Breaking the ice to improve motor outcomes in patients with chronic stroke: a retrospective clinical study on neuromodulation plus robotics

Improving Upper Limb and Gait Rehabilitation Outcomes in Post-Stroke Patients: A Scoping Review on the Additional Effects of Non-Invasive Brain Stimulation When Combined with Robot-Aided Rehabilitation

Robot-aided rehabilitation (RAR) and non-invasive brain stimulation (NIBS) are the two main interventions for post-stroke rehabilitation. The efficacy of both approaches in combination has not been well established yet. The importance of coupling these interventions, which both enhance brain plasticity to promote recovery, lies in augmenting the rehabilitation potential to constrain the limitation in daily living activities and the quality of life following stroke. This review aimed to evaluate the evidence of NIBS coupled with RAR in improving rehabilitation outcomes of upper limb and gait motor impairment in adult individuals with stroke. We included 18 clinical trials in this review. All studies were highly heterogeneous concerning the technical characteristics of robotic devices and NIBS protocols. However, the studies reported a global improvement in body structure and function and activity limitation for the upper limb, which were non-significant between the active and control groups. Concerning gait training protocols, the active group outperformed the control group in improving walking capacity and recovery. According to this review, NIBS and RAR in combination are promising but not yet largely recommendable as a systematic approach for stroke rehabilitation as there is not enough data about this. Therefore, more homogenous clinical trials are required, pointing out the best characteristics of the combined therapeutic protocols.

Measurement, Evaluation, and Control of Active Intelligent Gait Training Systems—Analysis of the Current State of the Art

Gait recognition and rehabilitation has been a research hotspot in recent years due to its importance to medical care and elderly care. Active intelligent rehabilitation and assistance systems for lower limbs integrates mechanical design, sensing technology, intelligent control, and robotics technology, and is one of the effective ways to resolve the above problems. In this review, crucial technologies and typical prototypes of active intelligent rehabilitation and assistance systems for gait training are introduced. The limitations, challenges, and future directions in terms of gait measurement and intention recognition, gait rehabilitation evaluation, and gait training control strategies are discussed. To address the core problems of the sensing, evaluation and control technology of the active intelligent gait training systems, the possible future research directions are proposed. Firstly, different sensing methods need to be proposed for the decoding of human movement intention. Secondly, the human walking ability evaluation models will be developed by integrating the clinical knowledge and lower limb movement data. Lastly, the personalized gait training strategy for collaborative control of human–machine systems needs to be implemented in the clinical applications.

Combining Robot-Assisted Gait Training and Non-Invasive Brain Stimulation in Chronic Stroke Patients: A Systematic Review

Gait impairment is one of the most common disorders of patients with chronic stroke, which hugely affects the ability to carry out the activities of daily living and the quality of life. Recently, traditional rehabilitation techniques have been associated with non-invasive brain stimulation (NIBS) techniques, which enhance brain plasticity, with the aim of promoting recovery in patients with chronic stroke. NIBS effectiveness in improving gait parameters in patients with chronic stroke has been in several studies evaluated. Robotic devices are emerging as promising tools for the treatment of stroke-related disabilities by performing repetitive, intensive, and task-specific treatments and have been proved to be effective for the enhancement of motor recovery in patients with chronic stroke. To date, several studies have examined the combination of NIBS with robotic-assisted gait training, but the effectiveness of this approach is not yet well established. The main purpose of this systematic review is to clarify whether the combination of NIBS and robot-assisted gait training may improve walking function in patients with chronic stroke. Our systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Studies eligible for review were identified through PubMed/MEDLINE, Embase, Scopus, and PEDro from inception to March 15, 2021, and the outcomes considered were gait assessments. Seven studies were included in the qualitative analysis of this systematic review, with a total population of 186 patients with chronic stroke. All studies specified technical characteristics of robotic devices and NIBS used, with high heterogeneity of protocols. Methodological studies have shown a significantly greater improvement in walking capacity recorded with 6MWT. Finally, research studies have highlighted a positive effect on walking recovery by combination of robot-assisted gait training with non-invasive brain stimulation. Furthermore, future studies should identify the best characteristics of the combined therapeutic protocols.

Effects of Combining Online Anodal Transcranial Direct Current Stimulation and Gait Training in Stroke Patients: A Systematic Review and Meta-Analysis

Objective: Combining transcranial direct current stimulation (tDCS) and repetitive gait training may be effective for gait performance recovery after stroke; however, the timing of stimulation to obtain the best outcomes remains unclear. We performed a systematic review and meta-analysis to establish evidence for changes in gait performance between online stimulation (tDCS and repetitive gait training simultaneously) and offline stimulation (gait training after tDCS). Methods: We comprehensively searched the electronic databases Medline, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature, and included studies that combined cases of anodal tDCS with motor-related areas of the lower limbs and gait training. Nine studies fulfilled the inclusion criteria and were included in the systematic review, of which six were included in the meta-analysis. Result: The pooled effect estimate showed that anodal tDCS significantly improved the 10-m walking test (p = 0.04; I ² = 0%) and 6-min walking test (p = 0.001; I ² = 0%) in online stimulation compared to sham tDCS. Conclusion: Our findings suggested that simultaneous interventions may effectively improve walking ability. However, we cannot draw definitive conclusions because of the small sample size. More high-quality studies are needed on the effects of online stimulation, including various stimulation parameters.

Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study

Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure.

A narrative review on non-invasive stimulation of the cerebellum in neurological diseases

IMPORTANCE

The cerebellum plays an important role in motor, cognitive, and affective functions owing to its dense interconnections with basal ganglia and cerebral cortex. This review aimed at summarizing the non-invasive cerebellar stimulation (NICS) approaches used to modulate cerebellar output and treat cerebellar dysfunction in the motor domain.

OBSERVATION

The utility of NICS in the treatment of cerebellar and non-cerebellar neurological diseases (including Parkinson's disease, dementia, cerebellar ataxia, and stroke) is discussed. NICS induces meaningful clinical effects from repeated sessions alone in both cerebellar and non-cerebellar diseases. However, there are no conclusive data on this issue and several concerns need to be still addressed before NICS could be considered a valuable, standard therapeutic tool.

CONCLUSIONS AND RELEVANCE

Even though some challenges must be overcome to adopt NICS in a wider clinical setting, this tool might become a useful strategy to help patients with lesions in the cerebellum and cerebral areas that are connected with the cerebellum whether one could enhance cerebellar activity with the intention of facilitating the cerebellum and the entire, related network, rather than attempting to facilitate a partially damaged cortical region or inhibiting the homologs' contralateral area. The different outcome of each approach would depend on the residual functional reserve of the cerebellum, which is confirmed as a critical element to be probed preliminary in order to define the best patient-tailored NICS.