Perspectives of wheelchair users with chronic spinal cord injury following a walking program using a wearable robotic exoskeleton.

PURPOSE: To examine the perspectives of wheelchair users with spinal cord injury (WUSCI) regarding their participation in a 16-week walking program using a wearable robotic exoskeleton (WRE); and explore concerns and expectations regarding potential use of this device and intervention in the context of a home or community-based adapted physical activity program. METHOD: Semi-structured interviews were conducted using a narrative research, 3 weeks post-intervention. Thematic analysis resulted in 6 themes and 21 subthemes. RESULTS: Seven men and 4 women aged between 32 and 72 years were interviewed; 8 of them had a complete SCI. After the walking program, WUSCI reported positive psychological aspects (having fun and motivation) and experiencing improvements in physical aspects (strength, endurance, balance and flexibility, blood circulation and intestinal transit). The structural aspects of the WRE device were acceptable in a lab with research personnel (appearance, size, weight, and comfort). Participants had concerns about safety on uneven surfaces, and possibility of falling. They expressed the desire to use the WRE for more life habits than just walking. CONCLUSION: This is the first study in which WUSCI report that the WRE should be implemented in initial rehabilitation. Lack of availability for community use after rehabilitation remains a concern.

Participation in a walking training program using a wearable robotic exoskeleton, 1-3 times weekly over several weeks, may be well tolerated and provide physical and psychological benefits for wheelchair users with spinal cord injuries.Using a robotic exoskeleton during initial rehabilitation may be well received and help with regaining strength, endurance, balance, and flexibility as well as promoting blood circulation and intestinal transit.The use of the wearable robotic exoskeleton always needs supervision of a clinician for walking and can't be used independently by wheelchair users; there is no possibility for hands free for household tasks (e.g., washing floors, accessing cupboards or reaching shelves, using stairs), and for recreation (e.g., exercising, taking walks, cultural activities, concerts).

Where Are We on Proprioception Assessment Tests Among Poststroke Individuals? A Systematic Review of Psychometric Properties.

BACKGROUND AND PURPOSE: Proprioception is often impaired in poststroke individuals. This is a significant issue since altered proprioception is associated with poorer physical function outcomes poststroke. However, there is limited consensus on the best tools for assessing proprioception and support for their widespread use by clinicians. The objective is to appraise the psychometric properties of each test used to assess proprioception in poststroke individuals. METHODS: A systematic search was performed according to PRISMA guidelines using the databases MEDLINE, Cochrane Library, PEDro, DiTa, and BioMedicalCentral for articles published up to January 2021. RESULTS: Sixteen studies of low methodological quality were included. Sixteen different proprioception assessment tests were extracted. The proprioception portion of the Fugl-Meyer Assessment Scale was found to be the most valid and reliable tool for screening patients in clinical settings. Although no real gold standard exists, the technological devices demonstrated better responsiveness and measurement accuracy than clinical tests. Technological devices might be more appropriate for assessing proprioception recovery or better suited for research purposes. DISCUSSION AND CONCLUSIONS: This review revealed low-quality articles and a paucity of tests with good psychometric properties available to clinicians to properly screen and assess all subcomponents of proprioception. In perspective, technological devices, such as robotic orthoses or muscle vibration, may provide the best potential for assessing the different subcomponents of proprioception. Further studies should be conducted to develop and investigate such approaches.Video, Supplemental Digital Content 1, available at:http://links.lww.com/JNPT/A388.

Rehabilitation Supported by Technology: Protocol for an International Cocreation and User Experience Study.

BACKGROUND: Living labs in the health and well-being domain have become increasingly common over the past decade but vary in available infrastructure, implemented study designs, and outcome measures. The Horizon 2020 Project Virtual Health and Wellbeing Living Lab Infrastructure aims to harmonize living lab procedures and open living lab infrastructures to facilitate and promote research activities in the health and well-being domain in Europe and beyond. This protocol will describe the design of a joint research activity, focusing on the use of innovative technology for both rehabilitation interventions and data collection in a rehabilitation context. OBJECTIVE: With this joint research activity, this study primarily aims to gain insight into each living lab's infrastructure and procedures to harmonize health and well-being living lab procedures and infrastructures in Europe and beyond, particularly in the context of rehabilitation. Secondarily, this study aims to investigate the potential of innovative technologies for rehabilitation through living lab methodologies. METHODS: This study has a mixed methods design comprising multiple phases. There are two main phases of data collection: cocreation (phase 1) and small-scale pilot studies (phase 2), which are preceded by a preliminary harmonization of procedures among the different international living labs. An intermediate phase further allows the implementation of minor adjustments to the intervention or protocol depending on the input that was obtained in the cocreation phase. A total of 6 small-scale pilot studies using innovative technologies for intervention or data collection will be performed across 4 countries. The target study sample comprises patients with stroke and older adults with mild cognitive impairment. The third and final phases involve Delphi procedures to reach a consensus on harmonized procedures and protocols. RESULTS: Phase 1 data collection will begin in March 2022, and phase 2 data collection will begin in June 2022. Results will include the output of the cocreation sessions, small-scale pilot studies, and advice on harmonizing procedures and protocols for health and well-being living labs focusing on rehabilitation. CONCLUSIONS: The knowledge gained by the execution of this research will lead to harmonized procedures and protocols in a rehabilitation context for health and well-being living labs in Europe and beyond. In addition to the harmonized procedures and protocols in rehabilitation, we will also be able to provide new insights for improving the implementation of innovative technologies in rehabilitation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/34537.

Perception of gait motion during multiple lower-limb vibrations in young healthy individuals: a pilot study.

In virtual reality (VR), immersion can be created through synchronous visuomotor stimulations and enhanced by adding auditory or kinesthetic stimulations. Multiple patterned vibrations applied at the lower limbs might be a way to induce kinesthetic perception of gait motion that could be combined with VR stimulations to add the perception of self-motion. However, gait motion perception using multiple vibrations has not yet been evaluated. The objective of the study was to quantify the perception of gait motion while applying multiple, patterned vibrations to the lower limbs in healthy individuals. Twenty young healthy participants (25.1 ± 4.4 years) experienced multiple vibrations in 1-min trials. Stimulation consisted of a vibration pattern based on the sequence of muscle lengthening during a 2-s gait cycle. Stimulation was applied on participants in a standing position, under 11 experimental conditions controlling visual information (eyes open/closed), vibration frequency (40-80 Hz), and number and location of the joints stimulated (hips, knees, ankles isolated or combined two by two). Perception of gait motion was quantified for each condition using a 10-point visual analog scale (VAS, 0: "no perception", 10: "Perception of gait movements"). All participants except one achieved a score higher than 5/10 in at least one condition. Great variability was found for perception of gait motion within participants and conditions (VAS ranging from 0 to 9.6/10). Differences were found between conditions (p < 0.01), with higher mean and median scores in conditions that included knee vibration. Inducing gait motion perception is possible using multiple vibrations in healthy individuals. Stimulation of the knees seems to positively influence perception of gait motion.

Effects of Varying Overground Walking Speeds on Lower-Extremity Muscle Synergies in Healthy Individuals.

The effects of walking speeds on lower-extremity muscle synergies (MSs) were investigated among 20 adults who walked 20 m at SLOW (0.6 ± 0.2 m/s), natural (NAT; 1.4 ± 0.1 m/s), and FAST (1.9 ± 0.1 m/s) speeds. Surface electromyography of eight lower-extremity muscles was recorded before extracting MSs using a nonnegative matrix factorization algorithm. Increasing walking speed tended to merge MSs associated with weight acceptance and limb deceleration, whereas reducing walking speed does not change the number and composition of MSs. Varying gait speed, particularly decreasing speed, may represent a gait training strategy needing additional attention given its effects on MSs.

Clinicians' perspectives on inertial measurement units in clinical practice.

Inertial measurement units (IMUs) have been increasingly popular in rehabilitation research. However, despite their accessibility and potential advantages, their uptake and acceptance by health professionals remain a big challenge. The development of an IMU-based clinical tool must bring together engineers, researchers and clinicians. This study is part of a developmental process with the investigation of clinicians' perspectives about IMUs. Clinicians from four rehabilitation centers were invited to a 30-minute presentation on IMUs. Then, two one-hour focus groups were conducted with volunteer clinicians in each rehabilitation center on: 1) IMUs and their clinical usefulness, and 2) IMUs data analysis and visualization interface. Fifteen clinicians took part in the first focus groups. They expressed their thoughts on: 1) categories of variables that would be useful to measure with IMUs in clinical practice, and 2) desired characteristics of the IMUs. Twenty-three clinicians participated to the second focus groups, discussing: 1) functionalities, 2) display options, 3) clinical data reported and associated information, and 4) data collection duration. Potential influence of IMUs on clinical practice and added value were discussed in both focus groups. Clinicians expressed positive opinions about the use of IMUs, but their expectations were high before considering using IMUs in their practice.

Effects of an Overground Walking Program With a Robotic Exoskeleton on Long-Term Manual Wheelchair Users With a Chronic Spinal Cord Injury: Protocol for a Self-Controlled Interventional Study.

BACKGROUND: In wheelchair users with a chronic spinal cord injury (WUSCI), prolonged nonactive sitting time and reduced physical activity-typically linked to this mode of mobility-contribute to the development or exacerbation of cardiorespiratory, musculoskeletal, and endocrine-metabolic health complications that are often linked to increased risks of chronic pain or psychological morbidity. Limited evidence suggests that engaging in a walking program with a wearable robotic exoskeleton may be a promising physical activity intervention to counter these detrimental health effects. OBJECTIVE: This study's overall goals are as follows: (1) to determine the effects of a 16-week wearable robotic exoskeleton-assisted walking program on organic systems, functional capacities, and multifaceted psychosocial factors and (2) to determine self-reported satisfaction and perspectives with regard to the intervention and the device. METHODS: A total of 20 WUSCI, who have had their injuries for more than 18 months, will complete an overground wearable robotic exoskeleton-assisted walking program (34 sessions; 60 min/session) supervised by a physiotherapist over a 16-week period (one to three sessions/week). Data will be collected 1 month prior to the program, at the beginning, and at the end as well as 2 months after completing the program. Assessments will characterize sociodemographic characteristics; anthropometric parameters; sensorimotor impairments; pain; lower extremity range of motion and spasticity; wheelchair abilities; cardiorespiratory fitness; upper extremity strength; bone architecture and mineral density at the femur, tibia, and radius; total and regional body composition; health-related quality of life; and psychological health. Interviews and an online questionnaire will be conducted to measure users' satisfaction levels and perspectives at the end of the program. Differences across measurement times will be verified using appropriate parametric or nonparametric analyses of variance for repeated measures. RESULTS: This study is currently underway with active recruitment in Montréal, Québec, Canada. Results are expected in the spring of 2021. CONCLUSIONS: The results from this study will be essential to guide the development, implementation, and evaluation of future evidence-based wearable robotic exoskeleton-assisted walking programs offered in the community, and to initiate a reflection regarding the use of wearable robotic exoskeletons during initial rehabilitation following a spinal cord injury. TRIAL REGISTRATION: ClinicalTrials.gov NCT03989752; https://clinicaltrials.gov/ct2/show/NCT03989752. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/19251.

Intense and unpredictable perturbations during gait training improve dynamic balance abilities in chronic hemiparetic individuals: a randomized controlled pilot trial.

BACKGROUND: Previous studies have assessed the effects of perturbation training on balance after stroke. However, the perturbations were either applied while standing or were small in amplitude during gait, which is not representative of the most common fall conditions. The perturbations were also combined with other challenges such as progressive increases in treadmill speed. OBJECTIVE: To determine the benefit of treadmill training with intense and unpredictable perturbations compared to treadmill walking-only training for dynamic balance and gait post-stroke. METHODS: Twenty-one individuals post-stroke with reduced dynamic balance abilities, with or without a history of fall and ability to walk on a treadmill without external support or a walking aid for at least 1 min were allocated to either an unpredictable gait perturbation (Perturb) group or a walking-only (NonPerturb) group through covariate adaptive randomization. Nine training sessions were conducted over 3 weeks. NonPerturb participants only walked on the treadmill but were offered perturbation training after the control intervention. Pre- and post-training evaluations included balance and gait abilities, maximal knee strength, balance confidence and community integration. Six-week phone follow-ups were conducted for balance confidence and community integration. Satisfaction with perturbation training was also assessed. RESULTS: With no baseline differences between groups (p > 0.075), perturbation training yielded large improvements in most variables in the Perturb (p < 0.05, Effect Size: ES > .46) group (n = 10) and the NonPerturb (p ≤ .089, ES > .45) group (n = 7 post-crossing), except for maximal strength (p > .23) in the NonPerturb group. Walking-only training in the NonPerturb group (n = 8, pre-crossing) mostly had no effect (p > .292, ES < .26), except on balance confidence (p = .063, ES = .46). The effects of the gait training were still present on balance confidence and community integration at follow-up. Satisfaction with the training program was high. CONCLUSION: Intense and unpredictable gait perturbations have the potential to be an efficient component of training to improve balance abilities and community integration in individuals with chronic stroke. Retrospective registration: ClinicalTrials.gov. March 18th, 2020. Identifier: NCT04314830.

Effects of robotic exoskeleton control options on lower limb muscle synergies during overground walking: An exploratory study among able-bodied adults.

BACKGROUND: The effects of lower limb (L/L) control options, developed for overground walking with a wearable robotic exoskeleton (WRE), on the neuromotor control of L/L muscles [i.e., muscle synergies (MSs)] during walking remain uncertain. OBJECTIVE: To gain initial insights regarding the effects of different control options on the number of MSs at the L/L and on their muscle weighting within each MS when walking with a WRE. METHODS: Twenty able-bodied adults walked overground without and with the WRE set at two control options with a predetermined foot pathway imposed by the WRE, and at three other control options with free L/L kinematics in the sagittal plane. Surface electromyography of eight right L/L muscles was recorded. MSs were extracted using a non-negative matrix factorisation algorithm. Cosine similarity and correlation coefficients characterised similarities between the MSs characteristics. RESULTS: Freely moving the L/L in the sagittal plane (i.e., non-trajectory controlled options) during WRE walking best duplicated typical MSs extracted when walking without WRE. Conversely, WRE walking while fully controlling the L/L trajectory presented the lowest correlations to all MSs extracted when walking without WRE, especially during early swing and L/L deceleration. CONCLUSION: Neuromotor control of L/L muscles is affected by the selected control option during WRE walking, particularly when a predetermined foot pathway is imposed. SIGNIFICANCE: This exploratory study represents the first step in informing the decision-making process regarding the use of different L/L control options when using WRE and calls for further research among adults with sensorimotor impairments.

Wearable exoskeleton control modes selected during overground walking affect muscle synergies in adults with a chronic incomplete spinal cord injury.

STUDY DESIGN: Case series. BACKGROUND: Changes in the number of muscle synergies (MSs) and in the weighting of muscles composing each MS are typically altered following an incomplete spinal cord injury (iSCI). Wearable robotic exoskeletons (WRE) represent a promising rehabilitation option, though the effects of various WRE control modes on MSs still remain unknown. OBJECTIVE: This case series characterizes how WRE control modes affect the number of MSs and the weighting of muscles composing each MS in individuals with iSCI. SETTING: Pathokinesioly laboratory of a rehabilitation research center. METHODS: Three participants with a chronic iSCI walked at a self-selected comfortable speed without and with a WRE set in two trajectory-controlled (Total Assistance, TOT; Assistance-as-Needed, ADAPT) and three non-trajectory controlled modes (High Assistance, HASSIST; High Resistance, HRESIST; NEUTRAL). Surface EMG of eight lower extremity (L/E) muscles was recorded and used to extract MSs using a nonnegative matrix factorization algorithm. Cosine similarity and weighting relative differences characterized similarities in MSs between individuals with iSCI and able-bodied controls. RESULTS: The mode providing movement assistance within a self-selected L/E trajectory (HASSIST) best replicated MSs in able-bodied controls during overground walking. MSs extracted with the trajectory-controlled modes differed to the greatest extent from able-bodied group MSs. CONCLUSIONS: Most WRE control modes did not replicate the motor control required for typical L/E muscle coordination during stereotypical overground walking. These results highlight the need to gain a better understanding of the effects of various control modes on L/E motor control for rehabilitation professionals to incorporate research evidence when selecting WRE control mode(s) during WRE locomotor interventions.

The effects of a strong desire to void on gait for incontinent and continent older community-dwelling women at risk of falls.

AIMS: The fall rate in urgency urinary incontinence (UUI) and mixed UI (MUI) older women is higher when compared with that of continent women. One hypothesis is that a strong desire to void (SDV) could alter gait parameters and therefore increase the risk of falls. The aim of this study was to investigate and compare the effect of SDV on gait parameters in UUI/MUI and continent older women who experienced falls. The secondary aim was to determine the relationship between UI severity and gait parameters in incontinent women. METHODS: A quasi-experimental pilot study was conducted with two groups of healthy community-dwelling women who experienced at least one fall in the last year: continent (n = 17; age: 74.1 ± 4.3) and UUI/MUI (n = 15; age: 73.5 ± 5.9). We recorded, analyzed, and compared spatiotemporal gait parameters for participants in each group with both SDV and no desire to void condition. RESULTS: A pattern of reduced velocity (P = 0.05) and stride width (P = 0.02) was observed in both groups with SDV. Incontinence severity was correlated with reduced velocity (rs = -0.63, P = 0.01), increased stance time (rs = 0.65, P = .01) and stance time variability (rs = 0.65, P = .01) in no desire to void condition and with reduced velocity (rs = -0.56, P = .03) and increased stride length variability (rs = 0.54, P = .04) in SDV condition. CONCLUSIONS: SDV reduced gait velocity and stride width regardless of continence status in older women at risk of falls. Further, UI severity in the UUI/MUI women was correlated to reduced gait velocity and increased variability. Our findings could explain the higher fall rate in this population.

Cortical dynamics of sensorimotor information processing associated with balance control in adolescents with and without idiopathic scoliosis.

OBJECTIVE: This study aims at examining the cortical dynamics of sensorimotor information processing related to balance control in participants with adolescent idiopathic scoliosis (AIS) and in age-matched controls (CTL). METHODS: Cortical dynamics during standing balance control were assessed in 13 girls with AIS and 13 age-matched controls using electroencephalography. Time-frequency analysis were used to determine frequency power during ankle proprioception alteration (ankle tendons co-vibration interval) or reintegration of ankle proprioception (post-vibration interval) with or without vision. RESULTS: Balance control did not differ between groups. In the co-vibration interval, a significant suppression in alpha (8-12 Hz) and beta (13-30 Hz) band power and a significant increase in theta (4-7 Hz) band power were found respectively in the vision and non-vision condition in the AIS group compared to the CTL group. In the post-vibration interval, significant suppressions in beta (13-30 Hz) and gamma (30-50 Hz) band power were observed in the AIS group in the non-vision condition. CONCLUSION: Participants with AIS showed brain oscillations differences compared to CTL in the sensorimotor cortex while controlling their balance in various sensory conditions. SIGNIFICANCE: Future study using evaluation of cortical dynamics could serve documenting whether rehabilitation programs have an effect on sensorimotor function in AIS.

Slow and faster post-stroke walkers have a different trunk progression and braking impulse during gait.

BACKGROUND: Braking forces absorbed by the leading paretic limb are greater than expected with regard to gait speed and not correlated with propulsive forces generated by the non-paretic limb in individuals with severe hemiparesis. Altered foot placement due to poor sensorimotor capacities may explain excessive braking forces. RESEARCH QUESTION: The main objective of this study was to determine whether paretic foot placement was related to paretic braking forces in post-stroke individuals with various self-selected walking speeds and motor deficits. METHODS: In this cross-sectional study, 34 chronic hemiparetic post-stroke individuals, divided into slow (< 0.7 m/s, n = 17) and faster (n = 17) subgroups, walked at their self-selected speed. Kinematic and kinetic parameters were measured. Braking impulses, peak braking forces, step characteristics and clinical status were compared between groups and limbs, and their correlations were tested using Pearson (or Spearman) correlation tests. RESULTS: On the paretic side, braking impulses and step length were similar between groups despite the slower walking speed in the slow group. Paretic peak braking forces and step length were correlated in both groups (r = 0.5). Paretic braking forces were correlated with walking speed, foot placement ahead of the pelvis, trunk progression (TP) from non-paretic initial contact to paretic initial contact, and better motor function of the paretic limb for the faster walkers (0.6 < r < 0.7), but not for the slow walkers. Among the slow walkers, reduced TP ahead of the paretic foot was correlated with a higher paretic impulse (r =  -0.6). SIGNIFICANCE: Better motor function likely helped the faster walkers to decelerate their center of mass appropriately relative to their walking speed. In the slow hemiparetic walkers, TP ahead of the paretic foot was perturbed. Clinicians should therefore consider vasti and plantar flexor muscle tone and activity that likely restrict TP ahead of the paretic foot and increase braking forces.

Activity Monitor Placed at the Nonparetic Ankle Is Accurate in Measuring Step Counts During Community Walking in Poststroke Individuals: A Validation Study.

BACKGROUND: Different environmental factors may affect the accuracy of step-count activity monitors (AM). However, the validation conditions for AM accuracy largely differ from ecological environments. OBJECTIVES: To assess and compare the accuracy of AM in counting steps among poststroke individuals: during different locomotor tasks, with AM placed at the nonparetic ankle or hip, and when walking in a laboratory or inside a mall. DESIGN: Validation study. SETTINGS: Laboratory and community settings. PARTICIPANTS: Twenty persons with chronic hemiparesis, independent walkers. METHODS: First session: participants performed level walking (6-minute walk test [6MWT]), ramps, and stairs in the laboratory with AM placed at the nonparetic ankle and hip. Second session: participants walked a mall circuit, including the three tasks, with AM placed at the nonparetic ankle. The sessions were video recorded. MAIN OUTCOME MEASUREMENTS: Absolute difference between the steps counted by AM and the steps viewed on the video recordings (errors, %); occurrence of errors greater than 10%. RESULTS: Median errors were similar for the 6MWT (0.86 [0.22, 7.70]%), ramps (2.17 [0.89, 9.61]%), and stairs (8.33 [2.65, 19.22]%) with AM at the ankle. Step-count error was lower when AM was placed at the ankle (8.33 [2.65, 19.22]%) than at the hip (9.26 [3.25, 42.63]%, P = .03). The greatest errors were observed among the slowest participants (≤0.4 m/s) on ramps and stairs, whereas some faster participants (>1 m/s) experienced the greatest error during the 6MWT. Median error was slightly increased in the mall circuit (2.67 [0.61, 12.54]%) compared with the 6MWT (0.50 [0.24, 6.79]%, P = .04), with more participants showing errors >10% during the circuit (7 vs 2, P = .05). CONCLUSIONS: Step counts are accurately measured with AM placed at the nonparetic ankle in laboratory and community settings. Accuracy can be altered by stairs and ramps among the slowest walkers and by prolonged walking tasks among faster walkers. LEVEL OF EVIDENCE: III.

Satisfaction and perceptions of long-term manual wheelchair users with a spinal cord injury upon completion of a locomotor training program with an overground robotic exoskeleton.

AIM: The main objectives of this study were to quantify clients' satisfaction and perception upon completion of a locomotor training program with an overground robotic exoskeleton. METHODS: A group of 14 wheelchair users with a spinal cord injury, who finished a 6-8-week locomotor training program with the robotic exoskeleton (18 training sessions), were invited to complete a web-based electronic questionnaire. This questionnaire encompassed 41 statements organized around seven key domains: overall satisfaction related to the training program, satisfaction related to the overground robotic exoskeleton, satisfaction related to the program attributes, perceived learnability, perceived health benefits and risks and perceived motivation to engage in physical activity. Each statement was rated using a visual analogue scale ranging from "0 = totally disagree" to "100 = completely agree". RESULTS: Overall, respondents unanimously considered themselves satisfied with the locomotor training program with the robotic exoskeleton (95.7 ± 0.7%) and provided positive feedback about the robotic exoskeleton itself (82.3 ± 6.9%), the attributes of the locomotor training program (84.5 ± 6.9%) and their ability to learn to perform sit-stand transfers and walk with the robotic exoskeleton (79.6 ± 17%). Respondents perceived some health benefits (67.9 ± 16.7%) and have reported no fear of developing secondary complications or of potential risk for themselves linked to the use of the robotic exoskeleton (16.7 ± 8.2%). At the end of the program, respondents felt motivated to engage in a regular physical activity program (91.3 ± 0.1%). CONCLUSION: This study provides new insights on satisfaction and perceptions of wheelchair users while also confirming the relevance to continue to improve such technologies, and informing the development of future clinical trials. Implications for Rehabilitation All long-term manual wheelchair users with a spinal cord injury who participated in the study are unanimously satisfied upon completion of a 6-8-week locomotor training program with the robotic exoskeleton and would recommend the program to their peers. All long-term manual wheelchair users with a spinal cord injury who participated in the study offered positive feedback about the robotic exoskeleton itself and feel it is easy to learn to perform sit-stand transfers and walk with the robotic exoskeleton. All long-term manual wheelchair users with a spinal cord injury who participated in the study predominantly perceived improvements in their overall health status, upper limb strength and endurance as well as in their sleep and psychological well-being upon completion of a 6-8-week locomotor training program with the robotic exoskeleton. All long-term manual wheelchair users with a spinal cord injury who participated in the study unanimously felt motivated to engage in a regular physical activity program adapted to their condition and most of them do plan to continue to participate in moderate-to-strenuous physical exercise. Additional research on clients' perspectives, especially satisfaction with the overground exoskeleton and locomotor training program attributes, is needed.

More symmetrical gait after split-belt treadmill walking does not modify dynamic and postural balance in individuals post-stroke.

Spontaneous gait is often asymmetrical in individuals post-stroke, despite their ability to walk more symmetrically on demand. Given the sensorimotor deficits in the paretic limb, this asymmetrical gait may facilitate balance maintenance. We used a split-belt walking protocol to alter gait asymmetry and determine the effects on dynamic and postural balance. Twenty individuals post-stroke walked on a split-belt treadmill. In two separate periods, the effects of walking with the non-paretic leg, and then the paretic one, on the faster belt on spatio-temporal symmetry and balance were compared before and after these perturbation periods. Kinematic and kinetic data were collected using a motion analysis system and an instrumented treadmill to determine symmetry ratios of spatiotemporal parameters and dynamic and postural balance. Balance, quantified by the concepts of stabilizing and destabilizing forces, was compared before and after split-belt walking for subgroups of participants who improved and worsened their symmetry. The side on the slow belt during split-belt walking, but not the changes in asymmetry, affected balance. Difficulty in maintaining balance was higher during stance phase of the leg that was on the slow belt and lower on the contralateral side after split-belt walking, mostly because the center of pressure was closer (higher difficulty) or further (lower difficulty) from the limit of the base of support, respectively. Changes in spatiotemporal parameters may be sought without additional alteration of balance during gait post-stroke.

Locomotor training using an overground robotic exoskeleton in long-term manual wheelchair users with a chronic spinal cord injury living in the community: Lessons learned from a feasibility study in terms of recruitment, attendance, learnability, performance and safety.

BACKGROUND: For individuals who sustain a complete motor spinal cord injury (SCI) and rely on a wheelchair as their primary mode of locomotion, overground robotic exoskeletons represent a promising solution to stand and walk again. Although overground robotic exoskeletons have gained tremendous attention over the past decade and are now being transferred from laboratories to clinical settings, their effects remain unclear given the paucity of scientific evidence and the absence of large-scale clinical trials. This study aims to examine the feasibility of a locomotor training program with an overground robotic exoskeleton in terms of recruitment, attendance, and drop-out rates as well as walking performance, learnability, and safety. METHODS: Individuals with a SCI were invited to participate in a 6 to 8-week locomotor training program with a robotic exoskeleton encompassing 18 sessions. Selected participants underwent a comprehensive screening process and completed two familiarization sessions with the robotic exoskeleton. The outcome measures were the rate of recruitment of potential participants, the rate of attendance at training sessions, the rate of drop-outs, the ability to walk with the exoskeleton, and its progression over the program as well as the adverse events. RESULTS: Out of 49 individuals who expressed their interest in participating in the study, only 14 initiated the program (recruitment rate = 28.6%). Of these, 13 individuals completed the program (drop-out rate = 7.1%) and attended 17.6 ± 1.1 sessions (attendance rate = 97.9%). Their greatest standing time, walking time, and number of steps taken during a session were 64.5 ± 10.2 min, 47.2 ± 11.3 min, and 1843 ± 577 steps, respectively. During the training program, these last three parameters increased by 45.3%, 102.1%, and 248.7%, respectively. At the end of the program, when walking with the exoskeleton, most participants required one therapist (85.7%), needed stand-by or contact-guard assistance (57.1%), used forearm crutches (71.4%), and reached a walking speed of 0.25 ± 0.05 m/s. Five participants reported training-related pain or stiffness in the upper extremities during the program. One participant sustained bilateral calcaneal fractures and stopped the program. CONCLUSIONS: This study confirms that larger clinical trials investigating the effects of a locomotor training program with an overground robotic exoskeleton are feasible and relatively safe in individuals with complete motor SCI. Moreover, to optimize the recruitment rate and safety in future trials, this study now highlights the need of developing pre-training rehabilitation programs to increase passive lower extremity range of motion and standing tolerance. This study also calls for the development of clinical practice guidelines targeting fragility fracture risk assessment linked to the use of overground robotic exoskeletons.

Cardiorespiratory demand and rate of perceived exertion during overground walking with a robotic exoskeleton in long-term manual wheelchair users with chronic spinal cord injury: A cross-sectional study.

BACKGROUND: Many wheelchair users adopt a sedentary lifestyle, which results in progressive physical deconditioning with increased risk of musculoskeletal, cardiovascular and endocrine/metabolic morbidity and mortality. Engaging in a walking program with an overground robotic exoskeleton may be an effective strategy for mitigating these potential negative health consequences and optimizing fitness in this population. However, additional research is warranted to inform the development of adapted physical activity programs incorporating this technology. OBJECTIVES: To determine cardiorespiratory demands during sitting, standing and overground walking with a robotic exoskeleton and to verify whether such overground walking results in at least moderate-intensity physical exercise. METHODS: We enrolled 13 long-term wheelchair users with complete motor spinal cord injury in a walking program with an overground robotic exoskeleton. Cardiorespiratory measures and rate of perceived exertion (RPE) were recorded by using a portable gas analyzer system during sitting, standing and four 10m walking tasks with the robotic exoskeleton. Each participant also performed an arm crank ergometer test to determine maximal cardiorespiratory ability (i.e., peak heart rate and O2 uptake [HRpeak, VO2peak]). RESULTS: Cardiorespiratory measures increased by a range of 9%-35% from sitting to standing and further increased by 22%-52% from standing to walking with the robotic exoskeleton. During walking, median oxygen cost (O2Walking), relative HR (%HRpeak), relative O2 consumption (%VO2peak) and respiratory exchange ratio (RER) reached 0.29mL/kg/m, 82.9%, 41.8% and 0.9, respectively, whereas median RPE reached 3.2/10. O2Walking was moderately influenced by total number of sessions and steps taken with the robotic exoskeleton since the start of the walking program. CONCLUSION: Overground walking with the robotic exoskeleton over a short distance allowed wheelchair users to achieve a moderate-intensity level of exercise. Hence, an overground locomotor training program with a robotic exoskeleton may have cardiorespiratory health benefits in the population studied.

How does wearable robotic exoskeleton affect overground walking performance measured with the 10-m and six-minute walk tests after a basic locomotor training in healthy individuals?

It is still unknown to what extent overground walking with a WRE is equivalent to natural overground walking without a WRE. Hence, the interpretability of the 10-m (10MWT) and six-minute (6MWT) walk tests during overground walking with a WRE against reference values collected during natural overground walking without a WRE is challenging. This study aimed to 1) compare walking performance across three different overground walking conditions: natural walking without a WRE, walking with a WRE providing minimal assistance (active walking), and walking with a WRE proving complete assistance (passive walking) and 2) assess the association and the agreement between the 10MWT and the 6MWT during passive and active walking with a WRE. Seventeen healthy individuals who underwent basic locomotor training with a WRE performed the 10MWT (preferred and maximal speeds) and the 6MWT under the three conditions. For the 10MWT, the speed progressively and significantly decreased from natural walking without a WRE (preferred: 1.40±0.18m/s; maximal: 2.16±0.19m/s), to active walking with a WRE (preferred: 0.48±0.10m/s; maximal: 0.61±0.14m/s), and to passive walking with a WRE (preferred: 0.38±0.09m/s; maximal: 0.42±0.10m/s). For the 6MWT, total distances decreased from walking without a WRE (609±53.9m), to active walking with a WRE (196.6±42.6m), and to passive walking with a WRE (144.3±33.3m). The 10MWT and 6MWT provide distinct information and can't be used interchangeably to document speed only during active walking with the WRE. Speed and distance drastically decrease during active and, even more so, passive walking with the WRE in comparison to walking without a WRE. Selection of walking tests should depend on the level of assistance provided by the WRE.

Introducing a psychological postural threat alters gait and balance parameters among young participants but not among most older participants.

The fear of falling can be manipulated by introducing a postural threat (e.g., an elevated support surface) during stance and gait. Under these conditions, balance parameters are altered in both young and elderly individuals. This study aimed to dissociate the physical and psychological aspects of the threat and show the impact of a verbal warning cue of imminent perturbation during gait among young and elderly healthy participants. Ten young subjects (29.4 ± 3.9 years) and ten subjects aged over 65 years (72.9 ± 3.5) participated in the study. Spatiotemporal and balance parameters were quantified during eight consecutive gait cycles using a motion analysis system and an instrumented treadmill. These parameters were compared twice in the control trial and before/after a verbal warning cue of imminent perturbation during gait ("postural threat") in perturbation trials and between groups using repeated measure ANOVAs. RESULTS: The verbal cue yielded reduced step length (p = 0.008), increased step width (p = 0.049), advanced relative position of the center of mass (p = 0.016), increased stabilizing force (p = 0.003), and decreased destabilizing force (p = 0.002). This warning effect was not observed in the older participant group analyses but was found for three participants based on individual data analyses. The warning effect in younger participants was not specific to impending perturbation conditions. Most gait and balance parameters were altered in the older group (p < 0.05) versus the younger group in each condition, regardless of the warning cue. A psychological threat affects gait and balance similarly to a physical threat among young participants but not among most older participants.