Recovery of walking ability using a robotic device in subacute stroke patients: a randomized controlled study

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effects of Combined Virtual Reality Exercises and Robot Assisted Gait Training on Cognitive Functions, Daily Living Activities, and Quality of Life in High Functioning Individuals With Subacute Stroke

Stroke is a global health concern causing significant mortality. Survivors face physical, cognitive, and emotional challenges, affecting their life satisfaction and social participation. Robot-assisted gait training with virtual reality, like Lokomat, is a promising rehabilitation tool. We investigated its impact on cognitive status, activities of daily living, and quality of life in individuals with stroke. Between September 2022 and August 2023, we exposed 34 first stroke patients (8 women, 26 men; M age = 59.15, SD = 11.09; M height = 170.47, SD = 8.13 cm; M weight = 75.97; SD = 10.87 kg; M days since stroke = 70.44, SD = 33.65) in the subacute stage (3-6 months post-stroke) to Lokomat exercise. Participant exclusion criteria were Lokamat exercise inability, disabilities incompatible with intended measurements, and any cognitive limitations. The Control Group (CG) received conventional physiotherapy, while the Lokomat Group (LG) received both conventional physiotherapy and robot-assisted gait training with virtual reality, administered by an occupational therapist. Evaluations were conducted by a physiotherapist who was unaware of the participants' group assignments and included assessments with the Montreal Cognitive Assessment, Lawton Brody Instrumental Activities of Daily Living Scale, and Stroke Specific Quality of Life Scale (SS-QoL). Both groups demonstrated an improved quality of life, but the LG outperformed the CG with regard to SS-QoL (p = .01) on measures of Energy (p = .002) and Mobility (p = .005). Both groups showed improvements in cognitive functioning (p < .001) with no between-group difference, and in activities of daily living (p < .05) for which the LG was superior to the CG (p = .023). Thus, adding robot-assisted gait training with Lokomat and virtual reality improved self-reported quality of life and daily activities at levels beyond conventional physiotherapy for patients in the subacute stroke phase. An incremental impact on cognitive functions was not evident, possibly due to rapid cognitive recovery or this was undetected by limited cognitive testing.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Technological Advances in Stroke Rehabilitation: Robotics and Virtual Reality

Robotic technology and virtual reality (VR) have been widely studied technologies in stroke rehabilitation over the last few decades. Both technologies have typically been considered as ways to enhance recovery through promoting intensive, repetitive, and engaging therapies. In this review, we present the current evidence from interventional clinical trials that employ either robotics, VR, or a combination of both modalities to facilitate post-stroke recovery. Broadly speaking, both technologies have demonstrated some success in improving post-stroke outcomes and complementing conventional therapy. However, more high-quality, randomized, multicenter trials are required to confirm our current understanding of their role in precision stroke recovery.

Simultaneous high-definition transcranial direct current stimulation and robot-assisted gait training in stroke patients

This study investigates whether simultaneous high-definition transcranial direct current stimulation (HD-tDCS) enhances the effects of robot-assisted gait training in stroke patients. Twenty-four participants were randomly allocated to either the robot-assisted gait training with real HD-tDCS group (real HD-tDCS group) or robot-assisted gait training with sham HD-tDCS group (sham HD-tDCS group). Over four weeks, both groups completed 10 sessions. The 10 Meter Walk Test, Timed Up and Go, Functional Ambulation Category, Functional Reach Test, Berg Balance Scale, Dynamic Gait Index, Fugl-Meyer Assessment, and Korean version of the Modified Barthel Index were conducted before, immediately after, and one month after the intervention. The real HD-tDCS group showed significant improvements in the 10 Meter Walk Test, Timed Up and Go, Functional Reach Test, and Berg Balance Scale immediately and one month after the intervention, compared with before the intervention. Significant improvements in the Dynamic Gait Index and Fugl-Meyer Assessment were also observed immediately after the intervention. The sham HD-tDCS group showed no significant improvements in any of the tests. Application of HD-tDCS during robot-assisted gait training has a positive effect on gait and physical function in chronic stroke patients, ensuring long-term training effects. Our results suggest the effectiveness of HD-tDCS as a complementary tool to enhance robotic gait rehabilitation therapy in chronic stroke patients.

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

Background

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

Methods

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

Results

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

Conclusion

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

Efficacy of Robots-Assisted Therapy in Patients With Stroke: A Meta-analysis Update

BACKGROUND

Robot-assisted therapy (RAT) could address an unmet need to relieve the strain on healthcare providers and intensify treatment in the context of an increasing stroke incidence. A comprehensive meta-analysis could provide firmer data about the topic by considering methodology limitations discovered in previous reviews and providing more rigorous evidence.

OBJECTIVE

This meta-analysis study identifies RAT's efficacy for patients with stroke.

METHODS

A systematic search of the 7 databases from January 10 to February 1, 2022, located relevant publications. We used the updated Cochrane risk-of-bias checklist for 52 trials to assess the methodologic quality of the included studies. The efficacy of RAT for patients with stroke was estimated using a pooled random-effects model in the Stata 16 software application.

RESULTS

The final analysis included 2774 patients with stroke from 52 trials. In those patients, RAT was proven to improve quality of movement (mean difference, 0.15; 95% confidence interval, 0.03-0.28) and to reduce balance disturbances (mean difference, -1.28; 95% confidence interval, -2.48 to -0.09) and pain (standardized mean difference, -0.34; 95% confidence interval, -0.58 to -0.09).

CONCLUSIONS

Robot-assisted therapy seems to improve the quality of mobility and reduce balance disturbances and pain for patients with stroke. These findings will help develop advanced rehabilitation robots and could improve health outcomes by facilitating health services for healthcare providers and patients with stroke.

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.

Assistive Technology Involving Postural Control and Gait Performance for Adults with Stroke: A Systematic Review and Meta-Analysis

This study aimed to comprehensively summarize assistive technology devices for postural control and gait performance in stroke patients. In the study, we searched for randomized controlled trials (RCTs) published until 31 December 2022 in four electrical databases. The most frequently applied assistive technology devices involving postural stability and gait function for stroke patients were robot-assistive technology devices. Out of 1065 initially retrieved citations that met the inclusion criteria, 30 RCTs (12 studies for subacute patients and 18 studies for chronic patients) were included in this review based on eligibility criteria. The meta-analysis included ten RCTs (five studies for subacute patients and five for chronic patients) based on the inclusion criteria of the data analysis. After analyzing, the variables, only two parameters, the Berg balance scale (BBS) and the functional ambulation category (FAC), which had relevant data from at least three studies measuring postural control and gait function, were selected for the meta-analysis. The meta-analysis revealed significant differences in the experimental group compared to the control group for BBS in both subacute and chronic stroke patients and for the FAC in chronic stroke patients. Robot-assistive training was found to be superior to regular therapy in improving postural stability for subacute and chronic stroke patients but not gait function. This review suggests that robot-assistive technology devices should be considered in rehabilitative approaches for postural stability and gait function for subacute and chronic stroke patients.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Combining robot-assisted therapy with virtual reality or using it alone? A systematic review on health-related quality of life in neurological patients

BACKGROUND

In the field of neurorehabilitation, robot-assisted therapy (RAT) and virtual reality (VR) have so far shown promising evidence on multiple motor and functional outcomes. The related effectiveness on patients' health-related quality of life (HRQoL) has been investigated across neurological populations but still remains unclear. The present study aimed to systematically review the studies investigating the effects of RAT alone and with VR on HRQoL in patients with different neurological diseases.

METHODS

A systematic review of the studies evaluating the impact of RAT alone and combined with VR on HRQoL in patients affected by neurological diseases (i.e., stroke, multiple sclerosis, spinal cord injury, Parkinson's Disease) was conducted according to PRISMA guidelines. Electronic searches of PubMed, Web of Science, Cochrane Library, CINAHL, Embase, and PsychINFO (2000-2022) were performed. Risk of bias was evaluated through the National Institute of Health Quality Assessment Tool. Descriptive data regarding the study design, participants, intervention, rehabilitation outcomes, robotic device typology, HRQoL measures, non-motor factors concurrently investigated, and main results were extracted and meta-synthetized.

RESULTS

The searches identified 3025 studies, of which 70 met the inclusion criteria. An overall heterogeneous configuration was found regarding the study design adopted, intervention procedures and technological devices implemented, rehabilitation outcomes (i.e., related to both upper and lower limb impairment), HRQoL measures administered, and main evidence. Most of the studies reported significant effects of both RAT and RAT plus VR on patients HRQoL, whether they adopted generic or disease-specific HRQoL measures. Significant post-intervention within-group changes were mainly found across neurological populations, while fewer studies reported significant between-group comparisons, and then, mostly in patients with stroke. Longitudinal investigations were also observed (up to 36 months), but significant longitudinal effects were exclusively found in patients with stroke or multiple sclerosis. Finally, concurrent evaluations on non-motor outcomes beside HRQoL included cognitive (i.e., memory, attention, executive functions) and psychological (i.e., mood, satisfaction with the treatment, device usability, fear of falling, motivation, self-efficacy, coping, and well-being) variables.

CONCLUSIONS

Despite the heterogeneity observed among the studies included, promising evidence was found on the effectiveness of RAT and RAT plus VR on HRQoL. However, further targeted short- and long-term investigations, are strongly recommended for specific HRQoL subcomponents and neurological populations, through the adoption of defined intervention procedures and disease-specific assessment methodology.

Control strategies used in lower limb exoskeletons for gait rehabilitation after brain injury: a systematic review and analysis of clinical effectiveness

BACKGROUND

In the past decade, there has been substantial progress in the development of robotic controllers that specify how lower-limb exoskeletons should interact with brain-injured patients. However, it is still an open question which exoskeleton control strategies can more effectively stimulate motor function recovery. In this review, we aim to complement previous literature surveys on the topic of exoskeleton control for gait rehabilitation by: (1) providing an updated structured framework of current control strategies, (2) analyzing the methodology of clinical validations used in the robotic interventions, and (3) reporting the potential relation between control strategies and clinical outcomes.

METHODS

Four databases were searched using database-specific search terms from January 2000 to September 2020. We identified 1648 articles, of which 159 were included and evaluated in full-text. We included studies that clinically evaluated the effectiveness of the exoskeleton on impaired participants, and which clearly explained or referenced the implemented control strategy.

RESULTS

(1) We found that assistive control (100% of exoskeletons) that followed rule-based algorithms (72%) based on ground reaction force thresholds (63%) in conjunction with trajectory-tracking control (97%) were the most implemented control strategies. Only 14% of the exoskeletons implemented adaptive control strategies. (2) Regarding the clinical validations used in the robotic interventions, we found high variability on the experimental protocols and outcome metrics selected. (3) With high grade of evidence and a moderate number of participants (N = 19), assistive control strategies that implemented a combination of trajectory-tracking and compliant control showed the highest clinical effectiveness for acute stroke. However, they also required the longest training time. With high grade of evidence and low number of participants (N = 8), assistive control strategies that followed a threshold-based algorithm with EMG as gait detection metric and control signal provided the highest improvements with the lowest training intensities for subacute stroke. Finally, with high grade of evidence and a moderate number of participants (N = 19), assistive control strategies that implemented adaptive oscillator algorithms together with trajectory-tracking control resulted in the highest improvements with reduced training intensities for individuals with chronic stroke.

CONCLUSIONS

Despite the efforts to develop novel and more effective controllers for exoskeleton-based gait neurorehabilitation, the current level of evidence on the effectiveness of the different control strategies on clinical outcomes is still low. There is a clear lack of standardization in the experimental protocols leading to high levels of heterogeneity. Standardized comparisons among control strategies analyzing the relation between control parameters and biomechanical metrics will fill this gap to better guide future technical developments. It is still an open question whether controllers that provide an on-line adaptation of the control parameters based on key biomechanical descriptors associated to the patients' specific pathology outperform current control strategies.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Randomized Controlled Trial of Robot-Assisted Gait Training versus Therapist-Assisted Treadmill Gait Training as Add-on Therapy in Early Subacute Stroke Patients: The GAITFAST Study Protocol

The GAITFAST study (gait recovery in patients after acute ischemic stroke) aims to compare the effects of treadmill-based robot-assisted gait training (RTGT) and therapist-assisted treadmill gait training (TTGT) added to conventional physical therapy in first-ever ischemic stroke patients. GAITFAST (Clinicaltrials.gov identifier: NCT04824482) was designed as a single-blind single-center prospective randomized clinical trial with two parallel groups and a primary endpoint of gait speed recovery up to 6 months after ischemic stroke. A total of 120 eligible and enrolled participants will be randomly allocated (1:1) in TTGT or RTGT. All enrolled patients will undergo a 2-week intensive inpatient rehabilitation including TTGT or RTGT followed by four clinical assessments (at the beginning of inpatient rehabilitation 8-15 days after stroke onset, after 2 weeks, and 3 and 6 months after the first assessment). Every clinical assessment will include the assessment of gait speed and walking dependency, fMRI activation measures, neurological and sensorimotor impairments, and gait biomechanics. In a random selection (1:2) of the 120 enrolled patients, multimodal magnetic resonance imaging (MRI) data will be acquired and analyzed. This study will provide insight into the mechanisms behind poststroke gait behavioral changes resulting from intensive rehabilitation including assisted gait training (RTGT or TTGT) in early subacute IS patients.

A technical report on a novel robotic lower limb rehabilitation device - Is ROBERT® a cost-effective solution for rehabilitation in Hong Kong?

A shortage of physiotherapist (PT) manpower is a barrier for providing better rehabilitation service in Hong Kong. Quality training can benefit patients with better recovery, on the contrary, insufficient training may cause a longer length of stay, readmission, and thus the burden of healthcare system. The estimated cost for PT services in Hospital Authority was HK$7.0 Billion in 2020. A novel Danish robot with a 7-joint robotic arm became popular in Denmark and Germany in the last two years. The robot is designed for lower limb patient rehabilitation. It can enhance the mobility of patients. Based on the experience of a university hospital in Denmark, this robotic rehabilitation was well accepted by both patients and PTs. Function-wise, the robot provides many clinical benefits to patients, especially stroke ones. A physiotherapist's time can be saved when the robot is being used. The cost-effectiveness of ROBERT® is better than PT performing repetitive exercises for lower limbs. The robot potentially provides a cost-effective solution to the Hong Kong healthcare system.

Optimal Intervention Timing for Robotic-Assisted Gait Training in Hemiplegic Stroke

This study was designed to determine the best intervention time (acute, subacute, and chronic stages) for Walkbot robot-assisted gait training (RAGT) rehabilitation to improve clinical outcomes, including sensorimotor function, balance, cognition, and activities of daily living, in hemiparetic stroke patients. Thirty-six stroke survivors (acute stage group (ASG), n = 11; subacute stage group (SSG), n = 15; chronic stage group (CSG), n = 10) consistently received Walkbot RAGT for 30 min/session, thrice a week, for 4 weeks. Six clinical outcome variables, including the Fugl–Meyer Assessment (FMA), Berg Balance Scale (BBS), Trunk Impairment Scale (TIS), Modified Barthel Index (MBI), Modified Ashworth Scale (MAS), and Mini-Mental State Examination, were examined before and after the intervention. Significant differences in the FMA, BBS, TIS, and MBI were observed between the ASG and the SSG or CSG. A significant time effect was observed for all variables, except for the MAS, in the ASG and SSG, whereas significant time effects were noted for the FMA, BBS, and TIS in the CSG. Overall, Walkbot RAGT was more favorable for acute stroke patients than for those with subacute or chronic stroke. This provides the first clinical evidence for the optimal intervention timing for RAGT in stroke.

Rethinking the tools in the toolbox

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

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

BACKGROUND

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

AIM

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

DESIGN

Systematic review with meta-analysis.

SETTING

The setting of the study included Units of Rehabilitation.

POPULATION

The analyzed population was represented by subacute stroke patients.

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL REHABILITATION IMPACT

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

Effects of robot (SUBAR)-assisted gait training in patients with chronic stroke: Randomized controlled trial

BACKGROUND

SUBAR is a new ground walking exoskeletal robot. The objective of this study is to investigate SUBAR-assisted gait training's effects in patients with chronic stroke.

METHODS

This preliminary study is a prospective randomized controlled trial. Thirty adults were enrolled 6 months after the onset of stroke with functional ambulation category scores ≥ 3. Patients were randomly assigned to receive robot-assisted gait training (SUBAR group, n = 15) or conventional physiotherapy (control group, n = 15). All patients received a total of 10 treatment sessions of 30 minutes each for 3 weeks. Before and after the 10-treatment sessions, patients were evaluated. The primary outcome is the 10 meter walk test and the secondary outcomes were the functional ambulation category scale, the Motricity Index-Lower, Modified Ashworth Scale (MAS), timed up and go, Rivermead Mobility Index, Berg Balance Scale (BBS), and gait analysis.

RESULTS

In the SUBAR group, MAS and step length were significantly improved between pre- and posttreatment measurements (Δmean ± SD: -1.1 ± 1.6 and 5.5 ± 7.6, P = .019 and .016, respectively). The SUBAR group improved the stride length and step length of the affected limb but not significantly. The control group had significant improvements in the BBS, MAS, and stride length between pre- and posttreatment measurements (Δmean ± SD: 3.5 ± 4.6, -0.8 ± 1.5, and 6.5 ± 9.5; P = .004, .031, and .035, respectively). The BBS improved more in the control group than in the SUBAR group. There were no other differences between the SUBAR group and the control group.

CONCLUSION

Our results suggest that SUBAR-assisted gait training improved gait parameters in patients with chronic stroke. However, there was no significant difference in most outcome measures compared to conventional physiotherapy. Further research is warranted to measure the effects of SUBAR-assisted gait training.

Robotic Exoskeleton Gait Training in Stroke: An Electromyography-Based Evaluation

The recovery of symmetric and efficient walking is one of the key goals of a rehabilitation program in patients with stroke. The use of overground exoskeletons alongside conventional gait training might help foster rhythmic muscle activation in the gait cycle toward a more efficient gait. About twenty-nine patients with subacute stroke have been recruited and underwent either conventional gait training or experimental training, including overground gait training using a wearable powered exoskeleton alongside conventional therapy. Before and after the rehabilitation treatment, we assessed: (i) gait functionality by means of clinical scales combined to obtain a Capacity Score, and (ii) gait neuromuscular lower limbs pattern using superficial EMG signals. Both groups improved their ability to walk in terms of functional gait, as detected by the Capacity Score. However, only the group treated with the robotic exoskeleton regained a controlled rhythmic neuromuscular pattern in the proximal lower limb muscles, as observed by the muscular activation analysis. Coherence analysis suggested that the control group (CG) improvement was mediated mainly by spinal cord control, while experimental group improvements were mediated by cortical-driven control. In subacute stroke patients, we hypothesize that exoskeleton multijoint powered fine control overground gait training, alongside conventional care, may lead to a more fine-tuned and efficient gait pattern.

Effects of therapy with a free-standing robotic exoskeleton on motor function and other health indicators in people with severe mobility impairment due to chronic stroke: A quasi-controlled study

Introduction

Robotic exoskeletons facilitate therapy in upright postures. This study aimed to evaluate potential health-related effects of this therapy for people with severe mobility impairment due to chronic stroke.

Methods

This quasi-controlled trial with 12 weeks of twice weekly therapy in a free-standing exoskeleton, and 12 weeks follow up, included people dependent for mobility, with stroke at least 3 months prior. The primary outcome was lower limb motor function. A battery of secondary outcomes was evaluated.

Results

Nine participants were enrolled. There was no change in motor function. There was a significant between phase difference in level of independence with activities of daily living (median post-intervention change = 5, IQR = 0, 10, p = 0.01), and grip strength (affected limb) (median post-intervention change = 1, IQR = 0, 2, p = 0.03). A significant difference was found for quadriceps strength (affected limb) (median change in wait phase = 4, IQR = 2, 7.5, p = 0.01). Participants consistently reported positive perceptions of the therapy.

Conclusions

Therapy with a free-standing exoskeleton is acceptable to participants and can facilitate improvements in level of independence and grip strength. Restrictions regarding eligibility to use the device, may reduce the clinical application of this therapy for people with stroke.

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.

Effect of assist-as-needed robotic gait training on the gait pattern post stroke: a randomized controlled trial

Background

Regaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AAN_mDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AAN_mDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation.

Methods

Thirty-four participants with unilateral, supratentorial stroke were enrolled (< 10 weeks post onset, Functional Ambulation Categories 3–5) and randomly assigned to six weeks of AAN_mDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3–5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (W_EXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2).

Results

Two participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AAN_mDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, W_EXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0–T1) and paretic step length (T0–T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AAN_mDOF robotic group compared to the conventional group (T0–T2).

Conclusions

Generally, AAN_mDOF robotic training was not superior to conventional training for improving gait pattern in subacute stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AAN_mDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing.

Trial registration Registry number Netherlands Trial Register (www.trialregister.nl): NTR5060. Registered 13 February 2015.

Robotic Exoskeleton Gait Training During Acute Stroke Inpatient Rehabilitation

Stroke is the leading cause of severe disability in adults resulting in mobility, balance, and coordination deficits. Robotic exoskeletons (REs) for stroke rehabilitation can provide the user with consistent, high dose repetition of movement, as well as balance and stability. The goal of this intervention study is to evaluate the ability of a RE to provide high dose gait therapy and the resulting effect on functional recovery for individuals with acute stroke. The investigation included a total of 44 participants. Twenty-two participants received RE gait training during inpatient rehabilitation (RE+SOC Group), and a matched sample of 22 individuals admitted to the same inpatient rehabilitation facility-receiving conventional standard of care treatment (SOC group). The effect of RE training was quantified using total distance walked during inpatient rehabilitation and functional independence measure (FIM). The total distance walked during inpatient rehabilitation showed a significant difference between the SOC and RE+SOC groups. RE+SOC walked twice the distance as SOC during the same duration (time spent in inpatient rehabilitation) of training. In addition, the average change in motor FIM showed a significant difference between the SOC and RE+SOC groups, where the average difference in motor FIM was higher in RE+SOC compared to the SOC group. The results suggest that RE provided increased dosing of gait training without increasing the duration of training during acute stroke rehabilitation. The RE+SOC group increased their motor FIM score (change from admission to discharge) compared to SOC group, both groups were matched for admission motor FIM scores suggesting that increased dosing may have improved motor function.

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.

Assessing Stiffness, Joint Torque and ROM for Paretic and Non-Paretic Lower Limbs during the Subacute Phase of Stroke Using Lokomat Tools

The efficacy of Lokomat on motor recovery in stroke patients is well known. However, few studies have examined Lokomat tools to assess stiffness, joint torque and range of motion (ROM) during the subacute phase of stroke. The purpose of this retrospective observational study is to assess the changes of joint torque, ROM and stiffness that were estimated with Lokomat tools, namely L-FORCE (lower limb-force), L-ROM (lower limb-range of motion)and L-STIFF (lower limb-stiff), for paretic and non-paretic lower limbs in the subacute phase of stroke, assuming that the tools were able to measure these changes. The data come from 10 subjects in the subacute phase who had their first ever-stroke and followed a treatment that included Lokomat. The measurements came from basal assessments (T0) and one-month follow-up (T1). The measures were compared between paretic and non-paretic legs, and between T0 and T1. Significant differences in stiffness, joint torque and ROM were obtained between the paretic and non-paretic limbs at both T0 and T1. A non-significant trend was obtained for reduced stiffness and increased torque and ROM between T0 and T1 of the paretic limbs. The Lokomat tools were able to measure the changes between paretic and non-paretic legs and the small changes between T0 and T1 measurements.

Pragmatic Solutions for Stroke Recovery and Improved Quality of Life in Low- and Middle-Income Countries-A Systematic Review

Background: Given the limited healthcare resources in low and middle income countries (LMICs), effective rehabilitation strategies that can be realistically adopted in such settings are required. Objective: A systematic review of literature was conducted to identify pragmatic solutions and outcomes capable of enhancing stroke recovery and quality of life of stroke survivors for low- and middle- income countries. Methods: PubMed, HINARI, and Directory of Open Access Journals databases were searched for published Randomized Controlled Trials (RCTs) till November 2018. Only completed trials published in English with non-pharmacological interventions on adult stroke survivors were included in the review while published protocols, pilot studies and feasibility analysis of trials were excluded. Obtained data were synthesized thematically and descriptively analyzed. Results: One thousand nine hundred and ninety six studies were identified while 347 (65.22% high quality) RCTs were found to be eligible for the review. The most commonly assessed variables (and outcome measure utility) were activities of daily living [75.79% of the studies, with Barthel Index (37.02%)], motor function [66.57%; with Fugl Meyer scale (71.88%)], and gait [31.12%; with 6 min walk test (38.67%)]. Majority of the innovatively high technology interventions such as robot therapy (95.24%), virtual reality (94.44%), transcranial direct current stimulation (78.95%), transcranial magnetic stimulation (88.0%) and functional electrical stimulation (85.00%) were conducted in high income countries. Several traditional and low-cost interventions such as constraint-induced movement therapy (CIMT), resistant and aerobic exercises (R&AE), task oriented therapy (TOT), body weight supported treadmill training (BWSTT) were reported to significantly contribute to the recovery of motor function, activity, participation, and improvement of quality of life after stroke. Conclusion: Several pragmatic, in terms of affordability, accessibility and utility, stroke rehabilitation solutions, and outcome measures that can be used in resource-limited settings were found to be effective in facilitating and enhancing post-stroke recovery and quality of life.

A randomized controlled study incorporating an electromechanical gait machine, the Hybrid Assistive Limb, in gait training of patients with severe limitations in walking in the subacute phase after stroke

Early onset, intensive and repetitive, gait training may improve outcome after stroke but for patients with severe limitations in walking, rehabilitation is a challenge. The Hybrid Assistive Limb (HAL) is a gait machine that captures voluntary actions and support gait motions. Previous studies of HAL indicate beneficial effects on walking, but these results need to be confirmed in blinded, randomized controlled studies. This study aimed to explore effects of incorporating gait training with HAL as part of an inpatient rehabilitation program after stroke. Thirty-two subacute stroke patients with severe limitations in walking were randomized to incorporated HAL training (4 days/week for 4 weeks) or conventional gait training only. Blinded assessments were carried out at baseline, after the intervention, and at 6 months post stroke. The primary outcome was walking independence according to the Functional Ambulation Categories. Secondary outcomes were the Fugl-Meyer Assessment, 2-Minute Walk Test, Berg Balance Scale, and the Barthel Index. No significant between-group differences were found regarding any primary or secondary outcomes. At 6 months, two thirds of all patients were independent in walking. Prediction of independent walking at 6 months was not influenced by treatment group, but by age (OR 0.848, CI 0.719-0.998, p = 0.048). This study found no difference between groups for any outcomes despite the extra resources required for the HAL training, but highlights the substantial improvements in walking seen when evidence-based rehabilitation is provided to patients, with severe limitations in walking in the subacute stage after stroke. In future studies potential subgroups of patients who will benefit the most from electromechanically-assisted gait training should be explored.

Effects of bodyweight support and guidance force on muscle activation during Locomat walking in people with stroke: a cross-sectional study

BACKGROUND

Locomat is a robotic exoskeleton providing guidance force and bodyweight support to facilitate intensive walking training for people with stroke. Although the Locomat has been reported to be effective in improving walking performance, the effects of training parameters on the neuromuscular control remain unclear. This study aimed to compare the muscle activities between Locomat walking and treadmill walking at a normal speed, as well as to investigate the effects of varying bodyweight support and guidance force on muscle activation patterns during Locomat walking in people with stroke.

METHODS

A cross-sectional study design was employed. Participants first performed an unrestrained walking on a treadmill and then walked in the Locomat with different levels of bodyweight support (30% or 50%) and guidance force (40% or 70%) at the same speed (1.2 m/s). Surface electromyography (sEMG) of seven muscles of the affected leg was recorded. The sEMG envelope was time-normalised and averaged over gait cycles. Mean sEMG amplitude was then calculated by normalising the sEMG amplitude with respect to the peak amplitude during treadmill walking for statistical analysis. A series of Non-parametric test and post hoc analysis were performed with a significance level of 0.05.

RESULTS

Fourteen participants with stroke were recruited at the Yangzhi Affiliated Rehabilitation Hospital of Tongji University (female n = 1; mean age 46.1 ± 11.1 years). Only the mean sEMG amplitude of vastus medialis oblique during Locomat walking (50% bodyweight support and 70% guidance force) was significantly lower than that during treadmill walking. Reducing both bodyweight and guidance increased muscle activity of gluteus medius and tibialis anterior. Activity of vastus medialis oblique muscle increased as bodyweight support reduced, while that of rectus femoris increased as guidance force decreased.

CONCLUSIONS

The effects of Locomat on reducing muscle activity in people with stroke were minimized when walking at a normal speed. Reducing bodyweight support and guidance force increased the activity of specific muscles during Locomat walking. Effects of bodyweight support, guidance force and speed should be taken into account when developing individualized Locomat training protocols for clients with stroke.

Clinical non-superiority of technology-assisted gait training with body weight support in patients with subacute stroke: A meta-analysis

BACKGROUND

Technology-assisted gait training (TAGT) with body weight support (BWS) has been designed to provide high numbers of repetitions during stepping practice, but its benefits have been inconclusive.

OBJECTIVE

We evaluated the superiority of TAGT over conventional overground training (COT) to judge the clinical benefits.

METHODS

We searched PubMed, Embase and Web of Science databases from their earliest record to July 1, 2019 and included randomized controlled trials of TAGT with BWS, such as robot-assisted gait training and body weight-supported treadmill training, for treating walking disability in patients within 6months after stroke. We conducted a meta-analysis of the outcomes motor impairment, mobility capacity, walking speed, endurance and fitness, balance, and activities of daily living as well as subgroup analyses of initial ambulatory ability and stroke duration.

RESULTS

Among 14robotics and 10body weight-supported treadmill studies included for review, 23studies involving 1452participants contributed to the meta-analysis. We found no significant standardized mean differences between TAGT and COT (P>0.05) across all outcome categories in the robotics subgroup, the body weight-supported treadmill subgroup, or both subgroups combined, for both the short and long term. Further subgroup analyses also revealed non-significant standardized mean differences (P>0.05) across all outcomes in the subgroups initially ambulatory, non-ambulatory, or stroke duration less than 3 months.

CONCLUSIONS

TAGT with BWS was not superior to COT in improving post-stroke recovery in patients with subacute stroke. Strategies other than simply increasing the repetitions by external assistance may be considered to augment the treatment effects of TAGT.

WITHDRAWN: Immediate Adaptations to Poststroke Walking Performance Using a Wearable Robotic Exoskeleton

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The Effect of a Low-Cost Body Weight-Supported Treadmill Trainer on Walking Speed and Joint Motion

Background and Objectives: Gait training with body weight-support has been shown to improve the walking speed of individuals with movement disorders. The AccesSportAmerica Gait Trainer is a low-cost, pre-market gait rehabilitation device that alters the stride characteristics of participants walking on a standard treadmill. The purpose of this study was to examine the biomechanical outcomes that training on this device has for people with brain injuries that affect motor functioning. It was hypothesized that there would be an increase in walking speed post-intervention, and that there would be an increase in step length and joint range-of-motion. Materials and Methods: An intervention study was conducted with 11 people with ambulatory difficulty caused by post-stroke hemiparesis (n = 7), traumatic brain injury (n = 3), and cerebral palsy (n = 1). The average time using the AccesSportAmerica Gait Trainer was 34.5 (SD = 6.0) minutes per session for 36.9 (SD = 21.8) sessions. Gait speed, step length and time, and joint flexion were measured during the 10 Meter Walk Test. Results: From pre- to post-intervention, there was a mean increase in walking speed of 0.19 m/s (SD = 0.06, p = 0.016, d = 0.40) and a decrease in step time of both affected and unaffected legs (affected: p = 0.011, d = 0.37; unaffected: p = 0.004, d = 0.67). There was no significant change in stride length or joint angles. Conclusions: The AccesSportAmerica Gait Trainer has the potential to improve the walking speed of people with ambulatory difficulty.

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.

Effectiveness and Superiority of Rehabilitative Treatments in Enhancing Motor Recovery Within 6 Months Poststroke: A Systemic Review

OBJECTIVE

To investigate the effects of various rehabilitative interventions aimed at enhancing poststroke motor recovery by assessing their effectiveness when compared with no treatment or placebo and their superiority when compared with conventional training program (CTP).

DATA SOURCE

A literature search was based on 19 Cochrane reviews and 26 other reviews. We also updated the searches in PubMed up to September 30, 2017.

STUDY SELECTION

Randomized controlled trials associated with 18 experimented training programs (ETP) were included if they evaluated the effects of the programs on either upper extremity (UE) or lower extremity (LE) motor recovery among adults within 6 months poststroke; included ≥10 participants in each arm; and had an intervention duration of ≥10 consecutive weekdays.

DATA EXTRACTION

Four reviewers evaluated the eligibility and quality of literature. Methodological quality was assessed using the PEDro scale.

DATA SYNTHESIS

Among the 178 included studies, 129 including 7450 participants were analyzed in this meta-analysis. Six ETPs were significantly effective in enhancing UE motor recovery, with the standard mean differences (SMDs) and 95% confidence intervals outlined as follow: constraint-induced movement therapy (0.82, 0.45-1.19), electrostimulation (ES)-motor (0.42, 0.22-0.63), mirror therapy (0.71, 0.22-1.20), mixed approach (0.21, 0.01-0.41), robot-assisted training (0.51, 0.22-0.80), and task-oriented training (0.57, 0.16-0.99). Six ETPs were significantly effective in enhancing LE motor recovery: body-weight-supported treadmill training (0.27, 0.01-0.52), caregiver-mediated training (0.64, 0.20-1.08), ES-motor (0.55, 0.27-0.83), mixed approach (0.35, 0.15-0.54), mirror therapy (0.56, 0.13-1.00), and virtual reality (0.60, 0.15-1.05). However, compared with CTPs, almost none of the ETPs exhibited significant SMDs for superiority.

CONCLUSIONS

Certain experimented interventions were effective in enhancing poststroke motor recovery, but little evidence supported the superiority of experimented interventions over conventional rehabilitation.

Assessing Effectiveness and Costs in Robot-Mediated Lower Limbs Rehabilitation: A Meta-Analysis and State of the Art

Robots were introduced in rehabilitation in the 90s to meet different needs, that is, reducing the physical effort of therapists. This work consists of a meta-analysis of robot-mediated lower limbs rehabilitation for stroke-affected patients; it aims at evaluating the effectiveness of the robotic approach through the use of wearable robots or operational machines with respect to the conventional approach (i.e., manual rehabilitation therapy). The primary assessed outcome is the patient's ability to recover walking independence, whereas the secondary outcome is the average walking speed. The therapy acceptability and the treatment costs are also assessed. The assessment shows that the robot-mediated therapy is more effective than the conventional one in reaching the primary outcome. As for the secondary outcome, there is no significant difference between the robotic (wearable robots or operational machines) and the conventional approach. Rehabilitation using wearable robots has a greater acceptability than the conventional one. This does not apply to operational machines. The cost of robotic treatment with wearable robots ranges from double to triple the cost of the conventional approach. On the contrary, rehabilitation using operational machines costs the same as the conventional treatment. Robotic rehabilitation based on operational machines is the most cost-effective approach.

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®.

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.

What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis

BACKGROUND

Studies about electromechanical-assisted devices proved the validity and effectiveness of these tools in gait rehabilitation, especially if used in association with conventional physiotherapy in stroke patients.

OBJECTIVE

The aim of this study was to compare the effects of different robotic devices in improving post-stroke gait abnormalities.

METHODS

A computerized literature research of articles was conducted in the databases MEDLINE, PEDro, COCHRANE, besides a search for the same items in the Library System of the University of Parma (Italy). We selected 13 randomized controlled trials, and the results were divided into sub-acute stroke patients and chronic stroke patients. We selected studies including at least one of the following test: 10-Meter Walking Test, 6-Minute Walk Test, Timed-Up-and-Go, 5-Meter Walk Test, and Functional Ambulation Categories.

RESULTS

Stroke patients who received physiotherapy treatment in combination with robotic devices, such as Lokomat or Gait Trainer, were more likely to reach better results, compared to patients who receive conventional gait training alone. Moreover, electromechanical-assisted gait training in association with Functional Electrical Stimulations produced more benefits than the only robotic treatment (-0.80 [-1.14; -0.46], p > .05).

CONCLUSIONS

The evaluation of the results confirm that the use of robotics can positively affect the outcome of a gait rehabilitation in patients with stroke. The effects of different devices seems to be similar on the most commonly outcome evaluated by this review.

Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review

BACKGROUND

Stroke is a leading cause of long-term disability, and rehabilitation, involving repetitive, high intensity, task-specific exercises, is the pathway to restoring motor skills. Robotic assistive devices are increasingly being used and it is hoped that with robotic devices, rehabilitation progress can be achieved for patients.

OBJECTIVES

To examine the effectiveness of robotic devices in the rehabilitation of stroke patients for upper limb mobility, lower limb mobility, and activities of daily living. The sustainability of treatment effect was also examined.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult stroke patients 18 years and over.

TYPES OF INTERVENTION(S)

Rehabilitation of stroke patients using robotic devices with assistive automation, compared to conventional physiotherapy.

OUTCOMES

Motor movements of upper limbs, walking movement of lower limbs and activities of daily living, including follow-up measurements to examine the sustainability of treatment effect.

TYPES OF STUDIES

Randomized and controlled clinical trials.

SEARCH STRATEGY

Published and unpublished studies in English were searched.

METHODOLOGICAL QUALITY

All studies meeting the review inclusion criteria were independently assessed for methodological quality by two reviewers.

DATA EXTRACTION

Quantitative data were extracted using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

DATA SYNTHESIS

Quantitative data were pooled in statistical meta-analysis. Effect sizes expressed as standardized mean difference, 95% confidence intervals and levels of heterogeneity (I) were calculated. Where statistical pooling was not possible, the findings were presented in narrative form.

RESULTS

Fifty-one studies with 1798 patients were included in this review. Thirty studies examined upper limb interventions and 21 studies evaluated lower limb gait training. Non-significant results were found for upper limb (SMD 0.07, 95% CI -0.11 to 0.26, I = 41%, P = 0.45), lower limb (SMD 0.17, 95% CI -0.15 to 0.48, I = 75%, P = 0.31) and activities of daily living (SMD 0.11, 95% CI -0.11 to 0.33, I = 66%, P = 0.32). For patients with severely impaired lower limbs, a significant difference was observed in favor of robotics (SMD 0.41, 95% CI 0.19 to 0.63, I = 28%, P = 0.0003). P-value analysis did not show significant results for the sustainability of treatment effect post intervention.

CONCLUSIONS

Robotic training is just as effective as conventional training for upper limb motor movement, lower limb walking mobility and for activities of daily living. For lower limb patients with severe impairment, robotic training produces better outcomes than conventional training. The sufficient quantity of studies included and the reasonable quality of Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence support the findings.For treatment sustainability of upper and lower limbs, robotic training is just as effective as conventional training. However, the low quality of GRADE evidence and the lower number of studies included require caution for this finding. For treatment sustainability of activities of daily living, the better quality of GRADE evidence and the larger number of studies analyzed indicate that robotic training is just as effective as conventional training.

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.

[Evaluation of motor skills recovery in post-stroke patients in the process of complex rehabilitation with the use of robotic kinesiotherapy]

AIM

To compare the efficacy of complex rehabilitation in patients receiving robotic kinesiotherapy and conventional physical therapy.

MATERIAL AND METHODS

In total 68 patients were examined, including 37 patients receiving traditional kinesiotherapy and sessions on the robotic complex 'Locomat' and 31 patients of the control group who received conventional physical therapy.

RESULTS AND CONCLUSION

There were statistical between-group differences in the indices of mobility, physical capabilities, strength and muscle tone in paretic extremities as well as the overall improvement of daily activity. The use of robotic devices has a positive impact on the rehabilitation of post-stroke patients.

The Effectiveness of Lower-Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: A Systematic Review

BACKGROUND

With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Regaining ambulation is a top priority for an increasing number of stroke survivors. However, despite an increase in research exploring these devices for lower limb rehabilitation, little is known of the effectiveness.

OBJECTIVE

This review aims to assess the effectiveness of lower limb wearable technology for improving activity and participation in adult stroke survivors.

METHODS

Randomized controlled trials (RCTs) of lower limb wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs.

RESULTS

In the review, we included 11 RCTs with collectively 550 participants at baseline and 474 participants at final follow-up including control groups and participants post stroke. Participants' stroke type and severity varied. Only one study found significant between-group differences for systems functioning and activity. Across the included RCTs, the lowest number of participants was 12 and the highest was 151 with a mean of 49 participants. The lowest number of participants to drop out of an RCT was zero in two of the studies and 19 in one study. Significant between-group differences were found across three of the 11 included trials. Out of the activity and participation measures alone, P values ranged from P=.87 to P ≤.001.

CONCLUSIONS

This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes, appropriateness of the RCT methodology for complex interventions, a lack of appropriate analysis of outcome data, and participant stroke severity.

Robot-assisted gait training improves brachial-ankle pulse wave velocity and peak aerobic capacity in subacute stroke patients with totally dependent ambulation: Randomized controlled trial

OBJECTIVE

Brachial-ankle pulse wave velocity (baPWV) evaluates arterial stiffness and also predicts early outcome in stroke patients. The objectives of this study were to investigate arterial stiffness of subacute nonfunctional ambulatory stroke patients and to compare the effects of robot-assisted gait therapy (RAGT) combined with rehabilitation therapy (RT) on arterial stiffness and functional recovery with those of RT alone.

METHOD

The RAGT group (N = 30) received 30 minutes of robot-assisted gait therapy and 30 minutes of conventional RT, and the control group (N = 26) received 60 minutes of RT, 5 times a week for 4 weeks. baPWV was measured and calculated using an automated device. The patients also performed a symptom-limited graded exercise stress test using a bicycle ergometer, and parameters of cardiopulmonary fitness were recorded. Clinical outcome measures were categorized into 4 categories: activities of daily living, balance, ambulatory function, and paretic leg motor function and were evaluated before and after the 4-week intervention.

RESULTS

Both groups exhibited significant functional recovery in all clinical outcome measures after the 4-week intervention. However, peak aerobic capacity, peak heart rate, exercise tolerance test duration, and baPWV improved only in the RAGT group, and the improvements in baPWV and peak aerobic capacity were more noticeable in the RAGT group than in the control group.

CONCLUSION

Robot-assisted gait therapy combined with conventional rehabilitation therapy represents an effective method for reversing arterial stiffness and improving peak aerobic capacity in subacute stroke patients with totally dependent ambulation. However, further large-scale studies with longer term follow-up periods are warranted to measure the effects of RAGT on secondary prevention after stroke.

Robotic neurorehabilitation in patients with chronic stroke: psychological well-being beyond motor improvement

Although gait abnormality is one of the most disabling events following stroke, cognitive, and psychological impairments can be devastating. The Lokomat is a robotic that has been used widely for gait rehabilitation in several movement disorders, especially in the acute and subacute phases. The aim of this study was to evaluate the effectiveness of gait robotic rehabilitation in patients affected by chronic stroke. Psychological impact was also taken into consideration. Thirty patients (13 women and 17 men) affected by chronic stroke entered the study. All participants underwent neurological examination with respect to ambulation, Ashworth, Functional Independence Measure, and Tinetti scales to assess their physical status, and Hamilton Rating Scale for Depression, Psychological General Well-being Index, and Coping Orientation to Problem Experienced to evaluate the Lokomat-related psychological impact before and after either a conventional treatment or the robotic training. During each rehabilitation period (separated by a no-treatment period), patients underwent a total of 40 1 h training sessions (i.e. five times a week for 8 weeks). After the conventional treatment, the patients did not achieve a significant improvement in the functional status, except balance (P<0.001) and walking ability (P<0.01), as per the Tinetti scale. Indeed, after the robotic rehabilitation, significant improvements were detected in almost all the motor and psychological scales that we investigated, particularly for Psychological General Well-being Index and Coping Orientation to Problem Experienced. Manual and robotic-assisted body weight-supported treadmill training optimizes the sensory inputs relevant to step training, repeated practice, as well as neuroplasticity. Several controlled trials have shown a superior effect of Lokomat treatment in stroke patients' walking ability and velocity in particular. Therefore, our preliminary results proved that active robotic training not only facilitates gait and physical function but also the psychological status, even in patients affected by chronic stroke.

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.