Systematic review of outcome measures of walking training using electromechanical and robotic devices in patients with stroke

Gut Microbiota Ecological and Functional Modulation in Post-Stroke Recovery Patients: An Italian Study

Ischemic stroke (IS) can be caused by perturbations of the gut-brain axis. An imbalance in the gut microbiota (GM), or dysbiosis, may be linked to several IS risk factors and can influence the brain through the production of different metabolites, such as short-chain fatty acids (SCFAs), indole and derivatives. This study examines ecological changes in the GM and its metabolic activities after stroke. Fecal samples of 10 IS patients were compared to 21 healthy controls (CTRLs). GM ecological profiles were generated via 16S rRNA taxonomy as functional profiles using metabolomics analysis performed with a gas chromatograph coupled to a mass spectrometer (GC-MS). Additionally fecal zonulin, a marker of gut permeability, was measured using an enzyme-linked immuno assay (ELISA). Data were analyzed using univariate and multivariate statistical analyses and correlated with clinical features and biochemical variables using correlation and nonparametric tests. Metabolomic analyses, carried out on a subject subgroup, revealed a high concentration of fecal metabolites, such as SCFAs, in the GM of IS patients, which was corroborated by the enrichment of SCFA-producing bacterial genera such as Bacteroides, Christensellaceae, Alistipes and Akkermansia. Conversely, indole and 3-methyl indole (skatole) decreased compared to a subset of six CTRLs. This study illustrates how IS might affect the gut microbial milieu and may suggest potential microbial and metabolic biomarkers of IS. Expanded populations of Akkermansia and enrichment of acetic acid could be considered potential disease phenotype signatures.

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.

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.

Application of Robotic Recovery Techniques to Stroke Survivors-Bibliometric Analysis

Stroke is a significant disability and death cause worldwide and is conventionally defined as a neurological impairment relating to the intense focal harm of the central nervous system (CNS) by vascular causative components. Although the applicability of robotic rehabilitation is a topic with considerable practical significance because it has produced noticeably higher improvements in motor function than regular (physical and occupational) therapy and exempted the therapists, most of the existing bibliometric papers were not focused on stroke survivors. Additionally, a modular system is designed by joining several medical end-effector devices to a single limb segment, which addresses the issue of potentially dangerous pathological compensatory motions. Searching the Web of Science database, 31,930 papers were identified, and using the VOSviewer software and science mapping technology, data were extracted on the most prolific countries, the connections between them, the most valuable journals according to certain factors, their average year of publication, the most influential papers, and the most relevant topical issues (bubble map of term occurrence). The most prolific country in the analyzed field and over the entire period evaluated (1975-2022) is the United States, and the most prolific journal is Neurorehabilitation and Neural Repair, observing a marked increase in the three periods of scientific interest for this field. The present paper assesses numerous scientific publications to provide, through statistical interpretation of the data, a detailed description of the use of robotic rehabilitation in stroke survivors. The findings may aid scientists, academics, and clinicians in establishing precise goals in the optimization of the management of stroke survivors via robotic rehabilitation, but also through easier access to scientifically validated literature.

Informing the development of an outcome set and banks of items to measure mobility among individuals with acquired brain injury using natural language processing

BACKGROUND

The sheer number of measures evaluating mobility and inconsistencies in terminology make it challenging to extract potential core domains and items. Automating a portion of the data synthesis would allow us to cover a much larger volume of studies and databases in a smaller fraction of the time compared to the usual process. Thus, the objective of this study was to identify a comprehensive outcome set and develop preliminary banks of items of mobility among individuals with acquired brain injury (ABI) using Natural Language Processing (NLP).

METHODS

An umbrella review of 47 reviews evaluating the content of mobility measures among individuals with ABI was conducted. A search was performed on 5 databases between 2000 and 2020. Two independent reviewers retrieved copies of the measures and extracted mobility domains and items. A pre-trained BERT model (state-of-the-art model for NLP) provided vector representations for each sentence. Using the International Classification of Functioning, Disability, and Health Framework (ICF) ontology as a guide for clustering, a k-means algorithm was used to retrieve clusters of similar sentences from their embeddings. The resulting embedding clusters were evaluated using the Silhouette score and fine-tuned according to expert input.

RESULTS

The study identified 246 mobility measures, including 474 domains and 2109 items. Encoding the clusters using the ICF ontology and expert knowledge helped in regrouping the items in a way that is more closely related to mobility terminology. Our best results identified banks of items that were used to create a 24 comprehensive outcome sets of mobility, including Upper Extremity Mobility, Emotional Function, Balance, Motor Control, Self-care, Social Life and Relationships, Cognition, Walking, Postural Transition, Recreation, and Leisure Activities, Activities of Daily Living, Physical Functioning, Communication, Work/Study, Climbing, Sensory Functions, General Health, Fatigue, Functional Independence, Pain, Alcohol and Drugs Use, Transportation, Sleeping, and Finances.

CONCLUSION

The banks of items of mobility domains represent a first step toward establishing a comprehensive outcome set and a common language of mobility to develop the ontology. It enables researchers and healthcare professionals to begin exposing the content of mobility measures as a way to assess mobility comprehensively.

Longitudinal changes in life-space mobility and the factors influencing it among chronic community-dwelling post-stroke patients

PURPOSE

To identify longitudinal changes in life-space mobility and the factors influencing it among chronic, stable post-stroke patients.

MATERIALS AND METHODS

This prospective study included Japanese post-stroke patients who received day-care rehabilitation services and could undergo three life-space mobility assessments (at baseline, 12, and 24 months) for over 2 years, using the Life-Space Assessment (LSA) tool. Physical function, cognitive function, and activities of daily living were assessed by self-selected comfortable gait speed, Mini-Mental State Examination (MMSE), and Functional Independence Measure Motor subscale (FIM motor) scores, respectively, in addition to age, sex, time from onset, stroke type, and comorbidities. A multivariable linear mixed-effects model was used to examine the longitudinal changes in LSA scores and associated factors.

RESULTS

A total of 89 participants were enrolled. At baseline, the median age was 74 years, 33% were women, and median time from onset was 75 months. The LSA scores significantly declined over the two-year period. In the multivariate linear mixed-effects model adjusted for clinical characteristics, comfortable gait speed and age were significantly associated with changes in the LSA score, independent of FIM motor scores and MMSE scores.

CONCLUSIONS

Life-space mobility may persistently decline, and gait function may be a determinant influencing these changes in community-dwelling chronic post-stroke patients.Implications for RehabilitationLimited life-space mobility leads to less frequent participation in social activities and an increased risk of adverse health outcomes such as hospitalization.Changes in life-space mobility should be considered in the rehabilitation care plan for chronic post-stroke patients.Life-space mobility may decline persistently in stable post-stroke patients, even if they have periodically received day-care rehabilitation services.Since gait speed is a predominant factor affecting life-space mobility, regular assessment of gait function and appropriate strategies are needed to prevent deterioration of gait speed in chronic post-stroke patients.

Comparison of high-intensive and low-intensive electromechanical-assisted gait training by Exowalk® in patients over 3-month post-stroke

BACKGROUND

This study was conducted to assess the effect of electromechanical-assisted gait training intensity on walking ability in patients over 3-month post-stroke.

METHODS

Data from two randomized controlled trials (RCTs) were collected under the same study design of assessment and intervention, excluding intervention time per session. After matching the inclusion criteria of two RCTs, the experimental groups of each RCT were defined as low-intensive (LI) and high-intensive (HI) group according to the intervention time per session. Primary outcome was the difference of the change in Functional Ambulatory Categories (FAC) between LI and HI gait training. Secondary outcomes were the difference of changes in mobility, walking speed, walking capacity, leg-muscle strength, balance and daily activity evaluated with Rivermead Mobility Index (RMI), 10 m walk test (10MWT), 6-min walk test (6MWT), Motricity Index (MI), Berg Balance Scale (BBS) and Modified Barthel Index (MBI) respectively.

RESULTS

The FAC improved after gait training in both groups. The secondary outcomes also improved in both groups except RMI and MI in HI group. The change of all outcomes were not different between groups except RMI. The change of RMI in the LI group was greater than that in the HI group statistically, but it did not meet minimal clinically important difference.

CONCLUSIONS

The improvement of walking ability after LI or HI gait training was not different if providing the same total gait training time. By providing the electromechanical gait training intensively, we could shorten the gait training period to improve walking ability and customize the training program according to the patient training abilities.

TRIAL REGISTRATION

Name of the registry: Clinical Research Information Service.

TRIAL REGISTRATION NUMBER

No. KCT0002195(RCT1), No. KCT0002552(RCT2). Date of registration: 10/04/2016(RCT1), 10/05/2017(RCT2). URL of the trial registry record: https://cris.nih.go.kr/cris/search.

Development of a 3D Relative Motion Method for Human-Robot Interaction Assessment

Exoskeletons have been assessed by qualitative and quantitative features known as performance indicators. Within these, the ergonomic indicators have been isolated, creating a lack of methodologies to analyze and assess physical interfaces. In this sense, this work presents a three-dimensional relative motion assessment method. This method quantifies the difference of orientation between the user’s limb and the exoskeleton link, providing a deeper understanding of the Human–Robot interaction. To this end, the AGoRA exoskeleton was configured in a resistive mode and assessed using an optoelectronic system. The interaction quantified a difference of orientation considerably at a maximum value of 41.1 degrees along the sagittal plane. It extended the understanding of the Human–Robot Interaction throughout the three principal human planes. Furthermore, the proposed method establishes a performance indicator of the physical interfaces of an exoskeleton.

Quality of mobility measures among individuals with acquired brain injury: an umbrella review

Background and objective

While several mobility measures exist, there is large variability across measures in how mobility is conceptualized, the source of information and the measurement properties making it challenging to select relevant mobility measures for individuals with acquired brain injury (ABI). Therefore, the objective was to conduct a comprehensive synthesis of existing evidence on the measurement properties, the interpretability and the feasibility of mobility measures from various sources of information (patients, clinicians, technology) using an umbrella review of published systematic reviews among individuals with ABI.

Methods

Ovid MEDLINE, CINHAL, Cochrane Library and EMBASE electronic databases were searched from 2000 to March 2020. Two independent reviewers appraised the methodological quality of the systematic reviews using the Joanna Briggs Institute critical appraisal checklist. Measurement properties and quality of evidence were applied according to COnsensus-based Standards for the Selection of Health Measurement Instrument (COSMIN) guidelines. Mobility measures were categorized using international standards with the international classification of functioning, disability and health (ICF).

Results

Thirty-five systematic reviews were included covering 147 mobility measures, of which 85% were mapped to the ICF Activity and Participation component. Results showed an acceptable overall "sufficient" rating for reliability, construct validity and responsiveness for 132 (90%), 127 (86%) and 76 (52%) of the measures, respectively; however, among these measures, ≤ 25% of the methods for evaluating these properties were rated as ‘high’ quality of evidence. Also, there was limited information that supports measure feasibility and scoring interpretability.

Conclusions

Future systematic reviews should report measures’ content validity to support the use of the measure in clinical care and research. More evaluations of the minimal important difference and floor and ceiling effects are needed to help guide clinical interpretation.

Registration information

International Prospective Register of Systematic Reviews (PROSPERO); ID: CRD42018100068.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03103-4.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

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

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

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

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

BACKGROUND

Robotic-Assisted Gait Training (RAGT) may enable high-intensive and task-specific gait training post-stroke. The effect of RAGT on gait movement patterns has however not been comprehensively reviewed. The purpose of this review was to summarize the evidence for potentially superior effects of RAGT on biomechanical measures of gait post-stroke when compared with non-robotic gait training alone.

METHODS

Nine databases were searched using database-specific search terms from their inception until January 2021. We included randomized controlled trials investigating the effects of RAGT (e.g., using exoskeletons or end-effectors) on spatiotemporal, kinematic and kinetic parameters among adults suffering from any stage of stroke. Screening, data extraction and judgement of risk of bias (using the Cochrane Risk of bias 2 tool) were performed by 2-3 independent reviewers. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria were used to evaluate the certainty of evidence for the biomechanical gait measures of interest.

RESULTS

Thirteen studies including a total of 412 individuals (mean age: 52-69 years; 264 males) met eligibility criteria and were included. RAGT was employed either as monotherapy or in combination with other therapies in a subacute or chronic phase post-stroke. The included studies showed a high risk of bias (n = 6), some concerns (n = 6) or a low risk of bias (n = 1). Meta-analyses using a random-effects model for gait speed, cadence, step length (non-affected side) and spatial asymmetry revealed no significant differences between the RAGT and comparator groups, while stride length (mean difference [MD] 2.86 cm), step length (affected side; MD 2.67 cm) and temporal asymmetry calculated in ratio-values (MD 0.09) improved slightly more in the RAGT groups. There were serious weaknesses with almost all GRADE domains (risk of bias, consistency, directness, or precision of the findings) for the included outcome measures (spatiotemporal and kinematic gait parameters). Kinetic parameters were not reported at all.

CONCLUSION

There were few relevant studies and the review synthesis revealed a very low certainty in current evidence for employing RAGT to improve gait biomechanics post-stroke. Further high-quality, robust clinical trials on RAGT that complement clinical data with biomechanical data are thus warranted to disentangle the potential effects of such interventions on gait biomechanics post-stroke.

Identifying Instruments to Assess Care Quality for Individuals With Custom Ankle Foot Orthoses: A Scoping Review

OBJECTIVES

We conducted 2 complementary scoping reviews to identify instruments that assess the experience and outcomes of custom ankle-foot orthosis (AFO) care in individuals with neurologic and traumatic conditions and to determine to what extent they might be psychometrically sound for AFO users. A stakeholder advisory committee considered to what extent the identified and psychometrically sound instruments might be feasible for use in developing quality measures for custom AFO users.

DATA SOURCES

Both scoping reviews were conducted using PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Systematic Reviews. The following were used for the first scoping review only: Cochrane Central Register of Controlled Trials and the Physiotherapy Evidence Database.

STUDY SELECTION

The initial scoping review yielded 79 articles with 82 instruments, 16 of which were used in 4 or more studies. The second scoping review yielded 57 articles reporting psychometric properties.

DATA EXTRACTION

Psychometric properties for populations who use AFOs were summarized for 15 of the 16 instruments. The advisory committee eliminated 2 insrtruments, noted overlap between 4 instruments in terms of the constructs measured, and suggested 6 potential contemporary substitutes.

DATA SYNTHESIS

Most instruments assessed activity (specifically mobility) and pertained to the National Quality Forum domain of "Health-Related Quality of Life." The 10-meter walk test, 6-minute walk test, Berg Balance Scale, Timed Up and Go, and Rivermead Mobility Index were reported to have adequate reliability and validity, and were considered feasible for administration in a clinical setting.

CONCLUSIONS

Complementary scoping reviews demonstrated that some instruments with reasonable psychometric properties are available that are feasible to use in developing quality measures for custom AFO care. However, experience of care instruments suitable for this population were not identified but are needed for a comprehensive evaluation of care quality for AFO users.

Patient and Clinician Perspectives on Quality-of-Care Topics for Users of Custom Ankle-Foot Orthoses

OBJECTIVE

As in all healthcare areas, there is a need to improve quality relevant to orthotic practice, but we lack information as to what aspects of healthcare quality are meaningful to measure. Thus, the objective was to identify issues that are important to the quality-of-care for people who use custom ankle-foot orthoses as identified by ankle-foot orthosis users, orthotists, and physical therapists.

DESIGN

We conducted focus groups with custom ankle-foot orthosis users, orthotists, and physical therapists. A stenographer took verbatim notes and provided transcripts. Research staff members assessed the transcripts using thematic analysis.

RESULTS

Participants included 5 ankle-foot orthosis users (1 focus group), 17 orthotists (2 focus groups), and 7 physical therapists (1 focus group). They discussed domains of quality-of-care relevant for people with ankle-foot orthoses. We identified 28 thematic codes addressing 10 broad themes of quality-of-care. Six of the broad themes (organizational characteristics, patient-clinician communication, care coordination, device fit and comfort, body function, activity, and participation) mapped to the National Quality Forum's person- and family-centered care concepts. Environment of care, clinician competencies, and device characteristics and usage were important to orthotic practice but do not map to any National Quality Forum concept. Participants did not mention the National Quality Forum concept of shared decision-making.

CONCLUSIONS

The quality themes provide information as to what aspects of healthcare quality are meaningful to measure with respect to orthotic care, thus providing guidance on how to measure and improve ankle-foot orthosis service delivery.

A Review of Robot-Assisted Lower-Limb Stroke Therapy: Unexplored Paths and Future Directions in Gait Rehabilitation

Stroke affects one out of every six people on Earth. Approximately 90% of stroke survivors have some functional disability with mobility being a major impairment, which not only affects important daily activities but also increases the likelihood of falling. Originally intended to supplement traditional post-stroke gait rehabilitation, robotic systems have gained remarkable attention in recent years as a tool to decrease the strain on physical therapists while increasing the precision and repeatability of the therapy. While some of the current methods for robot-assisted rehabilitation have had many positive and promising outcomes, there is moderate evidence of improvement in walking and motor recovery using robotic devices compared to traditional practice. In order to better understand how and where robot-assisted rehabilitation has been effective, it is imperative to identify the main schools of thought that have prevailed. This review intends to observe those perspectives through three different lenses: the goal and type of interaction, the physical implementation, and the sensorimotor pathways targeted by robotic devices. The ways that researchers approach the problem of restoring gait function are grouped together in an intuitive way. Seeing robot-assisted rehabilitation in this unique light can naturally provoke the development of new directions to potentially fill the current research gaps and eventually discover more effective ways to provide therapy. In particular, the idea of utilizing the human inter-limb coordination mechanisms is brought up as an especially promising area for rehabilitation and is extensively discussed.

Does robot-assisted gait training improve mobility, activities of daily living and quality of life in stroke? A single-blinded, randomized controlled trial

The purpose of this study was to investigate the effects of robot-assisted gait training (RAGT) on mobility, activities of daily living (ADLs), and quality of life (QoL) in stroke rehabilitation. Fifty-one stroke patients randomly assigned to Group 1, Group 2, and Group 3 received conventional training (CT) plus RAGT, CT, and RAGT, respectively. The training duration was for 6 weeks. The primary outcome measures were the Barthel Index (BI), Stroke Specific Quality of Life Scale (SS-QOL), 6-Minute Walk Test (6-MWT), and Stair Climbing Test (SCT). The secondary outcomes were Fugl Meyer Assessment-Lower Extremity (FMA-LE), Comfortable 10-m Walk Test (CWT), Fast 10-m Walk Test (FWT), and Rate of Perceived Exertion (RPE). The mean change in all the primary [BI (p = 0.001), 6-MWT (p = 0.001), SS-QOL (p < 0.0001), and SCT (p = 0.004)] and except the FWT (p = 0.354) all the other secondary outcomes [FMA-LE (p = 0.049), CWT (p = 0.025) and RPE (p = 0.023)] improved significantly between the three groups. In the subgroup analysis, BI, 6-MWT, SS-QOL, and SCT improved significantly in Group 1 compared to Group 2 and Group 3 (p < 0.016). However, FMA-LE, CWT, and the RPE significantly improved in Group 1 compared to Group 2 and, also, only CWT improved significantly in Group 1 compared to Group 3 (p = 0.011). In a subgroup analysis of the primary and secondary outcome measures, there were no significant differences in Group 2 compared to Group 3 (p > 0.05). While combined training leads to more improvement in mobility, ADLs, and QoL, CT showed a similar improvement compared to the RAGT in stroke patients.

Effects of Gait Treatment With a Single-Leg Hybrid Assistive Limb System After Acute Stroke: A Non-randomized Clinical Trial

We hypothesized that a single-leg version of the Hybrid Assistive Limb (HAL) system could improve the gait and physical function of patients with hemiparesis following a stroke. In this pilot study, we therefore compared the efficacy of HAL-based gait training with that of conventional gait training (CGT) in patients with acute stroke. Patients admitted to the participating university hospital were assigned to the HAL group, whereas those admitted to outside teaching hospitals under the same rehabilitation program who did not use the HAL were assigned to the control group. Over 3 weeks, all participants completed nine 20 min sessions of gait training, using either HAL (i.e., the single-leg version of HAL on the paretic side) or conventional methods (i.e., walking aids and gait orthoses). Outcome measures were evaluated before and after the nine training sessions. The Functional Ambulation Category (FAC) was the primary outcome measure, but the following secondary outcome measures were also assessed: National Institutes of Health Stroke Scale, Fugl-Meyer Assessment (Lower Extremity), comfortable walking speed, step length, cadence, 6-min walk distance, Barthel Index, and Functional Independence Measure. In total, 22 post-stroke participants completed the clinical trial: 12 in the HAL group and 10 in the CGT group. No serious adverse events occurred in either group. The HAL group showed significant improvement in FAC after nine sessions when compared with the CGT group (P = 0.014). However, secondary outcomes did not differ significantly between the groups. Our results demonstrate that HAL-based gait therapy may improve independent walking in patients with acute stroke hemiplegia who are dependent on ambulatory assistance. A larger-scale randomized controlled trial is needed to clarify the effectiveness of single-leg HAL therapy. Clinical Trial Registration: UMIN Clinical Trials Registry, identifier UMIN000022410.

Self-perceived functioning and disability after randomized conventional and electromechanically-assisted gait training in subacute stroke: A 6 months follow-up

BACKGROUND

Few previous studies have assessed self-perceived functioning, disability and recovery after electromechanically-assisted gait training (EAGT).

OBJECTIVE

To compare self-perceived functioning, disability and recovery after EAGT and after conventional gait training in the subacute stage after stroke, using the Stroke Impact Scale (SIS), and factors associated with self-perceived recovery, assessed at 6 months after stroke.

METHODS

Patients were randomized into two groups performing a 4-week intervention period of incorporated EAGT using the Hybrid Assistive Limb (HAL) or conventional physiotherapy only.

RESULTS

There were no significant differences in self-perceived strength, ADL, mobility, participation and percentage of recovery between intervention groups (p > 0.05). Self-perceived mobility was associated with improvements in objectively assessed walking speed/endurance and balance (R2 0.717, p = 0.002), and self-perceived recovery with self-perceived activities of daily living (ADL) ability (R2 0.34, p = 0.001).

CONCLUSIONS

This study indicates that EAGT and conventional gait training in the subacute stage after stroke have no differential impact on self-perceived functioning, disability and recovery at 6 months after stroke. Further, the study highlights the importance of interventions targeting ADL and self-care independence during stroke rehabilitation to enhance self-perceived recovery and clinical aspects to be targeted to enhance perceived mobility.

Feasibility of Robot-Assisted Gait Training with an End-Effector Type Device for Various Neurologic Disorders

Robots are being used to assist the recovery of walking ability for patients with neurologic disorders. This study aimed to evaluate the feasibility and functional improvement of training with robot-assisted gait training (RAGT) using the Morning Walk^®, an end-effector type robot using footplates and saddle seat support. A total of 189 individuals (65.1% men, 34.9% women; mean age, 53.2 years; age range: 5-87 years) with brain lesions, spinal cord injuries, Parkinson's disease, peripheral neuropathies, and pediatric patients were involved in this retrospectively registered clinical trial. Each participant performed 30 minutes of RAGT, five times a week, for a total of 24 sessions. Failure was defined as an inability to complete all 24 sessions, and the reasons for discontinuation were analyzed. Parameters of Medical Research Council scales and Functional Ambulation Categories were analyzed before and after RAGT training. Among the 189 patients, 22 (11.6%) failed to complete the RAGT. The reasons included decreased cooperation, musculoskeletal pain, saddle seat discomfort, excessive body-weight support, joint spasticity or restricted joint motion, urinary incontinence from an indwelling urinary catheter, and fatigue. Comparison between the pre- and post-training motor and ambulatory functions showed significant improvement. The result of the study indicates that the Morning Walk^® is feasible and safe and useful for functional improvement in patients with various neurologic disorders.

Trial Registration

Clinical Research Information Service Identifier: KCT0003627.

Evaluating the use of robotic and virtual reality rehabilitation technologies to improve function in stroke survivors: A narrative review

This review evaluates the effectiveness of robotic and virtual reality technologies used for neurological rehabilitation in stroke survivors. It examines each rehabilitation technology in turn before considering combinations of these technologies and the complexities of rehabilitation outcome assessment. There is high-quality evidence that upper-limb robotic rehabilitation technologies improve movement, strength and activities of daily living, whilst the evidence for robotic lower-limb rehabilitation is currently not as convincing. Virtual reality technologies also improve activities of daily living. Whilst the benefit of these technologies over dose-controlled conventional rehabilitation is likely to be small, there is a role for both technologies as part of a broader rehabilitation programme, where they may help to increase the intensity and amount of therapy delivered. Combining robotic and virtual reality technologies in a rehabilitation programme may further improve rehabilitation outcomes and we would advocate randomised controlled trials of these technologies in combination.

A qualitative study on user acceptance of a home-based stroke telerehabilitation system

Objective: This paper reports a qualitative study of a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education in the patient's home. The aims of the current report are to investigate patient perceived benefits of and barriers to using the telerehabilitation system at home.Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 13 participants who were patients in the subacute phase after stroke and had completed a six-week intervention using the home-based telerehabilitation system. Thematic analysis was conducted to analyze the data.Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions, cognitive abilities, and emotional well-being. They also perceived the system easy to use due to the engaging experience and the convenience of conducting sessions at home. Meanwhile, participants pointed out the importance of considering technical support and physical environment at home. Further, family members' support helped them sustain in their rehabilitation. Finally, adjusting difficulty levels and visualizing patients' rehabilitation progress might help them in continued use of the telerehabilitation system.Conclusion: Telerehabilitation systems can be used as an efficient and user-friendly tool to deliver home-based stroke rehabilitation that enhance patients' physical recovery and mental and social-emotional wellbeing. Such systems need to be designed to offer engaging experience, display of recovery progress, and flexibility of schedule and location, with consideration of facilitating and social factors.

Robot-Assisted Stair Climbing Training on Postural Control and Sensory Integration Processes in Chronic Post-stroke Patients: A Randomized Controlled Clinical Trial

Background

Postural control disturbances are one of the important causes of disability in stroke patients affecting balance and mobility. The impairment of sensory input integration from visual, somatosensory and vestibular systems contributes to postural control disorders in post-stroke patients. Robot-assisted gait training may be considered a valuable tool in improving gait and postural control abnormalities.

Objective

The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility.

Methods

This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with postural instability. The experimental group (EG, n = 16) received robot-assisted stair climbing training. The control group (n = 16) received sensory integration balance training. Training protocols lasted for 5 weeks (50 min/session, two sessions/week). Before, after, and at 1-month follow-up, a blinded rater evaluated patients using a comprehensive test battery. Primary outcome: Berg Balance Scale (BBS). Secondary outcomes:10-meter walking test, 6-min walking test, Dynamic gait index (DGI), stair climbing test (SCT) up and down, the Time Up and Go, and length of sway and sway area of the Center of Pressure (CoP) assessed using the stabilometric assessment.

Results

There was a non-significant main effect of group on primary and secondary outcomes. A significant Time × Group interaction was measured on 6-min walking test (p = 0.013) and on posturographic outcomes (p = 0.005). Post hoc within-group analysis showed only in the EG a significant reduction of sway area and the CoP length on compliant surface in the eyes-closed and dome conditions.

Conclusion

Postural control disorders in patients with chronic stroke may be ameliorated by robot-assisted stair climbing training and sensory integration balance training. The robot-assisted stair climbing training contributed to improving sensorimotor integration processes on compliant surfaces. Clinical trial registration (NCT03566901).

Effects of two different protocols of cerebellar transcranial direct current stimulation combined with transcutaneous spinal direct current stimulation on robot-assisted gait training in patients with chronic supratentorial stroke: A single blind, randomized controlled trial

BACKGROUND

The neural organization of locomotion involves motor patterns generated by spinal interneuronal networks and supraspinal structures, which are approachable by noninvasive stimulation techniques. Recent evidences supported the hypothesis that transcranial direct current stimulation (combined with transcutaneous spinal direct current stimulation) may actually enhance the effects of robot-assisted gait training in chronic stroke patients. The cerebellum has many connections to interact with neocortical areas and may provide some peculiar plasticity mechanisms. So, it has been proposed as "non-lesioned entry" to the motor or cognitive system for the application of noninvasive stimulation techniques in patients with supratentorial stroke.

OBJECTIVE

To compare the effects of two different protocols of cerebellar transcranial direct current stimulation combined with transcutaneous spinal direct current stimulation on robotic gait training in patients with chronic supratentorial stroke.

METHODS

Forty patients with chronic supratentorial stroke were randomly assigned into two groups. All patients received ten, 20-minute robotic gait training sessions, five days a week, for two consecutive weeks. Group 1 underwent cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere + cathodal transcutaneous spinal direct current stimulation in combination with robotic training. Group 2 underwent cathodal transcranial direct current stimulation over the ipsilesional cerebellar hemisphere + cathodal transcutaneous spinal direct current stimulation in combination with robotic training. The primary outcome was the 6-minute walk test performed before, after, and at follow-up at 2 and 4 weeks post-treatment.

RESULTS

No significant difference in the 6-minute walk test between groups was found at the first post-treatment evaluation (P = 0.976), as well as at the 2-week (P = 0.178) and the 4-week (P = 0.069) follow-up evaluations. Both groups showed significant within-group improvements in the 6-minute walk test at all time points.∥Conclusions: Our findings support the hypothesis that cathodal transcranial direct current stimulation over the contralesional or ipsilesional cerebellar hemisphere in combination with cathodal transcutaneous spinal direct current stimulation may lead to similar effects on robotic gait training in chronic supratentorial stroke patients.

Stroke Gait Rehabilitation: A Comparison of End-Effector, Overground Exoskeleton, and Conventional Gait Training

Gait recovery is one of the main goals of post-stroke rehabilitation and Robot-Assisted Gait Training (RAGT) has shown positive outcomes. However, there is a lack of studies in the literature comparing the effects of different devices. This paper aims to study the effects, in terms of clinical and gait outcomes, of treadmill-based and overground RAGT, compared to conventional gait training in stroke subjects. The results showed a significant improvement of clinical outcomes in both robotic treatments and in conventional therapy. The performance of locomotor tasks was clinically significant in the robotic groups only. The spatio-temporal gait parameters did not reveal any significant difference. Results suggest future multicentre studies on a larger number of subjects.

[Top-down and bottom-up approaches for the treatment of unilateral spatial neglect in stroke patients: A systematic review]

OBJECTIVE

To evaluate the effectiveness of top-down and bottom-up approaches in the rehabilitation of unilateral spatial neglect in stroke patients.

METHODOLOGY

We carried out a systematic review of randomized controlled trials from January of 2013 to March of 2017. The following databases were searched: Scopus, Science Direct, Web of Science, Pubmed and CINHAL. The methodological quality, level of scientific evidence and the strength of recommendation were evaluated.

RESULTS

We included 13 studies (294 subjects): nine studies (188 patients) carried out therapies with a bottom-up approach such us eye patching, virtual reality, optokinetic stimulation, transcranial magnetic stimulation and prism adaption; three studies (94 patients) evaluated therapies with a top-down approach such us visual scanning, sensory feedback and mental practice; one study incorporated both approaches. Nine of these studies showed improvements in spatial neglect scales; five of these used bottom-up approaches, another three used top-down approaches and the remaining study combined both approaches. Disability was evaluated by nine studies, and only three reported improvements. Three studies reported significant improvements in motor function in the intervention groups.

CONCLUSIONS

Top-down and bottom-up approaches could improve unilateral spatial neglect, disability and motor function in patients with stroke.

Orthotists' and physical therapists' perspectives on quality of care indicators for persons with custom ankle-foot orthoses

Purpose: To describe the priorities of orthotists and physical therapists about quality measurement themes, and the feasibility and utility of collecting data from persons using custom AFOs that could inform quality measure development.Materials and Methods: Online survey assessed respondents' perspectives and experiences. An Advisory Committee representing professional, organizational, and accreditor groups distributed survey invitations.Results: 461 orthotists and 153 physical therapists completed part or all of the survey; 60% rated 9 quality themes and 20 quality of care topics as extremely important, and 12 standard instruments as feasible and good to use for quality measurement. Patients were the preferred source of information for ease of scheduling, device weight, ease of donning and doffing, adherence to device use, beneficial effects, activity level and independence, and quality of life. Clinicians were the preferred source for material quality, device modifiability, and joint range of motion. Facility records were the preferred source for timeliness of device delivery and clinician follow-up. Respondents reported that gait speed and walking endurance were best obtained by patient performance.Conclusions: Results provide insight on the topics orthotists and physical therapists regard as priorities for defining healthcare quality for persons using custom ankle-foot orthoses and instruments for data collection.

Gait Characteristics in Patients With Ankylosing Spondylitis: Protocol for a Systematic Review

Background

Ankylosing spondylitis is a subtype of inflammatory rheumatic disease, affecting predominantly the axial skeleton and sacroiliac joints. The main clinical manifestations are spinal stiffness and inflammatory back pain, which can potentially affect gait ability of patients with ankylosing spondylitis. However, published studies show discrepancies regarding gait characteristics in ankylosing spondylitis and heterogeneity in terms of task requirement, types of equipment, data collection, and analysis techniques used to assess gait ability of patients with ankylosing spondylitis.

Objective

This review aimed to determine (1) the consequences of ankylosing spondylitis on gait and (2) how gait is assessed in patients with ankylosing spondylitis.

Methods

Three electronic databases—PubMed, Physiotherapy Evidence Database (PEDro), and Cochrane—were searched systematically with no limit on the publication date in order to identify studies satisfying the search criteria. The research focused on original research, using Boolean operators “AND” and “OR” in the combination of the Medical Subject Headings descriptors found in titles or abstracts: (Gait OR Walk OR Walking OR locomotor OR locomotion) AND (ankylosing spondylitis OR spondyloarthritis). Only English-language original articles were included.

Results

As of September 2018, the search was completed, and 168 records were obtained. After screening titles and abstracts, 19 full texts were reviewed. Of those, 17 were included in the review. We are currently in the process of data extraction and synthesis.

Conclusions

The systematic review will provide a synthesis and comprehensive evaluation of published studies on gait characteristics in patients with ankylosing spondylitis. This work is also intended to help identify the likely relevant directions for future research.

Trial Registration

PROSPERO CRD42018102540; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=102540

International Registered Report Identifier (IRRID)

DERR1-10.2196/12470

Overground wearable powered exoskeleton for gait training in subacute stroke subjects: clinical and gait assessments

BACKGROUND

Wearable powered exoskeletons provide intensive overground gait training with patient's active participation: these features promote a successful active motor relearning of ambulation in stroke survivors.

AIM

The aim of this study was to investigate the feasibility and the clinical effects of an overground exoskeleton-assisted gait training (OEAGT) in subacute stroke patients.

DESIGN

Prospective, pilot pre-post, open label, non-randomized experimental study.

SETTING

Four Italian neurological rehabilitation centers.

POPULATION

Forty-eight subacute stroke patients were enrolled. Two patients dropped out because of medical problems. Data analysis was conducted on 46 subjects (56.84±14.29 years; 27 male; 29 ischemic; 24 left hemiparesis).

METHODS

Patients underwent 15±2 sessions (60 min/session, 3-5 times/week) of OEAGT. Clinical and gait assessments were performed at the beginning (T1) and at the end (T2) of the training period: modified Barthel Index (BI), modified Ashworth Scale at Hip (MAS-H), Knee (MAS-K), and Ankle (MAS-A) level, Motricity Index (MI), Trunk Control Test (TCT), Functional Ambulation Classification (FAC), Walking Handicap Scale (WHS), 10-Meter Walking Test (10MWT), 6-Minute Walking Test (6mWT), Timed Up-and-Go test (TUG). The Technology Acceptance Model (TAM) questionnaire evaluated the acceptance of OEAGT by patients. Data stratification was performed using the time post the acute event and the onset of rehabilitation treatment, and the MI at T1. Wilcoxon's test (P<0.05) was used.

RESULTS

All clinical scales significantly improved at T2; no statistically significant changes were reported for MAS-H, MAS-K, MAS-A. The 69.57% patients were able to walk at T1; 17.39% were not able to walk at T1 but regained ambulation at T2; and 13.04% were not able to walk at either T1 or T2. The ambulant patients showed a statistical improvement in speed measured during the 10MWT and in the distance covered over a time of 6 minutes (6mWT). The results from the TAM questionnaire showed that all subjects perceived the OEAGT positively. The data stratification analysis suggests that the OEAGT does not have any restriction of use.

CONCLUSIONS

The OEAGT improved the clinical and gait outcomes in subacute patients. Randomized studies on larger samples are needed to confirm these data and to assess the efficacy of OEAGT.

CLINICAL REHABILITATION IMPACT

Introduce innovative rehabilitation strategies based on customized OEAGT.

Is the aquatic thermal environment a suitable place for providing rehabilitative treatment for person with Parkinson's disease? A retrospective study

Many authors showed that aquatic physiotherapy could improve quality of life and reduce postural instability and risk of falling in elderly subjects. The aim of this research was to explore if the thermal aquatic environment is a suitable place for rehabilitative training in person with Parkinson disease (PwP) with results comparable to the standard physiotherapy. A retrospective study was conducted on a database of 14 persons with Parkinson who were admitted to a thermal aquatic rehabilitation to undergo treatments made to improve gait and balance impairments. The rehabilitation training consisted of 45-min sessions conducted twice a week, on non-consecutive days, over 4 weeks of functional re-education and kinesitherapy in the thermal pool. Educational and prevention instructions were also given to the patients during each session. Additionally, nutrition (diet), health education, and cognitive behavioral advice were given to our patients by therapists. The clinical characteristics of the sample were age 66 ± 9, disease duration 7 ± 5, and Hoehn and Yahr 1.5 ± 0.5. The statistical analysis showed a statistically significant improvement for the UPDRS p = 0.0005, for The Berg Balance Scale p = 0.0078, for the PDQ8 p = 0.0039, Tinetti p = 0.0068, and for Mini BESTest p = 0.0002. Our data suggest that this intervention could become a useful strategy in the rehabilitation program of PwP. The simplicity of treatment and the lack of side effects endorse the use of thermal aquatic environment for the gait and balance recovery in PwP.

Home-based technologies for stroke rehabilitation: A systematic review

BACKGROUND

Many forms of home-based technology targeting stroke rehabilitation have been devised, and a number of human factors are important to their application, suggesting the need to examine this information in a comprehensive review.

OBJECTIVE

The systematic review aims to synthesize the current knowledge of technologies and human factors in home-based technologies for stroke rehabilitation.

METHODS

We conducted a systematic literature search in three electronic databases (IEEE, ACM, PubMed), including secondary citations from the literature search. We included articles that used technological means to help stroke patients conduct rehabilitation at home, reported empirical studies that evaluated the technologies with patients in the home environment, and were published in English. Three authors independently conducted the content analysis of searched articles using a list of interactively defined factors.

RESULTS

The search yielded 832 potentially relevant articles, leading to 31 articles that were included for in-depth analysis. The types of technology of reviewed articles included games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets. We present the merits and limitations of each type of technology. We then derive two main human factors in designing home-based technologies for stroke rehabilitation: designing for engagement (including external and internal motivation) and designing for the home environment (including understanding the social context, practical challenges, and technical proficiency).

CONCLUSION

This systematic review presents an overview of key technologies and human factors for designing home-based technologies for stroke rehabilitation.

Measurement properties of the upright motor control test in adults with subacute stroke

BACKGROUND

Previous studies have distilled the Upright Motor Control Test Knee Extension and Knee Flexion subscales (UMCT-KE and UMCT-KF, respectively) from the original 6-item instrument and examined these as stand-alone rapid tests of voluntary movement control in the standing position. Systematic review evidence suggests that the UMCT-KE and UMCT-KF may have value in predicting walking ability after stroke.

OBJECTIVE

To examine the interrater and intrarater reliability, and concurrent validity of the UMCT-KE and UMCT-KF, and associations with walking ability in adults with subacute stroke.

METHODS

A prospective repeated assessments design was implemented in a rehabilitation department in a public teaching hospital. A consecutive sample of patients with subacute first-time stroke (N = 50; mean age = 51 ± 12 years; 20 females; mean time post-stroke = 68 ± 48 days) completed the study. Three physical therapists independently administered the UMCT-KE and UMCT-KF on two testing occasions 2 days apart (t1 and t2). On t2, a fourth rater administered the Leg subscale of the Motricity Index (MI-Leg) as criterion standard.

RESULTS

The UMCT-KE and UMCT-KF demonstrated substantial to almost perfect interrater and intrarater reliability (W = 0.77-0.95), with lower limits of 95% confidence intervals extending to no lower than the substantial level. Both the UMCT-KE and UMCT-KF showed high correlations with the MI-Leg (ρ = 0.747-0.775) and significant associations with walking ability. p Values for all tests were <0.001.

CONCLUSIONS

The UMCT-KE and UMCT-KF are reliable and valid tests for rapidly estimating voluntary movement control of the lower limbs in adults with subacute stroke.

Combined effects of cerebellar transcranial direct current stimulation and transcutaneous spinal direct current stimulation on robot-assisted gait training in patients with chronic brain stroke: A pilot, single blind, randomized controlled trial

BACKGROUND

Preliminary evidence showed additional effects of anodal transcranial direct current stimulation over the damaged cerebral hemisphere combined with cathodal transcutaneous spinal direct current stimulation during robot-assisted gait training in chronic stroke patients. This is consistent with the neural organization of locomotion involving cortical and spinal control. The cerebellum is crucial for locomotor control, in particular for avoidance of obstacles, and adaptation to novel conditions during walking. Despite its key role in gait control, to date the effects of transcranial direct current stimulation of the cerebellum have not been investigated on brain stroke patients treated with robot-assisted gait training.

OBJECTIVE

To evaluate the effects of cerebellar transcranial direct current stimulation combined with transcutaneous spinal direct current stimulation on robot-assisted gait training in patients with chronic brain stroke.

METHODS

After balanced randomization, 20 chronic stroke patients received ten, 20-minute robot-assisted gait training sessions (five days a week, for two consecutive weeks) combined with central nervous system stimulation. Group 1 underwent on-line cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere + cathodal transcutaneous spinal direct current stimulation. Group 2 received on-line anodal transcranial direct current stimulation over the damaged cerebral hemisphere + cathodal transcutaneous spinal direct current stimulation. The primary outcome was the 6-minute walk test performed before, after, and at follow-up at 2 and 4 weeks post-treatment.

RESULTS

The significant differences in the 6-minute walk test noted between groups at the first post-treatment evaluation (p = 0.041) were not maintained at either the 2-week (P = 0.650) or the 4-week (P = 0.545) follow-up evaluations.

CONCLUSION

Our preliminary findings support the hypothesis that cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere in combination with cathodal transcutaneous spinal direct current stimulation might be useful to boost the effects of robot-assisted gait training in chronic brain stroke patients with walking impairment.

Wrist Robot-assisted Rehabilitation Treatment in Subacute and Chronic Stroke Patients: from Distal to Proximal Motor Recovery

In this study, the recovery of proximal and distal segments in stroke patients who received distal training alone was investigated. Forty (20 subacute and 20 chronic) stroke patients were recruited to perform wrist robot-assisted rehabilitation training. The upper extremity, shoulder-elbow and wrist subsections of the Fugl-Meyer Assessment Scale were used to assess the motor recovery of distal and proximal segments. In addition, the Modified Ashworth Scale, the Motricity Index and the Box & Block test were used as clinical outcome measures together with kinematic parameters to evaluate the effects of the training. Significant increases in the wrist and shoulder-elbow subsections of the Fugl-Meyer Assessment Scale, Motricity Index and Box & Block test were found in both groups. Average changes in shoulder-elbow and upper extremity subsections of the Fugl-Meyer Assessment Scale in the subacute group (6.10 ± 6.60 and 15.65 ± 14.04) were significantly higher (p < 0.05) than those in the chronic group (2.30 ± 2.76 and 6.60 ± 4.64). In addition, significant increases in the movement velocity, movement smoothness and movement quality were observed in the subacute group. Our findings provide evidence that following a robot-assisted rehabilitation treatment there is a distal-to-proximal generalization in subacute stroke patients.

Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to synthesize the best available evidence on the effectiveness of robotic assistive devices in the rehabilitation of adult stroke patients for recovery of impairments in the upper and lower limbs. The secondary objective is to investigate the sustainability of treatment effects associated with use of robotic devices.The specific review question to be addressed is: can robotic assistive devices help adult stroke patients regain motor movement of their upper and lower limbs?

Randomized controlled trial of robot-assisted gait training with dorsiflexion assistance on chronic stroke patients wearing ankle-foot-orthosis

BACKGROUND

Robot-assisted ankle-foot-orthosis (AFO) can provide immediate powered ankle assistance in post-stroke gait training. Our research team has developed a novel lightweight portable robot-assisted AFO which is capable of detecting walking intentions using sensor feedback of wearer's gait pattern. This study aims to investigate the therapeutic effects of robot-assisted gait training with ankle dorsiflexion assistance.

METHODS

This was a double-blinded randomized controlled trial. Nineteen chronic stroke patients with motor impairment at ankle participated in 20-session robot-assisted gait training for about five weeks, with 30-min over-ground walking and stair ambulation practices. Robot-assisted AFO either provided active powered ankle assistance during swing phase in Robotic Group (n = 9), or torque impedance at ankle joint as passive AFO in Sham Group (n = 10). Functional assessments were performed before and after the 20-session gait training with 3-month Follow-up. Primary outcome measure was gait independency assessed by Functional Ambulatory Category (FAC). Secondary outcome measures were clinical scores including Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Berg Balance Scale (BBS), Timed 10-Meter Walk Test (10MWT), Six-minute Walk Test (SMWT), supplemented by gait analysis. All outcome measures were performed in unassisted gait after patients had taken off the robot-assisted AFO. Repeated-measures analysis of covariance was conducted to test the group differences referenced to clinical scores before training.

RESULTS

After 20-session robot-assisted gait training with ankle dorsiflexion assistance, the active ankle assistance in Robotic Group induced changes in gait pattern with improved gait independency (all patients FAC ≥ 5 post-training and 3-month follow-up), motor recovery, walking speed, and greater confidence in affected side loading response (vertical ground reaction force + 1.49 N/kg, peak braking force + 0.24 N/kg) with heel strike instead of flat foot touch-down at initial contact (foot tilting + 1.91°). Sham Group reported reduction in affected leg range of motion (ankle dorsiflexion - 2.36° and knee flexion - 8.48°) during swing.

CONCLUSIONS

Robot-assisted gait training with ankle dorsiflexion assistance could improve gait independency and help stroke patients developing confidence in weight acceptance, but future development of robot-assisted AFO should consider more lightweight and custom-fit design.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02471248 . Registered 15 June 2015 retrospectively registered.

Recovery and compensation after robotic assisted gait training in chronic stroke survivors

Background: Gait re-education is a primary rehabilitation goal after stroke. In the last decades, robots with different mechanical structures have been extensively used in the clinical practice for gait training of stroke survivors. However, the effectiveness of robotic training is still controversial, especially for chronic subjects. In this study, we investigated the short-term effects of gait training assisted by an endpoint robot in a population of chronic stroke survivors.Methods: Subjects were evaluated before and after training with clinical scales and instrumented gait analysis. Our primary outcome indicator was the walking speed. Next, we investigated the changes in kinetic and kinematic gait patterns as well as the intersegmental coordination at the level of the lower limbs.Results: Most subjects improved their speed in over-ground walking, by modifying the temporal more than the spatial gait parameters. These changes led to an improvement in the ankle power for both sides and to a slight reduction of the inclination of the pelvis during the swing phase, mainly due to a decreased knee flexion and an increased hip extension on the unimpaired leg.Conclusions: These results indicate that the proposed training induced mainly a functional change rather than an improvement of the quality of gait.Implication for RehabilitationGait re-education is a primary goal in stroke rehabilitation.Nowadays several robotic devices for gait rehabilitation are used in the clinical practice, but their effectiveness is controversial, especially for chronic survivors.After a 20-session training with an endpoint robot the chronic stroke survivors showed an improvement in overground gait speed.The increased gait speed was mainly due to functional changes of the temporal parameters and of the kinetic variables at the level of both ankle joints, as well as to a reduction of compensatory strategies observable in the unimpaired side.

Early robot-assisted gait retraining in non-ambulatory patients with stroke: a single blind randomized controlled trial

BACKGROUND

Restoration of walking function is a primary concern of neurorehabilitation with respect to the aspired social and vocational reintegration. To date, the best practice for improving gait early after stroke is still object of debate. On one hand, repetitive task-specific approaches with higher intensities of walking have been observed to result in greater improvements of gait after stroke. Conversely there is some evidence that conventional gait training would be more effective for facilitating walking ability after stroke.

AIM

To compare the effects of an early treatment protocol of add-on robot-assisted gait training with add-on conventional overground physiotherapy for improving locomotion in non-ambulatory adult stroke patients.

DESIGN

Single-blind randomized controlled trial.

SETTING

Neurorehabilitation hospital.

POPULATION

Seventy-four subacute patients with first-ever ischemic stroke.

METHODS

The patients were randomized into two groups. The training program consisted of forty, 2-hour sessions (including 45 minutes basic training, 45 minutes add-on training plus rest periods), 5 days a week, for 8 consecutive weeks. Patients allocated to the add-on robot-assisted gait training were treated by means of the Lokomat. Patients allocated to the add-on conventional overground gait training aimed at improving postural control during gait, body weight transfer, stability during the stance phase, free swing phase, adequate heel contact and gait pattern. Primary outcome was the modified Emory Functional Ambulation Profile. Secondary outcomes were the Rivermead Motor Index, the Mobility Milestones and the Hochzirl Walking Aids Profile.

RESULTS

No significant difference was observed between groups with regards to age (P=0.661), time from stroke onset (P=0.413) and the primary outcome (P=0.854) at baseline evaluation. As to the primary outcome, no significant differences were found between groups at the end of the study. As During the 8-week training, within-group comparisons showed significant improvements of mean modified Emory Functional Ambulation Profile in both groups (P<0.001).

CONCLUSIONS

Our results support the hypothesis that an early treatment protocol of robot-assisted gait retraining is not superior to add-on conventional gait training intervention for improving locomotion in non-ambulatory stroke patients.

CLINICAL REHABILITATION IMPACT

This study might help to better understand the role of robot-assisted gait training in early phase stroke rehabilitation.

Kinematic measures for upper limb robot-assisted therapy following stroke and correlations with clinical outcome measures: A review

AIM OF THE STUDY

This review classifies the kinematic measures used to evaluate post-stroke motor impairment following upper limb robot-assisted rehabilitation and investigates their correlations with clinical outcome measures.

METHODS

An online literature search was carried out in PubMed, MEDLINE, Scopus and IEEE-Xplore databases. Kinematic parameters mentioned in the studies included were categorized into the International Classification of Functioning, Disability and Health (ICF) domains. The correlations between these parameters and the clinical scales were summarized.

RESULTS

Forty-nine kinematic parameters were identified from 67 articles involving 1750 patients. The most frequently used parameters were: movement speed, movement accuracy, peak speed, number of speed peaks, and movement distance and duration. According to the ICF domains, 44 kinematic parameters were categorized into Body Functions and Structure, 5 into Activities and no parameters were categorized into Participation and Personal and Environmental Factors. Thirteen articles investigated the correlations between kinematic parameters and clinical outcome measures. Some kinematic measures showed a significant correlation coefficient with clinical scores, but most were weak or moderate.

CONCLUSIONS

The proposed classification of kinematic measures into ICF domains and their correlations with clinical scales could contribute to identifying the most relevant ones for an integrated assessment of upper limb robot-assisted rehabilitation treatments following stroke. Increasing the assessment frequency by means of kinematic parameters could optimize clinical assessment procedures and enhance the effectiveness of rehabilitation treatments.

Effects of gait training using the Hybrid Assistive Limb® in recovery-phase stroke patients: A 2-month follow-up, randomized, controlled study

BACKGROUND

Gait training using the Hybrid Assistive Limb® (HAL®) may have beneficial effects on post-stroke gait function and independent walking. However, the long-term and medium-term efficacies of gait training using HAL® in stroke patients remain unclear.

OBJECTIVE

To compare the medium-term efficacy of gait training using a single-leg version of the Hybrid Assistive Limb® (HAL®) on the paretic side with conventional gait training (CGT) in recovery-phase stroke patients.

METHODS

Twenty-four post-stroke participants (HAL® group: n = 12, CGT group: n = 12) completed the trial. Over 4 weeks, all participants received twelve 20-min sessions of either HAL® (using the single-leg version of HAL® on the paretic side) or conventional (performed by skilled and experienced physical therapists) gait training. Outcome measures were evaluated prior to training, after 12 sessions, and at 8 and 12 weeks after intervention initiation. Functional Ambulation Category (FAC) was the primary outcome measure.

RESULTS

The HAL® group showed significant improvement in FAC after 12 sessions, and at 8 and 12 weeks compared to the conventional group (P = 0.02).

CONCLUSIONS

The results suggested that a gait training program based on HAL® may improve independent walking more efficiently than CGT at 1 and 2 months after intervention.

Effectiveness of robotic assisted rehabilitation for mobility and functional ability in adult stroke patients: a systematic review

BACKGROUND

Stroke is a leading cause of long-term disability, and rehabilitation, involving repetitive, high intensity, task-specific exercises, is the pathway to restoring motor skills. Robotic assistive devices are increasingly being used and it is hoped that with robotic devices, rehabilitation progress can be achieved for patients.

OBJECTIVES

To examine the effectiveness of robotic devices in the rehabilitation of stroke patients for upper limb mobility, lower limb mobility, and activities of daily living. The sustainability of treatment effect was also examined.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adult stroke patients 18 years and over.

TYPES OF INTERVENTION(S)

Rehabilitation of stroke patients using robotic devices with assistive automation, compared to conventional physiotherapy.

OUTCOMES

Motor movements of upper limbs, walking movement of lower limbs and activities of daily living, including follow-up measurements to examine the sustainability of treatment effect.

TYPES OF STUDIES

Randomized and controlled clinical trials.

SEARCH STRATEGY

Published and unpublished studies in English were searched.

METHODOLOGICAL QUALITY

All studies meeting the review inclusion criteria were independently assessed for methodological quality by two reviewers.

DATA EXTRACTION

Quantitative data were extracted using the standardized data extraction tool from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument.

DATA SYNTHESIS

Quantitative data were pooled in statistical meta-analysis. Effect sizes expressed as standardized mean difference, 95% confidence intervals and levels of heterogeneity (I) were calculated. Where statistical pooling was not possible, the findings were presented in narrative form.

RESULTS

Fifty-one studies with 1798 patients were included in this review. Thirty studies examined upper limb interventions and 21 studies evaluated lower limb gait training. Non-significant results were found for upper limb (SMD 0.07, 95% CI -0.11 to 0.26, I = 41%, P = 0.45), lower limb (SMD 0.17, 95% CI -0.15 to 0.48, I = 75%, P = 0.31) and activities of daily living (SMD 0.11, 95% CI -0.11 to 0.33, I = 66%, P = 0.32). For patients with severely impaired lower limbs, a significant difference was observed in favor of robotics (SMD 0.41, 95% CI 0.19 to 0.63, I = 28%, P = 0.0003). P-value analysis did not show significant results for the sustainability of treatment effect post intervention.

CONCLUSIONS

Robotic training is just as effective as conventional training for upper limb motor movement, lower limb walking mobility and for activities of daily living. For lower limb patients with severe impairment, robotic training produces better outcomes than conventional training. The sufficient quantity of studies included and the reasonable quality of Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence support the findings.For treatment sustainability of upper and lower limbs, robotic training is just as effective as conventional training. However, the low quality of GRADE evidence and the lower number of studies included require caution for this finding. For treatment sustainability of activities of daily living, the better quality of GRADE evidence and the larger number of studies analyzed indicate that robotic training is just as effective as conventional training.

A cross-sectional study comparing lateral and diagonal maximum weight shift in people with stroke and healthy controls and the correlation with balance, gait and fear of falling

Impaired balance is common post stroke and can be assessed by means of force-platforms measuring center of pressure (COP) displacements during static standing, or more dynamically during lateral maximum weight shift (MWS). However, activities of daily life also include diagonal MWS and since force platforms are nowadays commercially available, investigating lateral and diagonal MWS in a clinical setting might be feasible and clinically relevant. We investigated lateral and diagonal MWS while standing in patients with stroke (PwS) and healthy controls (HC), evaluated MWS towards the affected and the non-affected side for PwS and correlated MWS with measures of balance, gait and fear of falling. In a cross-sectional observational study including 36 ambulatory sub-acute inpatients and 32 age-matched HC, a force platform (BioRescue, RM Ingénierie, France) was used to measure lateral and diagonal MWS in standing. Clinical outcome measures collected were Berg Balance Scale and Community Balance and Mobility Scale (CBMS) for balance, 10-meter walk test (10MWT) for gait speed and Falls Efficacy Scale–international version for fear of falling. MWS for PwS towards the affected side was significantly smaller compared to HC (lateral: p = 0.029; diagonal-forward: p = 0.000). MWS for PwS was also significantly reduced towards the affected side in the diagonal-forward direction (p = 0.019) compared to the non-affected side of PwS. Strong correlations were found for MWS for PwS in the diagonal-forward direction towards the affected side, and clinical measures of balance (CBMS: r = 0.66) and gait speed (10MWT: r = 0.66). Our study showed that ambulatory sub-acute PwS, in comparison to HC, have decreased ability to shift their body weight diagonally forward in standing towards their affected side. This reduced ability is strongly related to clinical measures of balance and gait speed. Our results suggest that MWS in a diagonal-forward direction should receive attention in rehabilitation of ambulatory sub-acute PwS in an inpatient setting.

Effects of Robot-Assisted Training for the Unaffected Arm in Patients with Hemiparetic Cerebral Palsy: A Proof-of-Concept Pilot Study

On a voluntary basis, 10 adolescents with hemiparesis due to cerebral palsy and 11 neurologically healthy control subjects participated in this proof-of-concept pilot study. The aim was to examine the effects of robot-assisted training for the unaffected arm in patients with hemiparetic cerebral palsy. Baseline comparison between the unaffected arm of the hemiparetic patients with cerebral palsy and the dominant arm of healthy control subjects showed significant differences on the Jebsen-Taylor Hand Function test and action planning ability tests. Within-group comparison after ten 30-minute sessions (five days a week for two consecutive weeks) of robot-assisted training for the unaffected arm showed significant improvements in patients with cerebral palsy on the Jebsen-Taylor Hand Function test (performed at both hands) and action planning ability test (evaluated at the unaffected arm). Our findings are in line with previous evidences of action planning deficits at the unaffected arm in patients with hemiparetic cerebral palsy and support the hypothesis that robot-assisted training for the unaffected arm may be useful to improve manual dexterity and action planning in patients with hemiparesis due to cerebral palsy.

Assessment of demographic and clinical characteristics on functional status and disability of patients with stroke

OBJECTIVE

To determine the effects of demographic and clinical characteristics on mobility, disability, and activities of daily life of patients with stroke.

METHODS

This cross-sectional clinical study was performed in the Department of Physical Medicine and Rehabilitation in Cukurova University Faculty of Medicine in Adana, Turkey, between February 2011 and December 2011. The study included 126 patients with stroke. The Brunnstrom recovery scale (BRS), functional ambulation classification scale (FACS), modified Barthel index (MBI), modified Rankin scale (MRS), and Rivermead mobility index (RMI) were used in the evaluation of the functional status of stroke patients. Correlations between each scale and parameters including age, etiology, and duration of hemiplegia were assessed.

RESULTS

The major etiology of stroke was found as ischemic (77%). Hypertension was a major risk factor in both genders (72% for males, 85% for females). Statistically significant differences were found between ischemic and hemorrhagic stroke patients regarding the RMI, MBI, BRS, and the FACS (p<0.001). Age had a poor negative correlation with the FACS and RMI.

CONCLUSION

It is suggested that age is an important risk factor for the development of stroke, but it has no strong effect on functional status and disability in patients with stroke. The BRS, FACS, MBI, MRS, and RMI scales can be used in stroke patients whether they are under or over 65 years old in order to evaluate functional status and disability.

Hemorrhagic versus ischemic stroke: Who can best benefit from blended conventional physiotherapy with robotic-assisted gait therapy?

BACKGROUND

Contrary to common belief of clinicians that hemorrhagic stroke survivors have better functional prognoses than ischemic, recent studies show that ischemic survivors could experience similar or even better functional improvements. However, the influence of stroke subtype on gait and posture outcomes following an intervention blending conventional physiotherapy with robotic-assisted gait therapy is missing.

OBJECTIVE

This study compared gait and posture outcome measures between ambulatory hemorrhagic patients and ischemic patients, who received a similar 4 weeks' intervention blending a conventional bottom-up physiotherapy approach and an exoskeleton top-down robotic-assisted gait training (RAGT) approach with Lokomat.

METHODS

Forty adult hemiparetic stroke inpatient subjects were recruited: 20 hemorrhagic and 20 ischemic, matched by age, gender, side of hemisphere lesion, stroke severity, and locomotor impairments. Functional Ambulation Category, Postural Assessment Scale for Stroke, Tinetti Performance Oriented Mobility Assessment, 6 Minutes Walk Test, Timed Up and Go and 10-Meter Walk Test were performed before and after a 4-week long intervention. Functional gains were calculated for all tests.

RESULTS

Hemorrhagic and ischemic subjects showed significant improvements in Functional Ambulation Category (P<0.001 and P = 0.008, respectively), Postural Assessment Scale for Stroke (P<0.001 and P = 0.003), 6 Minutes Walk Test (P = 0.003 and P = 0.015) and 10-Meter Walk Test (P = 0.001 and P = 0.024). Ischemic patients also showed significant improvements in Timed Up and Go. Significantly greater mean Functional Ambulation Category and Tinetti Performance Oriented Mobility Assessment gains were observed for hemorrhagic compared to ischemic, with large (dz = 0.81) and medium (dz = 0.66) effect sizes, respectively.

CONCLUSION

Overall, both groups exhibited quasi similar functional improvements and benefits from the same type, length and frequency of blended conventional physiotherapy and RAGT protocol. The use of intensive treatment plans blending top-down physiotherapy and bottom-up robotic approaches is promising for post-stroke rehabilitation.

Analysis of consistency between temporospatial gait parameters and gait assessment with the use of Wisconsin Gait Scale in post-stroke patients

INTRODUCTION

Due to the increasing incidence and social effects of stroke there is a growing interest in finding methods enabling gait analysis in this group of patients. Observational techniques are predominantly applied in clinical practice; on the other hand advanced quantitative methods allow in-depth multidimensional gait assessment. The present study was designed to assess the consistency between temporospatial gait parameters acquired through 3-dimensional gait analysis and the results of gait assessment with the use of observational WGS in post stroke hemiparetic patients.

MATERIAL AND METHOD

The study was performed in a group of 30 post-stroke patients, over 6 months from the onset of ischaemic stroke, who were able to walk unassisted. Gait assessment based on WGS was performed by an experienced physiotherapist, with the use of video recordings. Assessment of temporospatial parameters was based on gait analysis performed with BTS Smart system.

RESULTS

The findings show moderate correlation between WGS based gait assessment and gait velocity (r=-0.39; p=0.0316). Similar relationship was identified between gait cycle duration and score in WGS for both unaffected (r=-0.36; p=0.0477) and affected side (r=-0.37; p=0.0426). Higher correlation level was demonstrated for stance phase on the unaffected side and gait assessment based on WGS (r=0.58; p=0.0009).

CONCLUSIONS

Gait assessments with the use of temporospatial parameters and with observational WGS were found to produce moderate and good consistent results. WSG is a useful, simple tool for assessing gait in post stroke hemiparetic patients.

[Evaluation of motor skills recovery in post-stroke patients in the process of complex rehabilitation with the use of robotic kinesiotherapy]

AIM

To compare the efficacy of complex rehabilitation in patients receiving robotic kinesiotherapy and conventional physical therapy.

MATERIAL AND METHODS

In total 68 patients were examined, including 37 patients receiving traditional kinesiotherapy and sessions on the robotic complex 'Locomat' and 31 patients of the control group who received conventional physical therapy.

RESULTS AND CONCLUSION

There were statistical between-group differences in the indices of mobility, physical capabilities, strength and muscle tone in paretic extremities as well as the overall improvement of daily activity. The use of robotic devices has a positive impact on the rehabilitation of post-stroke patients.