Overground robotic training effects on walking and secondary health conditions in individuals with spinal cord injury: systematic review

Exoskeleton-Assisted Rehabilitation and Neuroplasticity in Spinal Cord Injury

Spinal cord injury (SCI) results in neurological deficits below the level of injury, causing motor dysfunction and various severe multisystem complications. Rehabilitative training plays a crucial role in the recovery of individuals with SCI, and exoskeleton serves as an emerging and promising tool for rehabilitation, especially in promoting neuroplasticity and alleviating SCI-related complications. This article reviews the classifications and research progresses of medical exoskeletons designed for SCI patients and describes their performances in practical application separately. Meanwhile, we discuss their mechanisms for enhancing neuroplasticity and functional remodeling, as well as their palliative impacts on secondary complications. The potential trends in exoskeleton design are raised according to current progress and requirements on SCI rehabilitation.

Bilateral tibial fractures associated with powered exoskeleton use in complete spinal cord injury - a case report & literature review

INTRODUCTION

Powered robotic exoskeleton (PRE) physiotherapy programmes are a relatively novel frontier which allow patients with reduced mobility to engage in supported walking. Research is ongoing regarding their utility, risks, and benefits. This article describes the case of two fractures occurring in one patient using a PRE.

CASE

We report the case of a 54 year old man who sustained bilateral tibial fractures while using a PRE, on a background of T10 AIS A SCI. The initial session was discontinued due to acute severe bilateral knee swelling after approximately 15 min. The patient attended their local hospital the following day, where radiographs demonstrated bilateral proximal tibial fractures. The patient was treated with manipulation under anaesthetic and long-leg casting for five weeks, at which point he was stepped down to hinged knee braces which were weaned gradually while he remained non-weight bearing for 12 weeks. The patient was investigated with DEXA scan and was diagnosed with osteoporosis. He was liaised with rheumatology services and bone protection was initiated. Fracture healing was achieved and weight-bearing precautions were discontinued, however this period of immobilisation led to significant spasticity. The patient was discharged from orthopaedic services, with ongoing rehabilitation and physiotherapy follow-up.

CONCLUSION

PRE assisted physiotherapy programmes are a promising concept in terms of rehabilitation and independence, however they are not without risk and it is important that both providers and patients are aware of this. Furthermore, SCI patients are at increased risk for osteoporosis and should be monitored and considered for bone protection.

Overground Robotic Exoskeleton Training for Patients With Stroke on Walking-Related Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

OBJECTIVE

This review aims to evaluate the effectiveness of solely overground robotic exoskeleton (RE) training or overground RE training with conventional rehabilitation in improving walking ability, speed, and endurance among patients with stroke.

DATA SOURCES

Nine databases, 5 trial registries, gray literature, specified journals, and reference lists from inception until December 27, 2021.

STUDY SELECTION

Randomized controlled trials adopting overground robotic exoskeleton training for patients with any phases of stroke on walking-related outcomes were included.

DATA EXTRACTION

Two independent reviewers extracted items and performed risk of bias using the Cochrane Risk of Bias tool 1 and certainty of evidence using the Grades of Recommendation Assessment, Development, and Evaluation.

DATA SYNTHESIS

Twenty trials involving 758 participants across 11 countries were included in this review. The overall effect of overground robotic exoskeletons on walking ability at postintervention (d=0.21; 95% confidence interval [CI], 0.01, 0.42; Z=2.02; P=.04) and follow-up (d=0.37; 95% CI, 0.03, 0.71; Z=2.12; P=.03) and walking speed at postintervention (d=0.23; 95% CI, 0.01, 0.46; Z=2.01; P=.04) showed significant improvement compared with conventional rehabilitation. Subgroup analyses suggested that RE training should combine with conventional rehabilitation. A preferable gait training regime is <4 times per week over ≥6 weeks for ≤30 minutes per session among patients with chronic stroke and ambulatory status of independent walkers before training. Meta-regression did not identify any effect of the covariates on the treatment effect. The majority of randomized controlled trials had small sample sizes, and the certainty of the evidence was very low.

CONCLUSION

Overground RE training may have a beneficial effect on walking ability and walking speed to complement conventional rehabilitation. Further large-scale and long-term, high-quality trials are recommended to enhance the quality of overground RE training and confirm its sustainability.

Robotic rehabilitation therapy using Hybrid Assistive Limb (HAL) for patients with spinal cord lesions: A narrative review

Background

The Hybrid Assistive Limb (HAL) is a rehabilitation device that utilizes the "interactive biofeedback" hypothesis to facilitate the motion of the device according to the user's motion intention and appropriate sensory input evoked by HAL-supported motion. HAL has been studied extensively for its potential to promote walking function in patients with spinal cord lesions, including spinal cord injury.

Methods

We performed a narrative review of HAL rehabilitation for spinal cord lesions.

Results

Several reports have shown the effectiveness of HAL rehabilitation in the recovery of walking ability in patients with gait disturbance caused by compressive myelopathy. Clinical studies have also demonstrated potential mechanisms of action leading to clinical findings, including normalization of cortical excitability, improvement of muscle synergy, attenuation of difficulties in voluntarily initiating joint movement, and gait coordination changes.

Conclusions

However, further investigation with more sophisticated study designs is necessary to prove the true efficacy of HAL walking rehabilitation. HAL remains one of the most promising rehabilitation devices for promoting walking function in patients with spinal cord lesions.

Comparison of the dynamics of exoskeletal-assisted and unassisted locomotion in an FDA-approved lower extremity device: Controlled experiments and development of a subject-specific virtual simulator

Robotic exoskeletons have considerable, but largely untapped, potential to restore mobility in individuals with neurological disorders, and other conditions that result in partial or complete immobilization. The growing demand for these devices necessitates the development of technology to characterize the human-robot system during exoskeletal-assisted locomotion (EAL) and accelerate robot design refinements. The goal of this study was to combine controlled experiments with computational modeling to build a virtual simulator of EAL. The first objective was to acquire a minimum empirical dataset comprising human-robot kinematics, ground reaction forces, and electromyography during exoskeletal-assisted and unassisted locomotion from an able-bodied participant. The second objective was to quantify the dynamics of the human-robot system using a subject-specific virtual simulator reproducing EAL compared to the dynamics of normal gait. We trained an able-bodied participant to ambulate independently in a Food and Drug Administration-approved exoskeleton, the ReWalk P6.0 (ReWalk Robotics, Yoknaem, Israel). We analyzed the motion of the participant during exoskeletal-assisted and unassisted walking, sit-to-stand, and stand-to-sit maneuvers, with simultaneous measurements of (i) three-dimensional marker trajectories, (ii) ground reaction forces, (iii) electromyography, and (iv) exoskeleton encoder data. We created a virtual simulator in OpenSim, comprising a whole-body musculoskeletal model and a full-scale exoskeleton model, to determine the joint kinematics and moments during exoskeletal-assisted and unassisted maneuvers. Mean peak knee flexion angles of the human subject during exoskeletal-assisted walking were 50.1° ± 0.6° (left) and 52.6° ± 0.7° (right), compared to 68.6° ± 0.3° (left) and 70.7° ± 1.1° (right) during unassisted walking. Mean peak knee extension moments during exoskeletal-assisted walking were 0.10 ± 0.10 Nm/kg (left) and 0.22 ± 0.11 Nm/kg (right), compared to 0.64 ± 0.07 Nm/kg (left) and 0.73 ± 0.10 Nm/kg (right) during unassisted walking. This work provides a foundation for parametric studies to characterize the effects of human and robot design variables, and predictive modeling to optimize human-robot interaction during EAL.

Cost-effectiveness analysis of overground robotic training versus conventional locomotor training in people with spinal cord injury

BACKGROUND

Few, if any estimates of cost-effectiveness for locomotor training strategies following spinal cord injury (SCI) are available. The purpose of this study was to estimate the cost-effectiveness of locomotor training strategies following spinal cord injury (overground robotic locomotor training versus conventional locomotor training) by injury status (complete versus incomplete) using a practice-based cohort.

METHODS

A probabilistic cost-effectiveness analysis was conducted using a prospective, practice-based cohort from four participating Spinal Cord Injury Model System sites. Conventional locomotor training strategies (conventional training) were compared to overground robotic locomotor training (overground robotic training). Conventional locomotor training included treadmill-based training with body weight support, overground training, and stationary robotic systems. The outcome measures included the calculation of quality adjusted life years (QALYs) using the EQ-5D and therapy costs. We estimate cost-effectiveness using the incremental cost utility ratio and present results on the cost-effectiveness plane and on cost-effectiveness acceptability curves.

RESULTS

Participants in the prospective, practice-based cohort with complete EQ-5D data (n = 99) qualified for the analysis. Both conventional training and overground robotic training experienced an improvement in QALYs. Only people with incomplete SCI improved with conventional locomotor training, 0.045 (SD 0.28), and only people with complete SCI improved with overground robotic training, 0.097 (SD 0.20). Costs were lower for conventional training, $1758 (SD $1697) versus overground robotic training $3952 (SD $3989), and lower for those with incomplete versus complete injury. Conventional overground training was more effective and cost less than robotic therapy for people with incomplete SCI. Overground robotic training was more effective and cost more than conventional training for people with complete SCI. The incremental cost utility ratio for overground robotic training for people with complete spinal cord injury was $12,353/QALY.

CONCLUSIONS

The most cost-effective locomotor training strategy for people with SCI differed based on injury completeness. Conventional training was more cost-effective than overground robotic training for people with incomplete SCI. Overground robotic training was more cost-effective than conventional training for people with complete SCI. The effect estimates may be subject to limitations associated with small sample sizes and practice-based evidence methodology. These estimates provide a baseline for future research.

The Outcomes of Robotic Rehabilitation Assisted Devices Following Spinal Cord Injury and the Prevention of Secondary Associated Complications

Spinal cord injuries (SCIs) have major consequences on the patient’s health and life. Voluntary muscle paralysis caused by spinal cord damage affects the patient’s independence. Following SCI, an irreversible motor and sensory deficit occurs (spasticity, muscle paralysis, atrophy, pain, gait disorders, pain). This pathology has implications on the whole organism: on the osteoarticular, muscular, cardiovascular, respiratory, gastrointestinal, genito-urinary, skin, metabolic disorders, and neuro-psychic systems. The rehabilitation process for a subject having SCIs can be considered complex, since the pathophysiological mechanism and biochemical modifications occurring at the level of spinal cord are not yet fully elucidated. This review aims at evaluating the impact of robotic-assisted rehabilitation in subjects who have suffered SCI, both in terms of regaining mobility as a major dysfunction in patients with SCI, but also in terms of improving overall fitness and cardiovascular function, respiratory function, as well as the gastrointestinal system, bone density and finally the psychosocial issues, based on multiple clinical trials, and pilot studies. The researched literature in the topic revealed that in order to increase the chances of neuro-motor recovery and to obtain satisfactory results, the combination of robotic therapy, a complex recovery treatment and specific medication is one of the best decisions. Furthermore, the use of these exoskeletons facilitates better/greater autonomy for patients, as well as optimal social integration.

Efficacy of Overground Robotic Gait Training on Balance in Stroke Survivors: A Systematic Review and Meta-Analysis

Strokes often lead to a deficit in motor control that contributes to a reduced balance function. Impairments in the balance function severely limit the activities of daily living (ADL) in stroke survivors. The present systematic review and meta-analysis primarily aims to explore the efficacy of overground robot-assisted gait training (o-RAGT) on balance recovery in individuals with stroke. In addition, the efficacy on ADL is also investigated. This systematic review identified nine articles investigating the effects of o-RAGT on balance, four of which also assessed ADL. The results of the meta-analysis suggest that o-RAGT does not increase balance and ADL outcomes more than conventional therapy in individuals after stroke. The data should not be overestimated due to the low number of studies included in the meta-analysis and the wide confidence intervals. Subgroup analyses to investigate the influence of participant’s characteristics and training dosage were not performed due to lack of data availability. Further well-designed randomized controlled trials are needed to investigate the efficacy of o-RAGT on balance in individuals with stroke.