Recent Trends in Lower-Limb Robotic Rehabilitation Orthosis: Control Scheme and Strategy for Pneumatic Muscle Actuated Gait Trainers

Is 6 years enough time and recent enough for your stroke hospital to know about and implement this? You want to make sure  you aren't pushing the envelope on their ability to actually keep up-to-date on stroke research. No pressure on them, please.

Recent Trends in Lower-Limb Robotic Rehabilitation Orthosis: Control Scheme and Strategy for Pneumatic Muscle Actuated Gait Trainers

Mohd Azuwan Mat Dzahir 1,2,* and Shin-ichiroh Yamamoto 1  1 Shibaura Institute of Technology, Department of Bio-Science Engineering, 307 Fukasaku,  Minuma-ku, Saitama City, Saitama 337-8570, Japan; E-Mail: yamashin@se.shibaura-it.ac.jp 2 Universiti Teknologi Malaysia, Faculty of Mechanical Engineering, UTM Skudai,  Johor Bahru 81310, Malaysia
* Author to whom correspondence should be addressed; E-Mail: nb11503@shibaura-it.ac.jp or azuwan@fkm.utm.my; Tel.: +80-80-4094-8009.
Received: 10 January 2014; in revised form: 17 March 2014 / Accepted: 21 March 2014 /  Published: 14 April 2014

Abstract: 

It is a general assumption that pneumatic muscle-type actuators will play an important role in the development of an assistive rehabilitation robotics system. In the last decade, the development of a pneumatic muscle actuated lower-limb leg orthosis has been rather slow compared to other types of actuated leg orthoses that use AC motors, DC motors, pneumatic cylinders, linear actuators, series elastic actuators (SEA) and brushless servomotors. However, recent years have shown that the interest in this field has grown exponentially, mainly due to the demand for a more compliant and interactive  human-robotics system. This paper presents a survey of existing lower-limb leg orthoses for rehabilitation, which implement pneumatic muscle-type actuators, such as McKibben artificial muscles, rubbertuators, air muscles, pneumatic artificial muscles (PAM) or pneumatic muscle actuators (PMA). It reviews all the currently existing lower-limb rehabilitation orthosis systems in terms of comparison and evaluation of the design, as well as the control scheme and strategy, with the aim of clarifying the current and on-going research in the lower-limb robotic rehabilitation field.

Robotic-Assisted Gait Training Effect on Function and Gait Speed in Subacute and Chronic Stroke Population: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

I see absolutely nothing here that suggests that protocols were written up and distributed. SO USELESS.  And in the end of the full paper they suggest further research so they actually failed at their mission. I blame the mentors and senior researchers for allowing that failure to happen.

Robotic-Assisted Gait Training Effect on Function and Gait Speed in Subacute and Chronic Stroke Population: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

 Jaya Shanker Tedla,a
 Snehil Dixit,a
 Kumar Gular,a
 Mohammed Abohashrh,b,
a -  Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia;
b - Department of Basic Medical Science, College of Applied Medical Sciences, King Khalid University, Abha, Saudi Arabia
Received: March 25, 2019Accepted after revision: May 1, 2019Published online: June 5, 2019
Dr. Jaya Shanker TedlaDepartment of Medical Rehabilitation SciencesCollege of Applied Medical Sciences, King Khalid University C/3/108, Guraiger, Abha (Saudi Arabia)E-Mail jtedla

@

kku.edu.sa© 2019 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/ene
DOI: 10.1159/000500747
Keywords
Stroke · Robotic-assisted gait training · Gait speed

Abstract

Background:
 The review is intended to provide the effectiveness of robotic-assisted gait training (RAGT) for function-al gait recovery in post stroke survivors through a systematic review and to provide evidence for gait speed improvements through the meta-analysis of randomized controlled trials (RCTs).
Summary:
 In this systematic review, PubMed, Web of Science, Wiley Online Library, Science Direct, Science Robotics, Scopus, UpToDate, MEDLINE, Google Scholar, CINHAL, EMBASE, and EBSCO were reviewed to identify rel-evant RCTs. Articles included in the study were thoroughly examined by 2 independent reviewers. The included RCTs were having a PEDro score between 6 and 8 points. The initial database review yielded 1,371 studies and, following further screening; 9 studies finally were selected for systematic review and meta-analysis. Out of the 9 studies, 4 were on chronic stroke and 5 were on subacute stroke. The meta-analysis of gait speed showed an effect size value ranging between –0.91 and 0.64, with the total effect size of all the studies being –0.12. During subgroup analysis, the subacute stroke total effect size was identified as –0.48, and the chronic stroke total effect size was noted as 0.04. Meta-analysis revealed no significant differences between RAGT and conventional gait training (CGT).
Key Messages:
 Our systematic review revealed that the RAGT application demonstrated a better or similar effect to that of CGT in a post stroke population. A meta-analysis of gait speed involving all the studies identified here indicated no significant differences between RAGT and CGT. However, the subanalysis of chronic stroke survivors showed a slight positive effect of RAGT on gait speed.
© 2019 S. Karger AG, Basel
 

Physiological Responses and Perceived Exertion During Robot-Assisted and Body Weight–Supported Gait After Stroke

I don't see anything here that helps survivors recover better. Unless it indirectly is telling us that assisted walking help is not enough to get our required aerobic exercise. And they don't tell us what the protocol is for aerobic exercise.

Physiological Responses and Perceived Exertion During Robot-Assisted and Body Weight–Supported Gait After Stroke 

Show all authors

Nina Lefeber, MSc, Emma De Keersmaecker, MSc, Stieven Henderix, MSc, ...

First Published November 12, 2018 Research Article

https://doi.org/10.1177/1545968318810810

Article information

Abstract

Introduction. Physiological responses are rarely considered during walking after stroke and if considered, only during a short period (3-6 minutes). The aims of this study were to examine physiological responses during 30-minute robot-assisted and body weight–supported treadmill and overground walking and compare intensities with exercise guidelines.  
Methods. A total of 14 ambulatory stroke survivors (age: 61 ± 9 years; time after stroke: 2.8 ± 2.8 months) participated in 3 separate randomized walking trials. Patients walked overground, on a treadmill, and in the Lokomat (60% robotic guidance) for 30 minutes at matched speeds (2.0 ± 0.5 km/h) and matched levels of body weight support (BWS; 41% ± 16%). Breath-by-breath gas analysis, heart rate, and perceived exertion were assessed continuously.  
Results. Net oxygen consumption, net carbon dioxide production, net heart rate, and net minute ventilation were about half as high during robot-assisted gait as during body weight–supported treadmill and overground walking (P < .05). Net minute ventilation, net breathing frequency, and net perceived exertion significantly increased between 6 and 30 minutes (respectively, 1.8 L/min, 2 breaths/min, and 3.8 units). During Lokomat walking, exercise intensity was significantly below exercise recommendations; during body weight–supported overground and treadmill walking, minimum thresholds were reached (except for percentage of heart rate reserve during treadmill walking).
Conclusion. In ambulatory stroke survivors, the oxygen and cardiorespiratory demand during robot-assisted gait at constant workload are considerably lower than during overground and treadmill walking at matched speeds and levels of body weight support. Future studies should examine how can be exploited to induce aerobic exercise.(And why precisely do you want to induce aerobic exercise?)

Electromyography Assessment During Gait in a Robotic Exoskeleton for Acute Stroke

I got absolutely nothing out of this that would've helped at any time for my gait rehab.
https://www.frontiersin.org/articles/10.3389/fneur.2018.00630/full?

Ghaith J. Androwis^1,2, Rakesh Pilkar^1,3, Arvind Ramanujam¹ and Karen J. Nolan^1,2,3*

• ¹Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, United States
• ²Children's Specialized Hospital, Mountainside, NJ, United States
• ³Department of Physical Medicine and Rehabilitation, Rutgers–New Jersey Medical School, Newark, NJ, United States

Background: Robotic exoskeleton (RE) based gait training involves repetitive task-oriented movements and weight shifts to promote functional recovery. To effectively understand the neuromuscular alterations occurring due to hemiplegia as well as due to the utilization of RE in acute stroke, there is a need for electromyography (EMG) techniques that not only quantify the intensity of muscle activations but also quantify and compare activation timings in different gait training environments.

Purpose: To examine the applicability of a novel EMG analysis technique, Burst Duration Similarity Index (BDSI) during a single session of inpatient gait training in RE and during traditional overground gait training for individuals with acute stroke.

Methods: Surface EMG was collected bilaterally with and without the RE device for five participants with acute stroke during the normalized gait cycle to measure lower limb muscle activations. EMG outcomes included integrated EMG (iEMG) calculated from the root-mean-square profiles, and a novel measure, BDSI derived from activation timing comparisons.

Results: EMG data demonstrated volitional although varied levels of muscle activations on the affected and unaffected limbs, during gait with and without the RE. During the stance phase mean iEMG of the soleus (p = 0.019) and rectus femoris (RF) (p = 0.017) on the affected side significantly decreased with RE, as compared to without the RE. The differences in mean BDSI scores on the affected side with RE were significantly higher than without RE for the vastus lateralis (VL) (p = 0.010) and RF (p = 0.019).

Conclusions: A traditional amplitude analysis (iEMG) and a novel timing analysis (BDSI) techniques were presented to assess the neuromuscular adaptations resulting in lower extremities muscles during RE assisted hemiplegic gait post acute stroke. The RE gait training environment allowed participants with hemiplegia post acute stroke to preserve their volitional neuromuscular activations during gait iEMG and BDSI analyses showed that the neuromuscular changes occurring in the RE environment were characterized by correctly timed amplitude and temporal adaptations. As a result of these adaptations, VL and RF on the affected side closely matched the activation patterns of healthy gait. Preliminary EMG data suggests that the RE provides an effective gait training environment for in acute stroke rehabilitation.

Introduction

Recovery of function post stroke is based on neural adaptation, and progressive task specific repetitive training based on the principles of neuroplasticity (1, 2). While major advances have been made in early intervention for the treatment of patients post stroke, the majority of survivors have residual mobility challenges and hemiplegia (3, 4). Hemiplegia typically manifests in pronounced asymmetrical deficits and is one of the most common disabling impairments resulting from stroke (5). Asymmetrical gait can be associated with muscle weakness, leading to inefficient ambulation, balance control challenges and risk of musculoskeletal injury to the non-paretic limb (6, 7). Task-oriented, high-repetition movements can improve muscular strength, motor control and movement coordination in patients post stroke (2). The task-specific training pertains to the training driven to achieve a functional task such as walking rather than focusing on minimizing an impairment (8, 9). In acute phase, traditional gait rehabilitation administered by a physical therapist is strenuous, inconsistent (in terms of movements generated) and less intense (in terms of number of steps). Integrating robotic exoskeleton (RE) technology into standard of care programs during the critical acute phase when the injured nervous system is highly plastic could maximize repetitive practice (9, 10), improve functional outcome measurements and provide quality gait training (10, 11). Programmable RE technology can also be used to advance progression during treatment and under the guidance of a physical therapist can emulate some features of manual assistance in a consistent and reproducible manner (2). The RE based training involves repetitive task-oriented (gait) movements and weight shifts to promote functional recovery. RE gait training may lead to changes in muscle activation as it provides task-specific movements to the lower limbs, increased step dosing and may provide a more symmetrical gait pattern (12).

An additional challenge in acute stroke is that many patients have a difficult time producing volitional movements that can be practiced repeatedly especially during the acute stage. In order to recover from physiological and functional lower extremity deficits, the task-related activities should include contributions from appropriate muscle groups during practice of these movements (13). Using an RE during gait rehabilitation in the acute phase may allow volitional muscle activation and improved phasic coordination (activation timing) during walking. However, the accuracy of these muscle contributions should be tracked. Surface electromyography (EMG) is one of the most effective, non-invasive tools which provides easy access to underlying neuromuscular processes that cause muscles to generate force, produce movement and achieve any functional task (14). During gait, EMG data reveals characteristic patterns of activation associated with each involved muscle in terms of onset timings, burst durations and levels of activations (15). These characteristic patterns significantly differ between healthy and pathological gait and this information can be used to assess the levels of improvement in muscle function, motor control, and neuromuscular adaptations post rehabilitation interventions. Bilateral EMG recordings of lower extremities can be further utilized to compare changes on the paretic side with respect to non-paretic side to assess inter-limb synchronization post RE intervention in individuals with stroke related hemiplegia.

To effectively understand the alterations occurring due to the RE, there is a need for EMG techniques that not only quantify the intensity of muscle activations but also quantify and compare activation timings for a single muscle during different gait training environments (e.g., overground or RE assisted). Although EMG amplitude is one of the most common variables reported in the literature (14, 16, 17), it does not distinctively provide temporal information (on–off timings). Particularly, in a cyclic activity such as gait, it is not only important for lower extremity muscles to produce activations but also activate them at the accurate time, especially for individuals with neurological disability such as acute stroke (16). In the post-stroke gait rehabilitation setting, the need to assess temporal information is even more apparent as muscle activation timing may be altered due to, (1) hemiplegia secondary to stroke and (2) the presence of a RE. The temporal features extracted from EMG data can allow the assessment of accuracy of participant's volitional contributions during training but also assess the modifications that the RE guided gait training may have. Several techniques have been used to extract the temporal information of muscle activations; however, their applicability in the domain of RE based gait training in acute stroke is limited.

The purpose of this investigation was to examine the applicability of a novel EMG analysis technique, Burst Duration Similarity Index (BDSI) during a single session of inpatient gait training in a RE and during traditional over ground gait training for individuals with acute stroke. EMG outcomes included standard measures of integrated EMG (iEMG) calculated from the root-mean-square (RMS) profiles, and a novel measure, BDSI (18) which quantifies the similarity between the two muscle activations by measuring co-excitation (common active regions) and co-inhibition (common inactive regions) during gait. Using iEMG and BDSI EMG analyses techniques, we hypothesized that the RE gait training environment will preserve the volitional neuromuscular activations in acute stroke. Volitional neuromuscular activations represent the residual post stroke muscle function during walking in the lower limbs. Our secondary hypothesis is that the RE gait training environment will change the activation timing of lower extremity muscles, measured by applying the BDSI technique, to match established normative healthy gait muscle activation timing patterns (15).

What does best evidence tell us about robotic gait rehabilitation in stroke patients: A systematic review and meta-analysis

My doctor didn't think much of robotic gait trainers. I loved the Lokomat. Don't listen to your doctor biases. 
http://www.jocn-journal.com/article/S0967-5868(17)31166-9/abstract

Maria Federica Bruni

,

Corrado Melegari

,

Maria Cristina De Cola

,

Alessia Bramanti

,

Placido Bramanti

,

Rocco Salvatore CalabròCorrespondence information about the author Rocco Salvatore CalabròEmail the author Rocco Salvatore CalabròEmail the author Rocco Salvatore Calabrò

DOI: http://dx.doi.org/10.1016/j.jocn.2017.10.048

Objective

The aim of this study was to compare the effects of different robotic devices in improving post-stroke gait abnormalities.

Methods

A computerized literature research of articles was conducted in the databases MEDLINE, PEDro, COCHRANE, besides a search for the same items in the Library System of the University of Parma (Italy). We selected 13 randomized controlled trials, and the results were divided into sub-acute stroke patients and chronic stroke patients. We selected studies including at least one of the following test: 10-Meter Walking Test, 6-Minute Walk Test, Timed-Up-and-Go, 5-Meter Walk Test, and Functional Ambulation Categories.

Results

Stroke patients who received physiotherapy treatment in combination with robotic devices, such as Lokomat or Gait Trainer, were more likely to reach better results, compared to patients who receive conventional gait training alone. Moreover, electromechanical-assisted gait training in association with Functional Electrical Stimulations produced more benefits than the only robotic treatment (−0.80 [−1.14; −0.46], p > .05).

Conclusions

The evaluation of the results confirm that the use of robotics can positively affect the outcome of a gait rehabilitation in patients with stroke. The effects of different devices seems to be similar on the most commonly outcome evaluated by this review.

Keywords:

Stroke, Gait rehabilitation, Robotics, Lokomat, End-effector, Exoskeleton

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© 2017 Elsevier Ltd. All rights reserved.

Robot-assisted end-effector-based gait training in chronic stroke patients: A multicentric uncontrolled observational retrospective clinical study

You can see what they are talking about in this PDF. I liked using the Lokomat because it was the only thing strong enough to stop my leg spasticity. My doctor didn't think much of it, he was an idiot in that respect. I had to change clinics to get Lokomat training.

End-effector Machines for Gait Rehabilitation - ISA-UMH

http://search.naric.com/research/rehab/redesign_record.cfm?search=2&type=all&criteria=J76608&phrase=no&rec=134493&article_source=Rehab&international=0&international_language=&international_location=
NeuroRehabilitation , Volume 40(4) , Pgs. 483-492.

NARIC Accession Number: J76608.  What's this?
ISSN: 1053-8135.
Author(s): Mazzoleni, Stefano; Focacci, Antonella; Franceschini, Marco; Waldner, Andreas; Spagnuolo, Chiara; Battini, Elena; Bonaiuti, Donatella.
Publication Year: 2017.
Number of Pages: 10.
Abstract: Study evaluated the feasibility and effectiveness of exclusive use of robot-assisted end-effector-based gait training in patients with chronic stroke. One hundred chronic post-stroke patients from five rehabilitation centers underwent a robot-assisted end-effector-based gait training as their only rehabilitation treatment. Motor and gait functions were measured before and after the training using the following outcome measures: 6-Minute Walk Test (6MWT), 10-Meter Walk Test (10MWT), Timed Up and Go test (TUG), Modified Ashworth Scale, Motricity Index (MI), Functional Ambulation Classification (FAC) and Walking Handicap Scale. In order to investigate possible effects following the robot-assisted gait training based on the severity of gait impairment, patients were divided into two groups for analysis: those with severe impairment, assessed as FAC < 3 (Group 1) and those with moderate impairment, i.e., FAC ≥ 3 (Group 2). Statistically significant changes were observed in each clinical outcome measure after treatment. Significant changes were observed in the MI, TUG, and FAC in the Group 1 and in all clinical outcomes, with the exception of the 10MWT, in the Group 2. Fifty percent of patients in the Group 1 achieved the minimal clinically important difference (MCID) on the TUG and 61.4 percent of patients in the Group 2 reached the MCID on the 6MWT. This study demonstrated that chronic stroke patients exposed to only robot-assisted end-effector-based gait training showed significant improvements in global motor performances, gait endurance, balance and coordination, lower-limb strength, and even spasticity.
Descriptor Terms: AMBULATION, FEASIBILITY STUDIES, MOBILITY TRAINING, REHABILITATION TECHNOLOGY, ROBOTICS, STROKE.


Can this document be ordered through NARIC's document delivery service*?: Y.

Citation: Mazzoleni, Stefano, Focacci, Antonella, Franceschini, Marco, Waldner, Andreas, Spagnuolo, Chiara, Battini, Elena, Bonaiuti, Donatella. (2017). Robot-assisted end-effector-based gait training in chronic stroke patients: A multicentric uncontrolled observational retrospective clinical study.  NeuroRehabilitation , 40(4), Pgs. 483-492. Retrieved 10/11/2017, from REHABDATA database.

Rehabilitation Hospital Offering Robotic Service - Mountain Valley Regional Rehabilitation Hospital, Flagstaff

So fucking what? You don't state the results or efficacy of this device, that is the only thing survivors care about. 100% recovery is the goal, how many of your patients get there?
http://www.flagstaffbusinessnews.com/rehabilitation-hospital-offering-robotic-service/
Mountain Valley Regional Rehabilitation Hospital is the first facility in Northern Arizona to offer patients a new robotic service called ZeroG Overground Gait and Balance Training System. The advanced technology – which helps patients balance and walk independently – is a robotic body-weight support system mounted to a motorized trolley that rides along an overhead track.
ZeroG helps patients practice balance and walking skills independently and safely without risk of falling. The system compensates for weakness and poor coordination, which we believe will help accelerate therapy and maximize results.
During therapy, a therapist secures the patient into a comfortable harness that attaches to the ZeroG robot. The amount of support is individualized for each patient depending upon his or her ability level. Because the system prevents falls, the patient can participate in therapy with greater safety and confidence.
Dynamic body-weight support provides a consistent level of assistance during activities such as walking, balancing, climbing stairs, getting up and down from a chair or reaching activities. The system is designed to allow patients to safely practice at a higher level of intensity. As the patient progresses, the amount of dynamic support can be decreased so he or she does more under their own effort.
The system features real-time biofeedback for balance activities and interactive games. Patients are trained to move in response to targets on a screen, which requires them to mirror the activity physically to score points. ZeroG then records data from each therapy session so therapists can monitor functional progress.
ZeroG is one of the tools used at Mountain Valley Regional Rehabilitation Hospital to provide specialized rehabilitative care(not results) to patients recovering from disabilities caused by strokes, brain injuries, spinal cord injuries and orthopedic injuries. The hospital also provides intensive rehabilitation services to individuals living with neurological conditions such as multiple sclerosis and Parkinson’s disease and those needing specialized care following cardiac surgery.
The hospital’s patient care efforts(not results) have been recognized nationally for the past nine years in a row, ranking them among the Top 10 percent of inpatient rehabilitation facilities in the United States. The hospital also has received The Joint Commission’s Gold Seal of Approval and the organization’s disease-specific certifications for Stroke Rehabilitation and Traumatic Brain Injury Rehabilitation. FBN

By Erin Aafedt
Erin Aafedt is the director of therapy operations at Mountain Valley Regional Rehabilitation Hospital.

Effectiveness of robotic-assisted gait training in stroke rehabilitation: A retrospective matched control study

Pretty much useless since spontaneous recovery is going on during this time. No decent way to split which piece caused the improvement.

http://www.sciencedirect.com/science/article/pii/S101370251630046X

• Bryan Ping Ho Chung, MSc in Health Care^,

 Show more

http://dx.doi.org/10.1016/j.hkpj.2016.09.001

Get rights and content

Open Access funded by Hong Kong Physiotherapy Association

Under a Creative Commons license

---

Abstract

Objective

This study aimed to evaluate the effectiveness of robotic-assisted gait training (RAGT) in improving functional outcomes among stroke patients.

Design

This was a retrospective matched control study.

Setting

This study was conducted in an extended inpatient rehabilitation centre.

Patients and intervention

There were 14 patients with subacute stroke (4–31 days after stroke) in the RAGT group. Apart from traditional physiotherapy, the RAGT group received RAGT. The number of sessions for RAGT ranged from five to 33, and the frequency was three to five sessions per week, with each session lasting for 15–30 minutes. In the control group, there were 27 subacute stroke patients who were matched with the RAGT group in terms of age, days since stroke, premorbid ambulatory level, functional outcomes at admission, length of training, and number of physiotherapy sessions received. The control group received traditional physiotherapy but not RAGT.

Outcome measures

Modified Functional Ambulation Category (MFAC), Modified Rivermead Mobility Index (MRMI), Berg's Balance Scale (BBS), and Modified Barthel Index (MBI) to measure ambulation, mobility, balance, and activities of daily living, respectively.

Results

Both RAGT and control groups had significant within-group improvement in MFAC, MRMI, BBS, and MBI. However, the RAGT group had higher gain in MFAC, MRMI, BBS, and MBI than the control group. In addition, there were significant between-group differences in MFAC, MRMI, and BBS gains (p = 0.026, p = 0.010, and p = 0.042, respectively). There was no significant between-group difference (p = 0.597) in MBI gain (p = 0.597).

Conclusion

The results suggested that RAGT can provide stroke patients extra benefits in terms of ambulation, mobility, and balance. However, in the aspect of basic activities of daily living, the effect of RAGT on stroke patients is similar to that of traditional physiotherapy.

Keywords

• gait;
• physiotherapy;
• rehabilitation;
• robotic;
• stroke

---

Introduction

Stroke, also known as cerebrovascular accident, is an acute disturbance of focal or global cerebral function, with signs and symptoms lasting more than 24 hours or leading to death, presumably of vascular origin [1]. In Hong Kong, around 25,000 stroke patients are admitted to public hospitals under the Hong Kong Hospital Authority annually [2]. Although mortality and morbidity among stroke patients have declined due to medical advances, impacts on stroke survivors and community remain significant. The most widely recognized impairment caused by stroke is motor impairment, which restricts muscle movement or mobility function [3]. Many stroke patients experience difficulties in walking, and improving walking is one of the main goals of rehabilitation [4]. Since it was shown that the process of spontaneous recovery is almost completed within 6–10 weeks [5], early rehabilitation is essential to maximize the function of patients after stroke. Recent evidence suggests that high-intensity repetitive task-specific practice might be the most effective principle when trying to promote motor recovery after stroke [3]. Robotic-assisted gait training (RAGT) is a new global physiotherapy technology that applies the high-intensity repetitive principle to improve mobility of patients with stroke or other neurological disorders. The advantage of RAGT may be the reduction of the effort required by therapists compared with treadmill training with partial bodyweight support, as they no longer need to set the paretic limbs or assist in trunk movements [6]. People who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than people who receive gait training without these devices [7]. More specifically, people in the first 3 months after stroke and those who are not able to walk seem to benefit most from this type of intervention [7]. Evidence also shows that the use of RAGT in stroke patients has positive effects on their balance [8].

Randomized controlled trials and systemic reviews have demonstrated the effectiveness of RAGT for stroke patients in terms of functional outcomes such as walking ability [9], [10] and [11] and balance [8] and [11]. However, limited published evidence is available on the effectiveness of RAGT in improving other functioning activities such as basic activities of daily living (ADL) [12] and [13]. If RAGT can improve walking ability and balance of stroke patient, can RAGT also improve basic ADL of stroke patients? The hierarchical pattern of progression in basic ADL is in the following order: bathing, dressing, transferring, toileting, controlling continence, and feeding, with bathing being the most complex task and feeding the least [14]; however, walking ability and balance contribute to parts of basic ADL. Moreover, factors that make the greatest contribution to ADL after stroke were found to be balance, upper extremity function, and perceptual and cognitive functions [15]. If RAGT can improve ADL of stroke patients, which of the above factors is/are enhanced by RAGT? Can RAGT also enhance perceptual and cognitive functions of stroke patients? Hence, controlled studies are necessary to address these research questions. A retrospective study conducted by Dundar et al [13] investigated the effect of robotic training in functional independence measure and other functional outcomes of patients with subacute and chronic stroke. However, the study concluded that combining robotic training with conventional physiotherapy produced better improvement than conventional physiotherapy in terms of functional independence measure, but not walking status or balance. The result was opposite to the specificity of training principle [16] that gait training should produce more positive effect for walking and balance than ADL. Hence, this study intends to investigate the effectiveness of RAGT in improving functional mobility and basic ADL for stroke patients, and hopefully can lead to further randomized controlled studies to investigate the impact of RAGT on basic ADL.

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