Cortical connectivity reorganization Induced by tDCS and Robotic-Assisted gait training in individuals with spinal cord injury.

Background To investigate the effects of robot-assisted gait training (RAGT) on spasticity and pain in people with spinal cord injury (SCI). Material and methods. Four electronic databases (PubMed, Scopus, Medline, and Cochrane Central Register of Controlled Trials) were searched for studies published up to November 2019. Only human trials and of English language were included. The searched studies were reviewed and extracted independently by two authors. Randomized controlled trials (RCTs) and non-RCTs were pooled separately for analyses. Primary outcome measures included spasticity assessed by Ashworth scale (AS) or modified Ashworth scale (MAS) and pain assessed by VAS. Secondary outcome measures included lower extremity motor score (LEMS) and walking ability (i.e., 6-minute walk test, 10-meter walk test). Results A total of 225 studies were identified. Eighteen studies (7 RCTs and 11 non-RCTs) including 301 subjects met inclusion criteria. The outcome measure of spasticity significantly improved in favor of RAGT group in non-RCTs (AS: 95%CI = −0.202 to -0.068, p ≤ 0.001; MAS: 95%CI = −2.886 to -1.412, p ≤ 0.001). The results on pain did not show significant change after RAGT in either RCTs or non-RCTs. LEMS and walking ability significantly increased in favor of RAGT. Conclusions RAGT can improve spasticity and walking ability in people with SCI. The probable reason for no significant change in pain after RAGT is floor effect. RAGT is beneficial for normalizing muscle tone and for improving lower extremity function in people with SCI without causing extra pain.

Spinal cord injury (SCI) rehabilitation emphasizes locomotion. Robotic-assisted gait training (RAGT) is widely used in clinical settings because of its benefits; however, its efficacy remains controversial. We conducted a systematic review and meta-analysis to investigate the efficacy of RAGT in patients with SCI. We searched international and domestic databases for articles published until April 18, 2024. The meta-analysis employed a random effects model to determine the effect size as either mean difference (MD) or standardized MD (SMD). Evidence quality was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Twenty-three studies with a total of 690 participants were included in the final analysis. The overall pooled effect size for improvement in activities of daily living was 0.24, with SMD (95% confidence interval [95% CI], 0.04–0.43; GRADE: high) favoring RAGT over conventional rehabilitation. Muscular strength (MD, 0.23; 95% CI, 0.02–0.44; GRADE: high), walking index for SCI (MD, 0.31; 95% CI, 0.07–0.55; GRADE: moderate) and 6 min walk test distance (MD, 0.38; 95% CI, 0.14–0.63; GRADE: moderate) showed significant improvement in the robot group. Subgroup analysis revealed that subacute patients and intervention periods >2 months were more effective. This meta-analysis revealed that RAGT significantly improved activities of daily living, muscular strength, and walking abilities. Additional studies are needed to identify the optimal treatment protocol and specific patient groups for which the protocol is most effective.

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

Pediatric brain injuries frequently result in impaired mobility and functional limitations. Although treadmill-based exoskeletal robotic-assisted gait training (RAGT) may enhance gait performance, the optimal treatment parameters remain undefined. The present study evaluated the effects of treadmill-based exoskeletal RAGT on walking-related outcomes in children with brain injuries and examined the influence of training dosage on therapeutic outcomes. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases (PubMed, Embase, Science Direct, ProQuest, Cochrane Library, and PEDro) were searched for studies published between January 2010 and February 2025. Eligible studies included participants aged 2-18 years with brain injuries who received treadmill-based exoskeletal RAGT. Risk of bias was assessed using the Risk of Bias tool 2.0, Risk of Bias in Nonrandomized Studies of Intervention tool, and PEDro scale. Meta-analyses were conducted to estimate pooled effects and explore dose-response relationships. Twenty-four studies (N.=837) met the inclusion criteria; twenty were included in this meta-analysis. RAGT significantly increased gait speed (standardized mean difference [SMD]=0.40; 95% confidence interval [CI]=0.04 to 0.76; I2=30%; P=0.003) and Gross Motor Function Measure (GMFM) Dimension D (SMD=1.02; 95% CI=0.23 to 1.81; I2=83%; P=0.001). Improvements in the 6-minute walk test (SMD=0.43; 95% CI=-0.28 to 1.14; I2=76%; P=0.23) and GMFM Dimension E (SMD=0.49; 95% CI=-0.13 to 1.12; I2=77%; P=0.12) were nonsignificant. Subgroup and meta-analyses identified high session frequency, ≥20 total sessions, and initial body weight support ≤50% as factors associated with superior outcomes. By contrast, excessive frequency and high initial body weight support adversely affected GMFM Dimension E scores. Treadmill-based exoskeletal RAGT with conventional physical therapy improves gait speed and gross motor function in children with brain injuries. These findings provide preliminary guidance for optimizing training dosage. Additional high-quality trials with standardized protocols and extended follow-ups are required to validate these outcomes.

Gait training may lead to functional brain changes in Parkinson's disease (PD); however, there is a lack of studies investigating structural brain changes after gait training in PD. To investigate structural brain changes induced by 4 weeks of gait training in individuals with PD. Diffusion tensor imaging and structural T1 images were acquired in PD group before and after robot-assisted gait training or treadmill training, and in healthy control group. Tract-based spatial statistics and tensor-based morphometry were conducted to analyze the data. The outcome of gait training was assessed by gait speed and dual-task interference of cognitive or physical tests of the 10-meter walking test representing gait automaticity. The associations between structural brain changes and these outcomes were investigated using correlation analysis. A total of 31 individuals with PD (68.5±8.7 years, the Hoehn & Yahr stage of 2.5 or 3) and 28 healthy controls (66.6±8.8 years) participated in this study. Compared to the controls, PD group at baseline showed a significant increased fractional anisotropy (FA) in the right forceps minor and bilateral brainstem and reduced radial diffusivity (RD) in the right superior longitudinal fasciculus, as well as the expanded structural volumes in the several brain areas. After gait training, FA increased in the left internal capsule and it decreased in the left cerebellum Crus I, while the structural volume did not change. The increased FA in the left internal capsule positively correlated with the baseline gait speed and negatively correlated with gait speed improvement; moreover, the decreased FA in the left cerebellum Crus I negatively correlated with the baseline gait speed during the cognitive task. Gait training induces white matter changes in the brain of individuals with PD, which suggests the improvement of brain structural pathology to mitigate the impact of neurodegenerative consequences.

Objective. To compare the efficacy of robotic-assisted gait training with the Lokomat to conventional gait training in individuals with subacute stroke. Methods. A total of 63 participants <6 months poststroke with an initial walking speed between 0.1 to 0.6 m/s completed the multicenter, randomized clinical trial. All participants received twenty-four 1-hour sessions of either Lokomat or conventional gait training. Outcome measures were evaluated prior to training, after 12 and 24 sessions, and at a 3-month follow-up exam. Self-selected overground walking speed and distance walked in 6 minutes were the primary outcome measures, whereas secondary outcome measures included balance, mobility and function, cadence and symmetry, level of disability, and quality of life measures. Results. Participants who received conventional gait training experienced significantly greater gains in walking speed (P = .002) and distance (P = .03) than those trained on the Lokomat. These differences were maintained at the 3-month follow-up evaluation. Secondary measures were not different between the 2 groups, although a 2-fold greater improvement in cadence was observed in the conventional versus Lokomat group. Conclusions. For subacute stroke participants with moderate to severe gait impairments, the diversity of conventional gait training interventions appears to be more effective than robotic-assisted gait training for facilitating returns in walking ability.

Effect of two different programs of robotic assisted gait training in individuals with chronic motor incomplete spinal cord injury

The improvement of walking ability is a primary goal for spinal cord injury (SCI) patients. Robotic-assisted gait training (RAGT) is an innovative method for its improvement. This study evaluates the influence of RAGT vs. dynamic parapodium training (DPT) in improving gait motor functions in SCI patients. In this single-centre, single-blinded study, we enrolled 105 (39 and 64 with complete and incomplete SCI, respectively) patients. The investigated subjects received gait training with RAGT (experimental S1-group) and DPT (control S0-group), with six training sessions per week over seven weeks. The American Spinal Cord Injury Association Impairment Scale Motor Score (MS), Spinal Cord Independence Measure, version-III (SCIM-III), Walking Index for Spinal Cord Injury, version-II (WISCI-II), and Barthel Index (BI) were assessed in each patient before and after sessions. Patients with incomplete SCI assigned to the S1 rehabilitation group achieved more significant improvement in MS [2.58 (SE 1.21, p < 0.05)] and WISCI-II [3.07 (SE 1.02, p < 0.01])] scores in comparison with patients assigned to the S0 group. Despite the described improvement in the MS motor score, no progression between grades of AIS (A to B to C to D) was observed. A nonsignificant improvement between the groups for SCIM-III and BI was found. RAGT significantly improved gait functional parameters in SCI patients in comparison with conventional gait training with DPT. RAGT is a valid treatment option in SCI patients in the subacute phase. DPT should not be recommended for patients with incomplete SCI (AIS-C); in those patients, RAGT rehabilitation programs should be taken into consideration.

Purpose: The aim of this study was to report whether intensive body weight-supported treadmill training with a robotic exoskeleton could improve over-ground functional mobility in individuals with chronic spinal cord injury and to investigate its feasibility and safety. Methods: This was a case series design. Two male individuals with chronic (&gt; 1 year since injury) spinal cord injury (SCI) were included in this study. All subjects underwent intensive gait training sessions 5 times per week using exoskeleton for 12 weeks with a total of 60 sessions. The duration of the session was 60 minutes, including the installment of the HAL, gait training, and the removal of the HAL. The training was performed on a treadmill with adjustable speed and a lifter, under the supervision of a physiotherapist. Two types of outcomes were collected: treadmill-associated data and functional outcomes. Results: We observed a continuous increase in treadmill walking distance, time, and speed for both cases from baseline assessment until the end of the study at 12 weeks The findings from this study provide evidence that the Hybrid Assistive Limb (HAL) can be used with chronic spinal cord injury and can improve walking abilities in terms of distance, speed, and time. Conclusion: HAL can be used for gait training in rehabilitation facilities for individuals with chronic spinal cord injury and did not cause any serious adverse effects to the participating subjects. Our results support the findings of previous studies that show that treatment with HAL may result in improvement in gait parameters. However, more studies with a larger sample size are needed to compare the effect of HAL with conventional physical therapy

Systematic review about randomised trials comparing different training strategies to improve gait in people with spinal cord injuries (SCI). The aim of this systematic review was to compare the effectiveness of body-weight-supported treadmill training (BWSTT) and robotic-assisted gait training with overground gait training and other forms of physiotherapy in people with traumatic SCI. Systematic review conducted by researchers from Germany and Australia. An extensive search was conducted for randomised controlled trials involving people with traumatic SCI that compared either BWSTT or robotic-assisted gait training with overground gait training and other forms of physiotherapy. The two outcomes of interest were walking speed (m s-1) and walking distance (m). BWSTT and robotic-assisted gait training were analysed separately, and data were pooled across trials to derive mean between-group differences using a random-effects model. Thirteen randomised controlled trials involving 586 people were identified. Ten trials involving 462 participants compared BWSTT to overground gait training and other forms of physiotherapy, but only nine trials provided useable data. The pooled mean (95% confidence interval (CI)) between-group differences for walking speed and walking distance were -0.03 m s-1 (-0.10 to 0.04) and -7 m (-45 to 31), respectively, favouring overground gait training. Five trials involving 344 participants compared robotic-assisted gait training to overground gait training and other forms of physiotherapy but only three provided useable data. The pooled mean (95% CI) between-group differences for walking speed and walking distance were -0.04 m s-1 (95% CI -0.21 to 0.13) and -6 m (95% CI -86 to 74), respectively, favouring overground gait training. BWSTT and robotic-assisted gait training do not increase walking speed more than overground gait training and other forms of physiotherapy do, but their effects on walking distance are not clear.

Skilled reach training enhances robotic gait training to restore overground locomotion following spinal cord injury in rats

Context/Objective To explore changes in gait functions for patients with chronic spinal cord injury (SCI) before and after standard rehabilitation and rehabilitation with a wearable hip device, explore the utility of robot-assisted gait training (RAGT), and evaluate the safety and dose of RAGT. Design Single-arm, open-label, observational study. Setting A rehabilitation hospital. Participants Twelve patients with SCI. Interventions Standard rehabilitation after admission in the first phase. RAGT for two weeks in the second phase. Outcome measures Self-selected walking speed (SWS), step length, cadence, and the 6-minute walking distance were the primary outcomes. Walking Index for SCI score, lower extremity motor score, and spasticity were measured. Walking abilities were compared between the two periods using a generalized linear mixed model (GLMM). Correlations between assessments and changes in walking abilities during each period were analyzed. Results After standard rehabilitation for 66.1 ± 36.9 days, a period of 17.6 ± 3.3 days of RAGT was safely performed. SWS increased during both periods. GLMM showed that the increase in cadence was influenced by standard rehabilitation, whereas the limited step length increase was influenced by RAGT. During RAGT, the increase in step length was related to an increase in hip flexor function. Conclusions Gait speed in patients with SCI increased after rehabilitation, including RAGT, in the short-term. This increase was associated with improved muscle function in hip flexion at the start of RAGT. Trial Registration: This study was registered with the UMIN Clinical Trials Registry (UMIN-CTR; UMIN000042025)

Surface electromyography (sEMG) measurements are a valid method for sublesional muscle activity following spinal cord injury (SCI). In the literature there are few reports evaluating the effect of robotic assisted gait training (RAGT) on the sEMG properties change in SCI patients. The aim of this study was to evaluate the influence of RAGT on observed change of sEMG, and in 64 incomplete SCI patients in the sub-acute stage in relation to functional scales. In the presented single-centre single arm, single-blinded study, the patients were divided into two groups: experimental group with RAGT (exoskeleton EKSO-GT or Locomat-Pro) and the control group with dynamic parapodium training (DPT). The therapy was conducted in two cycles of three weeks for six days a week, with a seven day break between cycles. Obtained measurements were averaged peak muscle amplitude (AMA) in sEMG and maximal torque (MT) on Luna apparatus (muscle strength testing) and functional scales. Statistically significant differences between S0 and S1 were only observed for the change in MT values at the knee joint during extension, and positively correlated with American Spinal Injury Association Impairment Scale, lower limb motor score, and functional scales. A statistically increased value of the Walking Index for Spinal Cord Injury (WISCI-II) and motor score after rehabilitation relative to the initial value, was seen after RAGT in comparison to patients with DPT, but AMA did not differ between patients. sEMG did not provide sufficient information about SCI outcome after RAGT rehabilitation.

The aim of this review is to examine the physical determinants for functional walking as well as the efficacy of gait rehabilitation after spinal cord injury (SCI) in humans. The results indicate several important physical determinants in gait. Examples are provided of different interventions that produce beneficial effects on outcome measures of gait such as gait speed, stride length, walking endurance, motor recovery, and gait quality. These findings need to be considered in current SCI rehabilitation practices, but the efficacy of certain interventions remains unclear. Well-designed clinical trials are needed to provide evidence of the role of physical determinants in the development of new concepts and principles in locomotor recovery after SCI. This review focuses on relevant literature, and informs rehabilitation specialists and basic scientists about the physical determinants and factors to consider for optimization of gait training in individuals with incomplete SCI.

Objectives To investigate the safety and feasibility of repeated transcutaneous spinal direct current stimulation (tsDCS) as priming strategy during exoskeleton-assisted locomotor training in individuals with SCI and evaluate potential neurophysiologic and functional gait changes. Study Design Case series experimental design. Setting Research laboratory at a post-acute rehabilitation hospital. Participants Four participants with chronic incomplete SCI. Interventions Four participants with chronic incomplete SCI received three weeks of training consisting of two types of interventions after baseline (A): 20-minute tsDCS (anode or cathode) applied over the spinous processes of T10 followed by 20-minute exoskeleton-assisted locomotor training (B, B1, B2) and 20-minute exoskeleton-assisted locomotor training (C, C1, C2). Each phase consisted of five consecutive intervention sessions. Two participants underwent sequence A-B1-C-B2 and two sequence A-C1-B-C2. Soleus Hoffmann Reflex (H-reflex) and gait speed (10-m walk test) were assessed on the first and fifth days of training for each training type. Outcome Measures Adverse skin reactions or other events, H-reflex (Hmax/Mmax ratio), and gait speed (10-m walk test) Results No adverse events occurred. All participants tolerated tsDCS with no negative effects on their skin. Participants demonstrated varied responses in their H/M ratios after tsDCS followed by exoskeleton-assisted locomotor training as well as after exoskeleton-assisted locomotor training. No consistent pattern can be identified in this case series. Three participants showed an increase in gait speed after tsDCS combined with exoskeleton-assisted locomotor training. Conclusions Noninvasive repeated spinal stimulation can safely be used in individuals with incomplete SCI. Further large-scale research is necessary to determine the efficacy of tsDCS for priming the spinal cord in facilitating recovery of gait in individuals with SCI.