Clinical Significance of Robot Manipulators for Grasp, Balance, and Gait Recovery (from the Medical Point of View)

Abstract

Robots and virtual reality are now introduced in clinical neurorehabilitation practice. The inclusion of robots in the complex rehabilitation program supports functional recovery, ameliorates the quality of care, and increases the quality of life of patients. Grasp, balance, and gait are important activities, necessary for autonomy in everyday life. Therefore, grasp and gait recovery are important indices of the efficacy of neurorehabilitation. The application of robotic rehabilitation accelerates the process of grasp and gait training, improves the balance and gait stability, and ameliorates the independence of patients in everyday life. We have clinical experience with patients suffering from different neurological and neurosurgical conditions: hemiparesis after cerebral vascular accident, multiple sclerosis, and Guillain-Barre syndrome and after neurosurgical intervention for brain or spinal cord aneurysm, tumor, or trauma. Here, we present some of our own results in patients with post-stroke hemiparesis and with inferior paraparesis after spinal cord injury. We consider that the introduction of robots in the process of grasp, balance, and gait recovery of patients with neurological conditions and after neurosurgical interventions can be very useful for neurorehabilitation clinical practice.

1. Introduction

Robots and virtual reality are now introduced in clinical neurorehabilitation practice. We consider that the inclusion of robots in the complex rehabilitation program accelerates functional recovery, ameliorates the quality of care, and increases the quality of life of patients.

2. Rehabilitation, physical and rehabilitation medicine, and neurorehabilitation

2.1 Rehabilitation

Rehabilitation is a functional therapy, based on detailed functional assessment. The goals of rehabilitation are oriented to functional compensation and functional recovery, according to the World Disability Report of the World Health Organization and the World Bank [1]. Currently, in clinical rehabilitation practice, we apply the International Classification of Diseases (ICD) [2], the International Classification of Functioning, disability and Health (ICF) [3], and appropriate scales for the evaluation of the quality of life [4].

2.2 Physical and rehabilitation medicine

The medical specialty of Physical Medicine (or Physiatry) uses different physical modalities for the improvement of the patient’s quality of life. The principal objectives of Physical and Rehabilitation Medicine (PRM) are oriented to the “promotion of physical and cognitive functioning,” to “amelioration of autonomy and quality of life” and to “optimization of social participation” of patients with health-related disability and co-morbidity, according to the documents of the PRM-section of the European Union of Medical Specialists [5, 6, 7, 8]. For this, we need the support of rehabilitation medicine, rehabilitation therapy, and assistive technologies [1].

2.3 Neurorehabilitation algorithms

Neurorehabilitation (NR) is an interdiscipline – between neurology, neurosurgery, physical and rehabilitation medicine [9, 10].

The NR algorithm includes a detailed functional assessment and a complex program of care (with different natural and pre-formed physical factors) [4].

The functional assessment of the patient includes evaluation of the range of motion (goniometry), of muscle force and muscle weakness (dynamometry and manual muscle test); assessment of grasp, balance, gait, and autonomy in everyday life; ICD diagnostics and ICF evaluation.

The NR program is established by a synergic combination of several physical modalities: physical exercises, sports, activities, cryo- and thermo-procedures, mineral waters and peloids, electric currents, light (including laser), magnetic field, ultrasound, etc. [4, 9, 10]. In clinical practice, usually we prescribe one or two procedures with pre-formed modalities; one thermo- or cryo-agent; one or two physiotherapeutic methods (soft tissue techniques, manual therapy, analytic exercises); and one or two ergo therapeutic activities (sports; training of grasp, balance, gait or activities of daily living; self-care; domestic occupations; and professional activities) [9].

At the end of the NR course, a final functional assessment is required – with the goal to evaluate the efficacy of our intervention and to prescribe consecutive rehabilitation procedures. In chronic conditions, usually, we recommend an everyday program of physical exercises, combined with a number of rehabilitation courses of 10–30 procedures (for a period of 2 weeks to 1 month), applied periodically.

3. Grasp and gait: grasp and gait rehabilitation

3.1 Grasp, grip and prehension

Grasp is the ability of the digits to seize, for holding or picking up different objects, using the hand. The firm grasp is defined as grip. Prehension is the act of grasping or seizing; the name descends from the Latin verb “prehendere,” meaning “to seize” or “to grasp”. The traditional classification of Hippocrates is based on function. Hippocrates differentiates power grasp or grip for strength; and prehension grip or pinch for precision [10, 11, 12].

In rehabilitation clinical practice, we apply the conventional classification of Neumann, based on the purpose of the task and the number of involved fingers. He differentiates power and precision grasp; grip, pinch, and hook grip. All fingers are involved in grip; thumb and index are used in pinch; all fingers without thumb participate in hook grip. Investigators and practitioners divide power grasp into: cylindrical, spherical, and hook grips. In a cylindrical grasp, the entire palmar surface of the hand is positioned around a cylindrical shaped object, using many muscles: finger flexors, including thumb flexors, intrinsic muscles, and thumb abductors. During spherical grasp, the thenar and hypothenar eminences are in a cupping position; all interossei muscles and flexors are involved, especially those of the fourth and fifth fingers. In hook grasp, all fingers are flexed, with the participation of the muscle flexor digitorum profundus. The precision grasp is divided into various types: palmar pinch (pad-to-pad), tip-to-tip pinch, lateral or key pinch, pencil apprehension, and interdigital or cigarette grasp [10, 11].

3.2 Locomotion and gait

Locomotion is the act of moving from place to place by means of one’s own mechanisms or power [11]. The locomotion is realized: on foot (walking, running, ascending or descending stairs, jumping); on wheels (bicycling, skating, wheelchair); on hands and knees or hands and feet; rotary locomotion [11].

Gait is a manner of moving on foot [12]. Bipedal walking is an important characteristic of humans. The gait cycle is a repetitive pattern, including steps and strides. A step is one single footstep; a stride is the complete succession of one step with every lower extremity. The gait cycle is the sequence of one stance phase and one swing phase in proportion 3:2 (ratio 60 to 40%); the motion of every lower extremity is a combination of open-chain and closed-chain movements. Different sub-phases of the walking cycle are described [13, 14, 15]. Authors divide the stance phase into several sub-phases: heel strike (initial contact of the heel with the ground), foot flat (full contact of the foot with the base), mid-stance or support (support on one foot, with full weight bearing on this foot), heel-off, toe-off, and pre-swing (propulsion). The swing phase is divided into three sub-phases: acceleration (initial swing), mid-swing (constant velocity of the leg movement), and deceleration (late or terminal swing).

In clinical practice, we currently use several variables for gait analysis: step length, cadence (steps per minute), and walking velocity.

Pathological gait can be due to many musculoskeletal or neurological conditions. Every joint disorder of the lower limb may cause pathological gait: hip, knee, foot, and ankle pathology. Arthritis, muscle and joint contractures, leg length discrepancy, and pain can provoke the development of a pathological gait. Numerous neurological diseases can cause pathological gait types: hemiplegic gait, paraplegic gait, parkinsonian gait, and ataxic gait. The most frequent types of pathological gait in rehabilitation practice are presented in Figure 1. For example, spastic hemiparetic gait (Wernicke-Mann posture and gait – in patients with post-stroke hemiparesis), Parkinsonic gait, spastic paraparetic gait (in cases with multiple sclerosis, cerebral palsy, or after spinal cord injury at the thoracic level), gluteus medius gait (trendelenburg gait – in hip osteoarthritis), steppage gait (in peroneal paresis), antalgic gait (in discal hernia or in coxarthrosis), etc.

Figure 1.

Frequent pathological gait in rehabilitation.

In rehabilitation, we use many qualitative methods for the evaluation of gait: Walking tests for 2, 6 minutes, or for 10 meters; timed up and go (TUG) test; and Tinetti test. For balance assessment, we apply the Romberg test (with open eyes or with closed eyes).

3.3 Grasp and gait rehabilitation

Grasp and gait (GG) are important activities, necessary for autonomy in everyday life. Therefore, grasp, balance, and gait recovery are significant indices for the efficacy of rehabilitation.

We use standardized protocols for recovery of the grasp, balance, and gait [11].

Before the initiation of the grasp training, we need some preparation by functional exercises: bilateral hand use; thumb opposition; in-hand manipulation; and pre-writing activities – make a puzzle and cut the line. Occupational therapists propose some sensory-motor games – with tennis balls, cotton balls, Lego, finger paint, stamps, stickers, and putty activities. Ultimately, several authors discuss the impact of mirror box therapy – for training different grasp types, especially in patients with hemiplegia or hemiparesis [11].

In post-stroke hemiparesis, we observe a characteristic position of the body and extremities, and spastic hemiparetic gait (Wernicke – Mann posture and gait). We apply position therapy; proprioceptive neuromuscular facilitation (PNF); electrical stimulations for spasticity control and improvement of muscle weakness; cryotherapy or paraffin applications; grasp, balance, and gait training. In case of hemiparetic shoulder, we use interferential electric currents, low-intensity low-frequency magnetic field, functional electrical stimulations of the central fibers of the deltoid muscle, cryotherapy, and analytic exercises. In case of a developed hemiplegic hand, we apply magnetic field, laser therapy, paraffin or ice, active exercises, electrical stimulations of the antagonists of the spastic muscles, and mirror therapy.

The classical algorithm in multiple sclerosis includes magnetic field, cryotherapy, hydrotherapy with low temperature of the water (under the indifferent level), balneotherapy with mineral waters (containing sulphur), and underwater exercises.

In Parkinsonism, we use interferential currents, magnetic field, relaxing massage, physiotherapy, and occupational therapy.

In peripheral neurological conditions (as lumbo-sacral radiculopathy), we adapt the algorithm to the phase of the disease. During the acute stage, we apply diadynamic electric currents, magnetic field, transcutaneous electro-neuro-stimulation (TENS), deep oscillation (DO), relaxing massage, analytic exercises, and position therapy. In the sub-acute stage, we prefer TENS, middle-frequency electric currents (interferential currents, sinusoidal-modulated currents, Kotz currents), soft-tissue techniques, and active exercises. During the chronic stage, we include high-frequency electric currents, ultra-sound or phonophoresis with non-steroidal anti-inflammatory drugs, massage, exercises, peloids (therapeutic mud applications, sea lye compresses), balneotherapy, underwater massage, and underwater exercises. In cases with peripheral paresis, the algorithm recommends electrophoresis (iontophoresis) with galantamine hydrochloride (Bulgarian drug: Nivalin) and functional electrical stimulations (with exponential form of the pulses) in the motor points of the altered nerve and of the paretic muscles, analytic exercises, and underwater gymnastics. We consider most effective the gait training in water.

In orthopedic and traumatic disorders, the algorithm for gait recovery includes interferential currents, magnetic field, electrical stimulations, cryotherapy, and exercises. In bone fractures, we apply interferential currents, magnetic field, position therapy, and exercises for muscle force. In joint luxation, we prescribe interferential electric currents, magnetic field, TENS, diadynamic currents, cryotherapy, and exercises for range of motion.

In rheumatologic conditions, we use TENS, low and middle frequency electric currents, electrical stimulations, DO, soft tissue techniques, and active exercises. In degenerative joint conditions, we can use thermotherapy and peloids. In inflammatory joint diseases, during the acute stage we apply cryotherapy.

In every case, the basic rehabilitation algorithm must be adapted to the individual patient’s needs.

4. Robots, virtual reality, and robotic rehabilitation

4.1 Robot

The origin of the term “Robot” is from the proto-slavic word “robota” or “rabota,” meaning work or hard work in many Slavic languages, as Czech, Slovak, Bulgarian, Russian, Polish, Ukrainian, and others [16].

The Robot Institute of America defined a robot as “a programmable, multi-functional manipulator designed to move material, parts or specialized devices through variable programmed motions for the performance of a variety of tasks” [17].

The three Ds “Dull, Dirty, and Dangerous” describe the tasks of a robot (with repetitive movements and weight-support of patients in rehabilitation clinical practice) [18]. Robots help the staff in the process of control and measurements of patients’ movements [19].

Different types of robots are applied in neurorehabilitation: for upper and for lower extremities, unilateral (for grasp training) and bilateral (for gait training); exoskeletons and controllers of endpoint trajectories.

We must underline the difference between robots and electro-mechanical devices, (for example, treadmill with body weight support); the presence of “intelligent” sensors is the key point for differentiation [20].

4.2 Neurorobotics

Neurorobotics is the branch of science using neuroscience, robotics, and artificial intelligence [21].

Neurorobots have the capacity to adapt, due to their on-board sensors. The treadmill with body-weight support is an electro-mechanical device and not a robot [22]. On the other hand, Lokomat (a device for gait training) is a neurorobot, using sensors for adaptation of its function to the patient’s performance [17, 23].

The safety of the human beings is the most important in the construction of the robots. The three laws of robotics are firstly explained in the book of Isaac Asimov “I, Robot” in 1950 [24]. During the application of neurorobots, we need safety and efficacy. The formulation of the three laws of neurorobotics includes these requests [23]. The first law for safety of medical devices and robots and the need for a high Benefit/Risk ratio are supported by the requirements of the International Organization for Standardization [25, 26].

Many ethical dilemmas can be generated in the practice of robotic NR. We must clarify the ethical issues to constructors and therapists [27, 28].

The capacity of the artificial intelligence to support human intelligence is enormous [28, 29]. The main qualities of neurorobots for NR include high mechanical compliance, large range of force, adaptive assistance properties, possibility to assess the functional potential of the patient and to evaluate the progress of the functional level; flexibility (capacity for individualized treatment); and uniformity (sufficient scientific evidence), etc. [21, 30, 31].

Effectiveness of neurorobots in rehabilitation is proved by numerous studies on various topics, especially in patients after traumatic spinal cord injury, and on NR in post-stroke hemiparesis [32, 33].

Some limitations of NR robots are described: monotony, exacerbation of spasticity, economic barriers, etc. [21]

4.3 Virtual reality

In numerous sources, the term virtual reality (VR) is used for any computer-based technology providing monitor-based visualization. Nevertheless, the strict definition must include a user-computer interface, generating an environment including many sensorial channels (visual, auditory, and even smell and taste). A standard videogame is not a VR (for the moment). VR applies the three Is: immersion, interaction, and imagination [34].

Ultimately, many studies were published, proving efficacy of application of VR in neurorehabilitation, especially for the recovery of patients’ autonomy in activities of daily living, emphasizing grasp, balance, and gait [35, 36, 37, 38, 39, 40].

5. Robotic neurorehabilitation and neuroplasticity

5.1 Robotic NR

The goal of neurorehabilitation is to stimulate functional recovery by therapeutic interventions, oriented to excite the activity-dependent or experience-dependent neuroplasticity [10, 32].

Traditionally, NR uses methods and techniques of physical medicine: natural and preformed physical modalities, such as physiotherapy, occupational therapy, underwater exercises, soft-tissue techniques, electrical stimulations, TENS, magnetic field, laser, DO, etc. During the past few years, we observe the introduction of new methods in NR practice: constraint-induced movement therapy (intensive, experience-based, repetitive motor training of a paretic limb); weight-supported treadmill walking (intensive, experience-dependent functional movement training); motor training for language recovery; prism adaptation training for spatial neglect (with virtual feedback); transcranial magnetic stimulation; and transcranial direct current stimulation [19, 41, 42].

Principles of NR include task-specific and goal-oriented practice, increasing difficulty, multisensory stimulation, rhythmic cueing, knowledge of performance and of results, and social interaction [32, 43].

Many modern devices and techniques are applied ultimately in the clinical practice of NR, especially robotics (neurorobotics) and virtual reality [44]. The future of NR for post-stroke patients includes the application of modern devices, such as robots, brain-computer interfaces, noninvasive brain stimulators, neuroprosthesis, virtual reality, wearable devices, tablet PC, and others [20].

5.2 Neuroplasticity

According to the medical dictionaries: “neuroplasticity is the brain’s capacity to reorganize itself by forming new neural connections throughout life.” The “aim” of neuroplasticity is to optimize neural networks during phylogenesis, ontogenesis and physiological learning, and in case of brain disease [45, 46].

Principal mechanisms of brain repair are based on brain plasticity (spontaneous recovery, input of “axonal sprouting” and “mirror-neurons”, use-dependent plasticity, synaptic or gray matter plasticity, and white matter plasticity) [47]. Many factors influence neuroplasticity, for example, physical activity, exercises, diet, and rehabilitation procedures [48, 49, 50, 51].

The goal of NR is the patient’s adaptation to the “new” situation (of neuronal alteration).

Neuroplasticity is the pathophysiological basis for treatment of the cerebral lesions through physical training and rehabilitation, including goal-directed activities [10]. In practice, every rehabilitation process uses neuroplasticity (training plasticity, use-dependent or activity-depending plasticity) for functional recovery and amelioration of independence in the everyday life of neurological patients [52, 53].

6. Our clinical experience

We have clinical experience with patients suffering from different neurological and neurosurgical conditions: hemiparesis after cerebral vascular accident, multiple sclerosis, Guillain-Barre syndrome and after neurosurgical intervention for brain or spinal cord aneurysm, tumor, or trauma. Here, we present some of our own results with post-stroke hemiparesis and after spinal cord injury.

6.1 Robotic NR in post-stroke hemiparesis

The goals of stroke rehabilitation are to maximize functional independence; to prevent and manage comorbidities; to optimize psycho-social adaptation of patient and family; to enhance quality of life; to facilitate resumption of prior life roles; and to reintegrate patient in professional life and in social life.

The functional recovery after a cerebro-vascular accident depends on the three Ps: Preservation, Prevention and Plasticity (early treatment for preservation of the cerebral tissue, prevention of the brain loss and of eventual recurrent stroke, using plasticity through rehabilitation). The brain possesses a significant capacity to reorganize itself and to recover from loss of function, following a stroke. Rehabilitation training stimulates brain reorganization and accelerates functional recovery.

NR in post-stroke patients traditionally applies different PRM techniques: proprioceptive neuromuscular facilitation, Kabath and Brunnstrom methods, neurodevelopmental training (Bobath concept), and sensorimotor therapy (Rood approach). Ultimately, some modern modalities were included in the rehabilitation process, such as motor relearning program, constraint-induced movement therapy, mirror therapy, transcranial electric (direct current) stimulation, transcranial magnetic stimulation, low intensity focused transcranial ultrasonic stimulation, functional electrical stimulation (FES), vagus nerve stimulation, electromyographic (EMG) biofeedback, robotic devices, and virtual reality.

6.1.1 Clinical case of NR with exoskeleton in post-stroke hemiparesis

Ultimately, we observe an increasing frequency of cerebro-vascular diseases (with high levels of mortality and disability) in several countries, including Bulgaria.

We present a clinical case of a female patient, 67 years old, 3 months after an ischemic stroke.

For evaluation, we use detailed neurological exam, functional assessment through classical scales and the International Classification of Functioning (ICF). At the entry, the patient presented left spastic hemiparesis, motor functions level 3–4 according the Brunnstrom classification, left superficial hemi-hypoesthesia, and contractures of the left wrist and fingers, ankle, and toes.

For treatment, we applied a complex NR program (of 20 procedures), including traditional physiotherapy and ergotherapy procedures, balance and gait training, electrical stimulations for the muscles – extensors of the wrist, ankle, and toes of the paretic extremities (with tetanic pulses), and robotic NR with exoskeleton (a Cyberdyne device) for balance and gait training (Figure 2). According to dictionaries, an exoskeleton (from Greek ἔξω, éxō “outer” and σκελετός, skeletos “skeleton”) is the external skeleton that supports and protects the body, in distinction with the internal skeleton (endo-skeleton). In this case, we used the hybrid assistive limb (HAL) – exoskeleton for lower extremities (double leg), medium size, and leg length – size M.

Figure 2.

Gait training of a patient with post-stroke hemiparesis with exoskeleton.

We observed significant functional recovery: reduction of the muscle weakness and contractures, stabilization of the equilibrium, retrieval of the autonomic gait (with one cane), and amelioration of autonomy in activities of daily living. Therefore, the NR with exoskeleton improves the bipedal synchronization and ameliorates the “normal” gait pattern of the patient [54].

6.1.2 Robotic-based GG-NR of hemiparetics after stroke

6.1.2.1 NR program

During the NR process, we accentuate on functional recovery, capacities for different activities, and autonomy in everyday life. We apply a synergic combination of physiotherapy, occupational therapy, thermo- or cryotherapy, electrotherapy, etc. The duration of the NR course in our country traditionally is 20 procedures, 5 days a week, for 4 weeks. The PRM program includes:

• Physiotherapy: individualized movement program (proprioceptive neuro-muscular facilitation/PNF/techniques by Kabath or Bobath, analytic exercises for the paretic limbs, balance training, training of transfers and gait, exercises to stabilize the gait on flat terrain and on stairs; soft tissue techniques); duration 45 minutes, twice a day;

• Cryotherapy with ice block – distally in upper and lower extremities, duration 2–3 minutes per field, twice daily;

• Occupational therapy (OT), including training in activities of daily living (ADL), especially for self-care – 30 minutes, twice a day;

• Analytic exercises and manipulative activities (grasp training) with a mirror box (mirror therapy) – 10–20 minutes a day;

• Functional electrical stimulations (FES) – a stable method of application, for the extensors of the paretic upper and lower limbs (with special attention to the wrist and ankle) and for the flexors of the fingers and toes, with tetanic pulses, a procedure of 10–20 minutes, once a day;

• Training of the upper limb with tyro-motion devices – 30–60 minutes a day (see Figure 3);

• Training of the paretic lower limb with Lokomat Pro (Hocoma device) – a procedure of 45–60 minutes, every day (see Figure 4);

• Patient education (position therapy, control of spasticity, grasp and gait training; hypolipid and hypoglucid diet; ending of smoking and alcohol abuse; control of lipid profile and arterial hypertension; and stress control).

Figure 3.

Grasp and grip training of post-stroke patients with tyro-station.

Figure 4.

Gait training of patients with post-stroke hemiparesis.

6.1.2.2 Results of the robotic-based grasp-NR

Figure 3 presents the potential of the Tyro-motion station for training different types of grasp – cylindrical, precise, interdigital, etc.

The tyro-system has the capacity to realize quantitative evaluation of the grasp recovery during consecutive sessions (Figures 5–8). In different patients, we observed amelioration of the grasp and the autonomy in activities of daily living – ADL (Figure 5), of the joint range of motion (Figure 6) and of muscle force (Figure 7). The reduction of spasticity in the paretic upper extremity was evaluated using two spasticity scales – of Tardieu and of Ashworth (Figure 8).

Figure 5.

Traditional NR versus robotic NR – Our own results for upper limb.

Figure 6.

Efficacy of robotic NR on the range-of-motion of the upper extremity.

Figure 7.

Efficacy of robotic NR on the muscle force of the upper extremity.

Figure 8.

Reduction of spasticity in the upper limb muscles during robotic NR – Using both scales (of Ashworth and Tardieu).

During past few years, we had the possibility to realize a comparison between traditional NR and robotic NR [54]. The NR program in all patients with post-stroke hemiparesis included: traditional physiotherapy, occupational therapy, cryotherapy, and functional electrical stimulations. The control group (68 patients) received only these procedures. In the experimental group (54 patients), we added robotic NR – three sessions weekly. We obtained a significant increase of the force of the precise grasp with the paretic hand and amelioration in autonomy in activities of daily living (ADL), as presented in Figure 5.

6.1.2.3 Results of the robotic-based gait-NR

The Lokomat system of Hocoma is designated for intensive functional gait training, including a computer-guided electric orthosis for assistance of movements of lower extremities during locomotion (Figure 4). The device Lokomat Pro (professional) has the potential of regulation of the speed, load and robotic aid, and can be adapted to the patient’s measures and physical capacity. The exoskeleton of Lokomat Pro corrects the gait pattern. The inclusion of elements of virtual reality (audio-visual stimuli, as environment, music, games) ameliorates the patient’s tolerance, especially in children or in older adults.

Principal indications include motor weakness due to neurological diseases and conditions (hemiparesis after stroke or traumatic brain injury, multiple sclerosis, Parkinsonism, cerebral palsy, paraparesis after spinal cord injury, Guillain-Barre syndrome, and peripheral paresis) and degenerative joint diseases (as hip and knee osteoarthritis). The device can be applied in patients with a height of maximum 200 cm and weight up to 135 kg.

Absolute contra-indications include osteopenia and osteoporosis, fractures of lower limbs, cardiac or respiratory insufficiency, cognitive deficiency, infections, epilepsy, and pregnancy. Relative contra-indications are arthroplasty, muscle or joint contractures and joint instability in lower limbs, loss of control of the head and the upper part of the body, skin lesions in the region of contact with the orthosis, and electronic devices (as intrathecal baclofen pump and pace-maker).

The device has the potential to reduce partially the weight in lower limbs and to correct the gait pattern. These capacities are very useful in cases of muscle weakness and pathologic gait (Wernicke-Mann gait in post-stroke hemiparesis, spastic paraparetic gait in spinal cord injury at thoracic level, etc.).

The Lokomat Pro system of Hocoma has the capacity to realize quantitative evaluation of the gait recovery during consecutive sessions.

Figures 9–12 present the results of the Lokomat-NR of different patients with hemiparesis after cerebrovascular accident. We compared parameters between the first and the last therapeutic session – usually our patients have 20–30 procedures of 50 minutes, for a period of 1 to 3 months, and frequency of sessions is twice a week. The number of procedures is adapted to the patients’ potential and needs (physical condition and comorbidities). We observed an increase of the distance during the therapeutic session (Figure 9), increase of the duration of the procedure (Figure 10), increase of the gait velocity (Figure 11), and changes in body weight support – reduction of the relative part of the mechanic support (Figure 12).

Figure 9.

Lokomat Pro results: Increase of the distance during sessions.

Figure 10.

Increase of the duration of the procedure with Lokomat Pro.

Figure 11.

Locomat Pro results: Increase of the gait velocity.

Figure 12.

Body weight support – Reduction of the relative part of the mechanic support.

6.2 Lokomat NR after spinal cord injury with inferior paraparesis

Patients after spinal cord injury (SCI) present loss of motor control and loss of sensibility. In cases after SCI at thoracic level, we observe inferior spastic paraplegia. Entry at the NR department is usually 1 to 3 months after the neurosurgical stabilization (Figure 13).

Figure 13.

X-rays of typical patients with inferior paraplegia/paraparesis.

We apply a standard NR program, including physiotherapy, ergotherapy, cryotherapy, electrical stimulations for extensors of the ankle and toes, and balance and gait training with Lokomat Pro (Hocoma system).

6.2.1 Results of the Lokomat-NR of paraparetics after SCI

The next figures present the results of the Lokomat-NR of a series of patients with inferior paraparesis after spinal cord injury at the thoracic level.

We took out the data directly from the device, and we received significant results, comparing different sessions of robotic NR: amelioration of functional parameters of the gait, increase of the range of motion and the muscle force of lower extremities, and improvement of the proprioception in lower limbs.

The increase of the distance during a procedure is presented in Figure 14.

Figure 14.

Increase of the distance in paraparetics – Lokomat-NR.

The increase of the duration of the therapeutic session – Figure 15.

Figure 15.

Increase of the duration of the session in paraparetics – Lokomat-NR.

The reduction of the mechanic support during sessions with a graphic of the dynamics in body weight support is presented in Figure 16.

Figure 16.

Body weight support during sessions of Lokomat-NR.

Figure 17 demonstrates the increase of the range of motion in the lower limbs of paraparetics.

Figure 17.

Increase of the ROM in paraparetics – Lokomat-NR.

An amelioration of the proprioception is observed (Figure 18).

Figure 18.

Amelioration of the proprioception.

6.2.2 Traditional NR versus robotic NR – Our own results

During last years, we observed patients, treated with traditional NR and Lokomat-based NR. We noticed the difference in results, obtained in both types of rehabilitation methods – traditional NR and robotic NR [54].

Here, we present some results, concerning the autonomic gait.

The NR program in all 72 patients with post-traumatic inferior spastic paraparesis included traditional physiotherapy, occupational therapy, cryotherapy, and functional electrical stimulations. The control group (38 patients) received only these procedures. In patients of the experimental group (34 patients), we added robotic NR – three sessions weekly.

We obtained an increase of the velocity of the gait (with technical aids – wheelchair, crutches, and canes) in both groups, but the results were most significant in the experimental group (with Lokomat training), as demonstrated in Figure 19.

Figure 19.

Traditional versus robotic NR – Our own results for ambulation.

7. Conclusion

The application of robotic rehabilitation accelerates the process of grasp and gait recovery, improves the quality of care, and ameliorates the autonomy in everyday life of neurologic patients (especially with post-stroke hemiparesis and inferior paraparesis after spinal cord injury).

Complex neurorehabilitation with robots and virtual reality stimulates activity-induced neuroplasticity, enhances bimanual and bipedal synchronization, and corrects the patterns of the grasp, balance, and gait.

Acknowledgments

There is no financial support for this research and work.

No ethical issues. We respect the requirements of the Declaration of Helsinki (1964) for the protection of patients. All patients signed written informed consent for every diagnostic and therapeutic procedure and for publication of the correspondent data and photos.

Conflict of interest

Authors declare no conflict of interest.