Christopher Tomelleri

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.

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.

A new electromechanical trainer for sensorimotor rehabilitation of paralysed fingers: A case series in chronic and acute stroke patients

BackgroundThe functional outcome after stroke is improved by more intensive or sustained therapy. When the affected hand has no functional movement, therapy is mainly passive movements. A novel device for repeating controlled passive movements of paralysed fingers has been developed, which will allow therapists to concentrate on more complicated tasks. A powered cam shaft moves the four fingers in a physiological range of movement.MethodsAfter refining the training protocol in 2 chronic patients, 8 sub-acute stroke patients were randomised to receive additional therapy with the Finger Trainer for 20 min every work day for four weeks, or the same duration of bimanual group therapy, in addition to their usual rehabilitation.ResultsIn the chronic patients, there was a sustained reduction in finger and wrist spasticity, but there was no improvement in active movements. In the subacute patients, mean distal Fugl-Meyer score (0–30) increased in the control group from 1.25 to 2.75 (ns) and 0.75 to 6.75 in the treatment group (p < .05). Median Modified Ashworth score increased 0/5 to 2/5 in the control group, but not in the treatment group, 0 to 0. Only one patient, in the treatment group, regained function of the affected hand. No side effects occurred.ConclusionTreatment with the Finger Trainer was well tolerated in sub-acute & chronic stroke patients, whose abnormal muscle tone improved. In sub-acute stroke patients, the Finger Trainer group showed small improvements in active movement and avoided the increase in tone seen in the control group. This series was too small to demonstrate any effect on functional outcome however.

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.

Adaptive locomotor training on an end-effector gait robot: Evaluation of the ground reaction forces in different training conditions

The main goal of robotic gait rehabilitation is the restoration of independent gait. To achieve this goal different and specific patterns have to be practiced intensively in order to stimulate the learning process of the central nervous system. The gait robot G-EO Systems was designed to allow the repetitive practice of floor walking, stair climbing and stair descending. A novel control strategy allows training in adaptive mode. The force interactions between the foot and the ground were analyzed on 8 healthy volunteers in three different conditions: real floor walking on a treadmill, floor walking on the gait robot in passive mode, floor walking on the gait robot in adaptive mode. The ground reaction forces were measured by a Computer Dyno Graphy (CDG) analysis system. The results show different intensities of the ground reaction force across all of the three conditions. The intensities of force interactions during the adaptive training mode are comparable to the real walking on the treadmill. Slight deviations still occur in regard to the timing pattern of the forces. The adaptive control strategy comes closer to the physiological swing phase than the passive mode and seems to be a promising option for the treatment of gait disorders. Clinical trials will validate the efficacy of this new option in locomotor therapy on the patients.