Background: Postural control disturbances are one of the important causes of disability in stroke patients affecting balance and mobility. The impairment of sensory input integration from visual, somatosensory and vestibular systems contributes to postural control disorders in post-stroke patients. Robot-assisted gait training may be considered a valuable tool in improving gait and postural control abnormalities.
Objective: The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility.
Methods: This single-blind, randomized, controlled trial involved 32 chronic stroke outpatients with postural instability. The experimental group (EG, n = 16) received robot-assisted stair climbing training. The control group (n = 16) received sensory integration balance training. Training protocols lasted for 5 weeks (50 min/session, two sessions/week). Before, after, and at 1-month follow-up, a blinded rater evaluated patients using a comprehensive test battery. Primary outcome: Berg Balance Scale (BBS). Secondary outcomes:10-meter walking test, 6-min walking test, Dynamic gait index (DGI), stair climbing test (SCT) up and down, the Time Up and Go, and length of sway and sway area of the Center of Pressure (CoP) assessed using the stabilometric assessment.
Results: There was a non-significant main effect of group on primary and secondary outcomes. A significant Time × Group interaction was measured on 6-min walking test (p = 0.013) and on posturographic outcomes (p = 0.005). Post hoc within-group analysis showed only in the EG a significant reduction of sway area and the CoP length on compliant surface in the eyes-closed and dome conditions.
Conclusion: Postural control disorders in patients with chronic stroke may be ameliorated by robot-assisted stair climbing training and sensory integration balance training. The robot-assisted stair climbing training contributed to improving sensorimotor integration processes on compliant surfaces. Clinical trial registration (NCT03566901).
Postural control disturbances are one of the leading causes of disability in stroke patients, leading to problems with transferring, maintaining body position, mobility, and walking (Bruni et al., 2018). Therefore, the recovery of postural control is one of the main goals of post-stroke patients. Various and mixed components (i.e., weakness, joint limitation, alteration of tone, loss of movement coordination and sensory organization components) can affect postural control. Indeed, the challenge is to determine the relative weight placed on each of these factors and their interaction to plan specific rehabilitation programs (Bonan et al., 2004).
The two functional goals of postural control are postural orientation and equilibrium. The former involves the active alignment of the trunk and head to gravity, the base of support, visual surround and an internal reference. The latter involves the coordination of movement strategies to stabilize the center of body mass during self-initiated and externally triggered stability perturbations. Postural control during static and dynamic conditions requires a complex interaction between musculoskeletal and neural systems (Horak, 2006). Musculoskeletal components include biomechanical constraints such as the joint range of motion, muscle properties and limits of stability (Horak, 2006). Neural components include sensory and perceptual processes, motor processes involved in organizing muscles into neuromuscular synergies, and higher-level processes essential to plan and execute actions requiring postural control (Shumway-Cook and Woollacott, 2012). A disorder in any of these systems may affect postural control during static (in quite stance) and dynamic (gait) tasks and increase the risk of falling (Horak, 2006).
Literature emphasized the role of impairments of sensory input integration from visual, somatosensory and vestibular systems in leading to postural control disorders in post-stroke patients (Bonan et al., 2004; Smania et al., 2008). Healthy persons rely on somatosensory (70%), vision (10%) and vestibular (20%) information when standing on a firm base of support in a well-lit environment (Peterka, 2002). Conversely, in quite stance on an unstable surface, they increase sensory weighting to vestibular and vision information as they decrease their dependence on surface somatosensory inputs for postural orientation (Peterka, 2002). Bonan et al. (2004) investigate whether post-stroke postural control disturbances may be caused by the inability to select the pertinent somatosensory, vestibular or visual information. Forty patients with hemiplegia after a single hemisphere chronic stroke (at least 12 months) performed computerized dynamic posturography to assess the patient’s ability to use sensory inputs separately and to suppress inaccurate inputs in case of sensory conflict. Six sensory conditions were assessed by an equilibrium score, as a measure of body stability. Results show that patients with hemiplegia seem to rely mostly on visual input. In conditions of altered somatosensory information, with visual deprivation or visuo-vestibular conflict, the patient’s performance was significantly lower than healthy subjects. The mechanism of this excessive visual reliance remains unclear. However, higher-level inability to select the appropriate sensory input rather than to elementary sensory impairment has been advocated as a potential mechanism of action (Bonan et al., 2004).
Sensory strategies and sensory reweighting processes are essential to generate effective movement strategies (ankle, hip, and stepping strategies) which can be resolved through feed-back or feed-forward postural adjustments. The cerebral cortex shapes these postural responses both directly via corticospinal loops and indirectly via the brainstem centers (Jacobs and Horak, 2007). Moreover, the cerebellar- and basal ganglia-cortical loop is responsible for adapting postural responses according to prior experience and for optimizing postural responses, respectively (Jacobs and Horak, 2007).
Rehabilitation is the cornerstone in the management of postural control disorders in post-stroke patients (Pollock et al., 2014). To date, no one physical rehabilitation approach can be considered more effective than any other approach (Pollock et al., 2014). Specific treatments should be chosen according to the individual requirements and the evidence available for that specific treatment. Moreover, it appears to be most beneficial a mixture of different treatment for an individual patient (Pollock et al., 2014). Considering that, rehabilitation involving repetitive, high intensity, task-specific exercises is the pathway for restoring motor function after stroke (Mehrholz et al., 2013; Lo et al., 2017) robotic assistive devices for gait training have been progressively being used in neurorehabilitation to Sung et al. (2017). In the current literature, three primary evidence have been reported.
Firstly, a recent literature review highlights that robot-assisted gait training is advantageous as add-on therapy in stroke rehabilitation, as it adds special therapeutic effects that could not be afforded by conventional therapy alone (Morone et al., 2017; Sung et al., 2017). Specifically, robot-assisted gait training was beneficial for improving motor recovery, gait function, and postural control in post-stroke patients (Morone et al., 2017; Sung et al., 2017). Stroke patients who received physiotherapy treatment in combination with robotic devices were more likely to reach better outcomes compared to patients who received conventional training alone (Bruni et al., 2018).
Second, the systematic review by Swinnen et al. (2014) supported the use of robot-assisted gait therapy to improve postural control in subacute and chronic stroke patients. A wide variability among studies was reported about the robotic-device system and the therapy doses (3–5 times per week, 3–10 weeks, 12–25 sessions). However, significant improvements (Cohen’s d = 0.01 to 3.01) in postural control scores measured with the Berg Balance Scale (BBS), the Tinetti test, postural sway tests, and the Timed Up and Go (TUG) test were found after robot-assisted gait training. Interestingly, in five studies an end-effector device (gait trainer) was used (Peurala et al., 2005; Tong et al., 2006; Dias et al., 2007; Ng et al., 2008; Conesa et al., 2012). In two study, the exoskeleton was used (Hidler et al., 2009; Westlake and Patten, 2009). In one study, a single joint wearable knee orthosis was used (Wong et al., 2012). Because the limited number of studies available and methodological differences among them, more specific randomized controlled trial in specific populations are necessary to draw stronger conclusions (Swinnen et al., 2014).
Finally, technological and scientific development has led to the implementation of robotic devices specifically designed to overcome the motor limitation in different tasks. With this perspective, the robot-assisted end-effector-based stair climbing (RASC) is a promising approach to facilitate task-specific activity and cardiovascular stress (Hesse et al., 2010, 2012; Tomelleri et al., 2011; Stoller et al., 2014, 2016; Mazzoleni et al., 2017).
To date, no studies have been performed on the effects of RASC training in improving postural control and sensory integration processes in chronic post-stroke patients.
The primary aim of the study was to compare the effects of robot-assisted stair climbing training against sensory integration balance training on static and dynamic balance in chronic stroke patients. The secondary aims were to compare the training effects on sensory integration processes and mobility. The hypothesis was that the task-specific and repetitive robot-assisted stairs climbing training might act as sensory integration balance training, improving postural control because sensorimotor integration processes are essential for balance and walking.[…]
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