Early robot-assisted gait retraining in non-ambulatory patients with stroke: a single blind randomized controlled trial.

BACKGROUND: Restoration of walking function is a primary concern of neurorehabilitation with respect to the aspired social and vocational reintegration. To date, the best practice for improving gait early after stroke is still object of debate. On one hand, repetitive task-specific approaches with higher intensities of walking have been observed to result in greater improvements of gait after stroke. Conversely there is some evidence that conventional gait training would be more effective for facilitating walking ability after stroke. AIM: To compare the effects of an early treatment protocol of add-on robot-assisted gait training with add-on conventional overground physiotherapy for improving locomotion in non-ambulatory adult stroke patients. DESIGN: Single-blind randomized controlled trial. SETTING: Neurorehabilitation hospital. POPULATION: Seventy-four subacute patients with first-ever ischemic stroke. METHODS: The patients were randomized into two groups. The training program consisted of forty, 2-hour sessions (including 45 minutes basic training, 45 minutes add-on training plus rest periods), 5 days a week, for 8 consecutive weeks. Patients allocated to the add-on robot-assisted gait training were treated by means of the Lokomat. Patients allocated to the add-on conventional overground gait training aimed at improving postural control during gait, body weight transfer, stability during the stance phase, free swing phase, adequate heel contact and gait pattern. Primary outcome was the modified Emory Functional Ambulation Profile. Secondary outcomes were the Rivermead Motor Index, the Mobility Milestones and the Hochzirl Walking Aids Profile. RESULTS: No significant difference was observed between groups with regards to age (P=0.661), time from stroke onset (P=0.413) and the primary outcome (P=0.854) at baseline evaluation. As to the primary outcome, no significant differences were found between groups at the end of the study. As During the 8-week training, within-group comparisons showed significant improvements of mean modified Emory Functional Ambulation Profile in both groups (P<0.001). CONCLUSIONS: Our results support the hypothesis that an early treatment protocol of robot-assisted gait retraining is not superior to add-on conventional gait training intervention for improving locomotion in non-ambulatory stroke patients. CLINICAL REHABILITATION IMPACT: This study might help to better understand the role of robot-assisted gait training in early phase stroke rehabilitation.

Limitations of intrathecal baclofen for spastic hemiparesis following stroke.

OBJECTIVE: Intrathecal baclofen (ITB) has become the first choice in the management of deleterious spasticity that does not respond to oral and intramuscular medications following spinal cord injury, traumatic brain injury, and cerebral palsy. The usefulness of ITB in severe spastic hemiparesis following stroke is studied. METHODS: A total of 8 patients underwent clinical and video assessment following ITB bolus application (n=5) and during continuous infusion via a temporary catheter system (n=3). RESULTS: The mean daily dosage alleviating spasticity on the hemiparetic side-without affecting the nonparetic side-was 119 microg/day (range 50 to 360 microg/day). However, 6 patients experienced functional deterioration as ITB weakened their paretic side such that the antigravity pattern they used for ambulation was suppressed. In 2 patients, spasticity-associated pain and spasms subsided and they underwent implantation of a long-term drug delivery system. CONCLUSIONS: ITB may reduce spasticity in a dose-dependent manner irrespective of its origin. Although not primarily antinociceptive in humans, ITB may alleviate pain if arising from increased muscle tone. A functional benefit may result if ITB can uncover "subclinical" motor control that had been suppressed by spasticity. However, when a patient uses antigravity patterns for ambulation in the absence of more complex motor control, ITB may cause the loss of residual walking ability, which becomes a major limitation for patients with hemiplegic stroke.

Prospective, blinded, randomized crossover study of gait rehabilitation in stroke patients using the Lokomat gait orthosis.

OBJECTIVE: Treadmill training with partial body weight support has been suggested as a useful strategy for gait rehabilitation after stroke. This prospective, blinded, randomized controlled study of gait retraining tested the feasibility and potential efficacy of using an electromechanical-driven gait orthosis (Lokomat) for treadmill training. METHODS: Sixteen stroke patients, mostly within 3 months after onset, were randomized into 2 treatment groups, ABA or BAB (A = 3 weeks of Lokomat training, B = 3 weeks of conventional physical therapy) for 9 weeks of treatment. The outcome measures were the EU-Walking Scale, Rivermead Motor Assessment Scale, 10-m timed walking speed, 6-minute timed walking distance, Motricity Index, Medical Research Council Scale of strength, and Ashworth Scale of tone. RESULTS: The EU-Walking Scale, Rivermead Motor Assessment Scale, 6-minute timed walking distance, Medical Research Council Scale, and Ashworth Scale demonstrated significantly more improvement during the Lokomat training phase than during the conventional physical therapy phase within each 3-week interval. CONCLUSIONS: Despite the small number of patients, the present data suggest that the Lokomat robotic assistive device provides innovative possibilities for gait training in stroke rehabilitation while eliminating prolonged repetitive movements in a nonergonomic position on the part of the physical therapist.