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van Dellen F, Labruyère R. Settings matter: a scoping review on parameters in robot-assisted gait therapy identifies the importance of reporting standards. J Neuroeng Rehabil 2022; 19:40. [PMID: 35459246 PMCID: PMC9034544 DOI: 10.1186/s12984-022-01017-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 04/04/2022] [Indexed: 12/02/2022] Open
Abstract
Background Lokomat therapy for gait rehabilitation has become increasingly popular. Most evidence suggests that Lokomat therapy is equally effective as but not superior to standard therapy approaches. One reason might be that the Lokomat parameters to personalize therapy, such as gait speed, body weight support and Guidance Force, are not optimally used. However, there is little evidence available about the influence of Lokomat parameters on the effectiveness of the therapy. Nevertheless, an appropriate reporting of the applied therapy parameters is key to the successful clinical transfer of study results. The aim of this scoping review was therefore to evaluate how the currently available clinical studies report Lokomat parameter settings and map the current literature on Lokomat therapy parameters. Methods and results A systematic literature search was performed in three databases: Pubmed, Scopus and Embase. All primary research articles performing therapy with the Lokomat in neurologic populations in English or German were included. The quality of reporting of all clinical studies was assessed with a framework developed for this particular purpose. We identified 208 studies investigating Lokomat therapy in patients with neurologic diseases. The reporting quality was generally poor. Less than a third of the studies indicate which parameter settings have been applied. The usability of the reporting for a clinical transfer of promising results is therefore limited. Conclusion Although the currently available evidence on Lokomat parameters suggests that therapy parameters might have an influence on the effectiveness, there is currently not enough evidence available to provide detailed recommendations. Nevertheless, clinicians should pay close attention to the reported therapy parameters when translating research findings to their own clinical practice. To this end, we propose that the quality of reporting should be improved and we provide a reporting framework for authors as a quality control before submitting a Lokomat-related article. Supplementary Information The online version contains supplementary material available at 10.1186/s12984-022-01017-3.
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Affiliation(s)
- Florian van Dellen
- Sensory-Motor Systems Lab, Department of Health Sciences and Technology, ETH Zurich, Tannenstrasse 1, 8092, Zurich, Switzerland. .,Swiss Children's Rehab, University Children's Hospital Zurich, Mühlebergstrasse 104, 8910, Affoltern am Albis, Switzerland. .,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland.
| | - Rob Labruyère
- Swiss Children's Rehab, University Children's Hospital Zurich, Mühlebergstrasse 104, 8910, Affoltern am Albis, Switzerland.,Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Steinwiesstrasse 75, 8032, Zurich, Switzerland
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Effects of body weight support and guidance force settings on muscle synergy during Lokomat walking. Eur J Appl Physiol 2021; 121:2967-2980. [PMID: 34218291 DOI: 10.1007/s00421-021-04762-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/29/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND The Lokomat is a robotic device that has been suggested to make gait therapy easier, more comfortable, and more efficient. In this study, we asked whether the Lokomat promotes physiological muscle activation patterns, a fundamental question when considering motor learning and adaptation. METHODS We investigated lower limb muscles coordination in terms of muscle activity level, muscle activity pattern similarity, and muscle synergy in 15 healthy participants walking at 3 km/h on either a treadmill or in a Lokomat at various guidance forces (GF: 30, 50 or 70%) and body weight supports (BWS: 30, 50 or 70% of participant's body weight). RESULTS Walking in the Lokomat was associated with a greater activation level of the rectus femoris and vastus medialis (×2-3) compared to treadmill walking. The level of activity tended to be diminished in gastrocnemius and semi-tendinosus, which particularly affected the similarity with treadmill walking (normalized scalar product NSP = 0.7-0.8). GF and BWS independently altered the muscle activation pattern in terms of amplitude and shape. Increasing BWS decreased the level of activity in all but one muscle (the soleus). Increasing GF slightly improved the similarity with treadmill walking for the tibialis anterior and vastus medialis muscles. The muscle synergies (N = 4) were similar (NSP = 0.93-0.97), but a cross-validation procedure revealed an alteration by the Lokomat. The activation of these synergies differed (NSP = 0.74-0.82). CONCLUSION The effects of GF and BWS are modest compared to the effect of the Lokomat itself, suggesting that Lokomat design should be improved to promote more typical muscle activity patterns.
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Stampacchia G, Olivieri M, Rustici A, D'Avino C, Gerini A, Mazzoleni S. Gait rehabilitation in persons with spinal cord injury using innovative technologies: an observational study. Spinal Cord 2020; 58:988-997. [PMID: 32251368 DOI: 10.1038/s41393-020-0454-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Prospective, quasi-experimental study, pre- and post-design, single arm study. OBJECTIVES Investigate whether persons affected by SCI can safely experience walking function using Robotic Exoskeletons and Functional Electrical Stimulation (FES). SETTING Inpatient METHODS: 52 persons with SCI were recruited (36 completed the protocol) and assigned to one of two groups based on their Lower Limb Motor Scores (LEMS): Group A: LEMS ≥ 10 and Group B: LEMS < 10. Participants in Group A (n = 19) underwent 20 sessions of Robot-Assisted Gait Training (RAGT) on a treadmill followed by 20 sessions of FES during Overground Gait (FES-OG). Participants in Group B (n = 17) received 20 sessions of FES-cycling followed by 20 sessions of overground RAGT. The main outcome measures were: WISCI-II, 10MWT, 6MWT, TUG and SCIM-II. RESULTS 36 persons completed the study with no complications; only 4 of the 16 dropped out because of mild complications during the RAGT. Participants in Group A exhibited significant improvements in WISCI-II, 10MWT, 6MWT and TUG (p < 0.05), while those in Group B did not significantly improve their gait function but their walking velocity and resistance with the assistance of the robotic exoskeleton increased. SCIM-II scores increased followed therapy only in Group A. CONCLUSIONS Persons affected by SCI can safely experience their walking function with RAGT and FES therapy; only few mild complications were observed. Our data provides initial evidence of the potential value of these technologies, especially in persons with SCI having LEMS > 10.
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Affiliation(s)
| | | | | | - Carla D'Avino
- Spinal Cord Unit, Pisa University Hospital, Pisa, Italy
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Korupolu R, Stampas A, Singh M, Zhou P, Francisco G. Electrophysiological Outcome Measures in Spinal Cord Injury Clinical Trials: A Systematic Review. Top Spinal Cord Inj Rehabil 2020; 25:340-354. [PMID: 31844386 DOI: 10.1310/sci2504-340] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Electrophysiological measures are being increasingly utilized due to their ability to provide objective measurements with minimal bias and to detect subtle changes with quantitative data on neural function. Heterogeneous reporting of trial outcomes limits effective interstudy comparison and optimization of treatment. Objective: The objective of this systematic review is to describe the reporting of electrophysiological outcome measures in spinal cord injury (SCI) clinical trials in order to inform a subsequent consensus study. Methods: A systematic search of PubMed and EMBASE databases was conducted according to PRISMA guidelines. Adult human SCI clinical trials published in English between January 1, 2008 and September 15, 2018 with at least one electrophysiological outcome measure were eligible. Findings were reviewed by all authors to create a synthesis narrative describing each outcome measure. Results: Sixty-four SCI clinical trials were included in this review. Identified electrophysiological outcomes included electromyography activity (44%), motor evoked potentials (33%), somatosensory evoked potentials (33%), H-reflex (20%), reflex electromyography activity (11%), nerve conduction studies (9%), silent period (3%), contact heat evoked potentials (2%), and sympathetic skin response (2%). Heterogeneity was present in regard to both methods of measurement and reporting of electrophysiological outcome measures. Conclusion: This review demonstrates need for the development of a standardized reporting set for electrophysiological outcome measures. Limitations of this review include exclusion of non-English publications, studies more than 10 years old, and an inability to assess methodological quality of primary studies due to a lack of guidelines on reporting of systematic reviews of outcome measures.
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Affiliation(s)
- Radha Korupolu
- Department of Physical Medicine and Rehabilitation, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas
| | - Argyrios Stampas
- Department of Physical Medicine and Rehabilitation, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas
| | - Mani Singh
- Department of Physical Medicine and Rehabilitation, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas
| | - Ping Zhou
- Department of Physical Medicine and Rehabilitation, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas
| | - Gerard Francisco
- Department of Physical Medicine and Rehabilitation, University of Texas John P and Katherine G McGovern Medical School, Houston, Texas
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Effects of Robot-Assisted Gait Training in Individuals with Spinal Cord Injury: A Meta-analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2102785. [PMID: 32280681 PMCID: PMC7115057 DOI: 10.1155/2020/2102785] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022]
Abstract
Background To investigate the effects of robot-assisted gait training (RAGT) on spasticity and pain in people with spinal cord injury (SCI). Material and methods. Four electronic databases (PubMed, Scopus, Medline, and Cochrane Central Register of Controlled Trials) were searched for studies published up to November 2019. Only human trials and of English language were included. The searched studies were reviewed and extracted independently by two authors. Randomized controlled trials (RCTs) and non-RCTs were pooled separately for analyses. Primary outcome measures included spasticity assessed by Ashworth scale (AS) or modified Ashworth scale (MAS) and pain assessed by VAS. Secondary outcome measures included lower extremity motor score (LEMS) and walking ability (i.e., 6-minute walk test, 10-meter walk test). Results A total of 225 studies were identified. Eighteen studies (7 RCTs and 11 non-RCTs) including 301 subjects met inclusion criteria. The outcome measure of spasticity significantly improved in favor of RAGT group in non-RCTs (AS: 95%CI = −0.202 to -0.068, p ≤ 0.001; MAS: 95%CI = −2.886 to -1.412, p ≤ 0.001). The results on pain did not show significant change after RAGT in either RCTs or non-RCTs. LEMS and walking ability significantly increased in favor of RAGT. Conclusions RAGT can improve spasticity and walking ability in people with SCI. The probable reason for no significant change in pain after RAGT is floor effect. RAGT is beneficial for normalizing muscle tone and for improving lower extremity function in people with SCI without causing extra pain.
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van Kammen K, Boonstra AM, van der Woude LHV, Reinders-Messelink HA, den Otter R. Differences in muscle activity and temporal step parameters between Lokomat guided walking and treadmill walking in post-stroke hemiparetic patients and healthy walkers. J Neuroeng Rehabil 2017; 14:32. [PMID: 28427422 PMCID: PMC5397709 DOI: 10.1186/s12984-017-0244-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 04/13/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The Lokomat is a robotic exoskeleton that can be used to train gait function in hemiparetic stroke. To purposefully employ the Lokomat for training, it is important to understand (1) how Lokomat guided walking affects muscle activity following stroke and how these effects differ between patients and healthy walkers, (2) how abnormalities in the muscle activity of patients are modulated through Lokomat guided gait, and (3) how temporal step characteristics of patients were modulated during Lokomat guided walking. METHODS Ten hemiparetic stroke patients (>3 months post-stroke) and ten healthy age-matched controls walked on the treadmill and in the Lokomat (guidance force 50%, no bodyweight support) at matched speeds (0.56 m/s). Electromyography was used to record the activity of Gluteus Medius, Biceps Femoris, Vastus Lateralis, Medial Gastrocnemius and Tibialis Anterior, bilaterally in patients and of the dominant leg in healthy walkers. Pressure sensors placed in the footwear were used to determine relative durations of the first double support and the single support phases. RESULTS Overall, Lokomat guided walking was associated with a general lowering of muscle activity compared to treadmill walking, in patients as well as healthy walkers. The nature of these effects differed between groups for specific muscles, in that reductions in patients were larger if muscles were overly active during treadmill walking (unaffected Biceps Femoris and Gluteus Medius, affected Biceps Femoris and Vastus Lateralis), and smaller if activity was already abnormally low (affected Medial Gastrocnemius). Also, Lokomat guided walking was associated with a decrease in asymmetry in the relative duration of the single support phase. CONCLUSIONS In stroke patients, Lokomat guided walking results in a general reduction of muscle activity, that affects epochs of overactivity and epochs of reduced activity in a similar fashion. These findings should be taken into account when considering the clinical potential of the Lokomat training environment in stroke, and may inform further developments in the design of robotic gait trainers.
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Affiliation(s)
- Klaske van Kammen
- University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, P.O. Box 196 21, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands. .,Rehabilitation Center 'Revalidatie Friesland', Beetsterzwaag, The Netherlands.
| | - Anne M Boonstra
- Rehabilitation Center 'Revalidatie Friesland', Beetsterzwaag, The Netherlands
| | - Lucas H V van der Woude
- University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, P.O. Box 196 21, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands.,University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, The Netherlands
| | - Heleen A Reinders-Messelink
- Rehabilitation Center 'Revalidatie Friesland', Beetsterzwaag, The Netherlands.,University of Groningen, University Medical Center Groningen, Center for Rehabilitation, Groningen, The Netherlands
| | - Rob den Otter
- University of Groningen, University Medical Center Groningen, Center for Human Movement Sciences, P.O. Box 196 21, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
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Mirbagheri MM, Kindig MW, Niu X. Effects of robotic-locomotor training on stretch reflex function and muscular properties in individuals with spinal cord injury. Clin Neurophysiol 2014; 126:997-1006. [PMID: 25449559 DOI: 10.1016/j.clinph.2014.09.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 09/03/2014] [Accepted: 09/04/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We sought to determine the therapeutic effect of robotic-assisted step training (RAST) on neuromuscular abnormalities associated with spasticity by characterization of their recovery patterns in people with spinal cord injury (SCI). METHODS Twenty-three motor-incomplete SCI subjects received one-hour RAST sessions three times per week for 4 weeks, while an SCI control group received no training. Neuromuscular properties were assessed using ankle perturbations prior to and during the training, and a system-identification technique quantified stretch reflex and intrinsic stiffness magnitude and modulation with joint position. Growth-mixture modeling classified subjects based on similar intrinsic and reflex recovery patterns. RESULTS All recovery classes in the RAST group presented significant (p<0.05) reductions in intrinsic and reflex stiffness magnitude and modulation with position; the control group presented no changes over time. Subjects with larger baseline abnormalities exhibited larger reductions, and over longer training periods. CONCLUSIONS Our findings demonstrate that RAST can effectively reduce neuromuscular abnormalities, with greater improvements for subjects with higher baseline abnormalities. SIGNIFICANCE Our findings suggest, in addition to its primary goal of improving locomotor patterns, RAST can also reduce neuromuscular abnormalities associated with spasticity. These findings also demonstrate that these techniques can be used to characterize neuromuscular recovery patterns in response to various types of interventions.
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Affiliation(s)
- Mehdi M Mirbagheri
- Department of Physical Medicine and Rehabilitation, Northwestern University, USA; Sensory Motor Performance Program, Rehabilitation Institute of Chicago, USA.
| | - Matthew W Kindig
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, USA
| | - Xun Niu
- Department of Physical Medicine and Rehabilitation, Northwestern University, USA; Sensory Motor Performance Program, Rehabilitation Institute of Chicago, USA
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Varoqui D, Niu X, Mirbagheri MM. Ankle voluntary movement enhancement following robotic-assisted locomotor training in spinal cord injury. J Neuroeng Rehabil 2014; 11:46. [PMID: 24684813 PMCID: PMC3974744 DOI: 10.1186/1743-0003-11-46] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 03/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In incomplete spinal cord injury (iSCI), sensorimotor impairments result in severe limitations to ambulation. To improve walking capacity, physical therapies using robotic-assisted locomotor devices, such as the Lokomat, have been developed. Following locomotor training, an improvement in gait capabilities-characterized by increases in the over-ground walking speed and endurance-is generally observed in patients. To better understand the mechanisms underlying these improvements, we studied the effects of Lokomat training on impaired ankle voluntary movement, known to be an important limiting factor in gait for iSCI patients. METHODS Fifteen chronic iSCI subjects performed twelve 1-hour sessions of Lokomat training over the course of a month. The voluntary movement was qualified by measuring active range of motion, maximal velocity peak and trajectory smoothness for the spastic ankle during a movement from full plantar-flexion (PF) to full dorsi-flexion (DF) at the patient's maximum speed. Dorsi- and plantar-flexor muscle strength was quantified by isometric maximal voluntary contraction (MVC). Clinical assessments were also performed using the Timed Up and Go (TUG), the 10-meter walk (10MWT) and the 6-minute walk (6MWT) tests. All evaluations were performed both before and after the training and were compared to a control group of fifteen iSCI patients. RESULTS After the Lokomat training, the active range of motion, the maximal velocity, and the movement smoothness were significantly improved in the voluntary movement. Patients also exhibited an improvement in the MVC for their ankle dorsi- and plantar-flexor muscles. In terms of functional activity, we observed an enhancement in the mobility (TUG) and the over-ground gait velocity (10MWT) with training. Correlation tests indicated a significant relationship between ankle voluntary movement performance and the walking clinical assessments. CONCLUSIONS The improvements of the kinematic and kinetic parameters of the ankle voluntary movement, and their correlation with the functional assessments, support the therapeutic effect of robotic-assisted locomotor training on motor impairment in chronic iSCI.
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Affiliation(s)
- Deborah Varoqui
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Xun Niu
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Mehdi M Mirbagheri
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
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