Electromechanical-assisted training for walking after stroke

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical efficacy of overground powered exoskeleton for gait training in patients with subacute stroke: A randomized controlled pilot trial

BACKGROUND

To investigate the efficacy and usefulness of 12 sessions of overground robot-assisted gait training (RAGT) in subacute stroke patients.

METHODS

In this pilot study, 17 subacute stroke survivors were randomly assigned to the intervention (n = 9) and control (n = 8) groups. In addition to the conventional stroke neurorehabilitation program, the intervention group received 30 minutes of overground exoskeletal RAGT, while the control group received 30 minutes of conventional gait training by a physiotherapist. All interventions were performed in 12 sessions (3 times/week for 4 weeks). The primary aim was to assess ambulation ability using the functional ambulation category (FAC). The 10-m walk test, Berg Balance Scale, timed-up-and-go Timed-up-and-go, Fugl-Meyer assessment of lower extremity, pulmonary function test, the Korean version of the modified Barthel index, and Euro quality of life-5 dimensions (EQ-5D) were assessed. All outcomes were evaluated both before and after the intervention.

RESULTS

The Berg Balance Scale, Korean version of the modified Barthel index, and EQ-5D scores (P < .05) improved significantly in both groups. Only those in the RAGT group improved significantly in the FAC, timed-up-and-go, and 10-m walk test (P < .05). In the FAC and EQ-5D, the intervention group showed greater improvement than the control group (P < .05).

CONCLUSION

We found that 4 weeks of overground RAGT combined with conventional training may improve walking independence and quality of life in patients with subacute stroke.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Trial registration

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

Retrospective case-control study to compare exoskeleton-assisted walking with standard care in subacute non-traumatic brain injury patients

BACKGROUND

Advanced technologies are increasingly used to address impaired mobility after neurological insults, with growing evidence of their benefits for various populations. However, certain robotic devices have not been extensively investigated in specific conditions, limiting knowledge about optimal application for healthcare.

OBJECTIVE

To compare effectiveness of conventional gait training with exoskeleton-assisted walking for non-traumatic brain injury during early stage rehabilitation.

METHODS

Clinical evaluation data at admission and discharge were obtained in a retrospective case-control design. Patients received standard of care physical therapy either using Ekso GT or not. Within- or between-group statistical tests were performed to determine change over time and interventional differences.

RESULTS

This study analyzed forty-nine individuals (33% female), 20 controls and 29 Ekso participants who were equivalent at baseline. Both groups improved in Functional Independence Measure scores and ambulation ability (p < .00001 and p < .001, respectively). Control subjects demonstrated significantly different distance walked and assistance level values at discharge from those who were treated with the exoskeleton (p < .01).

CONCLUSION

Robotic locomotion is non-inferior for subacute functional recovery after non-traumatic brain injury. Conventional therapy produced larger gait performance gains during hospitalization. Further research is needed to understand specific factors influencing efficacy and the long-term implications after rehabilitation.

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.

Effect of exoskeleton-assisted Body Weight-Supported Treadmill Training on gait function for patients with chronic stroke: a scoping review

BACKGROUND

Therapeutic exercise for gait function using an exoskeleton-assisted Body Weight Supported Treadmill Training (BWSTT) has been identified as a potential intervention that allows for task-based repetitive training with appropriate kinematics while adjusting the amount of body weight support (BWS). Nonetheless, its effect on gait in patients with stroke in the chronic phase are yet to be clarified. The primary aim of this scoping review was to present the status of effectiveness of exoskeleton-assisted BWSTT in patients with chronic stroke. The secondary aims were to summarise intervention protocols, types and functions of BWSTT exoskeletal robotic devices currently used clinically.

METHOD AND RESULTS

Articles were accessed and collected from PubMed, Ovid MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases, which were completed in October 2020. Articles were included if the subjects were adults with stroke in the chronic phase (onset ≥ 6 months) and if they utilised a robotic exoskeleton with treadmill and body weight support and investigated the efficacy of gait exercise. A total of 721 studies were identified, of which 11 randomised controlled trials were selected. All included studies were published from 2008 to 2020. Overall, 309 subjects were enrolled; of these, 241 (156 males, 85 females) participated. Walking outcome measures were used more often to evaluate the functional aspects of gait than to evaluate gait independence. In 10 of 11 studies, showed the effectiveness of exoskeleton robot-assisted BWSTT in terms of outcomes contributing to improved gait function. Two studies reported that exoskeleton-assisted BWSTT with combination therapy was significantly more effective in improving than exoskeleton-assisted BWSTT alone. However, no significant difference was identified between the groups; compared with therapist-assisted BWSTT groups, exoskeleton-assisted BWSTT groups did not exhibit significant change.

CONCLUSION

This review suggests that exoskeleton-assisted BWSTT for patients with chronic stroke may be effective in improving walking function. However, the potential may be "to assist" and not because of using the robot. Further studies are required to verify its efficacy and strengthen evidence on intervention protocols.

Mathematical Analysis and Motion Capture System Utilization Method for Standardization Evaluation of Tracking Objectivity of 6-DOF Arm Structure for Rehabilitation Training Exercise Therapy Robot

A treatment method for suppressing shoulder pain by reducing the secretion of neurotransmitters in the brain is being studied in compliance with domestic and international standards. A robot is being developed to assist physical therapists in shoulder rehabilitation exercise treatment. The robot used for rehabilitation therapy enables the training of patients to perform rehabilitation exercises repeatedly. However, the biomechanical movement (or motion) of the shoulder joint should be accurately designed to enhance efficiency using a shoulder rehabilitation robot. Furthermore, safely treating patients by accurately evaluating biomechanical movements in compliance with domestic and international standards is a major task. Therefore, an in-depth analysis of shoulder movement is essential for understanding the mechanism of shoulder rehabilitation using robots. This paper proposes a method for analyzing shoulder movements. The rotation angle and range of motion (ROM) of the shoulder joint are measured by attaching a marker to the body and analyzing the inverse kinematics. The first motion is abduction and adduction, and the second is external and internal rotation. The location information of the marker is transmitted to an application software through an infrared camera. For the analysis using an inverse kinematics solution, five males and five females participated in the motion capture experiment. The subjects did not have any disability, and abduction and adduction were repeated 10 times. As a result, ROM of the abduction and adduction were 148° with males and 138.7° in females. Moreover, ROM of the external and internal rotation were 111.2° with males and 106° in females. Because this study enables tracking of the center coordinates of the joint suitably through a motion capture system, inverse kinematics can be accurately calculated. Additionally, a mathematical inverse kinematics equation will utilize follow-up study for designing an upper rehabilitations robot. The proposed method is assessed to be able to contribute to the definition of domestic and international standardization of rehabilitation robots and motion capture for objective evaluation.

A novel gait analysis system for detecting abnormal hemiparetic gait patterns during robot-assisted gait training: A criterion validity study among healthy adults

INTRODUCTION

Robot-assisted gait training has been reported to improve gait in individuals with hemiparetic stroke. Ideally, the gait training program should be customized based on individuals' gait characteristics and longitudinal changes. However, a gait robot that uses gait characteristics to provide individually tailored gait training has not been proposed. The new gait training robot, "Welwalk WW-2000," permits modification of various parameters, such as time and load of mechanical assistance for a patient's paralyzed leg. The robot is equipped with sensors and a markerless motion capture system to detect abnormal hemiparetic gait patterns during robot-assisted gait training. Thus, it can provide individually tailored gait training. This study aimed to investigate the criterion validity of the gait analysis system in the Welwalk WW-2000 in healthy adults.

MATERIALS AND METHODS

Twelve healthy participants simulated nine abnormal gait patterns that were often manifested in individuals with hemiparetic stroke while wearing the robot. Each participant was instructed to perform a total of 36 gait trials, with four levels of severity for each abnormal gait pattern. Fifteen strides for each gait trial were recorded using the markerless motion capture system in the Welwalk WW-2000 and a marker-based three-dimensional (3D) motion analysis system. The abnormal gait pattern index was then calculated for each stride from both systems. The correlation of the index values between the two methods was evaluated using Spearman's rank correlation coefficients for each gait pattern in each participant.

RESULTS

Using the participants' index values for each abnormal gait pattern obtained using the two motion analysis methods, the median Spearman's rank correlation coefficients ranged from 0.68 to 0.93, which corresponded to moderate to very high correlation.

CONCLUSION

The gait analysis system in the Welwalk WW-2000 for real-time detection of abnormal gait patterns during robot-assisted gait training was suggested to be a valid method for assessing gait characteristics in individuals with hemiparetic stroke.

CLINICAL TRIAL REGISTRATION

[https://jrct.niph.go.jp], identifier [jRCT 042190109].

Improving Upper Limb and Gait Rehabilitation Outcomes in Post-Stroke Patients: A Scoping Review on the Additional Effects of Non-Invasive Brain Stimulation When Combined with Robot-Aided Rehabilitation

Robot-aided rehabilitation (RAR) and non-invasive brain stimulation (NIBS) are the two main interventions for post-stroke rehabilitation. The efficacy of both approaches in combination has not been well established yet. The importance of coupling these interventions, which both enhance brain plasticity to promote recovery, lies in augmenting the rehabilitation potential to constrain the limitation in daily living activities and the quality of life following stroke. This review aimed to evaluate the evidence of NIBS coupled with RAR in improving rehabilitation outcomes of upper limb and gait motor impairment in adult individuals with stroke. We included 18 clinical trials in this review. All studies were highly heterogeneous concerning the technical characteristics of robotic devices and NIBS protocols. However, the studies reported a global improvement in body structure and function and activity limitation for the upper limb, which were non-significant between the active and control groups. Concerning gait training protocols, the active group outperformed the control group in improving walking capacity and recovery. According to this review, NIBS and RAR in combination are promising but not yet largely recommendable as a systematic approach for stroke rehabilitation as there is not enough data about this. Therefore, more homogenous clinical trials are required, pointing out the best characteristics of the combined therapeutic protocols.

RObotic-Assisted Rehabilitation for balance and gait in Stroke patients (ROAR-S): study protocol for a preliminary randomized controlled trial

BACKGROUND

Stroke, the incidence of which increases with age, has a negative impact on motor and cognitive performance, quality of life, and the independence of the person and his or her family, leading to a number of direct and indirect costs. Motor recovery is essential, especially in elderly patients, to enable the patient to be independent in activities of daily living and to prevent falls. Several studies have shown how robotic training associated with physical therapy influenced functional and motor outcomes of walking after stroke by improving endurance and walking strategies. Considering data from previous studies and patients' needs in gait and balance control, we hypothesized that robot-assisted balance treatment associated with physical therapy may be more effective than usual therapy performed by a physical therapist in terms of improving static, dynamic balance and gait, on fatigue and cognitive performance.

METHODS

This is an interventional, single-blinded, preliminary randomized control trial. Twenty-four patients of both sexes will be recruited, evaluated, and treated at the UOC Rehabilitation and Physical Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome from January to December 2022. Patients will be randomized into two groups: the experimental group will perform specific rehabilitation for balance disorder using the Hunova® robotic platform (Movendo Technology srl, Genoa, IT) for 3 times a week, for 4 weeks (12 total sessions), and for 45 min of treatment, in addition to conventional treatment, while the conventional group (GC) will perform only conventional treatment as per daily routine. All patients will undergo clinical and instrumental evaluation at the beginning and end of the 4 weeks of treatment.

CONCLUSIONS

The study aims to evaluate the improvement in balance, fatigue, quality of life, and motor and cognitive performance after combined conventional and robotic balance treatment with Hunova® (Movendo Technology srl, Genoa, IT) compared with conventional therapy alone. Robotic assessment to identify the most appropriate and individualized rehabilitation treatment may allow reducing disability and improving quality of life in the frail population. This would reduce direct and indirect social costs of care and treatment for the National Health Service and caregivers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05280587. Registered on March 15, 2022.

A Comprehensive Appraisal of Meta-Analyses of Exercise-Based Stroke Rehabilitation with Trial Sequential Analysis

Meta-analysis is a common technique used to synthesise the results of multiple studies through the combination of effect size estimates and testing statistics. Numerous meta-analyses have investigated the efficacy of exercise programmes for stroke rehabilitation. However, meta-analyses may also report false-positive results because of insufficient information or random errors. Trial sequential analysis (TSA) is an advanced technique for calculating the required information size (RIS) and more restrictive statistical significance levels for the precise assessment of any specific treatment. This study used TSA to examine whether published meta-analyses in the field of stroke rehabilitation reached the RIS and whether their overall effect sizes were sufficient. A comprehensive search of six electronic databases for articles published before May 2022 was conducted. The intervention methods were divided into four primary groups, namely aerobic or resistance exercise, machine-assisted exercise, task-oriented exercise, and theory-based exercise. The primary outcome measure was gait speed and the secondary outcome measure was balance function. The data were obtained either from the meta-analyses or as raw data from the original cited texts. All data analysis was performed in TSA software. In total, 38 articles with 46 analysable results were included in the TSA. Only 17 results (37.0%) reached the RIS. In conclusion, meta-analysis interpretation is challenging. Clinicians must consider the RIS of meta-analyses before applying the results in real-world situations. TSA can provide accurate evaluations of treatment effects, which is crucial to the development of evidence-based medicine.

[Early mobilization in the intensive care unit-Are robot-assisted systems the future?]

BACKGROUND

Intensive care unit (ICU) acquired weakness is associated with reduced physical function, increased mortality and reduced quality of life, and affects about 43% of survivors of critical illness. Lacking therapeutic options, the prevention of known risk factors and implementation of early mobilization is essential. Robotic assistance devices are increasingly being studied in mobilization.

OBJECTIVE

This qualitative review synthesizes the evidence of early mobilization in the ICU and focuses on the advantages of robotic assistance devices.

RESULTS

Active mobilization should begin early during critical care. Interventions commencing 72 h after admission to the ICU are considered early. Mobilization interventions during critical care have been shown to be safe and reduce the time on mechanical ventilation in the ICU and the length of delirious episodes. Protocolized early mobilization interventions led to more active mobilization and increased functional independence and mobility at hospital discharge. In rehabilitation after stroke, robot-assisted training increases the chance of regaining independent walking ability, especially in more severely impaired patients, seems to be safe and increases muscle strength and quality of life in small trials.

CONCLUSION

Early mobilization improves the outcome of the critically ill. Robotic devices support the gait training after stroke and are the subject of ongoing studies on early mobilization and verticalization in the intensive care setting.

Comparing the Effects of Exoskeletal-Type Robot-Assisted Gait Training on Patients with Ataxic or Hemiplegic Stroke

This study aimed to discover the effects of robotic rehabilitation utilizing an exoskeletal-type robot-assisted gait training (RAGT) device on patients with ataxic and hemiplegic stroke and to compare its effectiveness between the two groups. This was a retrospective study, and the electronic charts of 22 patients who underwent RAGT treatment from October 2019 to June 2021 were reviewed. Patients were divided into ataxic and hemiplegic groups based on their symptoms. The clinical outcome measures included the Berg balance scale (BBS), functional ambulation category (FAC), and mobility subcategories of the modified Barthel Index (MBI-m). Outcome measures were reviewed at two points within 48 h, before and after RAGT with EXOWALK®, a type of exoskeletal robot. After the RAGT sessions, total patients in both ataxic and hemiplegic groups demonstrated statistically significant improvements in BBS (p < 0.0001, p = 0.002, and p = 0.005, respectively) and MBI-m (p < 0.0001, p = 0.002, and p = 0.011, respectively). Additionally, FAC after RAGT was significantly improved (p = 0.0056). The regression coefficient of the number of RAGT treatments for BBS changes in the nine subjects was estimated to be 2.45; 3.50 in the ataxic group and 2.26 in the hemiplegic group. The regression coefficient of the number of RAGT treatments for MBI-m changes in the nine subjects was estimated to be 0.16; 4.00 in the ataxic group and −0.52 in the hemiplegic group. Our results suggest that RAGT using an exoskeletal-type robot, EXOWALK®, could be effective for improving walking capacity, balance, and daily activities of life in patients with ataxic and hemiplegic stroke.

Hybrid robot-assisted gait training for motor function in subacute stroke: a single-blind randomized controlled trial

Background

Robot-assisted gait training (RAGT) is a practical treatment that can complement conventional rehabilitation by providing high-intensity repetitive training for patients with stroke. RAGT systems are usually either of the end-effector or exoskeleton types. We developed a novel hybrid RAGT system that leverages the advantages of both types.

Objective

This single-blind randomized controlled trial evaluated the beneficial effects of the novel RAGT system both immediately after the intervention and at the 3-month follow-up in nonambulatory patients with subacute stroke.

Methods

We recruited 40 patients with subacute stroke who were equally randomized to receive conventional rehabilitation either alone or with the addition of 15 RAGT sessions. We assessed lower-extremity motor function, balance, and gait performance by using the following tools: active range of motion (AROM), manual muscle test (MMT), the Fugl–Meyer Assessment (FMA) lower-extremity subscale (FMA-LE) and total (FMA-total), Postural Assessment Scale for Stroke (PASS), Berg Balance Scale (BBS), Tinetti Performance-Oriented Mobility Assessment (POMA) balance and gait subscores, and the 3-m and 6-m walking speed and Timed Up and Go (TUG) tests. These measurements were performed before and after the intervention and at the 3-month follow-up.

Results

Both groups demonstrated significant within-group changes in the AROM, MMT, FMA-LE, FMA-total, PASS, BBS, POMA, TUG, and 3-m and 6-m walking speed tests before and after intervention and at the 3-month follow-up (p < 0.05). The RAGT group significantly outperformed the control group only in the FMA-LE (p = 0.014) and total (p = 0.002) assessments.

Conclusion

Although the novel hybrid RAGT is effective, strong evidence supporting its clinical effectiveness relative to controls in those with substantial leg dysfunction after stroke remains elusive.

Trial registration The study was registered with an International Standard Randomized Controlled Trial Number, ISRCTN, ISRCTN15088682. Registered retrospectively on September 16, 2016, at https://www.isrctn.com/ISRCTN15088682

Stroke survivor perceptions of using an exoskeleton during acute gait rehabilitation

Robotic-assisted gait training (RAGT) devices allow intensive high repetition of the gait cycle in individuals with locomotor disability, with reduced therapist effort. In addition to usual rehabilitation, RAGT post-stroke improves the likelihood of regaining independent walking, with maximum efficacy identified in the acute and subacute phases of stroke. This study explores the usability and acceptance of RAGT among persons with stroke in an acute hospital setting and examines users’ perceptions of two different modes of robotic assistance provided during rehabilitation. A mixed-methods approach comprised semi-structed interviews of end-user perspectives of RAGT in an acute hospital setting following stroke and two 10-point Likert scales rating how comfortable and how natural robotic gait felt using different assistance modes. Content analysis of qualitative data was undertaken with results synthesised by common meaning units. Quantitative data were reported using summary statistics, with Spearmann’s correlation co-efficient examining the relationship between Likert scale ratings and measures of participants’ stroke related disability. Ten individuals (6 men; 4 women; mean age of 64.5. ± 13 years) were recruited in an acute hospital setting following admission with a stroke diagnosis. Content analysis of interview transcripts identified discussion units centring around positive aspects of how helpful the device was, negative aspects related to set-up time, weight of the device and multiple instructions delivered during use. Initially participants identified that the device could look intimidating, and they feared falling in the device but they subsequently identified the correct mindset for using the device is to trust the technology and not be afraid. Mean ratings for device comfort (7.94 ± 1.4) and how natural walking felt (7.05 ± 1.9) were favourable. Interestingly, a strong relationship was identified, whereby the higher the level of disability, the more natural participants rated walking in the device during maximal assistance mode (rho = 0.62; p = 0.138). This study suggests individuals in the early phases of stroke perceive RAGT to be acceptable and helpful in the main, with some associated negative aspects. Walking in the device was rated as comfortable and natural. Those with greater disability rated the assisted walking as more natural.

The effects of robot-assisted gait training combined with non-invasive brain stimulation on lower limb function in patients with stroke and spinal cord injury: A systematic review and meta-analysis

Objective:

This study aimed to investigate the effect of robot-assisted gait training (RAGT) therapy combined with non-invasive brain stimulation (NIBS) on lower limb function in patients with stroke and spinal cord injury (SCI).

Data sources

PubMed, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, and Web of Science were searched.

Study selection

Randomized controlled trials (RCTs) published as of 3 March 2021. RCTs evaluating RAGT combined with NIBS, such as transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS), for lower limb function (e.g., Fugl-Meyer assessment for patients with stroke) and activities (i.e., gait velocity) in patients with stroke and SCI were included.

Data extraction

Two reviewers independently screened the records, extracted the data, and assessed the risk of bias.

Data synthesis

A meta-analysis of five studies (104 participants) and risk of bias were conducted. Pooled estimates demonstrated that RAGT combined with NIBS significantly improved lower limb function [standardized mean difference (SMD) = 0.52; 95% confidence interval (CI) = 0.06–0.99] but not lower limb activities (SMD = −0.13; 95% CI = −0.63–0.38). Subgroup analyses also failed to find a greater improvement in lower limb function of RAGT with tDCS compared to sham stimulation. No significant differences between participant characteristics or types of NIBS were observed.

Conclusion

This meta-analysis demonstrated that RAGT therapy in combination with NIBS was effective in patients with stroke and SCI. However, a greater improvement in lower limb function and activities were not observed using RAGT with tDCS compared to sham stimulation.

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.

Relation between Cortical Activation and Effort during Robot-Mediated Walking in Healthy People: A Functional Near-Infrared Spectroscopy Neuroimaging Study (fNIRS)

Force and effort are important components of a motor task that can impact rehabilitation effectiveness. However, few studies have evaluated the impact of these factors on cortical activation during gait. The purpose of the study was to investigate the relation between cortical activation and effort required during exoskeleton-mediated gait at different levels of physical assistance in healthy individuals. Twenty-four healthy participants walked 10 m with an exoskeleton that provided four levels of assistance: 100%, 50%, 0%, and 25% resistance. Functional near-infrared spectroscopy (fNIRS) was used to measure cerebral flow dynamics with a 20-channel (plus two reference channels) device that covered most cortical motor regions bilaterally. We measured changes in oxyhemoglobin (HbO2) and deoxyhemoglobin (HbR). According to HbO2 levels, cortical activation only differed slightly between the assisted conditions and rest. In contrast, bilateral and widespread cortical activation occurred during the two unassisted conditions (somatosensory, somatosensory association, primary motor, premotor, and supplementary motor cortices). A similar pattern was seen for HbR levels, with a smaller number of significant channels than for HbO2. These results confirmed the hypothesis that there is a relation between cortical activation and level of effort during gait. This finding should help to optimize neurological rehabilitation strategies to drive neuroplasticity.

Feasibility and cost description of highly intensive rehabilitation involving new technologies in patients with post-acute stroke-a trial of the Swiss RehabTech Initiative

Background

There is a need to provide highly repetitive and intensive therapy programs for patients after stroke to improve sensorimotor impairment. The employment of technology-assisted training may facilitate access to individualized rehabilitation of high intensity. The purpose of this study was to evaluate the safety and acceptance of a high-intensity technology-assisted training for patients after stroke in the subacute or chronic phase and to establish its feasibility for a subsequent randomized controlled trial.

Methods

A longitudinal, multi-center, single-group study was conducted in four rehabilitation clinics. Patients participated in a high-intensity 4-week technology-assisted trainings consisting of 3 to 5 training days per week and at least 5 training sessions per day with a duration of 45 min each. Feasibility was evaluated by examining recruitment, intervention-related outcomes (adherence, subjectively perceived effort and effectiveness, adverse events), patient-related outcomes, and efficiency gains. Secondary outcomes focused on all three domains of the International Classification of Functioning Disability and Health. Data were analyzed and presented in a descriptive manner.

Results

In total, 14 patients after stroke were included. Participants exercised between 12 and 21 days and received between 28 and 82 (mean 46 ± 15) technology-assisted trainings during the study period, which corresponded to 2 to 7 daily interventions. Treatment was safe. No serious adverse events were reported. Minor adverse events were related to tiredness and exertion. From baseline to the end of the intervention, patients improved in several functional performance assessments of the upper and lower extremities. The efficiency gains of the trainings amounted to 10% to 58%, in particular for training of the whole body and for walking training in severely impaired patients.

Conclusions

Highly intensive technology-assisted training appears to be feasible for in- and outpatients in the subacute or chronic phase after stroke. Further clinical trials are warranted in order to define the most comprehensive approach to highly intensive technology-assisted training and to investigate its efficacy in patients with neurological disorders.

Trial registration

ClinicalTrials.gov Identifier: NCT03641651 at August 31st 2018

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.

Robot-assisted gait training: more randomized controlled trials are needed! Or maybe not?

I was encouraged by the recent article by Kuo et al. entitled “Prediction of robotic neurorehabilitation functional ambulatory outcome in patients with neurological disorders” to write an opinion piece on the possible further development of stationary robot-assisted gait training research. Randomized clinical trials investigating stationary gait robots have not shown the superiority of these devices over comparable interventions regarding clinical effectiveness, and there are clinical practice guidelines that even recommend against their use. Nevertheless, these devices are still widely used, and our field needs to find ways to apply these devices more effectively. The authors of the article mentioned above feed different machine learning algorithms with patients’ data from the beginning of a robot-assisted gait training intervention using the robot Lokomat. The output of these algorithms allows predictions of the clinical outcome (i.e., functional ambulation categories) while the patients are still participating in the intervention. Such an analysis based on the collection of the device’s data could optimize the application of these devices. The article provides an example of how our field of research could make progress as we advance, and in this opinion piece, I would like to present my view on the prioritization of upcoming research on robot-assisted gait training. Furthermore, I briefly speculate on some drawbacks of randomized clinical trials in the field of robot-assisted gait training and how the quality and thus the effectiveness of robot-assisted gait training could potentially be improved based on the collection and analysis of clinical training data, a better patient selection and by giving greater weight to the motivational aspects for the participants.

Combining Robot-Assisted Gait Training and Non-Invasive Brain Stimulation in Chronic Stroke Patients: A Systematic Review

Gait impairment is one of the most common disorders of patients with chronic stroke, which hugely affects the ability to carry out the activities of daily living and the quality of life. Recently, traditional rehabilitation techniques have been associated with non-invasive brain stimulation (NIBS) techniques, which enhance brain plasticity, with the aim of promoting recovery in patients with chronic stroke. NIBS effectiveness in improving gait parameters in patients with chronic stroke has been in several studies evaluated. Robotic devices are emerging as promising tools for the treatment of stroke-related disabilities by performing repetitive, intensive, and task-specific treatments and have been proved to be effective for the enhancement of motor recovery in patients with chronic stroke. To date, several studies have examined the combination of NIBS with robotic-assisted gait training, but the effectiveness of this approach is not yet well established. The main purpose of this systematic review is to clarify whether the combination of NIBS and robot-assisted gait training may improve walking function in patients with chronic stroke. Our systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Studies eligible for review were identified through PubMed/MEDLINE, Embase, Scopus, and PEDro from inception to March 15, 2021, and the outcomes considered were gait assessments. Seven studies were included in the qualitative analysis of this systematic review, with a total population of 186 patients with chronic stroke. All studies specified technical characteristics of robotic devices and NIBS used, with high heterogeneity of protocols. Methodological studies have shown a significantly greater improvement in walking capacity recorded with 6MWT. Finally, research studies have highlighted a positive effect on walking recovery by combination of robot-assisted gait training with non-invasive brain stimulation. Furthermore, future studies should identify the best characteristics of the combined therapeutic protocols.

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

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

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

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

BACKGROUND

Lokomat therapy for gait rehabilitation has become increasingly popular. Most evidence suggests that Lokomat therapy is equally effective as but not superior to standard therapy approaches. One reason might be that the Lokomat parameters to personalize therapy, such as gait speed, body weight support and Guidance Force, are not optimally used. However, there is little evidence available about the influence of Lokomat parameters on the effectiveness of the therapy. Nevertheless, an appropriate reporting of the applied therapy parameters is key to the successful clinical transfer of study results. The aim of this scoping review was therefore to evaluate how the currently available clinical studies report Lokomat parameter settings and map the current literature on Lokomat therapy parameters.

METHODS AND RESULTS

A systematic literature search was performed in three databases: Pubmed, Scopus and Embase. All primary research articles performing therapy with the Lokomat in neurologic populations in English or German were included. The quality of reporting of all clinical studies was assessed with a framework developed for this particular purpose. We identified 208 studies investigating Lokomat therapy in patients with neurologic diseases. The reporting quality was generally poor. Less than a third of the studies indicate which parameter settings have been applied. The usability of the reporting for a clinical transfer of promising results is therefore limited.

CONCLUSION

Although the currently available evidence on Lokomat parameters suggests that therapy parameters might have an influence on the effectiveness, there is currently not enough evidence available to provide detailed recommendations. Nevertheless, clinicians should pay close attention to the reported therapy parameters when translating research findings to their own clinical practice. To this end, we propose that the quality of reporting should be improved and we provide a reporting framework for authors as a quality control before submitting a Lokomat-related article.

Gamified Neurorehabilitation Strategies for Post-stroke Motor Recovery: Challenges and Advantages

Abstract

Purpose of Review

Stroke is the leading cause of permanent motor disability in the United States (US), but there has been little progress in developing novel, effective strategies for treating post-stroke motor deficits. The past decade has seen the rapid development of many promising, gamified neurorehabilitation technologies; however, clinical adoption remains limited. The purpose of this review is to evaluate the recent literature surrounding the adoption and use of gamification in neurorehabilitation after stroke.

Recent Findings

Gamification of neurorehabilitation protocols is both feasible and effective. Deployment strategies and scalability need to be addressed with more rigor. Relationship between engaged time on task and rehabilitation outcomes should be explored further as it may create benefits beyond repetitive movement.

Summary

As gamification becomes a more common and feasible way of delivering exercise-based therapies, additional benefits of gamification are emerging. In spite of this, questions still exist about scalability and widespread clinical adoption.

Effects of Balance Exercise Assist Robot training for patients with hemiparetic stroke: a randomized controlled trial

Background

Robot-assisted rehabilitation for patients with stroke is promising. However, it is unclear whether additional balance training using a balance-focused robot combined with conventional rehabilitation programs supplements the balance function in patients with stroke. The purpose of this study was to compare the effects of Balance Exercise Assist Robot (BEAR) training combined with conventional inpatient rehabilitation training to those of conventional inpatient rehabilitation only in patients with hemiparetic stroke. We also aimed to determine whether BEAR training was superior to intensive balance training.

Methods

This assessor-blinded randomized controlled trial included 60 patients with first-ever hemiparetic stroke, admitted to rehabilitation wards between December 2016 and February 2019. Patients were randomly assigned to one of three groups, robotic balance training and conventional inpatient rehabilitation (BEAR group), intensive balance training and conventional inpatient rehabilitation (IBT group), or conventional inpatient rehabilitation-only (CR group). The intervention duration was 2 weeks, with assessments conducted pre- and post-intervention, and at 2 weeks follow-up. The primary outcome measure was a change in the Mini-Balance Evaluation Systems Test (Mini-BESTest) score from baseline.

Results

In total, 57 patients completed the intervention, and 48 patients were evaluated at the follow-up. Significant improvements in Mini-BESTest score were observed in the BEAR and IBT groups compared with in the CR group post-intervention and after the 2-week follow-up period (P < 0.05).

Conclusions

The addition of balance exercises using the BEAR alongside conventional inpatient rehabilitation improved balance in patients with subacute stroke.

Trial registration

https://www.umin.ac.jp/ctr; Unique Identifier: UMIN000025129. Registered on 2 December 2016.

Professionals' Views and Experiences of Using Rehabilitation Robotics With Stroke Survivors: A Mixed Methods Survey

Objective: To understand the reason for low implementation of clinical and home-based rehabilitation robots and their potential. Design: Online questionnaire (November 2020 and February 2021). Subjects: A total of 100 professionals in stroke rehabilitation area were involved (Physiotherapists n = 62, Occupation therapists n = 35). Interventions: Not applicable. Main Measures: Descriptive statistics and thematic content analysis were used to analyze the responses: 1. Participants' details, 2. Professionals' views and experience of using clinical rehabilitation robots, 3. Professionals' expectation and concerns of using home-based rehabilitation robots. Results: Of 100 responses, 37 had experience of rehabilitation robots. Professionals reported that patients enjoyed using them and they increased accessibility, autonomy, and convenience especially when used at home. The main emergent themes were: "aims and objectives for rehabilitation robotics," "requirements" (functional, software, and safety), "cost," "patient factors" (contraindications, cautions, and concerns), and "staff issues" (concerns and benefits). The main benefits of rehabilitation robots were that they provided greater choice for therapy, increased the amount/intensity of treatment, and greater motivation to practice. Professionals perceived logistical issues (ease of use, transport, and storage), cost and limited adaptability to patients' needs to be significant barriers to tier use, whilst acknowledging they can reduce staff workload to a certain extent. Conclusion: The main reported benefit of rehabilitation robots were they increased the amount of therapy and practice after stroke. Ease of use and adaptability are the key requirements. High cost and staffing resources were the main barriers.

Effective physical therapy activities to improve the supine-to-seated transfer time in stroke patients: an observational pilot study

[Purpose] This study aimed to examine the effective time allocation for physical therapy activities in patients with stroke. The primary outcome measure was the improvement in the time required to transition from the supine to the sitting position. [Participants and Methods] This study enrolled 19 inpatients with stroke. The activities performed during physical therapy were classified as nontherapeutic activities, minimal therapeutic activities, moderate therapeutic activities, high therapeutic activities, and other activities. We determined the relationship between the activities and the relative shortening ratio of the time required to sit up from the supine position for up to 13 weeks of physical therapy. We also considered the following background factors: patient information, functional independence measure, and Brunnstrom recovery stage. [Results] The Brunnstrom recovery stage for the lower extremity was identified as the confounding factor, and the participants were stratified into the Brunnstrom recovery stage 6 group, in which moderate therapeutic activities and other activities were significantly related to the relative shortening ratio. [Conclusion] The results suggested that other activities exerted a similar effect as moderate therapeutic activities in the Brunnstrom recovery stage 6 group and were more effective than high therapeutic activities in reducing the time required to sit up from the supine position.

Beneficial Effects of Robot-Assisted Gait Training on Functional Recovery in Women after Stroke: A Cohort Study

Background and Objectives: Robot-assisted gait training (RAGT) could be a rehabilitation option for patients after experiencing a stroke. This study aims to determine the sex-related response to robot-assisted gait training in a cohort of subacute stroke patients considering mixed results previously reported. Materials and Methods: In this study, 236 participants (145 males, 91 females) were admitted to a rehabilitation facility after experiencing a stroke and performed RAGT within a multidisciplinary rehabilitation program. Functional Independence Measure (FIM) and Functional Ambulatory Category (FAC) were assessed at admission and discharge to determine sex-related outcomes. Results: At the baseline, no significant difference among sexes was observed. At the end of rehabilitation, both males and females exhibited significant improvements in FIM (71% of males and 80% of females reaching the MCID cut-off value) and FAC (∆score: men 1.9 ± 1.0; women 2.1 ± 1.1). A more remarkable improvement was observed in women of the whole population during the study, but statistical significance was not reached. When analysing the FAC variations with respect to the total number of RAGT sessions, a more significant improvement was observed in women than men (p = 0.025). Conclusion: In conclusion, among subacute stroke patients, benefits were observed following RAGT during a multidisciplinary rehabilitation program in both sexes. A greater significant recovery for women with an ischemic stroke or concerning the number of sessions attended was also highlighted. The use of gait robotics for female patients may favour a selective functional recovery after stroke.

Effects of Robotic-Assisted Gait Training in Children and Adolescents with Cerebral Palsy: A Network Meta-Analysis

Gait disturbances are common in children and adolescents with cerebral palsy (CP). Robotic-assisted gait training (RAGT) is becoming increasingly widespread, and hence it is important to examine its effectiveness. A network meta-analysis (NMA) of clinical trials comparing treatments with RAGT vs. other physical therapy treatments was carried out. This study was conducted according to the NMA version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-NMA) guidelines and following the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. The outcome variables used were the D and E dimensions of the Gross Motor Function Measure (GMFM), gait speed, resistance, and stride length. Among 120 records, 8 trials were included. This NMA did not find statistically significant results for any of the comparisons examined in any of the outcomes studied and the magnitude of the effect size estimates was low or very low. Our NMA results should be interpreted with caution due to the high clinical heterogeneity of the studies included.

Effects of periodic robot rehabilitation using the Hybrid Assistive Limb for a year on gait function in chronic stroke patients

Using a robot for gait training in stroke patients has attracted attention for the last several decades. Previous studies reported positive effects of robot rehabilitation on gait function in the short term. However, the long-term effects of robot rehabilitation for stroke patients are still unclear. The purpose of the present study was to investigate the long-term effects of periodic gait training using the Hybrid Assistive Limb (HAL) on gait function in chronic stroke patients. Seven chronic stroke patients performed 8 gait training sessions using the HAL 3 times every few months. The maximal 10-m walk test and the 2-minute walking distance (2MWD) were measured before the first intervention and after the first, second, and third interventions. Gait speed, stride length, and cadence were calculated from the 10-m walk test. Repeated one-way analysis of variance showed a significant main effect on evaluation time of gait speed (F = 7.69, p < 0.01), 2MWD (F = 7.52, p < 0.01), stride length (F = 5.24, p < 0.01), and cadence (F = 8.43, p < 0.01). The effect sizes after the first, second, and third interventions compared to pre-intervention in gait speed (d = 0.39, 0.52, and 0.59) and 2MWD (d = 0.35, 0.46, and 0.57) showed a gradual improvement of gait function at every intervention. The results of the present study showed that gait function of chronic stroke patients improved over a year with periodic gait training using the HAL every few months.

Wearable Robotic Gait Training in Persons with Multiple Sclerosis: A Satisfaction Study

Wearable exoskeletons have showed improvements in levels of disability and quality of life in people with neurological disorders. However, it is important to understand users’ perspectives. The aim of this study was to explore the patients’ and physiotherapists’ satisfaction from gait training with the EKSO GT^® exoskeleton in people with multiple sclerosis (MS). A cross-sectional study with 54 participants was conducted. Clinical data and self-administered scales data were registered from all patients who performed sessions with EKSO GT^®. To evaluate patients’ satisfaction the Quebec User Evaluation with Assistive Technology and Client Satisfaction Questionnaire were used. A high level of satisfaction was reported for patients and for physiotherapists. A moderate correlation was found between the number of sessions and the patients’ satisfaction score (rho = 0.532; p < 0.001), and an excellent correlation between the physiotherapists’ time of experience in neurology rehabilitation and the satisfaction with the possibility of combining the device with other gait trainings approaches (rho = 0.723; p = 0.003). This study demonstrates a good degree of satisfaction for people with MS (31.3 ± 5.70 out of 40) and physiotherapists (38.50 ± 3.67 out of 45 points) with the EKSO GT^®. Effectiveness, safety and impact on the patients’ gait were the most highly rated characteristics of EKSO GT^®. Features such as comfort or weight of the device should be improved from the patients’ perspectives.

Efficacy and Safety Study of Wearable Cyborg HAL (Hybrid Assistive Limb) in Hemiplegic Patients With Acute Stroke (EARLY GAIT Study): Protocols for a Randomized Controlled Trial

We hypothesized that gait treatment with a wearable cyborg Hybrid Assistive Limb (HAL) would improve the walking ability of patients with hemiparesis after stroke. This study aims to evaluate the efficacy and safety of gait treatment using HAL versus conventional gait training (CGT) in hemiplegic patients with acute stroke and establish a protocol for doctor-initiated clinical trials for acute stroke. We will enroll patients with acute stroke at the University of Tsukuba Hospital. This study is a single-center, randomized, parallel-group, controlled trial (HAL group, n = 20; control group, n = 20) that will include three phases: (1) pre-observation phase (patient enrollment, baseline assessment, and randomization); (2) treatment phase (nine sessions, twice or thrice per week over 3−4 weeks; the HAL and control groups will perform gait treatment using HAL or CGT, respectively, and finally (3) post-treatment evaluation phase. The Functional Ambulation Category score will be the primary outcome measure, and the following secondary outcome measures will be assessed: Mini-Mental State Examination, Brunnstrom recovery stage of lower limbs, Fugl–Meyer assessment of lower limbs, 6-min walking distance, comfortable gait speed, step length, cadence, Barthel Index, Functional Independence Measure, gait posture, motion analysis (muscle activity), amount of activity (evaluated using an activity meter), stroke-specific QOL, and modified Rankin Scale score. The baseline assessment, post-treatment evaluation, and follow-up assessment will evaluate the overall outcome measures; for other evaluations, physical function evaluation centered on walking will be performed exclusively, excluding ADL and QOL scores. This study is a randomized controlled trial that aims to clarify the efficacy and safety of gait treatment using HAL compared with CGT in hemiplegic patients with acute stroke. In addition, we aim to establish a protocol for doctor-initiated clinical trials for acute stroke based on the study results. If our results demonstrate the effectiveness of the proposed treatment regarding outcomes of patients with hemiplegic acute stroke, this study will promote the treatment of these patients using the HAL system as an effective tool in future stroke rehabilitation programs. The study protocol was registered with the Japan Registry of Clinical Trials on October 14, 2020 (jRCTs032200151).

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.

Robotic Home-Based Rehabilitation Systems Design: From a Literature Review to a Conceptual Framework for Community-Based Remote Therapy During COVID-19 Pandemic

During the COVID-19 pandemic, the higher susceptibility of post-stroke patients to infection calls for extra safety precautions. Despite the imposed restrictions, early neurorehabilitation cannot be postponed due to its paramount importance for improving motor and functional recovery chances. Utilizing accessible state-of-the-art technologies, home-based rehabilitation devices are proposed as a sustainable solution in the current crisis. In this paper, a comprehensive review on developed home-based rehabilitation technologies of the last 10 years (2011-2020), categorizing them into upper and lower limb devices and considering both commercialized and state-of-the-art realms. Mechatronic, control, and software aspects of the system are discussed to provide a classified roadmap for home-based systems development. Subsequently, a conceptual framework on the development of smart and intelligent community-based home rehabilitation systems based on novel mechatronic technologies is proposed. In this framework, each rehabilitation device acts as an agent in the network, using the internet of things (IoT) technologies, which facilitates learning from the recorded data of the other agents, as well as the tele-supervision of the treatment by an expert. The presented design paradigm based on the above-mentioned leading technologies could lead to the development of promising home rehabilitation systems, which encourage stroke survivors to engage in under-supervised or unsupervised therapeutic activities.

The Effectiveness of Robot- vs. Virtual Reality-Based Gait Rehabilitation: A Propensity Score Matched Cohort

Robot assisted gait training (RAGT) and virtual reality plus treadmill training (VRTT) are two technologies that can support locomotion rehabilitation in children and adolescents affected by acquired brain injury (ABI). The literature provides evidence of their effectiveness in this population. However, a comparison between these methods is not available. This study aims at comparing the effectiveness of RAGT and VRTT for the gait rehabilitation of children and adolescents suffering from ABI. This is a prospective cohort study with propensity score matching. Between October 2016 and September 2018, all patients undergoing an intensive gait rehabilitation treatment based on RAGT or VRTT were prospectively observed. To minimize selection bias associated with the study design, patients who underwent RAGT or VRTT were retrospectively matched for age, gender, time elapsed from injury, level of impairment, and motor impairment using propensity score in a matching ratio of 1:1. Outcome measures were Gross Motor Function Mesure-88 (GMFM-88), six-min walking test (6MWT), Gillette Functional Assessment Questionnaire (FAQ), and three-dimensional gait analysis (GA). The FAQ and the GMFM-88 had a statistically significant increase in both groups while the 6MWT improved in the RAGT group only. GA highlighted changes at the proximal level in the RAGT group, and at the distal district in the VRTT group. Although preliminary, this work suggests that RAGT and VRTT protocols foster different motor improvements, thus recommending to couple the two therapies in the paediatric population with ABI.

Haptic-Enabled Hand Rehabilitation in Stroke Patients: A Scoping Review

There is a plethora of technology-assisted interventions for hand therapy, however, less is known about the effectiveness of these interventions. This scoping review aims to explore studies about technology-assisted interventions targeting hand rehabilitation to identify the most effective interventions. It is expected that multifaceted interventions targeting hand rehabilitation are more efficient therapeutic approaches than mono-interventions. The scoping review will aim to map the existing haptic-enabled interventions for upper limb rehabilitation and investigates their effects on motor and functional recovery in patients with stroke. The methodology used in this review is based on the Arksey and O’Malley framework, which includes the following stages: identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results. Results show that using three or four different technologies was more positive than using two technologies (one technology + haptics). In particular, when standardized as a percentage of outcomes, the combination of three technologies showed better results than the combination of haptics with one technology or with three other technologies. To conclude, this study portrayed haptic-enabled rehabilitation approaches that could help therapists decide which technology-enabled hand therapy approach is best suited to their needs. Those seeking to undertake research and development anticipate further opportunities to develop haptic-enabled hand telerehabilitation platforms.

Converging Robotic Technologies in Targeted Neural Rehabilitation: A Review of Emerging Solutions and Challenges

Recent advances in the field of neural rehabilitation, facilitated through technological innovation and improved neurophysiological knowledge of impaired motor control, have opened up new research directions. Such advances increase the relevance of existing interventions, as well as allow novel methodologies and technological synergies. New approaches attempt to partially overcome long-term disability caused by spinal cord injury, using either invasive bridging technologies or noninvasive human-machine interfaces. Muscular dystrophies benefit from electromyography and novel sensors that shed light on underlying neuromotor mechanisms in people with Duchenne. Novel wearable robotics devices are being tailored to specific patient populations, such as traumatic brain injury, stroke, and amputated individuals. In addition, developments in robot-assisted rehabilitation may enhance motor learning and generate movement repetitions by decoding the brain activity of patients during therapy. This is further facilitated by artificial intelligence algorithms coupled with faster electronics. The practical impact of integrating such technologies with neural rehabilitation treatment can be substantial. They can potentially empower nontechnically trained individuals-namely, family members and professional carers-to alter the programming of neural rehabilitation robotic setups, to actively get involved and intervene promptly at the point of care. This narrative review considers existing and emerging neural rehabilitation technologies through the perspective of replacing or restoring functions, enhancing, or improving natural neural output, as well as promoting or recruiting dormant neuroplasticity. Upon conclusion, we discuss the future directions for neural rehabilitation research, diagnosis, and treatment based on the discussed technologies and their major roadblocks. This future may eventually become possible through technological evolution and convergence of mutually beneficial technologies to create hybrid solutions.

Gait Recovery with an Overground Powered Exoskeleton: A Randomized Controlled Trial on Subacute Stroke Subjects

BACKGROUND

Overground Robot-Assisted Gait Training (o-RAGT) provides intensive gait rehabilitation. This study investigated the efficacy of o-RAGT in subacute stroke subjects, compared to conventional gait training.

METHODS

A multicenter randomized controlled trial was conducted on 75 subacute stroke subjects (38 in the Experimental Group (EG) and 37 in the Control Group (CG)). Both groups received 15 sessions of gait training (5 sessions/week for 60 min) and daily conventional rehabilitation. The subjects were assessed at the beginning (T1) and end (T2) of the training period with the primary outcome of a 6 Minutes Walking Test (6MWT), the Modified Ashworth Scale of the Affected lower Limb (MAS-AL), the Motricity Index of the Affected lower Limb (MI-AL), the Trunk Control Test (TCT), Functional Ambulation Classification (FAC), a 10 Meters Walking Test (10MWT), the modified Barthel Index (mBI), and the Walking Handicap Scale (WHS).

RESULTS

The 6MWT increased in both groups, which was confirmed by both frequentist and Bayesian analyses. Similar outcomes were registered in the MI-AL, 10MWT, mBI, and MAS-AL. The FAC and WHS showed a significant number of subjects improving in functional and community ambulation in both groups at T2.

CONCLUSIONS

The clinical effects of o-RAGT were similar to conventional gait training in subacute stroke subjects. The results obtained in this study are encouraging and suggest future clinical trials on the topic.