Where is the protocol located so survivors can bring it to their stroke medical 'professionals' attention? Top down dissemination of research is a complete fucking failure; bottom up is the way to go!
Effectiveness of unilateral lower-limb exoskeleton robot on balance and gait recovery and neuroplasticity in patients with subacute stroke: a randomized controlled trial
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 213 (2024)
Abstract
Background
Impaired balance and gait in stroke survivors are associated with decreased functional independence. This study aimed to evaluate the effectiveness of unilateral lower-limb exoskeleton robot-assisted overground gait training compared with conventional treatment and to explore the relationship between neuroplastic changes and motor function recovery in subacute stroke patients.
Methods
In this randomized, single-blind clinical trial, 40 patients with subacute stroke were recruited and randomly assigned to either a robot-assisted training (RT) group or a conventional training (CT) group. All outcome measures were assessed at the enrollment baseline (T0), 2nd week (T1) and 4th week (T2) of the treatment. The primary outcome was the between-group difference in the change in the Berg balance scale (BBS) score from baseline to T2. The secondary measures included longitudinal changes in the Fugl-Meyer assessment of the lower limb (FMA-LE), modified Barthel index (mBI), functional ambulation category (FAC), and locomotion assessment with gait analysis. In addition, the cortical activation pattern related to robot-assisted training was measured before and after intervention via functional near-infrared spectroscopy.
Results
A total of 30 patients with complete data were included in this study. Clinical outcomes improved after 4 weeks of training in both groups, with significantly better BBS (F = 6.341, p = 0.018, partial η2 = 0.185), FMA-LE (F = 5.979, p = 0.021, partial η2 = 0.176), FAC (F = 7.692, p = 0.010, partial η2 = 0.216), and mBI scores (F = 7.255, p = 0.042, partial η2 = 0.140) in the RT group than in the CT group. Both groups showed significant improvement in gait speed and stride cadence on the locomotion assessment. Only the RT group presented a significantly increased stride length (F = 4.913, p = 0.015, partial η2 = 0.267), support phase (F = 5.335, p = 0.011, partial η2 = 0.283), and toe-off angle (F = 3.829, p = 0.035, partial η2 = 0.228) on the affected side after the intervention. The RT group also showed increased neural activity response over the ipsilesional motor area and bilateral prefrontal cortex during robot-assisted weight-shift and gait training following 4 weeks of treatment.
Conclusions
Overground gait training with a unilateral exoskeleton robot showed improvements in balance and gait functions, resulting in better gait patterns and increased gait stability for stroke patients. The increased cortical response related to the ipsilesional motor areas and their related functional network is crucial in the rehabilitation of lower limb gait in post-stroke patients.
Introduction
Stroke is commonly associated with motor dysfunction of the lower extremities, manifested as decreased muscle strength, impaired balance, and abnormal gait. Despite professional rehabilitation attempts, 20–30% of patients still experience difficulties or loss of the ability to walk [1]. Three months after stroke, 85% of patients still have great potential to improve their walking ability, which is strongly correlated with quality of life of stroke survivors [2]. Consequently, improving walking ability is the primary focus of lower-limb rehabilitation for stroke patients.
Specific, repetitive, and high-intensity motor training is a key element in inducing functional neuroplasticity related to stroke motor rehabilitation within the 6-month post-stroke window [3, 4]. Thus, implementing gait training for stroke patients at an early stage is critical for the restoration of lower-limb function. However, traditional physical therapies are limited in providing long-term, high-quality gait training due to decreased muscle strength in early stroke patients. Robotic exoskeleton training is a promising way to deliver repetitive walking training assisted by mechanical legs, promoting the walking, balance, and daily living abilities of stroke patients [5, 6]. Achieving positive effects in gait training necessitates repetitive natural walking on the ground along with accurate proprioception and external sensory feedback [7]. Wearable robots possess the advantage of portability, enabling treatments to be performed in real-world scenarios, which have been widely applied to improve walking efficiency and enhance mobility in stroke patients [8,9,10,11]. Currently, robots for overground gait training mainly target chronic stroke survivors, with limited application in the subacute patients due to early muscle weakness. Based on the early-stage gait rehabilitation needs, the unilateral lower-limb exoskeleton robot is designed to support overground walking in real environments with active engagement of stroke patients with hemiplegia. However, there is scant evidence to support the effectiveness of overground gait training with a unilateral lower-limb exoskeleton robot for stroke patients in the literature.
Furthermore, restoring motor ability poststroke relies on brain functional reorganization. Assessment of cortical activation related to a specific task is essential for a better understanding of neural motor control. Currently, limited information is available on the cerebral mechanisms underlying locomotor recovery after stroke due to technical limitations in assessing cerebral activation during movement, particularly walking tasks. Recently, functional near-infrared spectroscopy (fNIRS) has gained attraction as a novel neuroimaging technology in stroke rehabilitation. Its low cost, portability, noninvasiveness, and motion tolerance make it a suitable for studying gait disturbances induced by stroke [12, 13]. Research has shown a bilateral increase in oxygenated hemoglobin (
[oxy-Hb]) in the sensorimotor cortex (SMC) and supplementary motor area (SMA) in stroke patients during gait training [14]. Additionally, increased activation in the SMC, SMA, and premotor cortex (PMC) was detected in healthy participants during exoskeleton robot walking in contrast to treadmill walking or stepping [15]. However, the effects of long-term robot-assisted overground gait training on neuroplastic reorganization have not been adequately studied in subacute patients.
This study aimed to compare the effectiveness of robot-assisted overground gait training and conventional training for the lower-limb rehabilitation of stroke patients with hemiplegia. Wearable gait analyzers(Where and what are these so our stroke medical 'professionals' can get an objective damage diagnosis of our gait problems, so they can prescribe EXACT PROTOCOLS to fix those problems?) combined with clinical assessment scales, including the Berg balance scale (BBS), Fugl Meyer assessment for lower extremity (FMA-LE), functional ambulation category (FAC), and modified Barthel index (mBI), were used to evaluate the motor function of the patients before and after 4 weeks of training. It was hypothesized that compared with conventional training (CT), robot-assisted training (RT) would have superior effects on both clinical outcomes and gait balance. Additionally, fNIRS was employed to monitor the cortical activation response of the patients during robot-assisted training. It was expected that the activation of ipsilesional motor-related cortices would increase following motor recovery of the lower limb. The results of this study will be used to explore the relationship between neuroplasticity and lower-limb motor recovery, thereby providing a theoretical basis for the clinical application of robot-assisted lower-limb rehabilitation.
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