Clinical effects of robot-assisted gait training and treadmill training for Parkinson's disease. A randomized controlled trial

Innovative technology-based interventions in Parkinson's disease: A systematic review and meta-analysis

OBJECTIVE

Novel technology-based interventions have the potential to improve motor symptoms and gait in Parkinson's disease (PD). Promising treatments include virtual-reality (VR) training, robotic assistance, and biofeedback. Their effectiveness remains unclear, and thus, we conducted a Bayesian network meta-analysis.

METHODS

We searched the Medline, Embase, Cochrane CENTRAL, and Clinicaltrials.gov databases until 2 April 2024 and only included randomized controlled trials. Outcomes included changes in UPDRS-III/MDS-UPDRS-III score, stride length, 10-meter walk test (10MWT), timed up-and-go (TUG) test, balance scale scores and quality-of-life (QoL) scores. Results were reported as mean differences (MD) or standardized mean differences (SMD), with 95% credible intervals (95% CrI).

RESULTS

Fifty-one randomized controlled trials with 2095 patients were included. For UPDRS (motor outcome), all interventions had similar efficacies. VR intervention was the most effective in improving TUG compared with control (MD: -4.36, 95% CrI: -8.57, -0.35), outperforming robotic, exercise, and proprioceptive interventions. Proprioceptive intervention significantly improved stride length compared to control intervention (MD: 0.11 m, 95% CrI: 0.03, 0.19), outperforming VR, robotic and exercise interventions. Virtual reality improved balance scale scores significantly compared to exercise intervention (SMD: 0.75, 95% CrI: 0.12, 1.39) and control intervention (SMD: 1.42, 95% CrI: 0.06, 2.77). Virtual reality intervention significantly improved QoL scores compared to control intervention (SMD: -0.95, 95% CrI: -1.43, -0.52), outperforming Internet-based interventions.

INTERPRETATION

VR-based and proprioceptive interventions were the most promising interventions, consistently ranking as the top treatment choices for most outcomes. Their use in clinical practice could be helpful in managing motor symptoms and QoL in PD.

Effectiveness of Technological Interventions for Older Adults With Parkinson Disease: Systematic Review

BACKGROUND

Among the older population, Parkinson disease (PD) stands out as a leading contributor to disability. Clinically, the foremost objectives in managing PD involve proactively delaying and preventing disability. Understanding the pivotal role of gait and balance in daily functionality holds substantial clinical significance, signaling imminent disability and prompting a reevaluation of management approaches. A key priority lies in identifying novel and effective interventions for symptoms that substantially contribute to disability.

OBJECTIVE

This paper presents a systematic review that critically examines the existing body of literature on the use of technology in the rehabilitation of older patients with PD. By synthesizing current evidence, we aim to provide insights into the state of the field, identify gaps in knowledge, and offer recommendations for future research and clinical practice.

METHODS

A systematic review of the literature was conducted in September 2023 analyzing manuscripts and papers of the last 5 years from the PubMed, Scopus, Embase, Web of Science, and CINAHL databases following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 14 papers were included. The inclusion criteria are as follows: (1) randomized controlled trial, (2) PD in people aged 65 years and older, and (3) use of technology in the rehabilitation training in the older population.

RESULTS

A large portion of effective interventions relies on the incorporation of technology, particularly through virtual reality exergames. This technology appears to have effects not only on the cognitive aspect but also on the physical domain. The analysis of the results clearly indicates that, in terms of gait and balance performance, the technological intervention outperforms the traditional approach, irrespective of the specific technology employed.

CONCLUSIONS

This systematic review seeks to shed light on the evolving landscape of technology-assisted rehabilitation for older individuals with PD. As we delve into the available evidence, we will assess the extent to which technology can serve as a valuable adjunct to conventional therapy, offering new avenues for optimized care and improved outcomes in this growing patient demographic. As we sift through the existing evidence, our goal is to evaluate the potential of technology as a valuable supplement to traditional therapy, presenting fresh opportunities for enhanced care and better outcomes in this expanding patient demographic.

The role of robot-assisted training on rehabilitation outcomes in Parkinson's disease: a systematic review and meta-analysis

PURPOSE

The study aims to assess the efficacy of robot-assisted rehabilitation training on upper and lower limb motor function and fatigue in Parkinson's disease (PD), and to explore the best-acting robotic rehabilitation program.

METHODS

We searched studies in seven databases and the search period was from the build to 30 June 2023. Two researchers independently screened studies and assessed the quality of the studies for data extraction.

RESULTS

A total of 21 studies were included, 18 studies related to lower limbs rehabilitation and 3 studies related to upper limbs rehabilitation, involving a total of 787 participants. The results showed that robot-assisted rehabilitation significantly improved indicators of lower limb motor function UPDRS Part III (WMD = -3.58, 95% CI = -5.91 to -1.25, p = 0.003) and BBS (WMD = 4.24, 95% CI = 2.88 to 5.54, p < 0.001), as well as non-motor symptoms of fatigue (WMD = -13.39, 95% CI = -17.92 to -8.86, p < 0.001) in PD patients. At the level of upper limb function, there was no statistically significant difference in the outcome measures of PFS (WMD = -0.25, 95% CI = -4.44 to 3.93, p = 0.9) and BBT (WMD = 1.73, 95% CI = -2.85 to 6.33, p = 0.458).

CONCLUSION

Robot-assisted rehabilitation significantly improved motor function, fatigue, and balance confidence in PD patients, but current evidence doesn't show that intelligent rehabilitation systems improve upper limb function. In particular, robotics combined with virtual reality worked best.

Robot-assisted gait training in patients with various neurological diseases: A mixed methods feasibility study

BACKGROUND

Walking impairment represents a relevant symptom in patients with neurological diseases often compromising social participation. Currently, mixed methods studies on robot-assisted gait training (RAGT) in patients with rare neurological diseases are lacking. This study aimed to explore the feasibility, acceptability, goal attainment and preliminary effects of RAGT in patients with common and rare neurological diseases and understand the intervention context and process.

METHODS

A mixed-methods feasibility study was conducted at an Austrian rehabilitation centre. Twenty-eight inpatients after stroke in the subacute and chronic phases, with multiple sclerosis, Parkinson's disease, spinal cord injury, spinocerebellar ataxia, acute/chronic inflammatory demyelinating polyneuropathy and motor neuron disease were included. Patients received RAGT for 45 minutes, 4x/week, for 4 weeks. Baseline and post-intervention assessments included gait parameters, walking and balance, and questionnaires. Semi-structured observations were conducted twice during the intervention period and analysed using thematic analysis. Descriptive statistics within the respective disease groups and calculation of effect sizes for the total sample were performed. Triangulation was employed to develop a deeper understanding of the research topic.

RESULTS

Data from 26 patients (mean age 61.6 years [standard deviation 13.2]) were analysed. RAGT was highly accepted by patients and feasible, indicated by recruitment, retention, and adherence rates of 84.8% (95% confidence interval, CI 0.7-0.9), 92.2% (95% CI 0.7-1.0) and 94.0% (95% CI 91.4-96.2), respectively. Goal attainment was high, and only mild adverse events occurred. Improvements in walking speed (10-Metre Walk Test, effect size r = 0.876), walking distance (6-Minute Walk Test, r = 0.877), functional mobility (Timed Up and Go, r = 0.875), gait distance (r = 0.829) and number of steps (r = 0.834) were observed. Four themes were identified: familiarising with RAGT; enjoyment and acceptance through a trusting therapeutic relationship; actively interacting; and minimising dissatisfaction.

DISCUSSION

Sufficiently powered randomised controlled trials are needed to validate our results.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00027887.

Lower-Limb Exoskeletons for Gait Training in Parkinson's Disease: The State of the Art and Future Perspectives

Gait dysfunction (GD) is a common impairment of Parkinson's disease (PD), which negatively impacts patients' quality of life. Among the most recent rehabilitation technologies, a lower-limb powered exoskeleton (LLEXO) arises as a useful instrument for gait training in several neurological conditions, including PD. However, some questions relating to methods of use, achievable results, and usefulness compared to traditional rehabilitation methodologies still require clear answers. Therefore, in this review, we aim to summarise and analyse all the studies that have applied an LLEXO to train gait in PD patients. Literature research on PubMed and Scopus retrieved five articles, comprising 46 PD participants stable on medications (age: 71.7 ± 3.7 years, 24 males, Hoehn and Yahr: 2.1 ± 0.6). Compared to traditional rehabilitation, low-profile lower-limb exoskeleton (lp-LLEXO) training brought major improvements towards walking capacity and gait speed, while there are no clear major benefits regarding the dual-task gait cost index and freezing of gait symptoms. Importantly, the results suggest that lp-LLEXO training is more beneficial for patients with an intermediate-to-severe level of disease severity (Hoehn and Yahr > 2.5). This review could provide a novel framework for implementing LLEXO in clinical practise, highlighting its benefits and limitations towards gait training.

Efficacy of exercise interventions combined with Selegiline in ameliorating freezing of gait in Parkinson's disease patients

OBJECTIVE

To evaluate the efficacy of exercise interventions combined with Selegiline in ameliorating freezing of gait (FOG) in Parkinson's disease (PD) patients.

METHODS

A total of 60 PD patients with FOG treated in the First People's Hospital of Fuyang District from January 2020 to January 2023 were retrospectively collected and analyzed. Patients were divided into a control group (n = 28, treated with Selegiline alone) and an observation group (n = 32, treated with Selegiline and exercise interventions). Gait parameters, FOG indices, motor and balance functions, Berg Balance, psychological status, and quality of life were compared between the groups pre- and post-treatment.

RESULTS

After treatment, the observation group exhibited longer step length, higher step speed, and lower step frequency (P = 0.000, 0.003, 0.001, respectively), with enhanced balance as indicated by lower Timed Up and Go Test and higher Berg Balance Scale scores than the control group (P = 0.000, 0.000, respectively). The Beck Depression Inventory and Beck Anxiety Inventory scores were notably lower in the observation group than those in the control group (P = 0.000, 0.004, respectively). Additionally, the observation group showed better quality of life across several dimensions of the Parkinson's Disease Quality of Life Questionnaire, including mobility, activities of daily living, emotional well-being, stigma, social support, cognition, communication, and bodily discomfort (P = 0.000, 0.000, 0.000, 0.000, 0.017, 0.000, 0.000, 0.000, respectively) than the control group.

CONCLUSION

The combination of exercise interventions and Selegiline effectively rectifies the gait parameters, enhances the balance function, alleviates psychological distress, and improves the overall quality of life in PD patients experiencing FOG.

Effects of rhythmic auditory stimulation on gait speed in older adult inpatients in a convalescent rehabilitation ward: a pilot randomized controlled trial

PURPOSE

To assess the impact of gait training with rhythmic auditory stimulation (RAS) on enhancing gait speed in older people admitted to a convalescent rehabilitation ward (CRW), compared to conventional gait training methods.

METHODS

The study was designed as a single-center, open-label, pilot, randomized, parallel-group study. Thirty older people admitted to CRW were divided into two groups: the experimental group, which received gait training with RAS (n = 15, females = 53.3%, mean age = 83.9, SD = 6.5), and the control group, which underwent usual gait training (n = 15, females = 60.0%, mean age = 81.3, SD = 8.4). Regardless of their assigned group, all participants underwent 30 min training sessions, five times a week, for 3 weeks. The primary outcome was the 10 m walk test (10mWT), and the secondary outcomes included the Medical Outcome Study 8-Item Short-Form Health Survey and the Japanese version of the modified Gait Efficacy Scale. All measurements were taken at baseline and again at week 3.

RESULTS

Results indicated that older people in CRWs in the experimental group showed significant improvements in their 10mWT (effect size - 1.02) compared to the control group. None of the secondary outcomes were significant.

CONCLUSIONS

This study suggests the preliminary effectiveness and feasibility of a gait practice intervention using RAS in a CRW.

TRIAL REGISTRATION

The University Hospital Medical Information Network (UMIN) Registered 1 October 2022 (UMIN000049089).

General Treatments Promoting Independent Living in Parkinson's Patients and Physical Therapy Approaches for Improving Gait-A Comprehensive Review

This study delves into the multifaceted approaches to treating Parkinson's disease (PD), a neurodegenerative disorder primarily affecting motor function but also manifesting in a variety of symptoms that vary greatly among individuals. The complexity of PD symptoms necessitates a comprehensive treatment strategy that integrates surgical interventions, pharmacotherapy, and physical therapy to tailor to the unique needs of each patient. Surgical options, such as deep brain stimulation (DBS), have been pivotal for patients not responding adequately to medication, offering significant symptom relief. Pharmacotherapy remains a cornerstone of PD management, utilizing drugs like levodopa, dopamine agonists, and others to manage symptoms and, in some cases, slow down disease progression. However, these treatments often lead to complications over time, such as motor fluctuations and dyskinesias, highlighting the need for precise dosage adjustments and sometimes combination therapies to optimize patient outcomes. Physical therapy plays a critical role in addressing the motor symptoms of PD, including bradykinesia, muscle rigidity, tremors, postural instability, and akinesia. PT techniques are tailored to improve mobility, balance, strength, and overall quality of life. Strategies such as gait and balance training, strengthening exercises, stretching, and functional training are employed to mitigate symptoms and enhance functional independence. Specialized approaches like proprioceptive neuromuscular facilitation (PNF), the Bobath concept, and the use of assistive devices are also integral to the rehabilitation process, aimed at improving patients' ability to perform daily activities and reducing the risk of falls. Innovations in technology have introduced robotic-assisted gait training (RAGT) and other assistive devices, offering new possibilities for patient care. These tools provide targeted support and feedback, allowing for more intensive and personalized rehabilitation sessions. Despite these advancements, high costs and accessibility issues remain challenges that need addressing. The inclusion of exercise and activity beyond structured PT sessions is encouraged, with evidence suggesting that regular physical activity can have neuroprotective effects, potentially slowing disease progression. Activities such as treadmill walking, cycling, and aquatic exercises not only improve physical symptoms but also contribute to emotional well-being and social interactions. In conclusion, treating PD requires a holistic approach that combines medical, surgical, and therapeutic strategies. While there is no cure, the goal is to maximize patients' functional abilities and quality of life through personalized treatment plans. This integrated approach, along with ongoing research and development of new therapies, offers hope for improving the management of PD and the lives of those affected by this challenging disease.

Use of a Robotic Walking Device for Home and Community Mobility in Parkinson Disease: A Randomized Controlled Trial

BACKGROUND/PURPOSE

Gait impairments in Parkinson disease (PD) contribute to decreased quality of life. This randomized controlled trial examined immediate- and longer-term effects of a single joint robotic exoskeleton device (EXOD), the Honda Walking Assist device, on gait.

METHODS

Participants (n = 45) with PD (Hoehn and Yahr stages 1-3) were randomized to a robotic-assisted gait training (RAGT) group (n = 23) or control (CON) group (n = 22). The RAGT group was tested with and without the EXOD at baseline and then received supervised in-home and community training with the EXOD twice weekly for 8 weeks. The CON group received no interventions. Outcome measures included gait speed (primary), gait endurance (6-minute walk test), perceived ease of walking, and questionnaires and logs assessing performance of daily activities, freezing of gait, and daily activity levels.

RESULTS

Forty participants completed the study. No significant immediate impact of EXOD usage on participants' gait measures was found. Differences in gait speed and secondary outcome measures postintervention were not significantly different between the RAGT and CON groups. Participants with greater disease severity (worse baseline motor scores) had greater improvements in stride length during unassisted walking after the intervention than those with lower severity (mean difference: 3.22, 95% confidence interval: 0.05-6.40; P = 0.04).

DISCUSSION AND CONCLUSIONS

All RAGT participants could use the EXOD safely. The RAGT treatment used in this mostly low impairment population of people with PD may be ineffective and/or was insufficiently dosed to see a positive treatment effect. Our findings suggest that RAGT interventions in PD may be more effective in individuals with greater motor impairments.

Exploring Potential Predictors of Treadmill Training Effects in People With Parkinson Disease

OBJECTIVE

To explore the potential predictors of people with Parkinson disease (PD) who would benefit the most from treadmill training.

DESIGN

A cohort study.

SETTING

Medical university rehabilitation settings.

PARTICIPANTS

Seventy participants diagnosed of idiopathic PD.

INTERVENTIONS

Twelve sessions of treadmill training.

MAIN OUTCOME MEASURES

Hierarchical logistic regression models were used to explore significant predictors of the treadmill training effect with respect to 3 health domains: Unified Parkinson's Disease Rating Scales part III (UPDRS III); gait speed; Parkinson's Disease Questionnaire-39 (PDQ-39). A receiver operating characteristic (ROC) curve analysis was conducted to identify proper cut-off points for clinical use.

RESULTS

Male sex (adjusted odds ratio [OR]: 3.73, P=.036) significantly predicted the improvement of UPDRS III. Individuals with a slower baseline gait speed (cut-off: 0.92 m/s, adjusted OR: 14.06, P<.001) and higher baseline balance confidence measured by the Activity-specific Balance Confidence scale (cut-off: 84.5 points, adjusted OR: 4.66, P=.022) have greater potential to achieve clinically relevant improvements in gait speed. A poorer baseline PDQ-39 score (cut-off: 23.1, adjusted OR: 7.47, P<.001) predicted a greater quality of life improvement after treadmill training.

CONCLUSIONS

These findings provide a guideline for clinicians to easily identify suitable candidates for treadmill training. Generalization to more advanced patients with PD warrants further investigation.

Exercising with a robotic exoskeleton can improve memory and gait in people with Parkinson's disease by facilitating progressive exercise intensity

People with Parkinson's disease (PwPD) can benefit from progressive high-intensity exercise facilitated with a lower-extremity exoskeleton, but the mechanisms explaining these benefits are unknown. We explored the relationship between exercise intensity progression and memory and gait outcomes in PwPD who performed 8 weeks (2 × per week) of progressive exercise with and without a lower-extremity powered exoskeleton, as the planned exploratory endpoint analysis of an open-label, parallel, pilot randomized controlled trial. Adults 50-85 years old with a confirmed diagnosis of PD participated. Twenty-seven participants randomized to exercise with (Exo = 13) or without (Nxo = 14) the exoskeleton were included in this exploratory endpoint analysis. Detailed exercise logs were kept and actigraphy was used to measure activity count*min-1 (ACPM) during all exercise sessions. Only the Exo group were able to progressively increase their ACPM over the entire 8-week intervention, whereas the Nxo group plateaued after 4 weeks. Exercise intensity progression correlated with change in the memory sub-scale of the SCOPA-COG and change in gait endurance from the 6MWT, consistent with the prevailing hypotheses linking high-intensity interval exercise to improved muscle and brain function via angiogenic and neurotrophic mechanisms. Facilitating high-intensity exercise with advanced rehabilitation technology is warranted for improving memory and gait endurance in PwPD.Registration: ClinicalTrials.gov, NCT03583879 (7/10/2018).

Effects of Manual Therapy on Parkinson's Gait: A Systematic Review

Manual therapy (MT) is commonly used in rehabilitation to deal with motor impairments in Parkinson's disease (PD). However, is MT an efficient method to improve gait in PD? To answer the question, a systematic review of clinical controlled trials was conducted. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome when sufficient data were available. If data were lacking, p values were reported. The PEDro scale was used for the quality assessment. Three studies were included in the review. MT improved Dynamic Gait Index (SMD = 1.47; 95% CI: 0.62, 2.32; PEDro score: 5/10, moderate level of evidence). MT also improved gait performances in terms of stride length, velocity of arm movements, linear velocities of the shoulder and the hip (p < 0.05; PEDro score: 2/10, limited level of evidence). There was no significant difference between groups after MT for any joint's range of motion during gait (p > 0.05; PEDro score: 6/10, moderate level of evidence). There is no strong level of evidence supporting the beneficial effect of MT to improve gait in PD. Further randomized controlled trials are needed to understand the impact of MT on gait in PD.

Multimodal fusion and human-robot interaction control of an intelligent robot

Introduction: Small-scaled robotic walkers play an increasingly important role in Activity of Daily Living (ADL) assistance in the face of ever-increasing rehab requirements and existing equipment drawbacks. This paper proposes a Rehabilitation Robotic Walker (RRW) for walking assistance and body weight support (BWS) during gait rehabilitation. Methods: The walker provides the patients with weight offloading and guiding force to mimic a series of the physiotherapist's (PT's) movements, and creates a natural, comfortable, and safe environment. This system consists of an omnidirectional mobile platform, a BWS mechanism, and a pelvic brace to smooth the motions of the pelvis. To recognize the human intentions, four force sensors, two joysticks, and one depth-sensing camera were used to monitor the human-machine information, and a multimodal fusion algorithm for intention recognition was proposed to improve the accuracy. Then the system obtained the heading angle E, the pelvic pose F, and the motion vector H via the camera, the force sensors, and the joysticks respectively, classified the intentions with feature extraction and information fusion, and finally outputted the motor speed control through the robot's kinematics. Results: To validate the validity of the algorithm above, a preliminary test with three volunteers was conducted to study the motion control. The results showed that the average error of the integral square error (ISE) was 2.90 and the minimum error was 1.96. Discussion: The results demonstrated the efficiency of the proposed method, and that the system is capable of providing walking assistance.

Effect of robot-assisted gait training on motor dysfunction in Parkinson's patients:A systematic review and meta-analysis

BACKGROUND

Robot-assisted gait training (RAGT) has been reported to treat motor dysfunction in patients with Parkinson's disease (PD) in the last few years. However, the benefits of RAGT for treating motor dysfunction in PD are still unclear.

OBJECTIVES

To investigate the efficacy of RAGT for motor dysfunction in PD patients.

METHODS

We searched PubMed, Web of Science, Cochrane Library, Embase, CNKI, Wanfang, Chinese Biomedical Literature Database (CBM), and Chinese VIP Database for randomized controlled trials investigating RAGT to improve motor dysfunction in PD from the databases' inception dates until September 1, 2022. The following outcome indexes were employed to evaluate motor dysfunction: the Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), 10-Meter Walk Test gait speed (10-MWT), gait speed, stride length, cadence Unified Parkinson Disease Rating Scale Part III (UPDRS III), 6-Minute Walk Test (6MWT), and the Timed Up and Go test (TUG). The meta-analysis was performed using the proper randomeffect model or fixed-effect model to evaluate the difference in efficacy between the RAGT and the control groups. The Cochrane Risk of Bias Tool was used for the included studies and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to interpret the certainty of the results.

RESULTS

The results consisted of 17 studies comprising a total of 670 participants. Six hundred and seven PD patients with motor dysfunction were included: 335 in the RAGT group and 335 in the control group. This meta-analysis results established that when compared with the control group, robot-assisted gait training improved the BBS results of PD patients (MD: 2.80, 95%CI: 2.11-3.49, P< 0.00001), ABC score (MD: 7.30, 95%CI: 5.08-9.52, P< 0.00001), 10-MWT (MD: 0.06, 95%CI: 0.03-0.10, P= 0.0009), gait speed (MD: 3.67, 95%CI: 2.58-4.76, P< 0.00001), stride length (MD: 5.53, 95%CI: 3.64-7.42, P< 0.00001), cadence (MD: 4.52, 95%CI: 0.94-8.10, P= 0.01), UPDRS III (MD: -2.16, 95%CI: -2.48--1.83, P< 0.00001), 6MWT (MD: 13.87, 95%CI: 11.92-15.82, P< 0.00001). However, RAGT did not significantly improve the TUG test result of patients with PD (MD =-0.56, 95% CI: -1.12-0.00, P= 0.05). No safety concerns or adverse reactions among robot-assisted gait training patients were observed.

CONCLUSION

Even though RAGT can improve balance function, walking function, and gait performance and has demonstrated positive results in several studies, there is currently insufficient compelling evidence to suggest that it can improve all aspects of lower motor function.

Effects of overground gait training assisted by a wearable exoskeleton in patients with Parkinson's disease

BACKGROUND

In the recent past, wearable devices have been used for gait rehabilitation in patients with Parkinson's disease. The objective of this paper is to analyze the outcome of a wearable hip orthosis whose assistance adapts in real time to the patient's gait kinematics via adaptive oscillators. In particular, this study focuses on a metric characterizing natural gait variability, i.e., the level of long-range autocorrelations (LRA) in series of stride durations.

METHODS

Eight patients with Parkinson's disease (Hoehn and Yahr stages 1[Formula: see text]2.5) performed overground gait training three times per week for four consecutive weeks, assisted by a wearable hip orthosis. Gait was assessed based on performance metrics such as the hip range of motion, speed, stride length and duration, and the level of LRA in inter-stride time series assessed using the Adaptive Fractal Analysis. These metrics were measured before, directly after, and 1 month after training.

RESULTS

After training, patients increased their hip range of motion, their gait speed and stride length, and decreased their stride duration. These improvements were maintained 1 month after training. Regarding long-range autocorrelations, the population's behavior was standardized towards a metric closer to the one of healthy individuals after training, but with no retention after 1 month.

CONCLUSION

This study showed that an overground gait training with adaptive robotic assistance has the potential to improve key gait metrics that are typically affected by Parkinson's disease and that lead to higher prevalence of fall.

TRIAL REGISTRATION

ClinicalTrials.gov Identifer NCT04314973. Registered on 11 April 2020.

A Physical Rehabilitation Approach for Parkinson's Disease: A Systematic Literature Review

Parkinson's disease (PD) is one of the most common neurological ailments. With diverse motor affectations (postural instability, resting tremor, bradykinesia, and rigidity), people with Parkinson's disease (PwP) have a broad spectrum of non-motor symptoms. These include autonomic function changes, cognitive deterioration, neuropsychiatric difficulties, and sleep interruptions. Psychological disturbances, such as anxiety and sadness, are common among PwP. This discomfort is often accompanied by a decrease in general functioning, both at work and in social contacts. Furthermore, people who are experiencing psychological distress have a quick decrease in both physical and cognitive capacities. Furthermore, Pwp who also suffer from anxiety and depression are more likely to acquire dementia. It is worth noting that studies have shown good outcomes in the treatment of physical disabilities in PWP and the various therapeutics available for each affected body part, such as in the legs when they have walking problems, resting tremor in their hands, or micrography, which is a common symptom in these patients. The medical research databases PubMed/Medline, Google Scholar, and the Cochrane Library were used to look for relevant materials. Upon meticulous scrutiny, a thorough investigation was conducted on the papers at hand. A total of 10 publications were meticulously selected based on stringent qualifying criteria. The present investigation examines various perspectives regarding the physical rehabilitation of individuals diagnosed with PD. The majority of therapeutic interventions employed revolve around cutting-edge technologies, such as virtual reality (VR), combined with exercise regimens. These interventions have demonstrated notable statistical significance in terms of enhancing various physical aspects, including endurance, performance, gait capacity, perception, and overall independence in daily life activities. One of the gathered studies makes use of the therapeutic benefits of yoga to help PwP deal with their anxiety and improve their mental health. Based on the aforementioned information, further investigation is required to ascertain the optimal approach for physical rehabilitation management and develop diverse strategies aimed at assisting individuals with PD in attaining physical autonomy.

The effect of rehabilitation interventions on freezing of gait in people with Parkinson's disease is unclear: a systematic review and meta-analyses

PURPOSE

To summarize the effects of rehabilitation interventions to reduce freezing of gait (FOG) in people with Parkinson's disease.

METHODS

A systematic review with meta-analyses of randomized trials of rehabilitation interventions that reported a FOG outcome was conducted. Quality of included studies and certainty of FOG outcome were assessed using the PEDro scale and GRADE framework.

RESULTS

Sixty-five studies were eligible, with 62 trialing physical therapy/exercise, and five trialing cognitive and/or behavioral therapies. All meta-analyses produced very low-certainty evidence. Physical therapy/exercise had a small effect on reducing FOG post-intervention compared to control (Hedges' g= -0.26, 95% CI= -0.38 to -0.14, 95% prediction interval (PI)= -0.38 to -0.14). We are uncertain of the effects on FOG post-intervention when comparing: exercise with cueing to without cueing (Hedges' g= -0.58, 95% CI= -0.86 to -0.29, 95% PI= -1.23 to 0.08); action observation training plus movement strategy practice to practice alone (Hedges' g= -0.56, 95% CI= -1.16 to 0.05); and dance to multimodal exercises (Hedges' g= -0.64, 95% CI= -1.53 to 0.25).

CONCLUSIONS

We are uncertain if physical therapy/exercise, cognitive or behavioral therapies, are effective at reducing FOG.Implications for rehabilitationFOG leads to impaired mobility and falls, but the effect of rehabilitation interventions (including physical therapy/exercise and cognitive/behavioral therapies) on FOG is small and uncertain.Until more robust evidence is generated, clinicians should assess FOG using both self-report and physical measures, as well as other related impairments such as cognition, anxiety, and fear of falling.Interventions for FOG should be personalized based on the individual's triggers and form part of a broader exercise program addressing gait, balance, and falls prevention.Interventions should continue over the long term and be closely monitored and adjusted as individual circumstances change.

The advantages of artificial intelligence-based gait assessment in detecting, predicting, and managing Parkinson's disease

Background

Parkinson's disease is a neurological disorder that can cause gait disturbance, leading to mobility issues and falls. Early diagnosis and prediction of freeze episodes are essential for mitigating symptoms and monitoring the disease.

Objective

This review aims to evaluate the use of artificial intelligence (AI)-based gait evaluation in diagnosing and managing Parkinson's disease, and to explore the potential benefits of this technology for clinical decision-making and treatment support.

Methods

A thorough review of published literature was conducted to identify studies, articles, and research related to AI-based gait evaluation in Parkinson's disease.

Results

AI-based gait evaluation has shown promise in preventing freeze episodes, improving diagnosis, and increasing motor independence in patients with Parkinson's disease. Its advantages include higher diagnostic accuracy, continuous monitoring, and personalized therapeutic interventions.

Conclusion

AI-based gait evaluation systems hold great promise for managing Parkinson's disease and improving patient outcomes. They offer the potential to transform clinical decision-making and inform personalized therapies, but further research is needed to determine their effectiveness and refine their use.

Patent Review of Lower Limb Rehabilitation Robotic Systems by Sensors and Actuation Systems Used

Robotic systems for lower limb rehabilitation are essential for improving patients' physical conditions in lower limb rehabilitation and assisting patients with various locomotor dysfunctions. These robotic systems mainly integrate sensors, actuation, and control systems and combine features from bionics, robotics, control, medicine, and other interdisciplinary fields. Several lower limb robotic systems have been proposed in the patent literature; some are commercially available. This review is an in-depth study of the patents related to robotic rehabilitation systems for lower limbs from the point of view of the sensors and actuation systems used. The patents awarded and published between 2013 and 2023 were investigated, and the temporal distribution of these patents is presented. Our results were obtained by examining the analyzed information from the three public patent databases. The patents were selected so that there were no duplicates after several filters were used in this review. For each patent database, the patents were analyzed according to the category of sensors and the number of sensors used. Additionally, for the main categories of sensors, an analysis was conducted depending on the type of sensors used. Afterwards, the actuation solutions for robotic rehabilitation systems for upper limbs described in the patents were analyzed, highlighting the main trends in their use. The results are presented with a schematic approach so that any user can easily find patents that use a specific type of sensor or a particular type of actuation system, and the sensors or actuation systems recommended to be used in some instances are highlighted.

Efficacy of rehabilitation robot-assisted gait training on lower extremity dyskinesia in patients with Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Robot-assisted training is used as a new rehabilitation training method for the treatment of motor dysfunction in neurological diseases. Robot-assisted gait training (RAGT) has been reported to treat motor dysfunction in patients with Parkinson's disease (PD). The purpose of this study was to summarize previous clinical studies comparing the effectiveness of RAGT and conventional training for lower extremity dyskinesia in PD patients.

METHODS

PubMed, Cochrane library, Scopus, Embase, EBSCO, Web of Science, CNKI, and Wanfang databases were searched. This study included all randomized controlled trials (RCTs) compared lower extremity RAGT with conventional training on motor impairment in PD patients. The retrieval time limit is from the establishment of the database to October 2022. Two researchers independently screened the literature, extracted data, assessed the risk of bias of included studies, and then used RevMan 5.3 software for meta-analysis.

RESULTS

A total of 14 RCTs with 572 patients were included. The results showed that compared with the control group, RAGT significantly improved the motor function evaluation-related indicators 10MWT, 6MWT, TUG and UPDRS III, 10MWT [MD= 0.08, 95 % CI (0.01, 0.14), P = 0.03], 6MWT [MD= 42.83, 95 % CI (22.05, 63.62), P < 0.0001], TUG[MD= -1.81, 95 % CI (-2.55, -1.08), P < 0.0001], UPDRS III [MD= - 3.82, 95 % CI (-4.27, -3.37), P < 0.00001]; For the balance function evaluation index BBS [MD= 3.33, 95 % CI (2.76, 3.89), P < 0.00001], the above results were significantly different significance.

CONCLUSION

The currently limited evidence suggests that RAGT provides evidence for the effectiveness of lower extremity motor function and balance dysfunction, and RAGT can significantly improve motor and balance function in PD patients.

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.

Evaluation of a novel technology-supported fall prevention intervention - study protocol of a multi-centre randomised controlled trial in older adults at increased risk of falls

BACKGROUND

Increasing number of falls and fall-related injuries in an aging society give rise to the need for effective fall prevention and rehabilitation strategies. Besides traditional exercise approaches, new technologies show promising options for fall prevention in older adults. As a new technology-based approach, the hunova robot can support fall prevention in older adults. The objective of this study is to implement and evaluate a novel technology-supported fall prevention intervention using the hunova robot compared to an inactive control group. The presented protocol aims at introducing a two-armed, multi-centre (four sites) randomised controlled trial, evaluating the effects of this new approach on the number of falls and number of fallers as primary outcomes.

METHODS

The full clinical trial incorporates community-dwelling older adults at risk of falls with a minimum age of 65 years. Including a one-year follow-up measurement, all participants are tested four times. The training programme for the intervention group comprises 24-32 weeks in which training sessions are scheduled mostly twice a week; the first 24 training sessions use the hunova robot, these are followed by a home-based programme of 24 training sessions. Fall-related risk factors as secondary endpoints are measured using the hunova robot. For this purpose, the hunova robot measures the participants' performance in several dimensions. The test outcomes are input for the calculation of an overall score which indicates the fall risk. The hunova-based measurements are accompanied by the timed-up-and-go test as a standard test within fall prevention studies.

DISCUSSION

This study is expected to lead to new insights which may help establish a new approach to fall prevention training for older adults at risk of falls. First positive results on risk factors can be expected after the first 24 training sessions using the hunova robot. As primary outcomes, the number of falls and fallers within the study (including the one-year follow-up period) are the most relevant parameters that should be positively influenced by our new approach to fall prevention. After the study completion, approaches to examine the cost-effectiveness and develop an implementation plan are relevant aspects for further steps.

TRIAL REGISTRATION

German Clinical Trial Register (DRKS), ID: DRKS00025897. Prospectively registered 16 August 2021, https://drks.de/search/de/trial/DRKS00025897 .

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.

[Rehabilitation's possibility of the patients with severe Parkinson's disease]

OBJECTIVE

The application of the individual rehabilitating approach by hypokinesia and lack of physical activity in severe Parkinson's disease patient.

MATERIAL AND METHODS

In the study were 43 patients with Parkinson's disease (17 men and 26 women; at the age 68.39±7.18 years) with 3-4 stage Hoehn and Yahr included. The physical state was previously defined. 10 individual complex lessons with the power exercises, the transfer training with external cueing, flexibility, balance-therapy, preparation of somatoreception to walking and the walking were in patient's stage with walking speed evaluation after the therapy conducted.

RESULTS

Before the treatment 25 (58%) persons could not the test «6 minutes walking» perform, the time of the test «Up and Go» was lengthened and the grip strength was decreased, moreover in women the grip strength was less critical level. After the treatment the all patients participated in the test «6 minutes walking». Walking distance increased by 32.17 meter; p<0.01.

THE CONCLUSION

The individual complex rehabilitation in patient stage's approach in severe Parkinson's disease patient let improve the walking.

Robot-assisted gait training in patients with Parkinson's disease: Implications for clinical practice. A systematic review

BACKGROUND

Gait impairments are common disabling symptoms of Parkinson's disease (PD). Among the approaches for gait rehabilitation, interest in robotic devices has grown in recent years. However, the effectiveness compared to other interventions, the optimum amount of training, the type of device, and which patients might benefit most remains unclear.

OBJECTIVE

To conduct a systematic review about the effects on gait of robot-assisted gait training (RAGT) in PD patients and to provide advice for clinical practice.

METHODS

A search was performed on PubMed, Scopus, PEDro, Cochrane library, Web of science, and guideline databases, following PRISMA guidelines. We included English articles if they used a robotic system with details about the intervention, the parameters, and the outcome measures. We evaluated the level and quality of evidence.

RESULTS

We included twenty papers out of 230 results: two systematic reviews, 9 randomized controlled trials, 4 uncontrolled studies, and 5 descriptive reports. Nine studies used an exoskeleton device and the remainders end-effector robots, with large variability in terms of subjects' disease-related disability.

CONCLUSIONS

RAGT showed benefits on gait and no adverse events were recorded. However, it does not seem superior to other interventions, except in patients with more severe symptoms and advanced disease.

A systematic review of digital technology to evaluate motor function and disease progression in motor neuron disease

Amyotrophic lateral sclerosis (ALS) is the most common subtype of motor neuron disease (MND). The current gold-standard measure of progression is the ALS Functional Rating Scale-Revised (ALS-FRS(R)), a clinician-administered questionnaire providing a composite score on physical functioning. Technology offers a potential alternative for assessing motor progression in both a clinical and research capacity that is more sensitive to detecting smaller changes in function. We reviewed studies evaluating the utility and suitability of these devices to evaluate motor function and disease progression in people with MND (pwMND). We systematically searched Google Scholar, PubMed and EMBASE applying no language or date restrictions. We extracted information on devices used and additional assessments undertaken. Twenty studies, involving 1275 (median 28 and ranging 6-584) pwMND, were included. Sensor type included accelerometers (n = 9), activity monitors (n = 4), smartphone apps (n = 4), gait (n = 3), kinetic sensors (n = 3), electrical impedance myography (n = 1) and dynamometers (n = 2). Seventeen (85%) of studies used the ALS-FRS(R) to evaluate concurrent validity. Participant feedback on device utility was generally positive, where evaluated in 25% of studies. All studies showed initial feasibility, warranting larger longitudinal studies to compare device sensitivity and validity beyond ALS-FRS(R). Risk of bias in the included studies was high, with a large amount of information to determine study quality unclear. Measurement of motor pathology and progression using technology is an emerging, and promising, area of MND research. Further well-powered longitudinal validation studies are needed.

Using gait robotics to improve symptoms of Parkinson's disease: an open-label, pilot randomized controlled trial

BACKGROUND

People with Parkinson's Disease (PD) have difficulty participating in exercise.

AIM

The primary objective of this pilot randomized controlled trial (RCT) was to determine if 8 weeks (2x per week) of bilateral exoskeleton (Exo) exercise results in positive changes in cognition and participation in adults with PD compared to exercising without an exoskeleton (Nxo) or wait-list control (Con).

DESIGN

Open-label, parallel, pilot randomized controlled trial.

SETTING

Neurorehabilitation clinic in a large urban center.

POPULATION

Adults 50-85 years old with a confirmed diagnosis of PD.

METHODS

Eight weeks of twice-weekly combined aerobic, strength and mobility exercise or wait-list control. Participants were randomly assigned to exercise with no exoskeleton (Nxo), exercise with the exoskeleton (Exo), or waitlist control (Con). Primary endpoints were change in cognitive function (SCOPA-COG) and mood. Secondary endpoints were change in gait speed, six-minute walk test (6MWT), freezing of gait, balance, and PD-specific health and quality of life outcomes. Safety endpoint was analysis of adverse events (AE).

RESULTS

Forty participated in the trial (Exo, N.=13; Nxo, N.=14; Con, N.=13). Significant improvement in the Memory & Learning domain of the SCOPA-COG (P=0.014) and 6MWT (P=0.008) were detected for the Exo group compared to the Nxo and/or Con group. No other statistically significant between-groups effects were found. There were no serious or unanticipated AE.

CONCLUSIONS

Functional exercise with a low-profile overground exoskeleton showed promising results for improving memory and gait endurance in people with PD across HY stages I-IV.

CLINICAL REHABILITATION IMPACT

Exoskeletons can improve participation in high-intensity exercise.

Detection and assessment of Parkinson's disease based on gait analysis: A survey

Neurological disorders represent one of the leading causes of disability and mortality in the world. Parkinson's Disease (PD), for example, affecting millions of people worldwide is often manifested as impaired posture and gait. These impairments have been used as a clinical sign for the early detection of PD, as well as an objective index for pervasive monitoring of the PD patients in daily life. This review presents the evidence that demonstrates the relationship between human gait and PD, and illustrates the role of different gait analysis systems based on vision or wearable sensors. It also provides a comprehensive overview of the available automatic recognition systems for the detection and management of PD. The intervening measures for improving gait performance are summarized, in which the smart devices for gait intervention are emphasized. Finally, this review highlights some of the new opportunities in detecting, monitoring, and treating of PD based on gait, which could facilitate the development of objective gait-based biomarkers for personalized support and treatment of PD.

Managing freezing of gait in Parkinson's disease: a systematic review and network meta-analysis

BACKGROUND

Freezing of gait (FOG) is one of the most disabling gait disorders affecting 80% of patients with Parkinson's disease (PD). Clinical guidelines recommend a behavioral approach for gait rehabilitation, but there is a wide diversity of behavioral modalities.

OBJECTIVE

The objective of this network meta-analysis was to compare the effectiveness of different behavioral interventions for FOG management in PD patients.

METHODS

Six databases were searched for randomized controlled trials of behavioral interventions for FOG management among PD patients from 1990 to December 2021. Bayesian network meta-analysis was used to combine both direct and indirect trial evidence on treatment effectiveness, while the surface under the cumulative ranking (SUCRA) score was used to estimate the ranked probability of intervention effectiveness.

RESULTS

Forty-six studies were included in the qualitative synthesis. Among, 36 studies (1454 patients) of 72 interventions or control conditions (12 classes) were included in the network meta-analysis, with a mean intervention period of 10.3 weeks. After adjusting for the moderating effect of baseline FOG severity, obstacle training [SMD -2.1; 95% credible interval (Crl): -3.3, -0.86], gait training with treadmill (SMD -1.2; 95% Crl: -2.0, -0.34), action observation training (SMD -1.0; 95% Crl: -1.9, -0.14), conventional physiotherapy (SMD -0.70; 95% Crl: -1.3, -0.12) and general exercise (SMD -0.64; 95% Crl: -1.2, -0.11) demonstrated significant improvement on immediate FOG severity compared to usual care. The SUCRA rankings suggest that obstacle training, gait training on treadmill and general exercises are most likely to reduce FOG severity.

CONCLUSION

Obstacle training, gait training on treadmill, general exercises, action observation training and conventional physiotherapy demonstrated immediate real-life benefits on FOG symptoms among patients with mild-moderate PD. With the promising findings, the sustained effects of high complexity motor training combined with attentional/cognitive strategy should be further explored. Future trials with rigorous research designs using both subjective and objective outcome measures, long-term follow-up and cost-effective analysis are warranted to establish effective behavioral strategies for FOG management.

Improving Upper Extremity Bradykinesia in Parkinson’s Disease: A Randomized Clinical Trial on the Use of Gravity-Supporting Exoskeletons

Hand movements are particularly impaired in patients with Parkinson’s Disease (PD), contributing to functional disability and difficulties in activities of daily living. Growing evidence has shown that robot-assisted therapy may be considered an effective and reliable method for the delivery of the highly repetitive training that is needed to trigger neuroplasticity, as intensive, repetitive and task-oriented training could be an ideal strategy to facilitate the relearning of motor function and to minimize motor deficit. The purpose of this study is to evaluate the improvement of hand function with semi-autonomous exercises using an upper extremity exoskeleton in patients with PD. A multicenter, parallel-group, randomized clinical trial was then carried out at the IRCCS Centro Neurolesi Bonino-Pulejo (Messina, Italy). Thirty subjects with a diagnosis of PD and a Hoehn–Yahr score between 2 and 3 were enrolled in the study. Patients were 1:1 randomized into either the experimental group (ERT), receiving 45 min training daily, 6 days weekly, for 8 weeks with Armeo^®Spring (Volketswil, Switzerland) (a gravity-supporting device), or the control group (CPT), which was subjected to the same amount of conventional physical therapy. Motor abilities were assessed before and after the end of the training. The main outcomes measures were the Nine-hole peg test and the motor section of the UPDRS. All patients belonging to ERT and 9 out of 15 patients belonging to the CPT completed the trial. ERT showed a greater improvement in the primary outcome measure (nine-hole peg test) than CPT. Moreover, a statistically significant improvement was found in ERT concerning upper limb mobility, and disease burden as compared to CPT. Using an upper extremity exoskeleton (i.e., the Armeo^®Spring) for semi-autonomous training in an inpatient setting is a new perspective to train patients with PD to improve their dexterity, executive function and, potentially, quality of life.

Artificial intelligence applications and robotic systems in Parkinson's disease (Review)

Parkinson's disease (PD) is the second most frequent neurodegenerative disorder following Alzheimer's disease. Advanced stages of PD, 4 or 5 of the Hoehn and Yahr Scale, are characterized by severe motor complications, limited mobility without assistance, risk of falling, and non-motor complications. The aim of this review was to provide a practical overview on specific artificial intelligence (AI) systems for the management of advanced stages of PD, as well as relevant technological limitations. The authors conducted a systematic search on PubMed and EMBASE with predefined keywords searching for studies published until December 2020. Full articles that satisfied the inclusion criteria were included in the systematic review. To minimize results bias, the reference list was manually searched for pertinent articles to identify any additional relevant missed publications. Exclusion criteria included the following: Other stages of PD than 4 and 5 of the Hoehn and Yahr Scale, case reports, reviews, practice guidelines, commentaries, opinions, letters, editorials, short surveys, articles in press, conference abstracts, conference papers, and abstracts published without a full article. The search identified 21 studies analyzing AI-based applications and robotic systems used for the management of advanced stages of PD, out of which 6 articles analyzed AI-based applications for autonomous management of pharmacologic therapy, 5 articles analyzed home-based telemedicine systems and 10 articles analysed robot-assisted gait training systems. The authors identified significant evidence demonstrating that current AI-based technologies are feasible for automatic management of patients with advanced stages of PD. Improving the quality of care and reducing the cost for patients and healthcare systems are the most important advantages.

Identification of the Exercise Load When Using a Balance Exercise Assist Robot

Objectives:

The Balance Exercise Assist Robot (BEAR) is a boarding-type robot developed to improve users’ balance performance. However, the exercise load experienced by users of the BEAR remains unclear. Therefore, this study aimed to identify the exercise load of BEAR users.

Methods:

Recruited healthy participants were fitted with an expiratory gas analyzer, and instructed to control the avatar displayed on the computer monitor by shifting their weight on the BEAR. Three types of activity (tennis, skiing, and rodeo) were prepared for the BEAR, and the difficulty of each activity had 40 levels. Each balance exercise for each level lasted for 90 s. The BEAR was administered at levels 1, 5, 10, and then up to 40 in steps of 5 for each activity. The major parameters that were evaluated were oxygen consumption (grossVO₂, netVO₂), metabolic equivalents (METs), and heart rate (HR). Two-way analysis of variance with Tukey’s post hoc test was applied to each level of each activity.

Results:

Fourteen healthy participants were recruited. For the rodeo activity, netVO₂ and MET values were significantly higher than those for tennis and skiing at level 20 (tennis vs. skiing vs. rodeo: netVO₂ 114.0±59.7 vs. 160.6±71.1 vs. 205.6±82.9, METs 1.47±0.22 vs. 1.72±0.37 vs. 1.90±0.29) and higher. Furthermore, comparisons within activity types showed that at level 40, netVO₂ and MET were significantly higher than for level 1. The exercise intensity was found to increase along with the exercise level for all three activity types, with rodeo being the highest at 2.74 METs.

Conclusions:

The current findings show that the BEAR can be used for balance practice without generating excessive cardiopulmonary stress.

Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association

A clinical practice guideline on Parkinson disease was developed by an American Physical Therapy Association volunteer guideline development group that consisted of physical therapists and a neurologist. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches for management of Parkinson disease. The Spanish version of this clinical practice guideline is available as a supplement (Suppl. Appendix 1).

Robot-assisted gait training with auditory and visual cues in Parkinson's disease: a randomized controlled trial

BACKGROUND

Robot-assisted gait training (RAGT) may have beneficial effects on Parkinson's disease (PD); however, the evidence to date is inconsistent.

OBJECTIVES

This study compared the effects of RAGT and treadmill training (TT) on gait speed, dual-task gait performance, and changes in resting-state brain functional connectivity in individuals with PD.

METHODS

In this prospective, single-center, randomized controlled trial with a parallel two-group design, 44 participants were randomly allocated to undergo 12 sessions (3 times per week for 4 weeks) of RAGT or TT. The primary outcome was gait speed on the 10-m walk test (10mWT) under comfortable walking conditions. Secondary outcomes included dual-task interference on gait speed, balance, disability scores, fear of falling, freezing of gait, and brain functional connectivity changes. All clinical outcomes were measured before (T0), immediately after (T1), and 1 month after treatment (T2).

RESULTS

The mean (SD) age of the participants was 68.1 (8.1) years, and mean disease duration 108.0 (61.5) months. The groups did not significantly differ on the 10mWT (T0-T1, p=0.726, Cohen's d=0.133; T0-T2, p=0.778, Cohen's d=0.121). We observed a significant time-by-group interaction (F=3.236, p=0.045) for cognitive dual-task interference, controlling for confounders. After treatment, coupling was decreased to a greater extent with RAGT than TT between the visual and dorsal attention networks (p=0.015), between bilateral fronto-parietal networks (p=0.043), and between auditory and medial temporal networks (p=0.018). Improvement in cognitive dual-task interference was positively correlated with enhanced visual and medial temporal network coupling overall (r=0.386, p=0.029) and with TT (r=0.545, p=0.024) but not RAGT (r=0.151, p=0.590).

CONCLUSIONS

RAGT was not superior to intensity-matched TT on improving gait functions in individuals with PD but may be beneficial in improving gait ability under cognitive dual-task conditions. The therapeutic mechanism and key functional connectivity changes associated with improvement may differ between treatment strategies.

Technology-Based Neurorehabilitation in Parkinson’s Disease—A Narrative Review

This narrative review provides a brief overview of the current literature on technology-based interventions for the neurorehabilitation of persons with Parkinson’s disease (PD). The role of brain–computer interfaces, exergaming/virtual-reality-based exercises, robot-assisted therapies and wearables is discussed. It is expected that technology-based neurorehabilitation will gain importance in the management of PD patients, although it is often not clear yet whether this approach is superior to conventional therapies. High-intensity technology-based neurorehabilitation may hold promise with respect to neuroprotective or neurorestorative actions in PD. Overall, more research is required in order to obtain more data on the feasibility, efficacy and safety of technology-based neurorehabilitation in persons with PD.

A systematic review on exercise and training-based interventions for freezing of gait in Parkinson's disease

Freezing of gait (FOG) in Parkinson's disease (PD) causes severe patient burden despite pharmacological management. Exercise and training are therefore advocated as important adjunct therapies. In this meta-analysis, we assess the existing evidence for such interventions to reduce FOG, and further examine which type of training helps the restoration of gait function in particular. The primary meta-analysis across 41 studies and 1838 patients revealed a favorable moderate effect size (ES = -0.37) of various training modalities for reducing subjective FOG-severity (p < 0.00001), though several interventions were not directly aimed at FOG and some included non-freezers. However, exercise and training also proved beneficial in a secondary analysis on freezers only (ES = -0.32, p = 0.007). We further revealed that dedicated training aimed at reducing FOG episodes (ES = -0.24) or ameliorating the underlying correlates of FOG (ES = -0.40) was moderately effective (p < 0.01), while generic exercises were not (ES = -0.14, p = 0.12). Relevantly, no retention effects were seen after cessation of training (ES = -0.08, p = 0.36). This review thereby supports the implementation of targeted training as a treatment for FOG with the need for long-term engagement.

Gait training with a wearable curara® robot for cerebellar ataxia: a single-arm study

Background

Ataxic gait is one of the most common and disabling symptoms in people with degenerative cerebellar ataxia. Intensive and well-coordinated inpatient rehabilitation improves ataxic gait. In addition to therapist-assisted gait training, robot-assisted gait training has been used for several neurological disorders; however, only a small number of trials have been conducted for degenerative cerebellar ataxia. We aimed to validate the rehabilitative effects of a wearable “curara®” robot developed in a single-arm study of people with degenerative cerebellar ataxia.

Methods

Twenty participants with spinocerebellar ataxia or multiple system atrophy with predominant cerebellar ataxia were enrolled. The clinical trial duration was 15 days. We used a curara® type 4 wearable robot for gait training. We measured the following items at days 0, 7, and 14: Scale for the Assessment and Rating of Ataxia, 10-m walking time (10 mWT), 6-min walking distance (6 mWD), and timed up and go test. Gait parameters (i.e., stride duration and length, standard deviation of stride duration and length, cadence, ratio of the stance and swing phases, minimum and maximum knee joint angles, and minimum and maximum hip joint angles) were obtained using a RehaGait®. On days 1–6 and 8–13, the participants were instructed to conduct gait training for 30 ± 5 min with curara®. We calculated the improvement rate as the difference of values between days 14 and 0 divided by the value on day 0. Differences in the gait parameters were analyzed using a generalized linear mixed model with Bonferroni’s correction.

Results

Data from 18 participants were analyzed. The mean improvement rate of the 10 mWT and 6 mWD was 19.0% and 29.0%, respectively. All gait parameters, except the standard deviation of stride duration and length, improved on day 14.

Conclusions

Two-week RAGT with curara® has rehabilitative effects on gait function comparable to those of therapist-assisted training. Although the long-term effects after a month of RAGT with curara® are unclear, curara® is an effective tool for gait training of people with degenerative ataxia.

Trial registration jRCT, jRCTs032180164. Registered: 27 February 2019; retrospectively registered. https://jrct.niph.go.jp/en-latest-detail/jRCTs032180164.

Effects of robot-assisted gait training on postural instability in Parkinson's disease: a systematic review

INTRODUCTION

Postural instability is a cardinal feature of Parkinson's disease, together with rest tremor, rigidity and bradykinesia. It is a highly disabling symptom that becomes increasingly common with disease progression and represents a major source of reduced quality of life in patients with Parkinson's disease. Rehabilitation aims to enable patients with Parkinson's disease to maintain their maximum level of mobility, activity and independence. To date, a wide range of rehabilitation approaches has been employed to treat postural instability in Parkinson's disease, including robotic training. Our main aim was to conduct a systematic review of current literature about the effects of robot-assisted gait training on postural instability in patients with Parkinson's disease.

EVIDENCE ACQUISITION

A systematic search using the following MeSH terms "Parkinson disease," "postural balance," "robotics," "rehabilitation" AND string "robotics [mh]" OR "robot-assisted" OR "electromechanical" AND "rehabilitation [mh]" OR "training" AND "postural balance [mh]" was conducted on PubMed, Cochrane Library and Pedro electronic databases. Full text articles in English published up to December 2020 were included. Data about patient characteristics, robotic devices, treatment procedures and outcome measures were considered. Every included article got checked for quality. Level of evidence was defined for all studies.

EVIDENCE SYNTHESIS

Three authors independently extracted and verified data. In total, 18 articles (2 systematic reviews, 9 randomized controlled trials, 4 uncontrolled studies and 3 case series/case reports) were included. Both end-effector and exoskeleton devices were investigated as to robot-assisted gait training modalities. No clear relationship between treatment parameters and clinical conditions was observed. We found a high level of evidence about the effects of robot-assisted gait training on balance and freezing of gait in patients with Parkinson's disease.

CONCLUSIONS

This systematic review provides to the reader a complete overview of current literature and levels of evidence about the effects of robot-assisted gait training on postural instability issues (static and dynamic balance, freezing of gait, falls, confidence in activities of daily living and gait parameters related to balance skills) in patients with Parkinson's disease.

Functional Gait Recovery after a Combination of Conventional Therapy and Overground Robot-Assisted Gait Training Is Not Associated with Significant Changes in Muscle Activation Pattern: An EMG Preliminary Study on Subjects Subacute Post Stroke

Background: Overground Robot-Assisted Gait Training (o-RAGT) appears to be a promising stroke rehabilitation in terms of clinical outcomes. The literature on surface ElectroMyoGraphy (sEMG) assessment in o-RAGT is limited. This paper aimed to assess muscle activation patterns with sEMG in subjects subacute post stroke after training with o-RAGT and conventional therapy. Methods: An observational preliminary study was carried out with subjects subacute post stroke who received 15 sessions of o-RAGT (5 sessions/week; 60 min) in combination with conventional therapy. The subjects were assessed with both clinical and instrumental evaluations. Gait kinematics and sEMG data were acquired before (T1) and after (T2) the period of treatment (during ecological gait), and during the first session of o-RAGT (o-RAGT₁). An eight-channel wireless sEMG device acquired in sEMG signals. Significant differences in sEMG outcomes were found in the BS of TA between T1 and T2. There were no other significant correlations between the sEMG outcomes and the clinical results between T1 and T2. Conclusions: There were significant functional gains in gait after complex intensive clinical rehabilitation with o-RAGT and conventional therapy. In addition, there was a significant increase in bilateral symmetry of the Tibialis Anterior muscles. At this stage of the signals from the tibialis anterior (TA), gastrocnemius medialis (GM), rectus femoris (RF), and biceps femoris caput longus (BF) muscles of each lower extremity. sEMG data processing extracted the Bilateral Symmetry (BS), the Co-Contraction (CC), and the Root Mean Square (RMS) coefficients. Results: Eight of 22 subjects in the subacute stage post stroke agreed to participate in this sEMG study. This subsample demonstrated a significant improvement in the motricity index of the affected lower limb and functional ambulation. The heterogeneity of the subjects’ characteristics and the small number of subjects was associated with high variability research, functional gait recovery was associated with minimal change in muscle activation patterns.

Body Weight Support Gait Training for Patients With Parkinson Disease: A Systematic Review and Meta-analyses

OBJECTIVE

To determine the effectiveness of body weight support (BWS) gait training to improve the clinical severity, gait, and balance in patients with Parkinson disease (PD).

DATA SOURCES

A literature search was conducted until July 2020 in MEDLINE, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Randomized controlled trials that aimed at determining the effectiveness of physical activity interventions with BWS during gait training in patients with PD.

DATA EXTRACTION

The methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool (RoB 2.0). Effect size (ES) and 95% confidence intervals [CIs] were calculated for the Unified Parkinson Disease Rating Scale (UPDRS), the UPDRS section III, the 6-minute walk test (6MWT), gait parameters (ie, velocity, cadence, stride length), and the Berg Balance Scale (BBS).

DATA SYNTHESIS

Twelve studies were included in the systematic review. The pooled ES for the effect of BWS on total UPDRS was -0.35 (95% CI, -0.57 to -0.12; I²=1.9%, P=.418), whereas for UPDRS III it was -0.35 (95% CI, -0.68 to -0.01; I²=66.4 %, P<.001). Furthermore, the pooled ES for 6MWT was 0.56 (95% CI, -0.07 to 1.18; I²=77.1%, P=.002), for gait velocity was 0.37 (95% CI, -0.10 to 0.84); I²=78.9%, P<.001), for cadence was 0.03 (95% CI, -0.25 to 0.30; I²=0.0%, P=.930), for stride length was 1.00 (95% CI, 0.23 to 1.78; I²=79.5%, P=.001), and for BBS was 0.65 (95% CI, 0.30, 0.99; I²=51.8%, P=.042).

CONCLUSIONS

Interventions with BWS could improve the general and motor clinical severity of patients with PD, as well as other parameters such as stride length and balance. However, the effect does not appear to be statistically significant in improving gait parameters such as velocity, cadence, and distance.

Gait Recovery with an Overground Powered Exoskeleton: A Randomized Controlled Trial on Subacute Stroke Subjects

BACKGROUND

Overground Robot-Assisted Gait Training (o-RAGT) provides intensive gait rehabilitation. This study investigated the efficacy of o-RAGT in subacute stroke subjects, compared to conventional gait training.

METHODS

A multicenter randomized controlled trial was conducted on 75 subacute stroke subjects (38 in the Experimental Group (EG) and 37 in the Control Group (CG)). Both groups received 15 sessions of gait training (5 sessions/week for 60 min) and daily conventional rehabilitation. The subjects were assessed at the beginning (T1) and end (T2) of the training period with the primary outcome of a 6 Minutes Walking Test (6MWT), the Modified Ashworth Scale of the Affected lower Limb (MAS-AL), the Motricity Index of the Affected lower Limb (MI-AL), the Trunk Control Test (TCT), Functional Ambulation Classification (FAC), a 10 Meters Walking Test (10MWT), the modified Barthel Index (mBI), and the Walking Handicap Scale (WHS).

RESULTS

The 6MWT increased in both groups, which was confirmed by both frequentist and Bayesian analyses. Similar outcomes were registered in the MI-AL, 10MWT, mBI, and MAS-AL. The FAC and WHS showed a significant number of subjects improving in functional and community ambulation in both groups at T2.

CONCLUSIONS

The clinical effects of o-RAGT were similar to conventional gait training in subacute stroke subjects. The results obtained in this study are encouraging and suggest future clinical trials on the topic.

Rehabilitation of older people with Parkinson's disease: an innovative protocol for RCT study to evaluate the potential of robotic-based technologies

Background

Parkinson’s disease is one of the most frequent causes of disability among the older adults. It is a chronic-progressive neuro-degenerative disease, characterized by several motor disorders. Balance disorders are a symptom that involves the body axis and do not respond to dopaminergic therapy used in Parkinson’s disease. Therefore, physiotherapy becomes an important intervention for the management of motor disorders. Originally, these rehabilitative approaches were based on empirical experiences, but several scientific evidences suggests that neuronal plasticity is exercise-dependent. In this context, robotic rehabilitation plays an important role because it allows to perform task-oriented exercises and to increase the number of repetitions and their intensity. This protocol study aims to evaluate the effectiveness of robotic-based intervention of the older adults with Parkinson’s disease, designed to improve the gait and to reduce the risk of falling.

Methods

This study is a single-blinded randomized controlled trial. The primary outcomes are: risk of falling, gait performance and fear of falling measured through Performance-Oriented Mobility Assessment (POMA), instrumental gait analysis and Short Falls Efficacy Scale – International (FES-I), respectively. One hundred ninety-five patients with PD will be recruited and randomly divided into three groups, to receive a traditional rehabilitation program or a robotic rehabilitation using Tymo system or Walker View in addition to the traditional therapy. Assessments will be performed at baseline, at the end of treatment and 6 months, 1 year and 2 years from the end of the treatment. A 10-treatment session will be conducted, divided into 2 training sessions per week, for 5 weeks. The control group will perform traditional therapy sessions lasting 50 min. The technological intervention group will carry out 30 min of traditional therapy and 20 min of treatment with a robotic system.

Discussion

The final goals of the present study are to propose a new approach in the PD rehabilitation, focused on the use of robotic device, and to check the results not only at the end of the treatment but also in the long term.

Trial registration

NCT04087031, registration date September 12, 2019.

Wearable Solutions for Patients with Parkinson's Disease and Neurocognitive Disorder: A Systematic Review

Prevalence of neurocognitive diseases in adult patients demands the use of wearable devices to transform the future of mental health. Recent development in wearable technology proclaimed its use in diagnosis, rehabilitation, assessment, and monitoring. This systematic review presents the state of the art of wearables used by Parkinson’s disease (PD) patients or the patients who are going through a neurocognitive disorder. This article is based on PRISMA guidelines, and the literature is searched between January 2009 to January 2020 analyzing four databases: PubMed, IEEE Xplorer, Elsevier, and ISI Web of Science. For further validity of articles, a new PEDro-inspired technique is implemented. In PEDro, five statistical indicators were set to classify relevant articles and later the citations were also considered to make strong assessment of relevant articles. This led to 46 articles that met inclusion criteria. Based on them, this systematic review examines different types of wearable devices, essential in improving early diagnose and monitoring, emphasizing their role in improving the quality of life, differentiating the various fitness and gait wearable-based exercises and their impact on the regression of disease and on the motor diagnosis tests and finally addressing the available wearable insoles and their role in rehabilitation. The research findings proved that sensor based wearable devices, and specially instrumented insoles, help not only in monitoring and diagnosis but also in tracking numerous exercises and their positive impact towards the improvement of quality of life among different Parkinson and neurocognitive patients.

Biofeedback Core Exercise Using Hybrid Assistive Limb for Physical Frailty Patients With or Without Parkinson's Disease

Introduction: Elderly people often exhibit "frailty," and motor dysfunction occurs. Several studies have reported about the relationship between motor dysfunction and frailty in Parkinson's disease (PD). This study aimed to test whether the core exercise using the hybrid assistive limb lumbar type for care support (HAL-CB02) may improve the motor functions in frailty patients with or without PD and to explore the optimal patient selection from the frailty cohort. Materials and Methods: We recruited 16 frailty patients (PD = 8; non-PD = 8). The participants performed core exercise and squats using HAL-CB02 for five sessions a week. Outcome measures were 10-m walking test, step length, timed up-and-go test, 30-s chair stand test, and visual analog scale. Evaluation was conducted at baseline, post-exercise, and 1- and 3-month follow-ups. Results: Both PD and non-PD patients showed significant improvement in all evaluation items post-exercise. Moreover, no significant difference was found in the improvement value between the two groups. Conclusions: Our results suggest that biofeedback exercise with HAL-CB02 is a safe and promising treatment for frailty patients. Motor dysfunction in PD patients may be partly due to physical frailty, and biofeedback exercise with HAL-CB02 is proposed as a treatment option.