Balance Rehabilitation through Robot-Assisted Gait Training in Post-Stroke Patients: A Systematic Review and Meta-Analysis

 So where is the protocol for this located so survivors can find it and bring it to their doctor's attention?

Balance Rehabilitation through Robot-Assisted Gait Training in Post-Stroke Patients: A Systematic Review and Meta-Analysis 

by

Alberto Loro

^1,2,*,

Margherita Beatrice Borg

^1,2,

Marco Battaglia

^1,2,

Angelo Paolo Amico

³,

Roberto Antenucci

⁴,

Paolo Benanti

⁵,

Michele Bertoni

⁶,

Luciano Bissolotti

⁷,

Paolo Boldrini

⁸,

Donatella Bonaiuti

⁸,

Thomas Bowman

⁹,

Marianna Capecci

¹⁰,

Enrico Castelli

¹¹,

Loredana Cavalli

¹²,

Nicoletta Cinone

¹³,

Lucia Cosenza

¹⁴,

Rita Di Censo

¹⁵,

Giuseppina Di Stefano

⁸,

Francesco Draicchio

¹⁶,

Vincenzo Falabella

¹⁷, add Show full author list

¹ Department of Health Sciences, Università del Piemonte Orientale “Amedeo Avogadro”, 28100 Novara, Italy

² Physical Medicine and Rehabilitation Unit, AOU Maggiore della Carità University Hospital, 28100 Novara, Italy

³ Physical Medicine and Rehabilitation Unit, Polyclinic of Bari, 70124 Bari, Italy

⁴ Rehabilitation Unit, Castel San Giovanni Hospital, 29015 Piacenza, Italy

⁵ Theology Department, Pontifical Gregorian University, 00187 Rome, Italy

⁶ Physical Medicine and Rehabilitation, ASST Sette Laghi, 21100 Varese, Italy

⁷ Casa di Cura Domus Salutis, Fondazione Teresa Camplani, 25100 Brescia, Italy

⁸ Robotic Rehabilitation Section, Italian Society of Physical and Rehabilitative Medicine (SIMFER), 00187 Rome, Italy

⁹ Neurorehabilitation Department, IRCCS Fondazione Don Carlo Gnocchi, 20148 Milan, Italy

¹⁰ Experimental and Clinic Medicine Department, Università Politecnica delle Marche (UNIVPM), 60126 Ancona, Italy

 

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^*

Author to whom correspondence should be addressed.

Brain Sci. 2023, 13(1), 92; https://doi.org/10.3390/brainsci13010092

Received: 1 December 2022 / Revised: 21 December 2022 / Accepted: 29 December 2022 / Published: 3 January 2023

(This article belongs to the Special Issue Robot-, Virtual Reality- and Sensor-Based Therapies Boosting Neuroplasticity in the Context of Motor and Cognitive Neurorehabilitation: Current State of the Art and Applications)

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Abstract

Background: 

 

Balance impairment is a common disability in post-stroke survivors, leading to reduced mobility and increased fall risk. Robotic gait training (RAGT) is largely used, along with traditional training. There is, however, no strong evidence about RAGT superiority, especially on balance. This study aims to determine RAGT efficacy on balance of post-stroke survivors. Methods: PubMed, Cochrane Library, and PeDRO databases were investigated. Randomized clinical trials evaluating RAGT efficacy on post-stroke survivor balance with Berg Balance Scale (BBS) or Timed Up and Go test (TUG) were searched. Meta-regression analyses were performed, considering weekly sessions, single-session duration, and robotic device used. Results: 

 

A total of 18 trials have been included. BBS pre-post treatment mean difference is higher in RAGT-treated patients, with a pMD of 2.17 (95% CI 0.79; 3.55). TUG pre-post mean difference is in favor of RAGT, but not statistically, with a pMD of −0.62 (95%CI − 3.66; 2.43). Meta-regression analyses showed no relevant association, except for TUG and treatment duration (β = −1.019, 95% CI − 1.827; −0.210, p-value = 0.0135). 

Conclusions: 

 

RAGT efficacy is equal to traditional therapy, while the combination of the two seems to lead to better outcomes than each individually performed. Robot-assisted balance training should be the focus of experimentation in the following years, given the great results in the first available trials. Given the massive heterogeneity of included patients, trials with more strict inclusion criteria (especially time from stroke) must be performed to finally define if and when RAGT is superior to traditional therapy.

Keywords:

rehabilitation; robotics; balance; stroke; gait

1. Introduction

Stroke is the second leading cause of death and the first cause of disability in the world. Given the rising mean age of the world’s population, the incidence of stroke is also steadily increasing, leading to higher economic burden through the years [1,2,3,4].

Aphasia and depression are often the causes of disability in post-stroke patients, but the most common disability tract is a reduced mobility due to hemiparesis [1,5]. This impairment is strictly connected to two main factors: a rapid change in muscle thickness and composition (visible within 1 month from the onset) and reduced central motor control [6,7]. All these impairments also lead to a reduced balance function: the patient is unable to maintain his center of gravity within his support base with or without the action of external forces [8]. After the clinical stabilization of the acute stroke, the rehabilitation program is usually focused on upper limb and gait rehabilitation, while balance is often a secondary or ignored outcome. This is a problematic point of rehabilitation programs because balance is a skill deeply involved in patients’ autonomy and independence. As a matter of fact, balance is not only fundamental in walking but also in many activities of daily life (ADL). It is also the main deficit involved in fall risk evaluation [9].

Nowadays, it is well known that an early and intensive mobilization protocol improves functional recovery after stroke, especially in young patients [10]. Along with the development of acute stroke management (early rehabilitation in stroke units, facilitation of brain repair mechanisms and experimental approaches, such as neuronal transplantation) [11], the management and rehabilitation of chronic stroke patients have recently seen great improvement. The greatest effort in stroke rehabilitation can be identified in four main outcome domains: physical fitness, ADL, arm-hand dexterity and function, and gait and mobility-related functions and activities [12]. Regardless of the main outcome pursued, many different neurorehabilitation techniques have been developed over the years for both sub-acute and chronic stroke survivors. Functional electrical stimulation (FES) has been largely used to contract muscles that are non-activable by the patient, improving complex motor function, such as gait. Along with peripheral stimulation, brain stimulation has been developed over the years. Transcranial direct current stimulation (tDCS) can be integrated during the rehabilitation program to improve limb movement and pain [13]. Manual therapy for strength and mobility recovery is the most used approach worldwide but is difficult to standardize, and it is heavily related to therapist dexterity and experience [14].

That is why, in the last 20 years, many technological devices have been developed, for both upper [15,16,17,18,19,20] and lower limb rehabilitation [21,22,23,24,25,26,27,28]. In this scenario, we can find many levels of assistance, with different ideas of rehabilitation beneath. First of all, there is the body weight-supported treadmill, in which the patients can practice a supervised and repetitive walk. Then, we can find overground exoskeleton, which provide patients with either full or partial guidance of the lower limbs during the whole gait cycle [13]. Lastly, there are also end-effectors, which are smaller devices that permit the patient to perform a specific joint movement during specific gait phases [29]. The development of these devices has improved the quality of post-stroke rehabilitation, guaranteeing patients early verticalization, gait training, and dismission [30,31,32].

The use of robotics for lower limb rehabilitation is currently starting to spread widely, but given the various protocols available worldwide, there is no consensus on which approach is the most effective [10]. Moreover, there is a lack of knowledge about the superiority of robotic treatment over standard treatment and which of the patients’ characteristics are to be considered when deciding whether or not to treat them with robotic devices. Furthermore, while there is some evidence on the efficacy of these devices for gait rehabilitation [33,34,35], more evidence on the balance outcomes is needed. More precisely, very few trials on robotic rehabilitation consider balance as an outcome and all the previous meta-analyses performed were not able to gather enough data to provide a sufficient statistical relevance. In addition, considering the high cost of these robotic devices, there is no certain evidence on their efficacy that completely justifies this kind of expenditure. The aim of this study is to sum up all the evidence about robotic-assisted gait training (RAGT) on balance rehabilitation. In particular, the study focuses on covering the lack of statistical relevance present in the actual literature, due to a small number of trials included, and tries to assess as many sub-group evaluations as possible.

 

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