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Gait Training Post-Stroke: Robotics and Ambulation

A brief look at retraining gait in a post stroke population utilizing robotic assistance.
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Scot Morrison

on 5 September 2012

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Transcript of Gait Training Post-Stroke: Robotics and Ambulation

Gait Training History - A quick look at traditional approachs Clinically we want to know what intervention strategy is going to give the best results in the most effecient and cost effective manner possible. What is "Evidence Based Practice" anyway? It has been defined as practice that is informed by the following three areas:
High quality clinical research
Professional knowledge
Patient preferences But to make an evidence based decision we have to answer a few questions.
The first is: 8O% of those who suffer a stroke end up with an impairment in gait.
Most regain some ability but initially...
40% need assistance
60% are limited in community ambulation

Thus retraining gait in a stroke patient is high on the list of things Physical Therapy gets involved with. Gait approaches It's about Motor Learning! So which is "right"? Different
perspectives Its Neurophysiological! Bobath

Brunnstrom

PNF

Vojta method

Rood technique

Johnstone method Bobath: Hypothesizes a relationship between spaticity and movement. Looks to inhibit tone through passive mobilization and avoids activating synergies and reflexes. Starts at the trunk and moves distally. (Belda-Lois et. al.) Brunnstrom: "Enhances pathologic synergies to obtain normal movement patterns and encourage the return of voluntary movement through reflex facilitation and sensory stimulation" (Belda-Lois et. al.) PNF: Rarely used for stroke; this method is based on spiral and diagonal patterns along with a variety of stimuli. Goal is to recruit more motor units and ultimately achieve normalized movement. (Belda-Lois et. al.) On top of all this even with therapy success is limited...
35% of those with initial paralysis don't regain useful ambulation.
25% of survivors are unable to walk without full physical assistance before hospital discharge. The Perfetti method

Carr & Shepherd

Conductive Education (PETO method)

Affolter method

Sensory Integration (Ayres method) Perfetti: Developed for controlling spasticity and later applied to all stroke related issues including gait. Starts with tactile recognition, proceeds to passive manipulation and ends with active manipulation. (Belda-Lois et. al.) PETO: Focus is on coping with disability. Specifically focuses on integrated approaches and coping with disability. (Belda-Lois et. al.) Carr & Shepherd: Everyone learns in the same manner. Posture & movement are interrelated and through appropriate sensory input motor response to a task can be modulated. Rehab focuses initially on movements that cannot be performed, then introduces functional tasks, and finishes with all of the training generalized into ADL's. (Belda-Lois et. al.) Affolter: This one assumes that the interaction between the patient and his/her environment is the key to learning. So the focus is on perception and comparisons to past experiences. This approach is rarely used and there is no data in the literature. (Belda-Lois et. al.) Ayres: Focus is on the role of sensory stimulus and perception. The emphasis is on sensory feedback and repetition. (Belda-Lois et. al.) So based on that it is not that suprising that a Cochran review done in 2007 that looked at this question determined that there isn't any evidence currently that can allow us to state that one approach is better than the other! When looking at functional recovery the gold standard is to match the method to specific pathologies and patients.

None of the above were actually developed for gait recovery in those with stroke! "Evidence Based Stool" Gait Training After Stroke: A look at the use of robotics in rehab (Traditional) BWSTT was based on some initial research that looked at spinalized cats in the 80's and found activation of the CPG.
Initially intended for spinal cord patients
Hypothesized to induce neuroplasticity and associated motor recovery
Some initial research is encouraging but a recent Cochran review decided a large scale study is needed before any conclusions are made.
Caveat! Human gait control has some major differences from that of mammals. Bodyweight support treadmill training (BWSTT)
Mental Imagery
Mirror therapy
Balance training
Strength training
Early intensive gait training*
Over ground training Current Gait Training Approaches: Bodyweight supported treadmill training Motor Imagery and Mirror Therapy Verma, R., Arya, K. N., Sharma, P., & Garg, R. K. (2012). Understanding gait control in post-stroke: implications for management. Journal of Bodywork and Movement Therapies, 16(1), 14–21. doi:10.1016/j.jbmt.2010.12.005 (Verma, Arya, Sharma, & Garg, 2012) (Verma, Arya, Sharma, & Garg, 2012) (Verma, Arya, Sharma, & Garg, 2012) (Verma, Arya, Sharma, & Garg, 2012), (Beldam-Lois et al., 2011) Human Gait Control "Bottom-up" - Spinal cord level
Generates human (and mammal) walking.
Intact after stroke.
Play a larger role in animals than humans for actual walking. "Top Down" Approach
Voluntary modifications of the gait cycle.
A Stroke impacts these areas.
Improvements in walking post stroke are associated with a strengthening of descending input from the brain. While both of these approaches are newer areas of study they hold a lot of promise. In a recent review of the literature Verma et al. found the research supports the follow statements about these:

Motor Imagery (MI) results in activation of related sensorymotor networks and in a recent RCT done by Hwang et al. in 2010 clinically significant gains in functional ambulation, balance, walking speed and stride length were made utelizing MI.
Mirror therapy has been shown to modulate functional reorganization of the motor cortex and result in clinically significant reductions in Brunnstrom scores. The other areas mentioned have varying levels of support as well and make up an important part of therapy. However... (Belda-Lois et al., 2011), (Verma, Arya, Sharma, & Garg, 2012) (Verma, Arya, Sharma, & Garg, 2012) (Belda-Lois et al., 2011), (Verma, Arya, Sharma, & Garg, 2012) (Belda-Lois et al., 2011), (Verma, Arya, Sharma, & Garg, 2012) (Herbert, Jamtvedt, Mead, & Hagen, 2005) (Belda-Lois et al., 2011) Today we want to look at how robotic training fits in to the overall therapy scheme and also look at some recommendations based on the current research. Interventions in this category are performed with "a device consisting of either a robotically driven exoskeleton orthosis or a robotic device with two foot plates that drive a stepping motion." (Verma, Arya, Sharma, & Garg, 2012) What's the research have to say? (Tefertiller, Pharo, Evans, & Winchester, 2011) Rehabilitation of gait after stroke: a review towards a top-down approach. (Belda-Lois et al., 2011) (cc) photo by medhead on Flickr “It is... conceivable to conclude that more constraining devices, such as Lokomat, could be helpful at the beginning of rehabilitation and with more severely affected patients.” and that "there is moderate evidence of improvement in walking and motor recovery using robotic devices... when compared to conventional therapy." After a review of current literature in an article they published last December, Belda et al. concluded: (Belda-Lois et al., 2011) Efficacy of rehabilitation robotics for walking training in neurological disorders: a review Conclusion. Robotic therapy combined with conventional therapy may be more effective than conventional therapy alone in patients with greater motor impairment during inpatient stroke rehabilitation.

Morone, G., Bragoni, M., Iosa, M., De Angelis, D., Venturiero, V., Coiro, P., Pratesi, L., et al. (2011). Who May Benefit From Robotic-Assisted Gait Training? A Randomized Clinical Trial in Patients With Subacute Stroke. Neurorehabilitation and Neural Repair, 25(7), 636–644. doi:10.1177/1545968311401034

Conclusions—The higher efficacy of the combination of robotic therapy and conventional therapy versus conventional therapy alone that was observed at discharge only in patients with greater motor impairments was sustained after 2 years.

Morone, G., Iosa, M., Bragoni, M., De Angelis, D., Venturiero, V., Coiro, P., Riso, R., et al. (2012). Who May Have Durable Benefit From Robotic Gait Training? A 2-Year Follow-Up Randomized Controlled Trial in Patients With Subacute Stroke. Stroke, 43(4), 1140–1142. doi:10.1161/STROKEAHA.111.638148 Two recent ones by the same authors concluded... In chronic conditions and for enhancing certain parameters the current research indicates that we are going to be fine going with traditional gait training, BWSTT w/o robotics, and general PT work. The available research shows that these work just as well or better. Positives of using robotics with appropriate populations include... Keep in mind: (cc) photo by medhead on Flickr Conclusions? Why do we care? First a definition: Takes less time and effort on the part of the PT.
Significantly increased FAC scores >3 (~Stand by Assist) in patients with robotic training vs. conventional therapy.
Increased walking speed overground compared to conventional therapy. (A bit of disagreement on this one)
Increased endurance.
Significantly increased independence in walking overground and also when compared to overground walking.
Results are maintained post therapy (at least 2 years) It is very important to stratify patients! Practical Applications Determine patients ambulation status. Consider the training dosage! So... Determine the patient's post stroke status Research indicates that those in the acute and subacute stages will benefit the most. The time frame indicated in the research is roughly 2.5-14 weeks post stroke. Those who were either unable to ambulate or at a very low level showed the most significant improvements when utilizing robotic ambulation as an intervention compared to other therapy techniques. The studies that showed strong effect in the patient population we are looking at generally utilized 20-30 minutes of training 5 days a week. We are targeting patients who:
Are 2.5-14 weeks post stroke.
Unable to ambulate.

And the dose will be 20-30 minutes 5 times a week in conjunction with traditional therapy. In a contemporary approach to post-stroke therapy robotic gait training is one piece of the larger puzzle. The focus of current practice is on reorganization of the brain through manipulation of peripheral bodyparts. In a post-stroke patient the cerebral cortex has had its function impaired. The cortex can then be reorganized through peripheral input such as robotic assisted gait or directly through such things as mental imagery and mirror therapy.

In conjunction with traditional therapy and Mental Imagery/Mirror therapy the evidence indicated that use of a robotic ambulation device can play a large role in helping the post-stroke patient regain their quality of life. In conclusion: (Verma, Arya, Sharma, & Garg, 2012) Thank you! References: Ada, L., Dean, C. M., Vargas, J., & Ennis, S. (2010). Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non-ambulatory patients early after stroke: a systematic review. Journal of Physiotherapy, 56(3), 153–161.
An, M., & Shaughnessy, M. (2011). The effects of exercise-based rehabilitation on balance and gait for stroke patients: a systematic review. The Journal of Neuroscience Nursing: Journal of the American Association of Neuroscience Nurses, 43(6), 298–307. doi:10.1097/JNN.0b013e318234ea24
Belda-Lois, J.-M., Mena-del Horno, S., Bermejo-Bosch, I., Moreno, J. C., Pons, J. L., Farina, D., Iosa, M., et al. (2011). Rehabilitation of gait after stroke: a review towards a top-down approach. Journal of Neuroengineering and Rehabilitation, 8, 66. doi:10.1186/1743-0003-8-66
Herbert, R., Jamtvedt, G., Mead, J., & Hagen, K. B. (2005). Practical Evidence-Based Physiotherapy (1st ed.). Butterworth-Heinemann.
Mayr, A., Kofler, M., Quirbach, E., Matzak, H., Fröhlich, K., & Saltuari, L. (2007). Prospective, Blinded, Randomized Crossover Study of Gait Rehabilitation in Stroke Patients Using the Lokomat Gait Orthosis. Neurorehabilitation and Neural Repair, 21(4), 307–314. doi:10.1177/1545968307300697
Mehrholz, J, Werner, C., Kugler, J., & Pohl, M. (2007). Electromechanical-assisted training for walking after stroke. Cochrane Database of Systematic Reviews (Online), (4), CD006185. doi:10.1002/14651858.CD006185.pub2
Mehrholz, Jan, & Pohl, M. (2012). Electromechanical-assisted gait training after stroke: A systematic review comparing end-effector and exoskeleton devices. Journal of Rehabilitation Medicine: Official Journal of the UEMS European Board of Physical and Rehabilitation Medicine, 44(3), 193–199. doi:10.2340/16501977-0943
Morone, G., Bragoni, M., Iosa, M., De Angelis, D., Venturiero, V., Coiro, P., Pratesi, L., et al. (2011). Who May Benefit From Robotic-Assisted Gait Training? A Randomized Clinical Trial in Patients With Subacute Stroke. Neurorehabilitation and Neural Repair, 25(7), 636–644. doi:10.1177/1545968311401034
Morone, G., Iosa, M., Bragoni, M., De Angelis, D., Venturiero, V., Coiro, P., Riso, R., et al. (2012). Who May Have Durable Benefit From Robotic Gait Training? A 2-Year Follow-Up Randomized Controlled Trial in Patients With Subacute Stroke. Stroke, 43(4), 1140–1142. doi:10.1161/STROKEAHA.111.638148
Pohl, M., Werner, C., Holzgraefe, M., Kroczek, G., Wingendorf, I., Hoölig, G., Koch, R., et al. (2007). Repetitive Locomotor Training and Physiotherapy Improve Walking and Basic Activities of Daily Living After Stroke: A Single-Blind, Randomized Multicentre Trial (DEutsche GAngtrainerStudie, DEGAS). Clinical Rehabilitation, 21(1), 17–27. doi:10.1177/0269215506071281
Tefertiller, C., Pharo, B., Evans, N., & Winchester, P. (2011). Efficacy of rehabilitation robotics for walking training in neurological disorders: a review. Journal of Rehabilitation Research and Development, 48(4), 387–416.
Verma, R., Arya, K. N., Sharma, P., & Garg, R. K. (2012). Understanding gait control in post-stroke: implications for management. Journal of Bodywork and Movement Therapies, 16(1), 14–21. doi:10.1016/j.jbmt.2010.12.005 Gait Training: another piece of the puzzle. Click Videos for more detail...
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