Effect of robotic-assisted gait training on objective biomechanical measures of gait in persons post-stroke: a systematic review and meta-analysis

Effectiveness of Robotic Devices for Medical Rehabilitation: An Umbrella Review

Background/Objectives: Clinical trials have investigated the efficacy of rehabilitation robotics for various pathological conditions, but the overall impact on rehabilitation practice remains unclear. We comprehensively examined and analyzed systematic reviews (SRs) of randomized controlled trials (RCTs) investigating rehabilitative interventions with robotic devices. Methods: Four databases were searched using term combinations of keywords related to robotic devices, rehabilitation, and SRs. The SR meta-analyses were categorized into "convincing", "highly suggestive", "suggestive", "weak", or "non-significant" depending on evidence strength and validity. Results: Overall, 62 SRs of 341 RCTs involving 14,522 participants were identified. Stroke was most frequently reported (40 SRs), followed by spinal cord injury (eight SRs), multiple sclerosis (four SRs), cerebral palsy (four SRs), Parkinson's disease (three SRs), and neurological disease (any disease causing limited upper- and lower-limb functioning; three SRs). Furthermore, 38, 21, and 3 SRs focused on lower-limb devices, upper-limb devices, and both upper- and lower-limb devices, respectively. Quantitative synthesis of robotic intervention effects was performed by 51 of 62 SRs. Robot-assisted training was effective for various outcome measures per disease. Meta-analyses offering suggestive evidence were limited to studies on stroke. Upper-limb devices were effective for motor control and activities of daily living, and lower-limb devices for walking independence in stroke. Conclusions: Robotic devices are useful for improving impairments and disabilities in several diseases. Further high-quality SRs including RCTs with large sample sizes and meta-analyses of these RCTs, particularly on non-stroke-related diseases, are required. Further research should also ascertain which type of robotic device is the most effective for improving each specific impairment or disability.

Clinical Feasibility of Applying Immersive Virtual Reality during Robot-Assisted Gait Training for Individuals with Neurological Diseases: A Pilot Study

BACKGROUND

Immersive virtual reality has the potential to motivate and challenge patients who need and want to relearn movements in the process of neurorehabilitation.

OBJECTIVE

The aim of this study was to evaluate the feasibility and user acceptance of an innovative immersive virtual reality system (head-mounted display) used in combination with robot-assisted gait training in subjects suffering from neurological diseases.

METHODS

Fifteen participants suffering from cerebrovascular accident or spinal cord injury completed a single session of immersive virtual reality using a head-mounted display during a Lokomat® gait session. Training parameters and safety indicators were collected, and acceptance was investigated among participants and therapists.

RESULTS

The results suggest that an immersive virtual reality system is feasible in terms of safety and tolerance. Furthermore, the very positive overall acceptance of the system suggests that it has the potential to be included in a robot-assisted gait training session using Lokomat®.

CONCLUSION

Overall, this study demonstrates that a fully immersive virtual reality system based on a head-mounted display is both feasible and well received by cerebrovascular accident and spinal cord injury patients and their therapists during robot-assisted gait training. This study suggests that such a virtual reality system could be a viable alternative to the screen-based training games currently used in neurorehabilitation. It may be especially suitable for enhancing patient motivation and adherence to training, particularly if the application is enjoyable and not mentally taxing.

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

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

Assistive technology on upper extremity function for stroke patients: A systematic review with meta-analysis

BACKGROUND

In stroke rehabilitation, the selection of appropriate assistive devices is of paramount importance for patients. Specifically, the choice of device can significantly influence the functional recovery of the upper limb, impacting their overall activities or functional tasks.

OBJECTIVES

This review aimed to comprehensively analyze and summarize the clinical evidence from randomized controlled trials (RCTs) regarding the therapeutic effects of commonly used assistive devices on upper extremity function in patients with stroke.

METHODS

To evaluate assistive devices for patients with stroke, we summarized qualitatively throughout synthesis of results, such as therapeutic intervention, intensity, outcome, and summary of results, and examined risk of bias, heterogeneity, mean difference, 95% confidence interval, and I-squared value. To analyze, we used RoB 2 and RevMan 5.4.

RESULTS

The qualitative synthesis included 31 RCTs. The randomization process and the reporting of results showed minimal bias, but there were issues with bias from intended interventions, and missing outcome data presented some concerns. The quantitative synthesis included 16 RCTs. There was a significant difference in the Fugl-Meyer assessment-upper extremity functioning (FMA-UE) scores between the groups, with a total mean difference (95% confidence interval) of 2.40 (0.21, 4.60), heterogeneity values were Tau2 = 0.32, chi-square = 8.22, degrees of freedom = 8 (p = 0.41), and I2 = 3% for FMA-UE and the test for the overall effect produced Z = 2.14 (p = 0.03) in patients with chronic stroke. However, there was no significant difference in all other outcome measures.

CONCLUSIONS

Upper-limb robots did not demonstrate significant superiority over conventional treatments in improving function of upper limbs, with the exception of FMA-UE scores for patients with chronic stroke. The mean difference of FMA-UE was also lower than minimally important difference. Nonetheless, the usage of upper-limb robots may contribute to enhanced function for patients with stroke, as those devices support clinicians and enable a greater number of movement repetitions within specific time frames.

Efficacy of robot-assisted gait training on lower extremity function in subacute stroke patients: a systematic review and meta-analysis

BACKGROUND

Robot-Assisted Gait Training (RAGT) is a novel technology widely employed in the field of neurological rehabilitation for patients with subacute stroke. However, the effectiveness of RAGT compared to conventional gait training (CGT) in improving lower extremity function remains a topic of debate. This study aimed to investigate and compare the effects of RAGT and CGT on lower extremity movement in patients with subacute stroke.

METHODS

Comprehensive search was conducted across multiple databases, including PubMed, Web of Science, Cochrane Library, EBSCO, Embase, Scopus, China National Knowledge Infrastructure, Wan Fang, SinoMed and Vip Journal Integration Platform. The database retrieval was performed up until July 9, 2024. Meta-analysis was conducted using RevMan 5.4 software.

RESULTS

A total of 24 RCTs were included in the analysis. The results indicate that, compared with CGT, RAGT led to significant improvements in the Fugl-Meyer Assessment for Lower Extremity [MD = 2.10, 95%CI (0.62, 3.59), P = 0.005], Functional Ambulation Category[MD = 0.44, 95%CI (0.23, 0.65), P < 0.001], Berg Balance Scale [MD = 4.55, 95%CI (3.00, 6.11), P < 0.001], Timed Up and Go test [MD = -4.05, 95%CI (-5.12, -2.98), P < 0.001], and 6-Minute Walk Test [MD = 30.66, 95%CI (22.36, 38.97), P < 0.001] for patients with subacute stroke. However, it did not show a significant effect on the 10-Meter Walk Test [MD = 0.06, 95%CI (-0.01, 0.14), P = 0.08].

CONCLUSIONS

This study provides evidence that RAGT can enhance lower extremity function, balance function, walking ability, and endurance levels compared to CGT. However, the quality of evidence for improvements in gait speed remains low.

The effect of using the hip exoskeleton assistive (HEXA) robot compared to conventional physiotherapy on clinical functional outcomes in stroke patients with hemiplegia: a pilot randomized controlled trial

TRIAL DESIGN

This study is a pilot randomized clinical trial aimed to investigate the effect of using Hip Exoskeleton Assistive (HEXA) robot compared to conventional physiotherapy on the quality of walking, disability, and quality of life of stroke patients with hemiplegia.

METHODS

In this study, 24 patients were randomly assigned to the intervention group (robotic physiotherapy with HEXA robot), or control group (conventional physiotherapy). In each session, both groups received 30 min of conventional physiotherapy including electrotherapy and conventional exercises, and then the intervention group did gait training for 30 min with the HEXA robot and the control group for 30 min without the HEXA robot. The treatment program was 12 sessions, 3 times a week. Before the 1st and after the 12th sessions, both groups were evaluated for walking quality, disability, and quality of life.

RESULTS

The results showed that the main effect of time was significant (P < 0.05) in all outcomes and patients in both groups achieved significant improvement in all outcomes after the intervention. The main effect of the group was also significant in the outcomes of 6MWT (P < 0.05) and TUG (P < 0.05), and the intervention group patients experienced more distance and speed in these two tests. This study was approved by the ethics committee of Mashhad University of Medical Sciences (IR.MUMS.FHMPM.REC.1400.079 dated 28th Jan 2022). The trial was registered with the clinical trials site of www.IRCT.ir (IRCT20210730052024N1) on January 28th 2022.

CONCLUSION

It seems that the HEXA robot can effectively improve walking capacity and speed.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

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

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

Powered single hip joint exoskeletons for gait rehabilitation: a systematic review and Meta-analysis

BACKGROUND

Gait disorders and as a consequence, robotic rehabilitation techniques are becoming increasingly prevalent as the population ages. In the area of rehabilitation robotics, using lightweight single hip joint exoskeletons are of significance. Considering no prior systematic review article on clinical outcomes, we aim to systematically review powered hip exoskeletons in terms of gait parameters and metabolic expenditure effects.

METHODS

Three databases of PubMed, Scopus, and Web of science were searched for clinical articles comparing outcomes of gait rehabilitation using hip motorized exoskeleton with conventional methods, on patients with gait disorder or healthy individuals. Of total number of 37 reviewed articles, 14 trials were quantitatively analyzed. Analyses performed in terms of gait spatiotemporal parameters like speed (self-speed and maximum speed), step length, stride length, cadence, and oxygen consumption.

RESULTS

Improved clinical outcomes of gait spatiotemporal parameters with hip joint exoskeletons are what our review's findings show. In terms of gait values, meta-analysis indicates that rehabilitation with single hip joint exoskeleton enhanced parameters of maximum speed by 0.13 m/s (0.10-0.17) and step length by 0.06 m (0.05-0.07). For the remaining investigated gait parameters, no statistically significant difference was observed. Regarding metabolic parameters, oxygen consumption was lower in individuals treated with hip exoskeleton (- 1.23 ml/min/kg; range - 2.13 to - 0.32).

CONCLUSION

Although the analysis demonstrated improvement with just specific gait measures utilizing powered hip exoskeletons, the lack of improvement in all parameters is likely caused by the high patient condition heterogeneity among the evaluated articles. We also noted in patients who rehabilitated with the hip exoskeleton, the oxygen cost was lower. More randomized controlled trials are needed to verify both the short- and long-term clinical outcomes, including patient-reported measures.

LEVEL OF EVIDENCE

Level I (systematic review and meta-analysis).

Evidence for gait improvement with robotic-assisted gait training of children with cerebral palsy remains uncertain

BACKGROUND

Cerebral palsy (CP) is a group of neuromotor diseases that develops as a result of damage to the developing central nervous system during the perinatal period. The condition is usually accompanied by musculoskeletal problems resulting in movement disorders. Gait improvement therefore, is an important part of its treatment. Roboticassisted gait training (RAGT) is a new potential rehabilitation tool for CP patients, however there is no clear evidence for the effectiveness of this method.

RESEARCH QUESTION

Can robotic-assisted gait training improve walking function in children with CP?

METHODS

A systematic search was performed in five databases: MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Scopus, and Web of Science. Eligible studies were randomized controlled trials (RCT) with CP patients under the age of 18. Gross motor function and kinematic gait parameters of patients were the main outcomes. Two authors determined the risk of bias of the RCTs independently using the revised Risk of Bias 2 (ROB 2) tool. Mean Differences (MDs) along with their 95% Confidence Interval (CI) were calculated when at least three studies were present for an outcome, subgroup analysis was performed based on the treatment of the control group.

RESULTS

Of the 7363 screened articles, 13 papers met our inclusion criteria and among them, 7 studies could be used in our meta-analyses. The results related to RAGT suggest nonsignificant improvement in standing and walking function (Gross Motor Function Measure D, E), moreover changes in gait speed, step length, and in cadence were also only comparable to controls.

SIGNIFICANCE

The results indicate that there is a trend in some gait parameters where the improvement was higher in the intervention group than in control group. The therapeutic effect of RAGT was probably not superior to physiotherapy combined with treadmill training.

Users' experiences of intensive robotic-assisted gait training post-stroke - "a push forward or feeling pushed around?"

PURPOSE

Robotic-assisted gait training (RAGT) is suggested to improve walking ability after stroke. The purpose of this study was to describe experiences of robotic-assisted gait training as part of a gait training intervention among persons in the chronic phase after stroke.

MATERIALS AND METHODS

Semi-structured interviews were performed with 13 participants after a 6-week intervention including treadmill gait training with the Hybrid Assistive Limb® (HAL) exoskeleton. Data were analysed using qualitative content analysis.

RESULTS

Four categories emerged: (1) A rare opportunity for potential improvements describes the mindset before the start of the intervention; (2) Being pushed to the limit represents the experience of engaging in intensive gait training; (3) Walking with both resistance and constraints reveals barriers and facilitators during HAL training; (4) Reaching the end and taking the next step alone illustrates feelings of confidence or concern as the intervention ended.

CONCLUSIONS

The gait training intervention including RAGT was considered demanding but appreciated. Support and concrete, individual feedback was crucial for motivation, whilst the lack of variation was a barrier. Results encourage further development of exoskeletons that are comfortable to wear and stimulate active participation by enabling smoothly synchronised movements performed during task-specific activities in different environments. IMPLICATIONS FOR REHABILITATIONWhen provided in a suitable context, the mental and physical challenges of intensive robotic-assisted gait training can be both inspiring and motivating.Support and engagement along with informative feedback from therapists are suggested crucial for motivation.Intensive task-specific gait training may preferably be performed in an enriched environment and combined with other physiotherapy treatments to stimulate engagement.

End-effector lower limb robot-assisted gait training effects in subacute stroke patients: A randomized controlled pilot trial

BACKGROUND

This pilot study investigated end-effector lower limb rehabilitation robot training effects in subacute stroke patients.

METHODS

Forty-nine stroke patients were randomly assigned to 2 treatment groups: a 30-minute end-effector lower limb rehabilitation robot training plus 1.5-hour conventional physiotherapy (robot group; n = 26), or a 2-hour conventional physiotherapy (control group; n = 23). All patients received 5 treatments weekly for 4 weeks. The functional ambulatory category was the primary outcome and the motricity index, Fugl Meyer assessment-lower extremity, rivermead mobility index, 10 meter walk test, Berg balance scale, and modified Barthel index were secondary outcomes.

RESULTS

All outcome measures significantly improved in both groups after training (P > .05). The robot group improved more in FAC than the control group (P = .005).

CONCLUSIONS

Compared with conventional physiotherapy alone, end-effector lower limb robot-assisted gait training with conventional physiotherapy improved subacute stroke patients walking ability.

Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

INTRODUCTION

Practicality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes.

OBJECTIVES

To determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.

DESIGN AND SETTING

Assessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.

PARTICIPANTS

Thirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).

INTERVENTION

Lokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.

MAIN OUTCOME MEASURES

Number of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post).

RESULTS

The desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge - admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy "dose".

CONCLUSIONS

With careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in 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.

Estimation of minimal detectable change in the 10-meter walking test for patients with stroke: a study stratified by gait speed

Objective

This study aimed to classify and calculate the minimal detectable changes (MDC) in gait time and gait speed in a 10-meter walking test (10MWT) in patients with stroke classified according to their gait speed.

Methods

The participants were 84 patients with stroke. Their gait times were measured twice each at their comfortable gait speed (CGS) and maximum gait speed (MGS) on a 10-meter straight track, and gait speed was calculated using gait time. Participants were assigned to three speed groups based on their CGS: low-speed (<0.4 m/s; n = 19); moderate-speed (0.4-0.8 m/s; n = 29); and high-speed (>0.8 m/s; n = 36). For each group, first and second retest reliability and MDC of CGS and MGS were calculated using gait time and gait speed in the 10MWT.

Results

MDCs in the 10MWT at CGS were: low-speed group, gait time 5.25 s, gait speed 0.05 m/s; moderate-speed group, gait time 2.83 s, gait speed 0.11 m/s; and high-speed group, gait time 1.58 s, gait speed 0.21 m/s. MDCs in the 10MWT at MGS were: low-speed group, gait time 7.26 s, gait speed 0.04 m/s; moderate-speed group, gait time 2.48 s, gait speed 0.12 m/s; and high-speed group, gait time 1.28 s, gait speed 0.19 m/s.

Conclusion

Since the MDC of gait speed and gait time differ depending on the participant's gait speed, it is necessary to interpret the results according to the participant's gait speed when judging the effectiveness of therapeutic interventions.

Overground Robotic Gait Trainer mTPAD Improves Gait Symmetry and Weight Bearing in Stroke Survivors

Stroke is a leading cause of disability, impairing the ability to generate propulsive forces and causing significant lateral gait asymmetry. We aim to improve stroke survivors' gaits by promoting weight-bearing during affected limb stance. External forces can encourage this; e.g., vertical forces can augment the gravitational force requiring higher ground reaction forces, or lateral forces can shift the center of mass over the stance foot, altering the lateral placement of the center of pressure. With our novel design of a mobile Tethered Pelvic Assist Device (mTPAD) paired with the DeepSole system to predict the user's gait cycle percentage, we demonstrate how to apply three-dimensional forces on the pelvis without lower limb constraints. This work is the first result in the literature that shows that with an applied lateral force during affected limb stance, the center of pressure trajectory's lateral symmetry is significantly closer to a 0% symmetry (5.5%) than without external force applied (-9.8%,p<0.05). Furthermore, the affected limb's maximum relative pressure (p) significantly increases from 233.7p to 234.1p (p<0.05) with an applied downward force, increasing affected limb loading. This work highlights how the mTPAD increases weight-bearing and propulsive forces during gait, which is a crucial goal for stroke survivors.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Unexpected running perturbations: Reliability and validity of a treadmill running protocol with analysis of provoked reflex activity in the lower extremities

Introduction

Balance is vital for human health and experiments have been conducted to measure the mechanisms of postural control, for example studying reflex responses to simulated perturbations. Such studies are frequent in walking but less common in running, and an understanding of reflex responses to trip-like disturbances could enhance our understanding of human gait and improve approaches to training and rehabilitation. Therefore, the primary aim of this study was to investigate the technical validity and reliability of a treadmill running protocol with perturbations. A further exploratory aim was to evaluate the associated neuromuscular reflex responses to the perturbations, in the lower limbs.

Methods

Twelve healthy participants completed a running protocol (9 km/h) test-retest (2 weeks apart), whereby 30 unilateral perturbations were executed via the treadmill belts (presets:2.0 m/s amplitude;150 ms delay (post-heel contact);100ms duration). Validity of the perturbations was assessed via mean ± SD comparison, percentage error calculation between the preset and recorded perturbation characteristics (PE%), and coefficient of variation (CV%). Test-retest reliability (TRV%) and Bland-Altman analysis (BLA; bias ± 1.96 * SD) was calculated for reliability. To measure reflex activity, electromyography (EMG) was applied in both legs. EMG amplitudes (root mean square normalized to unperturbed strides) and latencies [ms] were analysed descriptively.

Results

Left-side perturbation amplitude was 1.9 ± 0.1 m/s, delay 105 ± 2 ms, and duration 78 ± 1 ms. Right-side perturbation amplitude was 1.9 ± 0.1 m/s, delay 118 ± 2 ms, duration 78 ± 1 ms. PE% ranged from 5–30% for the recorded perturbations. CV% of the perturbations ranged from 19.5–76.8%. TRV% for the perturbations was 6.4–16.6%. BLA for the left was amplitude: 0.0 ± 0.3m/s, delay: 0 ± 17 ms, duration: 2 ± 13 ms, and for the right was amplitude: 0.1 ± 0.7, delay: 4 ± 40 ms, duration: 1 ± 35 ms. EMG amplitudes ranged from 175 ± 141%–454 ± 359% in both limbs. Latencies were 109 ± 12–116 ± 23 ms in the tibialis anterior, and 128 ± 49-157 ± 20 ms in the biceps femoris.

Discussion

Generally, this study indicated sufficient validity and reliability of the current setup considering the technical challenges and limitations, although the reliability of the right-sided perturbations could be questioned. The protocol provoked reflex responses in the lower extremities, especially in the leading leg. Acute neuromusculoskeletal adjustments to the perturbations could be studied and compared in clinical and healthy running populations, and the protocol could be utilised to monitor chronic adaptations to interventions over time.

Effect of robot-assisted gait training on quality of life and depression in neurological impairment: A systematic review and meta-analysis

OBJECTIVE

Robot-assisted gait training (RAGT) is often used as a rehabilitation tool for neurological impairments. The purpose of this study is to investigate the effects of rehabilitation with robotic devices on quality of life and depression.

DATA SOURCES

Two electronic databases (MEDLINE and Scopus) were searched for studies from inception up to December 2022.

REVIEW METHODS

Randomized controlled trials (RCTs) and non-RCTs were pooled separately for analyses, studying each one's mental and physical health and depression. Random effect meta-analyses were run using standardized mean difference and 95% confidence interval (CI).

RESULTS

A total of 853 studies were identified from the literature search. 31 studies (17 RCTs and 14 non-RCTs) including 1151 subjects met the inclusion criteria. 31 studies were selected for the systematic review and 27 studies for the meta-analysis. The outcome measure of mental health significantly improved in favor of the RAGT group in RCTs and non-RCTs (adjusted Hedges'g 0.72, 95% CI: 0.34-1.10, adjusted Hedges g = 0.80, 95% CI 0.21-1.39, respectively). We observed a significant effect of RAGT on physical health in RCTs and non-RCTs (adjusted Hedges'g 0.58, 95% CI 0.28, 0.88, adjusted Hedges g = 0.73, 95% CI 0.12, 1.33). After realizing a sensitivity analysis in RCTs, a positive impact on depression is observed (Hedges' g of -0.66, 95% CI -1.08 to -0.24).

CONCLUSION

This study suggests that RAGT could improve the quality of life of patients with neurological impairments. A positive impact on depression is also observed in the short term. Further studies are needed to differentiate grounded and overgrounded exoskeletons as well as RCT comparing overground exoskeletons with a control group.

Robotized Knee-Ankle-Foot Orthosis-Assisted Gait Training on Genu Recurvatum during Gait in Patients with Chronic Stroke: A Feasibility Study and Case Report

Genu recurvatum (knee hyperextension) is a common problem after stroke. It is important to promote the coordination between knee and ankle movements during gait; however, no study has investigated how multi-joint assistance affects genu recurvatum. We are developing a gait training technique that uses robotized knee-ankle-foot orthosis (KAFO) to assists the knee and ankle joints simultaneously. This report aimed to investigate the safety of robotized KAFO-assisted gait training (Experiment 1) and a clinical trial to treat genu recurvatum in a patient with stroke (Experiment 2). Six healthy participants and eight patients with chronic stroke participated in Experiment 1. They received robotized KAFO-assisted gait training for one or 10 sessions. One patient with chronic stroke participated in Experiment 2 to investigate the effect of robotized KAFO-assisted gait training on genu recurvatum. The patient received the training for 30 min/day for nine days. The robot consisted of KAFO and an attached actuator of four pneumatic artificial muscles. The assistance parameters were adjusted by therapists to prevent genu recurvatum during gait. In Experiment 2, we evaluated the knee joint angle during overground gait, Fugl-Meyer Assessment of lower extremity (FMA-LE), modified Ashworth scale (MAS), Gait Assessment and Intervention Tool (G.A.I.T.), 10-m gait speed test, and 6-min walk test (6MWT) before and after the intervention without the robot. All participants completed the training in both experiments safely. In Experiment 2, genu recurvatum, FMA-LE, MAS, G.A.I.T., and 6MWT improved after robotized KAFO-assisted gait training. The results indicated that the multi-joint assistance robot may be effective for genu recurvatum after stroke.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biopsychosocial effects and experience of use of robotic and virtual reality devices in neuromotor rehabilitation: A study protocol

BACKGROUND

Robot-assisted therapy (RAT) and virtual reality (VR)-based neuromotor rehabilitation have shown promising evidence in terms of patient's neuromotor recovery, so far. However, still little is known on the perceived experience of use of robotic and VR devices and the related psychosocial impact. The present study outlines a study protocol aiming to investigate the biopsychosocial effects and the experience of use of robotic and non-immersive VR devices in patients undergoing neuromotor rehabilitation.

METHODS

Adopting a prospective, two-arm, non-randomized study design, patients with different neuromotor diseases (i.e., acquired brain injury, Parkinson's Disease, and total knee/hip arthroplasty) undergoing rehabilitation will be included. In a real-world clinical setting, short- (4 weeks) and long-term (6 months) changes in multiple patient's health domains will be investigated, including the functional status (i.e., motor functioning, ADLs, risk of falls), cognitive functioning (i.e., attention and executive functions), physical and mental health-related quality of life (HRQoL), and the psychological status (i.e., anxiety and depression, quality of life satisfaction). At post-intervention, the overall rehabilitation experience, the psychosocial impact of the robotic and VR devices will be assessed, and technology perceived usability and experience of use will be evaluated through a mixed-methods approach, including both patients' and physiotherapists' perspectives. Repeated measures within-between interaction effects will be estimated, and association analyses will be performed to explore the inter-relationships among the variables investigated. Data collection is currently ongoing.

IMPLICATIONS

The biopsychosocial framework adopted will contribute to expanding the perspective on patient's recovery within the technology-based rehabilitation field beyond motor improvement. Moreover, the investigation of devices experience of use and usability will provide further insight into technology deployment in neuromotor rehabilitation programs, thereby maximising therapy engagement and effectiveness.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05399043.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

An impairment-specific hip exoskeleton assistance for gait training in subjects with acquired brain injury: a feasibility study

This study was designed to investigate the feasibility and the potential effects on walking performance of a short gait training with a novel impairment-specific hip assistance (iHA) through a bilateral active pelvis orthosis (APO) in patients with acquired brain injury (ABI). Fourteen subjects capable of independent gait and exhibiting mild-to-moderate gait deficits, due to an ABI, were enrolled. Subjects presenting deficit in hip flexion and/or extension were included and divided into two groups based on the presence (group A, n = 6) or absence (group B, n = 8) of knee hyperextension during stance phase of walking. Two iHA-based profiles were developed for the groups. The protocol included two overground gait training sessions using APO, and two evaluation sessions, pre and post training. Primary outcomes were pre vs. post-training walking distance and steady-state speed in the 6-min walking test. Secondary outcomes were self-selected speed, joint kinematics and kinetics, gait symmetry and forward propulsion, assessed through 3D gait analysis. Following the training, study participants significantly increased the walked distance and average steady-state speed in the 6-min walking tests, both when walking with and without the APO. The increased walked distance surpassed the minimal clinically important difference for groups A and B, (respectively, 42 and 57 m > 34 m). In group A, five out of six subjects had decreased knee hyperextension at the post-training session (on average the peak of the knee extension angle was reduced by 36%). Knee flexion during swing phase increased, by 16% and 31%, for A and B groups respectively. Two-day gait training with APO providing iHA was effective and safe in improving walking performance and knee kinematics in ABI survivors. These preliminary findings suggest that this strategy may be viable for subject-specific post-ABI gait rehabilitation.

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

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

Update on Stroke Rehabilitation in Motor Impairment

Motor impairment due to stroke limits patients' mobility, activities of daily living, and negatively affects their return to the workplace. It also reduces patients' quality of life and increases the socioeconomic burden of stroke. Therefore, optimizing the recovery of motor impairment after stroke is a very important goal for both individuals and society as a whole. The emergence and improvement of various technologies in the Fourth Industrial Revolution have exerted a major influence on the development of new rehabilitation methods and efficiency enhancements for existing methods. This review categorizes rehabilitation methods that promote the recovery of motor function into upper limb function and lower limb function and summarizes recent advances in stroke rehabilitation. Although debate continues regarding the effects of some rehabilitation therapies, it is hoped that the evidence will be improved through ongoing research so that clinicians can treat patients with a higher level of evidence.

Hardware Development and Safety Control Strategy Design for a Mobile Rehabilitation Robot

The use of bodyweight unloading force control on a treadmill with therapist manual assistance for gait training imposes constraints on natural walking. It influences the patient’s training effect for a full range of natural walks. This study presents a prototype and a safety controller for a mobile rehabilitation robot (MRR). The prototype integrates an autonomous mobile bodyweight support system (AMBSS) with a lower-limb exoskeleton system (LES) to simultaneously achieve natural over-ground gait training and motion relearning. Human-centered rehabilitation robots must guarantee the safety of patients in the presence of significant tracking errors. It is difficult for traditional stiff controllers to ensure safety and excellent tracking accuracy concurrently, because they cannot explicitly guarantee smooth, safe, and overdamped motions without overshoot. This paper integrated a linear extended state observer (LESO) into proxy-based sliding mode control (ILESO-PSMC) to overcome this problem. The LESO was used to observe the system’s unknown states and total disturbance simultaneously, ensuring that the “proxy” tracks the reference target accurately and avoids the unsafe control of the MRR. Based on the Lyapunov theorem to prove the closed-loop system stability, the proposed safety control strategy has three advantages: (1) it provides an accurate and safe control without worsening tracking performance during regular operation, (2) it guarantees safe recoveries and overdamped properties after abnormal events, and (3) it need not identify the system model and measure unknown system states as well as external disturbance, which is quite difficult for human–robot interaction (HRI) systems. The results demonstrate the feasibility of the proposed ILESO-PSMC for MRR. The experimental comparison also indicates better safety performance for the ILESO-PSMC than for the conventional proportional–integral–derivative (PID) control.

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.

Technical Diagnosis on Elite Female Discus Athletes Based on Grey Relational Analysis

The personalized training of elite athletes is the key to the breakthrough of Chinese track and field events in the Tokyo Olympic Games. The brilliance of Chinese women's throwing benefits from the closed-loop personalized training system. Training starts from the construction of accurate personalized technology and physical fitness model. This paper introduces the concept of champion model and puts forward a targeted technical training system based on the differentiation research of champion model. This paper mainly studies and analyzes some important technical parameters and achievements of elite female discus athletes aged 2018∼2021 by using the methods of Pearson, partial correlation and grey correlation analysis. We select from several technical parameters with significant differences, choose from several technical parameters that have significant difference, and calculate the correlation parameters and results. The results show that the influence degree of these technical parameters is as follows: torso angle of right foot touching the ground, discus release angle, discus release speed, shoulder and arm passing angle of left foot off the ground, discus moving distance of double support, center of mass moving distance of double support, and time of the second single support stage. This is different from our view that the hand speed is the most important, so the training of elite athletes should be more refined and specialized to promote the improvement of their performance. Through the application of technical diagnosis model in Chen Yang in a period of time, Chen Yang got her best result (65.14 m) in Chongqing Athletics Championship, which verified the success of the technical diagnosis model and application in this study.

Minimal Contact Robotic Stroke Rehabilitation on Risk of COVID-19, Work Efficiency and Sensorimotor Function

Patients with hemiparetic stroke undergo direct, labor-intensive hands-on conventional physical therapy to improve sensorimotor function, spasticity, balance, trunk stability, and activities of daily living (ADLs). Currently, direct, intensive hands-on therapeutic modalities have increased concerns during the coronavirus (COVID-19) global pandemic. We developed an innovative Walkbot to mitigate the issues surrounding conventional hands-on physical therapy. We aimed to compare the effects of minimal-contact robotic rehabilitation (MRR) and full-contact conventional rehabilitation (FCR) on static and dynamic balance, trunk stability, ADLs, spasticity, and cognition changes in patients with hemiparetic stroke. A total of 64 patients with hemiparetic stroke (mean age = 66.38 ± 13.17; 27 women) underwent either MRR or FCR three times/week for 6 weeks. Clinical outcome measurements included the Trunk Impairment Scale (TIS), the Berg Balance Scale (BBS), the modified Ashworth Scale (MAS), the Fugl—Meyer Assessment (FMA), and the modified Barthel Index (MBI) scores. A 2 × 2 repeated analysis of variance (ANOVA) was performed, and an independent t-test was used to determine statistical differences in the physiotherapists’ work efficiency and COVID-19 transmission risk. The ANOVA showed that MRR had effects superior to those of FCR on the TIS, the BBS, the FMA, and the MBI (p < 0.05), but not on the MAS (p = 0.230). MRR showed a greater decrease on the physiotherapist’s work efficiency and COVID-19 transmission risk (p < 0.05). Our results provide clinical evidence that robot-assisted locomotor training helps maximize the recovery of sensorimotor function, abnormal synergy, balance, ADLs, and trunk stability, and facilitates a safer environment and less labor demand than conventional stroke rehabilitation.

Core Sets of Kinematic Variables to Consider for Evaluation of Gait Post-stroke

Background

Instrumented gait analysis post-stroke is becoming increasingly more common in research and clinics. Although overall standardized procedures are proposed, an almost infinite number of potential variables for kinematic analysis is generated and there remains a lack of consensus regarding which are the most important for sufficient evaluation. The current aim was to identify a discriminative core set of kinematic variables for gait post-stroke.

Methods

We applied a three-step process of statistical analysis on commonly used kinematic gait variables comprising the whole body, derived from 3D motion data on 31 persons post-stroke and 41 non-disabled controls. The process of identifying relevant core sets involved: (1) exclusion of variables for which there were no significant group differences; (2) systematic investigation of one, or combinations of either two, three, or four significant variables whereby each core set was evaluated using a leave-one-out cross-validation combined with logistic regression to estimate a misclassification rate (MR).

Results

The best MR for one single variable was shown for the Duration of single-support (MR 0.10) or Duration of 2nd double-support (MR 0.11) phase, corresponding to an 89–90% probability of correctly classifying a person as post-stroke/control. Adding Pelvis sagittal ROM to either of the variables Self-selected gait speed or Stride length, alternatively adding Ankle sagittal ROM to the Duration of single-stance phase, increased the probability of correctly classifying individuals to 93–94% (MR 0.06). Combining three variables decreased the MR further to 0.04, suggesting a probability of 96% for correct classification. These core sets contained: (1) a spatial (Stride/Step length) or a temporal variable (Self-selected gait speed/Stance time/Swing time or Duration of 2nd double-support), (2) Pelvis sagittal ROM or Ankle plantarflexion during push-off, and (3) Arm Posture Score or Cadence or a knee/shoulder joint angle variable. Adding a fourth variable did not further improve the MR.

Conclusion

A core set combining a few crucial kinematic variables may sufficiently evaluate post-stroke gait and should receive more attention in rehabilitation. Our results may contribute toward a consensus on gait evaluation post-stroke, which could substantially facilitate future diagnosis and monitoring of rehabilitation progress.