Exercise with a wearable hip-assist robot improved physical function and walking efficiency in older adults

Wearable assistive robotics has emerged as a promising technology to supplement or replace motor functions and to retrain people recovering from an injury or living with reduced mobility. We developed delayed output feedback control for a wearable hip-assistive robot, the EX1, to provide gait assistance. Our purpose in this study was to investigate the effects of long-term exercise with EX1 on gait, physical function, and cardiopulmonary metabolic energy efficiency in elderly people. This study used parallel experimental (exercise with EX1) and control groups (exercise without EX1). A total of 60 community-dwelling elderly persons participated in 18 exercise intervention sessions during 6 weeks, and all participants were assessed at 5 time points: before exercise, after 9 exercise sessions, after 18 sessions, and 1 month and 3 months after the last session. The spatiotemporal gait parameters, kinematics, kinetics, and muscle strength of the trunk and lower extremities improved more after exercise with EX1 than in that without EX1. Furthermore, the effort of muscles over the trunk and lower extremities throughout the total gait cycle (100%) significantly decreased after exercise with EX1. The net metabolic energy costs during walking significantly improved, and functional assessment scores improved more in the experimental group than in the control group. Our findings provide evidence supporting the application of EX1 in physical activity and gait exercise is effective to improve age-related declines in gait, physical function, and cardiopulmonary metabolic efficiency among older adults.

Metaverse for Exercise Rehabilitation: Possibilities and Limitations

OBJECTIVES

This study aimed to obtain a consensus agreement from an expert panel on the metaverse for exercise rehabilitation in stroke patients using the Delphi technique.

METHODS

This study recruited twenty-two experts and conducted three rounds of online surveys between January and February 2023. The Delphi consensus technique was performed online to review and evaluate the framework module. A panel of experts, including scholars, physicians, physical therapists, and physical education specialists in the Republic of Korea, was invited to participate in this study. For each round, the expert consensus was defined as more than 90% of the expert panel agreeing or strongly agreeing with the proposed items.

RESULTS

A total of twenty experts completed the three Delphi rounds. First, virtual reality-assisted (VR) treadmill walking could improve cognitive function, concentration, muscular endurance, stroke prevention, proper weight maintenance, and cardiorespiratory function. Second, related technology, safety, price, place, and securing experts would be obstacles or challenges in VR-assisted treadmill walking for stroke patients. Third, the role of exercise instructors in exercise planning, performance, and assessment for VR-assisted treadmill walking is equally important, and reeducation for them is required. Fourth, VR-assisted treadmill walking for stroke patients requires an exercise intensity of at least five times a week, about one hour each time.

CONCLUSIONS

This study showed that the metaverse for exercise rehabilitation for stroke patients could be successfully developed and would be feasible to be implemented in the future. However, it would have limitations in terms of technology, safety, price, place, and expert factors to be overcome in the future.

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.

Effects of Robot-Assisted Gait Training with Body Weight Support on Gait and Balance in Stroke Patients

This study investigated the effects of robot-assisted gait training with body weight support on gait and balance in stroke patients. The study participants comprised 24 patients diagnosed with stroke. Patients were randomly assigned to four groups of six: robot A, B, C, and non-robot. The body weight support (BWS) for the harness of the robot was set to 30% of the patient’s body weight in robot group A, 50% in robot group B, and 70% in robot group C. All experimental groups received robot-assisted gait training and general physical therapy. The non-robot group underwent gait training using a p-bar, a treadmill, and general physical therapy. The intervention was performed for 30 min a day, five times a week, for 6 weeks. All participants received the intervention after the pre-test. A post-test was performed after all of the interventions were completed. Gait was measured using a 10 m Walking test (10MWT) and the timed up and go (TUG) test. Balance was assessed using the Berg Balance Scale (BBS). Robot groups A, B, and C showed significantly better 10MWT results than did the non-robot group (p < 0.5). TUG was significantly shorter in robot groups A, B, and C than in the non-robot group (p < 0.5). The BBS scores for robot group A improved significantly more than did those for robot groups B and C and the non-robot group (p < 0.5), indicating that robot-assisted gait training with body weight support effectively improved the gait of stroke patients.

The effect of pelvic movements of a gait training system for stroke patients: a single blind, randomized, parallel study

BACKGROUND

Aging societies lead to higher demand for gait rehabilitation as age-related neurological disorders such as stroke and spinal cord injury increase. Since conventional methods for gait rehabilitation are physically and economically burdensome, robotic gait training systems have been studied and commercialized, many of which provided movements confined in the sagittal plane. For better outcomes of gait rehabilitation with more natural gait patterns, however, it is desirable to provide pelvic movements in the transverse plane. In this study, a robotic gait training system capable of pelvic motions in the transverse plane was used to evaluate the effect of the pelvic motions on stroke patients.

METHOD

Healbot T, which is a robotic gait training system and capable of providing pelvic movements in the transverse plane as well as flexion/extension of the hip and knee joints and adduction/abduction of the hip joints, is introduced and used to evaluate the effect of the pelvic movement on gait training of stroke patients. Gait trainings in Healbot T with and without pelvic movements are carried out with stroke patients having hemiparesis.

EXPERIMENT

Twenty-four stroke patients with hemiparesis were randomly assigned into two groups and 23 of them successfully completed the experiment except one subject who had dropped out due to personal reasons. Pelvis-on group was provided with pelvic motions whereas no pelvic movement was allowed for pelvis-off group during 10 sessions of gait trainings in Healbot T. Electromyography (EMG) signals and interaction forces as well as the joint angles of the robot were measured. Gait parameters such as stride length, cadence, and walking speed were measured while walking on the ground without assistance of Healbot T after gait training on 1st, 5th, and 10th day.

RESULT

Stride length significantly increased in both groups. Furthermore, cadence and walking speed of the pelvis-on group were increased by 10.6% and 11.8%. Although interaction forces of both groups except the thighs showed no differences, EMG signals from gluteus medius of the pelvis-on group increased by 88.6% during stance phase. In addition, EMG signals of biceps femoris, gastrocnemius medial, and gastrocnemius lateral of the pelvis-on group increased whereas EMG signals of the pelvis-off group except gastrocnemius lateral showed no difference after gait trainings.

CONCLUSION

Gait training using a robotic gait training system with pelvic movements was conducted to investigate the effects of lateral and rotational pelvic movements in gait training of stroke patients. The pelvic movements affected to increase voluntary muscle activation during the stance phase as well as cadence and walking speed.

CLINICAL TRIAL REGISTRATION

KCT0003762, 2018-1254, Registered 28 October 2018, https://cris.nih.go.kr/cris/search/search_result_st01_kren.jsp?seq=14310&ltype=&rtype=.

Design, Manufacturing, and Control of a Pneumatic-Driven Passive Robotic Gait Training System for Muscle-Weakness in a Lower Limb

We designed and manufactured a pneumatic-driven robotic passive gait training system (PRPGTS), providing the functions of body-weight support, postural support, and gait orthosis for patients who suffer from weakened lower limbs. The PRPGTS was designed as a soft-joint gait training rehabilitation system. The soft joints provide passive safety for patients. The PRPGTS features three subsystems: a pneumatic body weight support system, a pneumatic postural support system, and a pneumatic gait orthosis system. The dynamic behavior of these three subsystems are all involved in the PRPGTS, causing an extremely complicated dynamic behavior; therefore, this paper applies five individual interval type-2 fuzzy sliding controllers (IT2FSC) to compensate for the system uncertainties and disturbances in the PRGTS. The IT2FSCs can provide accurate and correct positional trajectories under passive safety protection. The feasibility of weight reduction and gait training with the PRPGTS using the IT2FSCs is demonstrated with a healthy person, and the experimental results show that the PRPGTS is stable and provides a high-trajectory tracking performance.

Constraint-Induced Movement Therapy Combined With Botulinum Toxin for Post-stroke Spasticity: A Systematic Review and Meta-Analysis

Stroke is considered one of the main causes of adult disability and the second most serious cause of death worldwide. The combination of botulinum toxin type A (BTX) with rehabilitation techniques such as modified constraint-induced movement therapy (mCIMT) has emerged as a highly efficient intervention for stroke patients to start synchronized motor function along with spasticity reduction. The current systematic review and meta-analysis were conducted in order to evaluate the available literature about the safety and efficacy of constraint-induced movement therapy (CIMT) combined with BTX in stroke patients with upper limb spasticity. Searches were conducted on WoS (Web of Science), Ovid, EBSCO-ASC&BSC, and PubMed for identifying relevant literature published from 2000-2020. Randomized Controlled Trials (RCTs) and Quasi-experimental studies were considered for inclusion. Rayyan (systematic review tool) QCRI (Qatar Computing Research Institute) was used for independent screening of the studies by two reviewers. For risk of bias and study quality assessment, Cochrane risk of bias tool (RoB 2) and Physiotherapy Evidence Database (PEDro) scales were used. Cochrane review manager was used to carry out the meta-analyses of the included studies. The search resulted in a total of 13065 references, of which 4967 were duplicates. After the title, abstract and full-text screening, two RCTs were deemed eligible for inclusion. Both the RCTs scored 8 on PEDro and were level evidence. The studies were heterogeneous. The findings of this meta-analysis in all the three joints post-stroke spasticity assessed on modified Ashworth scale (MAS) at four weeks post-injection aren't statistically significant (elbow P-value 0.74, wrist P-value 0.57, fingers P-value 0.42), however, according to one of the included studies the therapeutic efficacy of the combination of BTX-mCIMT injection assessed at four weeks post-injection in wrist and finger flexors was promising.  The effectiveness of BTX-CIMT combination over conventional therapy (CT) for improving post-stroke spasticity still needs to be explored with long-term, multicenter rigorously designed RCTs having a good sample size. However, the BTX-CIMT combination is promising for enhancing motor function recovery and improving activities of daily living (ADLs).

DIMENSIONAL SYNTHESIS OF A GAIT REHABILITATION CABLE-SUSPENDED ROBOT ON MINIMUM 2-NORM TENSIONS

A new design of gait rehabilitation robot with cable-suspended configuration is proposed. Due to the under-constrained nature, it enables reducing the constraint feeling of patients. Cables are attached to cuffs mounted on the leg. A detailed mechanical design is presented and a kinematics model is developed. Dimensional synthesis is performed in two steps. First, the cable disposition should be determined within a range to maintain cable-suspended configuration using the minimum 2-norm solution of tensions. Second, the optimal cable disposition is achieved with the Root Mean Square of tension solutions. Gait rehabilitation robots with three or four cables are discussed and compared to determine dimensional parameters in terms of the locations of pulleys. A simulation model with ADAMS software is presented and the cable module is utilized to imitate the cable-driven system in real. Tension distribution is obtained from the simulation model, which is employed in comparison with the calculated values. The simulation results demonstrate the effectiveness of the presented method.

Effects of an exoskeleton-assisted gait training on post-stroke lower-limb muscle coordination

Objective.Powered exoskeletons have been used to help persons with gait impairment regain some walking ability. However, little is known about its impact on neuromuscular coordination in persons with stroke. The objective of this study is to investigate how a powered exoskeleton could affect the neuromuscular coordination of persons with post-stroke hemiparesis.Approach.Eleven able-bodied subjects and ten stroke subjects participated in a single-visit treadmill walking assessment, in which their motion and lower-limb muscle activities were captured. By comparing spatiotemporal parameters, kinematics, and muscle synergy pattern between two groups, we characterized the normal gait pattern and the post-stroke motor deficits. Five eligible stroke subjects received exoskeleton-assisted gait trainings and walking assessments were conducted pre-intervention (Pre) and post-intervention (Post), without (WO) and with (WT) the exoskeleton. We compared their gait performance between (a) Pre and Post to investigate the effect of exoskeleton-assisted gait training and, (b) WO and WT the exoskeleton to investigate the effect of exoskeleton wearing on stroke subjects.Main results.While four distinct motor modules were needed to describe lower-extremity activities during stead-speed walking among able-bodied subjects, three modules were sufficient for the paretic leg from the stroke subjects. Muscle coordination complexity, module composition and activation timing were preserved after the training, indicating the intervention did not significantly change the neuromuscular coordination. In contrast, walking WT the exoskeleton altered the stroke subjects' synergy pattern, especially on the paretic side. The changes were dominated by the activation profile modulation towards the normal pattern observed from the able-bodied group.Significance.This study gave us some critical insight into how a powered exoskeleton affects the stroke subjects' neuromuscular coordination during gait and demonstrated the potential to use muscle synergy as a method to evaluate the effect of the exoskeleton training.This study was registered at ClinicalTrials.gov (identifier: NCT03057652).

Exploiting telerobotics for sensorimotor rehabilitation: a locomotor embodiment

Background

Manual treadmill training is used for rehabilitating locomotor impairments but can be physically demanding for trainers. This has been addressed by enlisting robots, but in doing so, the ability of trainers to use their experience and judgment to modulate locomotor assistance on the fly has been lost. This paper explores the feasibility of a telerobotics approach for locomotor training that allows patients to receive remote physical assistance from trainers.

Methods

In the approach, a trainer holds a small robotic manipulandum that shadows the motion of a large robotic arm magnetically attached to a locomoting patient's leg. When the trainer deflects the manipulandum, the robotic arm applies a proportional force to the patient. An initial evaluation of the telerobotic system’s transparency (ability to follow the leg during unassisted locomotion) was performed with two unimpaired participants. Transparency was quantified by the magnitude of unwanted robot interaction forces. In a small six-session feasibility study, six individuals who had prior strokes telerobotically interacted with two trainers (separately), who assisted in altering a targeted gait feature: an increase in the affected leg’s swing length.

Results

During unassisted walking, unwanted robot interaction forces averaged 3−4 N (swing–stance) for unimpaired individuals and 2−3 N for the patients who survived strokes. Transients averaging about 10 N were sometimes present at heel-strike/toe-off. For five of six patients, these forces increased with treadmill speed during stance (R² = .99; p < 0.001) and increased with patient height during swing (R² = .71; p = 0.073). During assisted walking, the trainers applied 3.0 ± 2.8 N (mean ± standard deviation across patients) and 14.1 ± 3.4 N of force anteriorly and upwards, respectively. The patients exhibited a 20 ± 21% increase in unassisted swing length between Days 1−6 (p = 0.058).

Conclusions

The results support the feasibility of locomotor assistance with a telerobotics approach. Simultaneous measurement of trainer manipulative actions, patient motor responses, and the forces associated with these interactions may prove useful for testing sensorimotor rehabilitation hypotheses. Further research with clinicians as operators and randomized controlled trials are needed before conclusions regarding efficacy can be made.

Effectiveness of walking training on balance, motor functions, activity, participation and quality of life in people with chronic stroke: a systematic review with meta-analysis and meta-regression of recent randomized controlled trials

PURPOSE

To review and quantify the effects of walking training for the improvement of various aspects of physical function of people with chronic stroke.

METHODS

We conducted a systematic search and meta-analysis of randomized controlled trials (RCTs) of chronic stroke rehabilitation interventions published from 2008 to 2020 in English or French. Of the 6476-screened articles collated from four databases, 15 RCTs were included and analyzed. We performed a meta-regression with the total training time as dependent variable in order to have a better understanding of how did the training dosage affect the effect sizes.

RESULTS

Treadmill walking training was more effective on balance and motor functions (standardized mean difference (SMD)=0.70[0.02, 1.37], p = 0.04) and 0.56[0.15, 0.96], p = 0.007 respectively). Overground walking training improved significantly walking endurance (SMD = 0.38[0.16, 0.59], p < 0.001), walking speed (MD = 0.12[0.05, 0.18], p < 0.001), participation (SMD = 0.35[0.02, 0.68], p = 0.04) and quality of life (SMD = 0.46[0.12, 0.80], p = 0.008). Aquatic training improved balance (SMD = 2.41[1.20, 3.62], p < 0.001). The Meta-regression analysis did not show significant effect of total training time on the effect sizes.

CONCLUSION

Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in people with chronic stroke.Implications for rehabilitationTreadmill walking training is effective for improving balance and motor functions.Overground walking training improved significantly walking endurance, walking speed, participation and quality of life.Treadmill and overground walking protocols consisting of ≥30 min sessions conducted at least 3 days per week for about 8 weeks are beneficial for improving motor impairments, activity limitations, participation, and quality of life in patient with chronic stroke.

Electromechanical-assisted training for walking after stroke

BACKGROUND

Electromechanical- and robot-assisted gait-training devices are used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane Review first published in 2007 and previously updated in 2017.

OBJECTIVES

Primary • To determine whether electromechanical- and robot-assisted gait training versus normal care improves walking after stroke Secondary • To determine whether electromechanical- and robot-assisted gait training versus normal 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 the Cochrane Stroke Group Trials Register (last searched 6 January 2020); the Cochrane Central Register of Controlled Trials (CENTRAL; 2020 Issue 1), in the Cochrane Library; MEDLINE in Ovid (1950 to 6 January 2020); Embase (1980 to 6 January 2020); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 20 November 2019); the Allied and Complementary Medicine Database (AMED; 1985 to 6 January 2020); Web of Science (1899 to 7 January 2020); SPORTDiscus (1949 to 6 January 2020); the Physiotherapy Evidence Database (PEDro; searched 7 January 2020); and the engineering databases COMPENDEX (1972 to 16 January 2020) and Inspec (1969 to 6 January 2020). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted trial authors in an effort to identify further published, unpublished, and ongoing trials.

SELECTION 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 normal care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted data. We assessed the quality of evidence using the GRADE approach. The primary outcome was the proportion of participants walking independently at follow-up.

MAIN RESULTS

We included in this review update 62 trials involving 2440 participants. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (random effects) 2.01, 95% confidence interval (CI) 1.51 to 2.69; 38 studies, 1567 participants; P < 0.00001; I² = 0%; high-quality evidence) and increased mean walking velocity (mean difference (MD) 0.06 m/s, 95% CI 0.02 to 0.10; 42 studies, 1600 participants; P = 0.004; I² = 60%; low-quality evidence) but did not improve mean walking capacity (MD 10.9 metres walked in 6 minutes, 95% CI -5.7 to 27.4; 24 studies, 983 participants; P = 0.2; I² = 42%; moderate-quality evidence). Electromechanical-assisted gait training did not increase the risk of loss to the study during intervention nor the risk of death from all causes. Results must be interpreted with caution because (1) some trials investigated people who were independent in walking at the start of the study, (2) we found variation between trials with respect to devices used and duration and frequency of treatment, and (3) some trials included devices with functional electrical stimulation. Post hoc analysis showed that people who are non-ambulatory at the start of the intervention may benefit but ambulatory people may not benefit from this type of training. Post hoc analysis showed no differences between the types of devices used in studies regarding ability to walk but revealed differences between devices in terms of walking velocity and capacity.

AUTHORS' CONCLUSIONS

People who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices. We concluded that eight patients need to be treated to prevent one dependency in walking. Specifically, people in the first three months after stroke and those who are not able to walk seem to benefit most from this type of intervention. The role of the type of device is still not clear. 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 post stroke in their trial design.

Influence of Body Weight Support Systems on the Abnormal Gait Kinematic

In recent years, the Body Weight Support system has been considered to be an indispensable component in gait training systems, which be used to improve the ability to walk of hemiplegic, stroke, and spinal cord injury patients. Previous studies investigated the influence of the Body Weight Support system on gait parameters were based on the implementation with healthy subjects or patients with high assistance. Consequently, the influences of the Body Weight Support systems on gait rehabilitation in clinical practice are still unclear and need further investigation. In this study, we investigated the effects of the two Body Weight Support systems, the active body weight support system and the Counter Weight system, on an abnormal gait, which was generated by restriction of the right knee joint and 3 kg-weight on the right ankle joint. Both Body Weight Support systems improve the gait parameters of the abnormal gait such as the center of mass, the center of pressure, margin of stability, and step parameters. The active Body Weight Support system with the unloading force modulation showed more advanced and better behavior in comparison with the Counter Weight system. The results suggested the applicability of two Body Weight Support systems in clinical practice as a recovered gait intervention.

Data-Driven Optimal Assistance Control of a Lower Limb Exoskeleton for Hemiplegic Patients

More recently, lower limb exoskeletons (LLE) have gained considerable interests in strength augmentation, rehabilitation, and walking assistance scenarios. For walking assistance, the LLE is expected to control the affected leg to track the unaffected leg's motion naturally. A critical issue in this scenario is that the exoskeleton system needs to deal with unpredictable disturbance from the patient, and the controller has the ability to adapt to different wearers. To this end, a novel data-driven optimal control (DDOC) strategy is proposed to adapt different hemiplegic patients with unpredictable disturbances. The interaction relation between two lower limbs of LLE and the leg of patient's unaffected side are modeled in the context of leader-follower framework. Then, the walking assistance control problem is transformed into an optimal control problem. A policy iteration (PI) algorithm is utilized to obtain the optimal controller. To improve the online adaptation to different patients, an actor-critic neural network (AC/NN) structure of the reinforcement learning (RL) is employed to learn the optimal controller on the basis of PI algorithm. Finally, experiments both on a simulation environment and a real LLE system are conducted to verify the effectiveness of the proposed walking assistance control method.

Social Human-Robot Interaction for Gait Rehabilitation

Robot-assisted therapy for gait rehabilitation of patients with neurological disorders usually combines a body weight support system with a treadmill system. Lokomat is one of the most used devices for gait rehabilitation. This device allows therapists to focus on the patient and the therapy. However, this therapy session is based on multi-tasking processes, which are often difficult for a therapist to manage. In this work, a Socially Assistive Robot (SAR) was integrated into a neurorehabilitation program as a collaborator agent to promote patient engagement and performance during the therapy. This short-term study presents the effects comparing the social robot condition and control condition with a group of four neurological patients using repeated measurement design. As a remarkable result, patients improved thoracic 18.44% and cervical 32.23% posture on average with SAR assistance. This study demonstrated the feasibility of the integration of a social robot as a complement of gait rehabilitation programs.

Measurement and Analysis of Gait Pattern during Stair Walk for Improvement of Robotic Locomotion Rehabilitation System

Background

Robotic locomotion rehabilitation systems have been used for gait training in patients who have had a stroke. Most commercialized systems allow patients to perform simple exercises such as balancing or level walking, but an additional function such as stair-walk training is required to provide a wide range of recovery cycle rehabilitation. In this study, we analyzed stair-gait patterns and applied the result to a robotic rehabilitation system that can provide a vertical motion of footplates.

Methods

To obtain applicable data for the robotic system with vertically movable footplates, stair-walk action was measured using an optical marker-based motion capture system. The spatial position data of joints during stair walking was obtained from six healthy adults who participated in the experiment. The measured marker data were converted into joint kinematic data by using an algorithm that included resampling and normalization. The spatial position data are represented as angular trajectories and the relative displacement of each joint on the anatomical sagittal plane and movements of hip joints on the anatomical transverse plane.

Results

The average range of motion (ROM) of each joint was estimated as (−6.75°, 48.69°) at the hip, (8.20°, 93.78°) at the knee, and (−17.78°, 11.75°) at the ankle during ascent and as (6.41°, 31.67°) at the hip, (7.38°, 91.93°) at the knee, and (−24.89°, 24.18°) at the ankle during descent. Additionally, we attempted to create a more natural stair-gait pattern by analyzing the movement of the hip on the anatomical transverse plane. The hip movements were estimated to within ±1.57 cm and ±2.00 cm for hip translation and to within ±2.52° and ±2.70° for hip rotation during stair ascent and stair descent, respectively.

Conclusions

Based on the results, standard patterns of stair ascent and stair descent were derived and applied to a lower-limb rehabilitation robot with vertically movable footplates. The relative trajectory from the experiment ascertained that the function of stair walking in the robotic system properly worked within a normal ROM.

Conceptual Design and Computational Modeling Analysis of a Single-Leg System of a Quadruped Bionic Horse Robot Driven by a Cam-Linkage Mechanism

In this study, the configuration of a bionic horse robot for equine-assisted therapy is presented. A single-leg system with two degrees of freedom (DOFs) is driven by a cam-linkage mechanism, and it can adjust the span and height of the leg end-point trajectory. After a brief introduction on the quadruped bionic horse robot, the structure and working principle of a single-leg system are discussed in detail. Kinematic analysis of a single-leg system is conducted, and the relationships between the structural parameters and leg trajectory are obtained. On this basis, the pressure angle characteristics of the cam-linkage mechanism are studied, and the leg end-point trajectories of the robot are obtained for several inclination angles controlled by the rotation of the motor for the stride length adjusting. The closed-loop vector method is used for the kinematic analysis, and the motion analysis system is developed in MATLAB software. The motion analysis results are verified by a three-dimensional simulation model developed in Solidworks software. The presented research on the configuration, kinematic modeling, and pressure angle characteristics of the bionic horse robot lays the foundation for subsequent research on the practical application of the proposed bionic horse robot.

Short- and Mid-Term Improvement of Postural Balance after a Neurorehabilitation Program via Hippotherapy in Patients with Sensorimotor Impairment after Cerebral Palsy: A Preliminary Kinetic Approach

There is still a lack of studies focused on trunk neurorehabilitation. Accordingly, it is unclear which therapeutic modalities are the most effective in improving static/dynamic balance after brain damage. We designed a pilot study on hippotherapy to assess its short- and mid-term effect on dynamic postural balance in patients with moderate-to-severe sensorimotor impairment secondary to cerebral palsy. Five patients aged 15.4 ± 6.1 years old were recruited. All of them had moderate-to-severe alterations of the muscle tone with associated postural balance impairment. Standing and walking were also impaired. Ten minutes horse riding simulator followed by twenty minutes hippotherapy session were conducted during five session days separated by one week each. We analyzed the displacement of the Center of Pressure (COP) on the sitting surface of the simulator’s saddle by means of a customized pressure pad. We measured the general behavior of the COP displacement as well as the postural adjustments when pace changed from walk to trot to walk during the sessions and among sessions. Statistical analysis revealed an improved postural control both by the end of the session and from session 1 to session 5. These results suggest that hippotherapy might support regularization of postural control in a long-term neurorehabilitation context.

Weight-Supported Walking Assist Device for Knee Osteoarthritis Patients

Knee osteoarthritis patients have pain in their knee and it can become difficult to walk depending on the progress of symptoms. After performing chondrocyte implantation, it is necessary to reduce the load on the knee joint until the implanted cartilage is integrated. The purposes of this study were to develop a device that enables the user to walk and reduced the weight on the knee joint and to confirm basic performance of the device through experiments. The device was composed of a seat for supporting the body weight of the user, a prosthetic knee, and the floor reaction force sensor shoes. Experiments were conducted to confirm the basic performance of the device. As a result, an able-bodied participant who wore the device was able to walk while unloading two-thirds of their body weight onto their knee. As a result of gait analysis, it was found that the gait did not change significantly even when the device was worn.

Immediate Effects of Force Feedback and Plantar Somatosensory Stimuli on Inter-limb Coordination During Perturbed Walking

Single-sided motor weakness, also known as hemiparesis, is the most prevalent gait impairment among stroke survivors, which often results in gait asymmetry. Studies on robot-assisted gait training (RAGT) have shown positive effects of force feedback on spatial symmetry; somatosensory stimulation is thought to facilitate recovery of temporal symmetry. Despite the known importance of sensorimotor integration for motor recovery, interventions that incorporate RAGT and somatosensory stimuli have been largely overlooked so far. In this paper, we explore how gait symmetry can be restored in healthy subjects following unilateral foot perturbations, using adaptive assistive forces and plantar vibrotactile stimuli provided by a bilateral powered ankle-foot orthosis. Results suggest that combined force feedback and vibrotactile stimuli may be more effective than force feedback alone in reducing spatial asymmetry. Further, force feedback did not produce significant improvements in temporal symmetry, unlike the combined modality. We discuss possible implications of these preliminary findings for future training paradigms for RAGT.

Gaussian Process Trajectory Learning and Synthesis of Individualized Gait Motions

This paper proposes a Gaussian process-based method for trajectory learning and generation of individualized gait motions at arbitrary user-designated walking speeds, intended to be used in generating reference motions for robotic gait rehabilitation systems. We utilize a nonlinear dimension reduction technique based on Gaussian process dynamical models (GPDMs), in which the internal dynamics is modeled as a second-order Markov process evolving in a lower-dimensional latent space. After the GPDM parameters are identified with training data obtained from gait motions of healthy subjects walking at different speeds, our method then employs Gaussian process regression (GPR) to predict the initial two states of the latent space dynamics from any arbitrary desired walking speed and the anthropometric parameters of the test subject. Motions are then generated by directly mapping the latent space dynamics to joint trajectories. Experimental studies involving more than 100 subjects indicate that our method generates gait patterns with 30% less mean square prediction errors compared to recent state-of-the-art methods, while also allowing for arbitrary user-specified walking speeds.

Robotics for Lower Limb Rehabilitation

Improving walking function is a desirable outcome in rehabilitation and of high importance for social and vocational reintegration for persons with neurologic-related gait impairment. Robots for lower limb gait rehabilitation are designed principally to help automate repetitive labor-intensive training during neurorehabilitation. These include tethered exoskeletons, end-effector devices, untethered exoskeletons, and patient-guided suspension systems. This article reviews the first 3 categories and briefly mentions the fourth. Research is needed to further define the therapeutic applications of these devices. Additional technical improvements are expected regarding device size, controls, and battery life for untethered devices.

Toward Standardizing the Classification of Robotic Gait Rehabilitation Systems

With the existence of numerous rehabilitation systems, classification and comparison becomes difficult, especially due to the many factors involved. Moreover, most current reviews are descriptive and do not provide systematic methods for the visual comparison of systems. This review proposes a method for classifying systems and representing them graphically to easily visualize various characteristics of the different systems at the same time. This method could be an introduction for standardizing the evaluation of gait rehabilitation systems. It evaluates four main modules (body weight support, reciprocal stepping mechanism, pelvis mechanism, and environment module) of 27 different gait systems based on a set of characteristics. The combination of these modular evaluations provides a description of the system "in the space of rehabilitation." The evaluation of each robotic module, based on specific characteristics, showed diverse tendencies. While there is an augmented interest in developing more sophisticated reciprocal stepping mechanisms, few researchers are dedicated to enhance the properties of pelvis mechanisms.

Gait Training with Bilateral Rhythmic Auditory Stimulation in Stroke Patients: A Randomized Controlled Trial

The aim of this study was to investigate the effect of gait training with bilateral rhythmic auditory stimulation (RAS) on lower extremity rehabilitation in stroke patients. Forty-four participants (<6 months after stroke) were randomly allocated to the gait training with bilateral rhythmic auditory stimulation (GTBR) group (n = 23) and the control group (n = 21). The GTBR group had gait training with bilateral RAS for 30 min a day, 5 days a week, in a 6-week period, in addition to conventional therapy. The control group had gait training without RAS, and conventional therapy. Outcome measures included gait symmetry, gait ability, balance ability, and lower extremity function. Gait symmetry on step time showed significant improvements compared to baseline (p < 0.05) in the GTBR group, but not in the control group. Gait ability was significantly improved in both groups relative to baseline values (p < 0.05), and the GTBR group showed significantly greater improvement in comparison to the control group (p < 0.05). Both groups showed significant improvements in the Timed Up and Go test (TUG), Berg Balance Scale (BBS), and Fugl–Meyer Assessment (FMA) compared to baseline (p < 0.05). GTBR is an effective therapeutic method of improving symmetric gait in stroke rehabilitation. Moreover, we found that GTBR beat frequency matching fast step time might be even more beneficial in improving gait symmetry. Future studies may develop a method of applying RAS on step time and length for improvement of gait symmetry in stroke patients.

Comparative effects of robotic-assisted gait training combined with conventional physical therapy on paretic hip joint stiffness and kinematics between subacute and chronic hemiparetic stroke

BACKGROUND

Robotic-assisted gait training (RAGT) has been proposed as a novel, promising intervention paradigm to improve gait function in subacute or chronic stroke neurorehabilitation. However, the benefits of RAGT combined with conventional physical therapy for gait recovery in patients with subacute and chronic hemiparetic stroke remain unclear.

OBJECTIVES

The aim of the present study was to compare the effect of RAGT combine with conventional physical therapy on hip joint kinetics, kinematics, and clinical function characteristics between subacute and chronic hemiparetic stroke.

METHODS

Seventeen patients with hemiparetic stroke (nine subacute and eight chronic patients) performed progressive RAGT (session 1, 40 min) combined with conventional physical therapy (session 1, 40 min) 5 days per week, for an average of 86 sessions over 8 weeks. The clinical outcomes included the Functional Ambulation Category (FAC), modified Rankin scale (mRS), Korean version of the modified Barthel index (K-MBI), and modified Ashworth scale, in addition to hip joint kinetics and kinematics before and after intervention.

RESULTS

The mean change in active torque, resistive torque, and stiffness in the paretic hip joint did not differ significantly between the two groups. However, Cohen's effect size suggested a moderate difference between the groups in the hip flexion phase (d = 0.58, d = 0.70, and d = 0.70). The mean change in maximal hip flexion kinematics in the chronic group was significantly greater than that in the subacute group (p = 0.04, d = -0.70). The mean change in the clinical function test results between the groups was not statistically significant. However, both groups showed significantly improved FAC, mRS, and K-MBI scores.

CONCLUSIONS

RAGT combine with conventional physical therapy may be useful when selecting therapeutic interventions to improve the active torque, resistive torque, and stiffness in the paretic hip flexion phase in patients with chronic hemiparetic stroke who reached a plateau in the maximum locomotor recovery after conventional locomotor training.

A novel gait-based synthesis procedure for the design of 4-bar exoskeleton with natural trajectories

Background/Objective

Human walking involves the coordination of brain, nerves, and muscles. A disturbance in their coordination may result in gait disorder. The gait disorder may be treated through manually assisted gait training or with the aid of assistive devices/robotic devices. These robotic devices involve mechanisms which are synthesized using complex conventional procedures. Therefore, in this study, a new gait-based synthesis procedure is proposed, which simplifies the mechanism synthesis and helps to develop a mechanism which can be used in rehabilitation devices, bipeds, etc.

Methods

This article presents a novel procedure for the synthesis of 4-bar linkage using the natural gait trajectories. As opposed to the conventional synthesis procedures, in this procedure, a global reference frame is considered, which allows the use of hip trajectory while moving. Moreover, this method is divided into two stages, and five precision points are considered on the hip trajectory in each stage. In the first stage, the 4-bar linkage is designed, thereafter, the configurations of the linkage for the remaining precision points are determined in the second stage. The proposed synthesis procedure reduces the complexity involved in the synthesis and helps in the simplification of the problem formulation. A two-stage optimization problem is formulated for minimizing the error between the generated and desired hip trajectories. Two nature-inspired algorithms are used for solving the optimization problem. The obtained best results are presented, and the designed linkage is simulated in MATLAB.

Results

The best design of the linkage is obtained using particle swarm optimization. The trajectories generated by the designed linkage using the proposed methodology can accurately track the desired path, which indicates that designed linkage can achieve all the orientations required during walking. The positions of a whole lower limb at all the desired precision points are demonstrated by stick diagram for one gait.

Conclusion

The proposed methodology has reduced the complexity of synthesis procedures and used optimization techniques to obtain a feasible design of the mechanism. The stick diagram of the designed mechanism obtained using the proposed method indicates that the designed mechanism can walk smoothly. Hence, the designed mechanism can be used in the rehabilitation devices. Furthermore, a conceptual design of an exoskeleton knee is also presented.

The Translational Potential of this Article

Many hospitals and individuals have used the immobile and portable rehabilitation devices. These devices involve mechanisms, and the design of mechanism plays a vital role in the functioning of these devices; therefore, we have developed a new synthesis procedure for the design of the mechanism. Besides synthesis procedure, a mechanism is developed that can be used in the rehabilitation devices, bipeds, exoskeletons, etc., to benefit the society.

A Poincare map based analysis of stroke patients' walking after a rehabilitation by a robot

Since the past decade, rehabilitation robots have become common technologies for recovering gait ability after a stroke. Nevertheless, it is believed that these robots can be further enhanced. Hence, several researches are making progress in optimizing gait rehabilitation robots. However, most of these researches have only assessed the robots and their controllers in improving spatiotemporal and kinetic features of walking. There are not many researchers have focused on the robots' controllers' effects on the central nervous or neuromuscular systems. On the other hand, recently computational methods have been utilized to investigate the rehabilitations of neural disorders, through developing neuromechanical models. However, these methods have neither studied the robot-assisted gait rehabilitation, nor have they theoretically proved why rehabilitation exercises enhance patients' walking ability. Therefore, this paper merged a theoretical approach into a computational method to investigate the effects of gait rehabilitation robots on post-stroke neuromuscular system. To this end, a neuromechanical model of gait has been developed and thereby, the Poincare maps of intact and stroke people have been obtained. Comparison of these maps revealed why a stroke reduces the stability of walking. Then, the effect of an impedance controller, which is used in a rehabilitative robot, is scrutinized in stabilizing a walking motion. Obtaining the Poincare map of this close-loop system, proved that this controller improves motion stability. Finally, the effect of this controller is investigated by simulations and experiments. The experimental tests are performed by Arman rehabilitative robot. Clinical Reference Number: IR.TMU.REC.1394.254.

Model-Based Hybrid Cooperative Control of Hip-Knee Exoskeleton and FES Induced Ankle Muscles for Gait Rehabilitation

To regain mobility, stroke patients need to receive repetitive and intensive therapy. Robot-assisted rehabilitation is an active area of research. Cheap robotic leg rehabilitation devices should be developed to meet the demands and assist most patients. A low cost hip-knee exoskeleton prototype powered by pneumatic muscles was developed. On this basis, Functional Electrical Stimulation (FES) induced paralyzed muscles to realize ankle joint rehabilitation training. These three ankle muscles: the tibialis anterior, the soleus, and the gastrocnemius under electrical stimulation cooperated together to realize optimally coordinated control of dorsiflexion and plantar-flexion movement. As both of pneumatic muscle and FES induced muscle possess highly nonlinear characteristics, a sliding control algorithm called Chattering mitigation Robust Variable Control (CRVC) was applied to leg hybrid rehabilitation. The combination of exoskeleton and FES is a promising way to reduce the cost and the complexity of designing hip-knee-ankle exoskeleton. The proposed hybrid method was verified by treadmill-based gait training experiments.

The comparison of stepping responses following perturbations applied to pelvis during overground and treadmill walking

BACKGROUND

Treadmills are used frequently in rehabilitation enabling neurologically impaired subjects to train walking while being assisted by therapists. Numerous studies compared walking on treadmill and overground for unperturbed but not also perturbed conditions.

OBJECTIVE

The objective of this study was to compare stepping responses (step length, step width and step time) during overground and treadmill walking in a group of healthy subjects where balance assessment robots applied perturbing pushes to the subject's pelvis in sagittal and frontal planes.

METHODS

During walking in both balance assessment robots (overground and treadmill-based) with applied perturbations the stepping responses of a group of seven healthy subjects were assessed with a motion tracking camera.

RESULTS

The results show high degree of similarity of stepping responses between overground and treadmill walking for all perturbation directions. Both devices reproduced similar experimental conditions with relatively small standard deviations in the unperturbed walking as well as in perturbed walking.

CONCLUSIONS

Based on these results we may conclude that stepping responses following perturbations can be studied on an instrumented treadmill where ground reaction forces can be readily assessed which is not the case during perturbed overground walking.

Speed-Interactive Treadmill Training Using Smartphone-Based Motion Tracking Technology Improves Gait in Stroke Patients

This study was conducted to investigate the effects of speed-interactive treadmill training (SITT) using smartphone-based motion tracking technology on gait in stroke patients. Thirty-four chronic stroke patients were randomly divided into a SITT group (n = 18) and a standard treadmill training (control) group (n = 16). The SITT group underwent smartphone-based SSIT while the control group underwent standard treadmill training. Both groups performed the training for 35 min per session, 3 times per week, for 6 weeks. Both groups used nonmotorized treadmills so that patients could control the speed. Evaluation was conducted during the week before and after the training. The OptoGait system measured gait spatiotemporal parameters. Both groups showed significant improvement in the temporal and spatial gait parameters (p < .05). In the SITT group, compared to the control group, the two-way analysis of variance with repeated measures showed an improvement in the temporal and spatial gait parameters after the intervention period (p < .05). This study confirmed that SITT improved the gait function of stroke patients. Based on this result, the authors propose that SITT, by improving gait, can be used as an effective training method to improve patients' functional activities in the clinic.

Electromechanical-assisted training for walking after stroke

BACKGROUND

Electromechanical- and robotic-assisted gait-training devices are used in rehabilitation and might help to improve walking after stroke. This is an update of a Cochrane Review first published in 2007.

OBJECTIVES

To investigate the effects of automated electromechanical- and robotic-assisted gait-training devices for improving walking after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched 9 August 2016), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 8), MEDLINE in Ovid (1950 to 15 August 2016), Embase (1980 to 15 August 2016), CINAHL (1982 to 15 August 2016), AMED (1985 to 15 August 2016), Web of Science (1899 to 16 August 2016), SPORTDiscus (1949 to 15 September 2012), the Physiotherapy Evidence Database (PEDro) (searched 16 August 2016), and the engineering databases COMPENDEX (1972 to 16 November 2012) and Inspec (1969 to 26 August 2016). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists, and contacted authors in an effort to identify further published, unpublished, and ongoing trials.

SELECTION 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 robotic-assisted gait training versus normal care.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed methodological quality and risk of bias, and extracted the data. The primary outcome was the proportion of participants walking independently at follow-up.

MAIN RESULTS

We included 36 trials involving 1472 participants in this review update. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of participants becoming independent in walking (odds ratio (random effects) 1.94, 95% confidence interval (CI) 1.39 to 2.71; P < 0.001; I² = 8%; moderate-quality evidence) but did not significantly increase walking velocity (mean difference (MD) 0.04 m/s, 95% CI 0.00 to 0.09; P = 0.08; I² = 65%; low-quality evidence) or walking capacity (MD 5.84 metres walked in 6 minutes, 95% CI -16.73 to 28.40; P = 0.61; I² = 53%; very low-quality evidence). The results must be interpreted with caution because 1) some trials investigated people who were independent in walking at the start of the study, 2) we found variations between the trials with respect to devices used and duration and frequency of treatment, and 3) some trials included devices with functional electrical stimulation. Our planned subgroup analysis suggested that people in the acute phase may benefit, but people in the chronic phase may not benefit from electromechanical-assisted gait training. Post hoc analysis showed that people who are non-ambulatory at intervention onset may benefit, but ambulatory people may not benefit from this type of training. Post hoc analysis showed no differences between the types of devices used in studies regarding ability to walk, but significant differences were found between devices in terms of walking velocity.

AUTHORS' CONCLUSIONS

People who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices. We concluded that seven patients need to be treated to prevent one dependency in walking. Specifically, people in the first three months after stroke and those who are not able to walk seem to benefit most from this type of intervention. The role of the type of device is still not clear. Further research should consist of large definitive pragmatic phase III 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.

Virtual Reality Reflection Therapy Improves Balance and Gait in Patients with Chronic Stroke: Randomized Controlled Trials

Background

Virtual reality reflection therapy (VRRT) is a technically enhanced version of the mirror therapy concept. The aim of this study was to investigate whether VRRT could improve the postural balance and gait ability of patients with chronic stroke.

Material/Methods

Twenty-five patients with chronic stroke were randomly allocated into the VRRT group (n=13) and the control group (n=12). The participants in both groups performed a conventional rehabilitation program for 30 minutes. The VRRT group also performed a VRRT program for 30 minutes, five times a week for 4 weeks. The control group performed conventional rehabilitation program and a placebo VRRT program. Outcome measures included Berg Balance Scale (BBS), the Functional Reaching Test (FRT), and the Timed Up and Go (TUG) test (for dynamic balance ability), postural sway (for static balance ability), and 10 meter walking velocity (10 mWV) for gait ability.

Results

There were statistically significant improvements in the VRRT group compared with the control group for BBS, FRT, TUG, postural sway (mediolateral sway distance with eyes open and eyes closed, anteroposterior and total sway distance with eyes open but not with eyes closed), and 10 mWV (p<0.05).

Conclusions

Applying VRRT (even as a home treatment) along with a conventional rehabilitation program for patients with chronic stroke might be even more beneficial than conventional rehabilitation program alone in improving affected lower limb function. Future studies should investigate the effectiveness of VRRT with optimal patient selection, and duration and intensity of training.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Robotic gait rehabilitation and substitution devices in neurological disorders: where are we now?

Gait abnormalities following neurological disorders are often disabling, negatively affecting patients' quality of life. Therefore, regaining of walking is considered one of the primary objectives of the rehabilitation process. To overcome problems related to conventional physical therapy, in the last years there has been an intense technological development of robotic devices, and robotic rehabilitation has proved to play a major role in improving one's ability to walk. The robotic rehabilitation systems can be classified into stationary and overground walking systems, and several studies have demonstrated their usefulness in patients after severe acquired brain injury, spinal cord injury and other neurological diseases, including Parkinson's disease, multiple sclerosis and cerebral palsy. In this review, we want to highlight which are the most widely used devices today for gait neurological rehabilitation, focusing on their functioning, effectiveness and challenges. Novel and promising rehabilitation tools, including the use of virtual reality, are also discussed.

Views of physiatrists and physical therapists on the use of gait-training robots for stroke patients

[Purpose] Gait-training robots have been developed for stroke patients with gait disturbance. It is important to survey the views of physiatrists and physical therapists on the characteristics of these devices during their development. [Subjects and Methods] A total of 100 physiatrists and 100 physical therapists from 38 hospitals participated in our questionnaire survey. [Results] The most common answers about the merits of gait-training robots concern improving the treatment effects (28.5%), followed by standardizing treatment (19%), motivating patients about treatment (17%), and improving patients' self-esteem (14%). The subacute period (1-3 months post-stroke onset) was most often chosen as the ideal period (47.3%) for the use of these devices, and a functional ambulation classification of 0-2 was the most selected response for the optimal patient status (27%). The preferred model was the treadmill type (47.5%) over the overground walking type (40%). The most favored commercial price was $50,000-$100,000 (38.3%). The most selected optimal duration for robot-assisted gait therapy was 30-45 min (47%), followed by 15-30 min (29%), 45-60 min (18%), ≥ 60 min (5%), and < 15 min (1%). [Conclusion] Our study findings could guide the future designs of more effective gait-training robots for stroke patients.

The effect of 'device-in-charge' versus 'patient-in-charge' support during robotic gait training on walking ability and balance in chronic stroke survivors: A systematic review

This review describes the effects of two control strategies - used in robotic gait-training devices for chronic stroke survivors - on gait speed, endurance and balance. Control strategies are classified as 'patient-in-charge support', where the device 'empowers' the patient, and 'device-in-charge support', where the device imposes a pre-defined movement trajectory on the patient. Studies were collected up to 24 June 2015 and were included if they presented robotic gait training in chronic stroke survivors and used outcome measures that were indexed by the International Classification of Functioning, Disability and Health. In total, 11 articles were included. Methodological quality was assessed using the PEDro scale. Outcome measures were walking speed, endurance and balance. Pooled mean differences between pre and post measurements were calculated. No differences were found between studies that used device-in-charge support and patient-in-charge support. Training effects were small for both groups of control strategies, and none were considered to be clinically relevant as defined by the Minimal Clinically Important Difference. However, an important confounder is the short training duration among all included studies. As control strategies in robotic gait training are rapidly evolving, future research should take the recommendations that are made in this review into account.

Voluntary initiation of movement: multifunctional integration of subjective agency

This paper investigates subjective agency (SA) as a special type of efficacious action consciousness. Our central claims are, firstly, that SA is a conscious act of voluntarily initiating bodily motion. Secondly, we argue that SA is a case of multifunctional integration of behavioral functions being analogous to multisensory integration of sensory modalities. This is based on new perspectives on the initiation of action opened up by recent advancements in robot assisted neuro-rehabilitation which depends on the active participation of the patient and yields experimental evidence that there is SA in terms of a conscious act of voluntarily initiating bodily motion (phenomenal performance). Conventionally, action consciousness has been considered as a sense of agency (SoA). According to this view, the conscious subject merely echoes motor performance and does not cause bodily motion. Depending on sensory input, SoA is implemented by means of unifunctional integration (binding) and inevitably results in non-efficacious action consciousness. In contrast, SA comes as a phenomenal performance which causes motion and builds on multifunctional integration. Therefore, the common conception of the brain should be shifted toward multifunctional integration in order to allow for efficacious action consciousness. For this purpose, we suggest the heterarchic principle of asymmetric reciprocity and neural operators underlying SA. The general idea is that multifunctional integration allows conscious acts to be simultaneously implemented with motor behavior so that the resulting behavior (SA) comes as efficacious action consciousness. Regarding the neural implementation, multifunctional integration rather relies on operators than on modular functions. A robotic case study and possible experimental setups with testable hypotheses building on SA are presented.

Kinematics of turning during walking over ground and on a rotating treadmill

Background

After neurological injury, gait rehabilitation typically focuses on task oriented training with many repetitions of a particular movement. Modern rehabilitation devices, including treadmills, augment gait rehabilitation. However, they typically provide gait training only in the forward direction of walking, hence the mechanisms associated with changing direction during turning are not practiced. A regular treadmill extended with the addition of rotation around the vertical axis is a simple device that may enable the practice of turning during walking. The objective of this study was to investigate to what extent pelvis and torso rotations in the transversal plane, as well as stride lengths while walking on the proposed rotating treadmill, resemble those in over ground turning.

Methods

Ten neurologically and orthopedically intact subjects participated in the study. We recorded pelvis and torso rotations in the transversal plane and the stride lengths during over ground turning and while walking on a rotating treadmill in four experimental conditions of turning. The similarity between pelvis and torso rotations in over ground turning and pair-matching walking on the rotating treadmill was assessed using intra-class correlation coefficient (ICC - two-way mixed single measure model). Finally, left and right stride lengths in over ground turning as well as while walking on the rotating treadmill were compared using a paired t-test for each experimental condition.

Results

An agreement analysis showed average ICC ranging between 0.9405 and 0.9806 for pelvis and torso rotation trajectories respectively, across all experimental conditions and directions of turning. The results of the paired t-tests comparing left and right stride lengths showed that the stride of the outer leg was longer than the stride of the inner leg during over ground turning as well as when walking on the rotating treadmill. In all experimental conditions these differences were statistically significant.

Conclusions

In this study we found that pelvis rotation and torso rotation are similar when turning over ground as compared to walking on a rotating treadmill. Additionally, in both modes of turning, we found that the stride length of the outer leg is significantly longer than the stride length of the inner leg.

Electronic supplementary material

The online version of this article (doi:10.1186/1743-0003-11-127) contains supplementary material, which is available to authorized users.

What is the evidence for physical therapy poststroke? A systematic review and meta-analysis

BACKGROUND

Physical therapy (PT) is one of the key disciplines in interdisciplinary stroke rehabilitation. The aim of this systematic review was to provide an update of the evidence for stroke rehabilitation interventions in the domain of PT.

METHODS AND FINDINGS

Randomized controlled trials (RCTs) regarding PT in stroke rehabilitation were retrieved through a systematic search. Outcomes were classified according to the ICF. RCTs with a low risk of bias were quantitatively analyzed. Differences between phases poststroke were explored in subgroup analyses. A best evidence synthesis was performed for neurological treatment approaches. The search yielded 467 RCTs (N = 25373; median PEDro score 6 [IQR 5-7]), identifying 53 interventions. No adverse events were reported. Strong evidence was found for significant positive effects of 13 interventions related to gait, 11 interventions related to arm-hand activities, 1 intervention for ADL, and 3 interventions for physical fitness. Summary Effect Sizes (SESs) ranged from 0.17 (95%CI 0.03-0.70; I(2) = 0%) for therapeutic positioning of the paretic arm to 2.47 (95%CI 0.84-4.11; I(2) = 77%) for training of sitting balance. There is strong evidence that a higher dose of practice is better, with SESs ranging from 0.21 (95%CI 0.02-0.39; I(2) = 6%) for motor function of the paretic arm to 0.61 (95%CI 0.41-0.82; I(2) = 41%) for muscle strength of the paretic leg. Subgroup analyses yielded significant differences with respect to timing poststroke for 10 interventions. Neurological treatment approaches to training of body functions and activities showed equal or unfavorable effects when compared to other training interventions. Main limitations of the present review are not using individual patient data for meta-analyses and absence of correction for multiple testing.

CONCLUSIONS

There is strong evidence for PT interventions favoring intensive high repetitive task-oriented and task-specific training in all phases poststroke. Effects are mostly restricted to the actually trained functions and activities. Suggestions for prioritizing PT stroke research are given.