Does overground robotic gait training improve non-motor outcomes in patients with chronic stroke? Findings from a pilot study

The Effectiveness of Overground Robot Exoskeleton Gait Training on Gait Outcomes, Balance, and Motor Function in Patients with Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

This study aimed to investigate the effects of overground robot exoskeleton gait training on gait outcomes, balance, and motor function in patients with stroke.

METHODS

Following the PRISMA guidelines, literature searches were performed in the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, SCOPUS, Ovid-LWW, and RISS databases. A total of 504 articles were identified, of which 19 were included for analysis after application of the inclusion and exclusion criteria. The included literature was qualitatively evaluated using the PEDro scale, while the Egger's regression, funnel plot, and trim-and-fill methods were applied to assess and adjust for publication bias.

RESULTS

The averaged PEDro score was 6.21 points, indicating a high level of methodological quality. In the analysis based on dependent variables, higher effect sizes were observed in the following ascending order: gait speed (g = 0.26), motor function (g = 0.21), gait ability (g = 0.18), Timed Up and Go Test (g = -0.15), gait endurance (g = 0.11), and Berg Balance Scale (g = 0.05). Subgroup analyses further revealed significant differences in Asian populations (g = 0.26), sessions lasting longer than 30 min (g = 0.37), training frequency of three times per week or less (g = 0.38), and training duration of four weeks or less (g = 0.25). Overall, the results of this study indicate that overground robot exoskeleton gait training is effective at improving gait speed in patients with stroke, particularly when the sessions exceed 30 min, are conducted three times or less per week, and last for four weeks or less.

CONCLUSION

our results suggest that training is an effective intervention for patients with stroke, provided that appropriate goal-setting and intensity and overground robot exoskeleton gait are applied.

Effect of robotic exoskeleton training on lower limb function, activity and participation in stroke patients: a systematic review and meta-analysis of randomized controlled trials

Background

The current lower limb robotic exoskeleton training (LRET) for treating and managing stroke patients remains a huge challenge. Comprehensive ICF analysis and informative treatment options are needed. This review aims to analyze LRET' s efficacy for stroke patients, based on ICF, and explore the impact of intervention intensities, devices, and stroke phases.

Methods

We searched Web of Science, PubMed, and The Cochrane Library for RCTs on LRET for stroke patients. Two authors reviewed studies, extracted data, and assessed quality and bias. Standardized protocols were used. PEDro and ROB2 were employed for quality assessment. All analyses were done with RevMan 5.4.

Results

Thirty-four randomized controlled trials (1,166 participants) were included. For function, LRET significantly improved motor control (MD = 1.15, 95%CI = 0.29-2.01, p = 0.009, FMA-LE), and gait parameters (MD = 0.09, 95%CI = 0.03-0.16, p = 0.004, Instrumented Gait Velocity; MD = 0.06, 95%CI = 0.02-0.09, p = 0.002, Step length; MD = 4.48, 95%CI = 0.32-8.65, p = 0.04, Cadence) compared with conventional rehabilitation. For activity, LRET significantly improved walking independence (MD = 0.25, 95%CI = 0.02-0.48, p = 0.03, FAC), Gait Velocity (MD = 0.07, 95%CI = 0.03-0.11, p = 0.001) and balance (MD = 2.34, 95%CI = 0.21-4.47, p = 0.03, BBS). For participation, social participation (MD = 0.12, 95%CI = 0.03-0.21, p = 0.01, EQ-5D) was superior to conventional rehabilitation. Based on subgroup analyses, LRET improved motor control (MD = 1.37, 95%CI = 0.47-2.27, p = 0.003, FMA-LE), gait parameters (MD = 0.08, 95%CI = 0.02-0.14, p = 0.006, Step length), Gait Velocity (MD = 0.11, 95%CI = 0.03-0.19, p = 0.005) and activities of daily living (MD = 2.77, 95%CI = 1.37-4.16, p = 0.0001, BI) for the subacute patients, while no significant improvement for the chronic patients. For exoskeleton devices, treadmill-based exoskeletons showed significant superiority for balance (MD = 4.81, 95%CI = 3.10-6.52, p < 0.00001, BBS) and activities of daily living (MD = 2.67, 95%CI = 1.25-4.09, p = 0.00002, BI), while Over-ground exoskeletons was more effective for gait parameters (MD = 0.05, 95%CI = 0.02-0.08, p = 0.0009, Step length; MD = 6.60, 95%CI = 2.06-11.15, p = 0.004, Cadence) and walking independence (MD = 0.29, 95%CI = 0.14-0.44, p = 0.0002, FAC). Depending on the training regimen, better results may be achieved with daily training intensities of 45-60 min and weekly training intensities of 3 h or more.

Conclusion

These findings offer insights for healthcare professionals to make effective LRET choices based on stroke patient needs though uncertainties remain. Particularly, the assessment of ICF participation levels and the design of time-intensive training deserve further study.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, Unique Identifier: CRD42024501750.

Efficacy and safety of auricular therapy in the treatment of post-stroke constipation: A protocol for systematic review and meta-analysis

BACKGROUND

Constipation is one of the common gastrointestinal complications after stroke. It not only aggravates the condition of stroke, but also brings huge medical burden to patients, and has a negative impact on the quality of life of patients. Auricular therapy, as a part of Chinese traditional acupuncture and moxibustion, has been found to be effective in the clinical treatment of constipation. However, no systematic review has investigated the efficacy and safety of auricular therapy in the treatment of post-stroke constipation. Therefore, the aim of this systematic review is to assess the effectiveness and safety of auricular therapy for post-stroke constipation.

METHODS AND ANALYSIS

Eight electronic databases including PubMed, Cochrane Library/Cochrane Central Register of Controlled Trials, Web of Science, Embase, China National Knowledge Internet, Chinese Biomedical Literature Database, Wanfang, and VIP databases, will be searched for relevant studies published from inception to February 2023. Two reviewers will independently conduct research selection, data extraction, and evaluation of research quality. Only randomized controlled trials (RCTs) that assess the efficacy and safety of auricular therapy for the treatment of post-stroke constipation will be included in this study. We will use the Cochrane risk of bias assessment tool to evaluate the methodological qualities (including bias risk). If possible, a meta-analysis will be performed after screening.

RESULTS

This study may provide high-quality evidence for the efficacy and safety of auricular therapy in treating post-stroke constipation.

CONCLUSION

The conclusions of our study will provide an evidence to judge whether auricular therapy is an effective and safe intervention for patients with post-stroke constipation.

ETHICS AND DISSEMINATION

Ethical approval is not required, as this study was based on a review of published research. This review will be published in a peer-reviewed journal and disseminated electronically and in print.

TRIAL REGISTRATION

Registration number: PROSPERO CRD42023402242.

Lower extremity robotic exoskeleton devices for overground ambulation recovery in acquired brain injury-A review

Acquired brain injury (ABI) is a leading cause of ambulation deficits in the United States every year. ABI (stroke, traumatic brain injury and cerebral palsy) results in ambulation deficits with residual gait and balance deviations persisting even after 1 year. Current research is focused on evaluating the effect of robotic exoskeleton devices (RD) for overground gait and balance training. In order to understand the device effectiveness on neuroplasticity, it is important to understand RD effectiveness in the context of both downstream (functional, biomechanical and physiological) and upstream (cortical) metrics. The review identifies gaps in research areas and suggests recommendations for future research. We carefully delineate between the preliminary studies and randomized clinical trials in the interpretation of existing evidence. We present a comprehensive review of the clinical and pre-clinical research that evaluated therapeutic effects of RDs using various domains, diagnosis and stage of recovery.

Combining robot-assisted therapy with virtual reality or using it alone? A systematic review on health-related quality of life in neurological patients

BACKGROUND

In the field of neurorehabilitation, robot-assisted therapy (RAT) and virtual reality (VR) have so far shown promising evidence on multiple motor and functional outcomes. The related effectiveness on patients' health-related quality of life (HRQoL) has been investigated across neurological populations but still remains unclear. The present study aimed to systematically review the studies investigating the effects of RAT alone and with VR on HRQoL in patients with different neurological diseases.

METHODS

A systematic review of the studies evaluating the impact of RAT alone and combined with VR on HRQoL in patients affected by neurological diseases (i.e., stroke, multiple sclerosis, spinal cord injury, Parkinson's Disease) was conducted according to PRISMA guidelines. Electronic searches of PubMed, Web of Science, Cochrane Library, CINAHL, Embase, and PsychINFO (2000-2022) were performed. Risk of bias was evaluated through the National Institute of Health Quality Assessment Tool. Descriptive data regarding the study design, participants, intervention, rehabilitation outcomes, robotic device typology, HRQoL measures, non-motor factors concurrently investigated, and main results were extracted and meta-synthetized.

RESULTS

The searches identified 3025 studies, of which 70 met the inclusion criteria. An overall heterogeneous configuration was found regarding the study design adopted, intervention procedures and technological devices implemented, rehabilitation outcomes (i.e., related to both upper and lower limb impairment), HRQoL measures administered, and main evidence. Most of the studies reported significant effects of both RAT and RAT plus VR on patients HRQoL, whether they adopted generic or disease-specific HRQoL measures. Significant post-intervention within-group changes were mainly found across neurological populations, while fewer studies reported significant between-group comparisons, and then, mostly in patients with stroke. Longitudinal investigations were also observed (up to 36 months), but significant longitudinal effects were exclusively found in patients with stroke or multiple sclerosis. Finally, concurrent evaluations on non-motor outcomes beside HRQoL included cognitive (i.e., memory, attention, executive functions) and psychological (i.e., mood, satisfaction with the treatment, device usability, fear of falling, motivation, self-efficacy, coping, and well-being) variables.

CONCLUSIONS

Despite the heterogeneity observed among the studies included, promising evidence was found on the effectiveness of RAT and RAT plus VR on HRQoL. However, further targeted short- and long-term investigations, are strongly recommended for specific HRQoL subcomponents and neurological populations, through the adoption of defined intervention procedures and disease-specific assessment methodology.

Effect of wearable exoskeleton on post-stroke gait: A systematic review and meta-analysis

BACKGROUND

Wearable exoskeletons are a recently developed technology.

OBJECTIVES

The present systematic review aimed to investigate the effect of a wearable exoskeleton on post-stroke walking by considering its use in a gait training system and simply as an orthosis assisting walking.

METHODS

We systematically searched for randomised and quasi-randomised controlled trials in PubMed, Scopus, CINAHL and Embase databases from their earliest publication record to July 2021. We chose reports of trials investigating the effects of exoskeleton-assisted training or the effects of wearing an exoskeleton to assist walking. A meta-analysis was conducted to explore the benefits of the wearable exoskeleton on mobility capacity, walking speed, motor function, balance, endurance and activities of daily living.

RESULTS

We included 13 studies (492 participants) comparing exoskeleton-assisted training with dose-matched conventional gait training. Studies addressing the effect of wearing a wearable exoskeleton were unavailable. As compared with conventional gait training at the end of the intervention, exoskeleton-assisted training was superior for walking speed (mean difference [MD] 0.13 m/s, 95% CI 0.05; 0.21) and balance (standardized MD [SMD] 0.3, 95% CI 0.07; 0.54). The subgroup with chronic stroke (i.e., > 6 months) presented the outcome favouring exoskeleton-assisted training regarding overall mobility capacity (SMD 0.37, 95% CI 0.04; 0.69). At the end of follow-up, exoskeleton-assisted training was superior to conventional gait training in overall mobility (SMD 0.45, 95% CI 0.07; 0.84) and endurance (MD 46.23 m, 95% CI 9.90; 82.56).

CONCLUSIONS

Exoskeleton-assisted training was superior to dose-matched conventional gait training in several gait-related outcomes at the end of the intervention and follow-up in this systematic review and meta-analysis, which may support the use of exoskeleton-assisted training in the rehabilitation setting. Whether wearing versus not wearing a wearable exoskeleton is beneficial during walking remains unknown.

Effect of robot-assisted gait training on quality of life and depression in neurological impairment: A systematic review and meta-analysis

OBJECTIVE

Robot-assisted gait training (RAGT) is often used as a rehabilitation tool for neurological impairments. The purpose of this study is to investigate the effects of rehabilitation with robotic devices on quality of life and depression.

DATA SOURCES

Two electronic databases (MEDLINE and Scopus) were searched for studies from inception up to December 2022.

REVIEW METHODS

Randomized controlled trials (RCTs) and non-RCTs were pooled separately for analyses, studying each one's mental and physical health and depression. Random effect meta-analyses were run using standardized mean difference and 95% confidence interval (CI).

RESULTS

A total of 853 studies were identified from the literature search. 31 studies (17 RCTs and 14 non-RCTs) including 1151 subjects met the inclusion criteria. 31 studies were selected for the systematic review and 27 studies for the meta-analysis. The outcome measure of mental health significantly improved in favor of the RAGT group in RCTs and non-RCTs (adjusted Hedges'g 0.72, 95% CI: 0.34-1.10, adjusted Hedges g = 0.80, 95% CI 0.21-1.39, respectively). We observed a significant effect of RAGT on physical health in RCTs and non-RCTs (adjusted Hedges'g 0.58, 95% CI 0.28, 0.88, adjusted Hedges g = 0.73, 95% CI 0.12, 1.33). After realizing a sensitivity analysis in RCTs, a positive impact on depression is observed (Hedges' g of -0.66, 95% CI -1.08 to -0.24).

CONCLUSION

This study suggests that RAGT could improve the quality of life of patients with neurological impairments. A positive impact on depression is also observed in the short term. Further studies are needed to differentiate grounded and overgrounded exoskeletons as well as RCT comparing overground exoskeletons with a control group.

The Use of Sports Rehabilitation Robotics to Assist in the Recovery of Physical Abilities in Elderly Patients with Degenerative Diseases: A Literature Review

The increase in the number of elderly patients with degenerative diseases has brought additional medical and financial pressures, which are adding to the burden on society. The development of sports rehabilitation robotics (SRR) is becoming increasingly sophisticated at the technical level of its application; however, few studies have analyzed how it works and how effective it is in aiding rehabilitation, and fewer individualized exercise rehabilitation programs have been developed for elderly patients. The purpose of this study was to analyze the working methods and the effects of different types of SRR and then to suggest the feasibility of applying SRR to enhance the physical abilities of elderly patients with degenerative diseases. The researcher's team searched 633 English-language journal articles, which had been published over the past five years, and they selected 38 of them for a narrative literature review. Our summary found the following: (1) The current types of SRR are generally classified as end-effector robots, smart walkers, intelligent robotic rollators, and exoskeleton robots-exoskeleton robots were found to be the most widely used. (2) The current working methods include assistant tools as the main intermediaries-i.e., robots assist patients to participate; patients as the main intermediaries-i.e., patients dominate the assistant tools to participate; and sensors as the intermediaries-i.e., myoelectric-driven robots promote patient participation. (3) Better recovery was perceived for elderly patients when using SRR than is generally achieved through the traditional single-movement recovery methods, especially in strength, balance, endurance, and coordination. However, there was no significant improvement in their speed or agility after using SRR.

Biopsychosocial effects and experience of use of robotic and virtual reality devices in neuromotor rehabilitation: A study protocol

BACKGROUND

Robot-assisted therapy (RAT) and virtual reality (VR)-based neuromotor rehabilitation have shown promising evidence in terms of patient's neuromotor recovery, so far. However, still little is known on the perceived experience of use of robotic and VR devices and the related psychosocial impact. The present study outlines a study protocol aiming to investigate the biopsychosocial effects and the experience of use of robotic and non-immersive VR devices in patients undergoing neuromotor rehabilitation.

METHODS

Adopting a prospective, two-arm, non-randomized study design, patients with different neuromotor diseases (i.e., acquired brain injury, Parkinson's Disease, and total knee/hip arthroplasty) undergoing rehabilitation will be included. In a real-world clinical setting, short- (4 weeks) and long-term (6 months) changes in multiple patient's health domains will be investigated, including the functional status (i.e., motor functioning, ADLs, risk of falls), cognitive functioning (i.e., attention and executive functions), physical and mental health-related quality of life (HRQoL), and the psychological status (i.e., anxiety and depression, quality of life satisfaction). At post-intervention, the overall rehabilitation experience, the psychosocial impact of the robotic and VR devices will be assessed, and technology perceived usability and experience of use will be evaluated through a mixed-methods approach, including both patients' and physiotherapists' perspectives. Repeated measures within-between interaction effects will be estimated, and association analyses will be performed to explore the inter-relationships among the variables investigated. Data collection is currently ongoing.

IMPLICATIONS

The biopsychosocial framework adopted will contribute to expanding the perspective on patient's recovery within the technology-based rehabilitation field beyond motor improvement. Moreover, the investigation of devices experience of use and usability will provide further insight into technology deployment in neuromotor rehabilitation programs, thereby maximising therapy engagement and effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05399043.

What does evidence tell us about the use of gait robotic devices in patients with multiple sclerosis? A comprehensive systematic review on functional outcomes and clinical recommendations

INTRODUCTION

There is growing evidence on the efficacy of gait robotic rehabilitation in patients with multiple sclerosis (MS), but most of the studies have focused on gait parameters. Moreover, clear indications on the clinical use of robotics still lack. As part of the CICERONE Italian Consensus on Robotic Rehabilitation, the aim of this systematic review was to investigate the existing evidence concerning the role of lower limb robotic rehabilitation in improving functional recovery in patients with MS.

EVIDENCE ACQUISITION

We searched for and systematically reviewed evidence-based studies on gait robotic rehabilitation in MS, between January 1^st, 2010 and December 31^st, 2020, in the following databases: Cochrane Library, PEDro, PubMed and Google Scholar. The study quality was assessed by the 16-item assessment of multiple systematic reviews 2 (AMSTAR 2) and the 10-item PEDro scale for the other research studies.

EVIDENCE SYNTHESIS

After an accurate screening, only 17 papers were included in the review, and most of them (13 RCT) had a level II evidence. Most of the studies used the Lokomat as a grounded robotic device, two investigated the efficacy of end-effectors and two powered exoskeletons. Generally speaking, robotic treatment has beneficial effects on gait speed, endurance and balance with comparable outcomes to those of conventional treatments. However, in more severe patients (EDSS >6), robotics leads to better functional outcomes. Notably, after gait training with robotics (especially when coupled to virtual reality) MS patients also reach better non-motor outcomes, including spasticity, fatigue, pain, psychological well-being and quality of life. Unfortunately, no clinical indications emerge on the treatment protocols.

CONCLUSIONS

The present comprehensive systematic review highlights the potential beneficial role on functional outcomes of the lower limb robotic devices in people with MS. Future studies are warranted to evaluate the role of robotics not only for walking and balance outcomes, but also for other gait-training-related benefits, to identify appropriate outcome measures related to a specific subgroup of MS subjects' disease severity.

Is intensive gait training feasible and effective at old age? A retrospective case-control study on the use of Lokomat Free-D in patients with chronic stroke

BACKGROUND

In the last decade, the number of people over 60 has increased, leading to various healthcare problems. The aim of this retrospective study is to evaluate the effects of robotic rehabilitation in elderly patients as well as their perception of usability and adaptation to intensive robotic neurorehabilitation.

METHODS

This is a retrospective case-control study. Eighty elderly stroke patients were included in the analysis using an electronic data retrieval system. The enrolled patients were divided into two groups: the experimental group (EG) underwent rehabilitation training with Lokomat FreeD, equipped with a VR screen, while the control group (CG) performed traditional rehabilitation training. The two groups matched for age, sex, education, brain injury, stroke interval. The rehabilitation protocol included a total of 40 training sessions.

RESULTS

Both types of rehabilitation led to an improvement in the perceived level of disability (FIM) and in the performance in gait and balance (TT), highlighting a significant improvement especially in the EG. However, only in the EG, Lokomat training had induced an increase in the distance covered in 10 min (10 m walk test), and a significant improvement in mood (HRS-D). Moreover, Lokomat-FreeD was well tolerated by patients with high levels of usability.

CONCLUSIONS

Our results suggest that elderly patients may benefit from high-intensity robotic neurorehabilitation using the Lokomat-Pro FreeD.