Gait impairment in neurological disorders: a new technological approach

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Gait impairment in neurological disorders: a new technological approach

 Roberta Semprini,MD
a
Patrizio Sale, MD
a1
Calogero Foti,MD
b
Massimo Fini,MD
a
Marco Franceschini MD
a
a
IRCCS San Raffaele Pisana, Rome, Italy
b
Physical and Rehabilitation Medicine, Public HealthDepartment, Tor Vergata University, Rome, ItalyCorresponding author:Marco FranceschiniIRCCS San Raffaele Pisana Via della Pisana, 235Rome, Italy E-mail: marco.franceschini@sanraffaele.it
Summary 
Gait recovery is considered one of the main objectives of rehabilitation interventions in neurological disabilities, as restricted movement can significantly reduce an individualʼs ability to take part in normal activities of daily living. Locomotor training has been shown to improve gait rehabilitation. Studies have recently been published on the use of robots and other devices in patients with gait disabilities, particularly in the rehabilitation of the lower limbs. However, analysis of the recent literature reveals a relative paucity of strong methodological studies. The evidence that is available, while strong, is not yet sufficient to allow definite conclusions to be drawn regarding the efficacy of these devices. From these considerations, it is clear that validated and standardized methods need to be adopted for each of the different systems available. This would help to clarify the indications for and correct use of robotic devices in the different neurological disorders.
KEYWORDS: Exoskeleton, gait, rehabilitation, robot,treadmill.
Introduction
Gait recovery is considered one of the main objectives of rehabilitation interventions in neurological disabilities such as stroke, traumatic injuries, multiple sclerosis,Parkinsonʼs disease (PD), and peripheral nerve palsy(1). Depending on the site and extent of the lesion, the degree of disability after an acute event can range from moderate locomotion disorders (balance problems, slow walking speed, poor endurance and physiological alterations of locomotor patterns) to more serious conditions,such as hemiparesis, hemiplegia or even paraplegia (2). Movement restrictions,in particular gait disturbances,can significantly reduce an individualʼs possibility of tak-ing part in normal daily activities (1). Many neurophysiological studies on the role played by central and peripheral generators of movement (3-6)have shown that:i) supraspinal structures are not necessary to generate the basic motor patterns;ii) neural networks, or “central patterns generators”(CPGs), located entirely in the spinal cord, produce the basic rhythm of walking and are also capable of producing the rhythmic movements seen in swimming, walking and skipping, even without the control of the encephalon and sensory afferents;iii) the circuits of locomotion can be activated by signals descending from different cranial levels of the central nervous system (CNS).iv) supraspinal inputs play an important role not only in initiating locomotion but also in adapting the locomotor pattern to environmental and motivational conditions; v) the sensory afferents involved in cutaneous reflexes(esteroception) and muscle reflexes (proprioception),while not required for the activation of spinal neural net-works, have important regulatory functions in preserving balance and ensuring stability in all phases of the gaitcycle.Because these features are slightly modified with variations in the ground variables on which the subject is walking, robotic devices were introduced into clinical practice in order to obtain maximal benefits from gait rehabilitation programmes. Following their introduction,there appeared numerous studies (7-9) that assessed the efficacy and validity of body weight supported tread-mill training (BWSTT), which uses an adjustable speed mobile platform system, associated with classical reha-bilitation treatments in patients with gait disturbances.This type of exercise, which features among the activities of functional re-education (task-oriented therapy),also has aspects which go beyond the mere recovery of movement, and these include the benefits which result from early standing. Indeed, early restoration of the standing position promotes “normalization” of the bodyʼsposition in space and correct perception of spatial coordinates, thereby helping to prevent the onset of neurophysiological disorders. Furthermore, both the upright position and movement can help to reduce the risk of early heart disease and respiratory diseases.The aim of this review is to discuss clinical experiences in the use of these devices for rehabilitation, the advantages they offer patients and therapists, the clinical indications for their use, and their future perspectives.
Gait impairment in neurological disorders: a new technological approach
Functional Neurology 2009; 24(4): 179-183
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1
RS and PS contributed equally to this work.