The FreeD module's lateral translation timing in the gait robot Lokomat: a manual adaptation is necessary.

BACKGROUND: Pelvic and trunk movements are often restricted in stationary robotic gait trainers. The optional FreeD module of the driven gait orthosis Lokomat offers a combined, guided lateral translation and transverse rotation of the pelvis and may therefore support weight shifting during walking. However, from clinical experience, it seems that the default setting of this timing does not correspond well with the timing of the physiological pelvic movement during the gait cycle. In the software, a manual adaptation of the lateral translation's timing with respect to the gait cycle is possible. The aim of this study was to investigate if such an offset is indeed present and if a manual adaptation by the therapist can improve the timing towards a more physiological pattern comparable to physiological overground walking. METHODS & RESULTS: Children and adolescents with neurologic gait disorders and a Gross Motor Function Classification System level I-IV completed two different walking conditions (FreeD Default and FreeD Time Offset) in the Lokomat. The medio-lateral center of mass positions were calculated from RGB-Depth video recordings with a marker-less motion capture algorithm. Data of 22 patients (mean age: 12 ± 3 years) were analyzed. Kinematic analyses showed that in the FreeD Default condition, the maximum lateral center of mass excursion occurred too early. In the FreeD Time Offset condition, the manual adaptation by the therapists led to a delay of the maximum center of mass displacement by 8.2% in the first phase of the gait cycle and by 4.9% in the second phase of the gait cycle compared to the FreeD Default condition. The maximum lateral center of mass excursion was closer to that during physiological overground walking in the FreeD Time Offset condition than in the FreeD Default condition. CONCLUSION: A manual adaptation of the timing of the FreeD module in the Lokomat shifts pelvis kinematics in a direction of physiological overground walking. We recommend therapists to use this FreeD Time Offset function to adjust the phase of weight shifting for each patient individually to optimize the kinematic walking pattern when a restorative therapy approach is adopted.

Clustering trunk movements of children and adolescents with neurological gait disorders undergoing robot-assisted gait therapy: the functional ability determines if actuated pelvis movements are clinically useful.

INTRODUCTION: Robot-assisted gait therapy is frequently used for gait therapy in children and adolescents but has been shown to limit the physiological excursions of the trunk and pelvis. Actuated pelvis movements might support more physiological trunk patterns during robot-assisted training. However, not every patient is expected to react identically to actuated pelvis movements. Therefore, the aim of the present study was to identify different trunk movement patterns with and without actuated pelvis movements and compare them based on their similarity to the physiological gait pattern. METHODS AND RESULTS: A clustering algorithm was used to separate pediatric patients into three groups based on different kinematic reactions of the trunk to walking with and without actuated pelvis movements. The three clusters included 9, 11 and 15 patients and showed weak to strong correlations with physiological treadmill gait. The groups also statistically differed in clinical assessment scores, which were consistent with the strength of the correlations. Patients with a higher gait capacity reacted with more physiological trunk movements to actuated pelvis movements. CONCLUSION: Actuated pelvis movements do not lead to physiological trunk movements in patients with a poor trunk control, while patients with better walking functions can show physiological trunk movements. Therapists should carefully consider for whom and why they decide to include actuated pelvis movements in their therapy plan.

The FreeD module for the Lokomat facilitates a physiological movement pattern in healthy people - a proof of concept study.

BACKGROUND: A contralateral pelvic drop, a transverse rotation and a lateral translation of the pelvis are essential features of normal human gait. These motions are often restricted in robot-assisted gait devices. The optional FreeD module of the driven gait orthosis Lokomat (Hocoma AG, Switzerland) incorporates guided lateral translation and transverse rotation of the pelvis. It consequently should support weight shifting during walking. This study aimed to investigate the influence of the FreeD module on trunk kinematics and hip and trunk muscle activity. METHODS: Thirty- one healthy adults participated. A video analysis of their trunk movements was performed to investigate the lateral chest and pelvis displacement within the Lokomat (with and without FreeD), and this was compared to treadmill walking. Furthermore, surface electromyography (sEMG) signals from eight muscles were collected during walking in the Lokomat (with and without FreeD), on the treadmill, and overground. To compare the similarity of the sEMG patterns, Spearman's correlation analyses were applied. RESULTS: Walking with FreeD elicited a significantly higher lateral pelvis displacement and a lower lateral chest displacement (relative to the pelvis) compared to walking with a fixated pelvis. No significant differences in the sEMG patterns were found for the Lokomat conditions (with and without FreeD) when comparing it to treadmill or overground walking. CONCLUSIONS: The differences in pelvis displacement act as a proof of concept of the FreeD module. The reduction of relative lateral chest movement corresponds to a decrease in compensatory trunk movements and has its origin in allowing weight shifting through the FreeD module. Both Lokomat conditions showed very similar muscle activity patterns of the trunk and hip compared to overground and treadmill walking. This indicates that the Lokomat allows a physiological muscle activity of the trunk and hip during gait.

Correction to: The FreeD module for the Lokomat facilitates a physiological movement pattern in healthy people - a proof of concept study.

The original article [1] contains an error whereby the legends of Figs. 3 and 4 are erroneously swapped. As such, the correct configuration of these legends can be seen in the same figures below instead.

Can Lokomat therapy with children and adolescents be improved? An adaptive clinical pilot trial comparing Guidance force, Path control, and FreeD.

BACKGROUND: Robot-assisted gait therapy is increasingly being used in pediatric neurorehabilitation to complement conventional physical therapy. The robotic device applied in this study, the Lokomat (Hocoma AG, Switzerland), uses a position control mode (Guidance Force), where exact positions of the knee and hip joints throughout the gait cycle are stipulated. Such a mode has two disadvantages: Movement variability is restricted, and patients tend to walk passively. Kinematic variability and active participation, however, are crucial for motor learning. Recently, two new control modes were introduced. The Path Control mode allows the patient to walk within a virtual tunnel surrounding the ideal movement trajectory. The FreeD was developed to support weight shifting through mediolaterally moveable pelvis and leg cuffs. The aims of this study were twofold: 1) To present an overview of the currently available control modes of the Lokomat. 2) To evaluate if an increase in kinematic variability as provided by the new control modes influenced leg muscle activation patterns and intensity, as well as heart rate while walking in the Lokomat. METHODS: In 15 adolescents with neurological gait disorders who walked in the Lokomat, 3 conditions were compared: Guidance Force, Path Control, and FreeD. We analyzed surface electromyographic (sEMG) activity from 5 leg muscles of the more affected leg and heart rate. Muscle activation patterns were compared with norm curves. RESULTS: Several muscles, as well as heart rate, demonstrated tendencies towards a higher activation during conditions with more kinematic freedom. sEMG activation patterns of the M.rectus femoris and M.vastus medialis showed the highest similarity to over-ground walking under Path Control, whereas walking under FreeD led to unphysiological muscle activation in the tested sample. CONCLUSIONS: Results indicate that especially Path Control seems promising for adolescent patients undergoing neurorehabilitation, as it increases proximal leg muscle activity while facilitating a physiological muscle activation. Therefore, this may be a solution to increase kinematic variability and patients' active participation in robot-assisted gait training.

Practical Recommendations for Robot-Assisted Treadmill Therapy (Lokomat) in Children with Cerebral Palsy: Indications, Goal Setting, and Clinical Implementation within the WHO-ICF Framework.

Active participation and the highest level of independence during daily living are primary goals in neurorehabilitation. Therefore, standing and walking are key factors in many rehabilitation programs. Despite inconclusive evidence considering the best application and efficacy of robotic tools in the field of pediatric neurorehabilitation, robotic technologies have been implemented to complement conventional therapies in recent years. A group of experienced therapists and physicians joined in an "expert panel." They compared their clinical application protocols, discussed recurring open questions, and developed experience-based recommendations for robot-assisted treadmill therapy (exemplified by the Lokomat, Hocoma, Volketswil, Switzerland) with a focus on children with cerebral palsy. Specific indications and therapeutic goals were defined considering the severity of motor impairments and the International Classification of Functioning, Disability and Health framework (ICF). After five meetings, consensus was found and recommendations for the implementation of robot-assisted treadmill therapy including postsurgery rehabilitation were proposed. This article aims to provide a comprehensive overview on therapeutical applications in a fast developing field of medicine, where scientific evidence is still scarce. These recommendations can help physicians and therapists to plan the child's individual therapy protocol of robot-assisted treadmill therapy.

Specific Instructions Are Important: A Cross-sectional Study on Device Parameters and Instruction Types While Walking With a Robot in Children and Adolescents.

OBJECTIVE: The aim of the study is to evaluate how gait kinematics and muscle activity during robot-assisted gait training are affected by different combinations of parameter settings and a number of instruction types, ranging from no instructions to goal-specific instructions. DESIGN: Robots for gait therapy provide a haptic guidance, but too much guidance can limit the active participation. Therapists can stimulate this active participation either with instructions or by adapting device parameters. How these two factors interact is still unknown. In the present study, we test the interaction of three different parameter settings and four instruction types in a cross-sectional study with 20 children and adolescents without impairment. Gait kinematics and surface electromyography were measured to evaluate the immediate effects. RESULTS: We found that only goal-specific instructions in combination with a low guidance led to a moderate but significant change in gait kinematics. The muscle activity was altered by all instructions, but the biggest effect was found for goal-specific instructions with a 2.5 times higher surface electromyography amplitude compared to no instruction. CONCLUSIONS: Goal-specific instructions are a key element of robot-assisted gait therapy interventions and device parameter adjustments may be used to modulate their effects. Therapists should pay close attention to how they instruct patients.

Leg surface electromyography patterns in children with neuro-orthopedic disorders walking on a treadmill unassisted and assisted by a robot with and without encouragement.

BACKGROUND: Robot-assisted gait training and treadmill training can complement conventional physical therapy in children with neuro-orthopedic movement disorders. The aim of this study was to investigate surface electromyography (sEMG) activity patterns during robot-assisted gait training (with and without motivating instructions from a therapist) and unassisted treadmill walking and to compare these with physiological sEMG patterns. METHODS: Nine children with motor impairments and eight healthy children walked in various conditions: (a) on a treadmill in the driven gait orthosis Lokomat®, (b) same condition, with additional motivational instructions from a therapist, and (c) on the treadmill without assistance. sEMG recordings were made of the tibialis anterior, gastrocnemius lateralis, vastus medialis, and biceps femoris muscles. Differences in sEMG amplitudes between the three conditions were analyzed for the duration of stance and swing phase (for each group and muscle separately) using non-parametric tests. Spearman's correlation coefficients illustrated similarity of muscle activation patterns between conditions, between groups, and with published reference trajectories. RESULTS: The relative duration of stance and swing phase differed between patients and controls, and between driven gait orthosis conditions and treadmill walking. While sEMG amplitudes were higher when being encouraged by a therapist compared to robot-assisted gait training without instructions (0.008 ≤ p-value ≤ 0.015), muscle activation patterns were highly comparable (0.648 ≤ Spearman correlation coefficients ≤ 0.969). In general, comparisons of the sEMG patterns with published reference data of over-ground walking revealed that walking in the driven gait orthosis could induce more physiological muscle activation patterns compared to unsupported treadmill walking. CONCLUSIONS: Our results suggest that robotic-assisted gait training with therapeutic encouragement could appropriately increase muscle activity. Robotic-assisted gait training in general could induce physiological muscle activation patterns, which might indicate that this training exploits restorative rather than compensatory mechanisms.

Influence of virtual reality soccer game on walking performance in robotic assisted gait training for children.

BACKGROUND: Virtual reality (VR) offers powerful therapy options within a functional, purposeful and motivating context. Several studies have shown that patients' motivation plays a crucial role in determining therapy outcome. However, few studies have demonstrated the potential of VR in pediatric rehabilitation. Therefore, we developed a VR-based soccer scenario, which provided interactive elements to engage patients during robotic assisted treadmill training (RAGT). The aim of this study was to compare the immediate effect of different supportive conditions (VR versus non-VR conditions) on motor output in patients and healthy control children during training with the driven gait orthosis Lokomat*. METHODS: A total of 18 children (ten patients with different neurological gait disorders, eight healthy controls) took part in this study. They were instructed to walk on the Lokomat in four different, randomly-presented conditions: (1) walk normally without supporting assistance, (2) with therapists' instructions to promote active participation, (3) with VR as a motivating tool to walk actively and (4) with the VR tool combined with therapists' instructions. The Lokomat gait orthosis is equipped with sensors at hip and knee joint to measure man-machine interaction forces. Additionally, subjects' acceptance of the RAGT with VR was assessed using a questionnaire. RESULTS: The mixed ANOVA revealed significant main effects for the factor CONDITIONS (p < 0.001) and a significant interaction CONDITIONS x GROUP (p = 0.01). Tests of between-subjects effects showed no significant main effect for the GROUP (p = 0.592). Active participation in patients and control children increased significantly when supported and motivated either by therapists' instructions or by a VR scenario compared with the baseline measurement "normal walking" (p < 0.001). CONCLUSIONS: The VR scenario used here induces an immediate effect on motor output to a similar degree as the effect resulting from verbal instructions by the therapists. Further research needs to focus on the implementation of interactive design elements, which keep motivation high across and beyond RAGT sessions, especially in pediatric rehabilitation.

An Increase in Kinematic Freedom in the Lokomat Is Related to the Ability to Elicit a Physiological Muscle Activity Pattern: A Secondary Data Analysis Investigating Differences Between Guidance Force, Path Control, and FreeD.

Background: Robot-assisted gait therapy is a fast-growing field in pediatric neuro-rehabilitation. Understanding how these constantly developing technologies work is a prerequisite for shaping clinical application. For the Lokomat, two new features are supposed to increase patients' movement variability and should enable a more physiological gait pattern: Path Control and FreeD. This work provides a secondary data analysis of a previously published study, and looks at surface electromyography (sEMG) during Guidance Force walking and six sub-conditions of Path Control and FreeD. Objective: The aim was to evaluate different levels of kinematic freedom on the gait pattern of pediatric patients by modulating settings of Path Control and FreeD. Methods: Fifteen patients (mean age 16 ± 2 years) with neurological gait disorders completed the measurements. We analyzed sEMG amplitudes and the correlation of sEMG patterns with normative data of five leg muscles during walking conditions with increasing kinematic freedom in the Lokomat. The new outcome measure of inter-step similarity is introduced as a proxy for walking task complexity. Results: Within Path Control, sub-conditions showed significantly higher sEMG amplitudes in a majority of muscles with increasing kinematic freedom, and correlations with the norm pattern increased with increasing kinematic freedom. FreeD sub-conditions generally showed low or even negative correlations with the norm pattern and a lower inter-step similarity compared to Guidance Force. Conclusions: In general, this work highlights that the new hard- and software approaches of the Lokomat influence muscle activity differently. An increase of kinematic freedom of the walking condition led to an increase in muscular effort (Path Control) or to a higher step variability (FreeD) which can be interpreted as an increased task complexity of this condition. The inter-step similarity could be a helpful tool for the therapist to estimate the patient's state of strain.

Virtual realities as motivational tools for robotic assisted gait training in children: A surface electromyography study.

Patient's active cooperation is essential to achieve good outcome in pediatric rehabilitation. Therefore, virtual environments were developed to enhance robotic assisted gait training. The purpose of this study was to evaluate virtual realities as motivational tools during robotic assisted gait training with children in the pediatric Lokomat®. Nine children with different gait disorders and eight healthy children participated in the study. Muscular effort of the lower leg was assessed by surface electromyography during a randomly designed training protocol with virtual realities. Self reported motivation was investigated with two questionnaires. Comparisons were drawn through repeated measurement Analysis of Variance and paired-t-tests. The logarithmic transformed data showed that the electromyographic activity output in both groups was significantly higher during tasks with virtual realities than during normal walking conditions. These results support that virtual realities seem to be efficient motivational tools to increase children's muscular effort in the pediatric Lokomat®. The gaming aspect of virtual realities keeps children highly engaged during repetitive tasks.

Safety of robotic-assisted treadmill therapy in children and adolescents with gait impairment: a bi-centre survey.

OBJECTIVE: The aim of the present study was to report on adverse events encountered with robotic-assisted treadmill therapy in children and adolescents with gait disorders. METHODS: Eighty-nine patients who underwent a trial of robotic assisted treadmill therapy in the two participating centres were analysed. Demographic data and safety data of the patients were analysed using descriptive statistics. RESULTS: In 38 (42.7%) out of 89 patients, adverse events were documented. Most commonly, mild skin erythema at the sites of the cuffs of the device and muscle pain were encountered. In five patients (5.6%), open skin lesions (n = 2), joint pain (n = 2) or tendinopathy (n = 1) limited the continuation of the therapy with the Lokomat. No severe side-effects emerged. CONCLUSIONS: Robotic assisted treadmill therapy is a safe method to enable longer periods of gait therapy in children and adolescents with gait disorders.