An observational report of intensive robotic and manual gait training in sub-acute stroke

Lucas Conesa, Úrsula Costa, Eva Morales, Dylan J Edwards, Mar Cortes, Daniel León, Montserrat Bernabeu, Josep Medina, Lucas Conesa, Úrsula Costa, Eva Morales, Dylan J Edwards, Mar Cortes, Daniel León, Montserrat Bernabeu, Josep Medina

Abstract

Background: The use of automated electromechanical devices for gait training in neurological patients is increasing, yet the functional outcomes of well-defined training programs using these devices and the characteristics of patients that would most benefit are seldom reported in the literature. In an observational study of functional outcomes, we aimed to provide a benchmark for expected change in gait function in early stroke patients, from an intensive inpatient rehabilitation program including both robotic and manual gait training.

Methods: We followed 103 sub-acute stroke patients who met the clinical inclusion criteria for Body Weight Supported Robotic Gait Training (BWSRGT). Patients completed an intensive 8-week gait-training program comprising robotic gait training (weeks 0-4) followed by manual gait training (weeks 4-8). A change in clinical function was determined by the following assessments taken at 0, 4 and 8 weeks (baseline, mid-point and end-point respectively): Functional Ambulatory Categories (FAC), 10 m Walking Test (10 MWT), and Tinetti Gait and Balance Scales.

Results: Over half of the patients made a clinically meaningful improvement on the Tinetti Gait Scale (> 3 points) and Tinetti Balance Scale (> 5 points), while over 80% of the patients increased at least 1 point on the FAC scale (0-5) and improved walking speed by more than 0.2 m/s. Patients responded positively in gait function regardless of variables gender, age, aetiology (hemorrhagic/ischemic), and affected hemisphere. The most robust and significant change was observed for patients in the FAC categories two and three. The therapy was well tolerated and no patients withdrew for factors related to the type or intensity of training.

Conclusions: Eight-weeks of intensive rehabilitation including robotic and manual gait training was well tolerated by early stroke patients, and was associated with significant gains in function. Patients with mid-level gait dysfunction showed the most robust improvement following robotic training.

Figures

Figure 1
Figure 1
Schematic of the intensive rehabilitation program. The rehabilitation period comprised 8 weeks (5 hrs/day, 5 days/week); the first 4 weeks with Body-Weight-Supported-Robotic-Gait Training (BWSRGT) and the last 4 weeks Manual Gait Training. (*) Depending on patient individual needs and clinical goals.
Figure 2
Figure 2
A sub-acute stroke patient during the Robotic Gait training session. During the Body-Weight-Supported-Robotic-Gait Training (BWSRGT) the body weight is slightly unloaded via the use of a harness, while the fixed foot placement on the device ensures a set pattern that mimics human gait with alternate stance and swing phase.
Figure 3
Figure 3
Functional outcome results. Improvement in functional outcome across the robotic and manual training period (mean ± SD). For each outcome: (a) FAC (b) walking speed (c) Tinetti Gait and (d) Tinetti Balance, there was a significant increase following the robotic training, and further consolidation from the follow-up manual gait training.

References

    1. Roger VL, Go AS, Lloyd-Jones DM, Adams RJ, Berry JD, Brown TM, Carnethon MR, Dai S, de Simone G, Ford ES, Fox CS, Fullerton HJ, Gillespie C, Greenlund KJ, Hailpern SM, Heit JA, Ho PM, Howard VJ, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Makuc DM, Marcus GM, Marelli A, Matchar DB, McDermott MM, Meigs JB, Moy CS, Mozaffarian D, Mussolino ME, Nichol G, Paynter NP, Rosamond WD, Sorlie PD, Stafford RS, Turan TN, Turner MB, Wong ND, Wylie-Rosett J. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation. 2011;123:e18–e209. doi: 10.1161/CIR.0b013e3182009701.
    1. Fernandez de Bobadilla J, Sicras-Mainar A, Navarro-Artieda R, Planas-Comes A, Soto-Alvarez J, Sanchez-Maestre C, Alvarez-Martin C, Ezpeleta-Echevarri D. Estimation of the prevalence, incidence, comorbidities and direct costs associated to stroke patients requiring care in an area of the Spanish population. Rev Neurol. 2008;46:397–405.
    1. Young J, Forster A. Review of stroke rehabilitation. BMJ. 2007;334:86–90. doi: 10.1136/bmj.39059.456794.68.
    1. Dombovy ML. Understanding stroke recovery and rehabilitation: current and emerging approaches. Curr Neurol Neurosci Rep. 2004;4:31–35. doi: 10.1007/s11910-004-0008-6.
    1. Hummelsheim H, Mauritz KH. [The neurophysiological basis of exercise physical therapy in patients with central hemiparesis] Fortschr Neurol Psychiatr. 1993;61:208–216. doi: 10.1055/s-2007-999089.
    1. Barbeau H, Norman K, Fung J, Visintin M, Ladouceur M. Does neurorehabilitation play a role in the recovery of walking in neurological populations? Ann N Y Acad Sci. 1998;860:377–392. doi: 10.1111/j.1749-6632.1998.tb09063.x.
    1. Embrey DG, Holtz SL, Alon G, Brandsma BA, McCoy SW. Functional electrical stimulation to dorsiflexors and plantar flexors during gait to improve walking in adults with chronic hemiplegia. Arch Phys Med Rehabil. 2010;91:687–696. doi: 10.1016/j.apmr.2009.12.024.
    1. Mehrholz J, Werner C, Kugler J, Pohl M. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev. 2007. p. CD006185.
    1. Duncan PW, Sullivan KJ, Behrman AL, Azen SP, Wu SS, Nadeau SE, Dobkin BH, Rose DK, Tilson JK, Cen S, Hayden SK. Body-weight-supported treadmill rehabilitation after stroke. N Engl J Med. 2011;364:2026–2036. doi: 10.1056/NEJMoa1010790.
    1. Visintin M, Barbeau H, Korner-Bitensky N, Mayo NE. A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. Stroke. 1998;29:1122–1128. doi: 10.1161/01.STR.29.6.1122.
    1. Wernig A, Muller S, Nanassy A, Cagol E. Laufband therapy based on 'rules of spinal locomotion' is effective in spinal cord injured persons. Eur J Neurosci. 1995;7:823–829. doi: 10.1111/j.1460-9568.1995.tb00686.x.
    1. Hesse S, Bertelt C, Jahnke MT, Schaffrin A, Baake P, Malezic M, Mauritz KH. Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. Stroke. 1995;26:976–981. doi: 10.1161/01.STR.26.6.976.
    1. Franceschini M, Carda S, Agosti M, Antenucci R, Malgrati D, Cisari C. Walking after stroke: what does treadmill training with body weight support add to overground gait training in patients early after stroke?: a single-blind, randomized, controlled trial. Stroke. 2009;40:3079–3085. doi: 10.1161/STROKEAHA.109.555540.
    1. Werner C, Von Frankenberg S, Treig T, Konrad M, Hesse S. Treadmill training with partial body weight support and an electromechanical gait trainer for restoration of gait in subacute stroke patients: a randomized crossover study. Stroke. 2002;33:2895–2901. doi: 10.1161/01.STR.0000035734.61539.F6.
    1. Dickstein R. Rehabilitation of Gait Speed After Stroke: A Critical Review of Intervention Approaches. Neurorehabil Neural Repair. 2008.
    1. Bogey R, Hornby GT. Gait training strategies utilized in poststroke rehabilitation: are we really making a difference? Top Stroke Rehabil. 2007;14:1–8.
    1. Ada L, Dean CM, Morris ME, Simpson JM, Katrak P. Randomized trial of treadmill walking with body weight support to establish walking in subacute stroke: the MOBILISE trial. Stroke. 2011;41:1237–1242.
    1. Prabhakaran S, Zarahn E, Riley C, Speizer A, Chong JY, Lazar RM, Marshall RS, Krakauer JW. Inter-individual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair. 2008;22:64–71.
    1. Salbach NM, Mayo NE, Higgins J, Ahmed S, Finch LE, Richards CL. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil. 2001;82:1204–1212. doi: 10.1053/apmr.2001.24907.
    1. Masiero S, Avesani R, Armani M, Verena P, Ermani M. Predictive factors for ambulation in stroke patients in the rehabilitation setting: a multivariate analysis. Clin Neurol Neurosurg. 2007;109:763–769. doi: 10.1016/j.clineuro.2007.07.009.
    1. Plummer P, Behrman AL, Duncan PW, Spigel P, Saracino D, Martin J, Fox E, Thigpen M, Kautz SA. Effects of stroke severity and training duration on locomotor recovery after stroke: a pilot study. Neurorehabil Neural Repair. 2007;21:137–151. doi: 10.1177/1545968306295559.
    1. Pohl M, Werner C, Holzgraefe M, Kroczek G, Mehrholz J, Wingendorf I, Hoolig G, Koch R, Hesse S. Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS) Clin Rehabil. 2007;21:17–27. doi: 10.1177/0269215506071281.
    1. Moore JL, Roth EJ, Killian C, Hornby TG. Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a "plateau" in recovery. Stroke. 2010;41:129–135. doi: 10.1161/STROKEAHA.109.563247.
    1. Mehrholz J, Werner C, Hesse S, Pohl M. Immediate and long-term functional impact of repetitive locomotor training as an adjunct to conventional physiotherapy for non-ambulatory patients after stroke. Disabil Rehabil. 2008;30:830–836. doi: 10.1080/09638280701419326.
    1. Holden MK, Gill KM, Magliozzi MR, Nathan J, Piehl-Baker L. Clinical gait assessment in the neurologically impaired. Reliability and meaningfulness. Phys Ther. 1984;64:35–40.
    1. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986;34:119–126.
    1. Rossier P, Wade DT. Validity and reliability comparison of 4 mobility measures in patients presenting with neurologic impairment. Arch Phys Med Rehabil. 2001;82:9–13. doi: 10.1053/apmr.2001.9396.
    1. Mehrholz J, Wagner K, Rutte K, Meissner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007;88:1314–1319. doi: 10.1016/j.apmr.2007.06.764.
    1. Eng JJ, Chu KS, Dawson AS, Kim CM, Hepburn KE. Functional walk tests in individuals with stroke: relation to perceived exertion and myocardial exertion. Stroke. 2002;33:756–761. doi: 10.1161/hs0302.104195.
    1. de Oliveira CB, de Medeiros IR, Frota NA, Greters ME, Conforto AB. Balance control in hemiparetic stroke patients: main tools for evaluation. J Rehabil Res Dev. 2008;45:1215–1226. doi: 10.1682/JRRD.2007.09.0150.
    1. Schwartz I, Sajin A, Fisher I, Neeb M, Shochina M, Katz-Leurer M, Meiner Z. The effectiveness of locomotor therapy using robotic-assisted gait training in subacute stroke patients: a randomized controlled trial. PM R. 2009;1:516–523. doi: 10.1016/j.pmrj.2009.03.009.
    1. Husemann B, Muller F, Krewer C, Heller S, Koenig E. Effects of locomotion training with assistance of a robot-driven gait orthosis in hemiparetic patients after stroke: a randomized controlled pilot study. Stroke. 2007;38:349–354. doi: 10.1161/01.STR.0000254607.48765.cb.
    1. Peurala SH, Tarkka IM, Pitkanen K, Sivenius J. The effectiveness of body weight-supported gait training and floor walking in patients with chronic stroke. Arch Phys Med Rehabil. 2005;86:1557–1564. doi: 10.1016/j.apmr.2005.02.005.
    1. Peurala SH, Airaksinen O, Huuskonen P, Jakala P, Juhakoski M, Sandell K, Tarkka IM, Sivenius J. Effects of intensive therapy using gait trainer or floor walking exercises early after stroke. J Rehabil Med. 2009;41:166–173. doi: 10.2340/16501977-0304.
    1. Jorgensen JR, Bech-Pedersen DT, Zeeman P, Sorensen J, Andersen LL, Schonberger M. Effect of intensive outpatient physical training on gait performance and cardiovascular health in people with hemiparesis after stroke. Phys Ther. 2010;90:527–537. doi: 10.2522/ptj.20080404.
    1. Nadeau S, Arsenault AB, Gravel D, Bourbonnais D. Analysis of the clinical factors determining natural and maximal gait speeds in adults with a stroke. Am J Phys Med Rehabil. 1999;78:123–130. doi: 10.1097/00002060-199903000-00007.
    1. Chou SW, Wong AM, Leong CP, Hong WS, Tang FT, Lin TH. Postural control during sit-to stand and gait in stroke patients. Am J Phys Med Rehabil. 2003;82:42–47. doi: 10.1097/00002060-200301000-00007.
    1. Nichols DS. Balance retraining after stroke using force platform biofeedback. Phys Ther. 1997;77:553–558.
    1. Kollen B, van de Port I, Lindeman E, Twisk J, Kwakkel G. Predicting improvement in gait after stroke: a longitudinal prospective study. Stroke. 2005;36:2676–2680. doi: 10.1161/01.STR.0000190839.29234.50.
    1. Hendricks HT, van Limbeek J, Geurts AC, Zwarts MJ. Motor recovery after stroke: a systematic review of the literature. Arch Phys Med Rehabil. 2002;83:1629–1637. doi: 10.1053/apmr.2002.35473.
    1. Duarte E, Morales A, Pou M, Aguirrezabal A, Aguilar JJ, Escalada F. [Trunk control test: early predictor of gait balance and capacity at 6 months of the stroke] Neurologia. 2009;24:297–303.
    1. Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Arch Phys Med Rehabil. 2003;84:1458–1465. doi: 10.1016/S0003-9993(03)00361-7.
    1. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS. Recovery of walking function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1995;76:27–32. doi: 10.1016/S0003-9993(95)80038-7.
    1. Kwakkel G, Kollen B, Twisk J. Impact of time on improvement of outcome after stroke. Stroke. 2006;37:2348–2353. doi: 10.1161/01.STR.0000238594.91938.1e.
    1. Tong RK, Ng MF, Li LS. Effectiveness of gait training using an electromechanical gait trainer, with and without functional electric stimulation, in subacute stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2006;87:1298–1304. doi: 10.1016/j.apmr.2006.06.016.
    1. Trueblood PR. Partial body weight treadmill training in persons with chronic stroke. NeuroRehabilitation. 2001;16:141–153.
    1. Mayr A, Kofler M, Quirbach E, Matzak H, Frohlich K, Saltuari L. Prospective, blinded, randomized crossover study of gait rehabilitation in stroke patients using the Lokomat gait orthosis. Neurorehabil Neural Repair. 2007;21:307–314. doi: 10.1177/1545968307300697.
    1. Volpe BT, Huerta PT, Zipse JL, Rykman A, Edwards D, Dipietro L, Hogan N, Krebs HI. Robotic devices as therapeutic and diagnostic tools for stroke recovery. Arch Neurol. 2009;66:1086–1090. doi: 10.1001/archneurol.2009.182.
    1. Taub E, Miller NE, Novack TA, Cook EW, Fleming WC, Nepomuceno CS, Connell JS, Crago JE. Technique to improve chronic motor deficit after stroke. Arch Phys Med Rehabil. 1993;74:347–354.

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