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Implementation of a unilateral hip flexion exosuit to aid paretic limb advancement during inpatient gait retraining for individuals post-stroke: a feasibility study
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 121 (2024)
Abstract
Background
During inpatient rehabilitation, physical therapists (PTs) often need to manually advance patients’ limbs, adding physical burden to PTs and impacting gait retraining quality. Different electromechanical devices alleviate this burden by assisting a patient’s limb advancement and supporting their body weight. However, they are less ideal for neuromuscular engagement when patients no longer need body weight support but continue to require assistance with limb advancement as they recover. The objective of this study was to determine the feasibility of using a hip flexion exosuit to aid paretic limb advancement during inpatient rehabilitation post-stroke.
Methods
Fourteen individuals post-stroke received three to seven 1-hour walking sessions with the exosuit over one to two weeks in addition to standard care of inpatient rehabilitation. The exosuit assistance was either triggered by PTs or based on gait events detected by body-worn sensors. We evaluated clinical (distance, speed) and spatiotemporal (cadence, stride length, swing time symmetry) gait measures with and without exosuit assistance during 2-minute and 10-meter walk tests. Sessions were grouped by the assistance required from the PTs (limb advancement and balance support, balance support only, or none) without exosuit assistance.
Results
PTs successfully operated the exosuit in 97% of sessions, of which 70% assistance timing was PT-triggered to accommodate atypical gait. Exosuit assistance eliminated the need for manual limb advancement from PTs. In sessions with participants requiring limb advancement and balance support, the average distance and cadence during 2-minute walk test increased with exosuit assistance by 2.2 ± 3.1 m and 3.4 ± 1.9 steps/min, respectively (p < 0.017). In sessions with participants requiring balance support only, the average speed during 10-meter walk test increased with exosuit by 0.07 ± 0.12 m/s (p = 0.042). Clinical and spatiotemporal measures of independent ambulators were similar with and without exosuit (p > 0.339).
Conclusions
We incorporated a unilateral hip flexion exosuit into inpatient stroke rehabilitation in individuals with varying levels of impairments. The exosuit assistance removed the burden of manual limb advancement from the PTs and resulted in improved gait measures in some conditions. Future work will understand how to optimize controller and assistance profiles for this population.
Background
Stroke is a leading cause of adult disability in the United States, affecting nearly 800,000 individuals annually [1]. Functional impairment of individuals post-stroke increases the risk of falls and reduces quality of life [1]. Post-stroke physical therapy focuses on recovering the ability to walk and improving walking quality [2, 3]. Physical therapy involving repetitive mass practice and task-specific training has shown positive results in motor recovery [4,5,6], with the amount of practice during training positively associated with gait relearning [7, 8]. In addition, individuals experience rapid changes in their neuromotor pathway within three months following stroke incident, often defined as subacute phase of stroke [9]. Unsurprisingly, inpatient rehabilitation during this period has a large impact on the motor recovery, expected mobility, and independence in activities of daily living, especially for severely to moderately affected patients [10].
However, the significant mobility deficits exhibited by individuals with subacute stroke adds substantial physical burdens on physical therapists (PTs) during inpatient rehabilitation. Specifically, PTs may experience difficulty with manual lifting, static holding, and maintaining challenging postures which are necessary therapeutic handling [11, 12]. To promote safe ambulation for individuals with low mobility during gait retraining therapies, PTs must not only support body weight and assist with balance control, but also advance the patients’ limbs manually [13, 14] mainly due to their weakened hip flexors at movement initiation [15]. Coordinating these activities leads to high loads on the PT’s musculoskeletal system and induces a high risk of work-related disorders [11, 16]. Therefore, reliance on manual assistance provided by PTs makes it challenging for patients to receive mass practice that is essential in promoting motor recovery during inpatient rehabilitation [3, 17, 18].
In the past few decades, various electromechanical devices have been developed to assist ambulation of patients and reduce musculoskeletal load in PTs by providing body weight support and limb advancement assistance during gait retraining [16]. Examples of these devices include partial body weight supported treadmill training (PBWSTT) [19], end-effector-type gait devices [20], and portable exoskeletons [21, 22]. The use of electromechanical devices allows severely impaired patients to receive repetitive mass practice early [23, 24] and reduces the physical burden experienced by PTs. Interventions incorporating these devices have been shown to provide either improved or similar benefits compared to conventional therapy [13, 19, 22, 24,25,26,27,28,29,30,31,32,33,34,35]. However, while there has been recent development of electromechanical devices that enable gait retraining in diverse environments [36], the majority are limited to being used overground or on a treadmill [19,20,21,22]. Moreover, existing devices can involve substantial setup time, a high learning curve [37,38,39], or multiple PTs to operate [19, 27, 40]. Over the progression of rehabilitation, individuals post-stroke may no longer require substantial body weight support [26, 41]; however, they may continue to require limb advancement assistance across all stages of recovery [15, 42]. Devices that can assist limb advancement in a diverse range of activities and environments have the potential to promote gait relearning during inpatient rehabilitation more effectively.
The use of soft exosuits has been explored as a mean to deliver assistance for individuals post-stroke [43,44,45,46,47,48,49,50]. Contrary to rigid exoskeletons, exosuits do not provide body weight support. Instead, they utilize a lightweight and non-restrictive approach to allow assistance to supplement an individual’s walking capacity. Previous studies have evaluated the effect of exosuit assistance in individuals with chronic stroke. In these studies, exosuits effectively targeted the ankle to provide both immediate (i.e., orthotic effect) [43] and rehabilitative (i.e., therapeutic effect) [44,45,46] functional and biomechanical benefits in individuals post-stroke. Recently, a few preliminary studies have demonstrated a positive orthotic effect in biomechanical strategies of exosuits targeting the hip in individuals with chronic stroke [47, 48, 50]. The weakened hip flexors typical in individuals in their early stages of stroke recovery often contribute to difficulty in limb advancement and require manual assistance from PTs. Therefore, we anticipate that exosuit providing hip flexion assistance may be particularly useful during inpatient rehabilitation for individuals post-stroke to reduce the physical burden of PTs, promote mass practice, and maximize recovery progress. Unfortunately, the use of hip exosuits to aid inpatient rehabilitation during the early stages of stroke recovery is unexplored.
The objective of this study was to assess the feasibility of implementing a unilateral hip flexion exosuit as a tool to aid paretic limb advancement during inpatient gait retraining for individuals post-stroke. We describe the design of the exosuit, focusing on the integration of different suit components that enabled PTs to use the exosuit without in-person technical support. The exosuit was used concurrently with standard inpatient rehabilitation for 14 patients, each for one to two weeks. We quantified various clinical and spatiotemporal measures to investigate the role of our exosuit in reducing PT burden and improving the walking capacity of individuals post-stroke with various levels of impairment over the course of their recovery.
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