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

Exploring new horizons: Emerging therapeutic strategies for pediatric stroke

Pediatric stroke presents unique challenges, and optimizing treatment strategies is essential for improving outcomes in this vulnerable population. This review aims to provide an overview of new, innovative, and potential treatments for pediatric stroke, with a primary objective to stimulate further research in this field. Our review highlights several promising approaches in the realm of pediatric stroke management, including but not limited to stem cell therapy and robotic rehabilitation. These innovative interventions offer new avenues for enhancing functional recovery, reducing long-term disability, and tailoring treatments to individual patient needs. The findings of this review underscore the importance of ongoing research and development of innovative treatments in pediatric stroke. These advancements hold significant clinical relevance, offering the potential to improve the lives of children affected by stroke by enhancing the precision, efficacy, and accessibility of therapeutic interventions. Embracing these innovations is essential in our pursuit of better outcomes and a brighter future for pediatric stroke care.

Systematic review and network meta-analysis of robot-assisted gait training on lower limb function in patients with cerebral palsy

OBJECTIVE

This study aimed to evaluate the effectiveness of robot-assisted gait training (RAGT) in treating lower extremity function in patients with cerebral palsy (CP) and compare the efficacy differences between different robotic systems.

METHODS

PubMed, Web of Science, Cochrane Library, Embase, CNKI, VIP, CBM, and Wanfang databases were searched to collect randomized controlled trials of RAGT for lower extremity dysfunction in patients with CP from the time the databases were created until December 26, 2022. The D and E of Gross Motor Function Measure-88 (GMFM-88) assessed lower limb motor function. Berg Balance Scale (BBS) was used to assess balance function. Walking endurance and speed were assessed using the 6-minute walk test (6MWT) and walking speed. The modified Ashworth Scale (MAS) was used to assess the degree of muscle spasticity in the lower extremities. The Cochrane Risk Assessment Scale and the Physiotherapy Evidence Database (PEDro) scale were used for qualitative assessment in the studies included. RevMan 5.4 was used for data merging and statistical analysis. R 4.2.0 and ADDIS 1.16.8 were used to map the network relationships and to perform the network meta-analysis.

RESULTS

A total of 14 studies were included in the review. The meta-analysis showed that RAGT significantly improved GMFM-88 D and E, BBS, and 6MWT scores in CP patients compared with conventional rehabilitation. However, for walking speed and MAS, the intervention effect of RAGT was insignificant. The network meta-analysis showed that the best probability ranking for the effect of the 3 different robots on the GMFM-88 D score was LokoHelp (P = 0.66) > Lokomat (P = 0.28) > 3DCaLT (P = 0.06) and the best probability ranking for the GMFM-88 E score was LokoHelp (P = 0.63) > 3DCaLT (P = 0.21) > Lokomat (P = 0.16).

CONCLUSION

RAGT positively affects walking and balance function in patients with CP, while efficacy in improving gait speed and muscle spasticity is unknown. The best treatment among the different robots is LokoHelp. Future high-quality, long-term follow-up studies are needed to explore the clinical efficacy of RAGT in depth.

Net zero supply chain performance and industry 4.0 technologies: Past review and present introspective analysis for future research directions

Interest in applying Industry 4.0 technologies in supply chain operations has increased significantly due to the urgent need to combat climate change and achieve net-zero emissions. This study aims to thoroughly comprehend how Industry 4.0 technologies affect the efficiency of net-zero supply chains. To do so, the study systematically reviews the existing research using 68 academic papers that are thematically analysed and classified by potentials associated with Industry 4.0 in the context of net zero supply chain performance. The findings of this systematic literature review highlight the multifaceted role of Industry 4.0 technologies in achieving net-zero supply chain performance. However, the study also identifies challenges related to policy, technology, economy, and markets to harness these technologies effectively. A conceptual framework is proposed to help organizations strategically leverage Industry 4.0 technologies for sustainable supply chain performance. By identifying knowledge gaps, the review provides a roadmap for future research to explore the complex dynamics at the intersection of Industry 4.0 and sustainability. Practically, the study offers valuable insights for supply chain managers and policymakers on the opportunities and challenges associated with adopting Industry 4.0 technologies for sustainable practices. With the goal of achieving net-zero supply chain performance, this paper emphasizes the importance of a holistic, integrated approach to technology adoption and sustainability strategies.

Functional Repetitive Neuromuscular Magnetic Stimulation (frNMS) Targeting the Tibialis Anterior Muscle in Children with Upper Motor Neuron Syndrome: A Feasibility Study

Non-invasive neurostimulation as an adjunctive intervention to task-specific motor training is an approach to foster motor performance in patients affected by upper motor neuron syndrome (UMNS). Here, we present first-line data of repetitive neuromuscular magnetic stimulation (rNMS) in combination with personalized task-specific physical exercises targeting the tibialis anterior muscle to improve ankle dorsiflexion (functional rNMS (frNMS)). The main objective of this pilot study was to assess the feasibility in terms of adherence to frNMS, safety and practicability of frNMS, and satisfaction with frNMS. First, during 10 training sessions, only physical exercises were performed (study period (SP) A). After a 1 week break, frNMS was delivered during 10 sessions (SPC). Twelve children affected by UMNS (mean age 8.9 ± 1.6 years) adhered to 93% (SPA) and 94% (SPC) of the sessions, and omittance was not related to the intervention itself in any case. frNMS was safe (no AEs reported in 88% of sessions, no AE-related discontinuation). The practicability of and satisfaction with frNMS were high. Patient/caregiver-reported outcomes revealed meaningful benefits on the individual level. The strength of the ankle dorsiflexors (MRC score) clinically meaningfully increased in four participants as spasticity of ankle plantar flexors (Tardieu scores) decreased in four participants after SPC. frNMS was experienced as a feasible intervention for children affected by UMNS. Together with the beneficial effects achieved on the individual level in some participants, this first study supports further real-world, large-scale, sham-controlled investigations to investigate the specific effects and distinct mechanisms of action of frNMS.

Addressing gross motor function by functional repetitive neuromuscular magnetic stimulation targeting to the gluteal muscles in children with bilateral spastic cerebral palsy: benefits of functional repetitive neuromuscular magnetic stimulation targeting the gluteal muscles

Background

Impaired selective motor control, weakness and spasticity represent the key characteristics of motor disability in the context of bilateral spastic cerebral palsy. Independent walking ability is an important goal and training of the gluteal muscles can improve endurance and gait stability. Combining conventional physical excercises with a neuromodulatory, non-invasive technique like repetitive neuromuscular magnetic stimulation probably enhances effects of the treatment. This prospective study aimed to assess the clinical effects of repetitive neuromuscular magnetic stimulation in combination with a personalized functional physical training offered to children and adolescents with bilateral spastic cerebral palsy.

Methods

Eight participants Gross Motor Function Classification System level II and III (10.4 ± 2y5m; 50% Gross Motor Function Classification System level II) received a personalized intervention applying functional repetitive neuromuscular magnetic stimulation (12 sessions within 3 weeks; 12,600 total stimuli during each session). At baseline and follow up the following assessments were performed: 10-m-walking-test, 6-min-walking-test, GMFM-66. Six weeks after the end of treatment the patient-reported outcome measure Gait Outcome Assessment List was completed.

Results

GMFM-66 total score improved by 1.4% (p = 0.002), as did scoring in domain D for standing (1.9%, p = 0.109) and domain E for walking, jumping and running (2.6%, p = 0.021). Gait speed or distance walked during 6 min did not improve from baseline to follow up. Patient-reported outcome showed improvement in 4 patients in altogether 14 ratings. Caregiver-reported outcome reported benefits in 3 participants in altogether 10 ratings.

Conclusion

Repetitive neuromuscular magnetic stimulation promises to be a meaningful, non-invasive treatment approach for children and adolescents with bilateral spastic cerebral palsy that could be offered in a resource-efficient manner to a broad number of patients. To further investigate the promising effects of repetitive neuromuscular magnetic stimulation and its mechanisms of action, larger-scaled, controlled trials are needed as well as comprehensive neurophysiological investigations.

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.

Is robot-assisted gait training intensity a determinant of functional recovery early after stroke? A pragmatic observational study of clinical care

Gait rehabilitation is a critical factor in functional recovery after a stroke. The aim of this pragmatic observational study was to identify the optimal dose and timing of robot-assisted gait training (RAGT) that can lead to a favourable outcome in a sample of subacute stroke survivors. Subacute patients with stroke who underwent a RAGT within a multidisciplinary rehabilitation program were enrolled. A set of clinical (i.e. age, type of stroke and time since stroke) and rehabilitation stay outcomes (length of stay and RAGT number of sessions) were recorded to evaluate their impact on functional outcome measures by functional independence measure (FIM) or functional ambulation category (FAC). We included 236 patients (62.73 ± 11.82 year old); 38.44% were females, and 59.32% were ischaemic stroke patients. Patients that received at least 14 RAGT sessions, had 15.83% more chance to be responders compared to those that receive less sessions (P = 0.006). Similarly, younger patients (≤60 years) were more prone to be responders (+15.1%). Lastly, an early rehabilitation (<6 weeks) was found to be more efficient (+21.09%) in determining responsiveness (P < 0.001). Becoming newly independent for gait, that refers to a FAC score ≥4, was related with age and RAGT sessions (P = 0.001). In conclusion, a younger age (≤60 years), an early rehabilitation (<6 weeks since stroke) and a higher RAGT dose (at least 14 sessions) were related to a favourable outcome in patients with subacute stroke.

Global Trends and Hotspots in Research on Rehabilitation Robots: A Bibliometric Analysis From 2010 to 2020

Background: In recent years, with the development of medical science and artificial intelligence, research on rehabilitation robots has gained more and more attention, for nearly 10 years in the Web of Science database by journal of rehabilitation robot-related research literature analysis, to parse and track rehabilitation robot research hotspot and front, and provide some guidance for future research.

Methods: This study employed computer retrieval of rehabilitation robot-related research published in the core data collection of the Web of Science database from 2010 to 2020, using CiteSpace 5.7 visualization software. The hotspots and frontiers of rehabilitation robot research are analyzed from the aspects of high-influence countries or regions, institutions, authors, high-frequency keywords, and emergent words.

Results: A total of 3,194 articles were included. In recent years, the research on rehabilitation robots has been continuously hot, and the annual publication of relevant literature has shown a trend of steady growth. The United States ranked first with 819 papers, and China ranked second with 603 papers. Northwestern University ranked first with 161 publications. R. Riener, a professor at the University of Zurich, Switzerland, ranked as the first author with 48 articles. The Journal of Neural Engineering and Rehabilitation has the most published research, with 211 publications. In the past 10 years, research has focused on intelligent control, task analysis, and the learning, performance, and reliability of rehabilitation robots to realize the natural and precise interaction between humans and machines. Research on neural rehabilitation robots, brain–computer interface, virtual reality, flexible wearables, task analysis, and exoskeletons has attracted more and more attention.

Conclusions: At present, the brain–computer interface, virtual reality, flexible wearables, task analysis, and exoskeleton rehabilitation robots are the research trends and hotspots. Future research should focus on the application of machine learning (ML), dimensionality reduction, and feature engineering technologies in the research and development of rehabilitation robots to improve the speed and accuracy of algorithms. To achieve wide application and commercialization, future rehabilitation robots should also develop toward mass production and low cost. We should pay attention to the functional needs of patients, strengthen multidisciplinary communication and cooperation, and promote rehabilitation robots to better serve the rehabilitation medical field.

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.

What does evidence tell us about the use of gait robotic devices in patients with multiple sclerosis? A comprehensive systematic review on functional outcomes and clinical recommendations

INTRODUCTION

There is growing evidence on the efficacy of gait robotic rehabilitation in patients with multiple sclerosis (MS), but most of the studies have focused on gait parameters. Moreover, clear indications on the clinical use of robotics still lack. As part of the CICERONE Italian Consensus on Robotic Rehabilitation, the aim of this systematic review was to investigate the existing evidence concerning the role of lower limb robotic rehabilitation in improving functional recovery in patients with MS.

EVIDENCE ACQUISITION

We searched for and systematically reviewed evidence-based studies on gait robotic rehabilitation in MS, between January 1^st, 2010 and December 31^st, 2020, in the following databases: Cochrane Library, PEDro, PubMed and Google Scholar. The study quality was assessed by the 16-item assessment of multiple systematic reviews 2 (AMSTAR 2) and the 10-item PEDro scale for the other research studies.

EVIDENCE SYNTHESIS

After an accurate screening, only 17 papers were included in the review, and most of them (13 RCT) had a level II evidence. Most of the studies used the Lokomat as a grounded robotic device, two investigated the efficacy of end-effectors and two powered exoskeletons. Generally speaking, robotic treatment has beneficial effects on gait speed, endurance and balance with comparable outcomes to those of conventional treatments. However, in more severe patients (EDSS >6), robotics leads to better functional outcomes. Notably, after gait training with robotics (especially when coupled to virtual reality) MS patients also reach better non-motor outcomes, including spasticity, fatigue, pain, psychological well-being and quality of life. Unfortunately, no clinical indications emerge on the treatment protocols.

CONCLUSIONS

The present comprehensive systematic review highlights the potential beneficial role on functional outcomes of the lower limb robotic devices in people with MS. Future studies are warranted to evaluate the role of robotics not only for walking and balance outcomes, but also for other gait-training-related benefits, to identify appropriate outcome measures related to a specific subgroup of MS subjects' disease severity.

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-assisted gait rehabilitation following stroke: a systematic review of current guidelines and practical clinical recommendations

INTRODUCTION

Stroke is the third leading cause of adult disability worldwide, and lower extremity motor impairment is one of the major determinants of long-term disability. Although robotic therapy is becoming more and more utilized in research protocols for lower limb stroke rehabilitation, the gap between research evidence and its use in clinical practice is still significant. The aim of this study was to determine the scope, quality, and consistency of guidelines for robotic lower limb rehabilitation after stroke, in order to provide clinical recommendations.

EVIDENCE ACQUISITION

We systematically reviewed stroke rehabilitation guideline recommendations between January 1, 2010 and October 31, 2020. We explored electronic databases (N.=4), guideline repositories and professional rehabilitation networks (N.=12). Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and brief syntheses were used to evaluate and compare the different recommendations, considering only the most recent version.

EVIDENCE SYNTHESIS

From the 1219 papers screened, ten eligible guidelines were identified from seven different regions/countries. Four of the included guidelines focused on stroke management, the other six on stroke rehabilitation. Robotic rehabilitation is generally recommended to improve lower limb motor function, including gait and strength. Unfortunately, there is still no consensus about the timing, frequency, training session duration and the exact characteristics of subjects who could benefit from robotics.

CONCLUSIONS

Our systematic review shows that the introduction of robotic rehabilitation in standard treatment protocols seems to be the future of stroke rehabilitation. However, robot assisted gait training (RAGT) for stroke needs to be improved with new solutions and in clinical practice guidelines, especially in terms of applicability.

A Case Report on Robot-Aided Gait Training in Primary Lateral Sclerosis Rehabilitation: Rationale, Feasibility and Potential Effectiveness of a Novel Rehabilitation Approach

Primary lateral sclerosis (PLS) is an adult-onset idiopathic disorder of the upper motor neuron system. Robot-aided rehabilitation with the Lokomat-Pro (LT) allows maximizing motor training by finely and individually controlling motor activation. No data are currently available on the use of robot-aided rehabilitation in PLS. The aim of this case study was to evaluate the effectiveness of a customized robotic rehabilitation protocol in PLS. A 54-year-old woman, diagnosed with PLS five years before admission, came to our clinic to undergo rehabilitation training due to gait difficulties with spastic paraparesis. The patient was treated with two different approaches: conventional physiotherapy followed by a combined approach (i.e. PT plus LT). After the conventional PT rehabilitation, no significant functional improvement was noted. However, the combined approach led to a significant improvement in functional motor skills, including walking, balance and lower limb muscle strength, and spasticity. Our experimental training combining robot-aided and conventional rehabilitation could be a promising approach to mitigate the PLS disability burden.

Does overground robotic gait training improve non-motor outcomes in patients with chronic stroke? Findings from a pilot study

Stroke is the leading cause of disability among the elderly in the industrialized world. No more than 40% of stroke survivors walk independently, and only after receiving appropriate rehabilitation treatment; many stroke patients have also non-motor symptoms. The aim of this pilot study is to evaluate the effects of Ekso-training on non-motor outcomes, including gastrointestinal function and psychological well-being, in post stroke patients. We enrolled 30 post-stroke subjects, which were randomized into two groups in order of recruitment: 15 patients were trained with the overground exoskeleton Ekso-GT (experimental group, EG), whereas 15 patients were submitted to a standard gait training (control group, CG). Both the groups underwent the same amount of physiotherapy. At the end of the training, only in the EG we observed a significant improvement in constipation, mood, and coping strategies, with regard to social support, as well as in the perception of quality of life (as per SF-12). According to these preliminary data, overground robotic gait training can be considered a valuable tool in improving non-motor symptoms, including constipation and behavioral disorders in patients with chronic stroke.

Robotic Technology in Pediatric Neurorehabilitation. A Pilot Study of Human Factors in an Italian Pediatric Hospital

The introduction of robotic neurorehabilitation among the most recent technologies in pediatrics represents a new opportunity to treat pediatric patients. This study aims at evaluating the response of physiotherapists, patients and their parents to this new technology. The study considered the outcomes of technological innovation in physiotherapists (perception of the workload, satisfaction), as well as that in patients and their parents (quality of life, expectations, satisfaction) by comparing the answers to subjective questionnaires of those who made use of the new technology with those who used the traditional therapy. A total of 12 workers, 46 patients and 47 parents were enrolled in the study. Significant differences were recorded in the total workload score of physiotherapists who use the robotic technology compared with the traditional therapy (p < 0.001). Patients reported a higher quality of life and satisfaction after the use of the robotic neurorehabilitation therapy. The parents of patients undergoing the robotic therapy have moderately higher expectations and satisfaction than those undergoing the traditional therapy. In this pilot study, the robotic neurorehabilitation technique involved a significant increase in the patients’ and parents’ expectations. As it frequently happens in the introduction of new technologies, physiotherapists perceived a greater workload. Further studies are needed to verify the results achieved.

Highest ambulatory speed using Lokomat gait training for individuals with a motor-complete spinal cord injury: a clinical pilot study

BACKGROUND

Motor impairment and loss of ambulatory function are major consequences of a spinal cord injury (SCI). Exoskeletons are robotic devices that allow SCI patients with limited ambulatory function to walk. The mean walking speed of SCI patients using an exoskeleton is low: 0.26 m/s. Moreover, literature shows that a minimum speed of 0.59 m/s is required to replace wheelchairs in the community.

OBJECTIVE

To investigate the highest ambulatory speed for SCI patients in a Lokomat.

METHODS

This clinical pilot study took place in the Rehabilitation Center Kladruby, in Kladruby (Czech Republic). Six persons with motor-complete sub-acute SCI were recruited. Measurements were taken at baseline and directly after a 30 min Lokomat training. The highest achieved walking speed, vital parameters (respiratory frequency, heart rate, and blood pressure), visual analog scale for pain, and modified Ashworth scale for spasticity were recorded for each person.

RESULTS

The highest reached walking speed in the Lokomat was on average 0.63 m/s (SD 0.03 m/s). No negative effects on the vital parameters, pain, or spasticity were observed. A significant decrease in pain after the Lokomat training was observed: 95% CI [0.336, 1.664] (p = 0.012).

CONCLUSION

This study shows that it is possible for motor-complete SCI individuals to ambulate faster on a Lokomat (on average 0.63 m/s) than what is currently possible with over-ground exoskeletons. No negative effects were observed while ambulating on a Lokomat. Further research investigating walking speed in exoskeletons after SCI is recommended.

Lessons learned from conducting a pragmatic, randomized, crossover trial on robot-assisted gait training in children with cerebral palsy (PeLoGAIT)

PURPOSE

To investigate the effectiveness of outpatient robot-assisted gait training (RAGT) in ambulatory children with spastic cerebral palsy.

METHODS

Children were randomized to two different intervention sequences within a pragmatic crossover design. They performed five weeks of RAGT (3 sessions per week) and five weeks of usual care (UC). Dimension E of the Gross Motor Function Measure-88 (GMFM E) as the primary outcome as well as Dimension D (GMFM D), and timed walking tests were assessed before and after each treatment sequence and after a 5-week follow-up.

RESULTS

The trial was stopped early because of recruitment problems. We included 16 children with a mean age of 11.3 years (6.0-15.3 years). GMFM E median (IQR) change scores were -0.7 (-2.8 to 3.5) after RAGT and 0 (-2.4 to 2.4) after UC. Neither GMFM E nor any secondary outcome measure changed significantly after RAGT or UC, nor were any period, follow-up, or carry-over effects observable.

CONCLUSIONS

RAGT as a single intervention was not effective in improving walking abilities in the included children. It should be embedded in a holistic treatment approach, as it cannot cover all aspects relevant to gait. Furthermore, children's personalized rehabilitation goals should be carefully monitored with individualized measurement instruments.

Factors influencing harmonized health data collection, sharing and linkage in Denmark and Switzerland: A systematic review

Introduction

The digitalization of medicine has led to a considerable growth of heterogeneous health datasets, which could improve healthcare research if integrated into the clinical life cycle. This process requires, amongst other things, the harmonization of these datasets, which is a prerequisite to improve their quality, re-usability and interoperability. However, there is a wide range of factors that either hinder or favor the harmonized collection, sharing and linkage of health data.

Objective

This systematic review aims to identify barriers and facilitators to health data harmonization—including data sharing and linkage—by a comparative analysis of studies from Denmark and Switzerland.

Methods

Publications from PubMed, Web of Science, EMBASE and CINAHL involving cross-institutional or cross-border collection, sharing or linkage of health data from Denmark or Switzerland were searched to identify the reported barriers and facilitators to data harmonization.

Results

Of the 345 projects included, 240 were single-country and 105 were multinational studies. Regarding national projects, a Swiss study reported on average more barriers and facilitators than a Danish study. Barriers and facilitators of a technical nature were most frequently reported.

Conclusion

This systematic review gathered evidence from Denmark and Switzerland on barriers and facilitators concerning data harmonization, sharing and linkage. Barriers and facilitators were strictly interrelated with the national context where projects were carried out. Structural changes, such as legislation implemented at the national level, were mirrored in the projects. This underlines the impact of national strategies in the field of health data. Our findings also suggest that more openness and clarity in the reporting of both barriers and facilitators to data harmonization constitute a key element to promote the successful management of new projects using health data and the implementation of proper policies in this field. Our study findings are thus meaningful beyond these two countries.

Three by three weeks of robot-enhanced repetitive gait therapy within a global rehabilitation plan improves gross motor development in children with cerebral palsy - a retrospective cohort study

AIM

To assess the improvement in gross motor function following three blocks of a three-week, intensive robot-enhanced treadmill therapy (ROBERT-Program).

METHOD

retrospective chart review in a before-after interventional trial in children with cerebral palsy attending a university hospital outpatient rehabilitation centre. Patients received three blocks of a three-week, 12 sessions ROBERT-Program over a mean period of 24 months. Outcome measures were block specific and cumulative improvement in GMFM 66, D and E. Longterm GMFM 66 improvements were compared to the individuals' expected increment as derived from previously published GMFM-66 percentiles. 95% confidence intervals (CI) and paired t-test were calculated.

RESULTS

20 children (8 GMFCS Level II; 12 GMFCS Level III, mean age 5.9 years (CI: [5.0; 6.7])) were treated. For each block a significant increase in motor performance in similar size could be observed without deterioration between blocks. The cumulative improvement during 21 months observation period was: 6.5 (CI: [4.8; 8.2]) in GMFM 66, which represents a clinically meaningful effect size of 3.6 (CI: [1.4; 5.8]) above the expected improvement.

INTERPRETATION

Progressive clinically meaningful improvement in motor performance for three blocks of ROBERT-Program was observed. Cumulative GMFM 66 improvements exceeded the individuals' age-specific expected course.

Robotics for Lower Limb Rehabilitation

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