Kinematic, Muscular, and Metabolic Responses During Exoskeletal-, Elliptical-, or Therapist-Assisted Stepping in People With Incomplete Spinal Cord Injury

Background Robotic-assisted locomotor training has demonstrated some efficacy in individuals with neurological injury and is slowly gaining clinical acceptance. Both exoskeletal devices, which control individual joint movements, and elliptical devices, which control endpoint trajectories, have been utilized with specific patient populations and are available commercially. No studies have directly compared training efficacy or patient performance during stepping between devices. Objective The purpose of this study was to evaluate kinematic, electromyographic (EMG), and metabolic responses during elliptical- and exoskeletal-assisted stepping in individuals with incomplete spinal cord injury (SCI) compared with therapist-assisted stepping. Design A prospective, cross-sectional, repeated-measures design was used. Methods Participants with incomplete SCI (n=11) performed 3 separate bouts of exoskeletal-, elliptical-, or therapist-assisted stepping. Unilateral hip and knee sagittal-plane kinematics, lower-limb EMG recordings, and oxygen consumption were compared across stepping conditions and with control participants (n=10) during treadmill stepping. Results Exoskeletal stepping kinematics closely approximated normal gait patterns, whereas significantly greater hip and knee flexion postures were observed during elliptical-assisted stepping. Measures of kinematic variability indicated consistent patterns in control participants and during exoskeletal-assisted stepping, whereas therapist- and elliptical-assisted stepping kinematics were more variable. Despite specific differences, EMG patterns generally were similar across stepping conditions in the participants with SCI. In contrast, oxygen consumption was consistently greater during therapist-assisted stepping. Limitations Limitations included a small sample size, lack of ability to evaluate kinetics during stepping, unilateral EMG recordings, and sagittal-plane kinematics. Conclusions Despite specific differences in kinematics and EMG activity, metabolic activity was similar during stepping in each robotic device. Understanding potential differences and similarities in stepping performance with robotic assistance may be important in delivery of repeated locomotor training using robotic or therapist assistance and for consumers of robotic devices.

[1]  E Byron Marsolais,et al.  Response of sagittal plane gait kinematics to weight-supported treadmill training and functional neuromuscular stimulation following stroke. , 2004, Journal of rehabilitation research and development.

[2]  J. Hidler,et al.  Alterations in muscle activation patterns during robotic-assisted walking. , 2005, Clinical biomechanics.

[3]  S. Hesse,et al.  A mechanized gait trainer for restoring gait in nonambulatory subjects. , 2000, Archives of physical medicine and rehabilitation.

[4]  T. Hornby,et al.  Clinical and Quantitative Evaluation of Robotic-Assisted Treadmill Walking to Retrain Ambulation After Spinal Cord Injury , 2005 .

[5]  A. Sanabria,et al.  Randomized controlled trial. , 2005, World journal of surgery.

[6]  R. Kram,et al.  Energy cost and muscular activity required for leg swing during walking. , 2005, Journal of applied physiology.

[7]  L. Forrester,et al.  Treadmill Exercise Rehabilitation Improves Ambulatory Function and Cardiovascular Fitness in Patients With Chronic Stroke: A Randomized, Controlled Trial , 2005, Stroke.

[8]  Robert Riener,et al.  Controlling patient participation during robot-assisted gait training , 2011, Journal of NeuroEngineering and Rehabilitation.

[9]  J. Donelan,et al.  Mechanical and metabolic requirements for active lateral stabilization in human walking. , 2004, Journal of biomechanics.

[10]  T. Hornby,et al.  Metabolic Costs and Muscle Activity Patterns During Robotic- and Therapist-Assisted Treadmill Walking in Individuals With Incomplete Spinal Cord Injury , 2006, Physical Therapy.

[11]  S Hesse,et al.  Repetitive locomotor training and physiotherapy improve walking and basic activities of daily living after stroke: a single-blind, randomized multicentre trial (DEutsche GAngtrainerStudie, DEGAS) , 2007, Clinical rehabilitation.

[12]  B. Knowlton,et al.  Step training with body weight support: effect of treadmill speed and practice paradigms on poststroke locomotor recovery. , 2002, Archives of physical medicine and rehabilitation.

[13]  M. Lewek,et al.  Allowing Intralimb Kinematic Variability During Locomotor Training Poststroke Improves Kinematic Consistency: A Subgroup Analysis From a Randomized Clinical Trial , 2009, Physical Therapy.

[14]  Bruce H Dobkin,et al.  An Accelerometry-Based Comparison of 2 Robotic Assistive Devices for Treadmill Training of Gait , 2008, Neurorehabilitation and neural repair.

[15]  A. Behrman,et al.  Locomotor Training Restores Walking in a Nonambulatory Child With Chronic, Severe, Incomplete Cervical Spinal Cord Injury , 2008, Physical Therapy.

[16]  Alena M. Grabowski,et al.  Independent metabolic costs of supporting body weight and accelerating body mass during walking. , 2005, Journal of applied physiology.

[17]  Reliability of measurement of tempo-spatial parameters of gait after stroke using GaitMat II , 2004, Clinical rehabilitation.

[18]  R. Schmidt,et al.  Motor control and learning: A behavioral emphasis, 4th ed. , 2005 .

[19]  B. Dobkin,et al.  Human lumbosacral spinal cord interprets loading during stepping. , 1997, Journal of neurophysiology.

[20]  Joseph Hidler,et al.  Kinematic trajectories while walking within the Lokomat robotic gait-orthosis. , 2008, Clinical biomechanics.

[21]  L. Connell,et al.  What is Bobath? A survey of UK stroke physiotherapists' perceptions of the content of the Bobath concept to treat postural control and mobility problems after stroke , 2009, Disability and rehabilitation.

[22]  S. Harkema,et al.  Locomotor training after human spinal cord injury: a series of case studies. , 2000, Physical therapy.

[23]  E. Roth,et al.  Locomotor Training Improves Daily Stepping Activity and Gait Efficiency in Individuals Poststroke Who Have Reached a “Plateau” in Recovery , 2010, Stroke.

[24]  J. Perry,et al.  Gait Analysis , 2024 .

[25]  V. Dietz,et al.  Treadmill training of paraplegic patients using a robotic orthosis. , 2000, Journal of rehabilitation research and development.

[26]  John F. Ditunno,et al.  Walking index for spinal cord injury (WISCI II): scale revision. , 2001 .

[27]  B. Conway,et al.  Proprioceptive input resets central locomotor rhythm in the spinal cat , 2004, Experimental Brain Research.

[28]  S. Hesse,et al.  Development of an Advanced Mechanised Gait Trainer, Controlling Movement of the Centre of Mass, for Restoring Gait in Non-ambulant Subjects - Weiterentwicklung eines mechanisierten Gangtrainers mit Steuerung des Massenschwerpunktes zur Gangrehabilitation rollstuhlpflichtiger Patienten , 1999, Biomedizinische Technik. Biomedical engineering.

[29]  Thad W. Buster,et al.  Similarity of Joint Kinematics and Muscle Demands Between Elliptical Training and Walking: Implications for Practice , 2010, Physical Therapy.

[30]  Timothy D. Lee,et al.  Motor Control and Learning: A Behavioral Emphasis , 1982 .

[31]  V. Dietz,et al.  Driven gait orthosis for improvement of locomotor training in paraplegic patients , 2001, Spinal Cord.

[32]  Gerald V. Smith,et al.  Treadmill training improves fitness reserve in chronic stroke patients. , 2001, Archives of physical medicine and rehabilitation.

[33]  T Bajd,et al.  Comparison of visual and haptic feedback during training of lower extremities. , 2010, Gait & posture.

[34]  R. Herman,et al.  Spinal cord stimulation facilitates functional walking in a chronic, incomplete spinal cord injured , 2002, Spinal Cord.

[35]  R. Kram,et al.  Energy cost and muscular activity required for propulsion during walking. , 2003, Journal of applied physiology.

[36]  Robert Riener,et al.  Virtual reality for enhancement of robot-assisted gait training in children with central gait disorders. , 2011, Journal of rehabilitation medicine.

[37]  B. Bobath.  Adult hemiplegia: Evaluation and treatment , 1978 .

[38]  V R Edgerton,et al.  Recruitment of spinal motor pools during voluntary movements versus stepping after human spinal cord injury. , 2002, Journal of neurotrauma.

[39]  Gerald V. Smith,et al.  Treadmill aerobic exercise training reduces the energy expenditure and cardiovascular demands of hemiparetic gait in chronic stroke patients. A preliminary report. , 1997, Stroke.

[40]  Susan J Harkema,et al.  The human spinal cord interprets velocity-dependent afferent input during stepping. , 2004, Brain : a journal of neurology.

[41]  K. Pearson,et al.  Reversal of the influence of group Ib afferents from plantaris on activity in medial gastrocnemius muscle during locomotor activity. , 1993, Journal of neurophysiology.

[42]  C. Winstein,et al.  Effects of physical guidance and knowledge of results on motor learning: support for the guidance hypothesis. , 1994, Research quarterly for exercise and sport.

[43]  賢二 鈴木.  慢性副鼻腔炎に対するrandomized controlled study , 2002 .

[44]  Sandra B. Davis,et al.  Locomotor training progression and outcomes after incomplete spinal cord injury. , 2005, Physical therapy.

[45]  Marsha Johnson-Schmid,et al.  Adult Hemiplegia: Evaluation and Treatment (3rd ed.) , 1991 .

[46]  H. Barbeau,et al.  A new approach to retrain gait in stroke patients through body weight support and treadmill stimulation. , 1998, Stroke.

[47]  S. Katoh,et al.  Validation of the American Spinal Injury Association (ASIA) Motor Score and the National Acute Spinal Cord Injury Study (NASCIS) Motor Score , 1996, Spine.

[48]  T. Demott,et al.  Enhanced Gait-Related Improvements After Therapist- Versus Robotic-Assisted Locomotor Training in Subjects With Chronic Stroke: A Randomized Controlled Study , 2008, Stroke.

[49]  A Ashburn,et al.  Physiotherapy based on the Bobath concept in stroke rehabilitation: a survey within the UK. , 2001, Disability and rehabilitation.

[50]  Ann Ashburn,et al.  Gait outcome following outpatient physiotherapy based on the Bobath concept in people post stroke , 2006, Disability and rehabilitation.

[51]  M. Maležič,et al.  Treadmill training with partial body weight support compared with physiotherapy in nonambulatory hemiparetic patients. , 1995, Stroke.

[52]  H. Barbeau,et al.  A dynamic EMG profile index to quantify muscular activation disorder in spastic paretic gait. , 1989, Electroencephalography and clinical neurophysiology.

[53]  Susan D Horn,et al.  Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? , 2005, Archives of physical medicine and rehabilitation.

[54]  PL Dittuno,et al.  Walking index for spinal cord injury (WISCI II): scale revision , 2001, Spinal Cord.

[55]  Spinal cord stimulation facilitates functional walking in a chronic, incomplete spinal cord injured subject , 2002, Spinal Cord.