Gait Rehabilitation In Stroke Patients Research Articles

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

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

Brain-computer interface treatment for gait rehabilitation in stroke patients.

The use of Brain-Computer Interfaces (BCI) as rehabilitation tools for chronically ill neurological patients has become more widespread. BCIs combined with other techniques allow the user to restore neurological function by inducing neuroplasticity through real-time detection of motor-imagery (MI) as patients perform therapy tasks. Twenty-five stroke patients with gait disability were recruited for this study. Participants performed 25 sessions with the MI-BCI and assessment visits to track functional changes during the therapy. The results of this study demonstrated a clinically significant increase in walking speed of 0.19 m/s, 95%CI [0.13-0.25], p < 0.001. Patients also reduced spasticity and improved their range of motion and muscle contraction. The BCI treatment was effective in promoting long-lasting functional improvements in the gait speed of chronic stroke survivors. Patients have more movements in the lower limb; therefore, they can walk better and safer. This functional improvement can be explained by improved neuroplasticity in the central nervous system.

Re-learning mental representation of walking after a brain lesion. Effects of a cognitive-motor training with a robotic orthosis.

Stroke-related deficits often include motor impairments and gait dysfunction, leading to a limitation of social activities and consequently affecting the quality of life of stroke survivors. Neurorehabilitation takes advantage of the contribution of different techniques in order to achieve more benefits for patients. Robotic devices help to improve the outcomes of physical rehabilitation. Moreover, motor imagery seems to play a role in neurological rehabilitation since it leads to the activation of the same brain areas as actual movements. This study investigates the use of a combined physical and cognitive protocol for gait rehabilitation in stroke patients. Specifically, we tested the efficacy of a 5-week training program using a robotic orthosis (P.I.G.R.O.) in conjunction with motor imagery training. Twelve chronic stroke patients participated in the study. We evaluated balance and gait performance before and after the training. Six of them underwent fMRI examination before and after the training to assess the effects of the protocol on brain plasticity mechanisms in motor and imagery tasks. Our results show that the rehabilitation protocol can effectively improve gait performance and balance and reduce the risk of falls in stroke patients. Furthermore, the fMRI results suggest that rehabilitation is associated with cerebral plastic changes in motor networks. The present findings, if confirmed by future research, have the potential to advance the development of new, more effective rehabilitation approaches for stroke patients, improving their quality of life and reducing the burden of stroke-related disability.

Systematic Review of EMG-Driven Robots in Lower Extremity Post-Stroke Rehabilitation

Stroke is a prevalent health issue worldwide, often leading to lower extremity deficits and posing a significant challenge for physiotherapists in terms of gait rehabilitation. With the advent of technological advancements, new rehabilitation tools like EMG-driven robots have been developed. However, their effectiveness in rehabilitation needs to be explored due to their high cost. Therefore, this study aimed to determine whether EMG-driven robot therapy was more effective than conventional physiotherapy for gait rehabilitation in stroke patients. The researchers conducted a literature search using the PubMed, Cochrane, and PEDro databases and included only randomized controlled trials (RCTs) focused on stroke patients with gait impairment, assessed using clinical functional scales. The treatment compared EMG-driven robot therapy for the lower extremities with conventional therapy. The analysis included three studies, which showed no significant improvement in locomotion, functional outcomes, or balance parameters with EMG-driven robots alone. However, when combined with conventional physiotherapy, EMG-driven robots demonstrated improvement in these outcomes. Positive effects were observed for spasticity and thigh circumference. In conclusion, EMG-driven robots can be an effective way to improve gait rehabilitation in stroke patients; however, further research with a specific protocol and explanation of the adaptation to each patient is needed.

A Robot-Assisted Therapy to Increase Muscle Strength in Hemiplegic Gait Rehabilitation.

This study examines the feasibility of using a robot-assisted therapy methodology based on the Bobath concept to perform exercises applied in conventional therapy for gait rehabilitation in stroke patients. The aim of the therapy is to improve postural control and movement through exercises based on repetitive active-assisted joint mobilization, which is expected to produce strength changes in the lower limbs. As therapy progresses, robotic assistance is gradually reduced and the patient's burden increases with the goal of achieving a certain degree of independence. The relationship between force and range of motion led to the analysis of both parameters of interest. The study included 23 volunteers who performed 24 sessions, 2 sessions per week for 12 weeks, each lasting about 1 h. The results showed a significant increase in hip abduction and knee flexion strength on both sides, although there was a general trend of increased strength in all joints. However, the range of motion at the hip and ankle joints was reduced. The usefulness of this platform for transferring exercises from conventional to robot-assisted therapies was demonstrated, as well as the benefits that can be obtained in muscle strength training. However, it is suggested to complement the applied therapy with exercises for the maintenance and improvement of the range of motion.

High-Dorsiflexion Assistive System for Passive Swing Phase Dorsiflexion Training and Preventing Compensatory Movements

Over the last few years, numerous robotic ankle-foot orthoses have been developed to help stroke patients optimize gait rehabilitation. In this paper, we present a study on the effects of assistance on dorsiflexion-restricted gait. Our high-dorsiflexion assistive system aims to provide full assistance to realize passive training of dorsiflexion during the swing phase and prevent compensatory movements. This system, which includes a McKibben-type artificial muscle and an air source, is lightweight and provides a high-dorsiflexion torque. The device could help boost overground gait rehabilitation in stroke patients. With this system, we conducted an experiment on five healthy participants whose dorsiflexion movements were restricted, and the extent of their compensatory movements differed. The results of the processed surface electromyography data differed significantly when dorsiflexion movement was assisted by our system. The spatial parameters also showed significantly improved compensatory movement inclination with sufficient assistance. These results indicate the potential of our system to assist in passive training of ankle dorsiflexion movements and to prevent incorrect gait in patients with low dorsiflexion abilities.

Development of a vibrotactile cueing device that implicitly increases walking speed during gait training in stroke patients: an observational case series study

One of the main sequelae of stroke is difficulty walking, which is characterised by decreased walking speed and asymmetrical walking patterns. Physical therapists often rely on explicit motor learning strategies, i.e., providing mainly verbal instructions for how movements should be performed. However, the voluntary movement induced by explicit instruction may lead to associated unintended muscle contractions or higher cognitive demand, which could be detrimental. We introduce a vibrotactile cueing device that implicitly improves walking speed. The stroke patient walks while alternating vibrational cues are given to the left and right sides of their waist. At each specified step, cueing frequency increases in the cueing group without the patient’s awareness. The four patients in the cueing group did not notice the increase in walking speed during training; however, we observed an improvement in walking speed and cadence in patients using the proposed cueing system, which was maintained during the posttest phase. Additionally, patients using the cueing system were able to suppress excessive compensatory movements during training compared with patients who did not use the system. This case series study indicates that the proposed system for gait rehabilitation of stroke patients can enable an increase in walking speed without excessive effort.

Does feedback based on FES-evoked nociceptive withdrawal reflex condition event-related desynchronization? An exploratory study with brain-computer interfaces

Introduction. Event-related desynchronization (ERD) is used in brain-computer interfaces (BCI) to detect the user’s motor intention (MI) and convert it into a command for an actuator to provide sensory feedback or mobility, for example by means of functional electrical stimulation (FES). Recent studies have proposed to evoke the nociceptive withdrawal reflex (NWR) using FES, in order to evoke synergistic movements of the lower limb and to facilitate the gait rehabilitation of stroke patients. The use of NWR to provide sensorimotor feedback in ERD-based BCI is novel; thererfore, the conditioning effect that nociceptive stimuli might have on MI is still unknown. Objetive. To assess the ERD produced during the MI after FES-evoked NWR, in order to evaluate if nociceptive stimuli condition subsequent ERDs. Methods. Data from 528 electroencephalography trials of 8 healthy volunteers were recorded and analyzed. Volunteers used an ERD-based BCI, which provided two types of feedback: intrisic by the FES-evoked NWR and extrinsic by virtual reality. The electromyogram of the tibialis anterior muscle was also recorded. The main outcome variables were the normalized root mean square of the evoked electromyogram (RMS norm ), the average electroencephalogram amplitude at the ERD frequency during MI () and the percentage decrease of relative to rest () at the first MI subsequent to the activation of the BCI. Results. No evidence of changes of the RMS norm on both the (p = 0.663) and the (p = 0.252) of the subsequent MI was detected. A main effect of the type of feedback was found in the subsequent (p < 0.001), with intrinsic feedback resulting in a larger Conclusions. No evidence of ERD conditioning was observed using BCI feedback based on FES-evoked NWR . Significance. FES-evoked NWR could constitute a potential feedback modality in an ERD-based BCI to facilitate motor recovery of stroke people.

Pelvis-Toe Distance: 3-Dimensional Gait Characteristics of Functional Limb Shortening in Hemiparetic Stroke.

We aimed to investigate whether a newly defined distance in the lower limb can capture the characteristics of hemiplegic gait compared to healthy controls. Three-dimensional gait analyses were performed on 42 patients with chronic stroke and 10 age-matched controls. Pelvis-toe distance (PTD) was calculated as the absolute distance between an anterior superior iliac spine marker and a toe marker during gait normalized by PTD in the bipedal stance. The shortening peak during the swing phase was then quantified as PTDmin. The sagittal clearance angle, the frontal compensatory angle, gait speed, and the observational gait scale were also collected. PTDmin in the stroke group showed less shortening on the affected side and excessive shortening on the non-affected side compared to controls. PTDmin on the affected side correlated negatively with the sagittal clearance peak angle and positively with the frontal compensatory peak angle in the stroke group. PTDmin in stroke patients showed moderate to high correlations with gait speed and observational gait scale. PTDmin adequately reflected gait quality without being affected by apparent improvements due to frontal compensatory patterns. Our results showed that various impairments and compensations were included in the inability to shorten PTD, which can provide new perspectives on gait rehabilitation in stroke patients.

Patient-specific functional electrical stimulation strategy based on muscle synergy and walking posture analysis for gait rehabilitation of stroke patients.

ObjectiveTo evaluate a novel multi-channel functional electrical stimulation (FES) rehabilitation method based on the evaluation of patient-specific walking dysfunction.MethodsThis study investigated a novel multi-channel FES-based rehabilitation method that analysed the patient’s muscle synergy and walking posture. A patient-specific FES profile was produced in the pre-evaluation stage by comparing the muscle synergy and walking posture of the patient with those of healthy control subjects. During the rehabilitation phase, this profile was used to determine an appropriate FES pulse width and amplitude for stimulating the patient’s muscles as they walked across a flat surface.ResultsTwo stroke patients with hemiplegic symptoms participated in a clinical evaluation of the proposed method involving a 4-week course of rehabilitation. An evaluation of the rehabilitation results based on a comparison of the pre- and post-rehabilitation muscle synergy and walking posture revealed that the rehabilitation enhanced the muscle synergy similarity between the patients and healthy control subjects and their quantitative walking performance, as measured by a 10-m walk test and walking speed, by up to 23.38% and 30.00%, respectively.ConclusionThese results indicated that the proposed rehabilitation method improved walking ability by improving muscle coordination and adequately supporting weakened muscles in stroke patients.

Evaluating the effect of immersive virtual reality technology on gait rehabilitation in stroke patients: a study protocol for a randomized controlled trial

BackgroundThe high incidence of cerebral apoplexy makes it one of the most important causes of adult disability. Gait disorder is one of the hallmark symptoms in the sequelae of cerebral apoplexy. The recovery of walking ability is critical for improving patients’ quality of life. Innovative virtual reality technology has been widely used in post-stroke rehabilitation, whose effectiveness and safety have been widely verified. To date, however, there are few studies evaluating the effect of immersive virtual reality on stroke-related gait rehabilitation. This study outlines the application of immersive VR-assisted rehabilitation for gait rehabilitation of stroke patients for comparative evaluation with traditional rehabilitation.MethodsThe study describes a prospective, randomized controlled clinical trial. Thirty-six stroke patients will be screened and enrolled as subjects within 1 month of initial stroke and randomized into two groups. The VRT group (n = 18) will receive VR-assisted training (30 min) 5 days/week for 3 weeks. The non-VRT group (n = 18) will receive functional gait rehabilitation training (30 min) 5 days/week for 3 weeks. The primary outcomes and secondary outcomes will be conducted before intervention, 3 weeks after intervention, and 6 months after intervention. The primary outcomes will include time “up & go” test (TUGT). The secondary outcomes will include MMT muscle strength grading standard (MMT), Fugal-Meyer scale (FMA), motor function assessment scale (MAS), improved Barthel index scale (ADL), step with maximum knee angle, total support time, step frequency, step length, pace, and stride length.DiscussionVirtual reality is an innovative technology with broad applications, current and prospective. Immersive VR-assisted rehabilitation in patients with vivid treatment scenarios in the form of virtual games will stimulate patients’ interest through active participation. The feedback of VR games can also provide patients with performance awareness and effect feedback, which could be incentivizing. This study may reveal an improved method of stroke rehabilitation which can be helpful for clinical decision-making and future practice.Trial registrationChinese Clinical Trial Registry ChiCTR1900025375. Registered on 25 August 2019

Gait rehabilitation after stroke: review of the evidence of predictors, clinical outcomes and timing for interventions.

The recovery of walking capacity is one of the main aims in stroke rehabilitation. Being able to predict if and when a patient is going to walk after stroke is of major interest in terms of management of the patients and their family's expectations and in terms of discharge destination and timing previsions. This article reviews the recent literature regarding the predictive factors for gait recovery and the best recommendations in terms of gait rehabilitation in stroke patients. Trunk control and lower limb motor control (e.g. hip extensor muscle force) seem to be the best predictors of gait recovery as shown by the TWIST algorithm, which is a simple tool that can be applied in clinical practice at 1week post-stroke. In terms of walking performance, the 6-min walking test is the best predictor of community ambulation. Various techniques are available for gait rehabilitation, including treadmill training with or without body weight support, robotic-assisted therapy, virtual reality, circuit class training and self-rehabilitation programmes. These techniques should be applied at specific timing during post-stroke rehabilitation, according to patient's functional status.

Recovery of gait function with a wearable powered exoskeleton in sub-acute stroke patients using SEMG for fine tuning: Preliminary results

Gait recovery in post-stroke patients is one of the main goals of post-stroke rehabilitation. Wearable over-ground powered exoskeletons allow individuals with gait dysfunctions to perform an over-ground gait training. Literature lacks of clinical studies on exoskeleton-supported gait rehabilitation in stroke patients and on setting modalities. Ekso is a wearable exoskeleton equipped with 4 motors, which allows the patient to stand up, sit and walk on a flat hard surface. The aim of this study is to investigate the clinical effects of an over-ground walking training with a wearable powered exoskeleton (Ekso), after a sEMG fine tuning, in sub-acute stroke patients. This is a pilot pre-post, open label, non randomized, non controlled experimental study. 47 sub-acute stroke patients underwent a walking rehabilitation training of 15 sessions (60 min/session, 3 times/week) using Ekso. A surface electromyography (sEMG) of rectus femoris, hamstrings, tibialis anterior and soleus of both limbs was collected in order to define the best setting for each patient. Clinical evaluation was performed at the beginning of the training period (t1), and after 15 sessions (t2) using: Barthel Index, Ashworth scale, Motricity Index, Trunk Control Test, Functional Ambulation Scale, 10 meter walking test, 6 minutes walking test, and Walking Handicap Scale. Wilcoxon's tests ( P < 0.05) was used to detect significant changes between data. Significant statistical improvements were found between t0–t2 in Barthel Index, Motricity Index, Trunk Control Test, Functional Ambulation Scale, 10 meter walking test, and 6 minutes walking test. Fifteen sessions of over-ground gait training using a powered wearable robotic exoskeleton, set with sEMG, improve ambulatory functions in sub-acute post-stroke patients. Further studies are needed to better understand the treatment effect.

Efficacy of Robotic-Assisted Gait Training in chronic stroke patients: Preliminary results of an Italian bi-centre study.

The gait recovery is a realist goal in the rehabilitation of almost Stroke patients. Over the last years, the introduction of robotic technologies in gait rehabilitation of stroke patients has had a greatest interest. The aim of this study was to evaluate efficacy of Robotic Gait Training (RGT) in chronic stroke patients. Fourteen chronic stroke patients were divided into two groups. Six patients received RGT, eight patients received traditional gait rehabilitation. Patients were assessed with clinical scales, as well as with gait analysis, at the beginning and at the end of the treatment. Significant changes in some clinical scales for both the groups were detected. In the robotic group, patients showed higher percentage changes in the MRC scale (p = 0.020), in the 6MWT (p = 0.043) and in the Ashworth scale (hip: p = 0.008; knee: p = 0.043; ankle: p = 0.043) when compared with the traditional group. With respect to the gait analysis, we did not found any difference neither in the within-group analysis, nor in the between-group analysis. Both rehabilitation treatments do not change the compensatory strategies in chronic patients but the RGT offers to the patients a more intensive and controlled gait training increasing the gait endurance and decreasing spasticity in the lower limb.

Identifying the effects of using integrated haptic feedback for gait rehabilitation of stroke patients.

This paper evaluates the prospects of using a novel Integrated Haptic Feedback (IHF) system. IHF can provide over-ground gait training regimens for post-stroke ambulatory subjects. IHF system combines the use of a portable cane for kinesthetic feedback and a wearable vibrotactor array for tactile feedback. Continuous somatosensory input is aiforded to the users at the handle of cane; it serves the purpose of balance assurance at higher gait speeds. Besides, restricted use of upper limb for weight-bearing inspires the users to involve the paretic lower limbs more actively. Furthermore, tactile feedback contributes in enhancing the gait symmetry through afferent signal of vibration. Six post-stroke ambulatory individuals participated in walking trials to identity the effects of IHF system. Results indicate that while walking faster patients' body sway was not disturbed. Statistically significant increase was observed in temporal stance symmetry (p-value=0.02) and in paretic muscle (vastus medialis obliquus and semitendinosus) activation during stance phase (p-value<0.01). The IHF system can be a valuable tool to assist physical therapist in gait rehabilitation of post-stroke individuals.

The motivation, expectations and ease-of-use of robot-assisted gait rehabilitation in stroke patients and their therapists

The motivation, expectations and ease-of-use of robot-assisted gait rehabilitation in stroke patients and their therapists

A pilot clinical trial on a Variable Automated Speed and Sensing Treadmill (VASST) for hemiparetic gait rehabilitation in stroke patients.

Introduction: Impairments in walking speed and capacity are common problems after stroke which may benefit from treadmill training. However, standard treadmills, are unable to adapt to the slower walking speeds of stroke survivors and are unable to automate training progression. This study tests a Variable Automated Speed and Sensing Treadmill (VASST) using a standard clinical protocol. VASST is a semi-automated treadmill with multiple sensors and micro controllers, including wireless control to reposition a fall-prevention harness, variable pre-programmed exercise parameters and laser beam foot sensors positioned on the belt to detect subject's foot positions.Materials and Methods: An open-label study with assessor blinding was conducted in 10 community-dwelling chronic hemiplegic patients who could ambulate at least 0.1 m/s. Interventions included physiotherapist-supervised training on VASST for 60 min three times per week for 4 weeks (total 12 h). Outcome measures of gait speed, quantity, balance, and adverse events were assessed at baseline, 2, 4, and 8 weeks.Results: Ten subjects (8 males, mean age 55.5 years, 2.1 years post stroke) completed VASST training. Mean 10-m walk test speed was 0.69 m/s (SD = 0.29) and mean 6-min walk test distance was 178.3 m (84.0). After 4 weeks of training, 70% had significant positive gains in gait speed (0.06 m/s, SD = 0.08 m/s, P = 0.037); and 90% improved in walking distance. (54.3 m, SD = 30.9 m, P = 0.005). There were no adverse events.Discussion and Conclusion: This preliminary study demonstrates the initial feasibility and short-term efficacy of VASST for walking speed and distance for people with chronic post-stroke hemiplegia.

A novel robotic knee device with stance control and its kinematic weight optimization for rehabilitation

SUMMARYIt is important to develop a robotic orthosis or exoskeleton that can provide back-drivable and good assistive performances with lightweight structures for overground gait rehabilitation of stroke patients. In this paper, we describe a robotic knee device with a five-bar linkage to allow low-impedance voluntary knee motion within a specified rotation range during the swing phase, and to assist knee extension during the stance phase. The device can provide free motion through the five-bar linkage with 2-degree-of-freedom (DOF) actuation via the patient's shank using a linear actuator, and can assist knee extension at any controlled knee angle while bearing weight via a geared five-bar linkage with 1 DOF actuation of the linear actuator. The kinematic transition between the two modes can be implemented by contact with a circular structure and a linear link, and the resultant range of motion can be determined by the linear actuator. The kinematic weight of the device was optimized using the simple genetic algorithm to reduce the mass. The optimization cost function was based on the sum of the total link lengths and the actuator power. The optimization results reduced the total link length and motor power by 47% and 43%, respectively, compared to the initial design. We expect that the device will facilitate rehabilitation of stroke patients by allowing safe and free overground walking while providing support for stumbling.

The use of biomechanical visualisation in neurorehabilitation and its effect on ankle-foot orthosis (AFO) tuning in stroke

Background: Difficulties interpreting the biomechanical data captured by 3D gait analysis (3DGA) systems mean that it is rarely used in routine clinical practice for gait rehabilitation of stroke patients. Biomechanical visualisation software has been designed to make data clinically useful in the context of AFO fitting and tuning for stroke patients. Therapists can use objective quantitative data to assist clinical decision-making. Participants receive an improved understanding of their condition/treatment, and it allows progress tracking.

Robotic system for gait rehabilitation of stroke patients in the acute phase

Robotic system for gait rehabilitation of stroke patients in the acute phase