Neuroplastic Changes Following Brain Ischemia and their Contribution to Stroke Recovery: Novel Approaches in Neurorehabilitation

Ischemic damage to the brain triggers substantial reorganization of spared areas and pathways, which is associated with limited, spontaneous restoration of function. A better understanding of this plastic remodeling is crucial to develop more effective strategies for stroke rehabilitation. In this review article, we discuss advances in the comprehension of post-stroke network reorganization in patients and animal models. We first focus on rodent studies that have shed light on the mechanisms underlying neuronal remodeling in the perilesional area and contralesional hemisphere after motor cortex infarcts. Analysis of electrophysiological data has demonstrated brain-wide alterations in functional connectivity in both hemispheres, well beyond the infarcted area. We then illustrate the potential use of non-invasive brain stimulation (NIBS) techniques to boost recovery. We finally discuss rehabilitative protocols based on robotic devices as a tool to promote endogenous plasticity and functional restoration

Feasibility and efficacy of incorporating an exoskeleton in gait training during subacute stroke rehabilitation

Introduction: Hemiparesis is the most common acute manifestation of stroke and often has a strong negative impact on walking ability leaving one third of patients dependent in walking activities outside one’s home. Improved methods for training of gait during stroke rehabilitation could tackle the challenge of achieving independent walking and promote better outcomes. Several studies have explored the value of introducing electromechanical gait machines in stroke rehabilitation to enhance gait training. One example is the exoskeleton Hybrid Assistive Limb (HAL). The HAL system has been found feasible to use during rehabilitation in the chronic stage after stroke, however knowledge of the feasibility in the subacute stage after stroke and its efficacy compared to evidence-based conventional gait training is still limited. Aim: The overall aim of this thesis was to evaluate the safety and feasibility of HAL for gait training in the subacute stage after stroke and the effect of HAL training on functioning, disability and health compared to conventional gait training, as part of an inpatient rehabilitation program in patients with severe limitations in walking in the subacute stage after stroke. Methods: This thesis contains two studies where one is a safety and feasibility study (Study I) and one is a prospective, randomized, open labeled, blinded evaluation study (Study II). In Study I, eight patients performed HAL training 5 days/week. The number of training sessions were adjusted individually and varied from 6 to 31 (median 16). Safety and feasibility aspects of the training were evaluated as well as clinical outcomes on functioning and disability (e.g. independence in walking, walking speed, balance, movement functions and activities of daily living), assessed before and after the intervention period. In Study II, 32 patients were randomized to either conventional training only or HAL training in addition to the conventional training, 4 days per week for 4 weeks. Within and between- group differences in independence in walking, walking speed/endurance, balance, movement functions and activities of daily living were investigated before and after the intervention period, as well as 6 months post stroke. In addition, gait pattern functions were evaluated after the intervention in a three-dimensional gait laboratory. At 6 months post stroke self- perceived aspects on functioning disability and health were assessed and subsequently correlated to the clinical assessments. Results: In Study I HAL was found to be safe and feasible for gait training after stroke in patients with hemiparesis, unable to walk independently, undergoing an inpatient rehabilitation program. All patients improved in walking independence and speed, movement function, and activities of daily living during the intervention period. In addition, it was found that patients walked long distances during the HAL sessions, suggesting that HAL training may be an effective method to enhance gait training during rehabilitation of patients in the subacute stage after stroke. In Study II substantial but equal improvements in the clinically evaluated outcomes in the two intervention groups were found. At six months post stroke, two thirds of patients were independent in walking, and a younger age but not intervention group served as the best predictor. Gait patterns were similarly impaired in both groups and in line with previous reports on gait patterns post stroke. Further, self-perceived ratings on functioning, disability and health were explained by the ability to perform self-care activities and not by intervention group. Conclusion: To incorporate gait training with HAL is safe and feasible during inpatient rehabilitation in the subacute stage after stroke and may be a way to increase the dose (i.e. number of steps) in gait training in the subacute stage after stroke. Among these included younger patients with hemiparesis and severe limitations in walking in the subacute stage after stroke, substantial improvements in body function and activity as well as equally impaired gait patterns were observed both after incorporated HAL training and after conventional gait training only, but without between-group differences. In future studies, potential beneficial effects on cardiovascular, respiratory, and metabolic functions should be addressed. Further, as the stroke population is heterogeneous, potential subgroups of patients who may benefit the most from electromechanically-assisted gait training should be identified

Effects on mobility training and de-adaptations in subjects with Spinal Cord Injury due to a Wearable Robot: A preliminary report

open7noopenSale, Patrizio; Russo, Emanuele Francesco; Russo, Michele; Masiero, Stefano; Piccione, Francesco; Calabrò, Rocco Salvatore; Filoni, SerenaSale, Patrizio; Russo, Emanuele Francesco; Russo, Michele; Masiero, Stefano; Piccione, Francesco; Calabrò, Rocco Salvatore; Filoni, Seren

MIT-Skywalker: considerations on the Design of a Body Weight Support System

Background To provide body weight support during walking and balance training, one can employ two distinct embodiments: support through a harness hanging from an overhead system or support through a saddle/seat type. This paper presents a comparison of these two approaches. Ultimately, this comparison determined our selection of the body weight support system employed in the MIT-Skywalker, a robotic device developed for the rehabilitation/habilitation of gait and balance after a neurological injury. Method Here we will summarize our results with eight healthy subjects walking on the treadmill without any support, with 30% unloading supported by a harness hanging from an overhead system, and with a saddle/seat-like support system. We compared the center of mass as well as vertical and mediolateral trunk displacements across different walking speeds and support. Results The bicycle/saddle system had the highest values for the mediolateral inclination, while the overhead harness body weight support showed the lowest values at all speeds. The differences were statistically significant. Conclusion We selected the bicycle/saddle system for the MIT-Skywalker. It allows faster don-and-doff, better centers the patient to the split treadmill, and allows all forms of training. The overhead harness body weight support might be adequate for rhythmic walking training but limits any potential for balance training

Advanced technology for gait rehabilitation: An overview

Most gait training systems are designed for acute and subacute neurological inpatients. Many systems are used for relearning gait movements (nonfunctional training) or gait cycle training (functional gait training). Each system presents its own advantages and disadvantages in terms of functional outcomes. However, training gait cycle movements is not sufficient for the rehabilitation of ambulation. There is a need for new solutions to overcome the limitations of existing systems in order to ensure individually tailored training conditions for each of the potential users, no matter the complexity of his or her condition. There is also a need for a new, integrative approach in gait rehabilitation, one that encompasses and addresses all aspects of physical as well as psychological aspects of ambulation in real-life multitasking situations. In this respect, a multidisciplinary multinational team performed an overview of the current technology for gait rehabilitation and reviewed the principles of ambulation training

Role of Assistive Devices on Gait in Patients with Incomplete Spinal Cord Injury: Systematic Review

Background: People with incomplete spinal cord injury disabilities can be able to live a healthy, productive, and dignified life by using Assistive devices as their role in improving gait. Facilitate locomotion rehabilitation. And enable people with incomplete SCI to ambulate in an upright position. Objective: This systematic review aimed to examine the effectiveness of the role of using assistive devices in gait rehabilitation in patients with incomplete SCI. Material and Methods: Studies were identified from 2000 to 2020 by electronic search using PubMed, Cochrane Database of Systematic Reviews, Google Scholar, and Physiotherapy Evidence Database (Pedro). They were reviewed if they were randomized control trials focused on the effectiveness of Assistive Devices on Gait in Patients in age more than 18 years with incomplete Spinal Cord Injury being published in English. Eight studies were selected according to inclusive and exclusive criteria and descriptive analysis was conducted due to heterogeneity. Results: Eight trials were identified with good quality methodology. Descriptive analysis was applied for three studies that supported the use of assistive devices for those patients and meta-analysis was applied for five studies. The mean difference across all the five studies is -0.69 (95% CI -0.93, -0.45). According to AACPDM, there is level II evidence that supports the use of the assistive device as a method to be able to live a healthy, productive, and dignified life. Conclusion: The current level of evidence supports the effectiveness of assistive devices in improving gait in patients with incomplete spinal cord injury