Advanced Robotic Therapy Integrated Centers (ARTIC): an international collaboration facilitating the application of rehabilitation technologies

Abstract

Background: The application of rehabilitation robots has grown during the last decade. While meta-analyses have shown beneficial effects of robotic interventions for some patient groups, the evidence is less in others. We established the Advanced Robotic Therapy Integrated Centers (ARTIC) network with the goal of advancing the science and clinical practice of rehabilitation robotics. The investigators hope to exploit variations in practice to learn about current clinical application and outcomes. The aim of this paper is to introduce the ARTIC network to the clinical and research community, present the initial data set and its characteristics and compare the outcome data collected so far with data from prior studies.

Methods: ARTIC is a pragmatic observational study of clinical care. The database includes patients with various neurological and gait deficits who used the driven gait orthosis Lokomat® as part of their treatment. Patient characteristics, diagnosis-specific information, and indicators of impairment severity are collected. Core clinical assessments include the 10-Meter Walk Test and the Goal Attainment Scaling. Data from each Lokomat® training session are automatically collected.

Results: At time of analysis, the database contained data collected from 595 patients (cerebral palsy: n = 208; stroke: n = 129; spinal cord injury: n = 93; traumatic brain injury: n = 39; and various other diagnoses: n = 126). At onset, average walking speeds were slow. The training intensity increased from the first to the final therapy session and most patients achieved their goals.

Conclusions: The characteristics of the patients matched epidemiological data for the target populations. When patient characteristics differed from epidemiological data, this was mainly due to the selection criteria used to assess eligibility for Lokomat® training. While patients included in randomized controlled interventional trials have to fulfill many inclusion and exclusion criteria, the only selection criteria applying to patients in the ARTIC database are those required for use of the Lokomat®. We suggest that the ARTIC network offers an opportunity to investigate the clinical application and effectiveness of rehabilitation technologies for various diagnoses. Due to the standardization of assessments and the use of a common technology, this network could serve as a basis for researchers interested in specific interventional studies expanding beyond the Lokomat®.

Conflict of interest statement

Ethics approval and consent to participate

The local IRB approved the study for each site. Consent was given by the participants or their legal representatives in accordance with ethical guidelines.

Consent for publication

We obtained consent for publication of Fig. 1a from that person and from the parent of the child depicted in Fig. 1b.

Competing interests

The company Hocoma currently supports this network by means of financial support for programming the database and online meetings. Hocoma also provides resources to aid with communication between network members. However, Hocoma has no influence on the design of the study, data collection, analysis, and interpretation of data and in writing the manuscript nor decisions made within the ARTIC network.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1

Lokomat® system (of different generations) with (a) adult leg orthoses and (b) pediatric leg orthoses. Patients walk on a treadmill belt, are weight supported, and the exoskeleton device guides the legs through a physiological walking pattern

Fig. 2

ARTIC Database containing information on patient demographics, diagnosis and severity, assessments and training parameters. Training parameters are stored for each separate training session to enable an evaluation over time. The 10-Meter Walk Test and the Goal Attainment Scaling are two core clinical assessments

Fig. 3

Clinical characteristics of the patients. (a) The largest group of patients are those with a Cerebral Palsy (CP), followed by stroke, spinal cord injury (SCI) and traumatic brain injury (TBI). (b) The clinical diagnosis according to Bax and (c) the severity grade according to the Gross Motor Function Classification System (GMFCS) are shown for patients with CP. (d) For patients with stroke, the distribution between patients with ischemic versus hemorrhagic stroke is shown. (e) For patients with SCI, the ASIA Impairment Scale (AIS) is shown and reflects the severity (AIS A, sensorimotor complete; AIS B motor complete, sensory incomplete; AIS C and D sensorimotor incomplete with AIS C indicating that less than half of the muscles below the neurological level of lesion have a muscle grade of 3 or more and AIS D indicating that half or more of the muscles below the neurological level of lesion have a grade 3 or higher). (f) Finally, the distribution of the neurological level of lesion is presented. Abbreviations: C, cervical; T, thoracic; L, lumbar and S, Sacral

Fig. 4

Histograms showing the distribution of age for patients with Cerebral Palsy (CP), stroke, spinal cord injury (SCI), and traumatic brain injury (TBI). Please note the different scales on the y-axes. Grey lines indicate distributions of age, which are based on numbers from the following epidemiological studies: stroke [40], SCI [53], and TBI [61]

Fig. 5

Clinical outcome measures. On the left are the average and SD times (in seconds) presented that the patients need to walk 10 m at onset of Lokomat® training. For some patient groups, results are separated according to severity grades (e.g. the Gross Motor Function Classification Systems levels I, II, III or IV for patients with CP or the ASIA Impairment Scales C and D for patients with spinal cord injury) or etiology of stroke (ischemic versus hemorrhagic). Displayed at the right are the Goal Attainment Scores. Despite poor initial walking function, many patients achieved their goals (Goal Attainment Scores 0, 1 or 2; encircled in blue)