Rehabilitation of gait after stroke: a review towards a top-down approach

Efficacy of a newly designed trunk orthosis with joints providing resistive force in adults with post-stroke hemiparesis

BACKGROUND

Few studies have examined the efficacy of trunk orthoses that support the upper trunk and a paretic limb in stroke patients. To improve stability and alignment of the trunk and pelvis in hemiparetic patients, we developed a newly designed trunk orthosis that provides resistive force through spring joints.

OBJECTIVES

This study aimed to determine the newly designed trunk orthosis's biomechanical effects during level walking.

STUDY DESIGN

Before-after trials must be better.

METHODS

Measurements were taken for nine chronic-phase (>2 years post-onset) stroke patients using a three-dimensional motion capture system and force plates under three experimental conditions: self-selected gait speed without the newly designed trunk orthosis, with the newly designed trunk orthosis, and after newly designed trunk orthosis removal. We analyzed and compared spatiotemporal and kinetic parameters of the paretic and non-paretic limbs and kinematic parameters of the trunk and bilateral limbs.

RESULTS

Several pre-swing gait parameters (e.g. hip joint flexion moment and ankle joint plantar flexion angle) after newly designed trunk orthosis removal were significantly increased compared to those without newly designed trunk orthosis. Step length of the paretic limb tended to increase after newly designed trunk orthosis removal.

CONCLUSION

The newly designed trunk orthosis effectively modified trunk alignment, but larger improvements in kinetic and kinematic parameters were observed in the bilateral limbs after newly designed trunk orthosis removal than with the newly designed trunk orthosis.

CLINICAL RELEVANCE

Stroke patients improved only trunk malalignment while wearing the newly designed trunk orthosis. Gait after newly designed trunk orthosis removal was better than with the newly designed trunk orthosis. Positive changes after removal were mostly observed in pre-swing of the hemiparetic limb. The newly designed trunk orthosis might be effective for gait training in stroke patients.

Objective Evaluation of the Quality of Movement in Daily Life after Stroke

Background

Stroke survivors are commonly left with disabilities that impair activities of daily living. The main objective of their rehabilitation program is to maximize the functional performance at home. However, the actual performance of patients in their home environment is unknown. Therefore, objective evaluation of daily life activities of stroke survivors in their physical interaction with the environment is essential for optimal guidance of rehabilitation therapy. Monitoring daily life movements could be very challenging, as it may result in large amounts of data, without any context. Therefore, suitable metrics are necessary to quantify relevant aspects of movement performance during daily life. The objective of this study is to develop data processing methods, which can be used to process movement data into relevant metrics for the evaluation of intra-patient differences in quality of movements in a daily life setting.

Methods

Based on an iterative requirement process, functional and technical requirements were formulated. These were prioritized resulting in a coherent set of metrics. An activity monitor was developed to give context to captured movement data at home. Finally, the metrics will be demonstrated in two stroke participants during and after their rehabilitation phases.

Results

By using the final set of metrics, quality of movement can be evaluated in a daily life setting. As example to demonstrate potential of presented methods, data of two stroke patients were successfully analyzed. Differences between in-clinic measurements and measurements during daily life are observed by applying the presented metrics and visualization methods. Heel height profiles show intra-patient differences in height, distance, stride profile, and variability between strides during a 10-m walk test in the clinic and walking at home. Differences in distance and stride profile between both feet were larger at home, than in clinic. For the upper extremities, the participant was able to reach further away from the pelvis and cover a larger area.

Discussion

Presented methods can be used for the objective evaluation of intra-patient differences in movement quality between in-clinic and daily life measurements. Any observed progression or deterioration of movement quality could be used to decide on continuing, stopping, or adjusting rehabilitation programs.

Development of a robotic evaluation system for the ability of proprioceptive sensation in slow hand motion

This paper proposes a simple diagnostic methodology for checking the ability of proprioceptive/kinesthetic sensation by using a robotic device. The perception ability of virtual frictional forces is examined in operations of the robotic device by the hand at a uniform slow velocity along the virtual straight/circular path. Experimental results by healthy subjects demonstrate that percentage of correct answers for the designed perceptual tests changes in the motion direction as well as the arm configuration and the HFM (human force manipulability) measure. It can be supposed that the proposed methodology can be applied into the early detection of neuromuscular/neurological disorders.

Detecting intention to walk in stroke patients from pre-movement EEG correlates

BACKGROUND

Most studies in the field of brain-computer interfacing (BCI) for lower limbs rehabilitation are carried out with healthy subjects, even though insights gained from healthy populations may not generalize to patients in need of a BCI.

METHODS

We investigate the ability of a BCI to detect the intention to walk in stroke patients from pre-movement EEG correlates. Moreover, we also investigated how the motivation of the patients to execute a task related to the rehabilitation therapy affects the BCI accuracy. Nine chronic stroke patients performed a self-initiated walking task during three sessions, with an intersession interval of one week.

RESULTS

Using a decoder that combines temporal and spectral sparse classifiers we detected pre-movement state with an accuracy of 64 % in a range between 18 % and 85.2 %, with the chance level at 4 %. Furthermore, we found a significantly strong positive correlation (r = 0.561, p = 0.048) between the motivation of the patients to perform the rehabilitation related task and the accuracy of the BCI detector of their intention to walk.

CONCLUSIONS

We show that a detector based on temporal and spectral features can be used to classify pre-movement state in stroke patients. Additionally, we found that patients' motivation to perform the task showed a strong correlation to the attained detection rate of their walking intention.

An integrated neuro-robotic interface for stroke rehabilitation using the NASA X1 powered lower limb exoskeleton

Stroke remains a leading cause of disability, limiting independent ambulation in survivors, and consequently affecting quality of life (QOL). Recent technological advances in neural interfacing with robotic rehabilitation devices are promising in the context of gait rehabilitation. Here, the X1, NASA's powered robotic lower limb exoskeleton, is introduced as a potential diagnostic, assistive, and therapeutic tool for stroke rehabilitation. Additionally, the feasibility of decoding lower limb joint kinematics and kinetics during walking with the X1 from scalp electroencephalographic (EEG) signals--the first step towards the development of a brain-machine interface (BMI) system to the X1 exoskeleton--is demonstrated.

Automated extraction and validation of children's gait parameters with the Kinect

BACKGROUND

Gait analysis for therapy regimen prescription and monitoring requires patients to physically access clinics with specialized equipment. The timely availability of such infrastructure at the right frequency is especially important for small children. Besides being very costly, this is a challenge for many children living in rural areas. This is why this work develops a low-cost, portable, and automated approach for in-home gait analysis, based on the Microsoft Kinect.

METHODS

A robust and efficient method for extracting gait parameters is introduced, which copes with the high variability of noisy Kinect skeleton tracking data experienced across the population of young children. This is achieved by temporally segmenting the data with an approach based on coupling a probabilistic matching of stride template models, learned offline, with the estimation of their global and local temporal scaling. A preliminary study conducted on healthy children between 2 and 4 years of age is performed to analyze the accuracy, precision, repeatability, and concurrent validity of the proposed method against the GAITRite when measuring several spatial and temporal children's gait parameters.

RESULTS

The method has excellent accuracy and good precision, with segmenting temporal sequences of body joint locations into stride and step cycles. Also, the spatial and temporal gait parameters, estimated automatically, exhibit good concurrent validity with those provided by the GAITRite, as well as very good repeatability. In particular, on a range of nine gait parameters, the relative and absolute agreements were found to be good and excellent, and the overall agreements were found to be good and moderate.

CONCLUSION

This work enables and validates the automated use of the Kinect for children's gait analysis in healthy subjects. In particular, the approach makes a step forward towards developing a low-cost, portable, parent-operated in-home tool for clinicians assisting young children.

Intersession adaptation of the EEG-based detector of self-paced walking intention in stroke patients

Brain-computer interfaces (BCIs) have been used in patients with motor impairments as a rehabilitation tool, allowing the control of prosthetic devices with their brain signals. Typically, before each rehabilitation session a calibration phase is recorded to account for session-specific signal changes. Calibration is often an inconvenient process due to its length and patients' fatigue-proneness. This paper focuses on improving the performance of an EEG-based detector of walking intention for intersession transfer. Nine stroke subjects executed a self-paced walking task during three sessions, with one week between sessions. We performed an intersession adaptation by using 80% of one session's data and an additional 20% of a next session for training, and then we tested the detection model on the remaining part of the next session. In practice, this would constitute a longer initial calibration (40 minutes) and a shorter recalibration in subsequent sessions (10 minutes). After training set adaption we attain an average increase in performance of 13.5% over non-adaptive training. Furthermore, we used an approximation of Kullback-Leibler (KL) divergence to quantify the difference between training and testing sets for the non-adaptive and adaptive transfer. As a potential explanation for the improvement of intersession performance, we found a significant decrease in KL-divergence in the case of adaptive transfer.

Rehabilitation Interventions for Improving Social Participation After Stroke: A Systematic Review and Meta-analysis

BACKGROUND

Despite the fact that social participation is considered a pivotal outcome of a successful recovery after stroke, there has been little attention on the impact of activities and services on this important domain.

OBJECTIVE

To present a systematic review and meta-analysis from randomized controlled trials (RCTs) on the effects of rehabilitation interventions on social participation after stroke.

METHODS

A total of 8 electronic databases were searched for relevant RCTs that evaluated the effects of an intervention on the outcome of social participation after stroke. Reference lists of selected articles were hand searched to identify further relevant studies. The methodological quality of the studies was assessed using the Physiotherapy Evidence Database Scale. Standardized mean differences (SMDs) and confidence intervals (CIs) were estimated using fixed- and random-effect models.

RESULTS

In all, 24 RCTs involving 2042 stroke survivors were identified and reviewed, and 21 were included in the meta-analysis. There was a small beneficial effect of interventions that utilized exercise on social participation (10 studies; SMD = 0.43; 95% CI = 0.09, 0.78;P= .01) immediately after the program ended. Exercise in combination with other interventions (13 studies; SMD = 0.34; 95% CI = 0.10, 0.58;P= .006) also resulted in beneficial effects. No significant effect was observed for interventions that involved support services over 9 studies (SMD = 0.09 [95% CI = -0.04, 0.21];I(2)= 0%;P= .16).

CONCLUSIONS

The included studies provide evidence that rehabilitation interventions may be effective in improving social participation after stroke, especially if exercise is one of the components.

Effect of a virtual reality exercise program accompanied by cognitive tasks on the balance and gait of stroke patients

[Purpose] This study aimed to assess the effect of a virtual reality exercise program accompanied by cognitive tasks on the balance and gait of stroke patients. [Subjects] Twenty stroke patients were randomly assigned to two groups 10 to an experimental group that performed a virtual reality exercise program accompanied by cognitive tasks and 10 to a control group. The control group performed a proprioceptive neuromuscular facilitation exercise program. Balance was measured with the Berg Balance Scale. Gait was assessed using the Timed Up and Go Test. The paired t-test was used to compare groups before and after the experiment. The independent t-test was conducted to assess differences in the degree of change between the two groups before and after the experiment. [Results] Within-group comparison in the experimental group showed significant differences in the Berg Balance Scale and Timed Up and Go Test. In a comparison between groups, the differences in the Berg Balance Scale and Timed Up and Go Test in the experimental group appeared significant compared with the control group. [Conclusion] The results of the experiment indicate that a virtual reality exercise program accompanied by cognitive tasks has a positive effect on the balance and gait of stroke patients.

The H2 robotic exoskeleton for gait rehabilitation after stroke: early findings from a clinical study

BACKGROUND

Stroke significantly affects thousands of individuals annually, leading to considerable physical impairment and functional disability. Gait is one of the most important activities of daily living affected in stroke survivors. Recent technological developments in powered robotics exoskeletons can create powerful adjunctive tools for rehabilitation and potentially accelerate functional recovery. Here, we present the development and evaluation of a novel lower limb robotic exoskeleton, namely H2 (Technaid S.L., Spain), for gait rehabilitation in stroke survivors.

METHODS

H2 has six actuated joints and is designed to allow intensive overground gait training. An assistive gait control algorithm was developed to create a force field along a desired trajectory, only applying torque when patients deviate from the prescribed movement pattern. The device was evaluated in 3 hemiparetic stroke patients across 4 weeks of training per individual (approximately 12 sessions). The study was approved by the Institutional Review Board at the University of Houston. The main objective of this initial pre-clinical study was to evaluate the safety and usability of the exoskeleton. A Likert scale was used to measure patient's perception about the easy of use of the device.

RESULTS

Three stroke patients completed the study. The training was well tolerated and no adverse events occurred. Early findings demonstrate that H2 appears to be safe and easy to use in the participants of this study. The overground training environment employed as a means to enhance active patient engagement proved to be challenging and exciting for patients. These results are promising and encourage future rehabilitation training with a larger cohort of patients.

CONCLUSIONS

The developed exoskeleton enables longitudinal overground training of walking in hemiparetic patients after stroke. The system is robust and safe when applied to assist a stroke patient performing an overground walking task. Such device opens the opportunity to study means to optimize a rehabilitation treatment that can be customized for individuals.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov ( https://clinicaltrials.gov/show/NCT02114450 ).

Neuromechanical principles underlying movement modularity and their implications for rehabilitation

Neuromechanical principles define the properties and problems that shape neural solutions for movement. Although the theoretical and experimental evidence is debated, we present arguments for consistent structures in motor patterns, i.e., motor modules, that are neuromechanical solutions for movement particular to an individual and shaped by evolutionary, developmental, and learning processes. As a consequence, motor modules may be useful in assessing sensorimotor deficits specific to an individual and define targets for the rational development of novel rehabilitation therapies that enhance neural plasticity and sculpt motor recovery. We propose that motor module organization is disrupted and may be improved by therapy in spinal cord injury, stroke, and Parkinson's disease. Recent studies provide insights into the yet-unknown underlying neural mechanisms of motor modules, motor impairment, and motor learning and may lead to better understanding of the causal nature of modularity and its underlying neural substrates.

Using swing resistance and assistance to improve gait symmetry in individuals post-stroke

A major characteristic of hemiplegic gait observed in individuals post-stroke is spatial and temporal asymmetry, which may increase energy expenditure and the risk of falls. The purpose of this study was to examine the effects of swing resistance/assistance applied to the affected leg on gait symmetry in individuals post-stroke. We recruited 10 subjects with chronic stroke who demonstrated a shorter step length with their affected leg in comparison to the non-affected leg during walking. They participated in two test sessions for swing resistance and swing assistance, respectively. During the adaptation period, subjects counteracted the step length deviation caused by the applied swing resistance force, resulting in an aftereffect consisting of improved step length symmetry during the post-adaptation period. In contrast, subjects did not counteract step length deviation caused by swing assistance during adaptation period and produced no aftereffect during the post-adaptation period. Locomotor training with swing resistance applied to the affected leg may improve step length symmetry through error-based learning. Swing assistance reduces errors in step length during stepping; however, it is unclear whether this approach would improve step length symmetry. Results from this study may be used to develop training paradigms for improving gait symmetry of stroke survivors.

Voluntary initiation of movement: multifunctional integration of subjective agency

This paper investigates subjective agency (SA) as a special type of efficacious action consciousness. Our central claims are, firstly, that SA is a conscious act of voluntarily initiating bodily motion. Secondly, we argue that SA is a case of multifunctional integration of behavioral functions being analogous to multisensory integration of sensory modalities. This is based on new perspectives on the initiation of action opened up by recent advancements in robot assisted neuro-rehabilitation which depends on the active participation of the patient and yields experimental evidence that there is SA in terms of a conscious act of voluntarily initiating bodily motion (phenomenal performance). Conventionally, action consciousness has been considered as a sense of agency (SoA). According to this view, the conscious subject merely echoes motor performance and does not cause bodily motion. Depending on sensory input, SoA is implemented by means of unifunctional integration (binding) and inevitably results in non-efficacious action consciousness. In contrast, SA comes as a phenomenal performance which causes motion and builds on multifunctional integration. Therefore, the common conception of the brain should be shifted toward multifunctional integration in order to allow for efficacious action consciousness. For this purpose, we suggest the heterarchic principle of asymmetric reciprocity and neural operators underlying SA. The general idea is that multifunctional integration allows conscious acts to be simultaneously implemented with motor behavior so that the resulting behavior (SA) comes as efficacious action consciousness. Regarding the neural implementation, multifunctional integration rather relies on operators than on modular functions. A robotic case study and possible experimental setups with testable hypotheses building on SA are presented.

Proof of principle of a brain-computer interface approach to support poststroke arm rehabilitation in hospitalized patients: design, acceptability, and usability

OBJECTIVE

To evaluate the feasibility of brain-computer interface (BCI)-assisted motor imagery training to support hand/arm motor rehabilitation after stroke during hospitalization.

DESIGN

Proof-of-principle study.

SETTING

Neurorehabilitation hospital.

PARTICIPANTS

Convenience sample of patients (N=8) with new-onset arm plegia or paresis caused by unilateral stroke.

INTERVENTIONS

The BCI-based intervention was administered as an "add-on" to usual care and lasted 4 weeks. Under the supervision of a therapist, patients were asked to practice motor imagery of their affected hand and received as a discrete feedback the movements of a "virtual" hand superimposed on their own. Such a BCI-based device was installed in a rehabilitation hospital ward.

MAIN OUTCOME MEASURES

Following a user-centered design, we assessed system usability in terms of motivation, satisfaction (by means of visual analog scales), and workload (National Aeronautics and Space Administration-Task Load Index). The usability of the BCI-based system was also evaluated by 15 therapists who participated in a focus group.

RESULTS

All patients successfully accomplished the BCI training. Significant positive correlations were found between satisfaction and motivation (P=.001, r=.393). BCI performance correlated with interest (P=.027, r=.257) and motivation (P=.012, r=.289). During the focus group, professionals positively acknowledged the opportunity offered by BCI-assisted training to measure patients' adherence to rehabilitation.

CONCLUSIONS

An ecological BCI-based device to assist motor imagery practice was found to be feasible as an add-on intervention and tolerable by patients who were exposed to the system in the rehabilitation environment.

Hand-in-hand advances in biomedical engineering and sensorimotor restoration

BACKGROUND

Living in a multisensory world entails the continuous sensory processing of environmental information in order to enact appropriate motor routines. The interaction between our body and our brain is the crucial factor for achieving such sensorimotor integration ability. Several clinical conditions dramatically affect the constant body-brain exchange, but the latest developments in biomedical engineering provide promising solutions for overcoming this communication breakdown.

NEW METHOD

The ultimate technological developments succeeded in transforming neuronal electrical activity into computational input for robotic devices, giving birth to the era of the so-called brain-machine interfaces. Combining rehabilitation robotics and experimental neuroscience the rise of brain-machine interfaces into clinical protocols provided the technological solution for bypassing the neural disconnection and restore sensorimotor function.

RESULTS

Based on these advances, the recovery of sensorimotor functionality is progressively becoming a concrete reality. However, despite the success of several recent techniques, some open issues still need to be addressed.

COMPARISON WITH EXISTING METHOD(S)

Typical interventions for sensorimotor deficits include pharmaceutical treatments and manual/robotic assistance in passive movements. These procedures achieve symptoms relief but their applicability to more severe disconnection pathologies is limited (e.g. spinal cord injury or amputation).

CONCLUSIONS

Here we review how state-of-the-art solutions in biomedical engineering are continuously increasing expectances in sensorimotor rehabilitation, as well as the current challenges especially with regards to the translation of the signals from brain-machine interfaces into sensory feedback and the incorporation of brain-machine interfaces into daily activities.

Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: a feasibility pilot study

BACKGROUND

The leap motion controller (LMC) is a new optoelectronic system for capturing motion of both hands and controlling a virtual environment. Differently from previous devices, it optoelectronically tracks the fine movements of fingers neither using glows nor markers.

OBJECTIVE

This pilot study explored the feasibility of adapting the LMC, developed for videogames, to neurorehabilitation of elderly with subacute stroke.

METHODS

Four elderly patients (71.50 ± 4.51 years old) affected by stroke in subacute phase were enrolled and tested in a cross-over pilot trial in which six sessions of 30 minutes of LMC videogame-based therapy were added on conventional therapy. Measurements involved participation to the sessions, evaluated by means of the Pittsburgh Rehabilitation Participation Scale, hand ability and grasp force evaluated respectively by means of the Abilhand Scale and by means of the dynamometer.

RESULTS

Neither adverse effects nor spasticity increments were observed during LMC training. Participation to the sessions was excellent in three patients and very good in one patient during the LMC trial. In this period, patients showed a significantly higher improvement in hand abilities (P = 0.028) and grasp force (P = 0.006).

CONCLUSIONS

This feasibility pilot study was the first one using leap motion controller for conducting a videogame-based therapy. This study provided a proof of concept that LMC can be a suitable tool even for elderly patients with subacute stroke. LMC training was in fact performed with a high level of active participation, without adverse effects, and contributed to increase the recovery of hand abilities.

Test of a customized compliant ankle rehabilitation device in unpowered mode

Presented is the design, implementation, and initial gait testing of a lightweight, compliant robotic device for ankle rehabilitation. Many patients with neuromuscular disorders suffer deficits in sensorimotor control of the ankle joint, leading to an abnormal walking pattern. Robotic devices have been used to assist ankle rehabilitation. However, these devices are usually heavy and rigid, which can deviate a natural gait pattern. To address these issues, our team has developed a light weight, compliant ankle robotic device actuated by artificial pneumatic muscles. A total of 3 healthy subjects were recruited to test whether the mechanical structure of the device deviates gait. We used a 3-dimensional (3D) motion analysis system to record and analyze subjects' ankle kinematics during gait while walking barefoot and while wearing the device unpowered. The preliminary results suggest that the device caused some, but minimal changes in ankle kinematics during gait. The changes were mainly caused by the device's rigid footplate, used to support the foot and connect to the pneumatic muscles. The preliminary results will be used for future improvement of the device.

Control strategies for active lower extremity prosthetics and orthotics: a review

: Technological advancements have led to the development of numerous wearable robotic devices for the physical assistance and restoration of human locomotion. While many challenges remain with respect to the mechanical design of such devices, it is at least equally challenging and important to develop strategies to control them in concert with the intentions of the user.This work reviews the state-of-the-art techniques for controlling portable active lower limb prosthetic and orthotic (P/O) devices in the context of locomotive activities of daily living (ADL), and considers how these can be interfaced with the user's sensory-motor control system. This review underscores the practical challenges and opportunities associated with P/O control, which can be used to accelerate future developments in this field. Furthermore, this work provides a classification scheme for the comparison of the various control strategies.As a novel contribution, a general framework for the control of portable gait-assistance devices is proposed. This framework accounts for the physical and informatic interactions between the controller, the user, the environment, and the mechanical device itself. Such a treatment of P/Os--not as independent devices, but as actors within an ecosystem--is suggested to be necessary to structure the next generation of intelligent and multifunctional controllers.Each element of the proposed framework is discussed with respect to the role that it plays in the assistance of locomotion, along with how its states can be sensed as inputs to the controller. The reviewed controllers are shown to fit within different levels of a hierarchical scheme, which loosely resembles the structure and functionality of the nominal human central nervous system (CNS). Active and passive safety mechanisms are considered to be central aspects underlying all of P/O design and control, and are shown to be critical for regulatory approval of such devices for real-world use.The works discussed herein provide evidence that, while we are getting ever closer, significant challenges still exist for the development of controllers for portable powered P/O devices that can seamlessly integrate with the user's neuromusculoskeletal system and are practical for use in locomotive ADL.

Electroencephalography as a post-stroke assessment method: An updated review

Given that stroke is currently a serious problem in the population, employing more reliable and objective techniques for determining diagnosis and prognosis is necessary in order to enable effective clinical decision-making. EEG is a simple, low-cost, non-invasive tool that can provide information about the changes occurring in the cerebral cortex during the recovery process after stroke. EEG provides data on the evolution of cortical activation patterns which can be used to establish a prognosis geared toward harnessing each patient's full potential. This strategy can be used to prevent compensation and maladaptive plasticity, redirect treatments, and develop new interventions that will let stroke patients reach their new maximum motor levels.

Functional principal component analysis as a new methodology for the analysis of the impact of two rehabilitation protocols in functional recovery after stroke

BACKGROUND

This study addressed the problem of evaluating the effectiveness of two protocols of physiotherapy for functional recovery after stroke. In particular, the study explored the use of Functional Principal Component Analysis (FPCA), a multivariate data analysis in order to assess and clarify the process of regaining independence after stroke.

METHODS

A randomized double-blind controlled trial was performed. Thirteen subjects with residual hemiparesis after a single stroke episode were measured in both in- and outpatient settings at a district hospital. All subjects were able to walk before suffering the stroke and were hemodynamically stable within the first week after stroke. Control and target groups were treated with conventional physiotherapy for stroke, but specific techniques were added for treatment of the target group depending on patients' functional levels.Independence level was assessed with the Barthel Index (BI) throughout 7 evolution stages (hemodynamic stability, beginning of standing, beginning of physical therapy sessions in the physiotherapy ward and monthly assessment for 6 months after stroke).

RESULTS

FPCA was applied for data analysis. Statistically significant differences were found in the dynamics of the recovery process between the two physiotherapy protocols. The target group showed a trend of improvement six months after stroke that was not present in the control group.

CONCLUSIONS

FPCA is a method which may be used to provide greater insight into the analysis of the rehabilitation process than that provided by conventional parametric methods. So, by using the whole curves as basic data parameters, subtle differences in the rehabilitation process can be found.FPCA represents a future aid for the fine analysis of similar physiotherapy techniques, when applied in subjects with a huge variability of functional recovery, as in the case of post-stroke patients.

Neural coding for effective rehabilitation

Successful neurological rehabilitation depends on accurate diagnosis, effective treatment, and quantitative evaluation. Neural coding, a technology for interpretation of functional and structural information of the nervous system, has contributed to the advancements in neuroimaging, brain-machine interface (BMI), and design of training devices for rehabilitation purposes. In this review, we summarized the latest breakthroughs in neuroimaging from microscale to macroscale levels with potential diagnostic applications for rehabilitation. We also reviewed the achievements in electrocorticography (ECoG) coding with both animal models and human beings for BMI design, electromyography (EMG) interpretation for interaction with external robotic systems, and robot-assisted quantitative evaluation on the progress of rehabilitation programs. Future rehabilitation would be more home-based, automatic, and self-served by patients. Further investigations and breakthroughs are mainly needed in aspects of improving the computational efficiency in neuroimaging and multichannel ECoG by selection of localized neuroinformatics, validation of the effectiveness in BMI guided rehabilitation programs, and simplification of the system operation in training devices.

Applications of Brain-Machine Interface Systems in Stroke Recovery and Rehabilitation

Stroke is a leading cause of disability, significantly impacting the quality of life (QOL) in survivors, and rehabilitation remains the mainstay of treatment in these patients. Recent engineering and technological advances such as brain-machine interfaces (BMI) and robotic rehabilitative devices are promising to enhance stroke neu-rorehabilitation, to accelerate functional recovery and improve QOL. This review discusses the recent applications of BMI and robotic-assisted rehabilitation in stroke patients. We present the framework for integrated BMI and robotic-assisted therapies, and discuss their potential therapeutic, assistive and diagnostic functions in stroke rehabilitation. Finally, we conclude with an outlook on the potential challenges and future directions of these neurotechnologies, and their impact on clinical rehabilitation.

Shank-Rearfoot Joint Coupling with Chronic Ankle Instability

Chronic ankle instability (CAI) results in longstanding symptoms and subjective feelings of “giving way” following initial ankle sprain. Our purpose was to identify differences in joint coupling and variability between shank internal/external rotation and rearfoot inversion/eversion throughout the gait cycle of CAI subjects and healthy controls. Twenty-eight young adults participated (CAI, n = 15, control, n = 13). Kinematics were collected while walking and jogging on a treadmill. A vector coding method in which direction (θ) and magnitude of the angle-angle relationship and stride-to-stride variability (VCV) in shank-rearfoot coupling were calculated. In walking, the CAI group demonstrated lower θ, indicating a greater proportion of rearfoot-to-shank motion, compared with the control group in early and late swing. The CAI group had higher magnitude, indicating greater combined motion between the two segments, in early swing, but lower magnitude, indicating less combined motion, during late swing. The CAI group also had lower VCV measures, indicating less stride-to-stride variability during stance. In jogging, the CAI group had lower θ measures than the control group during stance and swing. Differences in shank-rearfoot coupling of the CAI group may be related to changes in sensorimotor control and lead to further instances of instability.

Unleashing the future potential of functional near-infrared spectroscopy in brain sciences

The wondrous innovations bound to the introduction of functional near-infrared spectroscopy in cognitive neuroscience are characterized by a multifaceted nature, ranging from technological improvements to sophisticated signal processing methods; the outstanding progress enabled scientists to investigate a variety of hard-to-test clinical populations and to successfully employ optical imaging in fields that were almost unimaginable twenty years ago. Here we illustrate how the emerging use of fNIRS methodologies might represent a drawing power in a variety of challenging experimental and medical contexts; we expect in the near future a wide increase of the use of wireless fNIRS, especially in children and in particular clinical populations, as well as a striking progress of fNIRS-BCI and hybrid BCI systems for neurofeedback and neurorehabilitation. These emerging trends might dramatically foster the future potential of fNIRS in brain sciences, provided that they are properly supported by a significant progress in signal processing and cognitive neuroscience.

A brain-computer interface for single-trial detection of gait initiation from movement related cortical potentials

OBJECTIVE

Applications of brain-computer interfacing (BCI) in neurorehabilitation have received increasing attention. The intention to perform a motor task can be detected from scalp EEG and used to control rehabilitation devices, resulting in a patient-driven rehabilitation paradigm. In this study, we present and validate a BCI system for detection of gait initiation using movement related cortical potentials (MRCP).

METHODS

The templates of MRCP were extracted from 9-channel scalp EEG during gait initiation in 9 healthy subjects. Independent component analysis (ICA) was used to remove artifacts, and the Laplacian spatial filter was applied to enhance the signal-to-noise ratio of MRCP. Following these pre-processing steps, a matched filter was used to perform single-trial detection of gait initiation.

RESULTS

ICA preprocessing was shown to significantly improve the detection performance. With ICA preprocessing, across all subjects, the true positive rate (TPR) of the detection was 76.9±8.97%, and the false positive rate was 2.93±1.09 per minute.

CONCLUSION

The results demonstrate the feasibility of detecting the intention of gait initiation from EEG signals, on a single trial basis.

SIGNIFICANCE

The results are important for the development of new gait rehabilitation strategies, either for recovery/replacement of function or for neuromodulation.

Rehabilitation of the hemiparetic gait by nociceptive withdrawal reflex-based functional electrical therapy: a randomized, single-blinded study

Background

Gait deficits are very common after stroke and improved therapeutic interventions are needed. The objective of this study was therefore to investigate the therapeutic use of the nociceptive withdrawal reflex to support gait training in the subacute post-stroke phase.

Methods

Individuals were randomly allocated to a treatment group that received physiotherapy-based gait training supported by withdrawal reflex stimulation and a control group that received physiotherapy-based gait training alone. Electrical stimuli delivered to the arch of the foot elicited the withdrawal reflex at heel-off with the purpose of facilitating the initiation and execution of the swing phase. Gait was assessed before and immediately after finishing treatment, and one month and six months after finishing treatment. Assessments included the Functional Ambulation Category (FAC) test, the preferred and maximum gait velocities, the duration of the stance phase in the hemiparetic side, the duration of the gait cycle, and the stance time symmetry ratio.

Results

The treatment group showed an improved post treatment preferred walking velocity (p < 0.001) and fast walking velocity (p < 0.001) compared to the control group. Furthermore, subjects in the treatment group with severe walking impairment at inclusion time showed the best improvement as assessed by a longer duration of the stance phase in the hemiparetic side (p < 0.002) and a shorter duration of the gait cycle (p < 0.002). The stance time symmetry ratio was significantly better for the treatment than the control group after finishing training (p < 0.02). No differences between groups were detected with the FAC test after finishing training (p = 0.09).

Conclusion

Withdrawal reflex-based functional electrical therapy was useful in the rehabilitation of the hemiparetic gait of severely impaired patients.

Plantar Pressure Distribution During Robotic-Assisted Gait in Post-stroke Hemiplegic Patients

Objective

To assess the plantar pressure distribution during the robotic-assisted walking, guided through normal symmetrical hip and knee physiological kinematic trajectories, with unassisted walking in post-stroke hemiplegic patients.

Methods

Fifteen hemiplegic stroke patients, who were able to walk a minimum of ten meters independently but with asymmetric gait patterns, were enrolled in this study. All the patients performed both the robotic-assisted walking (Lokomat) and the unassisted walking on the treadmill with the same body support in random order. The contact area, contact pressure, trajectory length of center of pressure (COP), temporal data on both limbs and asymmetric index of both limbs were obtained during both walking conditions, using the F-Scan in-shoe pressure measurement system.

Results

The contact area of midfoot and total foot on the affected side were significantly increased in robotic-assisted walking as compared to unassisted walking (p<0.01). The contact pressure of midfoot and total foot on affected limbs were also significantly increased in robotic-assisted walking (p<0.05). The anteroposterior and mediolateral trajectory length of COP were not significantly different between the two walking conditions, but their trajectory variability of COP was significantly improved (p<0.05). The asymmetric index of area, stance time, and swing time during robotic-assisted walking were statistically improved as compared with unassisted walking (p<0.05).

Conclusion

The robotic-assisted walking may be helpful in improving the gait stability and symmetry, but not the physiologic ankle rocker function.

Assisting drinking with an affordable BCI-controlled wearable robot and electrical stimulation: a preliminary investigation

Background

The aim of the present study is to demonstrate, through tests with healthy volunteers, the feasibility of potentially assisting individuals with neurological disorders via a portable assistive technology for the upper extremities (UE). For this purpose the task of independently drinking a glass of water was selected, as it is one of the most basic and vital activities of the daily living that is unfortunately not achievable by individuals severely affected by stroke.

Methods

To accomplish the aim of this study we introduce a wearable and portable system consisting of a novel lightweight Robotic Arm Orthosis (RAO), a Functional Electrical Stimulation (FES) system, and a simple wireless Brain-Computer Interface (BCI). This system is able to process electroencephalographic (EEG) signals and translate them into motions of the impaired arm. Five healthy volunteers participated in this study and were asked to simulate stroke patient symptoms with no voluntary control of their hand and arm. The setup was designed such as the volitional movements of the healthy volunteers’ UE did not interfere with the evaluation of the proposed assistive system. The drinking task was split into eleven phases of which seven were executed by detecting EEG-based signals through the BCI. The user was asked to imagine UE motion related to the specific phase of the task to be assisted. Once detected by the BCI the phase was initiated. Each phase was then terminated when the BCI detected the volunteers clenching their teeth.

Results

The drinking task was completed by all five participants with an average time of 127 seconds with a standard deviation of 23 seconds. The incremental motions of elbow extension and elbow flexion were the primary limiting factors for completing this task faster. The BCI control along with the volitional motions also depended upon the users pace, hence the noticeable deviation from the average time.

Conclusion

Through tests conducted with healthy volunteers, this study showed that our proposed system has the potential for successfully assisting individuals with neurological disorders and hemiparetic stroke to independently drink from a glass.

Motor learning perspectives on haptic training for the upper extremities

Recent developments in neurorehabilitation have spawned numerous new robotic rehabilitation therapies. However, many of the concepts upon which these therapies are based are not fully understood and it may be necessary to explore some of the motor learning principles that apply to the use of haptics for motor learning in non-clinical scenarios/populations. We conducted a review of studies that utilized a haptic training paradigm teaching healthy participants to perform a motor skill involving the upper extremities. We discuss studies in the context of four important motor learning concepts: performance versus learning, feedback, observational learning, and functional task difficulty. Additionally, we note that the proliferation of research in haptic training has led to an extensive vocabulary of terms, some of which may be misnomers or redundant. We propose a classification of terms describing haptic training in an effort to provide clarity and further contextualize the studies. We believe that making connections to motor learning principles and clarifying meanings will facilitate a fuller understanding of the outcomes of studies in basic science research and allow for more directed applications of these training techniques to clinical populations.

Recovery of walking ability using a robotic device in subacute stroke patients: a randomized controlled study

PURPOSE

This study investigates the effectiveness of Lokomat + conventional therapy in recovering walking ability in non-ambulatory subacute stroke subjects involved in inpatient rehabilitation.

METHOD

Thirty first-ever stroke patients completed 8 weeks of intervention. One group (n = 16) received Lokomat therapy twice a week, combined with three times 30 min a week of conventional overground therapy. The second group (n = 14) received conventional assisted overground therapy only, during a similar amount of time (3.5 h a week). The intervention was part of the normal rehabilitation program. Primary outcome measure was walking speed. Secondary outcome measures assessed other walking- and mobility-related tests, lower-limb strength and quality of life measures. All outcome measures were assessed before and after the intervention and at wk 24 and wk 36 after start of the intervention.

RESULTS

Patients showed significant (p < 0.05) gains in walking speed, other walking- and mobility related tests, and strength of the paretic knee extensors relative to baseline at all assessments. However, there were no significant differences in improvements in any of the variables between groups at any time during the study.

CONCLUSION

These results indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as conventional therapy alone. Implications for Rehabilitation Recovery of walking after stroke is important. Robot-assisted therapy is currently receiving much attention in research and rehabilitation practice as devices such as the Lokomat seem to be promising assistive devices. Technical developments, sub-optimal study designs in literature and new therapy insights warrant new effectiveness studies. RESULTS of a financially and practically feasible study indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as compared to conventional overground therapy alone.

Associations between prefrontal cortex activation and H-reflex modulation during dual task gait

Walking, although a largely automatic process, is controlled by the cortex and the spinal cord with corrective reflexes modulated through integration of neural signals from central and peripheral inputs at supraspinal level throughout the gait cycle. In this study we used an additional cognitive task to interfere with the automatic processing during walking in order to explore the neural mechanisms involved in healthy young adults. Participants were asked to walk on a treadmill at two speeds, both with and without additional cognitive load. We evaluated the impact of speed and cognitive load by analyzing activity of the prefrontal cortex (PFC) using functional Near-Infrared Spectroscopy (fNIRS) alongside spinal cord reflex activity measured by soleus H-reflex amplitude and gait changes obtained by using an inertial measuring unit. Repeated measures ANOVA revealed that fNIRS Oxy-Hb concentrations significantly increased in the PFC with dual task (walking while performing a cognitive task) compared to a single task (walking only; p < 0.05). PFC activity was unaffected by increases of walking speed. H-reflex amplitude and gait variables did not change in response to either dual task or increases in walking speed. When walking under additional cognitive load participants adapted by using greater activity in the PFC, but this adaptation did not detrimentally affect H-reflex amplitude or gait variables. Our findings suggest that in a healthy young population central mechanisms (PFC) are activated in response to cognitive loads but that H-reflex activity and gait performance can successfully be maintained. This study provides insights into the mechanisms behind healthy individuals safely performing dual task walking.

Infarct hemisphere and noninfarcted brain volumes affect locomotor performance following stroke

OBJECTIVE

Brain damage within the right middle cerebral artery (MCA) territory is particularly disruptive to mediolateral postural stabilization. The objective of this cross-sectional study was to test the hypothesis that chronic right MCA infarcts (as compared to left) are associated with slower and more bilaterally asymmetrical gait. We further hypothesized that in those with chronic right MCA infarct, locomotor performance is more dependent on gray matter (GM) volumes within noninfarcted regions of the brain that are involved in motor control yet lie outside of the MCA territory.

METHODS

Gait speed was assessed in 19 subjects with right MCA infarct, 20 with left MCA infarct, and 108 controls. Bilateral plantar pressure and temporal symmetry ratios were calculated in a subset of the cohort. GM volumes within 5 regions outside of the MCA territory (superior parietal lobe, precuneus, caudate, putamen, and cerebellum) were quantified from anatomic MRIs.

RESULTS

Right and left infarct groups had similar poststroke duration (7.6 ± 6.0 years), infarct size, and functional independence. The right infarct group demonstrated slower gait speed and greater asymmetry compared to the left infarct group and controls (p < 0.05). In the right infarct group only, those with larger GM volumes within the cerebellum (r(2) = 0.32, p = 0.02) and caudate (r(2) = 0.56, p < 0.001) exhibited faster gait speed.

CONCLUSION

Individuals with chronic lesions within the right MCA territory, as compared to the left MCA territory, exhibit slower, more asymmetrical gait. For these individuals, larger GM volumes within regions outside of the infarcted vascular territory may help preserve locomotor control.

The value of robotic systems in stroke rehabilitation

In this paper, we discuss robot-mediated neurorehabilitation as a significant emerging field in clinical medicine. Stroke rehabilitation is advancing toward more integrated processes, using robotics to facilitate this integration. Rehabilitation approaches have tremendous value in reducing long-term impairments in stroke patients during hospitalization and after discharge, of which robotic systems are a new modality that can provide more effective rehabilitation. The function of robotics in rehabilitative interventions has been examined extensively, generating positive yet not completely satisfactory clinical results. This article presents state-of-the-art robotic systems and their prospective function in poststroke rehabilitation of the upper and lower limbs.

Lower Limb Movement Preparation in Chronic Stroke: A Pilot Study Toward an fNIRS-BCI for Gait Rehabilitation

Background Thus far, most of the brain-computer interfaces (BCIs) developed for motor rehabilitation used electroencephalographic signals to drive prostheses that support upper limb movement. Only few BCIs used hemodynamic signals or were designed to control lower extremity prostheses. Recent technological developments indicate that functional near-infrared spectroscopy (fNIRS)-BCI can be exploited in rehabilitation of lower limb movement due to its great usability and reduced sensitivity to head motion artifacts. Objective The aim of this proof of concept study was to assess whether hemodynamic signals underlying lower limb motor preparation in stroke patients can be reliably measured and classified. Methods fNIRS data were acquired during preparation of left and right hip movement in 7 chronic stroke patients. Results Single-trial analysis indicated that specific hemodynamic changes associated with left and right hip movement preparation can be measured with fNIRS. Linear discriminant analysis classification of totHB signal changes in the premotor cortex and/or posterior parietal cortex indicated above chance accuracy in discriminating paretic from nonparetic movement preparation trials in most of the tested patients. Conclusion The results provide first evidence that fNIRS can detect brain activity associated with single-trial lower limb motor preparation in stroke patients. These findings encourage further investigation of fNIRS suitability for BCI applications in rehabilitation of patients with lower limb motor impairment after stroke.

Towards effective non-invasive brain-computer interfaces dedicated to gait rehabilitation systems

In the last few years, significant progress has been made in the field of walk rehabilitation. Motor cortex signals in bipedal monkeys have been interpreted to predict walk kinematics. Epidural electrical stimulation in rats and in one young paraplegic has been realized to partially restore motor control after spinal cord injury. However, these experimental trials are far from being applicable to all patients suffering from motor impairments. Therefore, it is thought that more simple rehabilitation systems are desirable in the meanwhile. The goal of this review is to describe and summarize the progress made in the development of non-invasive brain-computer interfaces dedicated to motor rehabilitation systems. In the first part, the main principles of human locomotion control are presented. The paper then focuses on the mechanisms of supra-spinal centers active during gait, including results from electroencephalography, functional brain imaging technologies [near-infrared spectroscopy (NIRS), functional magnetic resonance imaging (fMRI), positron-emission tomography (PET), single-photon emission-computed tomography (SPECT)] and invasive studies. The first brain-computer interface (BCI) applications to gait rehabilitation are then presented, with a discussion about the different strategies developed in the field. The challenges to raise for future systems are identified and discussed. Finally, we present some proposals to address these challenges, in order to contribute to the improvement of BCI for gait rehabilitation.

Influence of psychologic features on rehabilitation outcomes in patients with subacute stroke trained with robotic-aided walking therapy

OBJECTIVE

The aim of this study was to investigate whether the rehabilitation outcomes with robotic-aided gait therapy may be affected by patients' and caregivers' psychologic features after subacute stroke.

DESIGN

This is a controlled, longitudinal, observational pilot study conducted on 42 patients divided in robotic-assisted gait training plus conventional physical therapy group, robotic-assisted gait training dropout group, and conventional physical therapy group. The outcome measures were walking ability (Functional Ambulation Category) and independency in activities of daily living (Barthel Index) measured before and after intervention. Psychologic features were measured before intervention using the Hospital Anxiety and Depression Scale, the Eysenck Personality Questionnaire, and recovery locus of control in the patients and the State-Trait Anxiety Inventory and the Beck Depression Inventory in the caregivers.

RESULTS

Patient anxiety was significantly higher in those who refused/abandoned robotic therapy (P = 0.002). In the subjects allocated to the robotic group, the recovery of walking ability was significantly affected by the perceived recovery locus of control (P = 0.039, odds ratio = 14); and the recovery of independency in activities of daily living, by anxiety (P = 0.018, odds ratio = 0.042). Conversely, psychologic factors did not significantly affect the outcomes of conventional rehabilitation.

CONCLUSIONS

Psychologic features, particularly recovery locus of control and anxiety, affected the rehabilitative outcomes of the patients involved in robotic treatment more than those in conventional rehabilitation.

Kinematic and neurophysiological consequences of an assisted-force-feedback brain-machine interface training: a case study

In a proof-of-principle prototypical demonstration we describe a new type of brain-machine interface (BMI) paradigm for upper limb motor-training. The proposed technique allows a fast contingent and proportionally modulated stimulation of afferent proprioceptive and motor output neural pathways using operant learning. Continuous and immediate assisted-feedback of force proportional to rolandic rhythm oscillations during actual movements was employed and illustrated with a single case experiment. One hemiplegic patient was trained for 2 weeks coupling somatosensory brain oscillations with force-field control during a robot-mediated center-out motor-task whose execution approaches movements of everyday life. The robot facilitated actual movements adding a modulated force directed to the target, thus providing a non-delayed proprioceptive feedback. Neuro-electric, kinematic, and motor-behavioral measures were recorded in pre- and post-assessments without force assistance. Patient's healthy arm was used as control since neither a placebo control was possible nor other control conditions. We observed a generalized and significant kinematic improvement in the affected arm and a spatial accuracy improvement in both arms, together with an increase and focalization of the somatosensory rhythm changes used to provide assisted-force-feedback. The interpretation of the neurophysiological and kinematic evidences reported here is strictly related to the repetition of the motor-task and the presence of the assisted-force-feedback. Results are described as systematic observations only, without firm conclusions about the effectiveness of the methodology. In this prototypical view, the design of appropriate control conditions is discussed. This study presents a novel operant-learning-based BMI-application for motor-training coupling brain oscillations and force feedback during an actual movement.

Neurophysiology of robot-mediated training and therapy: a perspective for future use in clinical populations

The recovery of functional movements following injury to the central nervous system (CNS) is multifaceted and is accompanied by processes occurring in the injured and non-injured hemispheres of the brain or above/below a spinal cord lesion. The changes in the CNS are the consequence of functional and structural processes collectively termed neuroplasticity and these may occur spontaneously and/or be induced by movement practice. The neurophysiological mechanisms underlying such brain plasticity may take different forms in different types of injury, for example stroke vs. spinal cord injury (SCI). Recovery of movement can be enhanced by intensive, repetitive, variable, and rewarding motor practice. To this end, robots that enable or facilitate repetitive movements have been developed to assist recovery and rehabilitation. Here, we suggest that some elements of robot-mediated training such as assistance and perturbation may have the potential to enhance neuroplasticity. Together the elemental components for developing integrated robot-mediated training protocols may form part of a neurorehabilitation framework alongside those methods already employed by therapists. Robots could thus open up a wider choice of options for delivering movement rehabilitation grounded on the principles underpinning neuroplasticity in the human CNS.

Effect of Ankle-foot Orthosis on Gait Velocity and Cadence of Stroke Patients: A Systematic Review

[Purpose] The aim of the present study was to analyze the effect of an ankle-foot orthosis on gait variables (velocity and cadence) of stroke patients. To do this, a systematic review was conducted of four databases. [Subjects and Methods] The papers identified were evaluated based on the following inclusion criteria: 1) design: controlled, clinical trial; 2) population: stroke patients; 3) intervention: analysis of spatiotemporal variables of gait with an ankle-foot orthosis; 4) control group with different intervention or no intervention; and 5) outcome: improvement in gait velocity or cadence. [Results] Thirteen controlled trials addressing the effect of an ankle-foot orthosis on gait variables of stroke patients were found. They exhibited methodological quality of 3 or more points on the PEDro scale. [Conclusion] While the findings suggest the benefits of an AFO regarding gait velocity, the impact of this type of orthosis on cadence remains inconclusive. Thus, there is a need for further well-designed randomized, controlled, clinical trials to establish better scientific evidence for the effects of AFO usage on gait variables of stroke patients.

Acupuncture in subacute stroke: no benefits detected

BACKGROUND

There is debate concerning the effect of acupuncture on rehabilitation following stroke, with key reviews unable to find evidence of benefit. This lack of evidence may be due to poor study design, small sample size, and insufficient theoretical background.

OBJECTIVE

The present study was designed to determine whether acupuncture combined with conventional physical therapy improves motor function and activities of daily living in patients with subacute stroke compared with conventional physical therapy alone.

DESIGN

A multicenter, single-blinded, randomized study was conducted.

SETTING

Four rehabilitation centers in the Jiangsu province of China participated in this study.

PATIENTS

One hundred eighty-eight patients with subacute stroke admitted to the hospital were randomized into an acupuncture group and a conventional rehabilitation group.

INTERVENTIONS

A combination of body and scalp acupuncture was used for 3 months in the acupuncture group. All patients underwent conventional stroke rehabilitation.

MEASUREMENTS

The Fugl-Meyer Assessment (FMA) and Barthel Index (BI) were performed at baseline and at 1, 3, and 6 months after inclusion in the study.

RESULTS

No statistically significant differences were found at baseline between the groups. No statistically significant differences were found between the groups using the FMA motor scores and the BI scores at baseline or at 1, 3, or 6 months. Significant improvements were found in each group following treatment.

CONCLUSIONS

In patients with subacute stroke, the addition of body and scalp acupuncture to a regimen of conventional physical therapy does not result in further improvement in either motor function or ADL beyond the effect of conventional physical therapy alone.

Pilot study of locomotion improvement using hybrid assistive limb in chronic stroke patients

Background

Locomotor training using robots is increasingly being used for rehabilitation to reduce manpower and the heavy burden on therapists, and the effectiveness of such techniques has been investigated. The robot suit Hybrid Assistive Limb (HAL) has been developed to rehabilitate or support motor function in people with disabilities. The HAL provides motion support that is tailored to the wearer’s voluntary drive. We performed a pilot clinical trial to investigate the feasibility of locomotor training using the HAL in chronic stroke patients, and to examine differences between two functional ambulation subgroups.

Methods

Sixteen stroke patients in the chronic stage participated in this study. All patients were trained with the HAL over 16 sessions (20–30 min/day within 2 days/week). Primary outcomes were walking speed, cadence, and number of steps recorded during a 10-meter walk test (10MWT). Berg balance scale (BBS) and timed up and go (TUG) were also measured. All outcome measures were evaluated without wearing HAL assistance before and after the intervention in all patients as well as in the dependent ambulatory and independent ambulatory subgroups.

Results

All participants completed the intervention with no adverse events. Gait speed, cadence, number of steps during the 10MWT, and BBS increased significantly from 0.41 m/s to 0.45 m/s (P = 0.031), from 68.6 steps/min to 72.0 steps/min (P = 0.020), from 37.5 steps to 33.1 steps (P = 0.017), and from 40.6 to 45.4 (P = 0.004) respectively. The TUG test score improved, although this difference was not statistically significant. The findings in the dependent ambulatory subgroup primarily contributed to the significant differences observed in the group as a whole.

Conclusions

This pilot study showed that locomotor training using the HAL is feasible for chronic stroke patients. Randomized controlled trials are now required to demonstrate the effectiveness of HAL-based rehabilitation over conventional therapies.

Trial registration

UMIN000002969