Modular ankle robotics training in early subacute stroke: a randomized controlled pilot study

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.

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.

Extended Poststroke Rehabilitation Combined with Cerebrolysin Promotes Upper Limb Motor Recovery in Early Subacute Phase of Rehabilitation: A Randomized Clinical Study

Background and Objectives: The recovery of stroke patients with severe impairment is usually poor and limited and, unfortunately, under-investigated in clinical studies. In order to support neuroplasticity and modulate motor recovery, Cerebrolysin combined with rehabilitation treatment has proven effective in the acute stroke phase in moderate to severe motor impairment. The aim of this study was to determine the efficacy of extended poststroke rehabilitation combined with Cerebrolysin on upper limb motor recovery in subacute stroke patients with severe upper limb motor impairment. Materials and Methods: A randomized, double-blind, placebo-controlled study was conducted. Sixty patients at the early stage of severe sub-acute stroke who fulfilled all eligibility criteria were randomly assigned to the Cerebrolysin group or placebo group (𝑛 = 30 each). Both groups, after conducting three weeks of conventional rehabilitation treatment five days per week, continued to perform conventional rehabilitation treatment three times per week until 90 days of rehabilitation treatment. The primary outcome measure was the Action Research Arm Test (ARAT), and the secondary outcomes were the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) motor score, Barthel index (BI), and the National Institutes of Health Stroke Scale (NIHSS). The outcome data were evaluated before, after three weeks of treatment, and on the 90th day of rehabilitation treatment, and compared within groups and between the two groups. There were no adverse events. Results: Both groups showed a significant improvement (p < 0.001) over time in BI, FMA-UE, ARAT, and NIHSS scores. Patients receiving Cerebrolysin showed more significant improvement in post-stroke upper limb motor impairment and functioning compared to the placebo group after only three weeks, and the trend was maintained after 90 days of follow up. Conclusion: Cerebrolysin delivered in the early subacute post-stroke phase added to extended conventional rehabilitation treatment is beneficial and improves motor functional recovery in patients with severe motor impairment, especially on the paretic upper extremity.

Design and Experimental Research of 3-RRS Parallel Ankle Rehabilitation Robot

The ankle is a crucial joint that supports the human body weight. An ankle sprain will adversely affect the patient’s daily life, so it is of great significance to ensure its strength. To help patients with ankle dysfunction to carry out effective rehabilitation training, the bone structure and motion mechanism of the ankle were analyzed in this paper. Referring to the configuration of the lower-mobility parallel mechanism, a 3-RRS (R and S denote revolute and spherical joint respectively) parallel ankle rehabilitation robot (PARR) was proposed. The robot can realize both single and compound ankle rehabilitation training. The structure of the robot was introduced, and the kinematics model was established. The freedom of movement of the robot was analyzed using the screw theory, and the robot kinematics were analyzed using spherical analytics theory. A circular composite rehabilitation trajectory was planned, and the accuracy of the kinematics model was verified by virtual prototype simulation. The Multibody simulation results show that the trajectory of the target point is basically the same as the expected trajectory. The maximum trajectory error is about 2.5 mm in the simulation process, which is within the controllable range. The experimental results of the virtual prototype simulation show that the maximum angular deflection error of the three motors is 2° when running a circular trajectory, which meets the experimental requirements. Finally, a control strategy for passive rehabilitation training was designed, and the effectiveness of this control strategy was verified by a prototype experiment.

Effects of control strategies on gait in robot-assisted post-stroke lower limb rehabilitation: a systematic review

BACKGROUND

Stroke related motor function deficits affect patients' likelihood of returning to professional activities, limit their participation in society and functionality in daily living. Hence, robot-aided gait rehabilitation needs to be fruitful and effective from a motor learning perspective. For this reason, optimal human-robot interaction strategies are necessary to foster neuroplastic shaping during therapy. Therefore, we performed a systematic search on the effects of different control algorithms on quantitative objective gait parameters of post-acute stroke patients.

METHODS

We conducted a systematic search on four electronic databases using the Population Intervention Comparison and Outcome format. The heterogeneity of performance assessment, study designs and patients' numerosity prevented the possibility to conduct a rigorous meta-analysis, thus, the results were presented through narrative synthesis.

RESULTS

A total of 31 studies (out of 1036) met the inclusion criteria, without applying any temporal constraints. No controller preference with respect to gait parameters improvements was found. However, preferred solutions were encountered in the implementation of force control strategies mostly on rigid devices in therapeutic scenarios. Conversely, soft devices, which were all position-controlled, were found to be more commonly used in assistive scenarios. The effect of different controllers on gait could not be evaluated since conspicuous heterogeneity was found for both performance metrics and study designs.

CONCLUSIONS

Overall, due to the impossibility of performing a meta-analysis, this systematic review calls for an outcome standardisation in the evaluation of robot-aided gait rehabilitation. This could allow for the comparison of adaptive and human-dependent controllers with conventional ones, identifying the most suitable control strategies for specific pathologic gait patterns. This latter aspect could bolster individualized and personalized choices of control strategies during the therapeutic or assistive path.

PedBotHome: A Video Game-Based Robotic Ankle Device Created for Home Exercise in Children With Neurological Impairments

PURPOSE

This pilot study assesses the feasibility of using PedBotHome to promote adherence to a home exercise program, the ability of the device to withstand frequent use, and changes in participant ankle mobility.PedBotHome is a robotic ankle device with integrated video game software designed to improve ankle mobility in children with cerebral palsy.

METHODS

Eight participants enrolled in a 28-day trial of PedBotHome. Ankle strength, range of motion, and plantar flexor spasticity were measured pre- and posttrial. Performance was monitored remotely, and game settings were modified weekly by physical therapists.

RESULTS

Four participants met the study goal of 20 days of use. There were statistically significant improvements in ankle strength, spasticity, and range of motion.

CONCLUSIONS

PedBotHome is a feasible device to engage children with static neurological injuries in ankle home exercise. This pilot study expands the paradigm for future innovative home-based robotic rehabilitation.

Control Strategies for Gait Tele-Rehabilitation System Based on Parallel Robotics

Among end-effector robots for lower limb rehabilitation, systems based on Stewart–Gough platforms enable independent movement of each foot in six degrees of freedom. Nevertheless, control strategies described in recent literature have not been able to fully explore the potential of such a mechatronic system. In this work, we propose two novel approaches for controlling a gait simulator based on Stewart–Gough platforms. The first strategy provides the therapist direct control of each platform using movement data measured by wearable sensors. The following scheme is designed to improve the level of engagement of the patient by enabling a limited degree of control based on trunk inclination. Both strategies are designed to facilitate future studies in tele-rehabilitation settings. Experimental results have illustrated the feasibility of both control interfaces, either in terms of system performance or user subjective evaluation. Technical capacity to deploy in tele-rehabilitation was also verified in this work.

Intensive In-Bed Sensorimotor Rehabilitation of Early Subacute Stroke Survivors With Severe Hemiplegia Using a Wearable Robot

Rehabilitation for stroke survivors with severe motor impairment remains challenging. Early motor rehabilitation is critical for improving mobility function post stroke, but it is often delayed due to limited resources in clinical practice. The objectives of this study were to investigate the feasibility and effectiveness of early in-bed sensorimotor rehabilitation on acute stroke survivors with severe hemiplegia using a wearable ankle robot. Eighteen patients (9 in the study group and 9 in the control group) with severe hemiplegia and no active ankle movement were enrolled in acute/subacute phase post stroke. During a typical 3-week hospital stay, patients in the study group received ankle robot-guided in-bed training (50 minutes/session, 5 sessions/week), including motor relearning under real-time visual feedback of re-emerging motor output, strong passive stretching under intelligent control, and game-based active movement training with robotic assistance. Whereas the control group received passive ankle movement in the mid-range of motion and attempted active ankle movement without robotic assistance. After multi-session training, the study group achieved significantly greater improvements in Fugl-Meyer Lower Extremity motor score (p = 0.007), plantarflexor strength (p = 0.009), and active range of motion (p = 0.011) than controls. The study group showed earlier motor recovery for plantarflexion and dorsiflexion than the control group (p < 0.05). This study showed that in-bed sensorimotor rehabilitation guided by a wearable ankle robot through combining motor relearning in real-time feedback, strong passive stretching, and active movement training facilitated early motor recovery for stroke survivors with severe hemiplegia in the acute/subacute phase.

Effects of Robot-Aided Rehabilitation on the Ankle Joint Properties and Balance Function in Stroke Survivors: A Randomized Controlled Trial

Background: Stroke survivors with impaired control of the ankle due to stiff plantarflexors often experience abnormal posture control, which affects balance and locomotion. Forceful stretching may decrease ankle stiffness and improve balance. Recently, a robot-aided stretching device was developed to decrease ankle stiffness of patient post-stroke, however, their benefits compared to manual stretching exercises have not been done in a randomized controlled trial, and the correlations between the ankle joint biomechanical properties and balance are unclear.

Objective: To compare the effects of robot-aided to manual ankle stretching training in stroke survivors with the spastic ankle on the ankle joint properties and balance function post-stroke, and further explore the correlations between the ankle stiffness and balance.

Methods: Twenty inpatients post-stroke with ankle spasticity received 20 minutes of stretching training daily over two weeks. The experimental group used a robot-aided stretching device, and the control group received manual stretching. Outcome measures were evaluated before and after training. The primary outcome measure was ankle stiffness. The secondary outcome measures were passive dorsiflexion ranges of motion, dorsiflexor muscle strength, Modified Ashworth Scale (MAS), Fugl-Meyer Motor Assessment of Lower Extremity (FMA-LE), Berg Balance Scale (BBS), Modified Barthel Index (MBI), and the Pro-Kin balance test.

Results: After training, two groups showed significantly within-group improvements in dorsiflexor muscle strength, FMA-LE, BBS, MBI (P < 0.05). The between-group comparison showed no significant differences in all outcome measures (P > 0.0025). The experimental group significantly improved in the stiffness and passive range of motion of dorsiflexion, MAS. In the Pro-Kin test, the experimental group improved significantly with eyes closed and open (P < 0.05), but significant improvements were found in the control group only with eyes open (P < 0.05). Dorsiflexion stiffness was positively correlated with the Pro-Kin test results with eyes open and the MAS (P < 0.05).

Conclusions: The robot-aided and manual ankle stretching training provided similar significant improvements in the ankle properties and balance post-stroke. However, only the robot-aided stretching training improved spasticity and stiffness of dorsiflexion significantly. Ankle dorsiflexion stiffness was correlated with balance function.

Clinical Trial Registration:www.chictr.org.cn ChiCTR2000030108.

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.

Effects of stretching exercises on human gait: a systematic review and meta-analysis

Background: Stretching is commonly used in physical therapy as a rehabilitation tool to improve range of motion and motor function. However, is stretching an efficient method to improve gait, and if so, for which patient category? Methods: A systematic review of randomized and non-randomized controlled trials with meta-analysis was conducted using relevant databases. Every patient category and every type of stretching programs were included without multicomponent programs. Data were meta-analysed where possible. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome. The PEDro scale was used for the quality assessment. Results: Twelve studies were included in the analysis. Stretching improved gait performance as assessed by walking speed and stride length only in a study with a frail elderly population, with small effect sizes (both SMD= 0.49; 95% CI: 0.03, 0.96; PEDro score: 3/10). The total distance and the continuous walking distance of the six-minute walking test were also improved only in a study in an elderly population who had symptomatic peripheral artery disease, with large effect sizes (SMD= 1.56; 95% CI: 0.66, 2.45 and SMD= 3.05; 95% CI: 1.86, 4.23, respectively; PEDro score: 5/10). The results were conflicting in healthy older adults or no benefit was found for most of the performance, spatiotemporal, kinetic and angular related variables. Only one study (PEDro score: 6/10) showed improvements in stance phase duration (SMD=-1.92; 95% CI: -3.04, -0.81), swing phase duration (SMD=1.92; 95 CI: 0.81, 3.04), double support phase duration (SMD= -1.69; 95% CI: -2.76, -0.62) and step length (SMD=1.37; 95% CI: 0.36, 2.38) with large effect sizes. Conclusions: There is no strong evidence supporting the beneficial effect of using stretching to improve gait. Further randomized controlled trials are needed to understand the impact of stretching on human gait.

Effects of stretching exercises on human gait: a systematic review and meta-analysis

Background: Stretching is commonly used in physical therapy as a rehabilitation tool to improve range of motion and motor function. However, is stretching an efficient method to improve gait, and if so, for which patient category? Methods: A systematic review of randomized and non-randomized controlled trials with meta-analysis was conducted using relevant databases. Every patient category and every type of stretching programs were included without multicomponent programs. Data were meta-analysed where possible. Estimates of effect sizes (reported as standard mean difference (SMD)) with their respective 95% confidence interval (95% CI) were reported for each outcome. The PEDro scale was used for the quality assessment. Results: Twelve studies were included in the analysis. Stretching improved gait performance as assessed by walking speed and stride length only in a study with a frail elderly population, with small effect sizes (both SMD= 0.49; 95% CI: 0.03, 0.96; PEDro score: 3/10). The total distance and the continuous walking distance of the six-minute walking test were also improved only in a study in an elderly population who had symptomatic peripheral artery disease, with large effect sizes (SMD= 1.56; 95% CI: 0.66, 2.45 and SMD= 3.05; 95% CI: 1.86, 4.23, respectively; PEDro score: 5/10). The results were conflicting in healthy older adults or no benefit was found for most of the performance, spatiotemporal, kinetic and angular related variables. Only one study (PEDro score: 6/10) showed improvements in stance phase duration (SMD=-1.92; 95% CI: -3.04, -0.81), swing phase duration (SMD=1.92; 95 CI: 0.81, 3.04), double support phase duration (SMD= -1.69; 95% CI: -2.76, -0.62) and step length (SMD=1.37; 95% CI: 0.36, 2.38) with large effect sizes. Conclusions: There is no strong evidence supporting the beneficial effect of using stretching to improve gait. Further randomized controlled trials are needed to understand the impact of stretching on human gait.

Associations between changes in gait parameters, balance, and walking capacity during the first 3 months after stroke: a prospective observational study

BACKGROUND

Independent ambulation is a common rehabilitation goal after stroke, requiring adequate balance and efficiency of gait. Spatiotemporal gait parameters are expected to improve in the first 3 months and their association with balance and efficiency of gait may provide useful insights into the recovery of safe and independent mobility.

OBJECTIVE

Examine the associations between changes in spatiotemporal gait parameters, balance, and walking capacity during the first 3 months after stroke.

METHODS

This prospective observational study included participants diagnosed with stroke. Within the first 2 weeks after stroke onset and again 3 months (±2 weeks) later, gait was assessed using a GAITRite mat at self-selected gait speed, balance using the Berg Balance Scale (BBS), and walking capacity using the 6-minute walk test (6 MWT). Changes in gait parameters, balance, and walking capacity were assessed using paired sample t-tests, and linear regression analyses were used to assess associations between changes in spatiotemporal gait parameters, BBS, and 6MWT.

RESULTS

Seventy-nine participants (mean (SD) age 75.4 (8.5) years; 44 men) were included. Gait parameters, balance, and walking capacity all improved during follow-up. The bivariate regression analyses showed associations between improvements in all gait parameters, except walk ratio, with improvement in balance, and in all gait parameters with improvement in walking capacity. Only gait speed was associated with balance (13.8 points, 95% CI 0.5, 27.8, p = .0042) and walking capacity (256 m, 95% CI 173,340, p < .001) in the multivariate analyses.

CONCLUSION

Improved spatiotemporal gait parameters were associated with improved balance and walking capacity within the first 3 months after stroke.

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.

The Improvement of Walking Ability Following Stroke

BACKGROUND

Gait velocity and maximum walking distance are central parameters for measuring the success of rehabilitation of gait after a stroke. The goal of this study was to provide an overview of current evidence on the rehabilitation of gait after a stroke.

METHODS

A systematic review of randomized, controlled trials was carried out using network meta-analysis. The primary endpoint was gait velocity; secondary end- points were the ability to walk, maximum walking distance, and gait stability. The following interventions were analyzed: no gait training, conventional gait training (reference category), training on a treadmill with or without body weight support, training on a treadmill with or without a speed paradigm, and electromechanically assisted gait training with end-effector or exoskeleton apparatus.

RESULTS

The systematic search yielded 40 567 hits. 95 randomized, controlled trials involving a total of 4458 post-stroke patients were included in the meta-analysis. With respect to the primary endpoint of gait velocity, gait training assisted by end- effector apparatus led to significant improvement (mean difference [MD] = 0.16 m/s; 95% confidence interval [0.04; 0.28]). None of the other interventions improved gait velocity to any significant extent. With respect to one of the secondary endpoints, maximum walking distance, both gait training assisted by end-effector apparatus and treadmill training with body weight support led to significant improvement (MD = 47 m, [4; 90], and MD = 38 m, [4; 72], respectively). A network meta-analysis could not be performed with respect to the ability to walk (a different secondary endpoint) because of substantial inconsistencies in the data. The interventions did not differ significantly with respect to safety.

CONCLUSION

In comparison to conventional gait rehabilitation, gait training assisted by end-effector apparatus leads to a statistically significant and clinically relevant improvement in gait velocity and maximum walking distance after stroke, while treadmill training with body weight support leads to a statistically significant and clinically relevant improvement in maximum walking distance.

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.

Reviewing Clinical Effectiveness of Active Training Strategies of Platform-Based Ankle Rehabilitation Robots

Objective

This review aims to provide a systematical investigation of clinical effectiveness of active training strategies applied in platform-based ankle robots.

Method

English-language studies published from Jan 1980 to Aug 2017 were searched from four databases using key words of "Ankle^∗" AND "Robot^∗" AND "Effect^∗ OR Improv^∗ OR Increas^∗." Following an initial screening, three rounds of discrimination were successively conducted based on the title, the abstract, and the full paper.

Result

A total of 21 studies were selected with 311 patients involved; of them, 13 studies applied a single group while another eight studies used different groups for comparison to verify the therapeutic effect. Virtual-reality (VR) game training was applied in 19 studies, while two studies used proprioceptive neuromuscular facilitation (PNF) training.

Conclusion

Active training techniques delivered by platform ankle rehabilitation robots have been demonstrated with great potential for clinical applications. Training strategies are mostly combined with one another by considering rehabilitation schemes and motion ability of ankle joints. VR game environment has been commonly used with active ankle training. Bioelectrical signals integrated with VR game training can implement intelligent identification of movement intention and assessment. These further provide the foundation for advanced interactive training strategies that can lead to enhanced training safety and confidence for patients and better treatment efficacy.

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.

Early Rehabilitation After Stroke: a Narrative Review

PURPOSE OF REVIEW

Despite current rehabilitative strategies, stroke remains a leading cause of disability in the USA. There is a window of enhanced neuroplasticity early after stroke, during which the brain's dynamic response to injury is heightened and rehabilitation might be particularly effective. This review summarizes the evidence of the existence of this plastic window, and the evidence regarding safety and efficacy of early rehabilitative strategies for several stroke domain-specific deficits.

RECENT FINDINGS

Overall, trials of rehabilitation in the first 2 weeks after stroke are scarce. In the realm of very early mobilization, one large and one small trial found potential harm from mobilizing patients within the first 24 h after stroke, and only one small trial found benefit in doing so. For the upper extremity, constraint-induced movement therapy appears to have benefit when started within 2 weeks of stroke. Evidence for non-invasive brain stimulation in the acute period remains scant and inconclusive. For aphasia, the evidence is mixed, but intensive early therapy might be of benefit for patients with severe aphasia. Mirror therapy begun early after stroke shows promise for the alleviation of neglect. Novel approaches to treating dysphagia early after stroke appear promising, but the high rate of spontaneous improvement makes their benefit difficult to gauge. The optimal time to begin rehabilitation after a stroke remains unsettled, though the evidence is mounting that for at least some deficits, initiation of rehabilitative strategies within the first 2 weeks of stroke is beneficial. Commencing intensive therapy in the first 24 h may be harmful.

A Feasibility Study of SSVEP-Based Passive Training on an Ankle Rehabilitation Robot

Objective

This study aims to establish a steady-state visual evoked potential- (SSVEP-) based passive training protocol on an ankle rehabilitation robot and validate its feasibility.

Method

This paper combines SSVEP signals and the virtual reality circumstance through constructing information transmission loops between brains and ankle robots. The robot can judge motion intentions of subjects and trigger the training when subjects pay their attention on one of the four flickering circles. The virtual reality training circumstance provides real-time visual feedback of ankle rotation.

Result

All five subjects succeeded in conducting ankle training based on the SSVEP-triggered training strategy following their motion intentions. The lowest success rate is 80%, and the highest one is 100%. The lowest information transfer rate (ITR) is 11.5 bits/min when the biggest one of the robots for this proposed training is set as 24 bits/min.

Conclusion

The proposed training strategy is feasible and promising to be combined with a robot for ankle rehabilitation. Future work will focus on adopting more advanced data process techniques to improve the reliability of intention detection and investigating how patients respond to such a training strategy.

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.

A systematic review of mechanisms of gait speed change post-stroke. Part 1: spatiotemporal parameters and asymmetry ratios

BACKGROUND

In walking rehabilitation trials, self-selected walking speed (SSWS) has emerged as the dominant outcome measure to assess walking ability. However, this measure cannot differentiate between recovery of impaired movement and compensation strategies. Spatiotemporal variables and asymmetry ratios are frequently used to quantify gait deviations and are hypothesized markers of recovery.

OBJECTIVES

The purpose of this review is to investigate spatiotemporal variables and asymmetry ratios as mechanistic recovery measures in physical therapy intervention studies post-stroke.

METHODS

A systematic literature search was performed to identify physical therapy intervention studies with a statistically significant change in SSWS post intervention and concurrently collected spatiotemporal variables. Methodological quality was assessed using the Cochrane Collaboration's tool. Walking speed, spatiotemporal, and intervention data were extracted.

RESULTS

46 studies met the inclusion criteria, 41 of which reported raw spatiotemporal measures and 19 reported asymmetry ratio calculations. Study interventions included: aerobic training (n = 2), functional electrical stimulation (n = 5), hippotherapy (n = 2), motor dual task training (n = 2), multidimensional rehabilitation (n = 4), robotics (n = 4), sensory stimulation training (n = 8), strength/resistance training (n = 4), task specific locomotor rehabilitation (n = 9), and visually guided training (n = 6).

CONCLUSIONS

Spatiotemporal variables help describe gait deviations, but scale to speed, so consequently, may not be an independent factor in describing functional recovery and gains. Therefore, these variables are limited in explaining mechanistic changes involved in improving gait speed. Use of asymmetry measures provides additional information regarding the coordinative requirements for gait and can potentially indicate recovery. Additional laboratory-based mechanistic measures may be required to truly understand how walking speed improves.

Task-specific ankle robotics gait training after stroke: a randomized pilot study

BACKGROUND

An unsettled question in the use of robotics for post-stroke gait rehabilitation is whether task-specific locomotor training is more effective than targeting individual joint impairments to improve walking function. The paretic ankle is implicated in gait instability and fall risk, but is difficult to therapeutically isolate and refractory to recovery. We hypothesize that in chronic stroke, treadmill-integrated ankle robotics training is more effective to improve gait function than robotics focused on paretic ankle impairments.

FINDINGS

Participants with chronic hemiparetic gait were randomized to either six weeks of treadmill-integrated ankle robotics (n = 14) or dose-matched seated ankle robotics (n = 12) videogame training. Selected gait measures were collected at baseline, post-training, and six-week retention. Friedman, and Wilcoxon Sign Rank and Fisher's exact tests evaluated within and between group differences across time, respectively. Six weeks post-training, treadmill robotics proved more effective than seated robotics to increase walking velocity, paretic single support, paretic push-off impulse, and active dorsiflexion range of motion. Treadmill robotics durably improved gait dorsiflexion swing angle leading 6/7 initially requiring ankle braces to self-discarded them, while their unassisted paretic heel-first contacts increased from 44 % to 99.6 %, versus no change in assistive device usage (0/9) following seated robotics.

CONCLUSIONS

Treadmill-integrated, but not seated ankle robotics training, durably improves gait biomechanics, reversing foot drop, restoring walking propulsion, and establishing safer foot landing in chronic stroke that may reduce reliance on assistive devices. These findings support a task-specific approach integrating adaptive ankle robotics with locomotor training to optimize mobility recovery.

CLINICAL TRIAL IDENTIFIER

NCT01337960. https://clinicaltrials.gov/ct2/show/NCT01337960?term=NCT01337960&rank=1.

Robot-Aided Neurorehabilitation: A Pediatric Robot for Ankle Rehabilitation

This paper presents the pediAnklebot, an impedance-controlled low-friction, backdriveable robotic device developed at the Massachusetts Institute of Technology that trains the ankle of neurologically impaired children of ages 6-10 years old. The design attempts to overcome the known limitations of the lower extremity robotics and the unknown difficulties of what constitutes an appropriate therapeutic interaction with children. The robot's pilot clinical evaluation is on-going and it incorporates our recent findings on the ankle sensorimotor control in neurologically intact subjects, namely the speed-accuracy tradeoff, the deviation from an ideally smooth ankle trajectory, and the reaction time. We used these concepts to develop the kinematic and kinetic performance metrics that guided the ankle therapy in a similar fashion that we have done for our upper extremity devices. Here we report on the use of the device in at least nine training sessions for three neurologically impaired children. Results demonstrated a statistically significant improvement in the performance metrics assessing explicit and implicit motor learning. Based on these initial results, we are confident that the device will become an effective tool that harnesses plasticity to guide habilitation during childhood.

A Comparative Analysis of Speed Profile Models for Ankle Pointing Movements: Evidence that Lower and Upper Extremity Discrete Movements are Controlled by a Single Invariant Strategy

Little is known about whether our knowledge of how the central nervous system controls the upper extremities (UE), can generalize, and to what extent to the lower limbs. Our continuous efforts to design the ideal adaptive robotic therapy for the lower limbs of stroke patients and children with cerebral palsy highlighted the importance of analyzing and modeling the kinematics of the lower limbs, in general, and those of the ankle joints, in particular. We recruited 15 young healthy adults that performed in total 1,386 visually evoked, visually guided, and target-directed discrete pointing movements with their ankle in dorsal-plantar and inversion-eversion directions. Using a non-linear, least-squares error-minimization procedure, we estimated the parameters for 19 models, which were initially designed to capture the dynamics of upper limb movements of various complexity. We validated our models based on their ability to reconstruct the experimental data. Our results suggest a remarkable similarity between the top-performing models that described the speed profiles of ankle pointing movements and the ones previously found for the UE both during arm reaching and wrist pointing movements. Among the top performers were the support-bounded lognormal and the beta models that have a neurophysiological basis and have been successfully used in upper extremity studies with normal subjects and patients. Our findings suggest that the same model can be applied to different "human" hardware, perhaps revealing a key invariant in human motor control. These findings have a great potential to enhance our rehabilitation efforts in any population with lower extremity deficits by, for example, assessing the level of motor impairment and improvement as well as informing the design of control algorithms for therapeutic ankle robots.

Time-interval for integration of stabilizing haptic and visual information in subjects balancing under static and dynamic conditions

Maintaining equilibrium is basically a sensorimotor integration task. The central nervous system (CNS) continually and selectively weights and rapidly integrates sensory inputs from multiple sources, and coordinates multiple outputs. The weighting process is based on the availability and accuracy of afferent signals at a given instant, on the time-period required to process each input, and possibly on the plasticity of the relevant pathways. The likelihood that sensory inflow changes while balancing under static or dynamic conditions is high, because subjects can pass from a dark to a well-lit environment or from a tactile-guided stabilization to loss of haptic inflow. This review article presents recent data on the temporal events accompanying sensory transition, on which basic information is fragmentary. The processing time from sensory shift to reaching a new steady state includes the time to (a) subtract or integrate sensory inputs; (b) move from allocentric to egocentric reference or vice versa; and (c) adjust the calibration of motor activity in time and amplitude to the new sensory set. We present examples of processes of integration of posture-stabilizing information, and of the respective sensorimotor time-intervals while allowing or occluding vision or adding or subtracting tactile information. These intervals are short, in the order of 1–2 s for different postural conditions, modalities and deliberate or passive shift. They are just longer for haptic than visual shift, just shorter on withdrawal than on addition of stabilizing input, and on deliberate than unexpected mode. The delays are the shortest (for haptic shift) in blind subjects. Since automatic balance stabilization may be vulnerable to sensory-integration delays and to interference from concurrent cognitive tasks in patients with sensorimotor problems, insight into the processing time for balance control represents a critical step in the design of new balance- and locomotion training devices.