Training with robot-applied resistance in people with motor-incomplete spinal cord injury: Pilot study

Traumatic spinal cord injury: a review of the current state of art and future directions - what do we know and where are we going?

Background

Traumatic spinal cord injury (SCI) remains a devastating condition, with limited functional recovery despite advancements in clinical management and understanding of its mechanisms. SCI pathophysiology involves primary mechanical trauma and secondary neuroimmune and structural changes, leading to neuronal death and chronic functional deficits.

Methods

Through a comprehensive literature review of articles published in the PubMed, MEDLINE, Embase, and Cochrane Reviews Library databases, this article provides an update on the current management of traumatic SCI with a focus on these emerging therapeutic strategies that hold potential for future advancements in the field.

Results

Current management strategies include pre-hospital care, acute clinical interventions, surgical decompression and spine destabilization, and neurorehabilitation. Despite these interventions, SCI patients often fail to fully restore lost functions. Emerging therapies focus on neuroprotection, neuroregeneration, and neuromodulation, leveraging advances in molecular biomarkers, imaging techniques, and cell-based treatments. Neuroprotective agents, including the sodium-glutamate antagonist riluzole, aim to keep cells alive through the secondary injury phase, while regenerative strategies utilize neurotrophic factors and stem cell transplantation or approaches to target inhibitor molecules such as NOGO or RGMa to regenerate new cells, axons, and neural circuits. Neuromodulation techniques, such as electrical and magnetic field stimulation, offer promising avenues for functional recovery. Combining these novel therapies with traditional neurorehabilitation holds potential for improved outcomes.

Conclusions

While significant strides have been made in understanding the mechanisms underlying SCI and in developing novel therapeutic approaches, the challenge and opportunity will be to tailor treatments to fit the heterogenous clinical presentation of patients with SCI and to better understand the heterogeneity in clinical trajectories.

Enhanced rehabilitation for unstable pelvic tile C fractures: integrating mechanotherapy and early intervention

BACKGROUND AND OBJECTIVES

This study aimed to enhance the rehabilitation process for patients with unstable pelvic Tile C fractures resulting from polytrauma by integrating mechanotherapy using the Hocoma Lokomat robotic device with conventional rehabilitation methods. The goal was to improve functional recovery outcomes and minimize pain levels following surgical intervention.

METHODS

A total of 74 participants, aged 21 to 65 years, with severe unstable pelvic Tile C fractures were enrolled at Tongji Hospital's Department of Rehabilitation from 2022 to 2024. They were randomly divided into two groups: Group A (34 patients) received comprehensive rehabilitation including mechanotherapy with the Hocoma Lokomat, while Group B (40 patients) underwent only conventional therapeutic exercises. Functional outcomes were assessed using the Majeed pelvic score, and pain were monitored over time.

RESULTS

Group A demonstrated significantly better pelvic function scores compared to Group B throughout the rehabilitation period(91.53 ± 4.10vs. 88.17 ± 5.15). Additionally, at the six-month follow-up, Group A showed superior pain control benefits attributed to mechanotherapy(2.09 ± 1.10vs2.29 ± 1.12).

CONCLUSION

Integrating the Hocoma Lokomat into rehab for unstable pelvic Tile C fractures improves function and pain control versus conventional care. The study supports robotic-assisted therapy's benefits for polytrauma patients, advocating innovative rehab approaches.

The efficacy of exoskeleton robotic training on ambulation recovery in patients with spinal cord injury: A meta-analysis

Objective: To discuss the efficacy of exoskeleton robotic training on ambulation recovery in patients with spinal cord injury (SCI).Methods: PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched systematically from their inception to April 2022 for studies on exoskeleton robotic training in patients with SCI. The language was restricted to English. The retrieved studies were screened to select eligible clinical trials. Meta-analysis was performed using Review Manager 5.4.Results: Eleven randomized clinical trials (RCTs) involving 456 participants were included in the meta-analysis. The results of the meta-analysis showed that exoskeleton robotic training was more effective in improving FIM [SMD = 0.58, 95%CI = (0.07, 1.10), P = 0.03], LEMS [MD = 4.64, 95%CI = (3.58, 5.70), P<0.05], MAS [MD = 0.76, 95%CI = (0.48, 1.03), P<0.05] and BBS [MD = -3.11, 95%CI =  (-12.59, 6.36), P<0.05] in patients with SCI, compared to conventional gait training(CGT). Subgroup analysis showed that the exoskeleton robotic could significantly improve the walking endurance and walking speed of patients with a duration of injury within 6 months. The sensitivity of inverted funnel plot analysis is low, suggesting that the analysis results of this study are relatively stable.Conclusion: Exoskeleton robotic training improves ambulation in patients with SCI, especially for patients with a course of injury within six months.

Assessing the Efficacy of Lokomat Training in Pediatric Physiotherapy for Cerebral Palsy: A Progress Evaluation

Background: Gait disturbances in children with cerebral palsy can increase the hindrance caused by loss of independence and social engagement. The Lokomat, developed by Hocoma, shows promise as a supplementary tool for gait rehabilitation. This study investigates the impact of Lokomat training on gait parameters and trends observed during training. Methods: A total of 26 children (13 male individuals) with a diagnosis of cerebral palsy (CP), aged 4 to 23 years, were enrolled in the study. Patients participated in a standard comprehensive rehabilitation program with additional Lokomat training sessions. Gait function was assessed using the Timed Up and Go Test (TUG) and the 10 m walking test (10mWT) at the beginning and end of the rehabilitation period. Changes in Lokomat parameters (step number, session duration, speed, body weight support, and guidance force) were also analysed. Results: The median duration of the 10mWT and TUG significantly decreased across the groups after the treatment program. The highest increases were observed for the number of steps taken. Across the entire cohort, the linear trend curves for distance and number of steps exhibited near-perpendicular alignment with the horizontal axis, suggesting significant improvement in these parameters. A consistent trend was noted for speed, with the trend line aligned parallel with the horizontal axis. Decreasing trends were observed for body weight support and guidance force. Conclusions: Therapy with the Lokomat functioning as the active gait orthosis can be used as a form of support to the standard rehabilitation protocol for patients with CP.

The Current Update of Conventional and Innovative Treatment Strategies for Central Nervous System Injury

This review explores the complex challenges and advancements in the treatment of traumatic brain injury (TBI) and spinal cord injury (SCI). Traumatic injuries to the central nervous system (CNS) trigger intricate pathophysiological responses, frequently leading to profound and enduring disabilities. This article delves into the dual phases of injury-primary impacts and the subsequent secondary biochemical cascades-that worsen initial damage. Conventional treatments have traditionally prioritized immediate stabilization, surgical interventions, and supportive medical care to manage both the primary and secondary damage associated with central nervous system injuries. We explore current surgical and medical management strategies, emphasizing the crucial role of rehabilitation and the promising potential of stem cell therapies and immune modulation. Advances in stem cell therapy, gene editing, and neuroprosthetics are revolutionizing treatment approaches, providing opportunities not just for recovery but also for the regeneration of impaired neural tissues. This review aims to emphasize emerging therapeutic strategies that hold promise for enhancing outcomes and improving the quality of life for affected individuals worldwide.

Gait Performance and Brain Activity Are Improved by Gait Automatization during Robot-Assisted Gait Training in Patients with Burns: A Prospective, Randomized, Single-Blinded Study

Background: Patients with lower extremity burn injuries have decreased gait function. Gait dysfunctions are compensated by activation of executive areas such as the prefrontal cortex (PFC). Although robot-assisted gait training (RAGT) can improve gait function, the training mechanisms of RAGT are unknown. We aimed to determine the clinical effects of RAGT in patients with burns and investigate their underlying mechanisms. Methods: This single-blind, randomized controlled trial involved 54 patients with lower extremity burns. The RAGT group underwent RAGT using SUBAR® and conventional training. The control (CON) group underwent only conventional training. The primary outcome was cortical activity measured using a functional near-infrared spectroscopy device before and after 8 weeks of training to confirm the compensatory effect of gait dysfunction. The secondary outcomes were the functional ambulation category (FAC) to evaluate gait performance, 6-min walking test (6 MWT) distance to measure gait speed, isometric force and range of motion (ROM) of lower extremities to evaluate physical function, and the visual analog scale (VAS) score to evaluate subjective pain during gait. Results: PFC activation during the gait phase in the RAGT group decreased significantly compared with that of the CON. The VAS score decreased and FAC score improved after 8 weeks of training in both groups. The 6 MWT scores, isometric strengths (the left knee flexor and bilateral ankle plantar flexors), and the ROMs (the extensions of bilateral hip and bilateral knee) of the RAGT group were significantly improved compared with those of the CON. RAGT improved gait speed, lower extremity ROMs, and lower extremity muscles strengths in patients with burns. Conclusions: The improvement in gait speed and cerebral blood flow evaluation results suggests that the automatization of gait is related to the treatment mechanism during RAGT.

Functional resistance training during walking: do biomechanical and neural effects differ based on targeted joints?

Devices for functional resistance training (FRT) during walking are often configured to resist the knee or both the hip and knee joints. Adding resistance to the hip in addition to the knee should alter the effects of training; however, these configurations have not been directly compared. We examined how FRT during walking differs during the knee or hip and knee conditions. Fourteen non-disabled individuals received FRT during treadmill walking with a device configured to provide a viscous resistance to the knee or the hip and knee during separate visits. Between these configurations, we compared gait kinetics, muscle activation, kinematic aftereffects, peripheral fatigue, and corticospinal excitability. Adding resistance to the hip increased hip flexion moment and concentric power during the swing phase. However, this did not result in significant differences in muscle activation, aftereffects, peripheral fatigue, or corticospinal excitability between the configurations. Instead, both configurations produced similar changes in these variables. These results indicate that, aside from kinetics, walking with resistance at the hip and knee was not different from resisting the knee in the acute setting. However, further research is needed to determine if long-term training with resistance at the hip induces differential effects than resisting the knee alone.

The effect of robot-assisted gait training for patients with spinal cord injury: a systematic review and meta-analysis

Background

With the aging of the global population, Spinal injuries are often prone to occur and affect human health. The development of technology has put robots on the stage to assist in the treatment of spinal injuries.

Methods

A comprehensive literature search were carried out in multiple databases, including PubMed, Medline (Ovid), Web of Science, Cochrane, Embase, Scopus, CKNI, Wang fang, VIP database, Sino Med, Clinical Trails until 20th, June, 2023 to collect effect of robot-assisted gait training for patients with spinal cord injury patients. Primary outcome includes any changes of gait distance and gait speed. Secondary outcomes include any changes in functions (Such as TUG, Leg strength, 10 MWT) and any advent events. Data were extracted from two independent individuals and Cochrane Risk of Bias tool version 2.0 was assessed for the included studies. Systematic review and meta-analysis were performed by RevMan 5.3 software.

Results

11 studies were included in meta-analysis. The result showed that gait distance [WMD = 16.05, 95% CI (-15.73, 47.83), I2 = 69%], gait speed (RAGT vs. regular treatment) [WMD = 0.01, 95% CI (-0.04, 0.05), I2 = 43%], gait speed (RAGT vs. no intervention) [WMD = 0.07, 95% CI (0.01, 0.12), I2 = 0%], leg strength [WMD = 0.59, 95% CI (-1.22, 2.40), I2 = 29%], TUG [WMD = 9.25, 95% CI (2.76, 15.73), I2 = 74%], 10 MWT [WMD = 0.01, 95% CI (-0.15, 0.16), I2 = 0%], and 6 MWT [WMD = 1.79, 95% CI (-21.32, 24.90), I2 = 0%].

Conclusion

Robot-assisted gait training seems to be helpful for patients with spinal cord to improve TUG. It may not affect gait distance, gait speed, leg strength, 10 MWT, and 6 MWT.

Normative reference values for Obstacles Test and Curb Test and their correlation with demographic characteristics: a cross-sectional study in Saudi children

The Obstacles Test and Curb Test have been used to measure gait speed and functional balance in adults. Recently, they have been modified for use in children but the normative values have not been established. This requires correlating the sex, age, height, weight, and BMI% of children with the test results and developing prediction equations. In this cross-sectional study, the Obstacles Test and Curb Test were administered to a convenience sample of 240 typically developing children aged 6-11 years. The factors associated with the time to complete each test were studied and prediction equations were established. The completion times were 5.27 ± 0.81 s for the Obstacles Test and 2.82 ± 0.45 s for the Curb Test. The Obstacles Test showed a fair negative relationship with height (Pearson's r  = -0.41, P  < 0.001), age ( r  = -0.35, P  < 0.001), and weight ( r  = -0.32, P  < 0.05). The Curb Test also had fair negative correlations with height ( r  = -0.42, P  < 0.001), age ( r  = -0.39, P  < 0.001), and weight ( r  = -0.31, P  < 0.001). Both tests showed poor correlations with the sex [eta ( η ) = 0.15 and 0.12, respectively]. Nonetheless, age and sex emerged as the main predictors of both test scores, accounting for 14% and 17% of the total variance in the Obstacles Test and Curb Test times, respectively. Normative values and prediction equations for both tests in typically developing children may be used for individual comparisons and in clinical research for the evaluation of interventions targeting disabled children.

Effectiveness of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for incomplete spinal cord injury: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effects of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for people with incomplete spinal cord injury.

METHODS

PubMed, Embase, Web of Science, PEDro, CENTRAL and CINAHL were searched from inception until September 4, 2022. Randomized controlled trials that evaluated the effects of robotic-assisted gait training on cardiopulmonary fitness and exercise capacity for individuals with incomplete spinal cord injury were selected. Mean differences (MD) with 95% confidence interval (CI) were calculated. The methodological quality was evaluated by the Cochrane Risk of Bias 2.0 tool. Subgroup analyses were conducted according to the time since injury.

RESULTS

In total 19 studies involving 770 patients were eligible for analysis. Individuals with acute incomplete spinal cord injury in robotic-assisted gait training groups showed significantly greater improvements in 6-minute walking test (MD 53.32; 95% CI 33.49 to 73.15; P < 0.001), lower extremity motor scale (MD 5.22; 95% CI 3.63 to 6.80; P < 0.001) and walking index for spinal cord injury II (MD 3.18; 95% CI 1.34 to 5.02; P < 0.001). Robotic-assisted gait training improved peak oxygen consumption to a greater degree for chronic incomplete spinal cord injury patients (MD 4.90; 95% CI 0.96 to 8.84; P = 0.01).

CONCLUSION

Robot-assisted gait training may be a feasible and effective intervention in terms of cardiopulmonary fitness and exercise capacity for individuals with incomplete spinal cord injury.

Gait robot-assisted rehabilitation in persons with spinal cord injury: A scoping review

BACKGROUND

Many robots are available for gait rehabilitation (BWSTRT and ORET) and their application in persons with SCI allowed an improvement of walking function.

OBJECTIVE

The aim of the study is to compare the effects of different robotic exoskeletons gait training in persons with different SCI level and severity.

METHODS

Sixty-two studies were included in this systematic review; the study quality was assessed according to GRADE and PEDro's scale.

RESULTS

Quality assessment of included studies (n = 62) demonstrated a prevalence of evidence level 2; the quality of the studies was higher for BWSTRT (excellent and good) than for ORET (fair and good). Almost all persons recruited for BWSTRT had an incomplete SCI; both complete and incomplete SCI were recruited for ORET. The SCI lesion level in the persons recruited for BWSTRT are from cervical to sacral; mainly from thoracic to sacral for ORET; a high representation of AIS D lesion resulted both for BWSTRT (30%) and for ORET (45%). The walking performance, tested with 10MWT, 6MWT, TUG and WISCI, improved after exoskeleton training in persons with incomplete SCI lesions, when at least 20 sessions were applied. Persons with complete SCI lesions improved the dexterity in walking with exoskeleton, but did not recover independent walking function; symptoms such as spasticity, pain and cardiovascular endurance improved.

CONCLUSION

Different exoskeletons are available for walking rehabilitation in persons with SCI. The choice about the kind of robotic gait training should be addressed on the basis of the lesion severity and the possible comorbidities.

Applying Hip Stiffness With an Exoskeleton to Compensate Gait Kinematics

Neurological disorders and aging induce impaired gait kinematics. Despite recent advances, effective methods using lower-limb exoskeleton robots to restore gait kinematics are as yet limited. In this study, applying virtual stiffness using a hip exoskeleton was investigated as a possible method to guide users to change their gait kinematics. With a view to applications in locomotor rehabilitation, either to provide assistance or promote recovery, this study assessed whether imposed stiffness induced changes in the gait pattern during walking; and whether any changes persisted upon removal of the intervention, which would indicate changes in central neuro-motor control. Both positive and negative stiffness induced immediate and persistent changes of gait kinematics. However, the results showed little behavioral evidence of persistent changes in neuro-motor control, not even short-lived aftereffects. In addition, stride duration was little affected, suggesting that at least two dissociable layers exist in the neuro-motor control of human walking. The lack of neuro-motor adaptation suggests that, within broad limits, the central nervous system is surprisingly indifferent to the details of lower limb kinematics. The lack of neuro-motor adaptation also suggests that alternative methods may be required to implement a therapeutic technology to promote recovery. However, the immediate, significant, and reproducible changes in kinematics suggest that applying hip stiffness with an exoskeleton may be an effective assistive technology for compensation.

Motor improvements enabled by spinal cord stimulation combined with physical training after spinal cord injury: review of experimental evidence in animals and humans

Electrical spinal cord stimulation (SCS) has been gaining momentum as a potential therapy for motor paralysis in consequence of spinal cord injury (SCI). Specifically, recent studies combining SCS with activity-based training have reported unprecedented improvements in motor function in people with chronic SCI that persist even without stimulation. In this work, we first provide an overview of the critical scientific advancements that have led to the current uses of SCS in neurorehabilitation: e.g. the understanding that SCS activates dormant spinal circuits below the lesion by recruiting large-to-medium diameter sensory afferents within the posterior roots. We discuss how this led to the standardization of implant position which resulted in consistent observations by independent clinical studies that SCS in combination with physical training promotes improvements in motor performance and neurorecovery. While all reported participants were able to move previously paralyzed limbs from day 1, recovery of more complex motor functions was gradual, and the timeframe for first observations was proportional to the task complexity. Interestingly, individuals with SCI classified as AIS B and C regained motor function in paralyzed joints even without stimulation, but not individuals with motor and sensory complete SCI (AIS A). Experiments in animal models of SCI investigating the potential mechanisms underpinning this neurorecovery suggest a synaptic reorganization of cortico-reticulo-spinal circuits that correlate with improvements in voluntary motor control. Future experiments in humans and animal models of paralysis will be critical to understand the potential and limits for functional improvements in people with different types, levels, timeframes, and severities of SCI.

Motor slacking during resisted treadmill walking: Can visual feedback of kinematics reduce this behavior?

BACKGROUND

Functional resistance training is frequently applied to rehabilitate individuals with neuromusculoskeletal injuries. It is performed by applying resistance in conjunction with a task-specific training, such as walking. However, the benefits of this training may be limited by motor slacking, a phenomenon in which the human body attempts to reduce muscle activation levels or movement excursions to minimize metabolic- or movement-related costs. While kinematic feedback could reduce one's tendency to minimize effort during training, this has not been verified experimentally.

RESEARCH QUESTION

Does functional resistance training during walking lead to motor slacking, and can techniques such as visual feedback be used to reduce these effects?

METHODS

Fourteen able-bodied individuals participated in this experiment. Participants were trained by walking on a treadmill while a bidirectional resistance was applied to the knee using a robotic knee exoskeleton. During training, participants were either instructed to walk in a manner that felt natural or were provided real-time visual feedback of their kinematics. Electromyography and knee kinematics were measured to determine if adding resistance to the limb induced slacking and if feedback could reduce slacking behavior. Kinematic aftereffects were measured after training bouts to gauge adaptation.

RESULTS

Functional resistance training without feedback significantly reduced knee flexion when compared to baseline walking, indicating that participants were slacking. This reduction in knee flexion did not improve with continued training. Providing visual feedback of knee joint kinematics during training significantly increased knee muscle activation and kinematic aftereffects.

SIGNIFICANCE

The findings indicate that individuals are susceptible to motor slacking during functional resistance training, which could affect outcomes of this training. However, motor slacking can be reduced if training is provided in conjunction with a feedback paradigm. This finding underscores the importance of using additional methods that externally motivate motor adaptation when the body is not intrinsically motivated to do so.

Robot-assisted gait training in individuals with spinal cord injury: A systematic review for the clinical effectiveness of Lokomat

BACKGROUND

Spinal cord injury (SCI) is a critical medical condition that causes numerous impairments leading to accompanying disability. Robotic-assisted gait training (RAGT) offers many advantages, including the capability to increase the intensity and total duration of training while maintaining a physiological gait pattern. The effects of the RAGT 'Lokomat' on various impairments following SCI remain unclear.

OBJECTIVES

This review was conducted to examine the impacts of the RAGT 'Lokomat' on the impairments following SCI.

METHODS

We searched PubMed, SCOPUS, PEDro, REHABDATA, MEDLINE, EMBASE, and web of science from inception to January 2021. Experimental studies examining the effects of the Lokomat on the impairments following incomplete SCI were selected. The methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Sixteen studies were met the inclusion criteria. Thirteen were randomized controlled trials, two were clinical trials, and one was a pilot study. The scores on the PEDro scale ranged from two to eight, with a median score of six. The results showed evidence for the beneficial effects of the Lokomat on many motor impairments following incomplete SCI.

CONCLUSIONS

The Lokomat may improve gait speed, walking distance, strength, range of motion, and mobility after incomplete SCI. There is insufficient evidence for the effect of the Lokomat on balance, depression, cardiorespiratory fitness, and quality of life. The effects of the Lokomat on the lower extremity spasticity were limited.

Catalpol Protects Against Spinal Cord Injury in Mice Through Regulating MicroRNA-142-Mediated HMGB1/TLR4/NF-κB Signaling Pathway

Background: Spinal cord injury (SCI) is a devastating condition that leads to paralysis, disability and even death in severe cases. Inflammation, apoptosis and oxidative stress in neurons are key pathogenic processes in SCI. Catalpol (CTP), an iridoid glycoside extracted from Rehmannia glutinosa, has many pharmacological activities, such as anti-inflammatory, anti-oxidative and anti-apoptotic properties.

Purpose: Here, we investigated whether CTP could exert neuroprotective effects against SCI, and explored the underlying mechanism involved.

Methods: SCI was induced by a weight-drop device and treated with CTP (10 mg and 60 mg/kg). Then the locomotor function of SCI mice was evaluated by the BBB scores, spinal cord edema was measured by the wet/dry weight method, oxidative stress markers and inflammatory factors were detected by commercial kits and neuronal death was measured by TUNEL staining. Moreover, the microRNA expression profile in spinal cords from mice following SCI was analyzed using miRNA microarray. In addition, reactive oxygen species (ROS) generation, inflammatory response and cell apoptosis were detected in murine microglia BV2 cells under oxygen-glucose deprivation (OGD) and CTPtreatment.

Results: Our data showed that CTP treatment could improve the functional recovery, as well as suppress the apoptosis, alleviate inflammatory and oxidative response in SCI mice. In addition, CTP was found to be up-regulated miR-142 and the protective effects of CTP on apoptosis, inflammatory and oxidative response may relate to its regulation of HMGB1/TLR4/NF-κB pathway through miR-142.

Conclusion: Our findings suggest that CTP may protect the spinal cord from SCI by suppression of apoptosis, oxidative stress and inflammatory response via miR-142/HMGB1/TLR4/NF-κB pathway.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Pavlovian control of intraspinal microstimulation to produce over-ground walking

OBJECTIVE

Neuromodulation technologies are increasingly used for improving function after neural injury. To achieve a symbiotic relationship between device and user, the device must augment remaining function, and independently adapt to day-to-day changes in function. The goal of this study was to develop predictive control strategies to produce over-ground walking in a model of hemisection spinal cord injury (SCI) using intraspinal microstimulation (ISMS).

APPROACH

Eight cats were anaesthetized and placed in a sling over a walkway. The residual function of a hemisection SCI was mimicked by manually moving one hind-limb through the walking cycle. ISMS targeted motor networks in the lumbosacral enlargement to activate muscles in the other, presumably 'paralyzed' limb, using low levels of current (<130 μA). Four people took turns to move the 'intact' limb, generating four different walking styles. Two control strategies, which used ground reaction force and angular velocity information about the manually moved 'intact' limb to control the timing of the transitions of the 'paralyzed' limb through the step cycle, were compared. The first strategy used thresholds on the raw sensor values to initiate transitions. The second strategy used reinforcement learning and Pavlovian control to learn predictions about the sensor values. Thresholds on the predictions were then used to initiate transitions.

MAIN RESULTS

Both control strategies were able to produce alternating, over-ground walking. Transitions based on raw sensor values required manual tuning of thresholds for each person to produce walking, whereas Pavlovian control did not. Learning occurred quickly during walking: predictions of the sensor signals were learned rapidly, initiating correct transitions after ≤4 steps. Pavlovian control was resilient to different walking styles and different cats, and recovered from induced mistakes during walking.

SIGNIFICANCE

This work demonstrates, for the first time, that Pavlovian control can augment remaining function and facilitate personalized walking with minimal tuning requirements.

Effects of Robot-Assisted Gait Training in Individuals with Spinal Cord Injury: A Meta-analysis

Background

To investigate the effects of robot-assisted gait training (RAGT) on spasticity and pain in people with spinal cord injury (SCI). Material and methods. Four electronic databases (PubMed, Scopus, Medline, and Cochrane Central Register of Controlled Trials) were searched for studies published up to November 2019. Only human trials and of English language were included. The searched studies were reviewed and extracted independently by two authors. Randomized controlled trials (RCTs) and non-RCTs were pooled separately for analyses. Primary outcome measures included spasticity assessed by Ashworth scale (AS) or modified Ashworth scale (MAS) and pain assessed by VAS. Secondary outcome measures included lower extremity motor score (LEMS) and walking ability (i.e., 6-minute walk test, 10-meter walk test).

Results

A total of 225 studies were identified. Eighteen studies (7 RCTs and 11 non-RCTs) including 301 subjects met inclusion criteria. The outcome measure of spasticity significantly improved in favor of RAGT group in non-RCTs (AS: 95%CI = −0.202 to -0.068, p ≤ 0.001; MAS: 95%CI = −2.886 to -1.412, p ≤ 0.001). The results on pain did not show significant change after RAGT in either RCTs or non-RCTs. LEMS and walking ability significantly increased in favor of RAGT.

Conclusions

RAGT can improve spasticity and walking ability in people with SCI. The probable reason for no significant change in pain after RAGT is floor effect. RAGT is beneficial for normalizing muscle tone and for improving lower extremity function in people with SCI without causing extra pain.

Functional resistance training during walking: Mode of application differentially affects gait biomechanics and muscle activation patterns

BACKGROUND

Task-specific loading of the limbs-termed as functional resistance training-is commonly used in gait rehabilitation; however, the biomechanical and neuromuscular effects of various forms of functional resistance training have not been studied systematically. This information is crucial for correctly selecting the appropriate mode of functional resistance training when treating individuals with gait disorders.

RESEARCH QUESTION

To comprehensively evaluate the biomechanical (i.e., joint moment and power) and muscle activation changes with different forms of functional resistance training that are commonly used in clinics and research using biomechanical simulation-based analyses.

METHODS

We developed simulations of functional resistance training during walking using OpenSim (Gait2354, 23 degrees of freedom and 54 muscles) and custom MATLAB scripts. We investigated five modes of functional resistance training that have been commonly used in clinics or in research: (1) a weight attached at the ankle, (2) an elastic band attached at the ankle, (3) a viscous device attached to the hip and knee, (4) a weight attached at the pelvis, and (5) a constant backwards pulling force at the pelvis. Lower-extremity joint moments and powers were computed using inverse dynamics and muscle activations were estimated using computed muscle control while walking with each device under multiple resistance levels: normal walking with no resistance, and walking with 30, 60, and 90 Newtons of resistance.

RESULTS

The results indicate that the way in which resistance is applied during gait training differentially affects the internal joint moments, powers, and muscle activations as well as the joints and phase of the gait cycle where the resistance was experienced.

SIGNIFICANCE

The results highlight the importance of understanding the joints and muscles that are targeted by various modes of functional resistance training and carefully choosing the best mode of training that meets the specific therapeutic needs of the patient.

Ankle proprioception during gait in individuals with incomplete spinal cord injury

INTRODUCTION

Proprioception is known to be affected after a spinal cord injury (SCI). However, it is currently assessed during simple tasks that do not reflect activities of daily living. To better understand how proprioception affects movement, assessing it during a functional sensorimotor task such as walking is therefore of primary importance. Therefore, the objectives of this study were as follows: (a) measure the protocol reliability of a new robotic test in nondisabled controls; (b) evaluate the effect nonlesion-related factors such as sex, age, pain, and gait speed on ankle proprioception; and (c) assess ankle proprioception during walking in individuals with SCI.

METHODS

In the current study, ankle proprioception was assessed during gait in individuals with an incomplete spinal cord injury (iSCI; n = 15) using an electrohydraulic robotized ankle-foot orthosis (rAFO). Ankle proprioceptive threshold was quantified as the participants' ability to detect torque perturbations of varied amplitude applied during swing by the rAFO. In addition, test-retest reliability and the potential effect of nonlesion-related factors (sex, age, pain, and gait speed) were evaluated in nondisabled (ND; n = 65) participants.

RESULTS

During gait, individuals with iSCI had a 53% poorer proprioceptive threshold than ND controls (p < .05). Test-retest reliability was good (ICC = 0.78), and only gait speed affected proprioceptive threshold (p = .018).

CONCLUSION

This study is the first to show that ankle proprioception assessed during gait is impaired in individuals with an iSCI. The developed test can now be used to better characterize proprioception in population with other neurological conditions and has potential to maximize functional recovery during gait training in those populations.

Improvements in skilled walking associated with kinematic adaptations in people with spinal cord injury

Introduction

Individuals with motor-incomplete SCI (m-iSCI) remain limited community ambulators, partly because they have difficulty with the skilled walking requirements of everyday life that require adaptations in inter-joint coordination and range of motion of the lower limbs. Following locomotor training, individuals with SCI show improvements in skilled walking and walking speed, however there is limited understanding of how adaptations in lower limb kinematics following training contribute to improvements in walking.

Objective

To determine the relationship between changes in lower limb kinematics (range of motion and inter-joint coordination) and improvements in walking function (walking speed and skilled walking) following locomotor training.

Methods

Lower limb kinematics were recorded from 8 individuals with chronic m-iSCI during treadmill walking before and after a 3-month locomotor training program. Data were also collected from 5 able-bodied individuals to provide normative values. In individuals with SCI, muscle strength was used to define the stronger and weaker limb. Motion analysis was used to determine, hip, knee and ankle angles. Joint angle-angle plots (cyclograms) were used to quantify inter-joint coordination. Shape differences between pre-and post-training cyclograms were used to assess the changes in coordination and their relation to improvements in walking function. Walking function was assessed using the 10MWT for walking speed and the SCI-FAP for skilled walking. Comparing pre- and post-training cyclograms to the able-bodied pattern was used to understand the extent to which changes in coordination involved the recovery of normative motor patterns.

Results

Following training, improvements in skilled walking were significantly related to changes in hip-ankle coordination (ρ = − .833, p = 0.010) and knee range of motion (ρ = .833, p = 0.010) of the weaker limb. Inter-joint coordination tended to revert towards normative patterns, but not completely. No relationships were observed with walking speed.

Conclusion

Larger changes in hip-ankle coordination and a decrease in knee range of motion in the weaker limb during treadmill walking were related to improvements in skilled walking following locomotor training in individuals with SCI. The changes in coordination seem to reflect some restoration of normative patterns and the adoption of compensatory strategies, depending on the participant.

Rowing Simulator Modulates Water Density to Foster Motor Learning

Although robot-assisted training is present in various fields such as sports engineering and rehabilitation, provision of training strategies that optimally support individual motor learning remains as a challenge. Literature has shown that guidance strategies are useful for beginners, while skilled trainees should benefit from challenging conditions. The Challenge Point Theory also supports this in a way that learning is dependent on the available information, which serves as a challenge to the learner. So, learning can be fostered when the optimal amount of information is given according to the trainee's skill. Even though the framework explains the importance of difficulty modulation, there are no practical guidelines for complex dynamic tasks on how to match the difficulty to the trainee's skill progress. Therefore, the goal of this study was to determine the impact on learning of a complex motor task by a modulated task difficulty scheme during the training sessions, without distorting the nature of task. In this 3-day protocol study, we compared two groups of naïve participants for learning a sweep rowing task in a highly sophisticated rowing simulator. During trainings, groups received concurrent visual feedback displaying the requested oar movement. Control group performed the task under constant difficulty in the training sessions. Experimental group's task difficulty was modulated by changing the virtual water density that generated different heaviness of the simulated water-oar interaction, which yielded practice variability. Learning was assessed in terms of spatial and velocity magnitude errors and the variability for these metrics. Results of final day tests revealed that both groups reduced their error and variability for the chosen metrics. Notably, in addition to the provision of a very well established visual feedback and knowledge of results, experimental group's variable training protocol with modulated difficulty showed a potential to be advantageous for the spatial consistency and velocity accuracy. The outcomes of training and test runs indicate that we could successfully alter the performance of the trainees by changing the density value of the virtual water. Therefore, a follow-up study is necessary to investigate how to match different density values to the skill and performance improvement of the participants.

Walking speed is not the best outcome to evaluate the effect of robotic assisted gait training in people with motor incomplete Spinal Cord Injury: A Systematic Review with meta-analysis

CONTEXT

While there are previous systematic reviews on the effectiveness of the use of robotic-assisted gait training (RAGT) in people with spinal cord injuries (SCI), as this is a dynamic field, new studies have been produced that are now incorporated on this systematic review (SR) with meta-analysis, updating the available evidence on this area.

OBJECTIVE

To synthesise the available evidence on the use of RAGT, to improve gait, strength and functioning.

METHODS

SR and meta-analysis following the Cochrane Handbook for Systematic Reviews of Interventions were implemented. Cochrane Injuries Group Specialized Register, PubMed, MEDLINE, EMBASE, CINAHL, ISIWeb of Science (SCIEXPANDED) databases were reviewed for the period 1990 to December 2016. Three researchers independently identified and categorized trials; 293 studies were identified, 273 eliminated; remaining 15 randomized clinical trials (RCT) and five SR. Six studies had available data for meta-analysis (222 participants).

RESULTS

The pooled mean demonstrated a beneficial effect of RAGT for WISCI, FIM-L and LEMS (3.01, 2.74 and 1.95 respectively), and no effect for speed.

CONCLUSIONS

The results show a positive effect in the use of RAGT. However, this should be taken carefully due to heterogeneity of the studies, small samples and identified limitations of some of the included trials. These results highlight the relevance of implementing a well-designed multicenter RCT powered enough to evaluate different RAGT approaches.

Acquisition of a precision walking skill and the impact of proprioceptive deficits in people with motor-incomplete spinal cord injury

Many people with motor-incomplete spinal cord injury (m-iSCI) experience difficulty navigating obstacles, such as curbs and stairs. The ability to relearn walking skills may be limited by proprioceptive deficits. The purpose of this study was to determine the capacity of participants to acquire a precision walking skill, and to evaluate the influence of proprioceptive deficits on the skill acquisition in individuals with m-iSCI. Sixteen individuals with m-iSCI and eight controls performed a precision walking task that required matching their foot height to a target during the swing phase. Proprioceptive deficits were quantified at the hip and knee for joint position and movement detection sense. Participants completed 600 steps of training with visual feedback. Pretraining and posttraining tests were conducted without visual feedback, along with a transfer test with an ankle weight. Posttraining and transfer tests were repeated 1 day later. Participants returned to the laboratory 1 wk later to repeat the training. Performance was calculated as the vertical distance between the target and actual foot height for each step. The posttraining and transfer performances were similar between groups. However, participants with m-iSCI had a slower rate of acquisition to achieve a similar performance level compared with controls. Acquisition rate and posttraining performance of the precision walking task were related to lower limb joint position sense among SCI participants. Although they can achieve a similar level of performance in a precision walking task, proprioceptive deficits impair the rate of learning among individuals with m-iSCI compared with able-bodied controls. NEW & NOTEWORTHY People with motor-incomplete spinal cord injuries are able to achieve the same level of performance accuracy on a precision walking task as able-bodied controls; however, the rate of learning is slower, indicating that more practice is required to stabilize performance. Our findings also show a relationship between impaired sensory function and reduced accuracy when performing a precision walking task after spinal cord injury.

A wearable resistive robot facilitates locomotor adaptations during gait

BACKGROUND

Robotic-resisted treadmill walking is a form of task-specific training that has been used to improve gait function in individuals with neurological injury, such as stroke, spinal cord injury, or cerebral palsy. Traditionally, these devices use active elements (e.g., motors or actuators) to provide resistance during walking, making them bulky, expensive, and less suitable for overground or in-home rehabilitation. We recently developed a low-cost, wearable robotic brace that generates resistive torques across the knee joint using a simple magnetic brake. However, the possible effects of training with this device on gait function in a clinical population are currently unknown.

OBJECTIVE

The purpose of this study was to test the acute effects of resisted walking with this device on kinematics, muscle activation patterns, and gait velocity in chronic stroke survivors.

METHODS

Six stroke survivors wore the resistive brace and walked on a treadmill for 20 minutes (4×5 minutes) at their self-selected walking speed while simultaneously performing a foot trajectory-tracking task to minimize stiff-knee gait. Electromyography, sagittal plane gait kinematics, and overground gait velocity were collected to evaluate the acute effects of the device on gait function.

RESULTS

Robotic-resisted treadmill training resulted in a significant increase in quadriceps and hamstring EMG activity during walking. Significant aftereffects (i.e., improved joint excursions) were also observed on the hip and knee kinematics, which persisted for several steps after training. More importantly, training resulted in significant improvements in overground gait velocity. These results were consistent in all the subjects tested.

CONCLUSION

This study provides preliminary evidence indicating that robotic-resisted treadmill walking using our knee brace can result in meaningful biomechanical aftereffects that translate to overground walking.

Getting the Best Out of Advanced Rehabilitation Technology for the Lower Limbs: Minding Motor Learning Principles

Advanced technology, including gait-training devices, is increasingly being integrated into neurorehabilitation. However, to use gait-training devices to their optimal potential, it is important that they are applied in accordance with motor learning and locomotor training principles. In this article, we outline the most important principles and explain how advanced gait-training devices are best used to improve therapy outcome.

Activity-Based Physical Rehabilitation with Adjuvant Testosterone to Promote Neuromuscular Recovery after Spinal Cord Injury

Neuromuscular impairment and reduced musculoskeletal integrity are hallmarks of spinal cord injury (SCI) that hinder locomotor recovery. These impairments are precipitated by the neurological insult and resulting disuse, which has stimulated interest in activity-based physical rehabilitation therapies (ABTs) that promote neuromuscular plasticity after SCI. However, ABT efficacy declines as SCI severity increases. Additionally, many men with SCI exhibit low testosterone, which may exacerbate neuromusculoskeletal impairment. Incorporating testosterone adjuvant to ABTs may improve musculoskeletal recovery and neuroplasticity because androgens attenuate muscle loss and the slow-to-fast muscle fiber-type transition after SCI, in a manner independent from mechanical strain, and promote motoneuron survival. These neuromusculoskeletal benefits are promising, although testosterone alone produces only limited functional improvement in rodent SCI models. In this review, we discuss the (1) molecular deficits underlying muscle loss after SCI; (2) independent influences of testosterone and locomotor training on neuromuscular function and musculoskeletal integrity post-SCI; (3) hormonal and molecular mechanisms underlying the therapeutic efficacy of these strategies; and (4) evidence supporting a multimodal strategy involving ABT with adjuvant testosterone, as a potential means to promote more comprehensive neuromusculoskeletal recovery than either strategy alone.

Feasibility of robotic exoskeleton ambulation in a C4 person with incomplete spinal cord injury: a case report

INTRODUCTION

To determine whether an individual with C4 incomplete spinal cord injury (SCI) with limited hand functions can effectively operate a powered exoskeleton (Ekso) to improve parameters of physical activity as determined by swing-time, up-time, walk-time, and total number of steps.

CASE PRESENTATION

A 21-year-old male with incomplete chronic (>1 year postinjury) SCI C4, participated in a clinical exoskeleton program to determine the feasibility of standing up and walking with limited hand functions. The participant was invited to attend 3 sessions including fitting, familiarization and gait training separated by one week intervals. Walk-time, up-time and total number of steps were measured during each training session. A complete body composition assessment using dual-energy X-ray absorptiometry (DXA) of the spine, knees and hips was conducted before training.Using a platform walker and cuffing both hands, the participant managed to stand up and ambulate successfully using exoskeleton. Over the course of 2 weeks, maximum walk-time increased from 7 to 17 min and number of steps increased from 83 to 589 steps. The total up-time increased from 19 to 31 min.

DISCUSSION

Exoskeleton training may be a safe and feasible approach for persons with higher levels of SCI after effectively providing a supportive assistive device for weight shifting. The current case study demonstrates the use of a powered exoskeleton for an individual with high level tetraplegia (C4 and above) and limited hand functions.

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

Background

The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.

Methods

ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.

Results

At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.

Conclusions

The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.

A Semi-passive Planar Manipulandum for Upper-Extremity Rehabilitation

Robotic rehabilitation is a promising approach to treat individuals with neurological or orthopedic disorders. However, despite significant advancements in the field of rehabilitation robotics, this technology has found limited traction in clinical practice. A key reason for this issue is that most robots are expensive, bulky, and not scalable for in-home rehabilitation. Here, we introduce a semi-passive rehabilitation robot (SepaRRo) that uses controllable passive actuators (i.e., brakes) to provide controllable resistances at the end-effector over a large workspace in a manner that is cost-effective and safe for in-home use. We also validated the device through theoretical analyses, hardware experiments, and human subject experiments. We found that by including kinematic redundancies in the robot's linkages, the device was able to provide controllable resistances to purely resist the movement of the end-effector, or to gently steer (i.e., perturb) its motion away from the intended path. When testing these capabilities on human subjects, we found that many of the upper-extremity muscles could be selectively targeted based on the forcefield prescribed to the user. These results indicate that SepaRRo could serve as a low-cost therapeutic tool for upper-extremity rehabilitation; however, further testing is required to evaluate its therapeutic benefits in patient population.

Motor and psychosocial impact of robot-assisted gait training in a real-world rehabilitation setting: A pilot study

In the last decade robotic devices have been applied in rehabilitation to overcome walking disability in neurologic diseases with promising results. Robot assisted gait training (RAGT) using the Lokomat seems not only to improve gait parameters but also the perception of well-being. Data on the psychosocial patient-robot impact are limited, in particular in the real-world of RAGT, in the rehabilitation setting. During rehabilitation training, the Lokomat can be considered an “assistive device for movement”. This allowed the use of the Psychosocial Impact of Assistive Device Scale- PIADS to describe patient interaction with the Lokomat. The primary aim of this pilot study was to evaluate the psychosocial impact of the Lokomat in an in-patient rehabilitation setting using the PIADS; secondary aims were to assess whether the psychosocial impact of RAGT is different between pathological sub-groups and if the Lokomat influenced functional variables (Functional Independence Measure scale–FIM and parameters provided by the Lokomat itself). Thirty-nine consecutive patients (69% males, 54.0±18.0 years) eligible for Lokomat training, with etiologically heterogeneous walking disabilities (Parkinson’s Disease, n = 10; Spinal Cord Injury, n = 21; Ictus Event, n = 8) were enrolled. Patients were assessed with the FIM before and after rehabilitation with Lokomat, and the PIADS was administered after the rehabilitative period with Lokomat. Overall the PIADS score was positive (35.8±21.6), as well as the three sub-scales, pertaining to “ability”, “adaptability” and “self-esteem” (17.2±10.4, 8.9±5.5 and 10.1±6.6 respectively) with no between-group differences. All patients significantly improved in gait measure and motor FIM scale (difference after—before treatment values: 11.7±9.8 and 11.2±10.3 respectively), increased treadmill speed (0.4 ± 0.2m/s), reduced body weight support (-14.0±9.5%) and guidance force (-13.1 ± 10.7%). This pilot study indicates that Lokomat, in a real-world in-patient setting, may have a generalised approval, independent of disease, underlining the importance of the psycho-social framework for patients training with assistive robotic-devices.

Robotic assisted gait as a tool for rehabilitation of individuals with spinal cord injury: a systematic review

BACKGROUND

Spinal cord injury (SCI) is characterized by a total or partial deficit of sensory and motor pathways. Impairments of this injury compromise muscle recruitment and motor planning, thus reducing functional capacity. SCI patients commonly present psychological, intestinal, urinary, osteomioarticular, tegumentary, cardiorespiratory and neural alterations that aggravate in chronic phase. One of the neurorehabilitation goals is the restoration of these abilities by favoring improvement in the quality of life and functional independence. Current literature highlights several benefits of robotic gait therapies in SCI individuals.

OBJECTIVES

The purpose of this study was to compare the robotic gait devices, and systematize the scientific evidences of these devices as a tool for rehabilitation of SCI individuals.

METHODS

A systematic review was carried out in which relevant articles were identified by searching the following databases: Cochrane Library, PubMed, PEDro and Capes Periodic. Two authors selected the articles which used a robotic device for rehabilitation of spinal cord injury.

RESULTS

Databases search found 2941 articles, 39 articles were included due to meet the inclusion criteria. The robotic devices presented distinct features, with increasing application in the last years. Studies have shown promising results regarding the reduction of pain perception and spasticity level; alteration of the proprioceptive capacity, sensitivity to temperature, vibration, pressure, reflex behavior, electrical activity at muscular and cortical level, classification of the injury level; increase in walking speed, step length and distance traveled; improvements in sitting posture, intestinal, cardiorespiratory, metabolic, tegmental and psychological functions.

CONCLUSIONS

This systematic review shows a significant progress encompassing robotic devices as an innovative and effective therapy for the rehabilitation of individuals with SCI.

Robot-Applied Resistance Augments the Effects of Body Weight-Supported Treadmill Training on Stepping and Synaptic Plasticity in a Rodent Model of Spinal Cord Injury

BACKGROUND

The application of resistive forces has been used during body weight-supported treadmill training (BWSTT) to improve walking function after spinal cord injury (SCI). Whether this form of training actually augments the effects of BWSTT is not yet known.

OBJECTIVE

To determine if robotic-applied resistance augments the effects of BWSTT using a controlled experimental design in a rodent model of SCI.

METHODS

Spinally contused rats were treadmill trained using robotic resistance against horizontal (n = 9) or vertical (n = 8) hind limb movements. Hind limb stepping was tested before and after 6 weeks of training. Two control groups, one receiving standard training (ie, without resistance; n = 9) and one untrained (n = 8), were also tested. At the terminal experiment, the spinal cords were prepared for immunohistochemical analysis of synaptophysin.

RESULTS

Six weeks of training with horizontal resistance increased step length, whereas training with vertical resistance enhanced step height and movement velocity. None of these changes occurred in the group that received standard (ie, no resistance) training or in the untrained group. Only standard training increased the number of step cycles and shortened cycle period toward normal values. Synaptophysin expression in the ventral horn was highest in rats trained with horizontal resistance and in untrained rats and was positively correlated with step length.

CONCLUSIONS

Adding robotic-applied resistance to BWSTT produced gains in locomotor function over BWSTT alone. The impact of resistive forces on spinal connections may depend on the nature of the resistive forces and the synaptic milieu that is present after SCI.

Training to Improve Walking after Pediatric Spinal Cord Injury: A Systematic Review of Parameters and Walking Outcomes

Walking or locomotor training is often initiated following pediatric spinal cord injury (SCI). There is no synthesis of the literature on interventions targeting walking for pediatric SCI, although this would assist future clinical trials and interventions. To address this need, we completed a systematic review to summarize the who, what, when, and how of walking interventions in children with SCI. Participant characteristics, training parameters, and walking outcomes with training in pediatric SCI were identified and compared with training parameters and outcomes in adults with SCI. The PubMed, Medline, AMED, Embase, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for studies that included participants aged 1-17 years with a SCI acquired post-birth, physical interventions, and pre- and post-training walking measures. Two researchers evaluated each study's risk of bias using a domain-based approach. Training parameters and walking outcomes were extracted. Total training duration (duration × frequency × number of weeks) was calculated. Thirteen pediatric studies (n = 43 children) were included; all but one were case series/reports. Risk of bias was high in the pediatric studies. A 2012 adult review was updated (11 studies added). As with adults, the training durations, frequencies, and modes used with the children varied; however, overground walking practice was included in 10/13 pediatric studies. Improvements in walking capacity, speed, and distance were comparable between children and adults. There was a trend for greater gains with greater total training durations. There is a paucity of high-quality research examining interventions targeting walking after pediatric SCI; however, intensive training, including practice overground, results in notable improvements.

Robot-assisted gait training (Lokomat) improves walking function and activity in people with spinal cord injury: a systematic review

Abstract

Robot-assisted gait training (RAGT) after spinal cord injury (SCI) induces several different neurophysiological mechanisms to restore walking ability, including the activation of central pattern generators, task-specific stepping practice and massed exercise. However, there is no clear evidence for the optimal timing and efficacy of RAGT in people with SCI. The aim of our study was to assess the effects of RAGT on improvement in walking-related functional outcomes in patients with incomplete SCI compared with other rehabilitation modalities according to time elapsed since injury. This review included 10 trials involving 502 participants to meta-analysis. The acute RAGT groups showed significantly greater improvements in gait distance, leg strength, and functional level of mobility and independence than the over-ground training (OGT) groups. The pooled mean difference was 45.05 m (95% CI 13.81 to 76.29, P = 0.005, I² = 0%; two trials, 122 participants), 2.54 (LEMS, 95% CI 0.11 to 4.96, P = 0.04, I² = 0%; three trials, 211 participants) and 0.5 (WISCI-II and FIM-L, 95% CI 0.02 to 0.98, P = 0.04, I² = 67%; three trials, 211 participants), respectively. In the chronic RAGT group, significantly greater improvements in speed (pooled mean difference = 0.07 m/s, 95% CI 0.01 to 0.12, P = 0.01, I² = 0%; three trials, 124 participants) and balance measured by TUG (pooled mean difference = 9.25, 95% CI 2.76 to 15.73, P = 0.005, I² = 74%; three trials, 120 participants) were observed than in the group with no intervention. Thus, RAGT improves mobility-related outcomes to a greater degree than conventional OGT for patients with incomplete SCI, particularly during the acute stage. RAGT treatment is a promising technique to restore functional walking and improve locomotor ability, which might enable SCI patients to maintain a healthy lifestyle and increase their level of physical activity.

Trial registration

PROSPERO (CRD 42016037366). Registered 6 April 2016.

Supraspinal Control Predicts Locomotor Function and Forecasts Responsiveness to Training after Spinal Cord Injury

Restoration of walking ability is an area of great interest in the rehabilitation of persons with spinal cord injury. Because many cortical, subcortical, and spinal neural centers contribute to locomotor function, it is important that intervention strategies be designed to target neural elements at all levels of the neuraxis that are important for walking ability. While to date most strategies have focused on activation of spinal circuits, more recent studies are investigating the value of engaging supraspinal circuits. Despite the apparent potential of pharmacological, biological, and genetic approaches, as yet none has proved more effective than physical therapeutic rehabilitation strategies. By making optimal use of the potential of the nervous system to respond to training, strategies can be developed that meet the unique needs of each person. To complement the development of optimal training interventions, it is valuable to have the ability to predict future walking function based on early clinical presentation, and to forecast responsiveness to training. A number of clinical prediction rules and association models based on common clinical measures have been developed with the intent, respectively, to predict future walking function based on early clinical presentation, and to delineate characteristics associated with responsiveness to training. Further, a number of variables that are correlated with walking function have been identified. Not surprisingly, most of these prediction rules, association models, and correlated variables incorporate measures of volitional lower extremity strength, illustrating the important influence of supraspinal centers in the production of walking behavior in humans.