Multicenter Randomized Clinical Trial Evaluating the Effectiveness of the Lokomat in Subacute Stroke

Electromechanical-assisted training for walking after stroke

RATIONALE

Walking difficulties are common after a stroke. During rehabilitation, electromechanical and robotic gait-training devices can help improve walking. As the evidence and certainty of the evidence may have changed since our last update in 2020, we aimed to update the scientific evidence on the benefits and acceptability of these technologies to ensure they remain a viable option for stroke rehabilitation.

OBJECTIVES

Primary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) improves walking in adults after stroke. Secondary • To determine whether electromechanical- and robot-assisted gait training versus physiotherapy (or usual care) after stroke improves walking velocity, walking capacity, acceptability, and death from all causes until the end of the intervention phase.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and seven other databases. We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors to identify further published, unpublished, and ongoing trials. The date of the latest search was December 2023.

ELIGIBILITY CRITERIA

We included all randomised controlled trials and randomised controlled cross-over trials in people over the age of 18 years diagnosed with stroke of any severity, at any stage, in any setting, evaluating electromechanical- and robot-assisted gait training versus physiotherapy (or usual care).

OUTCOMES

Our critical outcome was the ability to walk independently, measured with the Functional Ambulation Category (FAC). An FAC score of 4 or 5 indicated independent walking over a 15-metre surface, irrespective of aids used, such as a cane. An FAC score less than 4 indicates dependency in walking (supervision or assistance, or both, must be given in performing walking). Important outcomes included walking velocity and capacity, as well as dropouts.

RISK OF BIAS

We used Cochrane's RoB 1 tool.

SYNTHESIS METHODS

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We used random-effects models for the meta-analysis. We assessed the certainty of evidence using the GRADE approach.

INCLUDED STUDIES

We included 101 studies (39 new studies plus 62 studies from previous versions) with a total of 4224 participants after stroke in our review update.

SYNTHESIS OF RESULTS

Electromechanical-assisted gait training in combination with physiotherapy probably increases the odds of participants becoming independent in walking (odds ratio (OR) 1.65, 95% confidence interval (CI) 1.21 to 2.25; P = 0.001; I² = 31%; 51 studies, 2148 participants; moderate-certainty evidence); probably does not increase mean walking velocity (mean difference (MD) 0.05 m/s, 95% CI 0.02 to 0.08; P < 0.001; I² = 58%; 73 studies, 3043 participants; moderate-certainty evidence); and does not increase mean walking capacity (MD 11 metres walked in 6 minutes, 95% CI 1.8 to 20.3; P = 0.02; I² = 43%; 42 studies, 1966 participants; high-certainty evidence). Electromechanical-assisted gait training does not increase or decrease the risk of loss to the study during the intervention or the risk of death from all causes (high-certainty evidence). At follow-up after study end, electromechanical-assisted gait training in combination with physiotherapy may not increase the odds of participants becoming independent in walking (OR 1.64, 95% CI 0.77 to 3.48; P = 0.20; I² = 69%; 8 studies, 569 participants; low-certainty evidence), and probably does not increase mean walking velocity (MD 0.05 m/s, 95% CI -0.03 to 0.13; P = 0.22; I² = 66%; 17 studies, 857 participants; moderate-certainty evidence) or mean walking capacity (MD 9.6 metres walked in 6 minutes, 95% CI -14.6 to 33.7; P = 0.44; I² = 53%; 15 studies, 736 participants; moderate-certainty evidence). Our results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study; and (2) there was variation between trials with respect to the devices used and duration and frequency of treatment.

AUTHORS' CONCLUSIONS

Moderate-certainty evidence shows that people who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are probably more likely to achieve independent walking than people who receive gait training without these devices.We concluded that nine patients need to be treated to prevent one dependency in walking. Further research should consist of large, definitive pragmatic phase 3 trials undertaken to address specific questions about the most effective frequency and duration of electromechanical-assisted gait training, as well as how long any benefit may last. Future trials should consider time poststroke in their trial design.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol (2006): doi:10.1002/14651858.CD006185 Original review (2007): doi:10.1002/14651858.CD006185.pub2 Review update (2013): doi:10.1002/14651858.CD006185.pub3 Review update (2017): doi:10.1002/14651858.CD006185.pub4 Review update (2020): doi:10.1002/14651858.CD006185.pub5.

Enhanced rehabilitation for unstable pelvic tile C fractures: integrating mechanotherapy and early intervention

BACKGROUND AND OBJECTIVES

This study aimed to enhance the rehabilitation process for patients with unstable pelvic Tile C fractures resulting from polytrauma by integrating mechanotherapy using the Hocoma Lokomat robotic device with conventional rehabilitation methods. The goal was to improve functional recovery outcomes and minimize pain levels following surgical intervention.

METHODS

A total of 74 participants, aged 21 to 65 years, with severe unstable pelvic Tile C fractures were enrolled at Tongji Hospital's Department of Rehabilitation from 2022 to 2024. They were randomly divided into two groups: Group A (34 patients) received comprehensive rehabilitation including mechanotherapy with the Hocoma Lokomat, while Group B (40 patients) underwent only conventional therapeutic exercises. Functional outcomes were assessed using the Majeed pelvic score, and pain were monitored over time.

RESULTS

Group A demonstrated significantly better pelvic function scores compared to Group B throughout the rehabilitation period(91.53 ± 4.10vs. 88.17 ± 5.15). Additionally, at the six-month follow-up, Group A showed superior pain control benefits attributed to mechanotherapy(2.09 ± 1.10vs2.29 ± 1.12).

CONCLUSION

Integrating the Hocoma Lokomat into rehab for unstable pelvic Tile C fractures improves function and pain control versus conventional care. The study supports robotic-assisted therapy's benefits for polytrauma patients, advocating innovative rehab approaches.

Reporting of Adverse Events in Studies Involving Treadmill Gait Training After Stroke: A Systematic Review

BackgroundTreadmill gait training has been widely employed in post-Stroke Rehabilitation. This form of training is not exempt from complications. As with any healthcare intervention, reports of adverse events must be adequately documented.ObjectiveTo assess the reporting of adverse events in clinical trials utilizing treadmill training in individuals with Stroke.MethodsSearches were carried out in seven databases, spanning from October to November 2019, with updates in May and June 2021, as well as in November and December 2022. Studies mentioning adverse events and having full-text available in English, Portuguese, or Spanish were considered. Outcome measures were occurrence, assessment, type, and severity of adverse events.ResultsFifty-one studies were included with 1,571 participants. The most frequent adverse events reported were pain (6 studies), new strokes (6 studies), and medical complications (4 studies) were the most commonly observed. Studies whose groups underwent treadmill training reported a higher number of adverse events compared to groups that did not receive this intervention.ConclusionsThe reporting of adverse events in studies involving treadmill training post-stroke is inconsistent and non-systematic. There appears to be an association between treadmill training and the occurrence of adverse events in this population.

Lokomat vs. Conventional Therapy-Impact on Gait Symmetry in Hemiparetic Patients: Preliminary Clinical Study

Background/Objectives: One of the primary goals of neurorehabilitation after stroke is gait reeducation, as it provides the patient with greater autonomy and enhances their safety in daily activities. A preliminary clinical study was undertaken to determine whether robotic gait reeducation using the Lokomat device is more effective than conventional therapy in achieving gait symmetry. Methods: The research group consisted of 107 patients, with an average age of 63.54 years, all in the subacute stage of hemiparesis. These patients underwent 4 weeks of neurorehabilitation and were assigned into experimental and control groups. The patients in the experimental group underwent neurorehabilitation (20 sessions) and twice-weekly walking on the Lokomat device (10 sessions). The control group received equivalent neurorehabilitation and conventional gait reeducation. We monitored the return of ideal limb loading (to a 50:50 ratio) and the restoration of the step length on the paretic limb to a physiological length (73 cm), as well as the subsequent restoration of gait symmetry. The measurements were performed using the HP Cosmos Zebris Treadmill FDM-T device. The Wilcoxon Signed Rank test was conducted within each group to analyze the effectiveness of gait reeducation before and after therapy. To compare the results between the two groups, the Mann-Whitney test (α = 0.05) was employed. Results: There was no significant difference between the robotic and conventional therapy groups (p = 0.432 (>0.05)). A significant change occurred only in the control group in the 50:50 limb loading parameter (p = 0.042). There were no significant changes in the other parameters. Conclusions: Under the conditions of our study, robot-guided gait reeducation did not appear to be more effective than conventional therapy. The monthly duration of gait reeducation is insufficient to achieve a symmetrical gait in patients with spastic hemiparesis.

Hands-free Atalante exoskeleton in post-stroke gait and balance rehabilitation: a safety study

BACKGROUND

Stroke often results in gait dysfunction, impairing daily activities and quality of life. Overground robotic exoskeletons hold promise for post-stroke rehabilitation. This study primarily aimed to assess the safety of hands-free Atalante exoskeleton training in post-stroke subjects, with a secondary aim to assess gait and balance.

METHODS

Forty subjects (10.2 ± 12.1 months post-stroke) with gait dysfunction (Functional Ambulation Category [FAC] score ≤ 3) underwent five training sessions over three weeks with a hands-free exoskeleton (Atalante, Wandercraft, France). Safety, the primary outcome, was evaluated by the number and severity of adverse events (AEs), judged by an independent clinical evaluation committee (CEC). A usability test was performed during the fifth training session followed by the exoskeleton use questionnaire. Gait and balance were assessed pre/post-training via walking capacity score (FAC), gait speed by 10-meter walk test (10MWT), walked distance by 6-minute walk test (6MWT), and balance by Berg Balance Scale (BBS). Spasticity was assessed with the Modified Ashworth scale. Anxiety and depression were quantified using the Hospital Anxiety and Depression Scale. Safety outcomes were analyzed using the Wilson, Lee and Dubin methods for proportions, and occurrence rates were computed. Within-group differences were compared using Wilcoxon, McNemar, and Friedman tests, with significance set at P < 0.05.

RESULTS

Thirty-one subjects completed the training sessions, while nine discontinued. The study reported two serious adverse events (SAE) (vertigo, dysarthria) and six AEs, with the CEC concluding that no SAE was linked to the device/study procedure. The average AE rate per session was 2.5 ± 1.4%, including four events possibly linked to the device/study procedure (knee pain [n = 1], skin lacerations [n = 3]), classified as negligible or minor by the CEC. A high proportion (82.6%) successfully completed the usability test and reported satisfaction (90%) on the exoskeleton use questionnaire. For gait and balance, favorable changes were observed in FAC, 10MWT, 6MWT, and BBS scores Post-training (p < 0.05, respectively). Spasticity, anxiety, and depression remained unchanged.

CONCLUSIONS

This study indicates that the hands-free Atalante exoskeleton is safe, feasible, and well-tolerated for gait and balance rehabilitation in post-stroke subjects, warranting larger randomized controlled trials to assess its efficacy.

TRIAL REGISTRATION

Evaluation of the Use of the Atalante Exoskeleton in Patients Presenting an Hemiplegia Due to Cerebrovascular Accident (INSPIRE) trial was registered at ClinicalTrials.gov (NCT04694001, registered on 20201231).

Management Approaches to Spastic Gait Disorders

Spastic gait presents clinically as the net mechanical consequence of neurological impairments of spasticity, weakness, and abnormal synergies and their interactions with the ground reaction force in patients with upper motor neuron syndromes and with some neuromuscular diseases. It is critical to differentiate whether the primary problem is weakness or spasticity, thus better understanding different phenotypes of spastic gait disorders. Pelvic girdle abnormality plays a pivotal role in determining the clinical presentation of gait disorders, since it determines the body vector and compensatory kinetic chain reactions in the knee and ankle joints. Knee joint abnormality can be a mechanical compensation for hip and/or ankle and foot abnormality. Diagnostic nerve blocks and instrumented gait analysis may be needed for diagnosing the underlying problems and developing an individualized plan of care. A wide spectrum of treatment options has been used to manage spastic gait disorders. Some are in early and investigational stages, such as neuromodulation modalities, while others are well-developed, such as therapeutic exercise, ankle-foot orthoses, botulinum toxin treatment, and surgical interventions. Physicians and other healthcare providers who manage spastic gait disorders should be familiar with these treatment options and should employ appropriate interventions concurrently rather than serially. The most effective treatments can be selected based on careful evaluation, inputs from patients, family, and therapists, along with appropriate goal setting. Treatment plans need to be re-evaluated for effectiveness, relevance, and in concordance with disease progress. This is particularly important for patients with progressive neuromuscular diseases such as amyotrophic lateral sclerosis.

Signal Characteristics, Motor Cortex Engagement, and Classification Performance of Combined Action Observation, Motor Imagery and SSMVEP (CAMS) BCI

Motor imagery (MI)-based Brain-Computer Interfaces (BCIs) have shown promise in engaging the motor cortex for recovery. However, individual responses to MI-based BCIs are highly variable and relatively weak. Conversely, combined action observation (AO) and motor imagery (MI) paradigms have demonstrated stronger responses compared to AO or MI alone, along with enhanced cortical excitability. In this study, a novel BCI called Combined AO, MI, and Steady-State Motion Visual Evoked Potential (SSMVEP) (CAMS) was proposed. CAMS was designed based on gait observation and imagination. Twenty-five healthy volunteers participated in the study with CAMS serving as the intervention and SSMVEP checkerboard as the control condition. We hypothesized the CAMS intervention can induce observable increases in the negativity of the movement-related cortical potential (MRCP) associated with ankle dorsiflexion. MRCP components, including Bereitschaftspotential, were measured pre- and post-intervention. Additionally, the signal characteristics of the visual and motor responses were quantified. Finally, a two-class visual BCI classification performance was assessed. A consistent increase in negativity was observed across all MRCP components in signals over the primary motor cortex, compared to the control condition. CAMS visual BCI achieved a median accuracy of 83.8%. These findings demonstrate the ability of CAMS BCI to enhance cortical excitability in relation to movement preparation and execution. The CAMS stimulus not only evokes SSMVEP-like activity and sensorimotor rhythm but also enhances the MRCP. These findings contribute to the understanding of CAMS paradigm in enhancing cortical excitability, consistent and reliable classification performance holding promise for motor rehabilitation outcomes and future BCI design considerations.

Overground robotic exoskeleton vs conventional therapy in inpatient stroke rehabilitation: results from a pragmatic, multicentre implementation programme

BACKGROUND

Despite the reported efficacy of overground robotic exoskeleton (ORE) for rehabilitation of mobility post-stroke, its effectiveness in real-world practice is still debated. We analysed prospectively collected data from Improving Mobility Via Exoskeleton (IMOVE), a multicentre clinical implementation programme of ORE enrolling participants with various neurological conditions and were given options to choose between 12 sessions of ORE or conventional therapy (control).

METHODS

This is analysis of participants under IMOVE who fulfilled the following criteria (i) primary diagnosis was stroke (ischemic, hemorrhagic; first or recurrent), (ii) onset of stroke was within 9 months and (iii) the intervention was during inpatient stay. They should also fulfill the general IMOVE inclusion and exclusion criteria which were resembling general clinical and manufacturing criteria of ORE. Outcome measures included Functional Ambulatory Category (FAC), Rivermead Mobility Index (RMI), Functional Independence Measure (FIM) and Clinical Outcome Variable Scale (COVS), measured immediately before and after the 12 sessions of therapy, and mean distance walked per session.

RESULTS

Of 149 participants (105 OREs and 44 controls), both groups improved significantly in motor outcomes with no significant between-group differences. Participants with baseline FAC 1 had significantly greater improvement in motor sub-score of FIM (FIM-motor) compared to controls (mean difference 8.4, 95% CI 0.65-16.07, ηp2 = 0.136, p = 0.034). The mean distance walked per session for ORE group was almost three times that of control for those with baseline FAC 0 (121.5 [SD 31.1]m vs 35.0 [SD 41.0]m, 95% CI 62.2-110.9, d = 2.54 p < 0.001) and FAC 1 (145.8 [SD 31.6]m vs 52.2 [SD 42.5]m, 95% CI 61.8-125.2, d = 2.71, p < 0.001). The difference was not observed for FAC 2 to 3 (162.9 [SD 29.2]m vs 134.2 [SD 87.5]m, 95% CI -22.2 to 79.7, d = 0.41, p = 0.252).

CONCLUSION

In a pragmatic setting, use of ORE for gait training enabled patients with lower ambulatory capacity to walk longer distances during therapy sessions. Patients who required continuous assistance during ambulation (FAC 1) had significantly better gains in FIM-motor compared to conventional therapy, suggesting possible benefit of ORE for this group.

TRIAL REGISTRATION

The trial was registered with clinicaltrials.gov (NCT05659121) on April 14, 2022.

A robot-based hybrid lower limb system for Assist-As-Needed rehabilitation of stroke patients: Technical evaluation and clinical feasibility

BACKGROUND

Although early rehabilitation is important following a stroke, severely affected patients have limited options for intensive rehabilitation as they are often bedridden. To create a system for early rehabilitation of lower extremities in these patients, we combined the robotic manipulator ROBERT® with electromyography (EMG)-triggered functional electrical stimulation (FES) and developed a novel user-driven Assist-As-Needed (AAN) control. The method is based on a state machine able to detect user movement capability, assessed by the presence of an EMG-trigger and the movement velocity, and provide different levels of assistance as required by the patient (no support, FES only, and simultaneous FES and mechanical assistance).

METHODS

To technically validate the system, we tested 10 able-bodied participants who were instructed to perform specific behaviors to test the system states while conducting knee extension and ankle dorsal flexion exercises. The system was also tested on two stroke patients to establish its clinical feasibility.

RESULTS

The technical validation showed that the state machine correctly detected the participants' behavior and activated the target AAN state in more than 96% of the exercise repetitions. The clinical feasibility test showed that the system successfully recognized the patients' movement capacity and activated assistive states according to their needs providing the minimal level of support required to exercise successfully.

CONCLUSIONS

The system was technically validated and preliminarily proved clinically feasible. The present study shows that the novel system can be used to deliver exercises with a high number of repetitions while engaging the participants' residual capabilities through the AAN strategy.

Effectiveness of the A3 robot on lower extremity motor function in stroke patients: A prospective, randomized controlled trial

BACKGROUND

The results of existing lower extremity robotics studies are conflicting, and few relevant clinical trials have examined short-term efficacy. In addition, most of the outcome indicators in existing studies are scales, which are not objective enough. We used the combination of objective instrument measurement and scale to explore the short-term efficacy of the lower limb A3 robot, to provide a clinical reference.

AIM

To investigate the improvement of lower limb walking ability and balance in stroke treated by A3 lower limb robot.

METHODS

Sixty stroke patients were recruited prospectively in a hospital and randomized into the A3 group and the control group. They received 30 min of A3 robotics training and 30 min of floor walking training in addition to 30 min of regular rehabilitation training. The training was performed five times a week, once a day, for 2 wk. The t-test or non-parametric test was used to compare the three-dimensional gait parameters and balance between the two groups before and after treatment.

RESULTS

The scores of basic activities of daily living, Stroke-Specific Quality of Life Scale, FM balance meter, Fugl-Meyer Assessment scores, Rivermead Mobility Index, Stride speed, Stride length, and Time Up and Go test in the two groups were significantly better than before treatment (19.29 ± 12.15 vs 3.52 ± 4.34; 22.57 ± 17.99 vs 4.07 ± 2.51; 1.21 ± 0.83 vs 0.18 ± 0.40; 3.50 ± 3.80 vs 0.96 ± 2.08; 2.07 ± 1.21 vs 0.41 ± 0.57; 0.89 ± 0.63 vs 0.11 ± 0.32; 12.38 ± 9.00 vs 2.80 ± 3.43; 18.84 ± 11.24 vs 3.80 ± 10.83; 45.12 ± 69.41 vs 8.41 ± 10.20; 29.45 ± 16.62 vs 8.68 ± 10.74; P < 0.05). All outcome indicators were significantly better in the A3 group than in the control group, except the area of the balance parameter.

CONCLUSION

For the short-term treatment of patients with subacute stroke, the addition of A3 robotic walking training to conventional physiotherapy appears to be more effective than the addition of ground-based walking training.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Implementation of a unilateral hip flexion exosuit to aid paretic limb advancement during inpatient gait retraining for individuals post-stroke: a feasibility study

BACKGROUND

During inpatient rehabilitation, physical therapists (PTs) often need to manually advance patients' limbs, adding physical burden to PTs and impacting gait retraining quality. Different electromechanical devices alleviate this burden by assisting a patient's limb advancement and supporting their body weight. However, they are less ideal for neuromuscular engagement when patients no longer need body weight support but continue to require assistance with limb advancement as they recover. The objective of this study was to determine the feasibility of using a hip flexion exosuit to aid paretic limb advancement during inpatient rehabilitation post-stroke.

METHODS

Fourteen individuals post-stroke received three to seven 1-hour walking sessions with the exosuit over one to two weeks in addition to standard care of inpatient rehabilitation. The exosuit assistance was either triggered by PTs or based on gait events detected by body-worn sensors. We evaluated clinical (distance, speed) and spatiotemporal (cadence, stride length, swing time symmetry) gait measures with and without exosuit assistance during 2-minute and 10-meter walk tests. Sessions were grouped by the assistance required from the PTs (limb advancement and balance support, balance support only, or none) without exosuit assistance.

RESULTS

PTs successfully operated the exosuit in 97% of sessions, of which 70% assistance timing was PT-triggered to accommodate atypical gait. Exosuit assistance eliminated the need for manual limb advancement from PTs. In sessions with participants requiring limb advancement and balance support, the average distance and cadence during 2-minute walk test increased with exosuit assistance by 2.2 ± 3.1 m and 3.4 ± 1.9 steps/min, respectively (p < 0.017). In sessions with participants requiring balance support only, the average speed during 10-meter walk test increased with exosuit by 0.07 ± 0.12 m/s (p = 0.042). Clinical and spatiotemporal measures of independent ambulators were similar with and without exosuit (p > 0.339).

CONCLUSIONS

We incorporated a unilateral hip flexion exosuit into inpatient stroke rehabilitation in individuals with varying levels of impairments. The exosuit assistance removed the burden of manual limb advancement from the PTs and resulted in improved gait measures in some conditions. Future work will understand how to optimize controller and assistance profiles for this population.

A single-center, assessor-blinded, randomized controlled clinical trial to test the safety and efficacy of a novel brain-computer interface controlled functional electrical stimulation (BCI-FES) intervention for gait rehabilitation in the chronic stroke population

BACKGROUND

In the United States, there are over seven million stroke survivors, with many facing gait impairments due to foot drop. This restricts their community ambulation and hinders functional independence, leading to several long-term health complications. Despite the best available physical therapy, gait function is incompletely recovered, and this occurs mainly during the acute phase post-stroke. Therapeutic options are limited currently. Novel therapies based on neurobiological principles have the potential to lead to long-term functional improvements. The Brain-Computer Interface (BCI) controlled Functional Electrical Stimulation (FES) system is one such strategy. It is based on Hebbian principles and has shown promise in early feasibility studies. The current study describes the BCI-FES clinical trial, which examines the safety and efficacy of this system, compared to conventional physical therapy (PT), to improve gait velocity for those with chronic gait impairment post-stroke. The trial also aims to find other secondary factors that may impact or accompany these improvements and establish the potential of Hebbian-based rehabilitation therapies.

METHODS

This Phase II clinical trial is a two-arm, randomized, controlled, longitudinal study with 66 stroke participants in the chronic (> 6 months) stage of gait impairment. The participants undergo either BCI-FES paired with PT or dose-matched PT sessions (three times weekly for four weeks). The primary outcome is gait velocity (10-meter walk test), and secondary outcomes include gait endurance, range of motion, strength, sensation, quality of life, and neurophysiological biomarkers. These measures are acquired longitudinally.

DISCUSSION

BCI-FES holds promise for gait velocity improvements in stroke patients. This clinical trial will evaluate the safety and efficacy of BCI-FES therapy when compared to dose-matched conventional therapy. The success of this trial will inform the potential utility of a Phase III efficacy trial.

TRIAL REGISTRATION

The trial was registered as "BCI-FES Therapy for Stroke Rehabilitation" on February 19, 2020, at clinicaltrials.gov with the identifier NCT04279067.

How robot-assisted gait training affects gait ability, balance and kinematic parameters after stroke: a systematic review and meta-analysis

INTRODUCTION

Gait ability is often cited by stroke survivors. Robot-assisted gait training (RAGT) can help stroke patients with lower limb motor impairment regain motor coordination.

EVIDENCE ACQUISITION

PubMed, Cochrane Library, Embase were systematically searched until September 2023, to identify randomized controlled trials presenting: stroke survivors as participants; RAGT as intervention; conventional rehabilitation as a comparator; gait assessment, through scales or quantitative parameters, as outcome measures.

EVIDENCE SYNTHESIS

Twenty-seven publications involving 1167 patients met the inclusion criteria. Meta-analysis showed no significant differences in speed, cadence, spatial symmetry, and changes in joint mobility angles between the RAGT group and the control group. In addition, RAGT was associated with changes in affected side step length (SMD=0.02, 95% CI: 0.01, 0.03; P<0.0001), temporal symmetry (SMD=-0.38, 95% CI: -0.6, -0.16; P=0.0006], Six-Minute Walk Test (SMD=25.14, 95% CI: 10.19, 40.09; P=0.0010] and Functional Ambulation Categories (SMD=0.32, 95% CI: 0.01, 0.63; P=0.04). According to the PEDro scale, 19 (70.4%) studies were of high quality and eight were of moderate quality (29.6%).

CONCLUSIONS

Taken together, the review synthesis showed that RAGT might have a potential role in the recovery of walking dysfunction after stroke. However, its superiority over conventional rehabilitation requires further research. Additionally, it may provide unexpected benefits that the effects of RAGT with different types or treatment protocols were further compared.

Gait Adaptation to Asymmetric Hip Stiffness Applied by a Robotic Exoskeleton

Wearable exoskeletons show significant potential for improving gait impairments, such as interlimb asymmetry. However, a more profound understanding of whether exoskeletons are capable of eliciting neural adaptation is needed. This study aimed to characterize how individuals adapt to bilateral asymmetric joint stiffness applied by a hip exoskeleton, similar to split-belt treadmill training. Thirteen unimpaired individuals performed a walking trial on the treadmill while wearing the exoskeleton. The right side of the exoskeleton acted as a positive stiffness torsional spring, pulling the thigh towards the neutral standing position, while the left acted as a negative stiffness spring pulling the thigh away from the neutral standing position. The results showed that this intervention applied by a hip exoskeleton elicited adaptation in spatiotemporal and kinetic gait measures similar to split-belt treadmill training. These results demonstrate the potential of the proposed intervention for retraining symmetric gait.

A Proof of Principle Study Conducted by Community-Dwelling Seniors Using a Novel Passive Gait Assist System

It is vital for rehabilitating patients to perform as many task-related exercises as possible. These patients often need either force or trajectory assistance in order to perform gait. While this can be provided in the form of traditional gait rehabilitation or currently emerging robot-assisted gait training, there is a need for an affordable means to assist gait training. In this study, we present a passive gait assistance device that is composed of a spring-bar system attached to an elastic cord and a specialized shoe. The shoe has two straps attached such that both plantar and dorsiflexion torque can be applied to the user depending on the angle of the pulling force. The merit of the devices is that it is an affordable means to provide the user with gait assistance while allowing some freedom of one’s foot movement. We show that, with 20 community-dwelling seniors, our system successfully produces plantar flexion and dorsiflexion torque according to the gait cycle. Furthermore, electromyography analysis suggests that plantar flexor demand during the late stance phase and dorsiflexor demand during the swing phase are significantly reduced.

Effects of robot-assisted walking training on balance, motor function, and ADL depending on severity levels in stroke patients

BACKGROUND

Despite the explosive increase in interest regarding Robot-Assisted Walking Training (RAWT) for stroke patients, very few studies have divided groups according to the severity levels of patients and conducted studies on the effects of RAWT.

OBJECTIVE

The purpose of this study was to present a definite basis for physical therapy using the robot-assisted walking device through a more detailed comparison and analysis and to select the optimal target of RAWT.

METHODS

This study was designed as a prospective and randomized controlled trial to investigate the effect of RAWT on balance, motor function, and Activities of Daily Living (ADL) depending on severity levels in stroke patients. 100 participants were randomly divided into study and control groups in equal numbers. The study group was 49 and the control group was 47. One from the study group and three from the control group were eliminated. The study period is four weeks in total, and RAWT is performed five times a week for 40 minutes only for study group. During the same period, all group members had 30 minutes of Conventional Physiotherapy (CP) five times a week.

RESULTS

The results of this study clearly confirmed that RAWT combined with CP produces more significant improvement in patients with stroke than the CP alone. And they indicated that RAWT had a more considerable effect in the poor or fair trunk control group for trunk balance and in the high fall risk group for balance. In motor function, RAWT showed its value in the severe and marked motor impairment group. The total or severe dependence group in ADL experienced more improvements for RAWT.

CONCLUSION

This study can be concluded that the lower the level of physical functions, the more effective it responds to RAWT. As demonstrated in the results of this study, the potential of current robotic technology appears to be greatest at very low functional levels of stroke patients. Patients with low functional levels among stroke patients may benefit from robot rehabilitation.

The effect of the Lokomat® robotic-orthosis system on lower extremity rehabilitation in patients with stroke: a systematic review and meta-analysis

Background

The Lokomat® is a device utilized for gait training in post-stroke patients. Through a systematic review, the objective was to determine whether robot-assisted gait training with the Lokomat® is more effective in enhancing lower extremity rehabilitation in patients with stroke in comparison to conventional physical therapy (CPT).

Methods

In this study, a systematic search was conducted in various databases, including CINAHL, MEDLINE, PubMed, Embase, Cochrane Library, Scopus, Web of Science, and Physiotherapy Evidence Database (PEDro), as well as bibliographies of previous meta-analyses, to identify all randomized controlled trials that investigated the use of Lokomat® devices in adult stroke patients. The study aimed to derive pooled estimates of standardized mean differences for six outcomes, namely, Fugl-Meyer Assessment lower-extremity subscale (FMA-LE), Berg Balance Scale (BBS), gait speed, functional ambulation category scale (FAC), timed up and go (TUG), and functional independence measure (FIM), through random effects meta-analyses.

Results

The review analyzed 21 studies with a total of 709 participants and found that the use of Lokomat® in stroke patients resulted in favorable outcomes for the recovery of balance as measured by the BBS (mean difference = 2.71, 95% CI 1.39 to 4.03; p < 0.0001). However, the FAC showed that Lokomat® was less effective than the CPT group (mean difference = -0.28, 95% CI -0.45 to 0.11, P = 0.001). There were no significant differences in FMA-LE (mean difference = 1.27, 95% CI -0.88 to 3.42, P = 0.25), gait speed (mean difference = 0.02, 95% CI -0.03 to 0.07, P = 0.44), TUG (mean difference = -0.12, 95% CI -0.71 to 0.46, P = 0.68), or FIM (mean difference = 2.12, 95% CI -2.92 to 7.16, P = 0.41) between the Lokomat® and CPT groups for stroke patients.

Conclusion

Our results indicate that, with the exception of more notable improvements in balance, robot-assisted gait training utilizing the Lokomat® was not superior to CPT based on the current literature. Considering its ability to reduce therapists' work intensity and burden, the way in which Lokomat® is applied should be strengthened, or future randomized controlled trial studies should use more sensitive assessment criteria.

Proactive outcome monitoring and standardisation of physiotherapy stroke rehabilitation - A retrospective functional outcomes analysis of Accelerated Stroke Ambulation Programme (ASAP)

Background

A clinical quality improvement programme named Accelerated Stroke Ambulation Programme (ASAP) was piloted in Physiotherapy Department of Tai Po Hospital from 1st October 2019 to 30th September 2020 and executed as a standard practice afterwards. The goal of ASAP was to facilitate early maximal walking ability of stroke patients in early rehabilitation phase. ASAP featured (1) proactive outcome monitoring and standardised process compliance monitoring by a patient database - Stroke Registry; (2) standardised mobility prediction by Reference Modified Rivermead Mobility Index (MRMI) Gain and (3) standardised intervention database - Stroke Treatment Library.

Objective

To investigate the effectiveness of ASAP in an inpatient rehabilitation setting for stroke patients in terms of functional outcomes.

Methods

The design was a retrospective comparative study to analyse the difference in functional outcomes of Pre-ASAP Group (1st October 2018 - 30th September 2019) and Post-ASAP Group (1st October 2020-30th September 2021). The primary outcome measures were MRMI, Berg's Balance Scale (BBS), Modified Barthel Index (MBI), MRMI Gain, BBS Gain, MBI Gain, MRMI Efficiency, BBS Efficiency and MBI Efficiency.

Results

There 348 subjects in Pre-ASAP Group and 281 subjects in Post-ASAP Group. Both groups had highly significant within-group improvement in MRMI, BBS and MBI (p < 0 . 001 ). The MRMI Gain of Pre-ASAP Group and Post-ASAP Group was 6.32 and 7.42, respectively; and the difference was significant (p < 0 . 05 ). The BBS Gain of Pre-ASAP Group and Post-ASAP Group was 8.17 and 9.70, respectively; and the difference was in margin of significance (p = 0 . 069 ). The MBI Gain of Pre-ASAP Group and Post-ASAP Group was 10.69 and 11.96, respectively; but the difference was non-significant (p = 0 . 280 ). The MRMI Efficiency, BBS Efficiency and MBI Efficiency of Post-ASAP Group were higher than Pre-ASAP Group but the difference was non-significant. The results of this study reflected that stroke rehabilitation programme with proactive outcome monitoring, standardised process compliance monitoring, standardised mobility prediction and standardised intervention database was practical in real clinical practice with better functional outcomes than traditional physiotherapy practice which were dominated by personal preference and experience of therapists.

Conclusion

Proactive outcome monitoring, standardised process compliance monitoring, standardised mobility prediction and standardised intervention database may enhance the effectiveness in terms of functional outcomes of stroke rehabilitation programme.

Effects of high-intensity gait training with and without soft robotic exosuits in people post-stroke: a development-of-concept pilot crossover trial

INTRODUCTION

High-intensity gait training is widely recognized as an effective rehabilitation approach after stroke. Soft robotic exosuits that enhance post-stroke gait mechanics have the potential to improve the rehabilitative outcomes achieved by high-intensity gait training. The objective of this development-of-concept pilot crossover study was to evaluate the outcomes achieved by high-intensity gait training with versus without soft robotic exosuits.

METHODS

In this 2-arm pilot crossover study, four individuals post-stroke completed twelve visits of speed-based, high-intensity gait training: six consecutive visits of Robotic Exosuit Augmented Locomotion (REAL) gait training and six consecutive visits without the exosuit (CONTROL). The intervention arms were counterbalanced across study participants and separated by 6 + weeks of washout. Walking function was evaluated before and after each intervention using 6-minute walk test (6MWT) distance and 10-m walk test (10mWT) speed. Moreover, 10mWT speeds were evaluated before each training visit, with the time-course of change in walking speed computed for each intervention arm. For each participant, changes in each outcome were compared to minimal clinically-important difference (MCID) thresholds. Secondary analyses focused on changes in propulsion mechanics and associated biomechanical metrics.

RESULTS

Large between-group effects were observed for 6MWT distance (d = 1.41) and 10mWT speed (d = 1.14). REAL gait training resulted in an average pre-post change of 68 ± 27 m (p = 0.015) in 6MWT distance, compared to a pre-post change of 30 ± 16 m (p = 0.035) after CONTROL gait training. Similarly, REAL training resulted in a pre-post change of 0.08 ± 0.03 m/s (p = 0.012) in 10mWT speed, compared to a pre-post change of 0.01 ± 06 m/s (p = 0.76) after CONTROL. For both outcomes, 3 of 4 (75%) study participants surpassed MCIDs after REAL training, whereas 1 of 4 (25%) surpassed MCIDs after CONTROL training. Across the training visits, REAL training resulted in a 1.67 faster rate of improvement in walking speed. Similar patterns of improvement were observed for the secondary gait biomechanical outcomes, with REAL training resulting in significantly improved paretic propulsion for 3 of 4 study participants (p < 0.05) compared to 1 of 4 after CONTROL.

CONCLUSION

Soft robotic exosuits have the potential to enhance the rehabilitative outcomes produced by high-intensity gait training after stroke. Findings of this development-of-concept pilot crossover trial motivate continued development and study of the REAL gait training program.

The Effect of Robot-Assisted Training on Arm Function, Walking, Balance, and Activities of Daily Living After Stroke: A Systematic Review and Meta-Analysis

This meta-analysis aimed to compare the effects of robot-assisted training (RAT) with those of conventional therapy (CT), considering the potential sources of heterogeneity in the previous studies. We searched three international electronic databases (MEDLINE, Embase, and the Cochrane Library) to identify relevant studies. Risk of bias assessment was performed using the Cochrane's Risk of Bias 1.0 tool. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations method. The meta-analyses for each outcome of the respective domains were performed using 24 randomized controlled trials (RCTs) on robot-assisted arm training (RAAT) for arm function, 7 RCTs on RAAT for activities of daily living (ADL), 12 RCTs on robot-assisted gait training (RAGT) for balance, 6 RCTs on RAGT for walking, and 7 RCTs on RAGT for ADL. The random-effects model for the meta-analysis revealed that RAAT has significant superiority over CT in improving arm function, and ADL. We also showed that RAGT has significant superiority over CT in improving balance. Our study provides high-level evidence for the superiority of RAT over CT in terms of functional recovery after stroke. Therefore, physicians should consider RAT as a therapeutic option for facilitating functional recovery after stroke.

Gait adaptation to asymmetric hip stiffness applied by a robotic exoskeleton

Wearable exoskeletons show significant potential for improving gait impairments, such as interlimb asymmetry. However, a more profound understanding of whether exoskeletons are capable of eliciting neural adaptation is needed. This study aimed to characterize how individuals adapt to bilateral asymmetric joint stiffness applied by a hip exoskeleton, similar to split-belt treadmill training. Thirteen unimpaired individuals performed a walking trial on the treadmill while wearing the exoskeleton. The right side of the exoskeleton acted as a positive stiffness torsional spring, pulling the thigh towards the neutral standing position, while the left acted as a negative stiffness spring pulling the thigh away from the neutral standing position. The results showed that this intervention applied by a hip exoskeleton elicited adaptation in spatiotemporal and kinetic gait measures similar to split-belt treadmill training. These results demonstrate the potential of the proposed intervention for retraining symmetric gait.

Effect of overground gait training with 'Mobility Assisted Robotic System-MARS' on gait parameters in patients with stroke: a pre-post study

OBJECTIVE

To observe the effect of overground gait training with 'Mobility Assisted Robotic System-MARS' on gait parameters in patients with stroke.

PATIENTS & METHODS

This prospective pre-post study was conducted in a tertiary teaching research hospital with 29 adult stroke patients, with age up to 65 years. Patients fulfilling the inclusion criteria were divided in 2 groups based on the duration of stroke (≤ 6 months-sub-acute & > 6 months-chronic stroke) and provided overground gait training with MARS robot for 12 sessions (1 h/session) over a period of 2-3 weeks. Primary outcome measures were; 10-Meter walk test-10MWT, 6-min' walk test-6MWT and Timed up & Go-TUG tests. Secondary outcome measures were Functional Ambulation Category-FAC, Modified Rankin Scale-MRS and Scandinavian Stroke Scale-SSS.

RESULTS

No adverse events were reported. Twenty-five patients who were able to perform 10-MWT at the beginning of study were included in the final analysis with 12 in sub-acute and 13 in chronic stroke group. All primary and secondary outcome measures showed significant improvement in gait parameters at the end of the training (p < 0.05) barring 10-Meter walk test in sub-acute stroke group (p = 0.255). Chronic stroke group showed significant minimum clinically important difference-MCID difference in endurance (6MWT) at the end of the training and both groups showed better 'minimal detectable change-MDC' in balance (TUG) at the end of the training.

CONCLUSIONS

Patients in both the groups showed significant improvement in walking speed, endurance, balance and independence at the end of the training with overground gait training with MARS Robot.

CLINICAL TRIAL REGISTRY

National Clinical Trial Registry of India (CTRI/2021/08/035695,16/08/2021).

The effects of Robot-assisted gait training and virtual reality on balance and gait in stroke survivors: A randomized controlled trial

BACKGROUND

Stroke survivors often experience balance and gait problems, which can affect their quality of life and independence in daily living activities. Robot-assisted gait training, such as Lokomat with virtual reality, has been found to be effective in improving gait and balance. However, the specific effects of each virtual reality application on balance and spatiotemporal parameters of gait are not yet established. This study aims to investigate the effects of different virtual reality applications on these parameters.

RESEARCH QUESTION

What are the specific effects of each Lokomat augmented performance feedback application on balance and spatiotemporal parameters of gait in stroke survivors?

METHODS

The study is a randomized controlled trial conducted with four groups: Control Group, Endurance Group, Attention and Motivation Group, and Activity Timing Group. All participants received six weeks of physiotherapy, and Lokomat groups had additional robot-assisted gait training with Lokomat for three days a week. The Endurance group used Lokomat with Faster, Attention and Motivation Group with Gabarello and Smile, and Activity Timing Group with Curve Pursuit, Treasures, and High Flyer applications. Various tests were used to assess walking and balance in the study (gait analysis, 6-minute walk test, 10-meter walk test, Berg Balance Scale, postural stability, and limits of stability).

RESULTS AND SIGNIFICANCE

The study involved 56 male stroke survivors (mean age: 60.02 ± 6.83 years, post-stroke time: 238.88 ± 40.88 days). All groups improved walking speed and distance significantly, but Endurance was better (p < 0.001). Balance improved significantly in all groups, but Attention and Motivation was superior in Berg Balance Scale, postural stability, and limits of stability (p < 0.001). The selection of virtual reality applications during robot-assisted gait training according to rehabilitation goals is important for successful rehabilitation, as these applications may have varying effects on balance and walking.

Gait training with a wearable powered robot during stroke rehabilitation: a randomized parallel-group trial

BACKGROUND

We have developed a wearable rehabilitation robot, "curara®," and examined its immediate effect in patients with spinocerebellar degeneration and stroke, but its rehabilitative effect has not been clarified. The purpose of this study was to examine the effect of this device on gait training in stroke patients.

METHODS

Forty stroke patients were enrolled in this study. The participants were divided randomly into two groups (groups A and B). The participants assigned to group A received RAGT with curara® type 4, whereas those in group B received conventional therapist-assisted gait training. The clinical trial period was 15 days. The participants performed 10 sessions of gait training (5 times per week) each lasting 30 ± 5 min per day. The 10-m walking time (10mWT), and 6-minute walking distance (6MWD) were evaluated as the main outcomes. Timed up and go and Berg Balance Scale (BBS) were also examined. Gait parameters (stride duration and length, standard deviation of stride duration and length, cadence, ratio of the stance/swing phases, minimum/maximum knee joint angle, and minimum/maximum hip joint angle) were measured using a RehaGait®. The items other than BBS were measured on days 0, 7, and 14, whereas BBS was measured on days 0 and 14. The improvement rate was calculated as the difference of values between days 14 and 0 divided by the value on day 0. The improvement rates of the 10mWT and 6MWD were set as the main outcomes.

RESULTS

The data of 35 participants were analyzed. There was no significant difference in the main outcomes between both groups at the end of gait training. As for intragroup changes, gait speed, stride length, stride duration, and cadence were improved significantly between days 0 and 14 in each group. When examining the interaction effect between the day of measurement and group, stride duration (p = 0.006) and cadence (p = 0.012) were more significantly improved in group A than in group B.

CONCLUSIONS

This novel wearable powered robot may have the potential to improve gait speed of individuals in stroke rehabilitation.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs032180163). Registered on February 22, 2019; https://jrct.niph.go.jp/en-latest-detail/jRCTs032180163 . UMIN CLINICAL TRIALS REGISTRY (UMIN000034237): Registered on September 22, 2018; https://center6.umin.ac.jp/cgi-open-bin/icdr/ctr_view.cgi?recptno=R000038939 .

Is Leg-Driven Treadmill-Based Exoskeleton Robot Training Beneficial to Poststroke Patients: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to systematically review the effects of leg-driven treadmill-based exoskeleton robot training on balance and walking ability in poststroke patients.

DESIGN

The PubMed, Cochrane Library, Embase, Web of Science, Medline, CNKI, VIP, and Wanfang databases were searched from inception to August 2021. The literature quality was evaluated using Cochrane Handbook. Primary outcomes include the Functional Ambulation Category Scale and Berg Balance Scale, and secondary outcomes include the 10 meter walk test, 6 minute walk test, and gait assessment cadence were analyzed.

RESULTS

Seventeen randomized controlled trials were included in the systematic review, 15 studies in meta-analysis. Primary outcomes showed no significant difference in the Functional Ambulation Category Scale score; subgroup with the exoskeleton robot + conventional therapy of the Berg Balance Scale score was significantly increased; secondary outcomes showed no significance in 6 minute walk test or 10 meter walk test. The cadence score increased for the subgroup with an onset of more than 6 mos in the treatment group. The control group performed better than the subgroup with an onset of less than 6 mos.

CONCLUSIONS

Leg-driven treadmill-based exoskeleton robot training can improve balance function in poststroke patients and is beneficial for patients with an onset of greater than 6 mos. However, there is no evidence to support the efficacy of walking ability.

Opportunities and challenges in the development of exoskeletons for locomotor assistance

Exoskeletons can augment the performance of unimpaired users and restore movement in individuals with gait impairments. Knowledge of how users interact with wearable devices and of the physiology of locomotion have informed the design of rigid and soft exoskeletons that can specifically target a single joint or a single activity. In this Review, we highlight the main advances of the past two decades in exoskeleton technology and in the development of lower-extremity exoskeletons for locomotor assistance, discuss research needs for such wearable robots and the clinical requirements for exoskeleton-assisted gait rehabilitation, and outline the main clinical challenges and opportunities for exoskeleton technology.

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.

The effect of robot-assisted gait training frequency on walking, functional recovery, and quality of life in patients with stroke

AIM

This study aims to investigate the effects of robot-assisted gait training (RAGT) frequency on walking, functional recovery, QoL and mood.

METHODS

Sixty patients aged 50-75, diagnosed with post-stroke hemiplegia were entered into the retrospective analysis. Participants who scored maximum 3 on the Modified Rankin Scale and were diagnosed with moderate stroke according to The NIH Stroke Scale were included in the study. The participants in group 1 (G1) received only conventional treatment (CT), in group 2 (G2) participants received one session of RAGT per week in addition to the CT program, and group 3 (G3) received two sessions of RAGT per week in addition to the CT program. 6-min walk test (6-MWT), Barthel Index (BI), Stroke-Specific Quality of Life Scale (SSQoL), and Beck Depression Inventory (BDI) were recorded.

RESULTS

Median change in SSQoL of G3 was significantly higher from median change of G1 (p < 0.05), and median change in BDI of G3 was significantly lower than median change of G1 (p < 0.05). Median change in BDI of G3 was also significantly lower from change of G2 (p < 0.05).

CONCLUSION

Two weekly sessions of RAGT in addition to CT exhibit positive effects on QoL and mood but no additional contribution to functional status.

Robotic versus Conventional Overground Gait Training in Subacute Stroke Survivors: A Multicenter Controlled Clinical Trial

BACKGROUND

Although stroke survivors can benefit from robotic gait rehabilitation, stationary robot-assisted gait training needs further investigation. In this paper, we investigated the efficacy of this approach (with an exoskeleton or an end-effector robot) in comparison to the conventional overground gait training in subacute stroke survivors.

METHODS

In a multicenter controlled clinical trial, 89 subacute stroke survivors conducted twenty sessions of robot-assisted gait training (Robotic Group) or overground gait training (Control Group) in addition to the standard daily therapy. The robotic training was performed with an exoskeleton (RobotEXO-group) or an end-effector (RobotEND-group). Clinical outcomes were assessed before (T0) and after (T1) the treatment. The walking speed during the 10-Meter Walk Test (10 MWT) was the primary outcome of this study, and secondary outcomes were the 6-Minute Walk Test (6 MWT), Timed Up and Go test (TUG), and the modified Barthel Index (mBI).

RESULTS

The main characteristics assessed in the Robotic and Control groups did not differ at baseline. A significant benefit was detected from the 10 MWT in the Robotic Group at the end of the study period (primary endpoint). A benefit was also observed from the following parameters: 6 MWT, TUG, and mBI. Moreover, patients belonging to the Robot Group outperformed the Control Group in gait speed, endurance, balance, and ADL. The RobotEND-group improved their walking speed more than the RobotEXO-group.

CONCLUSION

The stationary robot-assisted training improved walking ability better than the conventional training in subacute stroke survivors. These results suggest that people with subacute stroke may benefit from Robot-Assisted training in potentiating gait speed and endurance. Our results also support that end-effector robots would be superior to exoskeleton robots for improving gait speed enhancement.

Balance Rehabilitation through Robot-Assisted Gait Training in Post-Stroke Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Balance impairment is a common disability in post-stroke survivors, leading to reduced mobility and increased fall risk. Robotic gait training (RAGT) is largely used, along with traditional training. There is, however, no strong evidence about RAGT superiority, especially on balance. This study aims to determine RAGT efficacy on balance of post-stroke survivors.

METHODS

PubMed, Cochrane Library, and PeDRO databases were investigated. Randomized clinical trials evaluating RAGT efficacy on post-stroke survivor balance with Berg Balance Scale (BBS) or Timed Up and Go test (TUG) were searched. Meta-regression analyses were performed, considering weekly sessions, single-session duration, and robotic device used.

RESULTS

A total of 18 trials have been included. BBS pre-post treatment mean difference is higher in RAGT-treated patients, with a pMD of 2.17 (95% CI 0.79; 3.55). TUG pre-post mean difference is in favor of RAGT, but not statistically, with a pMD of -0.62 (95%CI - 3.66; 2.43). Meta-regression analyses showed no relevant association, except for TUG and treatment duration (β = -1.019, 95% CI - 1.827; -0.210, p-value = 0.0135).

CONCLUSIONS

RAGT efficacy is equal to traditional therapy, while the combination of the two seems to lead to better outcomes than each individually performed. Robot-assisted balance training should be the focus of experimentation in the following years, given the great results in the first available trials. Given the massive heterogeneity of included patients, trials with more strict inclusion criteria (especially time from stroke) must be performed to finally define if and when RAGT is superior to traditional therapy.

Effect of gait training using Welwalk on gait pattern in individuals with hemiparetic stroke: a cross-sectional study

Introduction

We aimed to explore the effect of gait training using Welwalk on gait patterns by comparing differences in gait patterns between robotic-assisted gait training using Welwalk and gait training using an orthosis in individuals with hemiparetic stroke.

Methods

This study included 23 individuals with hemiparetic stroke who underwent gait training with Welwalk combined with overground gait training using an orthosis. Three-dimensional motion analysis on a treadmill was performed under two conditions for each participant: during gait training with Welwalk and with the ankle-foot orthosis. The spatiotemporal parameters and gait patterns were compared between the two conditions.

Results

The affected step length was significantly longer, the step width was significantly wider, and the affected single support phase ratio was significantly higher in the Welwalk condition than in the orthosis condition. The index values of abnormal gait patterns were significantly lower while using Welwalk than in the orthosis condition. The following four indices were lower in the Welwalk condition: contralateral vaulting, insufficient knee flexion, excessive hip external rotation during the paretic swing phase, and paretic forefoot contact.

Discussion

Gait training using Welwalk increased the affected step length, step width, and single support phase while suppressing abnormal gait patterns as compared to gait training using the ankle-foot orthosis. This study suggests that gait training using Welwalk may promote a more efficient gait pattern reacquisition that suppresses abnormal gait patterns.

Trial registration

Prospectively registered in the Japan Registry of Clinical Trials (https://jrct.niph.go.jp; jRCTs042180152).

A Comparison of Three Common Rehabilitation Interventions Used to Improve Cardiovascular Fitness after Stroke: An Overview of the Literature

Background

One of the most frequent consequences of stroke is a reduction in heart function. After a stroke, one of the main aims of physiotherapy practice is to improve cardiovascular fitness (CVF). This paper is aimed at identifying the best effective intervention of improving the cardiovascular fitness (CVF) after stroke while focusing on body weight-supported treadmill training (BWSTT), over gait training (OGT), and therapeutic exercise.

Methods

Different electronic databases were searched until July 2022. Controlled randomized trials examining the effects of BWSTT, OGT, and therapeutic exercise to improve CVF on an ambulatory person with stroke, written in English and reporting cardiovascular fitness or at least one of its indicators, such as peak oxygen consumption (VO₂), gait speed, gait energy expenditure, and functional independence measure for locomotion (FIM-L), were included. The quality of the methodology was evaluated using the Physiotherapy Evidence Database (PEDro) scale.

Results

The research yielded 3854 relevant studies, of which 22 met the eligibility criteria. The primary indicators of the CVF, VO₂ and energy expenditure, were used to examine the CVF in only three studies, while the rest used other indicators of the CVF. There was a lack of sufficient evidence to establish the superiority of one intervention over another. However, it appears that utilizing BWSTT to improve the CVF after stroke is effective.

Conclusion

Physiotherapy has the potential to enhance the CVF of stroke patients. However, effective interventions and long-term effects remain debatable.

Evidence-based improvement of gait in post-stroke patients following robot-assisted training: A systematic review

BACKGROUND

The recovery of walking after stroke is a priority goal for recovering autonomy. In the last years robotic systems employed for Robotic Assisted Gait Training (RAGT) were developed. However, literature and clinical practice did not offer standardized RAGT protocol or pattern of evaluation scales.

OBJECTIVE

This systematic review aimed to summarize the available evidence on the use of RAGT in post-stroke, following the CICERONE Consensus indications.

METHODS

The literature search was conducted on PubMed, Cochrane Library and PEDro, including studies with the following criteria: 1) adult post-stroke survivors with gait disability in acute/subacute/chronic phase; 2) RAGT as intervention; 3) any comparators; 4) outcome regarding impairment, activity, and participation; 5) both primary studies and reviews.

RESULTS

Sixty-one articles were selected. Data about characteristics of patients, level of disability, robotic devices used, RAGT protocols, outcome measures, and level of evidence were extracted.

CONCLUSION

It is possible to identify robotic devices that are more suitable for specific phase disease and level of disability, but we identified significant variability in dose and protocols. RAGT as an add-on treatment seemed to be prevalent. Further studies are needed to investigate the outcomes achieved as a function of RAGT doses delivered.

Effectiveness of a wearable ankle-tubing gait training on ankle kinematics and motor control in hemiparetic stroke

BACKGROUND: While excessive ankle plantarflexion is a common neuromuscular impairment resulting from insufficient coordination of selective ankle neuromotor control and kinematics during gait. We recently developed a wearable, inexpensive and sustainable wearable ankle-tubing gait training (WAGT) aimed at improving selective ankle motor control and kinematic coordination. OBJECTIVE: We investigated the effects of WAGT on tibialis anterior (TA) and gastrocnemius (GCM) muscle electromyography (EMG) activity, TA: GCM muscle imbalance ratio, and ankle joint kinematics during gait in hemiparetic stroke patients. METHODS: A convenience sample of 33 participants (15 non-stroke healthy adults and 18 hemiparetic stroke patients) underwent standardized electromyography and kinematic biomechanical tests under conventional gait training (CGT) and WAGT conditions. Analysis of variance (ANOVA) was used to determine the significance of differences in the TA: GCM muscle activation, muscle imbalance ratio, and ankle joint kinematics before and after the intervention and between the two groups at P < 0.05. RESULTS: WAGT was more effective than CGT in improving TA muscle activation (P < 0.01), TA: GCM muscle imbalance ratio (P < 0.01), and kinematic movement (P < 0.01) in adults with or without hemiparetic stroke. CONCLUSIONS: This study demonstrated that WAGT is relatively ease to design, wear and affordable to most clinicians and patients, hence it is suitable for many health care applications to correct gait-related movement abnormalities presented in the hemiparetic stroke patients.

Adjustable Parameters and the Effectiveness of Adjunct Robot-Assisted Gait Training in Individuals with Chronic Stroke

The aims of this study were (1) to compare the effect of robot-assisted gait orthosis (RAGO) plus conventional physiotherapy with the effect of conventional therapy alone on functional outcomes, including balance, walking ability, muscle strength, daily activity, and cognition, in chronic stroke patients, and (2) to determine the association of adjustable parameters of RAGO on functional outcomes. Adjustable parameters of RAGO included guidance force, treadmill speed, and body-weight support. This retrospective cohort study enrolled 32 patients with chronic stroke. Of these, 16 patients received RAGO plus conventional physiotherapy (RAGO group), and 16 patients received conventional physiotherapy alone (control group). Balance was assessed using the Berg Balance Scale, walking ability using the Functional Ambulation Category, muscle strength using the Motricity Index, daily activity using the Barthel Index, and cognition using the Mini-Mental State Examination. The scores were assessed before and after training. The Mini–Mental State Examination and the Berg Balance Scale increased significantly in both groups, whereas improvements in the Motricity Index and the Barthel Index were only observed in the RAGO group after intervention. During RAGO training, reducing guidance force and body-weight support assistance was associated with improvements in the Barthel Index, whereas higher treadmill walking speed was associated with improvements in the Berg Balance Scale. Our study found that RAGO combination therapy resulted in improvements in more functional outcomes than did conventional training alone. The adjustable parameters of the RAGO training were partly associated with training outcomes.

Rethinking the tools in the toolbox

The commentary by Dr. Labruyere on the article by Kuo et al. (J Neuroeng Rehabil. 2021; 18:174) posits that randomized trials evaluating the comparative efficacy of robotic devices for patients with neurological injury may not be needed. The primary argument is that researchers and clinicians do not know how to optimize training parameters to maximize the benefits of this therapy, and studies vary in how they deliver robotic-assisted training. While I concur with the suggestion that additional trials using robotic devices as therapeutic tools are not warranted, an alternative hypothesis is that future studies will yield similar equivocal results regardless of the training parameters used. Attempts are made to detail arguments supporting this premise, including the notion that the original rationale for providing robotic-assisted walking training, particularly with exoskeletal devices, was flawed and that the design of some of the more commonly used devices places inherent limitations on the ability to maximize neuromuscular demands during training. While these devices arrived nearly 20 years ago amid substantial enthusiasm, we have since learned valuable lessons from robotic-assisted and other rehabilitation studies on some of the critical parameters that influence neuromuscular and cardiovascular activity during locomotor training, and different strategies are now needed to optimize rehabilitation outcomes.

Effect of gait rehabilitation with a footpad-type locomotion interface on gait ability in subacute stroke patients

BACKGROUND: Gait rehabilitation using a footpad-type locomotion interface has been reported as effective in improving gait ability in chronic stroke patients. However, the effect on subacute stroke patients is unknown. OBJECTIVE: To compare the effect of gait rehabilitation using a footpad-type locomotion interface (Gait Training with Locomotion Interface group; GTLI group) with conventional gait rehabilitation (control group) in subacute stroke patients. METHODS: Twenty-one stroke patients (GTLI group: n = 13, control group: n = 8) participated in the study. All participants received gait rehabilitation using the footpad-type locomotion interface or conventional gait rehabilitation for 20 minutes x 20 sessions. Outcome measures were functional ambulation Category (FAC), gait speed, gait endurance and lower muscle strength. Measures were taken at baseline and 1, 2, 3 and 4 weeks. RESULT: The GTLI group significantly improved gait speed and gait endurance compared with the control group. However, FAC and lower limb muscle strength were not significantly different. CONCLUSIONS: The results suggest that gait rehabilitation using the footpad-type locomotion interface can improve gait ability better than conventional gait rehabilitation.

Is robot-assisted gait training intensity a determinant of functional recovery early after stroke? A pragmatic observational study of clinical care

Gait rehabilitation is a critical factor in functional recovery after a stroke. The aim of this pragmatic observational study was to identify the optimal dose and timing of robot-assisted gait training (RAGT) that can lead to a favourable outcome in a sample of subacute stroke survivors. Subacute patients with stroke who underwent a RAGT within a multidisciplinary rehabilitation program were enrolled. A set of clinical (i.e. age, type of stroke and time since stroke) and rehabilitation stay outcomes (length of stay and RAGT number of sessions) were recorded to evaluate their impact on functional outcome measures by functional independence measure (FIM) or functional ambulation category (FAC). We included 236 patients (62.73 ± 11.82 year old); 38.44% were females, and 59.32% were ischaemic stroke patients. Patients that received at least 14 RAGT sessions, had 15.83% more chance to be responders compared to those that receive less sessions (P = 0.006). Similarly, younger patients (≤60 years) were more prone to be responders (+15.1%). Lastly, an early rehabilitation (<6 weeks) was found to be more efficient (+21.09%) in determining responsiveness (P < 0.001). Becoming newly independent for gait, that refers to a FAC score ≥4, was related with age and RAGT sessions (P = 0.001). In conclusion, a younger age (≤60 years), an early rehabilitation (<6 weeks since stroke) and a higher RAGT dose (at least 14 sessions) were related to a favourable outcome in patients with subacute stroke.

A Home-based Tele-rehabilitation System with Enhanced Therapist-patient Remote Interaction: A Feasibility Study

As a promising alternative to hospital-based manual therapy, robot-assisted tele-rehabilitation therapy has shown significant benefits in reducing the therapist's workload and accelerating the patient's recovery process. However, existing telerobotic systems for rehabilitation face barriers to implementing appropriate therapy treatment due to the lack of effective therapist-patient interactive capabilities. In this paper, we develop a home-based tele-rehabilitation system that implements two alternative training methods, including a haptic-enabled guided training that allows the therapist to adjust the intensity of therapeutic movements provided by the rehabilitation device and a surface electromyography (sEMG)-based supervised training that explores remote assessment of the patient's kinesthetic awareness. Preliminary experiments were conducted to demonstrate the feasibility of the proposed alternative training methods and evaluate the functionality of the developed tele-rehabilitation system. Results showed that the proposed tele-rehabilitation system enabled therapist-in-the-loop to dynamically adjust the rehabilitation intensity and provided more interactivity in therapist-patient remote interaction.

Efficacy of electromechanical-assisted gait training on clinical walking function and gait symmetry after brain injury of stroke: a randomized controlled trial

Electromechanical-assisted gait training may be an effective intervention to promote motor recovery after brain injury. However, many studies still have difficulties in clarifying the difference between electromechanical-assisted gait training and conventional gait training. To evaluate the effectiveness of electromechanical-assisted gait training compared to that of conventional gait training on clinical walking function and gait symmetry of stroke patients. We randomly assigned patients with stroke (n = 144) to a control group (physical therapist-assisted gait training) and an experimental group (electromechanical gait training). Both types of gait training were done for 30 min each day, 5 days a week for 4 weeks. The primary endpoint was the change in functional ambulatory category (FAC). Secondary endpoints were clinical walking functions and gait symmetries of swing time and step length. All outcomes were measured at baseline (pre-intervention) and at 4 weeks after the baseline (post-intervention). FAC showed significant improvement after the intervention, as did clinical walking functions, in both groups. The step-length asymmetry improved in the control group, but that in the experimental group and the swing-time asymmetry in both groups did not show significant improvement. In the subgroup analysis of stroke duration of 90 days, FAC and clinical walking functions showed more significant improvement in the subacute group than in the chronic group. However, gait symmetries did not show any significant changes in either the subacute or the chronic group. Electromechanically assisted gait training by EXOWALK was as effective as conventional gait training with a physiotherapist. Although clinical walking function in the subacute group improved more than in the chronic group, gait asymmetry did not improve for either group after gait training.

Trial registration: KCT0003411 Clinical Research Information Service (CRIS), Republic of Korea.

Settings matter: a scoping review on parameters in robot-assisted gait therapy identifies the importance of reporting standards

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.

Gait Entrainment to Torque Pulses from a Hip Exoskeleton Robot

Robot-aided locomotor rehabilitation has proven challenging. To facilitate progress, it is important to first understand the neuro-mechanical dynamics and control of unimpaired human locomotion. Our previous studies found that human gait entrained to periodic torque pulses at the ankle when the pulse period was close to preferred stride duration. Moreover, synchronized gait exhibited constant phase relation with the pulses so that the robot provided mechanical assistance. To test the generality of mechanical gait entrainment, this study characterized unimpaired human subjects' responses to periodic torque pulses during overground walking. The intervention was applied by a hip exoskeleton robot, Samsung GEMS-H. Gait entrainment was assessed based on the time-course of the phase at which torque pulses occurred within each stride. Experiments were conducted for two consecutive days to evaluate whether the second day elicited more entrainment. Whether entrainment was affected by the difference between pulse period and preferred stride duration was also assessed. Results indicated that the intervention evoked gait entrainment that occurred more often when the period of perturbation was closer to subjects' preferred stride duration, but the difference between consecutive days was insignificant. Entrainment was accompanied by convergence of pulse phase to a similar value across all conditions, where the robot maximized mechanical assistance. Clear evidence of motor adaptation indicated the potential of the intervention for rehabilitation. This study quantified important aspects of the nonlinear neuro-mechanical dynamics underlying unimpaired human walking, which will inform the development of effective approaches to robot-aided locomotor rehabilitation, exploiting natural dynamics in a minimally-encumbering way.

Efficacy of robotic exoskeleton for gait rehabilitation in patients with subacute stroke : a systematic review

BACKGROUND

Stroke is the most common cause of disability in Western Countries. It can lead to loss of mobility, capability to walk and ultimately loss of independence in activities of daily living (ADL). Several rehabilitative approaches have been proposed in these years. Robot-assisted gait rehabilitation (RAGT) plays a crucial role to perform a repetitive, intensive, and task-oriented treatment in stroke survivors. However, there are still few data on its role in subacute stroke patients.

AIM

The aim of the present study was to assess the efficacy of RAGT for gait recovery in subacute stroke survivors.

DESIGN

Systematic review with meta-analysis.

SETTING

The setting of the study included Units of Rehabilitation.

POPULATION

The analyzed population was represented by subacute stroke patients.

METHODS

PubMed, Scopus, Web of Science, CENTRAL, and PEDro were systematically searched until January 18, 2021, to identify randomized controlled trials (RCTs) presenting: stroke survivors in subacute phase (≤6 months) as participants; exoskeleton robots devices as intervention; conventional rehabilitation as a comparator; gait assessment, through qualitative scales, quantitative gait scales or quantitative parameters, as outcome measures. We also performed a meta-analysis of the mean difference in the functional ambulation category (FAC) via the random effect method.

RESULTS

Out of 3188 records, 14 RCTs were analyzed in this systematic review. The 14 studies have been published in the last 14 years (from 2006 to 2021) and included 576 stroke survivors, of which 306 received RAGT, and 270 underwent conventional rehabilitation. Lokomat robotic system was the most investigated robotic exoskeleton by the RCTs included (N.=9), albeit the meta-analysis demonstrated a non-significant difference of -0.09 in FAC (95% CI: -0.22.0.03) between Lokomat and conventional therapy. According to the PEDro scale, 11 (78.5%) were classified as good-quality studies, two as fair-quality studies (14.3%), and one as poor-quality study (7.1%).

CONCLUSIONS

Taken together, these findings showed that RAGT might have a potential role in gait recovery in subacute stroke survivors. However, further RCTs comparing the efficacy of RAGT with conventional physical therapy are still warranted in the neurorehabilitation field.

CLINICAL REHABILITATION IMPACT

This systematic review provides information on the efficacy of RAGT in allowing subacute stroke patients to perform high-intensity gait training with a lower physical burden on PRM professionals.

Effects of Sensory Interventions on Fatigue in People With Multiple Sclerosis: A Systematic Review

BACKGROUND

Fatigue is 1 of the most common and annoying symptoms in patients with multiple sclerosis (MS). The purpose of this study was to investigate the effect of sensory interventions on fatigue in people with MS based on a systematic review of sensory evidence.

METHODS

The Google Scholar, PubMed, Scopus, and Cochrane Library databases were searched from January 1990 to July 2020. Studies with nonpharmacologic sensory interventions as a main or secondary intervention according to the assessment of fatigue as the primary or secondary therapy outcome in patients with MS were included.

RESULTS

Nine articles were reviewed by examining the inclusion and exclusion criteria. Four types of interventions were related to exercises, including sensory integration exercises, vestibular rehabilitation, Frenkel exercises, and exercises with or without vibration; and 2 types were performed using robots and 1 type using vibration only. Vestibular rehabilitation therapies, exercise-based sensory integration interventions, and the use of vibration have shown significant effects in relieving fatigue in patients with MS.

CONCLUSIONS

The evidence in this study is insufficient to show a dramatic effect of sensory integration therapy in various forms. However, despite the studies, sensory integration therapy can be considered a potential treatment for fatigue in patients with MS. Further studies with stronger methods are needed to make this treatment a reality.

Applying Hip Stiffness With an Exoskeleton to Compensate Gait Kinematics

Neurological disorders and aging induce impaired gait kinematics. Despite recent advances, effective methods using lower-limb exoskeleton robots to restore gait kinematics are as yet limited. In this study, applying virtual stiffness using a hip exoskeleton was investigated as a possible method to guide users to change their gait kinematics. With a view to applications in locomotor rehabilitation, either to provide assistance or promote recovery, this study assessed whether imposed stiffness induced changes in the gait pattern during walking; and whether any changes persisted upon removal of the intervention, which would indicate changes in central neuro-motor control. Both positive and negative stiffness induced immediate and persistent changes of gait kinematics. However, the results showed little behavioral evidence of persistent changes in neuro-motor control, not even short-lived aftereffects. In addition, stride duration was little affected, suggesting that at least two dissociable layers exist in the neuro-motor control of human walking. The lack of neuro-motor adaptation suggests that, within broad limits, the central nervous system is surprisingly indifferent to the details of lower limb kinematics. The lack of neuro-motor adaptation also suggests that alternative methods may be required to implement a therapeutic technology to promote recovery. However, the immediate, significant, and reproducible changes in kinematics suggest that applying hip stiffness with an exoskeleton may be an effective assistive technology for compensation.

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

BACKGROUND

Individuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke.

METHODS

An assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months.

RESULTS

Thirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported.

CONCLUSIONS

This study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes. Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016).

Robot-Assisted Gait Training Plan for Patients in Poststroke Recovery Period: A Single Blind Randomized Controlled Trial

BACKGROUND

Walking dysfunction exists in most patients after stroke. Evidence regarding gait training in two weeks is scarce in resource-limited settings; this study was conducted to investigate the effects of a short-term robot-assisted gait training plan for patients with stroke.

METHODS

85 patients were randomly assigned to one of two treatment groups, with 31 patients in withdrawal before treatment. The training program comprised 14 2-hour sessions, for 2 consecutive weeks. Patients allocated to the robot-assisted gait training group were treated using the Gait Training and Evaluation System A3 from NX (RT group, n = 27). Another group of patients was allocated to the conventional overground gait training group (PT group, n = 27). Outcome measurements were assessed using time-space parameter gait analysis, Fugl-Meyer Assessment (FMA), and Timed Up and Go test (TUG) scores.

RESULTS

In the time-space parameter analysis of gait, the two groups exhibited no significant changes in time parameters, but the RT group exhibited a significant effect on changes in space parameters (stride length, walk velocity, and toe out angle, P < 0.05). After training, FMA scores (20.22 ± 2.68) of the PT group and FMA scores (25.89 ± 4.6) of the RT group were significant. In the Timed Up and Go test, FMA scores of the PT group (22.43 ± 3.95) were significant, whereas those in the RT group (21.31 ± 4.92) were not. The comparison between groups revealed no significant differences.

CONCLUSION

Both the RT group and the PT group can partially improve the walking ability of stroke patients within 2 weeks.

Viscous field training induces after effects but hinders recovery of overground locomotion following spinal cord injury in rats

Robotic-assisted gait training was able to improve the unassisted overground locomotion of rats following a cervical spinal cord injury. Specifically, four weeks of daily step training in the Robomedica Rodent Robotic Motor Performance System, where the device actively guided the hindlimbs through a pre-injury stepping pattern while the rats walked over a moving treadmill belt in a quadrupedal posture, was able to improve unassisted overground locomotion as measured by the CatWalk gait analysis device. Unfortunately the improvements were minimal. In fact, control animals that received only body weight supported treadmill training and no active robotic forces showed an even greater restoration of unassisted overground locomotion. This led us to further investigate the effects of the specific forces used in rehabilitative training. The robotic training device was modified to apply assistive (negative viscosity) or resistive (viscous) fields in lieu of the standard active guidance. Within the device, daily training with a viscous field resulted in small, constrained steps that were similar to pre-injury steps. However, when the robot was off for weekly assessments, the steps opened up and deviated away from pre-injury levels. Training in a negative viscosity field produced the opposite effect; large open steps that were unlike pre-injury during daily training, and constrained steps that were more like pre-injury during weekly assessment. These training induced after-effects washed out 2 weeks after the cessation of training. Additionally, these distinct after effects seen in the training device did not translate to distinct differences in the recovery of unassisted overground locomotion, with the body weight supported treadmill training controls showing the greatest recovery of overground locomotion. Still, the fact that different applied forces can induce different after effects has interesting implications for rehabilitative training - is it better to have healthy looking steps during training only to induce abnormal after effects, or have abnormal performance during training but with desirable after effects? The data presented here is the first step in addressing this question.