ROBOTICS LOKOMAT _ ADULT & PEDIATRIC LOKOMAT MODULES (2006)

 * A 'pioneering world first' - Hyperbaric Oxygen Therapy combined with the Australian first Lokomat (Robotic Gait Assisted Walking) to promote functional changes and neuroplasticity (Hooper 2006).

 ** Malcolm R. Hooper pioneered ‘off-label’ applications of Hyperbaric Oxygenation in Australia (1996). 

HyperMED (OXYMED) installed the Australian first LOKOMAT (Adult and Pediatric Robotic Gait Assisted Walking) in 2006. The combination effects of HBO and LOKOMAT for brain and spinal cord injury – a ‘world first’.

 * 'OXYMED is like a neuro-recovery boot camp; we make no apology for 'politely pushing the patient'  the objective is to penetrate the deeper neurovascular structures, unlock dormant pathways and promote functional changes.' (Hooper 2006)

 

In Australia, the combination effects of HBO/LOKOMAT are viewed as ‘novel and unique'.   AHPRA vs Dr Malcolm R Hooper (2009-2013)

 ** Today across the USA, in excess of 1200 medical facilities provide similar HBO applications for chronic neurologic and other complex illness disorders. There are in excess of 500-LOKOMATS worldwide and a growing market for personal exoskeletons assisting patient mobility and functionality.

 *** OXYMED (HyperMED) pioneering efforts contributed to LOKOMAT funding across Australia (South Australia boasting 3x Lokomat systems 2013), fundraising at The Royal Melbourne Hospital (2014) and in 2018 funding under the National Disability Scheme 9NDIS)is also fundraising for a LOKOMAT.

Rehabilitation Market 2018

The Rehabilitation Robot Market Size at $641 Million in 2018 and is Expected to Grow Dramatically to Reach $6.4 Billion by 2025

Worldwide Rehabilitation Robot markets are expected to achieve significant growth as robots replace much of the human work in physical therapy. 

* The robots are steadier, make fewer mistakes, support treatment for longer durations, and decrease the cost of rehabilitation for many conditions. The robots permit a more accurate rehabilitation routine for any specific condition than is possible with human physical therapy in many cases. 

Robotics has a tremendous ability to reduce disability and lead to better outcomes for patients with stroke. With the use of rehabilitation robots, patient recovery of function is able to be more substantial than what is achieved now. Whereas traditional rehabilitation with a human therapist goes on for a few weeks, people using robots are able to make continued progress in regaining functionality even years after an injury or stroke.

It is a question of cost. While insurance pays for a small amount of rehabilitation needed, generally provided by a human therapist, using a robot is a far less costly process, and can be effective over the long term, even without reimbursement. Marketing has a tremendous effect in convincing people that they can achieve improvements from rehabilitation processes even after years of effort.
HyperMED LOKOMAT Australian Experience (Hooper 2008) 


Rehabilitation robotics devices are used for assisting the performance of sensorimotor functions. Devices help arm, hand, leg rehabilitation by supporting a repetitive motion that builds neurological pathways to support the use of the muscles. Development of different robotic schemes for assisting therapeutic training is innovative. 
Robotic therapy stimulus of upper limbs provides an example of the excellent motor recovery after stroke that can be achieved using rehabilitation robots. Lower limb systems and exoskeleton systems provide wheelchair-bound patients the ability to get out of a wheelchair 

Robotic rehabilitation equipment is mostly used in rehabilitation clinical facilities. There is a huge opportunity for launching a homecare equipment market if it is done through sports clubs rather than through clinical facilities. People expect insurance to pay for medical equipment but are willing to spend bundles on sports trainer equipment for the home. Rehabilitation robots can help stroke patients years after an event, so it makes a difference if someone keeps working to improve their functioning. 

 

Vendors will very likely have to develop a strong rehabilitation robotic market presence as these devices evolve a homecare aspect. The expense of nursing home rehabilitation has been very high, limiting the use of rehabilitation to a few weeks or months at the most. Rehabilitation robots realistically extend the use of an automated process for rehabilitation in the home. The availability of affordable devices that improve mobility is not likely to go unnoticed by the sports clubs and the baby boomer generation, now entering the over 65 age group and seeking to maintain lifestyle. 

As clinicians realize that more gains can be made by using rehabilitation robots in the home, the pace of acquisitions will likely pick up.

Exoskeleton markets will be separate and additive to this market. A separate exoskeleton market will create more growth. Market growth is a result of the effectiveness of robotic treatment of muscle difficulty. The usefulness of the rehabilitation robots is increasing. Doing more sophisticated combinations of exercise has become more feasible as the technology evolves. Patients generally practice 1,000 varied movements per session. With the robots, more sessions are possible. 

bupa.PNG

Nine News reports, the first robotic gait trainer in Australian is helping Bupa Therapy patient, Nicole Skermer walk again with her goal of getting back on her feet by Christmas.

After a fall that led to a haemorrhage on her brain, Nicole hasn’t been able to walk for four years and before that suffered a series of health complications including three brain tumours.

Nicole has been visiting Bupa Therapy for just under a month now with the assistance of Neuro Physiotherapist, Vicky Cook to help retrain her brain to walk again.

Vicky has been working with Nicole on the robotic gait machine which helps Nicole move and take more steps than she could if she was using other equipment such as a treadmill.

“With the harness and robotic features of the device we can get those repetitions happening and the intensity that’s needed to actually change the brain to heal itself,” says Vicky.

Bupa Therapy is the only place in Australia that has this new device that can be used on patients suffering a range of disabilities including spinal cord injury, stroke, multiple sclerosis, Parkinson’s disease, brain injuries and cerebral palsy.

OXYMED Comment - these are exactly the same conditions Dr Hooper was held to account by AHPRA vs Hooper 2013

Australian Broadcasting Commission 10 November 2015

Robot Lokomat helps teach seven-year-old girl with cerebral palsy to walk

The Australian Broadcasting Commission reports on the amazing benefits to a young Adelaide patient.

AHPRA vs Dr Malcolm R Hooper (2009-2013)

  • The LOKOMAT featured in the ABC story was the original Lokomat I, (Dr Mal Hooper) brought to Australia in 2006, combining the merits of Hyperbaric Oxygen Therapy and Lokomat (Robotic Gait Assisted Walking) being a world first for patients with brain and spinal cord injuries including cerebral palsy conditions.

  • However the Chiropractic Board of Australia and AHPRA (Australian Health Practitioner Regulatory Authority) took action against me (Hooper) in 2009 escalating a 'patient complaint' to the VCAT (Victorian Civil Administration Tribunal) for 'unaccepted treatment' referring to the modalities (HBO & Lokomat) as 'novel and unique applications not supported by the greater percentage of medical doctors or medical organisation in Australia'.

  • The 'notifier patient' patient under cross examination stated that he 'lodged his complaint to avoid the debt' and then 'wiped the web of his fund raising website' and promotional activities including 'podcast and You Tube recordings testifying to the benefits of treatments' received at HyperMED.

LOKOMAT (Robotic Gait Assisted Walking) Gait Training

  • LOKOMAT is NOT passive involvement.

  • The LOKOMAT is constantly adjusted to best assist the functional responses of the patient. Patients commence with passive assistance however as the patient compliance builds the LOKOMAT settings and various programs are tailored to the patient performance and capabilities.

  • Some patients have high level spasticity and others a complete loss of tone. Each patient's presentation is different - LOKOMAT provides excellent opportunity to 'best-fit' the patients specific capabilities and capacity to re-train function. And this is replicable on every separate training session!

  • In addition the support harness treadmill system are utilized independent of the LOKOMAT to promote functional changes. Functional changes being driven by 'man and machine' are then put to the test with the patient then able to implement strategies being focused on during each LOKOMAT session.

  • This combination effect is both unique and significant towards each neurologic patient developing a sense of supportive assistance whilst focusing on improving functional independence.

  • Walking requires a 'fluid like connection between spinal reflex generators and higher brain centres'. The combined approach is invaluable to promote functional changes - neuroplasticity (the ability to salvage back what has been damaged).

 

 

Background Information - LOKOMAT (Robotic Gait Assisted Walking)

  • For the past 15-years body weight supported treadmill training (BWSTT) has become a prominent gait rehabilitation method in leading rehabilitation centers throughout the world. This type of locomotor training has many functional benefits but the labor costs are considerable. To reduce therapist effort, Robotically Gait Assisted BWSTT (LOKOMAT) has been shown to be more accurate and financially feasible, compared to the other BWSTT modalities. Currently 80+ LOKOMAT systems are in use in large NeuroRehabilitation hospitals in the USA and approximately 500 LOKOMAT systems found in 31 Countries (2013).

  • In December 2006 HyperMED NeuroRecovery located in Melbourne installed Australia’s first Adult and Pediatric LOKOMAT systems (Robotic Gait Assisted Body Weight-Support Treadmill Training) providing opportunity for adults and children with gait impairment due to spinal or cerebral motor disorder to improve functional outcomes.

  • Neural plasticity refers to the natural ability of the neurons in the nervous system to generate and develop new connections aimed at repairing the neuronal damages. In the other word, they can learn new tasks. Based on this fact, locomotor training focuses on retraining the nervous system through simulating and repetition of walking gait, in order to regain their function and/or enhance their existing potentials. By repetitively stimulating the muscles and nerves in the lower body LOKOMAT Gait Assisted Training works to awaken dormant neural pathways controlling standing, stepping and balance. 

  • Experiments conducted on spinalized cats demonstrate that treadmill walk was possible suggesting evidence of a central gait pattern generator which remain active; these spinal generators drive the ability to re-learn function. When these generators are not activated the spinal circuits remain dormant; this inability to realize a movement combined with the neuroplasticity of the central nervous system may induce a secondary functional incapacity called “learning non use” – the ability to sit!

  • Locomotor Gait Assisted Training refers to an intervention for retraining patients to walk after neurologic injury providing repetitive, intensive and task specific training that induces neuronal plasticity and subsequently cortical reorganization after brain and spinal cord damage. The goals of locomotor training are to capitalize on the intrinsic mechanisms of the CNS that respond to sensory input associated with walking to generate a stepping response and the ability of the CNS to learn through intensive, task-specific repetition and practice. Task specific training such as gait assisted walking enables repair and reorganization of processes in the central nervous system. In order to walk or regain functional capacity the injured patient must ‘re-learn to walk’.

 

Activity Based Rehabilitation after neurological injury relies on three KEY principles of motor learning.

  • Practice is the first principle. All other things being equal, more functional learning will occur with more 'accurate' practice.

  • Specificity is the second principle. The best way to improve performance of a motor task is to 'execute that specific motor task repeated many times.'

  • Effort is the third principle. Individuals need to maintain a high degree of 'focus, participation and involvement' to facilitate motor learning.

  • These three principles are critical to promoting activity-dependent plasticity (i.e. altering the efficacy and excitation patterns of neural pathways by activating those pathways). With regards to neurological rehabilitation, it is important to emphasize that plasticity occurs in neural pathways that are active.

  • Over the past decades, extensive research studies have assessed and evaluated the use and benefits of body weight-supported locomotor training. These studies reveal that BWSTT can effectively improve walking parameters such as speed, limb coordination, distance, and level of independence. It has also been shown that BWSTT in incomplete SCI patients can also lead some positive neurological alterations namely stepping ability, corticospinal tract function, and increased electromyography activity.

  • Manually assisted treadmill training has been used for more than 15-years as a regular training for patients with spinal cord injury and stroke. The most extensive study published to date found that 80% of wheelchair bound patients with chronic incomplete spinal cord injury gained functional walking ability after functional training - Spinal Cord Inj Rehabil 2005.

  • Unfortunately BWSTT has not found prominence in Australian hospitals or private rehabilitation clinics.

 

What Are The Limits of LOKOMAT Gait Training?

  • Patients with spinal cord injuries who have been wheelchair bound for many years are still potentially able to ambulate. Improving a patient to the point that he/she no longer needs a wheelchair to move would definitely lead to reducing the yearly costs of his/her neurological disease as well as the financial burden of wheelchair-associated complications such as; pressure ulcers, circulatory disorders, osteoporosis and attendant care. LOKOMAT Gait Training also records improved cardiovascular performance and reductions in spasticity, bone loss and bladder/bowel complications.

  • The LOKOMAT has been suggested to be predestined for patients with complex neurologic disability who are too weak to walk over-ground without external support and thus require the assistance of several therapists to perform body-weight- supported treadmill training. Our experience (HyperMED NeuroRecovery) is that LOKOMAT Gait Training is highly adaptable for all patients with disability. LOKOMAT Gait Training can provide numerous accurate repetitions necessary to restore activity especially walking function with neurologic patients.

  • LOKOMAT Gait Training kinetic settings can be varied and specifically adjusted throughout the training session intensifying functional outcomes. Patients with incomplete spinal lesions and with stroke undertaking LOKOMAT Gait Training have measurable functional changes; reflex stiffness and spasticity are significantly reduced; range of motion, peak velocity and acceleration of voluntary movements are increased with patients with incomplete spinal lesions and stroke. Therefore the walking ability improves as well as functional independence.

  • Additionally, it has been revealed that LOKOMAT Gait Training can lead to functional improvements in patients with different neurological diseases such as; Multiple Sclerosis, Chronic Stroke, Parkinson’s Diseases, Cerebral Palsy (CP), as well as the other various types of idiopathic and secondary muscular dystrophies and neurological disorders in adult and children. In stroke hemiparetic patients BWSTT has been shown to improve balance, lower limb motor recovery, walking speed, endurance, and other important gait characteristics such as symmetry, stride length and double stance time.

  • Moreover, a number of research studies have shown that LOKOMAT Gait Training can not only improve the gait in neurological patients but also positively affect cardiovascular and general health regulations. For this reason, to keep a level of maintenance treadmill training after the initial period of intense training is highly recommended.

Front Neurosci. 2018 Jun 1;12:374. doi: 10.3389/fnins.2018.00374. eCollection 2018.

Supplemental Stimulation Improves Swing Phase Kinematics During Exoskeleton Assisted Gait of SCI Subjects With Severe Muscle Spasticity.

Spasticity is a common comorbidity associated with spinal cord injury (SCI). Robotic exoskeletons have recently emerged to facilitate legged mobility in people with motor complete SCI. Involuntary muscle activity attributed to spasticity, however, can prevent such individuals from using an exoskeleton. Specifically, although most exoskeleton technologies can accommodate low to moderate spasticity, the presence of moderate to severe spasticity can significantly impair gait kinematics when using an exoskeleton. In an effort to potentially enable individuals with moderate to severe spasticity to use exoskeletons more effectively, this study investigates the use of common peroneal stimulation in conjunction with exoskeleton gait assistance.

The electrical stimulation is timed with the exoskeleton swing phase, and is intended to acutely suppress extensor spasticity through recruitment of the flexion withdrawal reflex (i.e., while the stimulation is activated) to enable improved exoskeletal walking. In order to examine the potential efficacy of this approach, two SCI subjects with severe extensor spasticity (i.e., modified Ashworth ratings of three to four) walked in an exoskeleton with and without supplemental stimulation while knee and hip motion was measured during swing phase. Stimulation was alternated on and off every ten steps to eliminate transient therapeutic effects, enabling the acute effects of stimulation to be isolated.

These experiments indicated that common peroneal stimulation on average increased peak hip flexion during the swing phase of walking by 21.1° (236%) and peak knee flexion by 14.4° (56%). Additionally, use of the stimulation decreased the swing phase RMS motor current by 228 mA (15%) at the hip motors and 734 mA (38%) at the knee motors, indicating improved kinematics were achieved with reduced effort from the exoskeleton. Walking with the exoskeleton did not have a significant effect on modified Ashworth scores, indicating the common peroneal stimulation has only acute effects on suppressing extensor tone and aiding flexion. This preliminary data indicates that such supplemental stimulation may be used to improve the quality of movement provided by exoskeletons for persons with severe extensor spasticity in the lower limb.

What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis.

J Clin Neurosci 2018 Feb 6;48:11-17. Epub 2017 Dec 6.

Background: Studies about electromechanical-assisted devices proved the validity and effectiveness of these tools in gait rehabilitation, especially if used in association with conventional physiotherapy in stroke patients.


Objective: The aim of this study was to compare the effects of different robotic devices in improving post-stroke gait abnormalities.
Methods: A computerized literature research of articles was conducted in the databases MEDLINE, PEDro, COCHRANE, besides a search for the same items in the Library System of the University of Parma (Italy). We selected 13 randomized controlled trials, and the results were divided into sub-acute stroke patients and chronic stroke patients. We selected studies including at least one of the following test: 10-Meter Walking Test, 6-Minute Walk Test, Timed-Up-and-Go, 5-Meter Walk Test, and Functional Ambulation Categories.

Results: Stroke patients who received physiotherapy treatment in combination with robotic devices, such as Lokomat or Gait Trainer, were more likely to reach better results, compared to patients who receive conventional gait training alone. Moreover, electromechanical-assisted gait training in association with Functional Electrical Stimulations produced more benefits than the only robotic treatment (-0.80 [-1.14; -0.46], p > .05).

Conclusions: The evaluation of the results confirm that the use of robotics can positively affect the outcome of a gait rehabilitation in patients with stroke. The effects of different devices seems to be similar on the most commonly outcome evaluated by this review.

Effect of robotic-assisted gait rehabilitation on dynamic equilibrium control in the gait of children with cerebral palsy.

Gait Posture 2018 Feb 11;60:55-60. Epub 2017 Nov 11.

Centre de Santé-Institut Rossetti-PEP06, Unité Clinique d'Analyse du Mouvement, 400, Boulevard de la Madeleine, 06000 Nice, France; Université Côte d'Azur, LAMHESS, France.​

Due to the intensity and repetition of movement, robotic assisted gait training therapy could have a beneficial effect on the recovery and improvement of postural and locomotor functions of the patient.

This study sought to highlight the effects of robotic-assisted gait rehabilitation in gait of children with Cerebral Palsy (CP). We analyzed the different strategies before and after this rehabilitation which was used in order to generate forward motion while maintaining balance. Data were collected by a motion analysis system (Vicon® - Oxford Metrics, Oxford, UK). The children were divided into two groups in such a way as to obtain a randomized controlled population: i) a group of fourteen children (Treated Group) underwent 20 sessions of roboticassisted gait training therapy using the driven gait orthosis Lokomat®Pediatric (Hocoma AG, Volketswil, Switzerland) compared to ii) a group of sixteen children without sessions of Lokomat®Pediatric (Control Group). Significant differences are observed for the TG between the preand post-test values of the locomotor parameters and of the kinetic data of the propulsive forces of the Center of Mass (COM) and of the Center of Pressure (COP) dynamic trajectory. This first study, although performed on a limited number of patients, shows the usefulness of this robotic gait rehabilitation mainly in the balance control in gait. Indeed after this rehabilitation, these children improve their gait that is especially characterized by a more appropriate time lag between the time instant of COM-COP trajectory divergence and the time instant when the forward propulsive forces became apparent.

Robot-Assisted Body-Weight-Supported Treadmill Training in Gait Impairment in Multiple Sclerosis Patients: A Pilot Study.

Adv Exp Med Biol 2018 Feb 13. Epub 2018 Feb 13.

Department of Physiotherapy, College of Rehabilitation, Warsaw, Poland.​

This study deals with the use of a robot-assisted body-weight-supported treadmill training in multiple sclerosis (MS) patients with gait dysfunction. Twenty MS patients (10 men and 10 women) of the mean of 46.3 ± 8.5 years were assigned to a six-week-long training period with the use of robot-assisted treadmill training of increasing intensity of the Lokomat type. The outcome measure consisted of the difference in motion-dependent torque of lower extremity joint muscles after training compared with baseline before training. We found that the training uniformly and significantly augmented the torque of both extensors and flexors of the hip and knee joints. The muscle power in the lower limbs of SM patients was improved, leading to corrective changes of disordered walking movements, which enabled the patients to walk with less effort and less assistance of care givers. The torque augmentation could have its role in affecting the function of the lower extremity muscle groups during walking.

The results of this pilot study suggest that the robot-assisted body-weight-supported treadmill training may be a potential adjunct measure in the rehabilitation paradigm of 'gait reeducation' in peripheral neuropathies.

What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis.

J Clin Neurosci 2018 Feb 6;48:11-17. Epub 2017 Dec 6.

IRCCS Centro Neurolesi "Bonino Pulejo", Messina, Italy. Electronic address:​

Background: Studies about electromechanical-assisted devices proved the validity and effectiveness of these tools in gait rehabilitation, especially if used in association with conventional physiotherapy in stroke patients.
Objective: The aim of this study was to compare the effects of different robotic devices in improving post-stroke gait abnormalities.
Methods: A computerized literature research of articles was conducted in the databases MEDLINE, PEDro, COCHRANE, besides a search for the same items in the Library System of the University of Parma (Italy). We selected 13 randomized controlled trials, and the results were divided into sub-acute stroke patients and chronic stroke patients. We selected studies including at least one of the following test: 10-Meter Walking Test, 6-Minute Walk Test, Timed-Up-and-Go, 5-Meter Walk Test, and Functional Ambulation Categories.
Results: Stroke patients who received physiotherapy treatment in combination with robotic devices, such as Lokomat or Gait Trainer, were more likely to reach better results, compared to patients who receive conventional gait training alone. Moreover, electromechanical-assisted gait training in association with Functional Electrical Stimulations produced more benefits than the only robotic treatment (-0.80 [-1.14; -0.46], p > .05).
Conclusions: The evaluation of the results confirm that the use of robotics can positively affect the outcome of a gait rehabilitation in patients with stroke. The effects of different devices seems to be similar on the most commonly outcome evaluated by this review.

Lokomat therapy in Colombia: Current state and cognitive aspects.

IEEE Int Conf Rehabil Robot 2017 Jul;2017:394-399

Neurological disorders frequently affect walking function which is one of the most fundamental skills to improve quality of life and autonomy, and Lokomat has been a key piece for gait's rehabilitation. In this study, a diagnosis about the development of the Robot-assisted therapy rehabilitation with Lokomat in Colombia is made. The study was performed by collecting some anthropometric and demographic data of the patients that use Lokomat, followed by a survey of cognitive aspects. With the purpose to compare the current state of the robotic therapies it was found that in Colombia the benefits of this treatment have not being fully exploited. Regarding the cognitive aspects, most of the patients that use Lokomat as a rehabilitation therapy feel comfortable (47%), very safe (68%) and have a perspective of significant results with the therapy (68%). However, when compared the number of patients in therapy with Lokomat with the number of the population that has gait disabilities, it is found that few Colombians have access to this type of therapy.

Sci Rep. 2017 Oct 18;7(1):13512. doi: 10.1038/s41598-017-13554-2.

The Effects of Exoskeleton Assisted Knee Extension on Lower-Extremity Gait Kinematics, Kinetics, and Muscle Activity in Children with Cerebral Palsy.

Lerner ZF1,2, Damiano DL1, Bulea TC3.

Author information

Abstract

Individuals with cerebral palsy often exhibit crouch gait, a debilitating and inefficient walking pattern marked by excessive knee flexion that worsens with age. To address the need for improved treatment, we sought to evaluate if providing external knee extension assistance could reduce the excessive burden placed on the knee extensor muscles as measured by knee moments. We evaluated a novel pediatric exoskeleton designed to provide appropriately-timed extensor torque to the knee joint during walking in a multi-week exploratory clinical study. Seven individuals (5-19 years) with mild-moderate crouch gait from cerebral palsy (GMFCS I-II) completed the study. For six participants, powered knee extension assistance favorably reduced the excessive stance-phase knee extensor moment present during crouch gait by a mean of 35% in early stance and 76% in late stance. Peak stance-phase knee and hip extension increased by 12° and 8°, respectively. Knee extensor muscle activity decreased slightly during exoskeleton-assisted walking compared to baseline, while knee flexor activity was elevated in some participants. These findings support the use of wearable exoskeletons for the management of crouch gait and provide insights into their future implementation.

Trials. 2017 Feb 27;18(1):88. doi: 10.1186/s13063-017-1838-2.

The effectiveness of Robot-Assisted Gait Training versus conventional therapy on mobility in severely disabled progressIve Multiple sclerosis patients (RAGTIME): study protocol for a randomized controlled trial

Gait and mobility impairments affect the quality of life (QoL) of patients with progressive multiple sclerosis (MS). Robot-assisted gait training (RAGT) is an effective rehabilitative treatment but evidence of its superiority compared to other options is lacking. Furthermore, the response to rehabilitation is multidimensional, person-specific and possibly involves functional reorganization processes. The aims of this study are: (1) to test the effectiveness on gait speed, mobility, balance, fatigue and QoL of RAGT compared to conventional therapy (CT) in progressive MS and (2) to explore changes of clinical and circulating biomarkers of neural plasticity.

METHODS:

This will be a parallel-group, randomized controlled trial design with the assessor blinded to the group allocation of participants. Ninety-eight (49 per arm) progressive MS patients (EDSS scale 6-7) will be randomly assigned to receive twelve 2-h training sessions over a 4-week period (three sessions/week) of either: (1) RAGT intervention on a robotic-driven gait orthosis (Lokomat, Hocoma, Switzerland). The training parameters (torque of the knee and hip drives, treadmill speed, body weight support) are set during the first session and progressively adjusted during training progression or (2) individual conventional physiotherapy focusing on over-ground walking training performed with the habitual walking device. The same assessors will perform outcome measurements at four time points: baseline (before the first intervention session); intermediate (after six training sessions); end of treatment (after the completion of 12 sessions); and follow-up (after 3 months from the end of the training program). The primary outcome is gait speed, assessed by the Timed 25-Foot Walk Test. We will also assess walking endurance, balance, depression, fatigue and QoL as well as instrumental laboratory markers (muscle metabolism, cerebral venous hemodynamics, cortical activation) and circulating laboratory markers (rare circulating cell populations pro and anti-inflammatory cytokines/chemokines, growth factors, neurotrophic factors, coagulation factors, other plasma proteins suggested by transcriptomic analysis and metabolic parameters).

DISCUSSION:

The RAGT training is expected to improve mobility compared to the active control intervention in progressive MS. Unique to this study is the analysis of various potential markers of plasticity in relation with clinical outcomes.

Eur J Paediatr Neurol. 2017 Feb 2. pii: S1090-3798(17)30072-7. doi: 10.1016/j.ejpn.2017.01.012. [Epub ahead of print]

Robotic-assisted gait training improves walking abilities in diplegic children with cerebral palsy.

Wallard L1, Dietrich G2, Kerlirzin Y2, Bredin J3.

Author information

Abstract

The robotic-assisted gait training therapy (RAGT), based on intensity and repetition of movement, presents beneficial effects on recovery and improvement of postural and locomotor functions of the patient. This study sought to highlight the effect of this RAGT on the dynamic equilibrium control during walking in children with Cerebral Palsy (CP) by analyzing the different postural strategies of the fullbody (upper/lower body) before and after this RAGT in order to generate forward motion while maintaining balance. Data were collected by a motion analysis system (Vicon® - Oxford Metrics). Thirty children with bilateral spastic CP were evaluated using a full-body marker set which allows assessing both the lower and upper limb kinematics. The children were divided into two groups in such a way as to obtain a randomized controlled population: i) a group of fourteen children (Treated Group) underwent 20 sessions of RAGT using the driven gait orthosis Lokomat®Pediatric (Hocoma) compared to ii) a group of sixteen children without sessions of Lokomat®Pediatric (Control Group) receiving only daily physiotherapy. Significant improvements are observed between the TG pre- and post-test values of i) the kinematic data of the full-body in the sagittal and frontal planes and ii) the Gross Motor Function Measure test (D and E). This study shows the usefulness of this RAGT mainly in the balance control in gait. Indeed, the Treated Group use new dynamic strategies of gait that are especially characterized by a more appropriate control of the upper body associated with an improvement of the lower limbs kinematics.

Can Lokomat therapy with children and adolescents be improved? An adaptive clinical pilot trial comparing Guidance force, Path control, and FreeD.

J Neuroeng Rehabil 2017 Jul 14;14(1):76. Epub 2017 Jul 14.

Rehabilitation Center Affoltern am Albis, Children's University Hospital Zurich, Muehlebergstrasse 104, CH-8910, Affoltern am Albis, Switzerland.

  • July 2017

Background: Robot-assisted gait therapy is increasingly being used in pediatric neurorehabilitation to complement conventional physical therapy. The robotic device applied in this study, the Lokomat (Hocoma AG, Switzerland), uses a position control mode (Guidance Force), where exact positions of the knee and hip joints throughout the gait cycle are stipulated. Such a mode has two disadvantages: Movement variability is restricted, and patients tend to walk passively. Kinematic variability and active participation, however, are crucial for motor learning. Recently, two new control modes were introduced. The Path Control mode allows the patient to walk within a virtual tunnel surrounding the ideal movement trajectory. The FreeD was developed to support weight shifting through mediolaterally moveable pelvis and leg cuffs. The aims of this study were twofold: 1) To present an overview of the currently available control modes of the Lokomat. 2) To evaluate if an increase in kinematic variability as provided by the new control modes influenced leg muscle activation patterns and intensity, as well as heart rate while walking in the Lokomat.

Methods: In 15 adolescents with neurological gait disorders who walked in the Lokomat, 3 conditions were compared: Guidance Force, Path Control, and FreeD. We analyzed surface electromyographic (sEMG) activity from 5 leg muscles of the more affected leg and heart rate. Muscle activation patterns were compared with norm curves.

Results: Several muscles, as well as heart rate, demonstrated tendencies towards a higher activation during conditions with more kinematic freedom. sEMG activation patterns of the M.rectus femoris and M.vastus medialis showed the highest similarity to over-ground walking under Path Control, whereas walking under FreeD led to unphysiological muscle activation in the tested sample.

Conclusions: Results indicate that especially Path Control seems promising for adolescent patients undergoing neurorehabilitation, as it increases proximal leg muscle activity while facilitating a physiological muscle activation. Therefore, this may be a solution to increase kinematic variability and patients' active participation in robot-assisted gait training.

Overground vs. treadmill-based robotic gait training to improve seated balance in people with motor-complete spinal cord injury: a case report.

J Neuroeng Rehabil 2017 Apr 11;14(1):27. Epub 2017 Apr 11.

School of Kinesiology, University of British Columbia, Vancouver, BC, Canada.​

Background: Robotic overground gait training devices, such as the Ekso, require users to actively participate in triggering steps through weight-shifting movements. It remains unknown how much the trunk muscles are activated during these movements, and if it is possible to transfer training effects to seated balance control. This study was conducted to compare the activity of postural control muscles of the trunk during overground (Ekso) vs. treadmill-based (Lokomat) robotic gait training, and evaluate changes in seated balance control in people with high-thoracic motor-complete spinal cord injury (SCI).
Methods: Three individuals with motor-complete SCI from C7-T4, assumed to have no voluntary motor function below the chest, underwent robotic gait training. The participants were randomly assigned to Ekso-Lokomat-Ekso or Lokomat-Ekso-Lokomat for 10 sessions within each intervention phase for a total of 30 sessions. We evaluated static and dynamic balance control through analysis of center of pressure (COP) movements after each intervention phase. Surface electromyography was used to compare activity of the abdominal and erector spinae muscles during Ekso and Lokomat walking.
Results: We observed improved postural stability after training with Ekso compared to Lokomat during static balance tasks, indicated by reduced COP root mean square distance and ellipse area. In addition, Ekso training increased total distance of COP movements during a dynamic balance task. The trunk muscles showed increased activation during Ekso overground walking compared to Lokomat walking.
Conclusions: Our findings suggest that the Ekso actively recruits trunk muscles through postural control mechanisms, which may lead to improved balance during sitting. Developing effective training strategies to reactivate the trunk muscles is important to facilitate independence during seated balance activity in people with SCI.

Int J Neurosci. 2017 Jan 28:1-23. doi: 10.1080/00207454.2017.1288623. [Epub ahead of print]

Robotic-assisted gait training in Parkinson's Disease: A 3-month follow-up randomized clinical trial.

Furnari A1, Calabrò RS2, De Cola MC2, Bartolo M1, Castelli A1, Mapelli A1, Buttacchio G1, Farini E1, Bramanti P2, Casale R1.

Author information

Abstract

PURPOSE:

The aim of this study was to evaluate the efficacy of a Robotic-Assisted Gait Training (RAGT), together with a conventional exercise program (CEP), to improve PD ambulation, as compared to standard gait training.

METHODS:

Thirty-eight patients with mild PD stage (H&Y 2-2.5) were randomly assigned to an experimental group (EG) or a control group (CG). The 19 patients in EG received 30 min RAGT (using Lokomat device), whereas the 19 controls received a conventional gait training; both groups received 30 min of CEP. Participants were evaluated before (T0), immediately after (T1), and 12 weeks after the end of treatment (T2), by using 10-MWT, Tinetti Test and the motor score of the UPDRS-III.

RESULTS:

We found that Tinetti Walking (TW) (X2 (3) = 31.75; p < 0.001), Tinetti Balance (X2 (3) = 74.07; p < 0.001), UPDRS-III (X2 (3) = 6.87; p < 0.001), and GDS (X2 (3) = 28.83; p < 0.001) scores were affected by the type of the rehabilitative treatment. At T2 we found a significant difference between the two groups for TW (t = 2.62; p < 0.02, d = 0.85). Concerning all the study outcomes, a significant improvement was observed from T0 to T1 in both the groups. However, the functional motor gain at T2 was maintained only in the EG.

CONCLUSIONS:

RAGT may significantly improve walking ability, motor function and for a maximum period of 3 months. Thus, our findings support the importance of a RAGT as a valid rehabilitative tool for PD.

Int J Phys Med Rehabil. 2016 Oct;4(5). pii: 370. doi: 10.4172/2329-9096.1000370. Epub 2016 Oct 12.

Robotic Assist-As-Needed as an Alternative to Therapist-Assisted Gait Rehabilitation.

Srivastava S1, Kao PC2, Reisman DS3, Scholz JP3, Agrawal SK4, Higginson JS5.

Author information

Abstract

OBJECTIVE:

Body Weight Supported Treadmill Training (BWSTT) with therapists' assistance is often used for gait rehabilitation post-stroke. However, this training method is labor-intensive, requiring at least one or as many as three therapists at once for manual assistance. Previously, we demonstrated that providing movement guidance using a performance-based robot-aided gait training (RAGT) that applies a compliant, assist-as-needed force-field improves gait pattern and functional walking ability in people post-stroke. In the current study, we compared the effects of assist-as-needed RAGT combined with functional electrical stimulation and visual feedback with BWSTT to determine if RAGT could serve as an alternative for locomotor training.

METHODS:

Twelve stroke survivors were randomly assigned to one of the two groups, either receiving BWSTT with manual assistance or RAGT with functional electrical stimulation and visual feedback. All subjects received fifteen 40-minutes training sessions.

RESULTS:

Clinical measures, kinematic data, and EMG data were collected before and immediately after the training for fifteen sessions. Subjects receiving RAGT demonstrated significant improvements in their self-selected over-ground walking speed, Functional Gait Assessment, Timed Up and Go scores, swing-phase peak knee flexion angle, and muscle coordination pattern. Subjects receiving BWSTT demonstrated significant improvements in the Six-minute walk test. However, there was an overall trend toward improvement in most measures with both interventions, thus there were no significant between-group differences in the improvements following training.

CONCLUSION:

The current findings suggest that RAGT worked at least as well as BWSTT and thus may be used as an alternative rehabilitation method to improve gait pattern post-stroke as it requires less physical effort from the therapists compared to BWSTT.

PM R. 2017 Jan 16. pii: S1934-1482(17)30030-8. doi: 10.1016/j.pmrj.2016.12.010. [Epub ahead of print]

A Comparison of Locomotor Therapy Interventions: Partial Body Weight-Supported Treadmill, Lokomat, and G-EO Training in People With Traumatic Brain Injury.

Esquenazi A1, Lee S2, Wikoff A2, Packel A2, Toczylowski T2, Feeley J2.

Literature in the application of gait training techniques in persons with traumatic brain injury (TBI) is limited. Current techniques require multiple staff and are physically demanding. The use of a robotic locomotor training may provide improved training capacity for this population.

OBJECTIVE:

To examine the impact of 3 different modes of locomotor therapy on gait velocity and spatiotemporal symmetry using an end effector robot (G-EO); a robotic exoskeleton (Lokomat), and manual assisted partial-body weight supported treadmill training (PBWSTT) in participants with traumatic brain injury.

PARTICIPANTS:

A total of 22 individuals with ≥12 months chronic TBI with hemiparetic pattern able to walk overground without assistance at velocities between 0.2 and 0.6 m/s.

INTERVENTION:

Eighteen sessions of 45 minutes of assigned locomotor training.

OUTCOME MEASURES:

Overground walking self-selected velocity (SSV), maximal velocity (MV), spatiotemporal asymmetry ratio, 6-Minute Walk Test (6MWT), and mobility domain of Stroke Impact Scale (MSIS).

RESULTS:

Severity in walking dysfunction was similar across groups as determined by walking velocity data. At baseline, participants in the Lokomat group had a baseline velocity that was slightly slower compared with the other groups. Training elicited a statistically significant median increase in SSV for all groups compared with pretraining (Lokomat, P = .04; G-EO, P = .03; and PBWSTT, P = .02) and MV excluding the G-EO group (Lokomat, P = .04; PBWSTT, P = .03 and G-EO, P = .15). There were no pre-post significant differences in swing time, stance time, and step length asymmetry ratios at SSV or MV for any of the interventions. Mean rank in the change of SSV and MV was not statistically significantly different between groups. Participants in the G-EO and PBWSTT groups significantly improved their 6MWT posttraining (P = .04 and .03, respectively). The MSIS significantly improved only for the Lokomat group (P = .04 and .03). The data did not elicit between-groups significant differences for 6MWT and MSIS. There was less use of staff for Lokomat than G-EO.

CONCLUSIONS:

Locomotor therapy using G-EO, Lokomat, or PBWSTT in individuals with chronic TBI increased SSV and MV without significant changes in gait symmetry. Staffing needed for therapy provision was the least for the Lokomat. A larger study may further elucidate changes in gait symmetry and other training parameters.

PLoS One. 2015 Oct 20;10(10):e0140626. doi: 10.1371/journal.pone.0140626. eCollection 2015.

Human-Robot Interaction: Does Robotic Guidance Force Affect Gait-Related Brain Dynamics during Robot-Assisted Treadmill Walking?

Knaepen K1, Mierau A2, Swinnen E3, Fernandez Tellez H4, Michielsen M5, Kerckhofs E3, Lefeber D6, Meeusen R7.

Author information

Abstract

In order to determine optimal training parameters for robot-assisted treadmill walking, it is essential to understand how a robotic device interacts with its wearer, and thus, how parameter settings of the device affect locomotor control. The aim of this study was to assess the effect of different levels of guidance force during robot-assisted treadmill walking on cortical activity. Eighteen healthy subjects walked at 2 km.h-1 on a treadmill with and without assistance of the Lokomat robotic gait orthosis. Event-related spectral perturbations and changes in power spectral density were investigated during unassisted treadmill walking as well as during robot-assisted treadmill walking at 30%, 60% and 100% guidance force (with 0% body weight support). Clustering of independent components revealed three clusters of activity in the sensorimotor cortex during treadmill walking and robot-assisted treadmill walking in healthy subjects. These clusters demonstrated gait-related spectral modulations in the mu, beta and low gamma bands over the sensorimotor cortex related to specific phases of the gait cycle. Moreover, mu and beta rhythms were suppressed in the right primary sensory cortex during treadmill walking compared to robot-assisted treadmill walking with 100% guidance force, indicating significantly larger involvement of the sensorimotor area during treadmill walking compared to robot-assisted treadmill walking. Only marginal differences in the spectral power of the mu, beta and low gamma bands could be identified between robot-assisted treadmill walking with different levels of guidance force. From these results it can be concluded that a high level of guidance force (i.e., 100% guidance force) and thus a less active participation during locomotion should be avoided during robot-assisted treadmill walking. This will optimize the involvement of the sensorimotor cortex which is known to be crucial for motor learning.

BRAIN INJURY AND NEURAL REGENERATION:

Gait improvement after treadmill training in ischemic stroke survivors: A critical review of f...

Xiang Xiao, Dongfeng Huang, Bryan O’Young

Neural Regeneration Research, Year 2012, Volume 7, Issue 31 [p. 2457-2464]

DOI: 10.3969/j.issn.1673-5374.2012.31.007

Stroke survivors often present with abnormal gait, movement training can improve the walking performance post-stroke, and functional MRI can objectively evaluate the brain functions before and after movement training. This paper analyzes the functional MRI changes in patients with ischemic stroke after treadmill training with voluntary and passive ankle dorsiflexion. Functional MRI showed that there are some changes in some regions of patients with ischemic stroke including primary sensorimotor cortex, supplementary motor area and cingulate motor area after treadmill training. These findings suggest that treadmill training likely improves ischemic stroke patients' lower limb functions and gait performance and promotes stroke recovery by changing patients' brain plasticity; meanwhile, the novel treadmill training methods can better training effects.

Research Highlights

  1. This paper summarizes the functional MRI changes in ischemic stroke patients after treadmill training with voluntary and passive ankle dorsiflexion. There are some changes in some regions of ischemic stroke patients including primary sensorimotor cortex, supplementary motor area and cingulate motor area after treadmill training.

  2. Treadmill training can influence the brain plasticity of ischemic stroke patients.

  3. Virtual reality-based treadmill exercise and the KineAssist are novel gait training methods. MRI-compatible device and tract-specific analysis may contribute to a better understanding of lower extremity motor control in persons after stroke.

Ambulation following spinal cord injury and its correlates

Nitin Menon, Anupam Gupta, Meeka Khanna, Arun B Taly

Annals of Indian Academy of Neurology, Year 2015, Volume 18, Issue 2 [p. 167-170]

DOI: 10.4103/0972-2327.150605 PMID: 26019413

Objectives: To assess walking ability of spinal cord injury (SCI) patients and observe its correlation with functional and neurological outcomes. Patients and Methods: The present prospective, observational study was conducted in a tertiary research hospital in India with 66 patients (46 males) between January 2012 and December 2013. Mean age was 32.62 ± 11.85 years (range 16-65 years), mean duration of injury was 85.3 ± 97.6 days (range 14-365 days) and mean length of stay in the rehabilitation unit was 38.08 ± 21.66 days (range 14-97 days) in the study. Walking Index for spinal cord injury (WISCI II) was used to assess ambulation of the SCI patients. Functional recovery was assessed using Barthel Index (BI) and Spinal Cord Independence Measures (SCIM). Neurological recovery was assessed using ASIA impairment scale (AIS). We tried to correlate ambulatory ability of the patients with functional and neurological recovery. Results: Ambulatory ability of the patients improved significantly using WISCI II (P < 0.001) when admission and discharge scores were compared (1.4 ± 3.5 vs 7.6 ± 6.03). Similarly, functional (BI: 31.7 ± 20.5 vs 58.4 ± 23.7 and SCIM: 29.9 ± 15.1 vs 56.2 ± 20.6) and neurological recovery were found to be very significant (P < 0.001) when admission vs discharge scores were compared. Improvement in WISCI II scores was significantly correlated with improvement in neurological (using AIS scores) and functional status (using BI and SCIM scores) (P < 0.001). Conclusions: Significant improvement was seen in WISCI II, BI, and SCIM scores after in-patient rehabilitation. Improvement in WISCI II scores also significantly correlated with functional and neurological recovery.

Aging Clin Exp Res. 2015 Dec;27(6):935-7. doi: 10.1007/s40520-015-0343-2. Epub 2015 Mar 12.

Lokomat training in vascular dementia: motor improvement and beyond!

Calabrò RS1, De Luca R2, Leo A2, Balletta T2, Marra A2, Bramanti P2.

Author information

Abstract

Vascular dementia (VaD) is a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain. Cognitive rehabilitation and physical therapy are the mainstays of dementia treatment, although often ineffective because of the scarce collaboration of the patients. However, emerging data suggest that physical activity may reduce the risk of cognitive impairment, mainly VaD, in older people living independently. Herein, we describe a 72-year-old male affected by VaD, in which traditional cognitive training in addition to intensive gait robotic rehabilitation (by using Lokomat device) led to a significant improvement in the motor and cognitive function. This promising finding may be related either to the intensive and repetitive aerobic exercises or to the task-oriented training with computerized visual feedback, which can be considered as a relevant tool to increase patients' motor output, involvement, and motivation during robotic training.

Vopr Kurortol Fizioter Lech Fiz Kult. 2014 May-Jun;(3):13-7.

[The influence of physical training with the use of a lokomat robotic system on the walking ability of the patients with post-stroke hemiparesis].

[Article in Russian]

Chernikova LAKlochkov AS.

Abstract

AIM:

The objective of the present study was to estimate the influence of the driven gait orthosis Lokomat on the functional mobility in the post-stroke hemiparethic patients and to elucidate the mechanisms underlying the improvement of functional mobility after the treatment.

MATERIALS AND METHODS:

The study included 141 patients presenting with post-stroke hemiparesis of the mean duration 12.00 [3.0; 14.5] months. The patients of the experimental group (n = 100) completed the robot-assisted training course, those of the control group (n = 41) were given conventional gait training therapy under the guidance of a specialist in therapeutic physical training. The results of the treatment were evaluated using the following clinical scales: Fugl-Meyer assessment scale, Modified Ashworth scale and Perry mobility scale. Step symmetry, intra- and inter-joint kinematics were measured using the 3D gait videoanalysis system before and after the treatment course.

RESULTS:

The study has demonstrated a decrease of step asymmetry, the improvement of kinematic gait parameters (hip flexion/extension and hip abduction/adduction amplitudes, hip abduction/ adduction and knee flexion/extension torque amplitudes) as well as inter- and intrajoint dynamic interactions. It is concluded that these changes can be the main causes behind the enhancement of the functional mobility of walking under the influence of training with the use of the driven gait orthosis Lokomat.

Disabil Rehabil Assist Technol. 2015 Mar;10(2):141-8. doi: 10.3109/17483107.2013.873489. Epub 2014 Mar 10.

Recovery of walking ability using a robotic device in subacute stroke patients: a randomized controlled study.

van Nunen MP1, Gerrits KHKonijnenbelt MJanssen TWde Haan A.

Author information

Abstract

PURPOSE:

This study investigates the effectiveness of Lokomat + conventional therapy in recovering walking ability in non-ambulatory subacute stroke subjects involved in inpatient rehabilitation.

METHOD:

Thirty first-ever stroke patients completed 8 weeks of intervention. One group (n = 16) received Lokomat therapy twice a week, combined with three times 30 min a week of conventional overground therapy. The second group (n = 14) received conventional assisted overground therapy only, during a similar amount of time (3.5 h a week). The intervention was part of the normal rehabilitation program. Primary outcome measure was walking speed. Secondary outcome measures assessed other walking- and mobility-related tests, lower-limb strength and quality of life measures. All outcome measures were assessed before and after the intervention and at wk 24 and wk 36 after start of the intervention.

RESULTS:

Patients showed significant (p < 0.05) gains in walking speed, other walking- and mobility related tests, and strength of the paretic knee extensors relative to baseline at all assessments. However, there were no significant differences in improvements in any of the variables between groups at any time during the study.

CONCLUSION:

These results indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as conventional therapy alone. Implications for Rehabilitation Recovery of walking after stroke is important. Robot-assisted therapy is currently receiving much attention in research and rehabilitation practice as devices such as the Lokomat seem to be promising assistive devices. Technical developments, sub-optimal study designs in literature and new therapy insights warrant new effectiveness studies. RESULTS of a financially and practically feasible study indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory

stroke patients as compared to conventional overground therapy alone.

Rehabilitation of multiple sclerosis patients in India

Nirmal Surya

Annals of Indian Academy of Neurology, Year 2015, Volume 18, Issue 5 [p. 43-47]

DOI: 10.4103/0972-2327.164828

Multiple sclerosis (MS) is a chronic progressive disease which is one of the leading causes of handicap in young subjects. The large range of symptoms associated with MS lead to continuing decline in neurologic status and quality of life. The coexistence of physical and cognitive impairments, together with the imprevisible evolution of the disease makes MS rehabilitation very challenging. The main objective of rehabilitation is, therefore, to ease the burden of symptoms by improving self-performance and independence. Inpatient, outpatient and Home rehabilitation with multidisciplinary team has been shown to be beneficial in improving disability. Individualized programs elaborated by a multidisciplinary team of experts are the key to success of rehabilitation. Family plays a big role and Family Based Rehabilitation will be important in long term rehab program in MS.

Int J Rehabil Res. 2015 Sep;38(3):219-25. doi: 10.1097/MRR.0000000000000114.

Robotic neurorehabilitation in patients with chronic stroke: psychological well-being beyond motor improvement.

Calabrò RS1, De Cola MCLeo AReitano SBalletta TTrombetta GNaro ARusso MBertè FDe Luca RBramanti P.

Author information

Abstract

Although gait abnormality is one of the most disabling events following stroke, cognitive, and psychological impairments can be devastating. The Lokomat is a robotic that has been used widely for gait rehabilitation in several movement disorders, especially in the acute and subacute phases. The aim of this study was to evaluate the effectiveness of gait robotic rehabilitation in patients affected by chronic stroke. Psychological impact was also taken into consideration. Thirty patients (13 women and 17 men) affected by chronic stroke entered the study. All participants underwent neurological examination with respect to ambulation, Ashworth, Functional Independence Measure, and Tinetti scales to assess their physical status, and Hamilton Rating Scale for Depression, Psychological General Well-being Index, and Coping Orientation to Problem Experienced to evaluate the Lokomat-related psychological impact before and after either a conventional treatment or the robotic training. During each rehabilitation period (separated by a no-treatment period), patients underwent a total of 40 1 h training sessions (i.e. five times a week for 8 weeks). After the conventional treatment, the patients did not achieve a significant improvement in the functional status, except balance (P<0.001) and walking ability (P<0.01), as per the Tinetti scale. Indeed, after the robotic rehabilitation, significant improvements were detected in almost all the motor and psychological scales that we investigated, particularly for Psychological General Well-being Index and Coping Orientation to Problem Experienced. Manual and robotic-assisted body weight-supported treadmill training optimizes the sensory inputs relevant to step training, repeated practice, as well as neuroplasticity. Several controlled trials have shown a superior effect of Lokomat treatment in stroke patients' walking ability and velocity in particular. Therefore, our preliminary results proved that active robotic training not only facilitates gait and physical function but also the psychological status, even in patients affected by chronic stroke.

Rehabilitation interventions to improve locomotor outcome in chronic stroke survivors: A prospect...

Abhishek Srivastava, Arun B Taly, Anupam Gupta, Thyloth Murali

Neurology India, Year 2015, Volume 63, Issue 3 [p. 347-352]

DOI: 10.4103/0028-3886.158202 PMID: 26053806

Objective: To ascertain whether rehabilitation interventions improve locomotion beyond 6 months post stroke.

Site: The Neurological Rehabilitation Department of a university tertiary research hospital.

Study Design: Prospective, repeated-measure study.

Patients: Patients with first episode of supra-tentorial stroke of more than 6 months duration.

Intervention: Twenty sessions of task-specific interventions consisting of lower limb resistive exercises and treadmill gait training to locomotor abilities (90 min/day, 5 days/week for 4 weeks). Evaluations were performed at the beginning and end of training and at a follow-up of 3 months.

Outcome Measures: Stroke severity (Scandinavian Stroke Scale - SSS), balance (Berg Balance scale - BBS), ambulation (Functional Ambulation Category), walking ability (speed 10-m walk test - WS) and functional ability (Barthel Index - BI). Results: Forty patients (32 men and eight women; age range: 22-65 years; mean post-stroke duration of 18.90 ± 12.76 months) were included in the study. Thirty-two (80.0%) patients completed their training and 28 (70.0%) patients reported at a follow up of 3-months. At the beginning, the end of training and at follow-up, the mean SSS scores were 41.71, 44.09, and 43.96; the BBS scores were 36.28, 46.75 and 46.82; the WS scores were 0.41, 0.53 and 0.51; and the BI scores were 77.34, 89.06 and 92.32, respectively. All outcome measures showed statistically significant improvement (P < 0.001) at the end of training and at follow-up.

Conclusion: Rehabilitation interventions significantly improve locomotor outcome even in the chronic phase following a stroke.