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Y. Suzuki1, D. Hirado2,3, T. Shirakawa2, Y. Urabe3
1Kyushu Nutrition Welfare University, Faculty of Rehabilitation, Kitakyushu, Japan, 2Matterhorn Rehabilitation Hospital, Department of Rehabilitation, Kure, Japan, 3Graduate School of Biomedical and Health Sciences, Hiroshima University, Department of Sports Rehabilitation, Hiroshima, Japan
Background: Intensive and repetitive robot-assisted gait training (RAGT) may improve gait independence after a stroke (Mehrholz J et al., 2017). However, several randomized controlled trials have negative evidence for the superiority of RAGT over conventional rehabilitation (Sczesny-Kaiser M et al., 2019, Wall A et al., 2020). The current challenge is identifying who would benefit the most from RAGT in a heterogeneous stroke population.
Purpose: To investigate descriptively the factors that may inhibit the improvement of gait independence through RAGT after a stroke.
Methods: Five patients after stroke were included in this study.
Case (1): male, 51 years old, thalamic hemorrhage, Stroke Impairment Assessment Set (SIAS)=34, Fugl–MeyerAssessment for Lower Extremity (FMA-LE)=12, Functional Ambulation Categories (FAC)=4;
Case (2): female, 70 years old, subcortical hemorrhage, SIAS=60, FMA-LE=15, FAC=1;
Case (3): female, 82 years old, medullary infarction, SIAS=63, FMA-LE=23, FAC=2;
Case (4): female, 85 years old, temporal occipital lobe and pontine infarction, SIAS=37, FMA-LE=20, FAC=0; Case (5): female, 88 years old, frontal lobe infarction, SIAS=26, FMA-LE=8, FAC=0.
Case (4) had a history of exertional angina pectoris and bilateral knee osteoarthritis, and
Case (5) had severe cognitive impairment with a revised Hasegawa dementia scale score of 4/30.
Participants performed the gait training with Hybrid Assistive Limb (HAL, Cyberdyne Inc., Japan) for 4 weeks (30 minutes/session, three to four times/week). To determine the effect of RAGT, the following parameters were assessed at baseline and after 4 weeks: SIAS, FMA-LE, and FAC. The walking distance for each training session with HAL was also quantified.
Case (1): male, 51 years old, thalamic hemorrhage, Stroke Impairment Assessment Set (SIAS)=34, Fugl–MeyerAssessment for Lower Extremity (FMA-LE)=12, Functional Ambulation Categories (FAC)=4;
Case (2): female, 70 years old, subcortical hemorrhage, SIAS=60, FMA-LE=15, FAC=1;
Case (3): female, 82 years old, medullary infarction, SIAS=63, FMA-LE=23, FAC=2;
Case (4): female, 85 years old, temporal occipital lobe and pontine infarction, SIAS=37, FMA-LE=20, FAC=0; Case (5): female, 88 years old, frontal lobe infarction, SIAS=26, FMA-LE=8, FAC=0.
Case (4) had a history of exertional angina pectoris and bilateral knee osteoarthritis, and
Case (5) had severe cognitive impairment with a revised Hasegawa dementia scale score of 4/30.
Participants performed the gait training with Hybrid Assistive Limb (HAL, Cyberdyne Inc., Japan) for 4 weeks (30 minutes/session, three to four times/week). To determine the effect of RAGT, the following parameters were assessed at baseline and after 4 weeks: SIAS, FMA-LE, and FAC. The walking distance for each training session with HAL was also quantified.
Results: The number of interventions and the amount of gait training per session for each case were:
Case (1): 16 times, 310.0±139.1 m/session (maximum 512.0 m);
Case (2): 16 times, 150.4±84.8 m/session (maximum 307.0 m);
Case (3): 16 times, 303.2±91.6 m/session (maximum 534.0 m);
Case (4): 13 times, 134.8±61.5 m/session (maximum 210 m);
Case (5): 12 times, 47.7±25.6 m/session (maximum 100.0 m).
The outcomes after 4 weeks intervention for each case were:
Case (1): SIAS=39, FMA-LE=15, FAC=4;
Case (2): SIAS=70, FMA-LE=27, FAC=3;
Case (3): SIAS=71, FMA-LE=30, FAC=3;
Case (4): SIAS=44, FMA-LE=24, FAC=2;
Case (5): SIAS=40, FMA-LE=19, FAC=1.
Case (1): 16 times, 310.0±139.1 m/session (maximum 512.0 m);
Case (2): 16 times, 150.4±84.8 m/session (maximum 307.0 m);
Case (3): 16 times, 303.2±91.6 m/session (maximum 534.0 m);
Case (4): 13 times, 134.8±61.5 m/session (maximum 210 m);
Case (5): 12 times, 47.7±25.6 m/session (maximum 100.0 m).
The outcomes after 4 weeks intervention for each case were:
Case (1): SIAS=39, FMA-LE=15, FAC=4;
Case (2): SIAS=70, FMA-LE=27, FAC=3;
Case (3): SIAS=71, FMA-LE=30, FAC=3;
Case (4): SIAS=44, FMA-LE=24, FAC=2;
Case (5): SIAS=40, FMA-LE=19, FAC=1.
Conclusions: Cases (2) and (3) had moderate to severe motor paralysis, but HAL enabled a relatively large amount of gait training, improving motor paralysis and achieving walking independence. Conversely,
Case (4) had moderate motor paralysis; however, due to comorbidities, the patient could not receive adequate gait training, and the effect of RAGT was limited.
Case (5) had severe motor paralysis and cognitive and frontal lobe dysfunction that did not benefit from RAGT, and gait independence did not improve.
Case (1) had a higher level of gait independence before intervention and would not have been a critical target for RAGT.
Case (4) had moderate motor paralysis; however, due to comorbidities, the patient could not receive adequate gait training, and the effect of RAGT was limited.
Case (5) had severe motor paralysis and cognitive and frontal lobe dysfunction that did not benefit from RAGT, and gait independence did not improve.
Case (1) had a higher level of gait independence before intervention and would not have been a critical target for RAGT.
Implications: Multiple comorbidities that affect gait training, and cognitive or frontal lobe dysfunction may restrict the benefits of RAGT and prevent improvement in gait independence.
Funding acknowledgements: This work was supported by JSPS KAKENHI, Grant Number 22K21260.
Keywords:
stroke rehabilitation
robot-assisted gait training
hybrid assistive limb
stroke rehabilitation
robot-assisted gait training
hybrid assistive limb
Topics:
Innovative technology: robotics
Neurology: stroke
Older people
Innovative technology: robotics
Neurology: stroke
Older people
Did this work require ethics approval? Yes
Institution: Matterhorn Rehabilitation Hospital
Committee: Institutional Ethical Review Board
Ethics number: MRH21003
All authors, affiliations and abstracts have been published as submitted.
