for this finding. For treatment sustainability of activities of daily living, the better quality of GRADE evidence and the larger number of studies analyzed indicate that robotic training is just as effective as conventional training.

How a diverse research ecosystem has generated new rehabilitation technologies: Review of NIDILRR's Rehabilitation Engineering Research Centers

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.

Innovating With Rehabilitation Technology in the Real World: Promises, Potentials, and Perspectives

In this article, we discuss robotic-assisted therapy as an emerging and significant field of clinical rehabilitation and its value proposition for innovating rehabilitation clinical practice. Attempts to achieve integration among clinicians' practices and bioengineers' machines often generate new challenges and controversies. To date, the literature is indicative of a sizeable number and variety of robotic devices in the field of clinical rehabilitation, some are commercially available; however, large-scale clinical outcomes are less positive than expected. The following main themes related to integrating rehabilitation technology in real-world clinical practice will be discussed: the application of current evidence-based practice and knowledge in relation to treatment in the rehabilitation clinic, perspectives from rehabilitation professionals using robotic-aided therapy with regard to challenges, and strategies for problem solving. Lastly, we present innovation philosophies with regard to sustainability of clinical rehabilitation technologies.

Slow Versus Fast Robot-Assisted Locomotor Training After Severe Stroke: A Randomized Controlled Trial

BACKGROUND AND PURPOSE

Robot-assisted locomotor training on a bodyweight-supported treadmill is a rehabilitation intervention that compels repetitive practice of gait movements. Standard treadmill speed may elicit rhythmic movements generated primarily by spinal circuits. Slower-than-standard treadmill speed may elicit discrete movements, which are more complex than rhythmic movements and involve cortical areas.

OBJECTIVE

Compare effects of fast (i.e., rhythmic) versus slow (i.e., discrete) robot-assisted locomotor training on a bodyweight-supported treadmill in subjects with chronic, severe gait deficit after stroke.

METHODS

Subjects (N = 18) were randomized to receive 30 sessions (5 d/wk) of either fast or slow robot-assisted locomotor training on a bodyweight-supported treadmill in an inpatient setting. Functional ambulation category, time up and go, 6-min walk test, 10-m walk test, Berg Balance Scale, and Fugl-Meyer Assessment were administered at baseline and postintervention.

RESULTS

The slow group had statistically significant improvement on functional ambulation category (first quartile-third quartile, P = 0.004), 6-min walk test (95% confidence interval [CI] = 1.8 to 49.0, P = 0.040), Berg Balance Scale (95% CI = 7.4 to 14.8, P < 0.0001), time up and go (95% CI = -79.1 to 5.0, P < 0.0030), and Fugl-Meyer Assessment (95% CI = 24.1 to 45.1, P < 0.0001). The fast group had statistically significant improvement on Berg Balance Scale (95% CI = 1.5 to 10.5, P = 0.02).

CONCLUSIONS

In initial stages of robot-assisted locomotor training on a bodyweight-supported treadmill after severe stroke, slow training targeting discrete movement may yield greater benefit than fast training.

MIT-Skywalker: considerations on the Design of a Body Weight Support System

BACKGROUND

To provide body weight support during walking and balance training, one can employ two distinct embodiments: support through a harness hanging from an overhead system or support through a saddle/seat type. This paper presents a comparison of these two approaches. Ultimately, this comparison determined our selection of the body weight support system employed in the MIT-Skywalker, a robotic device developed for the rehabilitation/habilitation of gait and balance after a neurological injury.

METHOD

Here we will summarize our results with eight healthy subjects walking on the treadmill without any support, with 30% unloading supported by a harness hanging from an overhead system, and with a saddle/seat-like support system. We compared the center of mass as well as vertical and mediolateral trunk displacements across different walking speeds and support.

RESULTS

The bicycle/saddle system had the highest values for the mediolateral inclination, while the overhead harness body weight support showed the lowest values at all speeds. The differences were statistically significant.

CONCLUSION

We selected the bicycle/saddle system for the MIT-Skywalker. It allows faster don-and-doff, better centers the patient to the split treadmill, and allows all forms of training. The overhead harness body weight support might be adequate for rhythmic walking training but limits any potential for balance training.

Treadmill training and body weight support for walking after stroke

BACKGROUND

Treadmill training, with or without body weight support using a harness, is used in rehabilitation and might help to improve walking after stroke. This is an update of the Cochrane review first published in 2003 and updated in 2005 and 2014.

OBJECTIVES

To determine if treadmill training and body weight support, individually or in combination, improve walking ability, quality of life, activities of daily living, dependency or death, and institutionalisation or death, compared with other physiotherapy gait-training interventions after stroke. The secondary objective was to determine the safety and acceptability of this method of gait training.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 14 February 2017), the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Reviews of Effects (DARE) (the Cochrane Library 2017, Issue 2), MEDLINE (1966 to 14 February 2017), Embase (1980 to 14 February 2017), CINAHL (1982 to 14 February 2017), AMED (1985 to 14 February 2017) and SPORTDiscus (1949 to 14 February 2017). We also handsearched relevant conference proceedings and ongoing trials and research registers, screened reference lists, and contacted trialists to identify further trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled and cross-over trials of treadmill training and body weight support, individually or in combination, for the treatment of walking after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias and methodological quality. The primary outcomes investigated were walking speed, endurance, and dependency.

MAIN RESULTS

We included 56 trials with 3105 participants in this updated review. The average age of the participants was 60 years, and the studies were carried out in both inpatient and outpatient settings. All participants had at least some walking difficulties and many could not walk without assistance. Overall, the use of treadmill training did not increase the chances of walking independently compared with other physiotherapy interventions (risk difference (RD) -0.00, 95% confidence interval (CI) -0.02 to 0.02; 18 trials, 1210 participants; P = 0.94; I² = 0%; low-quality evidence). Overall, the use of treadmill training in walking rehabilitation for people after stroke increased the walking velocity and walking endurance significantly. The pooled mean difference (MD) (random-effects model) for walking velocity was 0.06 m/s (95% CI 0.03 to 0.09; 47 trials, 2323 participants; P < 0.0001; I² = 44%; moderate-quality evidence) and the pooled MD for walking endurance was 14.19 metres (95% CI 2.92 to 25.46; 28 trials, 1680 participants; P = 0.01; I² = 27%; moderate-quality evidence). Overall, the use of treadmill training with body weight support in walking rehabilitation for people after stroke did not increase the walking velocity and walking endurance at the end of scheduled follow-up. The pooled MD (random-effects model) for walking velocity was 0.03 m/s (95% CI -0.05 to 0.10; 12 trials, 954 participants; P = 0.50; I² = 55%; low-quality evidence) and the pooled MD for walking endurance was 21.64 metres (95% CI -4.70 to 47.98; 10 trials, 882 participants; P = 0.11; I² = 47%; low-quality evidence). In 38 studies with a total of 1571 participants who were independent in walking at study onset, the use of treadmill training increased the walking velocity significantly. The pooled MD (random-effects model) for walking velocity was 0.08 m/s (95% CI 0.05 to 0.12; P < 0.00001; I2 = 49%). There were insufficient data to comment on any effects on quality of life or activities of daily living. Adverse events and dropouts did not occur more frequently in people receiving treadmill training and these were not judged to be clinically serious events.

AUTHORS' CONCLUSIONS

Overall, people after stroke who receive treadmill training, with or without body weight support, are not more likely to improve their ability to walk independently compared with people after stroke not receiving treadmill training, but walking speed and walking endurance may improve slightly in the short term. Specifically, people with stroke who are able to walk (but not people who are dependent in walking at start of treatment) appear to benefit most from this type of intervention with regard to walking speed and walking endurance. This review did not find, however, that improvements in walking speed and endurance may have persisting beneficial effects. Further research should specifically investigate the effects of different frequencies, durations, or intensities (in terms of speed increments and inclination) of treadmill training, as well as the use of handrails, in ambulatory participants, but not in dependent walkers.

Robotic Assistance for Training Finger Movement Using a Hebbian Model: A Randomized Controlled Trial

BACKGROUND

Robots that physically assist movement are increasingly used in rehabilitation therapy after stroke, yet some studies suggest robotic assistance discourages effort and reduces motor learning.

OBJECTIVE

To determine the therapeutic effects of high and low levels of robotic assistance during finger training.

METHODS

We designed a protocol that varied the amount of robotic assistance while controlling the number, amplitude, and exerted effort of training movements. Participants (n = 30) with a chronic stroke and moderate hemiparesis (average Box and Blocks Test 32 ± 18 and upper extremity Fugl-Meyer score 46 ± 12) actively moved their index and middle fingers to targets to play a musical game similar to GuitarHero 3 h/wk for 3 weeks. The participants were randomized to receive high assistance (causing 82% success at hitting targets) or low assistance (55% success). Participants performed ~8000 movements during 9 training sessions.

RESULTS

Both groups improved significantly at the 1-month follow-up on functional and impairment-based motor outcomes, on depression scores, and on self-efficacy of hand function, with no difference between groups in the primary endpoint (change in Box and Blocks). High assistance boosted motivation, as well as secondary motor outcomes (Fugl-Meyer and Lateral Pinch Strength)-particularly for individuals with more severe finger motor deficits. Individuals with impaired finger proprioception at baseline benefited less from the training.

CONCLUSIONS

Robot-assisted training can promote key psychological outcomes known to modulate motor learning and retention. Furthermore, the therapeutic effectiveness of robotic assistance appears to derive at least in part from proprioceptive stimulation, consistent with a Hebbian plasticity model.

Treadmill vs. overground walking: different response to physical interaction

Rehabilitation of human motor function is an issue of growing significance, and human-interactive robots offer promising potential to meet the need. For the lower extremity, however, robot-aided therapy has proven challenging. To inform effective approaches to robotic gait therapy, it is important to better understand unimpaired locomotor control: its sensitivity to different mechanical contexts and its response to perturbations. The present study evaluated the behavior of 14 healthy subjects who walked on a motorized treadmill and overground while wearing an exoskeletal ankle robot. Their response to a periodic series of ankle plantar flexion torque pulses, delivered at periods different from, but sufficiently close to, their preferred stride cadence, was assessed to determine whether gait entrainment occurred, how it differed across conditions, and if the adapted motor behavior persisted after perturbation. Certain aspects of locomotor control were exquisitely sensitive to walking context, while others were not. Gaits entrained more often and more rapidly during overground walking, yet, in all cases, entrained gaits synchronized the torque pulses with ankle push-off, where they provided assistance with propulsion. Furthermore, subjects entrained to perturbation periods that required an adaption toward slower cadence, even though the pulses acted to accelerate gait, indicating a neural adaptation of locomotor control. Lastly, during 15 post-perturbation strides, the entrained gait period was observed to persist more frequently during overground walking. This persistence was correlated with the number of strides walked at the entrained gait period (i.e., longer exposure), which also indicated a neural adaptation.NEW & NOTEWORTHY We show that the response of human locomotion to physical interaction differs between treadmill and overground walking. Subjects entrained to a periodic series of ankle plantar flexion torque pulses that shifted their gait cadence, synchronizing ankle push-off with the pulses (so that they assisted propulsion) even when gait cadence slowed. Entrainment was faster overground and, on removal of torque pulses, the entrained gait period persisted more prominently overground, indicating a neural adaptation of locomotor control.

Adaptive control of an actuated-ankle-foot-orthosis

This paper deals with the control of an active ankle foot orthosis (AAFO) to assist the gait of paretic patients. The AAFO system is driven by both, the residual human torque delivered by the muscles spanning the ankle joint and the AAFO's actuator's torque. A projection-based model reference adaptive control is proposed to assist dorsiflexion and plantar-flexion of the ankle joint during daily living walking activities. Unlike most classical model-based controllers, the proposed one does not require any prior estimation of the system's (foot-AAFO) parameters. The ankle reference trajectory was extracted from healthy subjects gait activities in a clinical environment. The input-to-state stability of the foot-AAFO system with respect to a bounded human muscular torque is proved in closed-loop based on a Lyapunov analysis. Preliminary experimental results with a healthy subject walking on a treadmill, show satisfactory results in terms of tracking performance and ankle assistance throughout the gait cycle.

Identifying the effects of using integrated haptic feedback for gait rehabilitation of stroke patients

This paper evaluates the prospects of using a novel Integrated Haptic Feedback (IHF) system. IHF can provide over-ground gait training regimens for post-stroke ambulatory subjects. IHF system combines the use of a portable cane for kinesthetic feedback and a wearable vibrotactor array for tactile feedback. Continuous somatosensory input is aiforded to the users at the handle of cane; it serves the purpose of balance assurance at higher gait speeds. Besides, restricted use of upper limb for weight-bearing inspires the users to involve the paretic lower limbs more actively. Furthermore, tactile feedback contributes in enhancing the gait symmetry through afferent signal of vibration. Six post-stroke ambulatory individuals participated in walking trials to identity the effects of IHF system. Results indicate that while walking faster patients' body sway was not disturbed. Statistically significant increase was observed in temporal stance symmetry (p-value=0.02) and in paretic muscle (vastus medialis obliquus and semitendinosus) activation during stance phase (p-value<0.01). The IHF system can be a valuable tool to assist physical therapist in gait rehabilitation of post-stroke individuals.

Variable Damping Force Tunnel for Gait Training Using ALEX III

Haptic feedback affects not only the quality of training but can also influence the physical design of robotic gait trainers by determining how much force needs to be applied to the user and the nature of the force. This paper presents the design of a variable damping force tunnel and explores the effect of the shape and strength of the damping field using ALEX III, a treadmill-based exoskeleton developed at Columbia University. The study consists of 32 healthy subjects who were trained for 40 minutes in the device. The subjects were trained to follow a footpath with a 50% increase in step height, so the foot would have 1.5 times the ground clearance. Subjects were assigned to one of four groups: linear high, linear low, parabolic high, and parabolic low. Linear or parabolic denotes the shape of the damping field, and high or low denotes the rate of change (strength) of the field based on error. It is shown that the new controller is capable of inducing gait adaptations in healthy individuals while walking in the device. All groups showed adaptations in step height, while only the high strength groups showed changes in normalized error area, a measure of how closely the desired path was followed.

Use of Lower-Limb Robotics to Enhance Practice and Participation in Individuals With Neurological Conditions

PURPOSE

To review lower-limb technology currently available for people with neurological disorders, such as spinal cord injury, stroke, or other conditions. We focus on 3 emerging technologies: treadmill-based training devices, exoskeletons, and other wearable robots.

SUMMARY OF KEY POINTS

Efficacy for these devices remains unclear, although preliminary data indicate that specific patient populations may benefit from robotic training used with more traditional physical therapy. Potential benefits include improved lower-limb function and a more typical gait trajectory.

STATEMENT OF CONCLUSIONS

Use of these devices is limited by insufficient data, cost, and in some cases size of the machine. However, robotic technology is likely to become more prevalent as these machines are enhanced and able to produce targeted physical rehabilitation.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Therapists should be aware of these technologies as they continue to advance but understand the limitations and challenges posed with therapeutic/mobility robots.

Hemorrhagic versus ischemic stroke: Who can best benefit from blended conventional physiotherapy with robotic-assisted gait therapy?

BACKGROUND

Contrary to common belief of clinicians that hemorrhagic stroke survivors have better functional prognoses than ischemic, recent studies show that ischemic survivors could experience similar or even better functional improvements. However, the influence of stroke subtype on gait and posture outcomes following an intervention blending conventional physiotherapy with robotic-assisted gait therapy is missing.

OBJECTIVE

This study compared gait and posture outcome measures between ambulatory hemorrhagic patients and ischemic patients, who received a similar 4 weeks' intervention blending a conventional bottom-up physiotherapy approach and an exoskeleton top-down robotic-assisted gait training (RAGT) approach with Lokomat.

METHODS

Forty adult hemiparetic stroke inpatient subjects were recruited: 20 hemorrhagic and 20 ischemic, matched by age, gender, side of hemisphere lesion, stroke severity, and locomotor impairments. Functional Ambulation Category, Postural Assessment Scale for Stroke, Tinetti Performance Oriented Mobility Assessment, 6 Minutes Walk Test, Timed Up and Go and 10-Meter Walk Test were performed before and after a 4-week long intervention. Functional gains were calculated for all tests.

RESULTS

Hemorrhagic and ischemic subjects showed significant improvements in Functional Ambulation Category (P<0.001 and P = 0.008, respectively), Postural Assessment Scale for Stroke (P<0.001 and P = 0.003), 6 Minutes Walk Test (P = 0.003 and P = 0.015) and 10-Meter Walk Test (P = 0.001 and P = 0.024). Ischemic patients also showed significant improvements in Timed Up and Go. Significantly greater mean Functional Ambulation Category and Tinetti Performance Oriented Mobility Assessment gains were observed for hemorrhagic compared to ischemic, with large (dz = 0.81) and medium (dz = 0.66) effect sizes, respectively.

CONCLUSION

Overall, both groups exhibited quasi similar functional improvements and benefits from the same type, length and frequency of blended conventional physiotherapy and RAGT protocol. The use of intensive treatment plans blending top-down physiotherapy and bottom-up robotic approaches is promising for post-stroke rehabilitation.

Robot-assisted gait training for stroke patients: current state of the art and perspectives of robotics

In this review, we give a brief outline of robot-mediated gait training for stroke patients, as an important emerging field in rehabilitation. Technological innovations are allowing rehabilitation to move toward more integrated processes, with improved efficiency and less long-term impairments. In particular, robot-mediated neurorehabilitation is a rapidly advancing field, which uses robotic systems to define new methods for treating neurological injuries, especially stroke. The use of robots in gait training can enhance rehabilitation, but it needs to be used according to well-defined neuroscientific principles. The field of robot-mediated neurorehabilitation brings challenges to both bioengineering and clinical practice. This article reviews the state of the art (including commercially available systems) and perspectives of robotics in poststroke rehabilitation for walking recovery. A critical revision, including the problems at stake regarding robotic clinical use, is also presented.