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Hara T, Takekawa T, Abo M. Gait Reconstruction Strategy Using Botulinum Toxin Therapy Combined with Rehabilitation. Toxins (Basel) 2024; 16:323. [PMID: 39057963 PMCID: PMC11281298 DOI: 10.3390/toxins16070323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 07/11/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Numerous studies have established a robust body of evidence for botulinum toxin A (BoNT-A) therapy as a treatment for upper motor neuron syndrome. These studies demonstrated improvements in spasticity, range of joint motion, and pain reduction. However, there are few studies that have focused on improvement of paralysis or functional enhancement as the primary outcome. This paper discusses the multifaceted aspects of spasticity assessment, administration, and rehabilitation with the goal of optimising the effects of BoNT-A on lower-limb spasticity and achieving functional improvement and gait reconstruction. This paper extracts studies on BoNT-A and rehabilitation for the lower limbs and provides new knowledge obtained from them. From these discussion,, key points in a walking reconstruction strategy through the combined use of BoNT-A and rehabilitation include: (1) injection techniques based on the identification of appropriate muscles through proper evaluation; (2) combined with rehabilitation; (3) effective spasticity control; (4) improvement in ankle joint range of motion; (5) promotion of a forward gait pattern; (6) adjustment of orthotics; and (7) maintenance of the effects through frequent BoNT-A administration. Based on these key points, the degree of muscle fibrosis and preintervention walking speed may serve as indicators for treatment strategies. With the accumulation of recent studies, a study focusing on walking functions is needed. As a result, it is suggested that BoNT-A treatment for lower limb spasticity should be established not just as a treatment for spasticity but also as a therapeutic strategy in the field of neurorehabilitation aimed at improving walking function.
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Affiliation(s)
- Takatoshi Hara
- Department of Physical Rehabilitation, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo 187-8551, Japan
| | - Toru Takekawa
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (T.T.); (M.A.)
| | - Masahiro Abo
- Department of Rehabilitation Medicine, The Jikei University School of Medicine, Tokyo 105-8461, Japan; (T.T.); (M.A.)
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Raciti L, Raciti G, Ammendolia A, de Sire A, Onesta MP, Calabrò RS. Improving Spasticity by Using Botulin Toxin: An Overview Focusing on Combined Approaches. Brain Sci 2024; 14:631. [PMID: 39061372 PMCID: PMC11274891 DOI: 10.3390/brainsci14070631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 06/11/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
Spasticity is a very common sign in the neurological field. It can be defined as "a motor disorder marked by a velocity-dependent increase in muscle tone or tonic stretch reflexes" associated with hypertonia. It leads to a high risk of limb deformities and pain that prejudices residual motor function, impairing quality of life". The treatment of spasticity depends on its severity and its location and, in general, it is based on rehabilitation, oral therapies (the gamma-aminobutyric acid b agonist baclofen) and injectable medications (i.e., botulin toxins, acting on polysynaptic reflex mechanisms). The botulin toxin type A (BoNT-A) injection has been effectively used to improve different types of spasticity. However, when BoNT-A is not sufficient, a combination of nonpharmacological approaches could be attempted. Therefore, additional intervention, such as conventional physical therapy by itself or further combined with robotic gait training, may be needed. Indeed, it has been shown that combination of BoNT-A and robotics has a positive effect on activity level and upper limb function in patients with stroke, including those in the chronic phase. The aim of this review is to evaluate the efficacy of pharmacological or nonpharmacological treatment in combination with BoNT-A injections on spasticity. The combined therapy of BoNT with conventional or adjunct activities or robot-assisted training, especially with end-effectors, is a valid tool to improve patients' performance and outcomes. The combined strategies might rise the toxin's effect, lowering its dosages of botulinum and reducing side effects and costs.
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Affiliation(s)
- Loredana Raciti
- Unità Spinale Unipolare, AO Cannizzaro, 98102 Catania, Italy; (L.R.); (M.P.O.)
| | - Gianfranco Raciti
- Department of Medical and Surgical Sciences, Magna Græcia University, 88100 Catanzaro, Italy; (G.R.); (A.A.); (A.d.S.)
| | - Antonio Ammendolia
- Department of Medical and Surgical Sciences, Magna Græcia University, 88100 Catanzaro, Italy; (G.R.); (A.A.); (A.d.S.)
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, Magna Græcia University, 88100 Catanzaro, Italy; (G.R.); (A.A.); (A.d.S.)
| | - Maria Pia Onesta
- Unità Spinale Unipolare, AO Cannizzaro, 98102 Catania, Italy; (L.R.); (M.P.O.)
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Cotinat M, Celerier M, Arquillière C, Flipo M, Prieur-Blanc N, Viton JM, Bensoussan L. Robotic gait training and botulinum toxin injection improve gait in the chronic post-stroke phase: A randomized controlled trial. Ann Phys Rehabil Med 2024; 67:101785. [PMID: 38118342 DOI: 10.1016/j.rehab.2023.101785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND Improving walking ability is one of the main goals of rehabilitation after stroke. When lower limb spasticity increases walking difficulty, botulinum toxin type A (BTx-A) injections can be combined with non-pharmacologic interventions such as intensive rehabilitation using a robotic approach. To the best of our knowledge, no comparisons have been made between the efficacy of robotic gait training and conventional physical therapy in combination with BTx-A injections. OBJECTIVE To conduct a randomized controlled trial to compare the efficacy on gait of robotic gait training versus conventional physiotherapy after BTx-A injection into the spastic triceps surae in people after stroke. METHOD Thirty-three participants in the chronic stroke phase with triceps surae spasticity inducing gait impairment were included. After BTx-A injection, participants were randomized into 2 groups. Group A underwent robotic gait training (Lokomat®) for 2 weeks, followed by conventional physiotherapy for 2 weeks (n = 15) and Group B underwent the same treatment in reverse order (n = 18). The efficacy of these methods was tested using the 6-minute walk test (6MWT), comparing post-test 1 and post-test 2 with the pre-test. RESULTS After the first period, the 6MWT increased significantly more in Group A than in Group B: the mean difference between the interventions was 33 m (95%CI 9; 58 p = 0.007; g = 0.95), in favor of Group A; after the second period, the 6MWT increased in both groups, but the 30 m difference between the groups still remained (95%CI 5; 55 p = 0.019; g = 0.73). CONCLUSION Two weeks of robotic gait training performed 2 weeks after BTx-A injections improved walking performance more than conventional physiotherapy. Large-scale studies are now required on the timing of robotic rehabilitation after BTx-A injection.
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Affiliation(s)
- Maëva Cotinat
- Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France; Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France.
| | - Mathilde Celerier
- Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France
| | - Clelia Arquillière
- Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France
| | - Margot Flipo
- Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France
| | - Nicolas Prieur-Blanc
- Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France
| | - Jean-Michel Viton
- Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France; Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France
| | - Laurent Bensoussan
- Aix Marseille Université, CNRS, INT UMR 7289, Marseille, France; Department of Physical and Rehabilitation Medicine, Marseille University Hospital, France; UGECAM Institut Universitaire de Réadaptation de Valmante Sud
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Yang J, Gong Y, Yu L, Peng L, Cui Y, Huang H. Effect of exoskeleton robot-assisted training on gait function in chronic stroke survivors: a systematic review of randomised controlled trials. BMJ Open 2023; 13:e074481. [PMID: 37709309 PMCID: PMC10503387 DOI: 10.1136/bmjopen-2023-074481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/30/2023] [Indexed: 09/16/2023] Open
Abstract
OBJECTIVES Numbers of research have reported the usage of robot-assisted gait training for walking restoration post-stroke. However, no consistent conclusion has been reached yet about the efficacy of exoskeleton robot-assisted training (ERAT) on gait function of stroke survivors, especially during the chronic period. We conducted a systematic review to investigate the efficacy of ERAT on gait function for chronic stroke survivors. DESIGN This review followed the Participant, Intervention, Comparison and Outcome principle. DATA SOURCES PubMed, Cochrane Library, Web of Science, Embase and Cumulative Index to Nursing and Allied Health Literature databases were systematically searched until December 2022. ELIGIBILITY CRITERIA Only randomised controlled trials (RCTs) were included and these RCTs took patients who had a chronic stroke as participants, exoskeleton robot-assisted gait training as intervention, regular rehabilitation therapy as comparison and gait-related functional assessments as outcomes. DATA EXTRACTION AND SYNTHESIS Data extraction and synthesis used the reporting checklist for systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The risk of bias and methodological quality of included studies were evaluated by two independent investigators under the guidance of Cochrane risk of bias. RESULTS Out of 278 studies, a total of 10 studies (n=323, mean age 57.6 years, 63.2% males) were identified in this systematic review. According to the Cochrane risk of bias, the quality of these studies was assessed as low risk. Six studies reported favourable effects of ERAT on gait function involving gait performance, balance function and physical endurance, and the ERAT group was significantly superior when compared with the control group. In contrast, the other four trials showed equal or negative effects of ERAT considering different study designs. All the included studies did not claim any serious adverse events. CONCLUSION ERAT could be an efficient intervention to improve gait function for individuals who had a chronic stroke. However, more rigorously designed trials are required to draw more solid evidence. PROSPERO REGISTRATION NUMBER CRD42023410796.
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Affiliation(s)
- Jinchao Yang
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yu Gong
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Lei Yu
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Laiying Peng
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Yuanfen Cui
- Department of Pain Management, Wuhan No 1 Hospital, Wuhan, China
| | - Hailong Huang
- Department of Rehabilitation Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
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Hwang S, Song CS. Assistive Technology Involving Postural Control and Gait Performance for Adults with Stroke: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2023; 11:2225. [PMID: 37570466 PMCID: PMC10418390 DOI: 10.3390/healthcare11152225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 07/20/2023] [Accepted: 08/04/2023] [Indexed: 08/13/2023] Open
Abstract
This study aimed to comprehensively summarize assistive technology devices for postural control and gait performance in stroke patients. In the study, we searched for randomized controlled trials (RCTs) published until 31 December 2022 in four electrical databases. The most frequently applied assistive technology devices involving postural stability and gait function for stroke patients were robot-assistive technology devices. Out of 1065 initially retrieved citations that met the inclusion criteria, 30 RCTs (12 studies for subacute patients and 18 studies for chronic patients) were included in this review based on eligibility criteria. The meta-analysis included ten RCTs (five studies for subacute patients and five for chronic patients) based on the inclusion criteria of the data analysis. After analyzing, the variables, only two parameters, the Berg balance scale (BBS) and the functional ambulation category (FAC), which had relevant data from at least three studies measuring postural control and gait function, were selected for the meta-analysis. The meta-analysis revealed significant differences in the experimental group compared to the control group for BBS in both subacute and chronic stroke patients and for the FAC in chronic stroke patients. Robot-assistive training was found to be superior to regular therapy in improving postural stability for subacute and chronic stroke patients but not gait function. This review suggests that robot-assistive technology devices should be considered in rehabilitative approaches for postural stability and gait function for subacute and chronic stroke patients.
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Affiliation(s)
- Sujin Hwang
- Department of Physical Therapy, Division of Health Science, Baekseok University, Cheonan 31065, Republic of Korea;
- The Graduate School of Health Welfare, Baekseok University, Seoul 06695, Republic of Korea
| | - Chiang-Soon Song
- Department of Occupational Therapy, College of Natural Science and Public Health and Safety, Chosun University, Gwangju 61452, Republic of Korea
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Synergic Effect of Robot-Assisted Rehabilitation and Antispasticity Therapy: A Narrative Review. Life (Basel) 2023; 13:life13020252. [PMID: 36836610 PMCID: PMC9958750 DOI: 10.3390/life13020252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Stroke and spinal cord injury are neurological disorders that cause disability and exert tremendous social and economic effects. Robot-assisted training (RAT), which may reduce spasticity, is widely applied in neurorehabilitation. The combined effects of RAT and antispasticity therapies, such as botulinum toxin A injection therapy, on functional recovery remain unclear. This review evaluated the effects of combined therapy on functional recovery and spasticity reduction. MATERIALS AND METHODS Studies evaluating the efficacy of RAT and antispasticity therapy in promoting functional recovery and reducing spasticity were systemically reviewed. Five randomized controlled trials (RCTs) were included. The modified Jadad scale was applied for quality assessment. Functional assessments, such as the Berg Balance Scale, were used to measure the primary outcome. Spasticity assessments, such as the modified Ashworth Scale, were used to measure the secondary outcome. RESULTS Combined therapy improves functional recovery in the lower limbs but does not reduce spasticity in the upper or lower limbs. CONCLUSIONS The evidence supports that combined therapy improves lower limb function but does not reduce spasticity. The considerable risk of bias among the included studies and the enrolled patients who did not receive interventions within the golden period of intervention are two major factors that should be considered when interpreting these results. Additional high-quality RCTs are required.
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Yamamoto R, Sasaki S, Kuwahara W, Kawakami M, Kaneko F. Effect of exoskeleton-assisted Body Weight-Supported Treadmill Training on gait function for patients with chronic stroke: a scoping review. J Neuroeng Rehabil 2022; 19:143. [PMID: 36544163 PMCID: PMC9768983 DOI: 10.1186/s12984-022-01111-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 11/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Therapeutic exercise for gait function using an exoskeleton-assisted Body Weight Supported Treadmill Training (BWSTT) has been identified as a potential intervention that allows for task-based repetitive training with appropriate kinematics while adjusting the amount of body weight support (BWS). Nonetheless, its effect on gait in patients with stroke in the chronic phase are yet to be clarified. The primary aim of this scoping review was to present the status of effectiveness of exoskeleton-assisted BWSTT in patients with chronic stroke. The secondary aims were to summarise intervention protocols, types and functions of BWSTT exoskeletal robotic devices currently used clinically. METHOD AND RESULTS Articles were accessed and collected from PubMed, Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases, which were completed in October 2020. Articles were included if the subjects were adults with stroke in the chronic phase (onset ≥ 6 months) and if they utilised a robotic exoskeleton with treadmill and body weight support and investigated the efficacy of gait exercise. A total of 721 studies were identified, of which 11 randomised controlled trials were selected. All included studies were published from 2008 to 2020. Overall, 309 subjects were enrolled; of these, 241 (156 males, 85 females) participated. Walking outcome measures were used more often to evaluate the functional aspects of gait than to evaluate gait independence. In 10 of 11 studies, showed the effectiveness of exoskeleton robot-assisted BWSTT in terms of outcomes contributing to improved gait function. Two studies reported that exoskeleton-assisted BWSTT with combination therapy was significantly more effective in improving than exoskeleton-assisted BWSTT alone. However, no significant difference was identified between the groups; compared with therapist-assisted BWSTT groups, exoskeleton-assisted BWSTT groups did not exhibit significant change. CONCLUSION This review suggests that exoskeleton-assisted BWSTT for patients with chronic stroke may be effective in improving walking function. However, the potential may be "to assist" and not because of using the robot. Further studies are required to verify its efficacy and strengthen evidence on intervention protocols.
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Affiliation(s)
- Rieko Yamamoto
- grid.26091.3c0000 0004 1936 9959Department of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi, Shjinjuku, Tokyo, Japan ,grid.268446.a0000 0001 2185 8709Department of Artificial Environment, Safety, Environment and System Engineering, Yokohama National University Graduate School of Environment and Information Sciences, 79-7, Tokiwadai, Hodogaya, Yokohama, Japan ,grid.39158.360000 0001 2173 7691Center for Environmental and Health Sciences, Hokkaido University, Kita 12, Nishi 7, Kita-ku, Sapporo, Japan
| | - Shun Sasaki
- grid.26091.3c0000 0004 1936 9959Department of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi, Shjinjuku, Tokyo, Japan ,Division of Health Promotion, ARCE Inc., Sagamihara, Japan
| | - Wataru Kuwahara
- grid.26091.3c0000 0004 1936 9959Department of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi, Shjinjuku, Tokyo, Japan ,grid.265074.20000 0001 1090 2030Department of Physical Therapy, Graduate School of Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashi-Oku, Arakawa-ku, Tokyo, Japan
| | - Michiyuki Kawakami
- grid.26091.3c0000 0004 1936 9959Department of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi, Shjinjuku, Tokyo, Japan
| | - Fuminari Kaneko
- grid.26091.3c0000 0004 1936 9959Department of Rehabilitation Medicine, Keio University School of Medicine, 35 Shinanomachi, Shjinjuku, Tokyo, Japan ,grid.265074.20000 0001 1090 2030Department of Physical Therapy, Graduate School of Health Sciences, Tokyo Metropolitan University, 7-2-10 Higashi-Oku, Arakawa-ku, Tokyo, Japan
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Sutherland E, Hill B, Singer BJ, Ashford S, Hoare B, Hastings-Ison T, Fheodoroff K, Berwick S, Dobson F, Williams G. Do randomised controlled trials evaluating functional outcomes following botulinum neurotoxin-A align with focal spasticity guidelines? A systematic review. Disabil Rehabil 2022; 44:8515-8523. [PMID: 34982603 DOI: 10.1080/09638288.2021.2011437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE The impact of botulinum neurotoxin-A (BoNT-A) on functional outcomes when managing focal muscle spasticity remains unclear. It is possible that randomised controlled trial (RCT) design and/or reporting may be a contributing factor. The objective of this review was to determine the extent to which RCTs evaluating functional outcomes following BoNT-A align with focal spasticity guidelines. MATERIALS AND METHODS RCTs published from 2010 were included if they targeted focal spasticity, included BoNT-A, randomised a physical intervention to the upper/lower limb, or the primary outcome(s) related to the activity/participation domains of the International Classification of Functioning, Disability, and Health. Data extraction and quality appraisal using the Modified PEDro and Modified McMasters Tool were performed independently by two reviewers. General research practices were also extracted such as compliance with therapy reporting guidelines. RESULTS Fifty-two RCTs were eligible. Individualised goal setting was uncommon (25%). Six studies (11.5%) included multi-disciplinary management, and five (9.6%) included patient/caregiver education. Four studies (7.7%) measured outcomes beyond 6 months. The Median Modified PEDro score was 11/15. CONCLUSIONS Alignment with focal spasticity guidelines in RCTs was generally low. Our understanding of the impact of focal spasticity management on functional outcomes may be improved if RCT design aligned more closely with guideline recommendations.IMPLICATIONS FOR REHABILITATIONThe influence of BoNT-A on improved functional outcomes is yet to be determined.Individualised goal setting with a multi-disciplinary team is uncommon in an RCT design, despite it being a key guideline recommendation.Given the long-term nature of spasticity management, guidelines recommend short as well as long-term reviews following intervention however RCTs rarely assess beyond 6 months.
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Affiliation(s)
- Edwina Sutherland
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Bridget Hill
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Barby J Singer
- Centre for Training in Subacute Care, WA Health, Fremantle Hospital, Fremantle, Australia.,School of Medical and Health Science, Edith Cowan University, Joondalup, Australia
| | - Stephen Ashford
- Regional Hyper-acute Rehabilitation Unit, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK.,Centre for Nurse, Midwife and Allied Health Led Research, University College London Hospitals, London, UK.,Faculty of Nursing, Midwifery and Palliative Care, Department of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Brian Hoare
- School of Occupational Therapy, La Trobe University, Bundoora, Australia.,Department of Paediatrics, Monash University, Clayton, Australia
| | - Tandy Hastings-Ison
- Hugh Williamson Gait Analysis Laboratory, Royal Children's Hospital, Parkville, Australia
| | | | - Steffen Berwick
- Speciality Clinic for Paediatric Neurology, Neurorehabilitation and Epilepsy, Schön Clinic Vogtareuth, Vogtareuth, Germany.,von Hauners' Children's Hospital, Munich University, Munich, Germany
| | - Fiona Dobson
- Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Gavin Williams
- Physiotherapy Department, Epworth Healthcare, Melbourne, Australia.,Faculty of Medicine, School of Physiotherapy, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
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Warutkar V, Dadgal R, Mangulkar UR. Use of Robotics in Gait Rehabilitation Following Stroke: A Review. Cureus 2022; 14:e31075. [DOI: 10.7759/cureus.31075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022] Open
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Ozsoy-Unubol T, Ata E, Cavlak M, Demir S, Candan Z, Yilmaz F. Effects of Robot-Assisted Gait Training in Patients With Multiple Sclerosis: A Single-Blinded Randomized Controlled Study. Am J Phys Med Rehabil 2022; 101:768-774. [PMID: 34686632 DOI: 10.1097/phm.0000000000001913] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aims to evaluate and compare the effects of conventional and robot-assisted gait training (RAGT) programs on fatigue, mood, and quality of life in patients with multiple sclerosis who have fatigue. METHODS In this single-blinded, randomized controlled study, 37 patients with multiple sclerosis were randomized into two groups: RAGT ( n = 18) and conventional gait training ( n = 19). The RAGT group had gait training with RoboGait, whereas the conventional gait training group received conventional physiotherapist-assisted gait training. Outcome measures were the Fatigue Severity Scale, Hospital Anxiety Depression Scale, Multiple Sclerosis Quality of Life-54, Extended Disability Status Scale, Functional Ambulation Category, Berg Balance Test, and 6-min walk test. RESULTS Baseline demographic, clinic, and functional data were similar. Both groups showed improvements in the Fatigue Severity Scale, Hospital Anxiety Depression Scale-Depression, Multiple Sclerosis Quality of Life, Berg Balance Test, and 6-min walk test scores after treatment. Only the RAGT group showed an improvement in Hospital Anxiety Depression Scale-Anxiety score. The RAGT group had better Fatigue Severity Scale, and Hospital Anxiety Depression Scale scores. CONCLUSION In combination with the standard rehabilitation program, both RAGT and conventional gait training are effective for multiple sclerosis. However, RAGT has superior effects in terms of fatigue, depression, and anxiety. Therefore, it may be preferred in multiple sclerosis patients who exhibit prominent symptoms of fatigue, depression, or anxiety.
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Affiliation(s)
- Tugba Ozsoy-Unubol
- From the University of Health Sciences, Sultan II. Abdulhamid Han Training and Research Hospital, Physical Medicine and Rehabilitation (TO-U, EA, MC, ZC); Medipol University, Institute of Health Sciences (MC); Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital, Neurology (SD); and University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital, Physical Medicine and Rehabilitation, İstanbul, Turkey (FY)
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11
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Abidin N, Ünlü Akyüz E, Cankurtaran D, Karaahmet ÖZ, Tezel N. The effect of robotic rehabilitation on posture and trunk control in non-ambulatory cerebral palsy. Assist Technol 2022:1-7. [PMID: 35385378 DOI: 10.1080/10400435.2022.2059592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 10/18/2022] Open
Abstract
The purpose of this study was to investigate the effects of a combined robot-assisted gait training (RAGT) with standard physiotherapy (PT) on trunk control and posture in non-ambulatory children with cerebral palsy (CP). This nonrandomized, controlled study included 31 CP assigned into two groups. Study Group: RAGT (three times a week, 30 min/session, for 6 weeks) + PT. Control group: PT only. The patients were evaluated using gross motor function measure (GMFM)-88 (Section B, Sitting) and Trunk Impairment Scale (TIS), pre-treatment and 3rd month post-treatment. In the RAGT group, significant improvements were observed in the GMFM-B and TIS scores at the 3rd month post-treatment (p < 0.05). Comparison of the changes in GMFM-B and TIS scores from end to beginning of the study, the change in TIS static are significantly higher in the RAGT group than control group (p < 0.05). Addition of RAGT to standard physiotherapy seems to improve trunk control, sitting balance, and posture in non-ambulatory CP.
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Affiliation(s)
- Nihan Abidin
- Clinic of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ece Ünlü Akyüz
- Clinic of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Damla Cankurtaran
- Clinic of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Özgür Zeliha Karaahmet
- Clinic of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Nihal Tezel
- Clinic of Physical Medicine and Rehabilitation, University of Health Sciences Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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Wissel J, Ri S. Assessment, goal setting, and botulinum neurotoxin a therapy in the management of post-stroke spastic movement disorder: updated perspectives on best practice. Expert Rev Neurother 2021; 22:27-42. [PMID: 34933648 DOI: 10.1080/14737175.2021.2021072] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Post-stroke spastic movement disorder (PS-SMD) appears up to 20% in the first week following stroke and 40% in the chronic phase. It may create major hurdles to overcome in early stroke rehabilitation and as one relevant factor that reduces quality of life to a major degree in the chronic phase. AREAS COVERED In this review, we discuss predictors,early identification, clinical assessments, goal setting, and management in multiprofessional team, including Botulinum neurotoxin A (BoNT-A) injection for early and chronic management of PS-SMD. EXPERT OPINION The earlier PS-SMD is recognized and managed, the better the outcome will be. The comprehensive management in the subacute or chronic phase of PS-SMD with BoNT-A injections requires detailed assessment, patient-centered goal setting, technical-guided injection, effective dosing of BoNT-A per site, muscle, and session and timed adjunctive treatment, delivered in a multi-professional team approach in conjunction with physical treatment. Evidence-based data showed BoNT-A injections are safe and effective in managing focal, multifocal, segmental PS-SMD and its complications. If indicated, BoNT-A therapy should be accompanied with adjunctive treatment in adequate time slots. BoNT-A could be added to oral, intrathecal, and surgical treatment in severe multisegmental or generalized PS-SMD to reach patient/caregiver's goals, especially in chronic PS-SMD.
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Affiliation(s)
- Jörg Wissel
- Department of Neurorehabilitation and Physical Therapy, Vivantes Klinikum Spandau, Neue Bergstrasse 6, 13585 Berlin, Germany.,Neurology and Psychosomatics at Wittenbergplatz, Out-Patient-Clinic, Ansbacher straße 17-19, 10787 Berlin, Germany
| | - Songjin Ri
- Neurology and Psychosomatics at Wittenbergplatz, Out-Patient-Clinic, Ansbacher straße 17-19, 10787 Berlin, Germany.,Department of Neurology, Charité University Hospital (CBS), Hindenburgdamm 30, Berlin 12203, Germany
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13
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Gonzalez A, Garcia L, Kilby J, McNair P. Robotic devices for paediatric rehabilitation: a review of design features. Biomed Eng Online 2021; 20:89. [PMID: 34488777 PMCID: PMC8420060 DOI: 10.1186/s12938-021-00920-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/06/2021] [Indexed: 01/11/2023] Open
Abstract
Children with physical disabilities often have limited performance in daily activities, hindering their physical development, social development and mental health. Therefore, rehabilitation is essential to mitigate the adverse effects of the different causes of physical disabilities and improve independence and quality of life. In the last decade, robotic rehabilitation has shown the potential to augment traditional physical rehabilitation. However, to date, most robotic rehabilitation devices are designed for adult patients who differ in their needs compared to paediatric patients, limiting the devices' potential because the paediatric patients' needs are not adequately considered. With this in mind, the current work reviews the existing literature on robotic rehabilitation for children with physical disabilities, intending to summarise how the rehabilitation robots could fulfil children's needs and inspire researchers to develop new devices. A literature search was conducted utilising the Web of Science, PubMed and Scopus databases. Based on the inclusion-exclusion criteria, 206 publications were included, and 58 robotic devices used by children with a physical disability were identified. Different design factors and the treated conditions using robotic technology were compared. Through the analyses, it was identified that weight, safety, operability and motivation were crucial factors to the successful design of devices for children. The majority of the current devices were used for lower limb rehabilitation. Neurological disorders, in particular cerebral palsy, were the most common conditions for which devices were designed. By far, the most common actuator was the electric motor. Usually, the devices present more than one training strategy being the assistive strategy the most used. The admittance/impedance method is the most popular to interface the robot with the children. Currently, there is a trend on developing exoskeletons, as they can assist children with daily life activities outside of the rehabilitation setting, propitiating a wider adoption of the technology. With this shift in focus, it appears likely that new technologies to actuate the system (e.g. serial elastic actuators) and to detect the intention (e.g. physiological signals) of children as they go about their daily activities will be required.
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Affiliation(s)
- Alberto Gonzalez
- BioDesign Lab, School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Lorenzo Garcia
- BioDesign Lab, School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand.
| | - Jeff Kilby
- BioDesign Lab, School of Engineering, Computer and Mathematical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Peter McNair
- Health and Rehabilitation Research Institute, Auckland University of Technology, Auckland, New Zealand
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Cumplido C, Delgado E, Ramos J, Puyuelo G, Garcés E, Destarac MA, Plaza A, Hernández M, Gutiérrez A, García E. Gait-assisted exoskeletons for children with cerebral palsy or spinal muscular atrophy: A systematic review. NeuroRehabilitation 2021; 49:333-348. [PMID: 34219676 DOI: 10.3233/nre-210135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cerebral Palsy (CP) and Spinal Muscular Atrophy (SMA) are common causes of motor disability in childhood. Gait exoskeletons are currently being used as part of rehabilitation for children with walking difficulties. OBJECTIVE To assess the safety and efficacy and describe the main characteristics of the clinical articles using robot-assisted gait training (RAGT) with exoskeleton for children with CP or SMA. METHODS A computer search was conducted in five bibliographic databases regarding clinical studies published in the last ten years. In order to be included in this review for further analysis, the studies had to meet the following criteria: (1) assess efficacy or safety of interventions; (2) population had to be children with CP or SMA aged between 3 and 14; (3) exoskeleton must be bilateral and assist lower limbs during walking. RESULTS Twenty-one articles were selected, of which only five were clinical trials. 108 participants met the inclusion criteria for this study, all with a diagnosis of CP. The evidence level of the selected papers was commonly low. CONCLUSIONS RAGT therapy seems to be safe for children with CP. However, further investigation is needed to confirm the results related to efficacy. There is no evidence of RAGT therapy for SMA children.
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Affiliation(s)
- Carlos Cumplido
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain
| | - Elena Delgado
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain
| | - Jaime Ramos
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain
| | - Gonzalo Puyuelo
- Marsi Bionics S.L., Madrid, Spain.,Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Madrid, Spain
| | - Elena Garcés
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain.,Marsi Bionics S.L., Madrid, Spain.,Programa de Doctorado en Ciencias de la Salud. Universidad de Alcalá, Madrid, Spain
| | | | - Alberto Plaza
- Marsi Bionics S.L., Madrid, Spain.,Universidad Politécnica de Madrid, Madrid, Spain
| | - Mar Hernández
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain
| | - Alba Gutiérrez
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain
| | - Elena García
- Centro de Automática y Robótica, Consejo Superior de Investigaciones Científicas (CSIC-UPM), Madrid, Spain
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15
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Kuroda MM, Mutsuzaki H, Yoshikawa K, Ohguro H, Nobuaki I. Gait training using a hybrid assistive limb after botulinum toxin treatment for cerebral palsy: a case report. J Phys Ther Sci 2021; 33:499-504. [PMID: 34177115 PMCID: PMC8219601 DOI: 10.1589/jpts.33.499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/26/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Hybrid Assistive Limb® (HAL; Cyberdyne, Tsukuba, Japan) is a wearable robot that assists patients based on their voluntary movements. We report gait training with HAL after botulinum toxin treatment for spasticity of the lower limb in cerebral palsy (CP). [Participant and Methods] The participant was a 36 year-old male with spastic diplegia due to periventricular leukomalacia, with Gross Motor Function Classification System (GMFCS) level II. HAL training was performed in 20-minute sessions (3 sessions/week for 4 weeks). The outcome measures were range of motion, spasticity, walking ability, muscle strength, gross motor function measure (GMFM), Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, immediately after, and one, two, and three months after HAL training. [Results] No adverse events were observed during training. After the HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), knee extension strength, GMFM, and COPM increased, and Physiological Cost Index declined. Three months post-intervention, gait speed, step length, cadence, 6MD, and GMFM remained higher than those observed within the first two months. [Conclusion] Gait training with HAL can be a safe and feasible method for patients with CP who undergo botulinum toxin treatment to improve walking ability and motor function.
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Affiliation(s)
- Mayumi Matsuda Kuroda
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences: 4669-2 Ami, Ami-machi, Ibaraki 300-0394, Japan
| | - Hirotaka Mutsuzaki
- Center for Medical Science, Ibaraki Prefectural University of Health Sciences, Japan
| | - Kenichi Yoshikawa
- Department of Physical Therapy, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| | - Haruka Ohguro
- Department of Pediatrics, Ibaraki Prefectural University of Health Sciences Hospital, Japan
| | - Iwasaki Nobuaki
- Department of Pediatrics, Ibaraki Prefectural University of Health Sciences Hospital, Japan
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16
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Allart E, Mazevet D, Idée S, Constant Boyer F, Bonan I. Adjunct therapies after botulinum toxin injections in spastic adults: systematic review and SOFMER recommendations. Ann Phys Rehabil Med 2021; 65:101544. [PMID: 34091058 DOI: 10.1016/j.rehab.2021.101544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/19/2021] [Accepted: 04/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Adjunct therapies (ATs) may further improve outcomes after botulinum toxin injections in spastic patients, but evidence was unclear in previous systematic reviews. OBJECTIVE To assess the efficacy of non-pharmacological ATs in spastic adults according to the International Classification of Functioning, Disability and Health and build an expert consensus based on a Delphi process. METHODS Four electronic databases were searched up to May 2020 for reports of comparative trials of non-pharmacologic ATs after botulinum toxin injections in spastic adults. Then 25 French experts participated in a two-round Delphi process to build recommendations on the use of ATs. RESULTS We included 32 studies (1202 participants, median 32/study) evaluating the effects of physical agents (n=9), joint posture procedures (JPPs, n=11), and active ATs (n=14), mainly after stroke. The average quality of articles was good for randomised controlled trials (median [interquartile range] PEDro score = 7 [6-8]) but moderate (n=2) or poor (n=2) for non-randomised controlled trials (Downs & Black checklist). Meta-analysis was precluded owing to the heterogeneity of ATs, control groups and outcome measures. There is evidence for the use of JPPs except low-dose manual stretching and soft posture techniques. Continuous postures (by taping or casting) are recommended; discontinuous postures (by orthosis) may be preferred in patients with active function. Device-free or device-assisted active ATs may be beneficial in the mid-term (> 3 months after botulinum toxin injections), particularly when performed at a high intensity (>3 hr/week) as in constraint-induced movement therapy. Self-rehabilitation remains understudied after a focal treatment, but its interest is highlighted by the experts. The use of physical agents is not recommended. CONCLUSIONS JPPs and active ATs (device-assisted or device-free) may further improve impairments and activities after botulinum toxin injections. Further studies are needed to better define the best strategies for ATs as a function of the individual treatment goals, participation and quality of life. Review Registration. PROSPERO (CRD42018105856).
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Affiliation(s)
- Etienne Allart
- CHU Lille, Neurorehabilitation Unit, 59000 Lille, France; Université Lille, INSERM UMR-S-1172, Lille Neuroscience and Cognition, 59000 Lille, France.
| | | | - Stéphane Idée
- CHU Strasbourg, PRM Department, 67000 Strasbourg, France
| | | | - Isabelle Bonan
- CHU Rennes, PRM Department, University of Rennes 1 & 2, 35000 Rennes, France; Unité Empenn (ex-Visages) U1228 INSERM-INRIA, IRISA UMR CNRS 6074, Campus de Beaulieu, 35042 Rennes cedex, France
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17
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Li DX, Zha FB, Long JJ, Liu F, Cao J, Wang YL. Effect of Robot Assisted Gait Training on Motor and Walking Function in Patients with Subacute Stroke: A Random Controlled Study. J Stroke Cerebrovasc Dis 2021; 30:105807. [PMID: 33895428 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105807] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Robot-assisted gait training has been confirmed to have beneficial effect on the rehabilitation of stroke patients. An exoskeleton robot, named BEAR-H1, is designed to help stroke patients with walking disabilities. METHODS 17 subjects in experimental group and 15 subjects in control group completed the study. The experimental group received 30 minutes of BEAR-H1 assisted gait training(BAGT), and the control group received 30 minutes of conventional training, 5 times/week for 4weeks. All subjects were evaluated with 6-minute walk test (6MWT), Fugl-Meyer Assessment for lower extremity (FMA-LE), Functional Ambulatory Classification (FAC), Modified Ashworth Scale (MAS), and gait analysis at baseline and after 4 weeks intervention. RESULTS The improvements of 6MWT, FMA-LE, gait speed, cadence, step length and cycle duration in BAGT group were more noticeable than in the control group. However, there was no difference in the assessment of MAS between two groups. CONCLUSIONS Our results showed that BAGT is an effective intervention to improve the motor and walking ability during 4 weeks training for subacute stroke patients.
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Affiliation(s)
- Dong-Xia Li
- Department of Rehabilitation, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, China.
| | - Fu-Bing Zha
- Department of Rehabilitation, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, China.
| | - Jian-Jun Long
- Department of Rehabilitation, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, China.
| | - Fang Liu
- Department of Rehabilitation, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, China.
| | - Jia Cao
- Department of Rehabilitation, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, China.
| | - Yu-Long Wang
- Department of Rehabilitation, Shenzhen Second People's Hospital, The First Affiliated Hospital of Shenzhen University, China.
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Mehrholz J, Thomas S, Kugler J, Pohl M, Elsner B. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev 2020; 10:CD006185. [PMID: 33091160 PMCID: PMC8189995 DOI: 10.1002/14651858.cd006185.pub5] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Electromechanical- and robot-assisted gait-training devices are used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane Review first published in 2007 and previously updated in 2017. OBJECTIVES Primary • To determine whether electromechanical- and robot-assisted gait training versus normal care improves walking after stroke Secondary • To determine whether electromechanical- and robot-assisted gait training versus normal care after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (last searched 6 January 2020); the Cochrane Central Register of Controlled Trials (CENTRAL; 2020 Issue 1), in the Cochrane Library; MEDLINE in Ovid (1950 to 6 January 2020); Embase (1980 to 6 January 2020); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 20 November 2019); the Allied and Complementary Medicine Database (AMED; 1985 to 6 January 2020); Web of Science (1899 to 7 January 2020); SPORTDiscus (1949 to 6 January 2020); the Physiotherapy Evidence Database (PEDro; searched 7 January 2020); and the engineering databases COMPENDEX (1972 to 16 January 2020) and Inspec (1969 to 6 January 2020). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors in an effort to identify further published, unpublished, and ongoing trials. SELECTION CRITERIA We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robot-assisted gait training versus normal care. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We assessed the quality of evidence using the GRADE approach. The primary outcome was the proportion of participants walking independently at follow-up. MAIN RESULTS We included in this review update 62 trials involving 2440 participants. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (random effects) 2.01, 95% confidence interval (CI) 1.51 to 2.69; 38 studies, 1567 participants; P < 0.00001; I² = 0%; high-quality evidence) and increased mean walking velocity (mean difference (MD) 0.06 m/s, 95% CI 0.02 to 0.10; 42 studies, 1600 participants; P = 0.004; I² = 60%; low-quality evidence) but did not improve mean walking capacity (MD 10.9 metres walked in 6 minutes, 95% CI -5.7 to 27.4; 24 studies, 983 participants; P = 0.2; I² = 42%; moderate-quality evidence). Electromechanical-assisted gait training did not increase the risk of loss to the study during intervention nor the risk of death from all causes. Results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study, (2) we found variation between trials with respect to devices used and duration and frequency of treatment, and (3) some trials included devices with functional electrical stimulation. Post hoc analysis showed that people who are non-ambulatory at the start of the intervention may benefit but ambulatory people may not benefit from this type of training. Post hoc analysis showed no differences between the types of devices used in studies regarding ability to walk but revealed differences between devices in terms of walking velocity and capacity. AUTHORS' CONCLUSIONS People who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices. We concluded that eight patients need to be treated to prevent one dependency in walking. Specifically, people in the first three months after stroke and those who are not able to walk seem to benefit most from this type of intervention. The role of the type of device is still not clear. Further research should consist of large definitive pragmatic phase 3 trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training, as well as how long any benefit may last. Future trials should consider time post stroke in their trial design.
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Affiliation(s)
- Jan Mehrholz
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
| | - Simone Thomas
- Wissenschaftliches Institut, Klinik Bavaria Kreischa, Kreischa, Germany
| | - Joachim Kugler
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
| | - Marcus Pohl
- Neurological Rehabilitation, Helios Klinik Schloss Pulsnitz, Pulsnitz, Germany
| | - Bernhard Elsner
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany
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Hara T, Momosaki R, Niimi M, Yamada N, Hara H, Abo M. Botulinum Toxin Therapy Combined with Rehabilitation for Stroke: A Systematic Review of Effect on Motor Function. Toxins (Basel) 2019; 11:toxins11120707. [PMID: 31817426 PMCID: PMC6950173 DOI: 10.3390/toxins11120707] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/16/2022] Open
Abstract
Aim: The purpose of this study was to examine the effectiveness of botulinum toxin A (BoNT-A) therapy combined with rehabilitation on motor function in post-stroke patients. Methods: The following sources up to December 31, 2018, were searched from inception for articles in English: Pubmed, Scopus, CINAHL, Embase, PsycINFO, and CENTRAL. Trials using injections of BoNT-A for upper and lower limb rehabilitation were examined. We excluded studies that were not performed for rehabilitation or were not evaluated for motor function. Results: Twenty-six studies were included. In addition to rehabilitation, nine studies used adjuvant treatment to improve spasticity or improve motor function. In the upper limbs, two of 14 articles indicated that significant improvement in upper limb motor function was observed compared to the control group. In the lower limbs, seven of 14 articles indicated that significant improvement in lower limb motor function was observed compared to the control group. Conclusions: The effect of combined with rehabilitation is limited after stroke, and there is not sufficient evidence, but results suggest that BoNT-A may help to improve motor function. In future studies, the establishment of optimal rehabilitation and evaluation times of BoNT-A treatment will be necessary for improving motor function and spasticity.
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Affiliation(s)
- Takatoshi Hara
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
- Correspondence: ; Tel.: +81-3-3433-1111; Fax: +81-3-3431-1206
| | - Ryo Momosaki
- Department of Rehabilitation Medicine, Teikyo University School of Medicine University Hospital, Mizonokuchi, Kanagawa 213-8507, Japan
| | - Masachika Niimi
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
| | - Naoki Yamada
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
| | - Hiroyoshi Hara
- Rehabilitation Center, Ainomiyako Neurosurgery Hospital, Osaka 538-0044, Japan
| | - Masahiro Abo
- Department of Rehabilitation Medicine The Jikei University School of Medicine 3-25-8, Nishi-Shinbashi, Minato-Ku, Tokyo 105-8461, Japan
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Martino Cinnera A, Pucello A, Lupo A, Gimigliano F, Mammucari E, Cicero DL, Iosa M, Paolucci S, Morone G. Upper limb motor improvement in chronic stroke after combining botulinum toxin A injection and multi-joints robot-assisted therapy: a case report. Oxf Med Case Reports 2019; 2019:omz097. [PMID: 31772737 PMCID: PMC6822606 DOI: 10.1093/omcr/omz097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/12/2019] [Accepted: 08/13/2019] [Indexed: 11/27/2022] Open
Abstract
Spasticity is one of the major complications after stroke. Botulinum toxin type A (BoNT-A) injection is commonly used to manage focal spasticity. However, it is uncertain whether BoNT-A can improve activities of daily living function of paretic arm. The recovery of functions of the affected arm is also the aim of robotic upper limb (UL) therapy. The motorized exoskeleton assists the patient in a large 3D work environment by promoting movement for the UL (shoulder, elbow, wrist, hand). The combination of the BoNT-A injection and the robotic therapy might enhance functional recovery after stroke. We reported the case of a chronic stroke patient in which the injection of BoNT-A was combined with multi-joint exoskeleton training. The patient showed improvement in the motor control of the UL, supporting the feasibility of this approach.
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Affiliation(s)
- Alex Martino Cinnera
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Alessandra Pucello
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Alessandro Lupo
- Local Health Department Gaetano Pini, Rehabilitation Unit Fanny Finzi Ottolenghi, Milan, Italy
| | - Francesca Gimigliano
- Department of Mental and Physical health and Preventive Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Elisa Mammucari
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Dario Lo Cicero
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Marco Iosa
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Stefano Paolucci
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
| | - Giovanni Morone
- Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy
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