Identifying best fall-related balance factors and robotic-assisted gait training attributes in 105 post-stroke patients using clinical machine learning models

BACKGROUND

Despite the promising effects of robot-assisted gait training (RAGT) on balance and gait in post-stroke rehabilitation, the optimal predictors of fall-related balance and effective RAGT attributes remain unclear in post-stroke patients at a high risk of fall.

OBJECTIVE

We aimed to determine the most accurate clinical machine learning (ML) algorithm for predicting fall-related balance factors and identifying RAGT attributes.

METHODS

We applied five ML algorithms- logistic regression, random forest, decision tree, support vector machine (SVM), and extreme gradient boosting (XGboost)- to a dataset of 105 post-stroke patients undergoing RAGT. The variables included the Berg Balance Scale score, walking speed, steps, hip and knee active torques, functional ambulation categories, Fugl- Meyer assessment (FMA), the Korean version of the Modified Barthel Index, and fall history.

RESULTS

The random forest algorithm excelled (receiver operating characteristic area under the curve; AUC = 0.91) in predicting balance improvement, outperforming the SVM (AUC = 0.76) and XGboost (AUC = 0.71). Key determinants identified were knee active torque, age, step count, number of RAGT sessions, FMA, and hip torque.

CONCLUSION

The random forest algorithm was the best prediction model for identifying fall-related balance and RAGT determinants, highlighting the importance of key factors for successful RAGT outcome performance in fall-related balance improvement.

Effectiveness of combined robotics and virtual reality on lower limb functional ability in stroke survivors: A systematic review of randomized controlled trials

Lower limb impairments are common consequences of stroke. Robotics and virtual reality (VR) play crucial roles in improving lower limb function post-stroke. This review aims to assess the effects of combined robot and VR interventions on lower limb functional ability poststroke and to provide recommendations for future studies in the rehabilitation field. PubMed, SCOPUS, CINAHL, MEDLINE, EMBASE, and Web of Science were searched from inception to March 1, 2024. Randomized controlled trials (RCTs) involving patients with a stroke, administering combined robot and VR compared with passive (i.e., rest) or active (any intervention), and including at least one outcome evaluating lower limb function (i.e., balance, gait, mobility, muscle tone, muscle strength, range of motion) or activities of daily living were selected. The Cochrane Collaboration tool was employed to evaluate the risk of bias in the included studies. Nine studies met the eligibility criteria. In total, 364 stroke survivors (Mean age 55.62 years) were involved in this review. According to the Cochrane Collaboration tool, five studies were classified as "high quality," "moderate quality" (n=3), and "low quality" (n=1). There are mixed findings on the effects of combined robot and VR on lower limb functional ability in stroke survivors. The evidence for the effects of combined robot and VR on lower limb functional ability post-stroke is promising. Further trials with long-term follow-up are strongly warranted to understand the immediate and long-term effect of combined robot and VR intervention on various lower limb impairments and to define the optimal treatment protocols.

Effects of robotic rehabilitation using the Erigo® device on patients with neurological injury: a systematic review and meta-analysis of randomized clinical trials

OBJECTIVE

To systematically review the effects of robotic rehabilitation with the Erigo® device on patients with neurological injury on safety, spasticity, muscle strength, functionality, gait/balance, and changes in the level of consciousness.

METHODS

MEDLINE, SciELO, EMBASE, The Cochrane Library - CENTRAL and PEDro databases were consulted without the restriction of date and language. Randomized controlled trials that evaluated the robotic rehabilitation and compared it to conventional or placebo therapy, isolated or in association with other therapy, were selected. Studies in which the treatment time was less than 10 sessions were excluded. The risk of bias was assessed with the use of the RoB 2.0 tool.

RESULTS

Nine studies were included, totaling 347 patients. The robotic rehabilitation performed by the Erigo® device proved to be safe for neurological patients. The meta-analysis showed an improvement for spasticity (MD = 0.29; 95% CI = -0.49 to -0.08; I2 = 0%), but there was no significant increase in muscle strength in patients with stroke (MD = 0.25; CI 95% = -0.22 to -0,71; I2 = 0%). Erigo® showed inconclusive effects on functionality, gait/balance and level of consciousness in patients with severe acquired brain injury and vegetative or minimally conscious state. All studies present some concerns for the risk of bias.

CONCLUSION

Erigo® as a robotic rehabilitation strategy is safe for patients with acquired brain injury and appears to reduce spasticity in patients with stroke. The effects on muscle strength, functionality, gait and balance and level of consciousness remain uncertain and the methodological quality of the clinical trials included in this review is limited.

A Comprehensive Review: Robot-Assisted Treatments for Gait Rehabilitation in Stroke Patients

Robot-assisted gait training (RAGT) is at the cutting edge of stroke rehabilitation, offering a groundbreaking method to improve motor recovery and enhance the quality of life for stroke survivors. This review investigates the effectiveness and application of various RAGT systems, including both end-effector and exoskeleton robots, in facilitating gait enhancements. The selection process for this comprehensive analysis involved a meticulous review of the literature from databases such as PubMed, the Cochrane Library, and EMBASE, focusing on studies published between 2018 and 2023. Ultimately, 27 studies met the criteria and were included in the final analysis. The focus of these studies was on the various RAGT systems and their role in promoting gait and balance improvements. The results of these studies conclusively show that patients experience significant positive effects from RAGT, and when combined with other physiotherapy methods, the outcomes are notably superior in enhancing functional ambulation and motor skills. This review emphasizes RAGT's capability to deliver a more customized and effective rehabilitation experience, highlighting the importance of tailoring interventions to meet the specific needs of each patient.

Usefulness of one-arm motorized gait device for chronic hemiplegic stroke survivors

BACKGROUND

After stroke, gait training is a key component of rehabilitation, and most individuals use a variety of walking aids depending on their physical condition and environment.

OBJECTIVE

This study aimed to investigate the potential effect of a one-arm motorized gait device for gait assist of chronic hemiplegic stroke survivors through comparison with traditional gait devices (parallel bar and hemi-walker).

METHODS

This study was conducted on 14 chronic hemiplegic stroke survivors. The participants were asked to walk under three conditions using different gait devices, and their gait parameters during walking were collected and analyzed. The first condition involved walking on parallel bars; second condition, walking using hemi-walkers; and third condition, walking using one-arm motorized gait devices. With the use of a gait analysis system, the spatio-temporal gait parameters in each condition were collected, such as gait velocity, cadence, step length, stride length, single support time, and double support time.

RESULTS

In the results by repeated-measures ANOVA or the Friedman test, a significant difference was found in the gait parameters among all three conditions (p< 0.05). The post-hoc test showed a significant change in the spatio-temporal gait parameters (especially, velocity, cadence and affected side single and double support time) when one-arm motorized gait device were used compared with parallel bars and hemi-walkers (p< 0.05).

CONCLUSION

The results of this study suggest that one-arm motorized gait devices developed for hemiplegic stroke survivors may be more effective potentially than parallel bars and hemi-walkers in gait assistance of chronic hemiplegic stroke survivors.

Advanced rehabilitation in ischaemic stroke research

At present, due to the rapid progress of treatment technology in the acute phase of ischaemic stroke, the mortality of patients has been greatly reduced but the number of disabled survivors is increasing, and most of them are elderly patients. Physicians and rehabilitation therapists pay attention to develop all kinds of therapist techniques including physical therapy techniques, robot-assisted technology and artificial intelligence technology, and study the molecular, cellular or synergistic mechanisms of rehabilitation therapies to promote the effect of rehabilitation therapy. Here, we discussed different animal and in vitro models of ischaemic stroke for rehabilitation studies; the compound concept and technology of neurological rehabilitation; all kinds of biological mechanisms of physical therapy; the significance, assessment and efficacy of neurological rehabilitation; the application of brain-computer interface, rehabilitation robotic and non-invasive brain stimulation technology in stroke rehabilitation.

Effects of soft robotic exosuit on ambulation ability in stroke patients: a systematic review

BACKGROUND

Robot-assisted gait training is incorporated into guidelines for stroke rehabilitation. It is a promising tool combined with conventional therapy for low ambulatory patients. The heavy weight and bulky appearance of a robotic exoskeleton limits its practicality. On the other hand, soft robotic exosuit (SRE) based on its light weight and inconspicuous property, is better tolerated by patients in daily life. The aim of this study is to review the efficacy of the SRE with regard to walking ability and biomechanical properties in stroke patients.

METHODS

Electronic searches were carried out in PubMed, Embase, Cochrane Library, Web of Science, and the Physiotherapy Evidence Database. Clinical trials that investigated the effectiveness of SREs on ambulation ability in patients with post-stroke hemiparesis were eligible. Qualitative data synthesis was subsequently performed.

RESULTS

Nine studies were identified as relevant, involving a total of 83 patients. For the assessment of SRE efficacy, outcome measures were walking ability and biomechanical properties. In terms of both immediate effect and training effect, SREs improved the walking speed, walking distance, peak ankle dorsiflexion angle during swing phase, peak paretic propulsion, stride length and compensated gait in stroke patients.

CONCLUSIONS

SRE improved the ambulation ability of stroke patients in terms of walking ability and biomechanical properties. The small number of studies limits the generalizability of interpretation. More controlled studies with better quality are required to reach a more solid conclusion on this issue.

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.

Introduction to a Twin Dual-Axis Robotic Platform for Studies of Lower Limb Biomechanics

This paper presents a twin dual-axis robotic platform system which is designed for the characterization of postural balance under various environmental conditions and quantification of bilateral ankle mechanics in 2 degrees-of-freedom (DOF) during standing and walking. Methods: Validation experiments were conducted to evaluate performance of the system: 1) to apply accurate position perturbations under different loading conditions; 2) to simulate a range of stiffness-defined mechanical environments; and 3) to reliably quantify the joint impedance of mechanical systems. In addition, several human experiments were performed to demonstrate the system's applicability for various lower limb biomechanics studies. The first two experiments quantified postural balance on a compliance-controlled surface (passive perturbations) and under oscillatory perturbations with various frequencies and amplitudes (active perturbations). The second two experiments quantified bilateral ankle mechanics, specifically, ankle impedance in 2-DOF during standing and walking. The validation experiments showed high accuracy of the platform system to apply position perturbations, simulate a range of mechanical environments, and quantify the joint impedance. Results of the human experiments further demonstrated that the platform system is sensitive enough to detect differences in postural balance control under challenging environmental conditions as well as bilateral differences in 2-DOF ankle mechanics. This robotic platform system will allow us to better understand lower limb biomechanics during functional tasks, while also providing invaluable knowledge for the design and control of many robotic systems including robotic exoskeletons, prostheses and robot-assisted balance training programs. Clinical and Translational Impact Statement- Our robotic platform system serves as a tool to better understand the biomechanics of both healthy and neurologically impaired individuals and to develop assistive robotics and rehabilitation training programs using this information.

Application of Robotic Recovery Techniques to Stroke Survivors-Bibliometric Analysis

Stroke is a significant disability and death cause worldwide and is conventionally defined as a neurological impairment relating to the intense focal harm of the central nervous system (CNS) by vascular causative components. Although the applicability of robotic rehabilitation is a topic with considerable practical significance because it has produced noticeably higher improvements in motor function than regular (physical and occupational) therapy and exempted the therapists, most of the existing bibliometric papers were not focused on stroke survivors. Additionally, a modular system is designed by joining several medical end-effector devices to a single limb segment, which addresses the issue of potentially dangerous pathological compensatory motions. Searching the Web of Science database, 31,930 papers were identified, and using the VOSviewer software and science mapping technology, data were extracted on the most prolific countries, the connections between them, the most valuable journals according to certain factors, their average year of publication, the most influential papers, and the most relevant topical issues (bubble map of term occurrence). The most prolific country in the analyzed field and over the entire period evaluated (1975-2022) is the United States, and the most prolific journal is Neurorehabilitation and Neural Repair, observing a marked increase in the three periods of scientific interest for this field. The present paper assesses numerous scientific publications to provide, through statistical interpretation of the data, a detailed description of the use of robotic rehabilitation in stroke survivors. The findings may aid scientists, academics, and clinicians in establishing precise goals in the optimization of the management of stroke survivors via robotic rehabilitation, but also through easier access to scientifically validated literature.

Efficacy of Robot-Assisted Gait Training Combined with Robotic Balance Training in Subacute Stroke Patients: A Randomized Clinical Trial

Recently, the use of robotic technology in gait and balance rehabilitation of stroke patients has been introduced, with positive results. The purpose of this study was to evaluate the effectiveness of robotic gait and trunk rehabilitation compared to robotic gait training alone on balance, activities, and participation measures in patients with subacute stroke. The study was a randomized, controlled, single blind, parallel group clinical trial. Thirty-six patients with first ischemic or hemorrhagic stroke event were enrolled, and they were randomized in two groups: Gait Group (GG), where they received only robotic treatment for gait rehabilitation through an end-effector system, and Gait/Trunk Group (GTG) where they performed end-effector gait rehabilitation and balance with a robotic platform, 3 times/week for 12 sessions/month. At the end of the study, there was an improvement in balance ability in both groups. Instead, the lower limb muscle strength and muscle tone significantly improved only in the GTG group, where we found a significant reduction in the trunk oscillations and displacement during dynamic exercises more than the GG group. The robotic platform which was added to the gait robotic treatment offers more intense and controlled training of the trunk that positively influences the tone and strength of lower limb muscles.

Comparison of high-intensive and low-intensive electromechanical-assisted gait training by Exowalk® in patients over 3-month post-stroke

BACKGROUND

This study was conducted to assess the effect of electromechanical-assisted gait training intensity on walking ability in patients over 3-month post-stroke.

METHODS

Data from two randomized controlled trials (RCTs) were collected under the same study design of assessment and intervention, excluding intervention time per session. After matching the inclusion criteria of two RCTs, the experimental groups of each RCT were defined as low-intensive (LI) and high-intensive (HI) group according to the intervention time per session. Primary outcome was the difference of the change in Functional Ambulatory Categories (FAC) between LI and HI gait training. Secondary outcomes were the difference of changes in mobility, walking speed, walking capacity, leg-muscle strength, balance and daily activity evaluated with Rivermead Mobility Index (RMI), 10 m walk test (10MWT), 6-min walk test (6MWT), Motricity Index (MI), Berg Balance Scale (BBS) and Modified Barthel Index (MBI) respectively.

RESULTS

The FAC improved after gait training in both groups. The secondary outcomes also improved in both groups except RMI and MI in HI group. The change of all outcomes were not different between groups except RMI. The change of RMI in the LI group was greater than that in the HI group statistically, but it did not meet minimal clinically important difference.

CONCLUSIONS

The improvement of walking ability after LI or HI gait training was not different if providing the same total gait training time. By providing the electromechanical gait training intensively, we could shorten the gait training period to improve walking ability and customize the training program according to the patient training abilities.

TRIAL REGISTRATION

Name of the registry: Clinical Research Information Service.

TRIAL REGISTRATION NUMBER

No. KCT0002195(RCT1), No. KCT0002552(RCT2). Date of registration: 10/04/2016(RCT1), 10/05/2017(RCT2). URL of the trial registry record: https://cris.nih.go.kr/cris/search.

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.

Robot Assisted Gait Training in a Patient with Ataxia

Background: Ataxia is a neurological sign characterized by motor coordination during gait/voluntary limb movements impairment. Ataxic gait leads to disability and worsening of quality of life; physiotherapy intervention is recommended to improve motor function. Recent studies showed benefits due to repetitive robotized assisted gait training using a static exoskeleton in patients affected by acquired ataxias. The aim of the study was to perform a preliminary evaluation of the short-term effects of overground UAN.GO^®-assisted gait training in an adult patient with ataxia but with no clear genetic pattern. Methods: This case report study was conducted on a single male adult patient, who presented ataxic spastic gait, posterior chain tightness, pes cavus, and unstable standing position. The patient underwent two preliminary sessions to take part in the study. Treatment protocol planned 10 sessions and each one lasted 80 min, 60 of which were spent in gait training using the mobile overground exoskeleton UAN.GO^®. At T1 (start of the study) and T10 (final evaluation) assessments using the Scale for the Assessment and Rating of Ataxia, Berg Balance Scale, 6-Minute Walking Test, and Likert Scale were administered. Space-time parameters of gait cycle were also evaluated: left and right step length, stance and swing percentages. Results: improvements on the Scale for the Assessment and Rating of Ataxia, Berg Balance Scale, and in the distance travelled at 6-Minute Walking Test emerged. The patient gave a positive opinion towards the treatment, showed by Likert Scale results. Kinematic gait analysis showed more physiological step length, stance and swing percentages, joint angles. The patient completed the training program with an excellent compliance. Discussion: Since these encouraging outcomes were obtained, it is possible to consider robot-assisted gait training performed with UAN.GO^® as a therapeutic option to improve motor and functional performance in patients with ataxic gait.

Different Effects of Robot-Assisted Gait and Independent Over-Ground Gait on Foot Plantar Pressure in Incomplete Spinal Cord Injury: A Preliminary Study

Background: There is insufficient evidence to establish the optimal treatment protocol for robot-assisted gait training. Objective: This study aimed to analyze the effects of robot-assisted gait and independent over-ground gait on foot pressure and to determine an effective training protocol for improvement of gait pattern in patients with incomplete spinal cord injury due to industrial accidents. Methods: Four patients with incomplete spinal cord injury due to an industrial accident who had gait disturbance underwent measurement of peak foot pressure and stance phase duration using a foot pressure analysis system with robot-assisted gait and independent over-ground gait. Results: The robot-assisted gait condition has lower peak foot pressure and shorter stance phase duration than the independent over-ground gait. Conclusions: In this study, robot-assisted gait was found to limit gait pattern improvement in patients with gait disturbance caused by incomplete spinal cord injury due to industrial accidents. Therefore, future research will be conducted to determine the optimal protocol for robot-assisted gait training for gait pattern improvement.

The Effect of Robotic Assisted Gait Training With Lokomat® on Balance Control After Stroke: Systematic Review and Meta-Analysis

Introduction: Disturbances of balance control are common after stroke, affecting the quality of gait and increasing the risk of falls. Because balance and gait disorders may persist also in the chronic stage, reducing individual independence and participation, they represent primary goals of neurorehabilitation programs. For this purpose, in recent years, numerous technological devices have been developed, among which one of the most widespread is the Lokomat®, an actuated exoskeleton that guide the patient's limbs, simulating a symmetrical bilateral gait. Preliminary evidence suggests that beyond gait parameters, robotic assisted gait training may also improve balance. Therefore, the aim of this systematic review was to summarize evidence about the effectiveness of Lokomat® in improving balance in stroke patients.

Methods: Randomized controlled trials published between January 1989 and August 2020, comparing Lokomat® training to conventional therapy for stroke patients, were retrieved from seven electronic databases. Balance, assessed by means of validated clinical scales, was considered as outcome measure. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of the studies. The study protocol was registered on PROSPERO (no. CRD42020197531).

Results: After the removal of the duplicates, according to the inclusion criteria, 13 studies were selected, involving 445 subacute or chronic stroke patients. Eleven papers contributed to three meta-analyses. Favorable results for recovery of balance in stroke survivors treated with Lokomat® were shown using Timed Up and Go (pooled mean difference = −3.40, 95% CI −4.35 to −2.44; p < 0.00001) and Rivermead Mobility Index as outcome measures (pooled mean difference = 0.40, 95% CI 0.26–0.55; p < 0.00001). Inconclusive results were found when balance was measured by means of the Berg Balance Scale (pooled mean difference = 0.17, 95% CI −0.26 to 0.60; p = 0.44).

Conclusions: Overall, most studies have shown beneficial effects of Lokomat® on balance recovery for stroke survivors, at least comparable to conventional physical therapy. However, due to the limited number of studies and their high heterogeneity, further research is needed to draw more solid and definitive conclusions.

Effects of body weight support and guidance force settings on muscle synergy during Lokomat walking

BACKGROUND

The Lokomat is a robotic device that has been suggested to make gait therapy easier, more comfortable, and more efficient. In this study, we asked whether the Lokomat promotes physiological muscle activation patterns, a fundamental question when considering motor learning and adaptation.

METHODS

We investigated lower limb muscles coordination in terms of muscle activity level, muscle activity pattern similarity, and muscle synergy in 15 healthy participants walking at 3 km/h on either a treadmill or in a Lokomat at various guidance forces (GF: 30, 50 or 70%) and body weight supports (BWS: 30, 50 or 70% of participant's body weight).

RESULTS

Walking in the Lokomat was associated with a greater activation level of the rectus femoris and vastus medialis (×2-3) compared to treadmill walking. The level of activity tended to be diminished in gastrocnemius and semi-tendinosus, which particularly affected the similarity with treadmill walking (normalized scalar product NSP = 0.7-0.8). GF and BWS independently altered the muscle activation pattern in terms of amplitude and shape. Increasing BWS decreased the level of activity in all but one muscle (the soleus). Increasing GF slightly improved the similarity with treadmill walking for the tibialis anterior and vastus medialis muscles. The muscle synergies (N = 4) were similar (NSP = 0.93-0.97), but a cross-validation procedure revealed an alteration by the Lokomat. The activation of these synergies differed (NSP = 0.74-0.82).

CONCLUSION

The effects of GF and BWS are modest compared to the effect of the Lokomat itself, suggesting that Lokomat design should be improved to promote more typical muscle activity patterns.

Gait-assisted exoskeletons for children with cerebral palsy or spinal muscular atrophy: A systematic review

BACKGROUND

Cerebral Palsy (CP) and Spinal Muscular Atrophy (SMA) are common causes of motor disability in childhood. Gait exoskeletons are currently being used as part of rehabilitation for children with walking difficulties.

OBJECTIVE

To assess the safety and efficacy and describe the main characteristics of the clinical articles using robot-assisted gait training (RAGT) with exoskeleton for children with CP or SMA.

METHODS

A computer search was conducted in five bibliographic databases regarding clinical studies published in the last ten years. In order to be included in this review for further analysis, the studies had to meet the following criteria: (1) assess efficacy or safety of interventions; (2) population had to be children with CP or SMA aged between 3 and 14; (3) exoskeleton must be bilateral and assist lower limbs during walking.

RESULTS

Twenty-one articles were selected, of which only five were clinical trials. 108 participants met the inclusion criteria for this study, all with a diagnosis of CP. The evidence level of the selected papers was commonly low.

CONCLUSIONS

RAGT therapy seems to be safe for children with CP. However, further investigation is needed to confirm the results related to efficacy. There is no evidence of RAGT therapy for SMA children.

Comparisons between Locomat and Walkbot robotic gait training regarding balance and lower extremity function among non-ambulatory chronic acquired brain injury survivors

ABSTRACT

Lower limb rehabilitation exoskeleton robots connect with the human body in a wearable way and control the movement of joints in the gait rehabilitation process. Among treadmill-based lower limb rehabilitation exoskeleton robots, Lokomat (Hocoma AG, Volketswil, Switzerland) has 4 actuated joints for bilateral hips and knees whereas Walkbot (P&S Mechanics, Seoul, Korea) has 6 bilateral actuated joints for bilateral hips, knees, and ankles. Lokomat and Walkbot robotic gait training systems have not been directly compared previously. The present study aimed to directly compare Lokomat and Walkbot robots in non-ambulatory chronic patients with acquired brain injury (ABI).The authors conducted a single-center, retrospective, cross-sectional study of 62 subjects with ABI who were admitted to the rehabilitation hospital. Patients were divided into 2 groups: Lokomat (n = 28) and Walkbot (n = 34). Patients were subjected to robot-assisted gait training (RAGT) combined with conventional physical therapy for a total of 14 (8-36) median (interquartile range) sessions. Baseline characteristics, including age, sex, lag time post-injury, ABI type, paralysis type, intervention sessions, lower extremity strength, spasticity, and cognitive function were assessed. Functional ambulation category (FAC) and Berg balance scale (BBS) were used for outcome measures.There were no significant differences in baseline characteristics between the groups. Baseline FAC score was 1 (0-2) in Lokomat and 1 (0-1) in Walkbot group. After the intervention, FAC scores improved significantly to 2 (1-3) in both groups (P < .05). Lokomat and Walkbot groups showed significantly enhanced BBS from 5 (2.75-24.25) and 15 (4-26.5) to 15 (4-26.5) and 22 (12-40), respectively (P < .05). Degree of improvements in both group were not significantly different with regard to balance (P = .56) and ambulatory ability (P = .74).This study indicates that both Locomat and Walkbot robotic gait training combined with conventional gait-oriented physiotherapy are promising intervention for gait rehabilitation in patients with chronic stage of ABI who are not able to walk independently.

Clinical Efficacy of a New Robot-assisted Gait Training System for Acute Stroke Patients

Purpose

Robot-assisted gait rehabilitation has been proposed as a plausible supplementary rehabilitation strategy in stroke rehabilitation in the last decade. However, its exact benefit over traditional rehabilitation remain sparse and unclear. It is therefore the purpose of the current study to comparatively investigate the clinical benefits of the additional robot-assisted training in acute stroke patients compared to standard hospital rehabilitation alone.

Methods

Ninety acute stroke patients (< 3 month) were recruited. All participants received the standard hospital neurorehabilitation comprises 45–60 min sessions daily for 3 weeks. Sixty patients also received an additional 30 min of robot-assisted gait training with the HIWIN MRG-P100 gait training system after each of the standard neurorehabilitation session. Outcome measures included: 1. Berg Balance Scale (BBS); 2. Brunnstrom Stage; 3. Pittsburgh Sleep Quality Index and 4. Taiwanese Depression Questionnaire (TDQ) which were assessed pre-treatment and then after every five training sessions.

Results

Both groups demonstrated significant improvement pre- and post-treatment for the BBS (robotic group p = 0.023; control group p = 0.033) but no significant difference (p > 0.1) between the groups were found. However, the robotic training group had more participants demonstrating larger BBS points of improvement as well as greater Brunnstrom stage of improvement, when compared to the control group. No significant within and between group statistical differences (p > 0.3) were found for Pittsburgh Sleep Quality Index and Taiwanese Depression Questionnaire.

Conclusion

The addition of robotic gait training on top of standard hospital neurorehabilitation for acute stroke patients appear to produce a slightly greater improvement in clinical functional outcomes, which is not transferred to psychological status.

Morning Walk®-Assisted Gait Training Improves Walking Ability and Balance in Patients with Ataxia: a Randomized Controlled Trial

This study aimed to investigate walking ability and balance improvement of patients with ataxia caused by brain lesions after end-effector type robot (Morning Walk^®)-assisted gait training. This study randomly assigned 19 patients to one of two groups: 30 minutes of Morning Walk^® training with 1 hour of conventional physiotherapy (Morning Walk^® group; n = 10) or 1.5 hours of conventional physiotherapy (Control group; n = 9). Five treatment sessions per week were given for 3 weeks. The primary outcomes were walking ability and balance, which were assessed by the functional ambulation category (FAC) and Berg Balance Scale (BBS), respectively. The secondary outcomes included 10-meter Walk Test (10mWT), Rivermead Mobility Index (RMI), Motricity Index (MI), and Modified Barthel Index (MBI). At baseline, there was no statistically significant difference between the two groups except MBI. After the treatment, the Morning Walk^® group showed significant improvement in the FAC, BBS, 10mWT, RMI and MBI. The control group showed significant improvement in the BBS, 10mWT, RMI and MBI. Inter-group comparison demonstrated that the ∆FAC, ∆10mWT and ∆RMI of the Morning Walk^® group were significantly higher than those of the control group. Our results suggest that the patients with ataxia receiving Morning Walk^®-assisted gait training might improve greater in walking ability and balance than those trained with conventional physiotherapy.

Review on motor imagery based BCI systems for upper limb post-stroke neurorehabilitation: From designing to application

Strokes are a growing cause of mortality and many stroke survivors suffer from motor impairment as well as other types of disabilities in their daily life activities. To treat these sequelae, motor imagery (MI) based brain-computer interface (BCI) systems have shown potential to serve as an effective neurorehabilitation tool for post-stroke rehabilitation therapy. In this review, different MI-BCI based strategies, including "Functional Electric Stimulation, Robotics Assistance and Hybrid Virtual Reality based Models," have been comprehensively reported for upper-limb neurorehabilitation. Each of these approaches have been presented to illustrate the in-depth advantages and challenges of the respective BCI systems. Additionally, the current state-of-the-art and main concerns regarding BCI based post-stroke neurorehabilitation devices have also been discussed. Finally, recommendations for future developments have been proposed while discussing the BCI neurorehabilitation systems.

A Review of Robot-Assisted Lower-Limb Stroke Therapy: Unexplored Paths and Future Directions in Gait Rehabilitation

Stroke affects one out of every six people on Earth. Approximately 90% of stroke survivors have some functional disability with mobility being a major impairment, which not only affects important daily activities but also increases the likelihood of falling. Originally intended to supplement traditional post-stroke gait rehabilitation, robotic systems have gained remarkable attention in recent years as a tool to decrease the strain on physical therapists while increasing the precision and repeatability of the therapy. While some of the current methods for robot-assisted rehabilitation have had many positive and promising outcomes, there is moderate evidence of improvement in walking and motor recovery using robotic devices compared to traditional practice. In order to better understand how and where robot-assisted rehabilitation has been effective, it is imperative to identify the main schools of thought that have prevailed. This review intends to observe those perspectives through three different lenses: the goal and type of interaction, the physical implementation, and the sensorimotor pathways targeted by robotic devices. The ways that researchers approach the problem of restoring gait function are grouped together in an intuitive way. Seeing robot-assisted rehabilitation in this unique light can naturally provoke the development of new directions to potentially fill the current research gaps and eventually discover more effective ways to provide therapy. In particular, the idea of utilizing the human inter-limb coordination mechanisms is brought up as an especially promising area for rehabilitation and is extensively discussed.

A qualitative study on user acceptance of a home-based stroke telerehabilitation system

Objective: This paper reports a qualitative study of a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education in the patient's home. The aims of the current report are to investigate patient perceived benefits of and barriers to using the telerehabilitation system at home.Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 13 participants who were patients in the subacute phase after stroke and had completed a six-week intervention using the home-based telerehabilitation system. Thematic analysis was conducted to analyze the data.Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions, cognitive abilities, and emotional well-being. They also perceived the system easy to use due to the engaging experience and the convenience of conducting sessions at home. Meanwhile, participants pointed out the importance of considering technical support and physical environment at home. Further, family members' support helped them sustain in their rehabilitation. Finally, adjusting difficulty levels and visualizing patients' rehabilitation progress might help them in continued use of the telerehabilitation system.Conclusion: Telerehabilitation systems can be used as an efficient and user-friendly tool to deliver home-based stroke rehabilitation that enhance patients' physical recovery and mental and social-emotional wellbeing. Such systems need to be designed to offer engaging experience, display of recovery progress, and flexibility of schedule and location, with consideration of facilitating and social factors.

Robot-Assisted Stair Climbing Training on Postural Control and Sensory Integration Processes in Chronic Post-stroke Patients: A Randomized Controlled Clinical Trial

BACKGROUND

Postural control disturbances are one of the important causes of disability in stroke patients affecting balance and mobility. The impairment of sensory input integration from visual, somatosensory and vestibular systems contributes to postural control disorders in post-stroke patients. Robot-assisted gait training may be considered a valuable tool in improving gait and postural control abnormalities.

OBJECTIVE

The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility.

METHODS

This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with postural instability. The experimental group (EG, n = 16) received robot-assisted stair climbing training. The control group (n = 16) received sensory integration balance training. Training protocols lasted for 5 weeks (50 min/session, two sessions/week). Before, after, and at 1-month follow-up, a blinded rater evaluated patients using a comprehensive test battery. Primary outcome: Berg Balance Scale (BBS). Secondary outcomes:10-meter walking test, 6-min walking test, Dynamic gait index (DGI), stair climbing test (SCT) up and down, the Time Up and Go, and length of sway and sway area of the Center of Pressure (CoP) assessed using the stabilometric assessment.

RESULTS

There was a non-significant main effect of group on primary and secondary outcomes. A significant Time × Group interaction was measured on 6-min walking test (p = 0.013) and on posturographic outcomes (p = 0.005). Post hoc within-group analysis showed only in the EG a significant reduction of sway area and the CoP length on compliant surface in the eyes-closed and dome conditions.

CONCLUSION

Postural control disorders in patients with chronic stroke may be ameliorated by robot-assisted stair climbing training and sensory integration balance training. The robot-assisted stair climbing training contributed to improving sensorimotor integration processes on compliant surfaces. Clinical trial registration (NCT03566901).

Exoskeleton and End-Effector Robots for Upper and Lower Limbs Rehabilitation: Narrative Review

Recovery of upper and lower limbs function is essential to reach independence in daily activities in patients with upper motor neuron syndrome (UMNS). Rehabilitation can provide a guide for motor recovery influencing the neurobiology of neuronal plasticity providing controlled, repetitive, and variable patterns. Increasing therapy dosage, intensity, number of repetition, execution of task-oriented exercises, and combining top-down and bottom-up approaches can promote plasticity and functional recovery. Robotic exoskeletons for upper and lower limbs, based on the principle of motor learning, have been introduced in neurorehabilitation. In this narrative review, we provide an overview of literature published on exoskeleton devices for upper and lower limb rehabilitation in patients with UMNS; we summarized the available current research evidence and outlined the new challenges that neurorehabilitation and bioengineering will have to face in the upcoming years. Robotic treatment should be considered a rehabilitation tool useful to generate a more complex, controlled multisensory stimulation of the patient and useful to modify the plasticity of neural connections through the experience of movement. Efficacy and efficiency of robotic treatment should be defined starting from intensity, complexity, and specificity of the robotic exercise, that are related to human-robot interaction in terms of motion, emotion, motivation, meaning of the task, feedback from the exoskeleton, and fine motion assistance. Duration of a single session, global period of the treatment, and the timing for beginning of robotic treatment are still open questions. There is the need to evaluate and individualize the treatment according to patient's characteristics. Robotic devices for upper and lower limbs open a window to define therapeutic modalities as possible beneficial drug, able to boost biological, neurobiological, and epigenetic changes in central nervous system. We need to implement large and innovative research programs to answer these issues in the near future.

Robot-assisted gait training for balance and lower extremity function in patients with infratentorial stroke: a single-blinded randomized controlled trial

Background

Balance impairments are common in patients with infratentorial stroke. Although robot-assisted gait training (RAGT) exerts positive effects on balance among patients with stroke, it remains unclear whether such training is superior to conventional physical therapy (CPT). Therefore, we aimed to investigate the effects of RAGT combined with CPT and compared them with the effects of CPT only on balance and lower extremity function among survivors of infratentorial stroke.

Methods

This study was a single-blinded, randomized controlled trial with a crossover design conducted at a single rehabilitation hospital. Patients (n = 19; 16 men, three women; mean age: 47.4 ± 11.6 years) with infratentorial stroke were randomly allocated to either group A (4 weeks of RAGT+CPT, followed by 4 weeks of CPT+CPT) or group B (4 weeks of CPT+CPT followed by 4 weeks of RAGT+CPT). Changes in dynamic and static balance as indicated by Berg Balance Scale scores were regarded as the primary outcome measure. Outcome measures were evaluated for each participant at baseline and after each 4-week intervention period.

Results

No significant differences in outcome-related variables were observed between group A and B at baseline. In addition, no significant time-by-group interactions were observed for any variables, indicating that intervention order had no effect on lower extremity function or balance. Significantly greater improvements in secondary functional outcomes such as lower extremity Fugl-Meyer assessment (FMA-LE) and scale for the assessment and rating of ataxia (SARA) were observed following the RAGT+CPT intervention than following the CPT+CPT intervention.

Conclusion

RAGT produces clinically significant improvements in balance and lower extremity function in individuals with infratentorial stroke. Thus, RAGT may be useful for patients with balance impairments secondary to other pathologies.

Trial registration

ClinicalTrials.gov Identifier NCT02680691. Registered 09 February 2016; retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12984-019-0553-5) contains supplementary material, which is available to authorized users.

Rehabilitation interventions for improving balance following stroke: An overview of systematic reviews

Background

The aim of this study was to synthesize evidence from systematic reviews, to summarise the effects of rehabilitation interventions for improving balance in stroke survivors.

Methods

We conducted an overview of systematic reviews (SRs). We included Cochrane Systematic Reviews and non-Cochrane Systematic Reviews of randomized-controlled clinical trials and not-randomized clinical trials, in all types of stroke, comparing the effects of interventions, control interventions and no interventions on balance-related outcomes. We conducted a comprehensive search of electronic databases, from inception to December 2017. Data extracted included: number and type of participants, type of intervention, control intervention, method of assessing risk of bias of primary studies, balance outcome measures and results of statistical meta-analyses. Methodological quality of included reviews was assessed using AMSTAR 2. A narrative description of the characteristics of the SRs was provided and results of meta-analyses summarised with reference to their methodological quality.

Results

51 SRs (248 primary studies and 10,638 participants) met the inclusion criteria and were included in the overview. All participants were adults with stroke. A wide variety of different balance and postural control outcomes were included. 61% of SRs focussed on the effectiveness of physical therapy, 20% virtual reality, 6% electromechanical devices, 4% Tai-Chi, whole body vibration and circuit training intervention, and 2% cognitive rehabilitation. The methodology of 54% of SRs were judged to be of a “low or critically low” quality, 23% “moderate” quality and 22% “high” quality.

Conclusions

There are 51 SRs of evidence relating to the effectiveness of interventions to improve balance in people with stroke, but the majority of these are of poor methodological quality, limiting our ability to draw clear implications. Only 22% of these SRs were judged to be of high quality, highlighting the need to address important methodological issues within rehabilitation research.

Development of KIINCE: A kinetic feedback-based robotic environment for study of neuromuscular coordination and rehabilitation of human standing and walking

Introduction

The objective of this article is to introduce the robotic platform KIINCE and its emphasis on the potential of kinetic objectives for studying and training human walking and standing. The device is motivated by the need to characterize and train lower limb muscle coordination to address balance deficits in impaired walking and standing.

Methods

The device measures the forces between the user and his or her environment, particularly the force of the ground on the feet (F) that reflects lower limb joint torque coordination. In an environment that allows for exploration of the user’s capabilities, various forms of real-time feedback guide neural training to produce F appropriate for remaining upright. Control of the foot plate motion is configurable and may be user driven or prescribed. Design choices are motivated from theory of motor control and learning as well as empirical observations of F during walking and standing.

Results

Preliminary studies of impaired individuals demonstrate the feasibility and potential utility of patient interaction with kinetic immersive interface for neuromuscular coordination enhancement.

Conclusion

Applications include study and rehabilitation of standing and walking after injury, amputation, and neurological insult, with an initial focus on stroke discussed here.

A Randomized and Controlled Crossover Study Investigating the Improvement of Walking and Posture Functions in Chronic Stroke Patients Using HAL Exoskeleton - The HALESTRO Study (HAL-Exoskeleton STROke Study)

Background: The exoskeleton HAL (hybrid assistive limb) has proven to improve walking functions in spinal cord injury and chronic stroke patients when using it for body-weight supported treadmill training (BWSTT). Compared with other robotic devices, it offers the possibility to initiate movements actively. Previous studies on stroke patients did not compare HAL-BWSTT with conventional physiotherapy (CPT). Therefore, we performed a crossover clinical trial comparing CPT and HAL-BWSTT in chronic stroke patients with hemiparesis, the HALESTRO study. Our hypothesis was that HAL-training would have greater effects on walking and posture functions compared to a mixed-approach CPT.

Methods: A total of 18 chronic stroke patients participated in this study. Treatment consisted of 30 CPT sessions and of 30 sessions of BWSTT with a double leg type HAL exoskeleton successively in a randomized, crossover study design. Primary outcome parameters were walking time and speed in 10-meter walk test (10MWT), time in timed-up-and-go test (TUG) and distance in 6-min walk test (6MWT). Secondary outcome parameters were the functional ambulatory categories (FAC) and the Berg-Balance Scale (BBS). Data were assessed at baseline, at crossover and at the end of the study, all without using and wearing HAL.

Results: Our study demonstrate neither a significant difference in walking parameters nor in functional and balance parameters. When HAL-BWSTT was applied to naïve patients, it led to an improvement in walking parameters and in balance abilities. Pooling all data, we could show a significant effect in 10MWT, 6MWT, FAC and BBS, both therapies sequentially applied over 12 weeks. Thereby, FAC improve from dependent to independent category (3 to 4). One patient dropped out of the study due to intensive fatigue after each training session.

Conclusion: HAL-BWSTT and mixed-approach CPT were effective therapies in chronic stroke patients. However, compared with CPT, HAL training with 30 sessions over 6 weeks was not more effective. The combination of both therapies led to an improvement of walking and balance functions. Robotic rehabilitation of walking disorders alone still lacks the proof of superiority in chronic stroke. Robotic treatment therapies and classical CPT rehabilitation concepts should be applied in an individualized therapy program.

Home-based technologies for stroke rehabilitation: A systematic review

BACKGROUND

Many forms of home-based technology targeting stroke rehabilitation have been devised, and a number of human factors are important to their application, suggesting the need to examine this information in a comprehensive review.

OBJECTIVE

The systematic review aims to synthesize the current knowledge of technologies and human factors in home-based technologies for stroke rehabilitation.

METHODS

We conducted a systematic literature search in three electronic databases (IEEE, ACM, PubMed), including secondary citations from the literature search. We included articles that used technological means to help stroke patients conduct rehabilitation at home, reported empirical studies that evaluated the technologies with patients in the home environment, and were published in English. Three authors independently conducted the content analysis of searched articles using a list of interactively defined factors.

RESULTS

The search yielded 832 potentially relevant articles, leading to 31 articles that were included for in-depth analysis. The types of technology of reviewed articles included games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets. We present the merits and limitations of each type of technology. We then derive two main human factors in designing home-based technologies for stroke rehabilitation: designing for engagement (including external and internal motivation) and designing for the home environment (including understanding the social context, practical challenges, and technical proficiency).

CONCLUSION

This systematic review presents an overview of key technologies and human factors for designing home-based technologies for stroke rehabilitation.

Robot-assisted gait training effectively improved lateropulsion in subacute stroke patients: a single-blinded randomized controlled trial

BACKGROUND

Some stroke patients are known to use nonparetic extremities to push toward the paretic side, a movement known as lateropulsion. Lateropulsion impairs postural balance and interferes with rehabilitation.

AIM

The aim of the present study was to investigate the effect of robot-assisted gait training (RAGT) on recovery from lateropulsion compared with conventional physical therapy (CPT).

DESIGN

This was a single-blinded, randomized controlled trial.

SETTING

Participants were recruited from a rehabilitation department of a tertiary hospital.

POPULATION

Patients diagnosed with lateropulsion after a stroke.

METHODS

Thirty-six subacute stroke patients with lateropulsion were recruited. RAGT was performed in the experimental group (N.=18), and CPT was performed in the control group (N.=18). The participants received treatment for 3 weeks, 30 minutes per day, 5 days per week. Outcomes were assessed before the intervention (T0), immediately after the intervention (T1), and 4 weeks after the intervention (T2). The Burke Lateropulsion Scale (BLS) was evaluated as a primary outcome to assess the severity of lateropulsion. The secondary outcome measures were the Berg Balance Scale (BBS), the Postural Assessment Scale for Stroke (PASS), and Somatosensory Evoked Potentials (SSEP).

RESULTS

After intervention, the experimental group showed greater improvement in the BLS score at T1 (experimental group: Δ=-1.9, control group: Δ=-1.1, P=0.032) and T2 (experimental group: Δ=-2.8, control group: Δ=-6.5, P<0.001) than the control group. In addition, the BBS was significantly improved in the experimental group at T1 (experimental group: Δ=+7.1, control group: Δ=+1.9, P<0.001) and T2 (experimental group: Δ=+13.0, control group: Δ=+6.1, P<0.001). There were significant between-group differences in the PASS at T1 (experimental group: Δ=+3.2, control group: Δ=+1.6, P=0.014) and T2 (experimental group: Δ=+8.8, control group: Δ=+4.3, P<0.001).

CONCLUSIONS

RAGT ameliorated lateropulsion and balance function more effectively than CPT in subacute stroke patients.

CLINICAL REHABILITATION IMPACT

Early RAGT may be recommended for patients with lateropulsion after stroke.

Do powered over-ground lower limb robotic exoskeletons affect outcomes in the rehabilitation of people with acquired brain injury?

Purpose: To assess the effects of lower limb robotic exoskeletons on outcomes in the rehabilitation of people with acquired brain injury.Materials and methods: A systematic review of seven electronic databases was conducted. The primary outcome of interest was neuromuscular function. Secondary outcomes included quality of life, mood, acceptability and safety. Studies were assessed for methodological quality and recommendations were made using the GRADE system.Results: Of 2469 identified studies, 13 (n = 322) were included in the review. Five contained data suitable for meta-analysis. When the data were pooled, there were no differences between exoskeleton and control for 6-Minute Walk Test, Timed Up and Go or 10-Meter Walk Test. Berg Balance Scale outcomes were significantly better in controls (MD = 2.74, CI = 1.12-4.36, p = 0.0009). There were no severe adverse events but drop-outs were 11.5% (n = 37). No studies reported the effect of robotic therapy on quality of life or mood. Methodological quality was on average fair (15.6/27 on Downs and Black Scale).Conclusions: Only small numbers of people with acquired brain injury had data suitable for analysis. The available data suggests no more benefit for gait or balance with robotic therapy than conventional therapy. However, some important outcomes have not been studied and further well-conducted research is needed to determine whether such devices offer benefit over conventional therapy, in particular subgroups of those with acquired brain injury.Implications for RehabilitationThere is adequate evidence to recommend that powered over-ground lower limb robotic exoskeletons should not be used clinically in those with ABI, and that use should be restricted to research.Further research (controlled trials) with dependent ambulators is recommended.Research of other outcomes such as acceptability, spasticity, sitting posture, cardiorespiratory and psychological function, should be considered.

The effects of body weight-supported treadmill training on static and dynamic balance in stroke patients: A pilot, single-blind, randomized trial

Objectives

This study aims to compare effectiveness of isolated body weight-supported treadmill training (BWSTT) with conventional and combined training on balance, mobility, and fear of falling in stroke patients.

Patients and methods

Between November 2014 and November 2015, a total of 45 post-stroke patients (32 males, 13 females; mean age 53.1±13.2 years; range, 19 to 73 years) were randomly assigned to combined training group (CombTG), conventional training group (CTG), and BWSTT group (BWSTTG). The CombTG received 45 min conventional therapy for five days a week along with 45 min of BWSTT twice a week. The CTG received only conventional therapy for five days a week. The BWSTTG received only BWSTT twice a week. Training duration was six weeks for all groups. Primary outcome measures were the Berg Balance Scale (BBS), affected and non-affected side Single Leg Stance Test (e-SLST/n-SLST), and Timed Up and Go Test (TUG) results. Secondary outcomes were the Falls Efficacy Scale-International (FES-I), Rivermead Mobility Index (RMI), Comfortable 10-m Walk Test (CWT), and Stair Climbing Test (SCT) results.

Results

The mean change of outcome measures demonstrated that the improvements between groups were significantly different among the three groups, except for the CWT (p=0.135). In subgroup analysis, except for the RMI and CWT, all primary and secondary outcome measures improved significantly in favor of the CombTG, compared to the CTG and BWSTTG (p<0.016). However, no statistically significant difference was found in the mean change of the CTG and BWSTTG (p>0.05).

Conclusion

This study demonstrates that combined training has considerable effects on balance, mobility, and fear of falling parameters, while lower frequency of isolated BWSTT is as much effective as higher frequency of conventional training in ambulatory post-stroke patients.

A Challenge-Based Approach to Body Weight-Supported Treadmill Training Poststroke: Protocol for a Randomized Controlled Trial

Background

Body weight support treadmill training protocols in conjunction with other modalities are commonly used to improve poststroke balance and walking function. However, typical body weight support paradigms tend to use consistently stable balance conditions, often with handrail support and or manual assistance.

Objective

In this paper, we describe our study protocol, which involved 2 unique body weight support treadmill training paradigms of similar training intensity that integrated dynamic balance challenges to help improve ambulatory function post stroke. The first paradigm emphasized walking without any handrails or manual assistance, that is, hands-free walking, and served as the control group, whereas the second paradigm incorporated practicing 9 essential challenging mobility skills, akin to environmental barriers encountered during community ambulation along with hands-free walking (ie hands-free + challenge walking).

Methods

We recruited individuals with chronic poststroke hemiparesis and randomized them to either group. Participants trained for 6 weeks on a self-driven, robotic treadmill interface that provided body weight support and a safe gait-training environment. We assessed participants at pre-, mid- and post 6 weeks of intervention-training, with a 6-month follow-up. We hypothesized greater walking improvements in the hands-free + challenge walking group following training because of increased practice opportunity of essential mobility skills along with hands-free walking.

Results

We assessed 77 individuals with chronic hemiparesis, and enrolled and randomized 30 individuals poststroke for our study (hands-free group=19 and hands-free + challenge walking group=20) from June 2012 to January 2015. Data collection along with 6-month follow-up continued until January 2016. Our primary outcome measure is change in comfortable walking speed from pre to post intervention for each group. We will also assess feasibility, adherence, postintervention efficacy, and changes in various exploratory secondary outcome measures. Additionally, we will also assess participant responses to a study survey, conducted at the end of training week, to gauge each group's training experiences.

Conclusions

Our treadmill training paradigms, and study protocol represent advances in standardized approaches to selecting body weight support levels without the necessity for using handrails or manual assistance, while progressively providing dynamic challenges for improving poststroke ambulatory function during rehabilitation.

Trial Registration

ClinicalTrials.gov NCT02787759; https://clinicaltrials.gov/ct2/show/NCT02787759 (Archived by Webcite at http://www.webcitation.org/6yJZCrIea)

Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies

Background

The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.

Methods

ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.

Results

At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.

Conclusions

The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.

A Comparative Study of Conventional Physiotherapy versus Robot-Assisted Gait Training Associated to Physiotherapy in Individuals with Ataxia after Stroke

OBJECTIVES

To assess the influence of RAGT on balance, coordination, and functional independence in activities of daily living of chronic stroke survivors with ataxia at least one year of injury.

METHODS

It was a randomized controlled trial. The patients were allocated to either therapist-assisted gait training (TAGT) or robotic-assisted gait training (RAGT). Both groups received 3 weekly sessions of physiotherapy with an estimated duration of 60 minutes each and prescribed home exercises. The following outcome measures were evaluated prior to and after the completion of the 5-month protocol treatment: BBS, TUG test, FIM, and SARA. For intragroup comparisons, the Wilcoxon test was used, and the Mann-Whitney test was used for between-group comparison.

RESULTS

Nineteen stroke survivors with ataxia sequel after one year of injury were recruited. Both groups showed statistically significant improvement (P < 0.05) in balance, functional independencein, and general ataxia symptoms. There were no statistically significant differences (P < 0.05) for between-group comparisons both at baseline and after completion of the protocol.

CONCLUSIONS

Chronic stroke patients with ataxia had significant improvements in balance and independence in activities of daily living after RAGT along with conventional therapy and home exercises. This trial was registered with trial registration number 39862414.6.0000.5505.

Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients

The purpose of this study was to critically evaluate the effects of robot-assisted gait training (RAGT) on gait-related function in patients with acute/subacute stroke. We conducted a systematic review of randomized controlled trials published between May 2012 and April 2016. This search included 334 articles (Cochrane, 51 articles; Embase, 175 articles; PubMed, 108 articles). Based on the inclusion and exclusion criteria, 7 studies were selected for this review. We performed a quality evaluation using the PEDro scale. In this review, 3 studies used an exoskeletal robot, and 4 studies used an end-effector robot as interventions. As a result, RAGT was found to be effective in improving walking ability in subacute stroke patients. Significant improvements in gait speed, functional ambulatory category, and Rivermead mobility index were found with RAGT compared with conventional physical therapy (p < 0.05). Therefore, aggressive weight support and gait training at an early stage using a robotic device are helpful, and robotic intervention should be applied according to the patient's functional level and onset time of stroke.

Overground gait training using a motorized assistive device in patients with severe disabilities after stroke

Regaining of the patient's ability to walk after stroke is an important goal of rehabilitation programmes. The ultimate goal of gait rehabilitation is to empower patients for overground walking. We have previously developed a prototype of a therapist-controlled mobile platform with compliant pelvis support mechanism that enables balance training during overground walking (device E-go). The aim of this pilot randomized controlled study was to explore the usefulness of the E-go in reducing the number of therapists needed during walking training, and to explore the effectiveness of the E-go on walking abilities in severely affected stroke patients. The study included 19 subacute poststroke patients divided into two groups. The experimental group (nine patients) trained to walk with the E-go and the control group trained within conventional physiotherapy programs for 3 weeks. Outcome measures were walking distance and speed, Fugl-Meyer Assessment, Berg Balance Scale, Functional Ambulation Category and the number of therapists needed during training. At the end of the training both groups significantly improved in walking speed, walking distance, Berg Balance Scale and Fugl-Meyer Assessment (P≤0.001), but there were no between-group differences. The experimental group on average needed a lower number of therapists (P=0.040). These findings highlight the potential of the E-go for overground walking training in severely disabled subacute stroke patients.

Overground vs. treadmill-based robotic gait training to improve seated balance in people with motor-complete spinal cord injury: a case report

Background

Robotic overground gait training devices, such as the Ekso, require users to actively participate in triggering steps through weight-shifting movements. It remains unknown how much the trunk muscles are activated during these movements, and if it is possible to transfer training effects to seated balance control. This study was conducted to compare the activity of postural control muscles of the trunk during overground (Ekso) vs. treadmill-based (Lokomat) robotic gait training, and evaluate changes in seated balance control in people with high-thoracic motor-complete spinal cord injury (SCI).

Methods

Three individuals with motor-complete SCI from C7-T4, assumed to have no voluntary motor function below the chest, underwent robotic gait training. The participants were randomly assigned to Ekso-Lokomat-Ekso or Lokomat-Ekso-Lokomat for 10 sessions within each intervention phase for a total of 30 sessions. We evaluated static and dynamic balance control through analysis of center of pressure (COP) movements after each intervention phase. Surface electromyography was used to compare activity of the abdominal and erector spinae muscles during Ekso and Lokomat walking.

Results

We observed improved postural stability after training with Ekso compared to Lokomat during static balance tasks, indicated by reduced COP root mean square distance and ellipse area. In addition, Ekso training increased total distance of COP movements during a dynamic balance task. The trunk muscles showed increased activation during Ekso overground walking compared to Lokomat walking.

Conclusions

Our findings suggest that the Ekso actively recruits trunk muscles through postural control mechanisms, which may lead to improved balance during sitting. Developing effective training strategies to reactivate the trunk muscles is important to facilitate independence during seated balance activity in people with SCI.

The effectiveness of robotic-assisted gait training for paediatric gait disorders: systematic review

BACKGROUND

Robotic-assisted gait training (RAGT) affords an opportunity to increase walking practice with mechanical assistance from robotic devices, rather than therapists, where the child may not be able to generate a sufficient or correct motion with enough repetitions to promote improvement. However the devices are expensive and clinicians and families need to understand if the approach is worthwhile for their children, and how it may be best delivered.

METHODS

The objective of this review was to identify and appraise the existing evidence for the effectiveness of RAGT for paediatric gait disorders, including modes of delivery and potential benefit. Six databases were searched from 1980 to October 2016, using relevant search terms. Any clinical trial that evaluated a clinical aspect of RAGT for children/adolescents with altered gait was selected for inclusion. Data were extracted following the PRISMA approach. Seventeen trials were identified, assessed for level of evidence and risk of bias, and appropriate data extracted for reporting.

RESULTS

Three randomized controlled trials were identified, with the remainder of lower level design. Most individual trials reported some positive benefits for RAGT with children with cerebral palsy (CP), on activity parameters such as standing ability, walking speed and distance. However a meta-analysis of the two eligible RCTs did not confirm this finding (p = 0.72). Training schedules were highly variable in duration and frequency and adverse events were either not reported or were minimal. There was a paucity of evidence for diagnoses other than CP.

CONCLUSION

There is weak and inconsistent evidence regarding the use of RAGT for children with gait disorders. If clinicians (and their clients) choose to use RAGT, they should monitor individual progress closely with appropriate outcome measures including monitoring of adverse events. Further research is required using higher level trial design, increased numbers, in specific populations and with relevant outcome measures to both confirm effectiveness and clarify training schedules.