Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

Duh! More rehab leads to better recovery. And you had to do research on that?

Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

• Mukul Talaty &
• Alberto Esquenazi 

Journal of NeuroEngineering and Rehabilitation volume 20, Article number: 134 (2023) Cite this article

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Abstract

Introduction

Practicality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes.

Objectives

To determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.

Design and setting

Assessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.

Participants

Thirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).

Intervention

Lokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.

Main outcome measures

Number of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post).

Results

The desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge – admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy “dose”.

Conclusions

With careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in study.

Introduction

Stroke is a major cause of impaired trunk control and gait disability. [1,2,3] Due to the altered supraspinal control, the abnormal gait pattern post-stroke may be the result of muscle weakness, spasticity and abnormal motor control. [4] Impaired walking ability not only reduces the functional independence of stroke survivors, but also affects quality of life and increases the risk of falls. [5, 6] Improving walking function is often a key component of the post-stroke rehabilitation program. Rehabilitation based on the concepts of repetitive, intensive, task-oriented training has been shown to be effective. [7, 8] Motor learning reflects a neural specificity of practice since motor skill acquisition involves the integration of the sensory and motor information that occurs during practice, and ultimately, leads to the sensorimotor solution that results in accurate, consistent and skillful movements. [9] In addition to quality, other key components of efficient and maximal recovery are timing, intensity and engagement of the rehabilitation intervention[10,11,12,13].

It is well established by both animal [14,15,16] and human studies [16,17,18] that the greatest recovery post-stroke occurs within the first three months. This emphasizes the need for early rehabilitative intervention approaches to improve balance and mobility in this population [16, 17]. In addition to starting early, while more exercise is also generally good, aspects of the optimal dose are not clear. Some key open questions regarding optimal therapy dosing are: (1) how much early extra therapy is practical to be delivered during acute rehabilitation? (2) is this well tolerated by patients? and (3) does delivery mode matter? We aimed to provide knowledge related to the volume of the optimal dose by comparing the outcomes of a robotic vs. a conventional therapist-driven supplemental early post-stroke gait training. The primary objective in this assessor-blinded, randomized controlled trial was to determine the feasibility of supplemental gait training in an inpatient rehabilitation facility (IRF) that requires at least three hours of daily therapy. Secondarily, we sought to compare the outcomes of two gait training modalities, a robotic (Lokomat®) and conventional gait training (CGT) techniques.

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