[ARTICLE] Effects of bodyweight support and guidance force on muscle activation during Locomat walking in people with stroke: a cross-sectional study – Full Text

Background

Locomat is a robotic exoskeleton providing guidance force and bodyweight support to facilitate intensive walking training for people with stroke. Although the Locomat has been reported to be effective in improving walking performance, the effects of training parameters on the neuromuscular control remain unclear. This study aimed to compare the muscle activities between Locomat walking and treadmill walking at a normal speed, as well as to investigate the effects of varying bodyweight support and guidance force on muscle activation patterns during Locomat walking in people with stroke.

Methods

A cross-sectional study design was employed. Participants first performed an unrestrained walking on a treadmill and then walked in the Locomat with different levels of bodyweight support (30% or 50%) and guidance force (40% or 70%) at the same speed (1.2 m/s). Surface electromyography (sEMG) of seven muscles of the affected leg was recorded. The sEMG envelope was time-normalised and averaged over gait cycles. Mean sEMG amplitude was then calculated by normalising the sEMG amplitude with respect to the peak amplitude during treadmill walking for statistical analysis. A series of Non-parametric test and post hoc analysis were performed with a significance level of 0.05.

Results

Fourteen participants with stroke were recruited at the Yangzhi Affiliated Rehabilitation Hospital of Tongji University (female n = 1; mean age 46.1 ± 11.1 years). Only the mean sEMG amplitude of vastus medialis oblique during Locomat walking (50% bodyweight support and 70% guidance force) was significantly lower than that during treadmill walking. Reducing both bodyweight and guidance increased muscle activity of gluteus medius and tibialis anterior. Activity of vastus medialis oblique muscle increased as bodyweight support reduced, while that of rectus femoris increased as guidance force decreased.

Conclusions

The effects of Locomat on reducing muscle activity in people with stroke were minimized when walking at a normal speed. Reducing bodyweight support and guidance force increased the activity of specific muscles during Locomat walking. Effects of bodyweight support, guidance force and speed should be taken into account when developing individualized Locomat training protocols for clients with stroke.

Gait disturbance is one of the major consequences associated with stroke. Due to the impaired supraspinal control, the gait pattern post stroke is characterized as muscle weakness, spasticity, abnormal muscular amplitude and asymmetrical temporal ordering of muscle activity [1, 2]. Impaired walking ability not only reduces the functional independency of stroke survivors, but also increases a series of risks, like fall [3,4,5]. The restoration of functional walking ability requires intensive training with a symmetrical gait pattern [6,7,8].

Various robot-assisted gait trainers, like Locomat, G-EO system Evolution and Gait Trainer, have been designed and implemented in gait rehabilitation for stroke patients [9,10,11,12,13,14,15]. These gait trainers enable a repetitive walking training with predefined normal gait pattern and largely reduce the physical demand of therapists [16]. Those robot-assisted gait trainers, like Locomat (Hocoma, Switzerland), can provide a range of adjustable functions, including bodyweight support (BWS), guidance force (GF) and walking speed, allowing clinicians to develop an individualised training protocol that best fits patient’s ability level [17, 18]. Locomat training, however, has been found to reduce muscle activities in both healthy individuals and people with stroke when compared to overground walking [19, 20]. For example, Coenen and colleagues [20] found that the application of BWS and GF significantly reduced activities of several muscles of affected leg in people with stroke. This feature of Locomat training is considered as a negative aspect of its clinical implication because voluntary contraction of muscles plays a key role in motor relearning [21]. In addition, the exoskeletons of Locomat limit the movement in sagittal plane and reduce the degree of freedom of pelvis which may lead to abnormal interaction between the leg and exoskeleton as well as abnormal muscle activity pattern [10, 22].

There is sufficient evidence showing that the Locomat training provided better improvement in terms of independent walking ability, walking speed, balance and disability than conventional physiotherapy to people with stroke [23,24,25,26,27,28]. There is also evidence that Locomat training significantly improved the duration of single stance phase, step length ratio on the paretic leg when walking on the ground [29, 30]. However, there are also studies showing that the Locomat was not superior to conventional therapy in people with stroke [9, 30, 31]. Despite the heterogeneous features of participants, the difference in training parameters of Locomat may also contribute to the controversial results. In healthy participants, there is ample evidence that BWS or GF can affect the activation of specific muscles [10, 19, 20, 32, 33]. There are also studies reporting significant interactions between BWS, GF and walking speed on voluntary control indicating that the mechanisms of those parameters are complex [32]. In a recent study, however, researchers reported that varying BWS and GF was not associated with changes of muscle activity in people with stroke, whereas increasing walk speed led to greater muscle activity [34]. Since the walking speeds used in previous studies were relatively low (0.56 m/s and 0.61 m/s respectively) [19, 20] and the increase of speed was associated with greater muscle activity [32, 35], it is of interest to investigate whether a higher walking speed would modulate the difference in muscle activity between Locomat walking and treadmill walking.

To further investigate the effects of BWS and GF on active muscle activity, this study aimed to compare the muscle activity level of affected leg between Locomat and treadmill walking at a normal speed in people with stroke. This study also investigated the effects of varying BWS and GF on muscle activity patterns during Locomat walking. Therefore, we hypothesized that when walking at a normal speed, people with stroke exhibit lower muscle activity in the affected leg during Locomat walking than during unrestrained treadmill walking. We also hypothesized that reducing BWS and GF will increase muscle activity level of the affected leg in people with stroke.

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