Andreas Waldner

Combined transcranial direct current stimulation and robot-assisted arm training in subacute stroke patients: an exploratory, randomized multicenter trial.

Background. No rehabilitation intervention has effectively improved functional use of the arm and hand in patients with severe upper limb paresis after stroke. Pilot studies suggest the potential for transcranial direct current stimulation and bilateral robotic training to enhance gains. Objective. In a double-blind, randomized trial the combination of these interventions was tested. Methods. This study randomized 96 patients with an ischemic supratentorial lesion of 3 to 8 weeks’ duration with severe impairment of motor control with a Fugl-Meyer score (FMS) for the upper limb <18 into 3 groups. For 6 weeks, group A received anodal stimulation of the lesioned hemisphere, group B received cathodal stimulation of the nonlesioned side for 20 minutes at 2.0 mA, and group C received sham stimulation. The electrodes were placed over the hand area and above the contralateral orbit. Contemporaneously, the subjects practiced 400 repetitions each of 2 different bilateral movements on a robotic assistive device. Results. The groups were matched at onset. The FMS improved in all patients at 6 weeks (P < .001). No between-group differences were found; initial versus finish FMS scores were 7.8 ± 3.8 versus 19.1 ± 14.4 in group A, 7.9 ± 3.4 versus 18.8 ± 10.5 in group B, and 8.2 ± 4.4 versus 19.2 ± 15.0 in group C. No significant changes between groups were present at 3 months. Conclusions. Neither anodal nor cathodal transcranial direct current stimulation enhanced the effect of bilateral arm training in this exploratory trial of patients with cortical involvement and severe weakness. Unilateral hand training and upregulation of the nonlesioned hemisphere might also be tried in this population.

Innovative gait robot for the repetitive practice of floor walking and stair climbing up and down in stroke patients

BackgroundStair climbing up and down is an essential part of everydays mobility. To enable wheelchair-dependent patients the repetitive practice of this task, a novel gait robot, G-EO-Systems (EO, Lat: I walk), based on the end-effector principle, has been designed. The trajectories of the foot plates are freely programmable enabling not only the practice of simulated floor walking but also stair climbing up and down. The article intended to compare lower limb muscle activation patterns of hemiparetic subjects during real floor walking and stairs climbing up, and during the corresponding simulated conditions on the machine, and secondly to demonstrate gait improvement on single case after training on the machine.MethodsThe muscle activation pattern of seven lower limb muscles of six hemiparetic patients during free and simulated walking on the floor and stair climbing was measured via dynamic electromyography. A non-ambulatory, sub-acute stroke patient additionally trained on the G-EO-Systems every workday for five weeks.ResultsThe muscle activation patterns were comparable during the real and simulated conditions, both on the floor and during stair climbing up. Minor differences, concerning the real and simulated floor walking conditions, were a delayed (prolonged) onset (duration) of the thigh muscle activation on the machine across all subjects. Concerning stair climbing conditions, the shank muscle activation was more phasic and timely correct in selected patients on the device. The severely affected subject regained walking and stair climbing ability.ConclusionsThe G-EO-Systems is an interesting new option in gait rehabilitation after stroke. The lower limb muscle activation patterns were comparable, a training thus feasible, and the positive case report warrants further clinical studies.

Improved gait after repetitive locomotor training in children with cerebral palsy.

Objective:The aim of this study was to evaluate the effectiveness of repetitive locomotor training with an electromechanical gait trainer in children with cerebral palsy. Design:In this randomized controlled trial, 18 ambulatory children with diplegic or tetraplegic cerebral palsy were randomly assigned to an experimental group or a control group. The experimental group received 30 mins of repetitive locomotor training with an applied technology (Gait Trainer GT I) plus 10 mins of passive joint mobilization and stretching exercises. The control group received 40 mins of conventional physiotherapy. Each subject underwent a total of 10 treatment sessions over a 2-wk period. Performance on the 10-m walk test, 6-min walk test, WeeFIM scale, and gait analysis was evaluated by a blinded rater before and after treatment and at 1-mo follow-up. Results:The experimental group showed significant posttreatment improvement on the 10-m walk test, 6-min walk test, hip kinematics, gait speed, and step length, all of which were maintained at the 1-mo follow-up assessment. No significant changes in performance parameters were observed in the control group. Conclusions:Repetitive locomotor training with an electromechanical gait trainer may improve gait velocity, endurance, spatiotemporal, and kinematic gait parameters in patients with cerebral palsy.

Modulation of event-related desynchronization in robot-assisted hand performance: brain oscillatory changes in active, passive and imagined movements

BackgroundRobot-assisted therapy in patients with neurological disease is an attempt to improve function in a moderate to severe hemiparetic arm. A better understanding of cortical modifications after robot-assisted training could aid in refining rehabilitation therapy protocols for stroke patients. Modifications of cortical activity in healthy subjects were evaluated during voluntary active movement, passive robot-assisted motor movement, and motor imagery tasks performed under unimanual and bimanual protocols.MethodsTwenty-one channel electroencephalography (EEG) was recorded with a video EEG system in 8 subjects. The subjects performed robot-assisted tasks using the Bi-Manu Track robot-assisted arm trainer. The motor paradigm was executed during one-day experimental sessions under eleven unimanual and bimanual protocols of active, passive and imaged movements. The event-related-synchronization/desynchronization (ERS/ERD) approach to the EEG data was applied to investigate where movement-related decreases in alpha and beta power were localized.ResultsVoluntary active unilateral hand movement was observed to significantly activate the contralateral side; however, bilateral activation was noted in all subjects on both the unilateral and bilateral active tasks, as well as desynchronization of alpha and beta brain oscillations during the passive robot-assisted motor tasks. During active-passive movement when the right hand drove the left one, there was predominant activation in the contralateral side. Conversely, when the left hand drove the right one, activation was bilateral, especially in the alpha range. Finally, significant contralateral EEG desynchronization was observed during the unilateral task and bilateral ERD during the bimanual task.ConclusionsThis study suggests new perspectives for the assessment of patients with neurological disease. The findings may be relevant for defining a baseline for future studies investigating the neural correlates of behavioral changes after robot-assisted training in stroke patients.

Robot-Assisted Gait Training in Patients With Parkinson Disease A Randomized Controlled Trial

Background. Gait impairment is a common cause of disability in Parkinson disease (PD). Electromechanical devices to assist stepping have been suggested as a potential intervention. Objective. To evaluate whether a rehabilitation program of robot-assisted gait training (RAGT) is more effective than conventional physiotherapy to improve walking. Methods. A total of 41 patients with PD were randomly assigned to 45-minute treatment sessions (12 in all), 3 days a week, for 4 consecutive weeks of either robotic stepper training (RST; n = 21) using the Gait Trainer or physiotherapy (PT; n = 20) with active joint mobilization and a modest amount of conventional gait training. Participants were evaluated before, immediately after, and 1 month after treatment. Primary outcomes were 10-m walking speed and distance walked in 6 minutes. Results. Baseline measures revealed no statistical differences between groups, but the PT group walked 0.12 m/s slower; 5 patients withdrew. A statistically significant improvement was found in favor of the RST group (walking speed 1.22 ± 0.19 m/s [P = .035]; distance 366.06 ± 78.54 m [P < .001]) compared with the PT group (0.98 ± 0.32 m/s; 280.11 ± 106.61 m). The RAGT mean speed increased by 0.13 m/s, which is probably not clinically important. Improvements were maintained 1 month later. Conclusions. RAGT may improve aspects of walking ability in patients with PD. Future trials should compare robotic assistive training with treadmill or equal amounts of overground walking practice.

Combined transcranial direct current stimulation and robot-assisted gait training in patients with chronic stroke: a preliminary comparison

Objective: To evaluate whether robot-assisted gait training combined with transcranial direct current stimulation is more effective than robot-assisted gait training alone or conventional walking rehabilitation for improving walking ability in stroke patients. Design: Pilot randomized clinical trial. Setting: Rehabilitation unit of a university hospital. Subjects: Thirty patients with chronic stroke. Interventions: All patients received ten 50-minute treatment sessions, five days a week, for two consecutive weeks. Group 1 (n = 10) underwent a robot-assisted gait training combined with transcranial direct current stimulation; group 2 (n = 10) underwent a robot-assisted gait training combined with sham transcranial direct current stimulation; group 3 (n = 10) performed overground walking exercises. Main measures: Patients were evaluated before, immediately after and two weeks post treatment. Primary outcomes: six-minute walking test, 10-m walking test. Results: No differences were found between groups 1 and 2 for all primary outcome measures at the after treatment and follow-up evaluations. A statistically significant improvement was found after treatment in performance on the six-minute walking test and the 10-m walking test in favour of group 1 (six-minute walking test: 205.20 ± 61.16 m; 10-m walking test: 16.20 ± 7.65 s) and group 2 (six-minute walking test: 182.5 ± 69.30 m; 10-m walking test: 17.71 ± 8.20 s) compared with group 3 (six-minute walking test: 116.30 ± 75.40 m; 10-m walking test: 26.30 ± 14.10 s). All improvements were maintained at the follow-up evaluation. Conclusions: In the present pilot study transcranial direct current stimulation had no additional effect on robot-assisted gait training in patients with chronic stroke. Larger studies are required to confirm these preliminary findings.

Robot-assisted practice of gait and stair climbing in nonambulatory stroke patients

A novel gait robot enabled nonambulatory patients the repetitive practice of gait and stair climbing. Thirty nonambulatory patients with subacute stroke were allocated to two groups. During 60 min sessions every workday for 4 weeks, the experimental group received 30 min of robot training and 30 min of physiotherapy and the control group received 60 min of physiotherapy. The primary variable was gait and stair climbing ability (Functional Ambulation Categories [FAC] score 0-5); secondary variables were gait velocity, Rivermead Mobility Index (RMI), and leg strength and tone blindly assessed at onset, intervention end, and follow-up. Both groups were comparable at onset and functionally improved over time. The improvements were significantly larger in the experimental group with respect to the FAC, RMI, velocity, and leg strength during the intervention. The FAC gains (mean +/- standard deviation) were 2.4 +/- 1.2 (experimental group) and 1.2 +/- 1.5 (control group), p = 0.01. At the end of the intervention, seven experimental group patients and one control group patient had reached an FAC score of 5, indicating an ability to climb up and down one flight of stairs. At follow-up, this superior gait ability persisted. In conclusion, the therapy on the novel gait robot resulted in a superior gait and stair climbing ability in nonambulatory patients with subacute stroke; a higher training intensity was the most likely explanation. A large randomized controlled trial should follow.

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

OBJECTIVE The aim of this systematic review was to identify appropriate selection criteria of clinical scales for future trials, starting from those most commonly reported in the literature, according to their psychometric properties and International Classification of Functioning, Disability and Health (ICF) domains. DATA SOURCES A computerized literature research of articles was conducted in MEDLINE, EMBASE, CINALH, PubMed, PsychINFO and Scopus databases. STUDY SELECTION Clinical trials evaluating the effects of electromechanical and robot-assisted gait training trials in stroke survivors. DATA EXTRACTION Fifteen independent authors performed an extensive literature review. DATA SYNTHESIS A total of 45 scales was identified from 27 studies involving 966 subjects. The most commonly used outcome measures were: Functional Ambulation Category (18 studies), 10-Meter Walking Test (13 studies), Motricity Index (12 studies), 6-Minute Walking Test (11 studies), Rivermead Mobility Index (8 studies) and Berg Balance Scale (8 studies). According to the ICF domains 1 outcome measure was categorized into Body Function and Structure, 5 into Activity and none into Participation. CONCLUSION The most commonly used scales evaluated the basic components of walking. Future studies should also include instrumental evaluation. Criteria for scale selection should be based on the ICF framework, psychometric properties and patient characteristics.

Robot-assisted vs. sensory integration training in treating gait and balance dysfunctions in patients with multiple sclerosis: a randomized controlled trial

Background: Extensive research on both healthy subjects and patients with central nervous damage has elucidated a crucial role of postural adjustment reactions and central sensory integration processes in generating and “shaping” locomotor function, respectively. Whether robotic-assisted gait devices might improve these functions in Multiple sclerosis (MS) patients is not fully investigated in literature. Purpose: The aim of this study was to compare the effectiveness of end-effector robot-assisted gait training (RAGT) and sensory integration balance training (SIBT) in improving walking and balance performance in patients with MS. Methods: Twenty-two patients with MS (EDSS: 1.5–6.5) were randomly assigned to two groups. The RAGT group (n = 12) underwent end-effector system training. The SIBT group (n = 10) underwent specific balance exercises. Each patient received twelve 50-min treatment sessions (2 days/week). A blinded rater evaluated patients before and after treatment as well as 1 month post treatment. Primary outcomes were walking speed and Berg Balance Scale. Secondary outcomes were the Activities-specific Balance Confidence Scale, Sensory Organization Balance Test, Stabilometric Assessment, Fatigue Severity Scale, cadence, step length, single and double support time, Multiple Sclerosis Quality of Life-54. Results: Between groups comparisons showed no significant differences on primary and secondary outcome measures over time. Within group comparisons showed significant improvements in both groups on the Berg Balance Scale (P = 0.001). Changes approaching significance were found on gait speed (P = 0.07) only in the RAGT group. Significant changes in balance task-related domains during standing and walking conditions were found in the SIBT group. Conclusion: Balance disorders in patients with MS may be ameliorated by RAGT and by SIBT.

Sensory integration balance training in patients with multiple sclerosis: A randomized, controlled trial

Background: Impaired sensory integration contributes to balance disorders in patients with multiple sclerosis (MS). Objective: The objective of this paper is to compare the effects of sensory integration balance training against conventional rehabilitation on balance disorders, the level of balance confidence perceived, quality of life, fatigue, frequency of falls, and sensory integration processing on a large sample of patients with MS. Methods: This single-blind, randomized, controlled trial involved 80 outpatients with MS (EDSS: 1.5–6.0) and subjective symptoms of balance disorders. The experimental group (n = 39) received specific training to improve central integration of afferent sensory inputs; the control group (n = 41) received conventional rehabilitation (15 treatment sessions of 50 minutes each). Before, after treatment, and at one month post-treatment, patients were evaluated by a blinded rater using the Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), Multiple Sclerosis Quality of Life-54, Fatigue Severity Scale (FSS), number of falls and the Sensory Organization Balance Test (SOT). Results: The experimental training program produced greater improvements than the control group training on the BBS (p < 0.001), the FSS (p < 0.002), number of falls (p = 0.002) and SOT (p < 0.05). Conclusions: Specific training to improve central integration of afferent sensory inputs may ameliorate balance disorders in patients with MS. Clinical Trial Registration (NCT01040117).