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Journal of NeuroEngineering and Rehabilitation
Published in: Journal of NeuroEngineering and Rehabilitation 1/2018

Open Access 01-12-2018 | Research

Randomized controlled trial of robot-assisted gait training with dorsiflexion assistance on chronic stroke patients wearing ankle-foot-orthosis

Authors: Ling-Fung Yeung, Corinna Ockenfeld, Man-Kit Pang, Hon-Wah Wai, Oi-Yan Soo, Sheung-Wai Li, Kai-Yu Tong

Published in: Journal of NeuroEngineering and Rehabilitation | Issue 1/2018

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Abstract

Background

Robot-assisted ankle-foot-orthosis (AFO) can provide immediate powered ankle assistance in post-stroke gait training. Our research team has developed a novel lightweight portable robot-assisted AFO which is capable of detecting walking intentions using sensor feedback of wearer’s gait pattern. This study aims to investigate the therapeutic effects of robot-assisted gait training with ankle dorsiflexion assistance.

Methods

This was a double-blinded randomized controlled trial. Nineteen chronic stroke patients with motor impairment at ankle participated in 20-session robot-assisted gait training for about five weeks, with 30-min over-ground walking and stair ambulation practices. Robot-assisted AFO either provided active powered ankle assistance during swing phase in Robotic Group (n = 9), or torque impedance at ankle joint as passive AFO in Sham Group (n = 10). Functional assessments were performed before and after the 20-session gait training with 3-month Follow-up. Primary outcome measure was gait independency assessed by Functional Ambulatory Category (FAC). Secondary outcome measures were clinical scores including Fugl-Meyer Assessment (FMA), Modified Ashworth Scale (MAS), Berg Balance Scale (BBS), Timed 10-Meter Walk Test (10MWT), Six-minute Walk Test (SMWT), supplemented by gait analysis. All outcome measures were performed in unassisted gait after patients had taken off the robot-assisted AFO. Repeated-measures analysis of covariance was conducted to test the group differences referenced to clinical scores before training.

Results

After 20-session robot-assisted gait training with ankle dorsiflexion assistance, the active ankle assistance in Robotic Group induced changes in gait pattern with improved gait independency (all patients FAC ≥ 5 post-training and 3-month follow-up), motor recovery, walking speed, and greater confidence in affected side loading response (vertical ground reaction force + 1.49 N/kg, peak braking force + 0.24 N/kg) with heel strike instead of flat foot touch-down at initial contact (foot tilting + 1.91°). Sham Group reported reduction in affected leg range of motion (ankle dorsiflexion − 2.36° and knee flexion − 8.48°) during swing.

Conclusions

Robot-assisted gait training with ankle dorsiflexion assistance could improve gait independency and help stroke patients developing confidence in weight acceptance, but future development of robot-assisted AFO should consider more lightweight and custom-fit design.

Trial registration

ClinicalTrials.gov NCT02471248. Registered 15 June 2015 retrospectively registered.
Appendix
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Literature
1.
2.
Beyaert C, Vasa R, Frykberg GE. Gait post-stroke: pathophysiology and rehabilitation strategies. Neurophysiol Clin. 2015;45:335–55.CrossRefPubMed
3.
Kitatani R, Ohata K, Aga Y, et al. Descending neural drives to ankle muscles during gait and their relationships with clinical functions in patients after stroke. Clin Neurophysiol. 2016;127:1512–20.CrossRefPubMed
4.
Moore S, Schurr K, Wales A, Moseley A, Herbert R. Observation and analysis of hemiplegic gait: swing phase. Aust J Physiother. 1993;39:271–8.CrossRefPubMed
5.
6.
Kim J, Oh S-I, Cho H, Kim HS, Chon J, Lee WJ, et al. Gait patterns of chronic ambulatory hemiplegic elderly compared with normal age-matched elderly. Int J Precis Eng Manuf. 2015;16:385–92.CrossRef
7.
8.
Lauziere S, Betschart M, Aissaoui R, Nadeau S. Understanding spatial and temporal gait asymmetries in individuals post stroke. Int J Phys Med Rehabil. 2014;2:201.
9.
Weerdesteyn V, de Niet M, van Duijnhoven HJR, Geurts ACH. Falls in individuals with stroke. J Rehabil Res Dev. 2008;45:1195.CrossRefPubMed
10.
Burpee JL, Lewek MD. Biomechanical gait characteristics of naturally occurring unsuccessful foot clearance during swing in individuals with chronic stroke. Clin Biomech. 2015;30:1102–7.CrossRef
11.
Kramer S, Johnson L, Bernhardt J, Cumming T. Energy expenditure and cost during walking after stroke: a systematic review. Arch Phys Med Rehabil. 2016;97:619–32.CrossRefPubMed
12.
Franceschini M, Rampello A, Agosti M, Massucci M, Bovolenta F, Sale P. Walking performance: correlation between energy cost of walking and walking participation. New statistical approach concerning outcome measurement. PLoS One. 2013;8:e56669.CrossRefPubMedPubMedCentral
13.
Tyson SF, Sadeghi-Demneh E, Nester CJ. A systematic review and meta-analysis of the effect of an ankle-foot orthosis on gait biomechanics after stroke. Clin Rehabil. 2013;27:879–91.CrossRefPubMed
14.
Tyson SF, Kent RM. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Arch Phys Med Rehabil. 2013;94:1377–85.CrossRefPubMed
15.
Bethoux F, Rogers HL, Nolan KJ, Abrams GM, Annaswamy T, Brandstater M, et al. Long-term follow-up to a randomized controlled trial comparing peroneal nerve functional electrical stimulation to an ankle foot orthosis for patients with chronic stroke. Neurorehab Neural Repair. 2015;29:911–22.CrossRef
16.
Dollar AM, Herr H. Lower extremity exoskeletons and active orthoses: challenges and state-of-the-art. IEEE Trans Robot. 2008;24:144–58.CrossRef
17.
Shorter KA, Xia J, Hsiao-Wecksler ET, Durfee WK, Kogler GF. Technologies for powered ankle-foot orthotic systems: possibilities and challenges. IEEE/ASME Trans Mechatron. 2013;18:337–47.CrossRef
18.
Alam M, Choudhury IA, Bin Mamat A. Mechanism and design analysis of articulated ankle foot orthoses for drop-foot. Sci World J. 2014;2014:867869.
19.
Blaya JA, Herr H. Adaptive control of a variable-impedance ankle-foot orthosis to assist drop-foot gait. IEEE Trans Neural Syst Rehab Eng. 2004;12:24–31.CrossRef
20.
Ward J, Sugar T, Standeven J, Engsberg JR. Stroke survivor gait adaptation and performance after training on a powered ankle foot orthosis. In: Robotics and Automation 2010 IEEE International Conference; 2010. p. 211–6.CrossRef
21.
Kreisel SH, Hennerici MG, Bäzner H. Pathophysiology of stroke rehabilitation: the natural course of clinical recovery, use-dependent plasticity and rehabilitative outcome. Cerebrovasc Dis. 2007;23:243–55.CrossRefPubMed
22.
Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51:S225–39.CrossRefPubMed
23.
Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8:741–54.CrossRefPubMed
24.
Thomas LH, French B, Coupe J, McMahon N, Connell L, Harrison J, et al. Repetitive task training for improving functional ability after stroke: a major update of a Cochrane review. Stroke. 2017;48:e102–3.CrossRef
25.
Forrester LW, Roy A, Krebs HI, Macko RF. Ankle training with a robotic device improves hemiparetic gait after a stroke. Neurorehabl Neural Re. 2011;25:369–77.CrossRef
26.
Perez MA, Lungholt BK, Nyborg K, Nielsen JB. Motor skill training induces changes in the excitability of the leg cortical area in healthy humans. Exp Brain Res. 2004;159:197–205.CrossRefPubMed
27.
Salbach NM, Mayo NE, Wood-Dauphinee S, Hanley JA, Richards CL, Côté R. A task-orientated intervention enhances walking distance and speed in the first year post stroke: a randomized controlled trial. Clin Rehabil. 2004;18(5):509–19.CrossRefPubMed
28.
Tucker MR, Olivier J, Pagel A, Bleuler H, Bouri M, Lambercy O, et al. Control strategies for active lower extremity prosthetics and orthotics: a review. J Neuroeng Rehabil. 2015;12(1)
29.
Lo AC. Clinical designs of recent robot rehabilitation trials. Am J Phys Med Rehabil. 2012;91:S204–16.CrossRefPubMed
30.
Mehrholz J, Thomas S, Werner C, Kugler J, Pohl M, Elsner B. Electromechanical-assisted training for walking after stroke. Cochrane Database Syst Rev. 2017;5:CD006185.PubMed
31.
Mehrholz J, Wagner K, Rutte K, Meissner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007;88(10):1314–9.CrossRefPubMed
32.
Yeung LF, Ockenfeld C, Pang MK, Wai HW, Soo OY, Li SW, et al. Design of an exoskeleton ankle robot for robot-assisted gait training of stroke patients. IEEE Int Conf Rehabil Robot. 2017;2017:211–5.PubMed
33.
Riener R, Rabuffetti M, Frigo C. Stair ascent and descent at different inclinations. Gait Posture. 2002;15(1):32–44.CrossRefPubMed
34.
Geroin C, Mazzoleni S, Smania N, Gandolfi M, Bonaiuti D, Gasperini G, et al. Systematic review of outcome measures of walking training using electromechanical and robotic devices in patients with stroke. J Rehabil Med. 2013;45:987–96.CrossRefPubMed
35.
Billingham SA, Whitehead AL, Julious SA. An audit of sample sizes for pilot and feasibility trials being undertaken in the United Kingdom registered in the United Kingdom clinical research network database. BMC Med Res Methodol. 2013;13:104.CrossRefPubMedPubMedCentral
36.
Lotze M, Braun C, Birbaumer N, Anders S, Cohen LG. Motor learning elicited by voluntary drive. Brain. 2003;126:866–72.CrossRefPubMed
37.
Pennycott A, Wyss D, Vallery H, Klamroth-Marganska V, Riener R. Towards more effective robotic gait training for stroke rehabilitation: a review. J Neuroeng Rehabil. 2012;9:65.CrossRefPubMedPubMedCentral
38.
39.
Bortole M, Venkatakrishnan A, Zhu F, Moreno JC, Francisco GE, Pons JL, et al. The H2 robotic exoskeleton for gait rehabilitation after stroke: early findings from a clinical study. J Neuroeng Rehabil. 2015;12:54.CrossRefPubMedPubMedCentral
40.
Perry J, Garrett M, Gronley JK, Mulroy SJ. Classification of walking handicap in the stroke population. Stroke. 1995;26:982–9.CrossRefPubMed
41.
Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54:743–9.CrossRefPubMed
42.
Pandian S, Arya KN, Kumar D. Minimal clinically important difference of the lower-extremity fugl-meyer assessment in chronic-stroke. Top Stroke Rehabil. 2016;23:233–9.CrossRefPubMed
43.
Lewek MD, Randall EP. Reliability of spatiotemporal asymmetry during overground walking for individuals following chronic stroke. J Neurol Phys Ther. 2011;35:116–21.CrossRefPubMed
44.
Sheffler LR, Taylor PN, Gunzler DD, Buurke JH, Ijzerman MJ, Chae J. Randomized controlled trial of surface peroneal nerve stimulation for motor relearning in lower limb hemiparesis. Arch Phys Med Rehabil. 2013;94:1007–14.CrossRefPubMedPubMedCentral
45.
Stansfield BW, Hillman SJ, Hazlewood ME, Lawson AA, Mann AM, Loudon IR, et al. Normalized speed, not age, characterizes ground reaction force patterns in 5-to 12-year-old children walking at self-selected speeds. J Pediatr Orthop. 2001;21:395–402.PubMed
46.
Rossi S, Colazza A, Petrarca M, Castelli E, Cappa P, Krebs HI. Feasibility study of a wearable exoskeleton for children: is the gait altered by adding masses on lower limbs? PLoS One. 2013;8:e73139.CrossRefPubMedPubMedCentral
47.
Khanna I, Roy A, Rodgers MM, Krebs HI, Macko RM, Forrester LW. Effects of unilateral robotic limb loading on gait characteristics in subjects with chronic stroke. J Neuroeng Rehab. 2010;7(1)
48.
Browning RC, Modica JR, Kram R, Goswami A. The effects of adding mass to the legs on the energetics and biomechanics of walking. Med Sci Sports Exerc. 2007;39:515–25.CrossRefPubMed
Metadata
Title
Randomized controlled trial of robot-assisted gait training with dorsiflexion assistance on chronic stroke patients wearing ankle-foot-orthosis
Authors
Ling-Fung Yeung
Corinna Ockenfeld
Man-Kit Pang
Hon-Wah Wai
Oi-Yan Soo
Sheung-Wai Li
Kai-Yu Tong
Publication date
01-12-2018
Publisher
BioMed Central
Published in
Journal of NeuroEngineering and Rehabilitation / Issue 1/2018
Electronic ISSN: 1743-0003
DOI
https://doi.org/10.1186/s12984-018-0394-7

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