THERAPY Magazin
Robot-assisted gait rehabilitation update
Robot-assisted gait training (RAGT) improves walking recovery after stroke. Learn how end-effector devices outperform traditional therapy and why training intensity and step dose are key to success in modern neurorehabilitation.
Jakob Tiebel
Business Owner, N+ Digital Health Agency
Update on the effectiveness and practical applicability of robot-assisted procedures for gait rehabilitation of patients after stroke
Advances in stroke rehabilitation are characterised, among other things, by robot-assisted gait training (RAGT). Studies show that RAGT using end-effector devices significantly improves walking ability. These technologies enable intensive, precise training that promotes neuronal plasticity and motor recovery. Despite the successes, questions remain about the optimal intensity and dosage, which require further research. The article provides an update on the latest developments and their integration into clinical practice.
In recent years, the field of stroke rehabilitation has changed considerably with the advent of robot-assisted therapy, which, in contrast to traditional rehabilitation methods, marks a paradigm shift. In view of the urgent need for more targeted, more intensive task-orientated rehabilitation strategies, robot-assisted gait training (RAGT) has proven to be a particularly effective method and has become established in clinical practice.
The integration of RAGT with traditional physiotherapy promises to improve post-stroke outcome by addressing both the physical and neurological aspects of gait rehabilitation, providing a more comprehensive approach to stroke rehabilitation.
The rationale for integrating RAGT into stroke rehabilitation is based on the scientific principles of neuroplasticity and motor learning. Neuroplasticity describes the brain’s remarkable ability to reorganise itself by forming new neuronal connections in response to learning or after injury. In the context of stroke rehabilitation, this plasticity is crucial for the recovery of motor functions that have been lost or impaired by brain injury [1-3].
RAGT utilises this principle by providing consistent and repetitive training, which is essential for stimulating and strengthening these new neural pathways. Such repetitive practice of walking movements using robotic support helps to retrain the brain and gradually restore the neural circuits for motor function. This is particularly important in stroke rehabilitation, where the aim is to relearn and improve motor skills such as walking [1-3].
In recent years, the field of stroke rehabilitation has changed considerably with the advent of robot-assisted therapy, which, in contrast to traditional rehabilitation methods, marks a paradigm shift. In view of the urgent need for more targeted, more intensive task-orientated rehabilitation strategies, robot-assisted gait training (RAGT) has proven to be a particularly effective method and has become established in clinical practice.
The integration of RAGT with traditional physiotherapy promises to improve post-stroke outcome by addressing both the physical and neurological aspects of gait rehabilitation, providing a more comprehensive approach to stroke rehabilitation.
The rationale for integrating RAGT into stroke rehabilitation is based on the scientific principles of neuroplasticity and motor learning. Neuroplasticity describes the brain’s remarkable ability to reorganise itself by forming new neuronal connections in response to learning or after injury. In the context of stroke rehabilitation, this plasticity is crucial for the recovery of motor functions that have been lost or impaired by brain injury [1-3].
RAGT utilises this principle by providing consistent and repetitive training, which is essential for stimulating and strengthening these new neural pathways. Such repetitive practice of walking movements using robotic support helps to retrain the brain and gradually restore the neural circuits for motor function. This is particularly important in stroke rehabilitation, where the aim is to relearn and improve motor skills such as walking [1-3].
Effective methods:
End-effector-assisted gait training and treadmill therapy with partial body weight support are particularly effective in improving walking speed and gait endurance after a stroke.
RAGT utilises advanced robotic devices and systems specifically designed to support, enhance and guide the lower limbs during walking. These technologies range from end-effector devices and robot-assisted treadmills to innovative wearable exoskeletons that adapt closely to the user’s body to support gait training. Exoskeletons provide direct physical support for the legs. They actively help with leg movements to compensate for weaknesses and ensure correct gait patterns. End-effector devices, on the other hand, focus on guiding the feet along a predetermined path and thus offer a more “active” and therefore presumably more effective method of gait rehabilitation [4-8].
The basic aim of RAGT in the field of stroke rehabilitation is to create a training environment characterised by high intensity, repetitive exercises and task-related activities. This approach is based on the principles of motor learning, which state that high-intensity training is crucial to sufficiently challenge the motor system and achieve significant improvements. A high number of repetitions is important for anchoring motor skills, as continuous practice improves execution [9-11].
Another advantage of RAGT over traditional gait rehabilitation methods is the ability to ensure consistent and controlled training. The robotic devices can precisely control movement patterns, speed and resistance, ensuring that patients perform the exercises with the correct form and intensity. This level of control is difficult to achieve with manual therapy alone. In addition, RAGT enables intensive training without physical strain for therapists and with a reduced risk of injury for patients. This is particularly important for patients with severe impairments who require comprehensive support during training [9-12].
The basic aim of RAGT in the field of stroke rehabilitation is to create a training environment characterised by high intensity, repetitive exercises and task-related activities. This approach is based on the principles of motor learning, which state that high-intensity training is crucial to sufficiently challenge the motor system and achieve significant improvements. A high number of repetitions is important for anchoring motor skills, as continuous practice improves execution [9-11].
Another advantage of RAGT over traditional gait rehabilitation methods is the ability to ensure consistent and controlled training. The robotic devices can precisely control movement patterns, speed and resistance, ensuring that patients perform the exercises with the correct form and intensity. This level of control is difficult to achieve with manual therapy alone. In addition, RAGT enables intensive training without physical strain for therapists and with a reduced risk of injury for patients. This is particularly important for patients with severe impairments who require comprehensive support during training [9-12].
Update from network meta-analyses
In everyday clinical practice, the question often arises as to which patients benefit most from which method of improving walking ability after a stroke. A network meta-analysis conducted by Mehrholz and colleagues in 2018 aimed not only to summarise the current evidence on gait rehabilitation after a stroke, but also to statistically compare all approaches to gait rehabilitation for the first time. The evaluation included 95 randomised controlled trials with a total of 4,458 patients. For the primary and secondary endpoints of walking speed and walking distance (endurance), gait training with end-effector-assisted devices and treadmill training with body weight support in particular achieved significant improvements. No difference was identified between the safety of the individual interventions [13].
In everyday clinical practice, the question often arises as to which patients benefit most from which method of improving walking ability after a stroke. A network meta-analysis conducted by Mehrholz and colleagues in 2018 aimed not only to summarise the current evidence on gait rehabilitation after a stroke, but also to statistically compare all approaches to gait rehabilitation for the first time. The evaluation included 95 randomised controlled trials with a total of 4,458 patients. For the primary and secondary endpoints of walking speed and walking distance (endurance), gait training with end-effector-assisted devices and treadmill training with body weight support in particular achieved significant improvements. No difference was identified between the safety of the individual interventions [13].
The analyses suggest that, compared to conventional gait rehabilitation, end-effector-assisted gait training and treadmill therapy with partial body weight support in particular can bring about significant and clinically meaningful improvements in walking speed and gait endurance after a stroke. For severely affected non-ambulatory patients, the use of end-effector-assisted gait training is particularly recommended. For less severely affected patients who are able to walk, on the other hand, treadmill therapy with partial body weight support is recommended. The key feature for clinical decision-making is whether the patient is already able to perform repeated stepping movements independently or to what extent guiding the distal tips of the limbs along the movement trajectory of the gait trainer offers an advantage for the therapy (e.g. forcing higher walking speed, greater step length, etc.).
Update on intensity and dose-response relationship
High-intensity gait training is recommended in stroke rehabilitation to improve walking speed, walking distance and balance. However, identifying effective and efficient implementation methods still remains somewhat of a challenge in practice.
In stroke rehabilitation, research continues to identify gaps between scientific knowledge and clinical practice. Studies and meta-analyses on gait rehabilitation describe the significantly positive effects and impacts of gait rehabilitation interventions characterised by a high number of steps and high aerobic (i.e. cardiovascular) intensities. Studies on these interventions show significantly improved walking speed, endurance and walking economy in people who have had a stroke. In particular, gait training performed at 60% to 80% of the predicted heart rate (HR) reserve can result in 2000 to 6000 steps per physiotherapy session.
High-intensity gait training is recommended in stroke rehabilitation to improve walking speed, walking distance and balance. However, identifying effective and efficient implementation methods still remains somewhat of a challenge in practice.
In stroke rehabilitation, research continues to identify gaps between scientific knowledge and clinical practice. Studies and meta-analyses on gait rehabilitation describe the significantly positive effects and impacts of gait rehabilitation interventions characterised by a high number of steps and high aerobic (i.e. cardiovascular) intensities. Studies on these interventions show significantly improved walking speed, endurance and walking economy in people who have had a stroke. In particular, gait training performed at 60% to 80% of the predicted heart rate (HR) reserve can result in 2000 to 6000 steps per physiotherapy session.
Intensity is crucial:
High-intensity gait training, performed at 60% to 80% of the heart rate reserve, shows significant improvements in walking speed and endurance, while low-intensity training is less effective.
Previous studies and guidelines have already pointed to the correlation between this “dose” of step exercises and improvements in therapy outcomes. A recent clinical practice guideline on locomotor strategies strongly recommends the use of moderate to high-intensity gait training for patients with diagnoses affecting the central nervous system [14-21].
A high-quality study by Hornby et al. (2019, 2022) shows that high-intensity gait training at 70-80% of heart rate reserve results in significant improvements in walking speed and gait endurance, regardless of the exercise variation. At least 70 steps per minute are necessary to achieve significant progress. The PHYS-STROKE study (Nave et al. 2019) supports these findings by showing that low-intensity gait training did not lead to significant improvements. This emphasises the importance of higher training intensities and a minimum number of steps in neurological gait therapy [19-21].
A high-quality study by Hornby et al. (2019, 2022) shows that high-intensity gait training at 70-80% of heart rate reserve results in significant improvements in walking speed and gait endurance, regardless of the exercise variation. At least 70 steps per minute are necessary to achieve significant progress. The PHYS-STROKE study (Nave et al. 2019) supports these findings by showing that low-intensity gait training did not lead to significant improvements. This emphasises the importance of higher training intensities and a minimum number of steps in neurological gait therapy [19-21].
High-intensity gait training can be recommended. This means walking exercises with a high number of repetitions and an intensity that increases the heart rate above a target level. The intensity should be between 60% and 80% of the patient’s maximum heart rate. It is important to note that high-intensity gait training is not only suitable for patients who can already walk. Many therapists may not realise that even patients with low functional capacity can handle increased intensity under controlled conditions and thus achieve greater progress in therapy. A consistent focus on high-intensity gait training using an end-effector gait trainer or a treadmill with partial weight support can help to use the limited time with the patient effectively and efficiently. When high-intensity gait training is at the centre of therapy, patients in current studies show significant improvements compared to control groups. An additional benefit of high-intensity exercise is the improvement in cardiovascular fitness and endurance, which can reduce the risk of another stroke.
Exoskeletons in comparison:
Wearable exoskeletons offer some benefits for improving mobility, but are not superior to other gait rehabilitation methods and require further research for optimisation and clinical application.
The question of the optimal intensity and the correct determination of a dose-response relationship in gait rehabilitation will remain a key issue that requires further research. Determining the optimal therapy dose will be of central importance for the further development of modern gait rehabilitation in order to further optimise active treatment interventions and improve motor outcomes. Randomised controlled trials have so far reported insufficiently on relevant aspects for determining the intensity and dose of the interventions. To date, there are neither clear recommendations nor a universal measurement method for the precise quantification of therapy intensity [22].
Update on mobile exoskeletons
Media and marketing often convey an image in which robotic exoskeletons enable people with brain damage or spinal cord injuries to resume everyday activities. However, these representations may not correspond to the actual technological or clinical reality. A detailed look at the current use of exoskeletons in rehabilitation shows both their advantages and their limitations. Despite the publication of 17 reviews in 2021 dealing with exoskeletons, the methodological quality of the studies was mostly inadequate, especially with regard to the description of patients and interventions. Most of the studies focussed on patients with spinal cord injury who were already able to walk and considered exoskeletons primarily as an aid in everyday life or as part of gait training in rehabilitation. While some studies suggest that exoskeletons may be particularly useful as a mobility aid at home, others show that current devices are limited for home use due to their weight, the need for support devices and the restricted range of motion. Studies on improving walking ability after stroke are still scarce and there is a lack of evidence of relevant clinical improvements. Individual studies show that although significant improvements in walking speed, step length and cadence were observed within the groups, there were often no significant differences between the groups. This suggests that although wearable exoskeletons can improve specific aspects of gait in individuals, their superiority over other forms of rehabilitation is not clear. Future developments must strive for close collaboration between engineers, clinicians and patients to improve the practicality of exoskeletons, while a sound cost-benefit analysis remains essential [23-27].
Media and marketing often convey an image in which robotic exoskeletons enable people with brain damage or spinal cord injuries to resume everyday activities. However, these representations may not correspond to the actual technological or clinical reality. A detailed look at the current use of exoskeletons in rehabilitation shows both their advantages and their limitations. Despite the publication of 17 reviews in 2021 dealing with exoskeletons, the methodological quality of the studies was mostly inadequate, especially with regard to the description of patients and interventions. Most of the studies focussed on patients with spinal cord injury who were already able to walk and considered exoskeletons primarily as an aid in everyday life or as part of gait training in rehabilitation. While some studies suggest that exoskeletons may be particularly useful as a mobility aid at home, others show that current devices are limited for home use due to their weight, the need for support devices and the restricted range of motion. Studies on improving walking ability after stroke are still scarce and there is a lack of evidence of relevant clinical improvements. Individual studies show that although significant improvements in walking speed, step length and cadence were observed within the groups, there were often no significant differences between the groups. This suggests that although wearable exoskeletons can improve specific aspects of gait in individuals, their superiority over other forms of rehabilitation is not clear. Future developments must strive for close collaboration between engineers, clinicians and patients to improve the practicality of exoskeletons, while a sound cost-benefit analysis remains essential [23-27].
It is recommended that the performance of mobile exoskeletons be critically evaluated in clinical practice, particularly in the context of neurorehabilitation. Close cooperation between developers, researchers and practitioners is essential in order to continuously improve the devices and optimise their suitability for practical use. Clinical use should be based on sound evidence to ensure that exoskeletons meet the actual needs of patients and provide the desired rehabilitative benefits. Practical experience to date strongly suggests that the technologies still need to be significantly improved in order to have a corresponding benefit in application.
Summary
Current studies show that end-effector robots achieve significant progress in gait function and balance by simulating walking movements in non-ambulatory patients in a repetitive and energy-efficient manner, thereby improving endurance, gait speed and stability. These stationary gait training systems effectively promote cortical activation and the recovery of motor functions through intensive, targeted rehabilitation that supports neuroplasticity and muscle training. In later rehabilitation phases, therapy should ideally transition seamlessly to treadmill training with or without partial body weight support and targeted everyday gait training.
However, the success of the therapy depends not only on the selection of the appropriate intervention, but also to a large extent on ensuring sufficient intensity and dose. Current research findings show that modern neurorehabilitation may require higher intensities, more progressive training protocols and a more targeted focus on minimum step counts and biological markers such as heart rate for adequate load control.
Although wearable exoskeletons improve mobility and provide realistic exercise opportunities, they do not currently demonstrate superior efficacy compared to other gait rehabilitation methods. This emphasises the need for further comparative studies to assess their relative effectiveness. Some studies suggest that an integrated approach combining proven and new therapies could potentially optimise rehabilitation outcomes.
Despite the robust evidence for the effectiveness of individual interventions, there are limitations such as small sample sizes and sometimes contradictory results. Future research should focus on larger, diverse patient groups, detailed subgroup analyses and long-term effects, and include direct comparisons between robotic systems and traditional therapies. Clarifying open questions on intensity and dose-response relationships is also crucial in order to refine robot-assisted gait training protocols and optimise their integration into clinical practice, which could ultimately lead to improved recovery outcomes for stroke survivors.
Current studies show that end-effector robots achieve significant progress in gait function and balance by simulating walking movements in non-ambulatory patients in a repetitive and energy-efficient manner, thereby improving endurance, gait speed and stability. These stationary gait training systems effectively promote cortical activation and the recovery of motor functions through intensive, targeted rehabilitation that supports neuroplasticity and muscle training. In later rehabilitation phases, therapy should ideally transition seamlessly to treadmill training with or without partial body weight support and targeted everyday gait training.
However, the success of the therapy depends not only on the selection of the appropriate intervention, but also to a large extent on ensuring sufficient intensity and dose. Current research findings show that modern neurorehabilitation may require higher intensities, more progressive training protocols and a more targeted focus on minimum step counts and biological markers such as heart rate for adequate load control.
Although wearable exoskeletons improve mobility and provide realistic exercise opportunities, they do not currently demonstrate superior efficacy compared to other gait rehabilitation methods. This emphasises the need for further comparative studies to assess their relative effectiveness. Some studies suggest that an integrated approach combining proven and new therapies could potentially optimise rehabilitation outcomes.
Despite the robust evidence for the effectiveness of individual interventions, there are limitations such as small sample sizes and sometimes contradictory results. Future research should focus on larger, diverse patient groups, detailed subgroup analyses and long-term effects, and include direct comparisons between robotic systems and traditional therapies. Clarifying open questions on intensity and dose-response relationships is also crucial in order to refine robot-assisted gait training protocols and optimise their integration into clinical practice, which could ultimately lead to improved recovery outcomes for stroke survivors.
Ambulante Rehabilitation
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Gait
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Stationäre Rehabilitation
Therapy & Practice
THERAPY 2024-II
THERAPY Magazine
Jakob Tiebel
Business Owner, N+ Digital Health Agency
Jakob Tiebel studied applied psychology with a focus on health economics. He has clinical expertise from his previous therapeutic work in neurorehabilitation. He conducts research and publishes on the theory-practice transfer in neurorehabilitation and is the owner of Native.Health, an agency for digital health marketing.
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