Effect of assist-as-needed robotic gait training on the gait pattern post stroke: a randomized controlled trial

LOPES was first written up in Sept. 2007.

LOPES researchers hope to get the device into rehabilitation clinics by early 2012, with a mid-2012 target for introduction into the market. 

Is it available and does your hospital know about it? Have they been following this for the past 13 years? Or are they completely incompetent? But then it doesn't seem to work that well. 

Earlier research here:

• LOPES (1)

• LOPES Exoskeleton (1)

 

Effect of assist-as-needed robotic gait training on the gait pattern post stroke: a randomized controlled trial 

• J. F. Alingh,
• B. M. Fleerkotte,
• B. E. Groen,
• J. S. Rietman,
• V. Weerdesteyn,
• E. H. F. van Asseldonk,
• A. C. H. Geurts &
• J. H. Buurke 

Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 26 (2021) Cite this article

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Abstract

Background

Regaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AAN_mDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AAN_mDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation.

Methods

Thirty-four participants with unilateral, supratentorial stroke were enrolled (< 10 weeks post onset, Functional Ambulation Categories 3–5) and randomly assigned to six weeks of AAN_mDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3–5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (W_EXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2).

Results

Two participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AAN_mDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, W_EXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0–T1) and paretic step length (T0–T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AAN_mDOF robotic group compared to the conventional group (T0–T2).

Conclusions

Generally, AAN_mDOF robotic training was not superior to conventional training for improving gait pattern in subacute(What does subacute mean?) stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AAN_mDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing.

Trial registration Registry number Netherlands Trial Register (www.trialregister.nl): NTR5060. Registered 13 February 2015.

 

Low-Frequency Repetitive Transcranial Magnetic Stimulation Over Contralesional Motor Cortex for Motor Recovery in Subacute Ischemic Stroke: A Randomized Sham-Controlled Trial

So nothing useful found but more research requested. You'll have to ask what the definition of subacute is?

Low-Frequency Repetitive Transcranial Magnetic Stimulation Over Contralesional Motor Cortex for Motor Recovery in Subacute Ischemic Stroke: A Randomized Sham-Controlled Trial

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Won-Seok Kim, MD, PhD, Bum Sun Kwon, MD, PhD, Han Gil Seo, MD, PhD, ...

First Published August 18, 2020 Research Article 

https://doi.org/10.1177/1545968320948610

Article information

 

Abstract

Background

Low-frequency repetitive transcranial magnetic stimulation (rTMS) over the contralesional motor cortex (M1) has demonstrated beneficial effects on motor recovery, but evidence among patients with subacute stroke is lacking. We aimed to investigate whether 1-Hz rTMS over the contralesional M1 versus sham rTMS could improve arm function in patients with subacute ischemic stroke when combined with rehabilitative motor training.

Methods

In total, 77 patients who were within 90 days after their first-ever ischemic stroke were enrolled and randomly allocated to either real (n = 40) or sham rTMS (n = 37). We delivered 1-Hz 30-minute active or sham rTMS before each daily 30-minute occupational therapy sessions over a 2-week period. The primary endpoint was changes in the Box and Block Test (BBT) score immediately after the end of treatment (EOT). Secondary analyses assessed changes in Fugl-Meyer assessment, Finger Tapping Test (FTT), Brunnstrom stage, and grip strength.

Clinical Trial Registration

ClinialTrials.gov (NCT02082015).

Results

Changes in BBT immediately after the end of treatment did not differ significantly between the 2 groups (P = .267). Subgroup analysis according to cortical involvement revealed that real rTMS resulted in improvements in BBT at 1 month after EOT (17.4 ± 9.8 real vs 10.9 ± 10.3 sham; P = .023) and Brunnstrom stage of the hand immediately after EOT (0.6 ± 0.5 real vs 0.2 ± 0.5 sham; P = .023), only in the group without cortical involvement.

Conclusion

The effects of real and sham rTMS did not differ significantly among patients within 3 months poststroke. The location of stroke lesions should be considered for future clinical trials.

Keywords stroke, transcranial magnetic stimulation, rehabilitation, motor cortex, recovery of function, neuronal plasticity

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β-Oscillations Reflect Recovery of the Paretic Upper Limb in Subacute Stroke

What fucking stupidity.  Tell me EXACTLY how this is going to help survivors recover. EXACTLY!  

And this from Sept. 2015 was not enough to answer your questions on β-oscillations? Hopefully your answer is not subacute vs. chronic.

Reinforcement learning of self-regulated β-oscillations for motor restoration in chronic stroke Sept. 2015

β-Oscillations Reflect Recovery of the Paretic Upper Limb in Subacute Stroke

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Chih-Wei Tang, MD, Fu-Jung Hsiao, PhD, Po-Lei Lee, PhD, ...

First Published April 23, 2020 Research Article

https://doi.org/10.1177/1545968320913502

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Abstract

Background.
Recovery of upper limb function post-stroke can be partly predicted by initial motor function, but the mechanisms underpinning these improvements have yet to be determined. Here, we sought to identify neural correlates of post-stroke recovery using longitudinal magnetoencephalography (MEG) assessments in subacute stroke survivors.  
Methods.
First-ever, subcortical ischemic stroke survivors with unilateral mild to moderate hand paresis were evaluated at 3, 5, and 12 weeks after stroke using a finger-lifting task in the MEG. Cortical activity patterns in the β-band (16-30 Hz) were compared with matched healthy controls.  
Results.
All stroke survivors (n=22; 17 males) had improvements in action research arm test (ARAT) and Fugl-Meyer upper extremity (FM-UE) scores between 3 and 12 weeks. At 3 weeks post-stroke the peak amplitudes of the movement-related ipsilesional β-band event-related desynchronization (β-ERD) and synchronization (β-ERS) in primary motor cortex (M1) were significantly lower than the healthy controls (p<0.001) and were correlated with both the FM-UE and ARAT scores (r=0.51-0.69, p<0.017). The decreased β-ERS peak amplitudes were observed both in paretic and non-paretic hand movement particularly at 3 weeks post-stroke, suggesting a generalized disinhibition status. The peak amplitudes of ipsilesional β-ERS at week 3 post-stroke correlated with the FM-UE score at 12 weeks (r=0.54, p=0.03) but no longer significant when controlling for the FM-UE score at 3 weeks post-stroke. 
Conclusions.
Although early β-band activity does not independently predict outcome at 3 months after stroke, it mirrors functional changes, giving a potential insight into the mechanisms underpinning recovery of motor function in subacute stroke.

Keywords stroke, motor recovery, magnetoencephalography, β-oscillations, event-related synchronization, event-related desynchronization

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Outcome of Subacute Stroke Rehabilitation

2 things to note from this;
1. The doctor does nothing.
2. Nowhere are protocols referred to, so this research is not repeatable.
http://stroke.ahajournals.org/content/29/4/779.long

Ole Morten Rønning, Bjørn Guldvog

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https://doi.org/10.1161/01.STR.29.4.779

Stroke. 1998;29:779-784

Originally published April 1, 1998

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Abstract

Background and Purpose—Organized acute stroke treatment reduces mortality, functional deficits, and the need of institutionalization after stroke. It is largely unknown whether the effects of treatment are due to early or subacute efforts. The aim of this randomized, controlled study was to test the hypothesis that rehabilitation of stroke patients in the subacute phase in a hospital rehabilitation unit is beneficial in reducing death and dependency and increasing health-related quality of life.

Methods—251 patients initially treated in the hospital were randomized to subacute rehabilitation in a hospital rehabilitation unit (n=127) or to the health services in the municipality (n=124) and were followed up for 7 months.

Results—The combined outcome of patients being dead or dependent (Barthel Index score of <75) was 23% in the hospital group and 38% in the municipality group (P=.01). Seven-month survival rates were 90.6% and 83.9% (P=.11), respectively. Dependency in activities of daily living was 12.6% in the hospital group and 25.0% in the municipality group (P=.07). Patients with a BI score of <50 before rehabilitation had significantly better outcome in the hospital rehabilitation unit, with fewer patients becoming dependent (P=.005) and patients having higher Scandinavian Stroke Scale (P=.026) and BI scores (P=.005). No significant differences in health-related quality of life were found. Many patients treated in the municipalities (30%) did not receive any organized rehabilitation in this study.

Conclusions—Subacute rehabilitation of stroke patients in a hospital-based rehabilitation unit improves outcome. Patients with moderate or severe stroke appear to benefit most.

• rehabilitation
• stroke management
• stroke outcome

Studies of services specialized in caring for patients with acute stroke show that well-organized management reduces mortality, neurological deficits, functional disability, and long-term institutional care.^{1 2 3 4 5 6 7 8 9} Still remaining unanswered are the questions of which components in the care of acute stroke patients are effective,¹ where and how rehabilitation of stroke patients in the subacute period should take place, and whether all stroke patients should be offered subacute coordinated multidisciplinary rehabilitation.¹⁰

It has been maintained that the patients most appropriate for subacute rehabilitation are those with moderately severe deficits,⁷ although one particular study⁹ showed that severely disabled patients with a poor prognosis had a better outcome when treated in a stroke rehabilitation unit. A subgroup analysis of an overview of stroke trials showed that stroke severity was not associated with the effectiveness of the treatment.¹

The resources available for long-term rehabilitation may be limited by an increasing number of stroke patients. Few randomized controlled studies exist that evaluate management of stroke patients after the acute treatment.^{2 7 11 12 13} In these studies the groups that were offered specialized subacute stroke rehabilitation had fewer deaths and better functional outcome (although not to a level of significance in each trial). One study¹³ has shown that specialist community rehabilitation after the acute treatment is clinically as effective as hospital care. The Stroke Unit Trialists’ Collaboration¹ showed that admission of stroke patients a week or more after a stroke did not eliminate the effectiveness of the stroke unit care.

It is therefore still under debate whether patients in the subacute phase should be offered rehabilitation in their local environment or in hospital-based rehabilitation units^{14 15} and which level of rehabilitation is proper for different subgroups.¹⁶ We have previously shown that treatment in an acute stroke unit with a length of stay of approximately 7 days reduces mortality¹⁷ and neurological but not functional deficits.¹⁸ We considered the length of stay in the acute stroke unit to be too short to affect functional disability.

This study was performed to assess the efficacy of a hospital-based rehabilitation program in reducing neurological impairment and functional disability and increasing health-related quality of life among patients with subacute stroke. We also wanted to determine whether severity influenced the benefit of a rehabilitation unit with a subacute rehabilitation program.

Nitrogen balance in patients with hemiparetic stroke during the subacute rehabilitation phase

No clue how knowing this helps your stroke recovery. That is really the only valid question that stroke researchers should be answering for everything they do. A great stroke association would make sure that occurs.
http://onlinelibrary.wiley.com/doi/10.1111/jhn.12457/full

• First published: January 2017Full publication history
• DOI: 10.1111/jhn.12457View/save citation
• Cited by: 0 articles

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Abstract

Background

In highly invasive diseases, metabolism commonly changes. Hypercatabolism is frequent in acute stroke, and nitrogen balance tends to be negative. However, there has been no study describing nitrogen balance in subacute and chronic stroke patients. The present study aimed to examine nitrogen balance in the subacute and chronic phases and to identify the factors related to it.

Methods

Nitrogen balance was calculated from the collected urine of 56 patients with subacute stroke [mean (SD) 53.8 (18.4) days post-stroke] who were admitted for rehabilitation for their first-ever ischaemic or nonsurgical haemorrhagic stroke. In the first experiment, their nitrogen balance was measured during the rehabilitation phase, and factors (type, severity of hemiparesis, activities of daily living, dysphagia and malnutrition status) related to it were evaluated. The second experiment was performed to describe the time course of nitrogen balance in 31 consecutive patients, with assessments made at admission and at discharge.

Results

Nitrogen balance was positive in all patients in the subacute phase. A significant difference was seen in nitrogen balance between high and low fat-free mass in male patients. In the chronic phase, nitrogen balance was positive in 96% of the patients. There was no significant difference in nitrogen balance between discharge and admission.

Conclusions

In the subacute and chronic phases of stroke, it was confirmed that hypercatabolism had resolved and that intensive rehabilitation is possible in the convalescent period of stroke.

Connectivity-Based Predictions of Hand Motor Outcome for Patients at the Subacute Stage After Stroke

No clue if any of this has a truly objective basis for predictions. Lots of big words used though. I bet your doctor can't translate this into 8th grade English either.
http://journal.frontiersin.org/article/10.3389/fnhum.2016.00101/full?

Julia Lindow¹, Martin Domin¹, Matthias Grothe², Ulrike Horn¹, Simon B. Eickhoff^3,4 and Martin Lotze^1*

• ¹Functional Imaging Unit, Center for Diagnostic Radiology, University of Greifswald, Greifswald, Germany
• ²Institute of Neurology, University of Greifswald, Greifswald, Germany
• ³Institute of Clinical Neuroscience and Medical Psychology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
• ⁴Institute of Neuroscience and Medicine (INM-1), Research Centre Jülich, Jülich, Germany

Background: Connectivity-based predictions of hand motor outcome have been proposed to be useful in stroke patients. We intended to assess the prognostic value of different imaging methods on short-term (3 months) and long-term (6 months) motor outcome after stroke.
Methods: We measured resting state functional connectivity (rsFC), diffusion weighted imaging (DWI) and grip strength in 19 stroke patients within the first days (5–9 days) after stroke. Outcome measurements for short-term (3 months) and long-term (6 months) motor function was assessed by the Motricity Index (MI) of the upper limb and the box and block test (BB). Patients were predominantly mildly affected since signed consent was necessary at inclusion. We performed a multiple stepwise regression analysis to compare the predictive value of rsFC, DWI and clinical measurements.
Results: Patients showed relevant improvement in both motor outcome tests. As expected grip strength at inclusion was a predictor for short- and long-term motor outcome as assessed by MI. Diffusion-based tract volume (DTV) of the tracts between ipsilesional primary motor cortex and contralesional anterior cerebellar hemisphere showed a strong trend (p = 0.05) for a predictive power for long-term motor outcome as measured by MI. DTV of the interhemispheric tracts between both primary motor cortices was predictive for both short- and long-term motor outcome in BB. rsFC was not associated with motor outcome.
Conclusions: Grip strength is a good predictor of hand motor outcome concerning strength-related measurements (MI) for mildly affected subacute patients. Therefore additional connectivity measurements seem to be redundant in this group. Using more complex movement recruiting bilateral motor areas as an outcome parameter, DTV and in particular interhemispheric pathways might enhance predictive value of hand motor outcome.

Introduction

Stroke is the leading cause of adult disability worldwide, leaving a majority of patients with lingering upper limb impairment (World Health Organization, 2012). Knowing more about motor outcome would be advantageous to achieve the best results in rehabilitation. For long-term motor outcome prediction, parameters are needed that can be assessed within the first days, when patients are in the acute care units.

Functional magnetic resonance imaging (fMRI) raised high expectations because functional representation of movements can be assessed longitudinally in vivo. However, activation fMRI protocols are demanding and patients’ compliance is difficult to control for. In contrast, resting state fMRI (rs-fMRI) requires little compliance and can therefore be conducted comparable to structural MRI in the acute (0–24 h after stroke onset) to subacute (24 h to 6 weeks after stroke) phase after stroke (Di Pino et al., 2014). Especially rs-fMRI functional connectivity (FC) between cortical motor areas has been described to be associated with motor impairment (Carter et al., 2010). Astonishingly, only a low number of studies examined the prognostic value of resting-state functional connectivity (rsFC) for motor outcome in acute stroke patients.

To date the best predictor of later hand motor outcome is the initially measured hand motor impairment. Especially the Fugl-Meyer test (Sanford et al., 1993) has been described as a valuable predictor of hand motor outcome for 2, 6 and 12 months after stroke for mildly to moderately impaired patients (Feys et al., 2000). Likewise the active motion range is known to be a good predictor of short-term (3 months; Beebe and Lang, 2009) and long-term (6 months; Smania et al., 2007) hand motor outcome.

In more severely affected stroke patients, the intactness of the corticospinal tract (CST), as tested with diffusion weighted imaging (DWI) is useful for the prediction of hand motor outcome (Lindenberg et al., 2012; Stinear et al., 2012; Groisser et al., 2014; Byblow et al., 2015). TMS-measures such as the asymmetry index of hand muscle motor evoked potentials is a clinically well suited predictive method for describing motor outcome in patients after stroke (e.g., Stinear et al., 2012; Byblow et al., 2015). At the subacute phase, a positive association between fractional anisotropy (FA) measured at the height of the posterior limb of the internal capsule of the ipsilesional side and hand motor performance has been shown (Jang et al., 2005; Konishi et al., 2005; Nelles et al., 2008; Byblow et al., 2015). Most authors used FA as well as axial and radial diffusivity for quantification of intactness of the CST. When comparing the predictive value of these measurements, differences in axial diffusivity of the pyramidal tract from the ipsilesional to the contralesional hemisphere at the acute phase had the highest association with 3 and 6 months motor outcome of grip strength and nine hole peg test (NHPT) in a sample of 10 initially strongly impaired stroke patients (Groisser et al., 2014). Probabilistic tractography methods using the DWI data are capable of reconstructing diffusion pathways over long distances even when fibers are crossing (Lindenberg et al., 2010). We thought that the possibility to find alterations among long anatomical pathways might be advantageous for predicting motor outcome even in less severely impaired patients.

Carter et al. (2012a,b) assessed connectivity approaches as a promising method for understanding the impact of cerebral lesions on motor function and its restitution. Consequently, they combined DWI of the CST with FC measurements as assessed by rs-fMRI. For rs-fMRI positive associations with motor performance at the chronic phase after stroke (>6 weeks after stroke; Di Pino et al., 2014) have been described between homotopic motor areas of the affected and the unaffected side indicating that more “balanced” activity between hemispheres is associated with better upper-limb control (Urbin et al., 2014). For rs-fMRI two studies describe a positive association between homolog motor areas between both hemispheres and motor performance (Carter et al., 2010, 2012a). However, both did not measure future motor outcome using resting state connectivity but performed only correlative measurements assessed at about the same time. Overall, stroke patients with motor impairment show decreased interhemispheric M1-connectiviy and increased resting-state connectivity between ipsilesional M1 and secondary motor areas particularly in the ipsilesional hemisphere (Rehme et al., 2015). Over a period of 3 months the reduced interhemispheric M1 rsFC normalizes (Golestani et al., 2013). To date only one study has applied longitudinal motor outcome measurements to investigate the value of rsFC for predicting motor outcome. Park et al. (2011) investigated rs-fMRI in 12 subacute stroke patients and found a positive association between 6 months motor outcome measured with Fugl-Meyer-Score and rsFC of the ipsilesional M1 with the contralesional thalamus, supplementary motor area (SMA), and medial frontal gyrus.

The present study examined the prognostic value of motor (grip strength, NHPT), and clinical (NIH stroke scale; NIHSS) scores, DWI of long tracts and rs-FC for patients at the subacute stage with predominantly only mild unilateral brain damage. We used two different motor outcome scores: the motricity index (MI) for upper limb and the box and block test (BB) to examine separate aspects of upper limb function namely strength (MI), and hand grip transfer (BB). We hypothesized that intactness of long tracts, would be a predictor for both scores. However, hand strength is represented unilaterally, whereas grip transfer recruits bilateral resources from both hemispheres (Lotze et al., 2012). More bilateral activation might involve increased information transfer (inhibitory or excitatory) via the corpus callosum between both primary motor cortices (M1). Therefore we hypothesized that integrity of interhemispheric fibers would be better predictors for BB, whereas CST integrity might be a better predictor for MI. In addition, we expected lower rsFC between ipsilesional primary motor cortex and contralesional secondary motor areas (SMA, dorsal premotor cortex, dPMC) to be associated with better motor outcome (MI and BB; Wang et al., 2010).