A new line of wearable robotics developed by The University of Texas Health Science Center at Houston (UTHealth) and The City University of New York, City College (CCNY) could keep seniors on their feet longer. A prototype developed by Hao Su, PhD, an assistant professor at CCNY, and tested by Gerard Francisco, MD, and Shuo-Hsiu (James) Chang, PT, PhD, of McGovern Medical School at UTHealth, fared well in a pilot study of people with walking difficulties. Now with the support of a $1.3 million grant from the National Institute on Disability, Independent Living, and Rehabilitation Research, the three researchers plan to evaluate the model on seniors who have difficulty with their gait or stride.
Shuo-Hsiu (James) Chang, PT, PhD, (center) and Hao Su, PhD, are testing a mobility device for seniors. Photograph by UTHealth.
Conventional exoskeletons are typically heavy, bulky, expensive, and primarily suitable for individuals with little voluntary movement. In contrast, the hybrid soft exoskeleton developed by the team is 60% lighter than commercially available exoskeletons and less costly. It combines the advantages of rigid exoskeletons and textile-based exosuits with assistive control algorithms to monitor, augment, and compensate for the loss of gait function. “Our model is run by the user, not the robot. Wearers aren’t forced to walk in a predefined path,” said Francisco, the chair of physical medicine and rehabilitation at McGovern Medical School and the chief medical officer at TIRR Memorial Hermann, Houston.
The team’s long-term vision is to make assistive robots accessible to everyone who needs them, said Chang, assistant professor of physical medicine and rehabilitation at McGovern Medical School and the administrative director of the NeuroRecovery Research Center at TIRR Memorial Hermann. “There is a pressing need for wearable robots that can improve the quality of life for broader populations in community settings,” he said.
Atypical walking in the months and years after stroke constrain community reintegration and reduce mobility, health, and quality of life. The ReWalk ReStore™ is a soft robotic exosuit designed to assist the propulsion and ground clearance subtasks of post-stroke walking by actively assisting paretic ankle plantarflexion and dorsiflexion. Previous proof-of-concept evaluations of the technology demonstrated improved gait mechanics and energetics and faster and farther walking in users with post-stroke hemiparesis. We sought to determine the safety, reliability, and feasibility of using the ReStore™ during post-stroke rehabilitation.
A multi-site clinical trial (NCT03499210) was conducted in preparation for an application to the United States Food and Drug Administration (FDA). The study included 44 users with post-stroke hemiparesis who completed up to 5 days of training with the ReStore™ on the treadmill and over ground. In addition to primary and secondary endpoints of safety and device reliability across all training activities, an exploratory evaluation of the effect of multiple exposures to using the device on users’ maximum walking speeds with and without the device was conducted prior to and following the five training visits.
All 44 study participants completed safety and reliability evaluations. Thirty-six study participants completed all five training days. No device-related falls or serious adverse events were reported. A low rate of device malfunctions was reported by clinician-operators. Regardless of their reliance on ancillary assistive devices, after only 5 days of walking practice with the device, study participants increased both their device-assisted (Δ: 0.10 ± 0.03 m/s) and unassisted (Δ: 0.07 ± 0.03 m/s) maximum walking speeds (P’s < 0.05).
When used under the direction of a licensed physical therapist, the ReStore™ soft exosuit is safe and reliable for use during post-stroke gait rehabilitation to provide targeted assistance of both paretic ankle plantarflexion and dorsiflexion during treadmill and overground walking.
Bipedal locomotion is characterized by alternating periods of single and double limb support, with ground clearance by the swing limb and propulsion by the trailing stance limb serving as crucial walking subtasks [1, 2]. Healthy individuals are able to generate an ankle dorsiflexion moment during each limb’s swing phase to lift the foot and facilitate ground clearance. They are also able to generate an ankle plantarflexion moment during each limb’s late stance phase to produce the propulsive force required to advance the limb and body . In contrast, post-stroke hemiparesis results in impaired paretic dorsiflexion and plantarflexion that, in turn, hinders ground clearance and propulsion [4,5,6,7,8] and, ultimately, necessitates compensatory walking strategies [9, 10] that make walking more effortful and unstable [11,12,13,14].
The ReWalk ReStore™ is a soft robotic exosuit designed to augment the paretic ankle’s ability to produce both dorsiflexor and plantarflexor moments during walking. In early proof-of-concept studies conducted with a research version of the device [15, 16], exosuits were shown to facilitate immediate increases in swing phase paretic ankle dorsiflexion by an average 5 degrees , the propulsion force generated by the paretic limb by an average 10% , and the positive center of mass (COM) power generated by the paretic limb during late stance phase by an average 22% . Together, these improvements in paretic limb function resulted in reduced propulsion asymmetry by 20%  and the asymmetry in positive COM power generated during late stance phase by 39% . Also observed were immediate reductions in hip hiking and circumduction compensations of over 20% , reductions in the energy cost of walking by an average 10% [17, 18], faster overground walking speeds by a median 0.14 m/s, and farther walking distances during the 6-min walk test by a median 32m .
Building on this foundational biomechanical, physiological, and clinical research, the objective of this multi-site clinical trial was to evaluate safety, feasibility, and reliability of using exosuits during post-stroke rehabilitation in preparation for a commercial clinical application to the United States Food and Drug Administration (FDA). In contrast to previous laboratory-based research that studied the immediate effects of exosuit prototypes on clinical, biomechanical, and physiological outcomes, this translational research sought to determine the safety of clinicians and patients with post-stroke hemiparesis using the commercially-adapted ReStore™ in clinical settings, the feasibility of clinician operators applying the ReStore™ during both treadmill and over ground gait training activities, and the reliability of the technology across multiple training visits. In addition to outcomes of safety, feasibility, and device reliability, an exploratory evaluation of the impact that multiple training visits with the device have on users’ maximum walking speeds, both with and without the device, was also included.
The ReStore™ is indicated for use by individuals with post-stroke hemiparesis undergoing stroke rehabilitation under the supervision of a licensed physical therapist. To assess the safety, device reliability, and clinical feasibility of using the ReStore™ during post-stroke gait rehabilitation, a multi-site trial was conducted. The trial included five clinical sites and 44 users with post-stroke hemiparesis. The study was approved by the Institutional Review Boards of Boston University, Spaulding Rehabilitation Hospital, The Shirley Ryan AbilityLab, TIRR Memorial Hermann Hospital, Kessler Rehabilitation Hospital, and Moss Rehabilitation Hospital. Written informed consent was secured for all participants.
Study inclusion and exclusion criteria
Study participant eligibility requirements consisted of: (i) one-sided ischemic or hemorrhagic stroke, (ii) > 2 weeks post-stroke, (iii) age > 18 years, (iv) height between 4′8″ and 6′7″, (v) weight < 264lbs, (vi) medical clearance, (vii) ability to ambulate at least 5 ft without an AFO and with no more than minimal contact assistance, (viii) ability to follow a 3-step command, (ix) ability to fit suit components, (x) no greater than 5 degrees of ankle plantar flexion contracture, and (xi) Modified Ashworth Scale for tone at 3 or less for ankle dorsiflexor and plantarflexor muscles. Exclusion criteria included: (i) severe aphasia limiting ability to express needs or discomfort verbally or non-verbally, (ii) serious co-morbidities that interfere with ability to participate, (iii) significant Peripheral Artery Disease, (iv) colostomy bag, (v) current pregnancy, (vi) uncontrolled hypertension, (vii) participation in any other clinical trial, (viii) open wounds or broken skin at device locations requiring medical management, (ix) urethane allergies, (x) and current DVT.
After screening and enrollment, study participants completed up to two walking evaluations and five device exposure visits. Each exposure visit consisted of up to 20 min of overground walking practice and 20 min of treadmill walking practice while receiving assistance from the device. The visit schedule consisted of a minimum of two visits per week, with the expectation of no more than 4 weeks between the pretraining and posttraining evaluations. Actual activities and durations were dependent on each study participant’s abilities as determined by the treating physical therapist as per their usual practices. The target level for plantarflexion assistance during all active walking with the ReStore™ was 25% of the user’s bodyweight [17, 19]. The target level for dorsiflexion assistance was the minimum needed for adequate ground clearance and heel strike, as determined visually by the physical therapist.
The exosuit consists of motors worn at the waist that generate mechanical forces that are transmitted by cables to attachment points located proximally on a functional textile worn around the calf and distally on a shoe insole (Fig. 1). The overall weight of the exosuit is approximately 5kgs, with the vast majority of the weight located proximally in the actuation pack worn at the waist. Each functional textile contains a detachable liner that can be washed. For users who require medio-lateral ankle support in addition to ankle plantarflexion and dorsiflexion assistance, an optional textile component that prevents ankle inversion without restricting dorsiflexion and plantarflexion can also be used. Inertial sensors that attach to a patient’s shoes measure gait events and automate the independent timing of the active ankle plantarflexion and dorsiflexion assistance provided by the ReStore™ as previously described . Load cell sensors located at the end of each cable are used to monitor the interaction between user and exosuit and ensure that the target level of assistance is achieved [16, 17]. A hand-held device with a graphical interface allows clinicians to monitor patients’ performance and select and progress, in real-time, the assistance parameters (Fig. 2).
Objectives: To evaluate effect of Vojta Therapy on balance and
walking of community dwelling chronic stroke patients. Study design: Single group clinical trial with pre and post test. Setting: VojtaTherapy clinic, Division of Physical Therapy,
Department of Rehabilitation Medicine, Trang Hospital. Subjects: Community dwelling chronic stroke patients with
abnormal gait referred to the VojtaTherapy clinic. Methods: Every participant did a timed up and go test (TUGT)
immediately before and after the VojtaTherapy. Techniques were
chosen according to response of patients with 30 minutes per
session. Treatment and assessment were repeated once a week
for three weeks. Results: Twenty chronic stroke patients with average age of
63.1 (SD = 13.23) years and average duration after stroke of
58.35 (SD = 52.83) months were enrolled into the study. The
median TUGT scores of the first, second and third pre-treatment
were 28, 22 and 19.5 respectively. Friedman test demonstrated a
significant difference (p < 0.001). Median TUGT Score of the first,
second, and third post treatment TUGT score were 22.5, 18 and
18.5 respectively. Wilcoxon test showed significant difference of
pre versus post treatments in everysessions (p < 0.0001). Conclusion: Once a week of VojtaTherapy for three weeks can
improve walking in community dwelling chronic stroke patients. Download Full Text PDF
Wearable activity monitors that track step count can increase the wearer’s physical activity and motivation but are infrequently designed for the slower gait speed and compensatory patterns after stroke. New and available technology may allow for the design of stroke-specific wearable monitoring devices, capable of detecting more than just step counts, which may enhance how rehabilitation is delivered. The objective of this study was to identify important considerations in the development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke.
A qualitative research design with focus groups was used to collect data. Five focus groups were conducted, audio recorded, and transcribed verbatim. Data were analyzed using content analysis to generate overarching categories representing the stakeholder considerations for the development of stroke-specific wearable monitor technology for the lower extremity.
A total of 17 physical therapists took part in four focus group discussions and three individuals with stroke participated in the fifth focus group. Our analysis identified four main categories for consideration: 1) ‘Variability’ described the heterogeneity of patient presentation, therapy approaches, and therapeutic goals that are taken into account for stroke rehabilitation; 2) ‘Context of use’ described the different settings and purposes for which stakeholders could foresee employing stroke-specific wearable technology; 3) ‘Crucial design features’ identified the measures, functions, and device characteristics that should be considered for incorporation into prospective technology to enhance uptake; and 4) ‘Barriers to adopting technology’ highlighted challenges, including personal attitudes and design flaws, that may limit the integration of current and future wearable monitoring technology into clinical practice.
The findings from this qualitative study suggest that the development of stroke-specific lower extremity wearable monitoring technology is viewed positively by physical therapists and individuals with stroke. While a single, specific device or function may not accommodate all the variable needs of therapists and their clients, it was agreed that wearable monitoring technology could enhance how physical therapists assess and treat their clients. Future wearable devices should be developed in consideration of the highlighted design features and potential barriers for uptake.
Individuals with stroke commonly face mobility limitations, beginning at stroke onset  and continuing past discharge into the community , and demonstrate a range of gait deviations due to altered motor control and resulting compensatory movement patterns . Improving walking quality and quantity is a major focus of therapy , as doing so can improve mobility, fitness, quality of life, and prevent secondary complications [5, 6]. One avenue to target walking for individuals with stroke may be to utilize wearable monitoring technology, as previous research has shown that application of an activity monitor can improve user self-efficacy and physical activity levels in various patient populations including older adults, breast cancer survivors, and those with chronic obstructive pulmonary disease [7,8,9,10,11]. Additionally, wearable monitors have been increasingly utilized by therapists and researchers to assess various outcomes relating to exercise and physical activity, [12, 13] within therapy and between visits, to ensure exercise targets are met .
The majority of currently available wearable monitoring technology has not been developed specifically for stroke-related impairments and movement patterns. For example, consumer activity monitors are often limited by a minimum walking speed or movement amplitude in order to provide accurate and reliable feedback [15, 16]. Research efforts have attempted to adapt available wearable monitoring technology to meet the needs of individuals with stroke with increasing accuracy, from simple solutions such as wearing hip-situated fitness trackers at the ankle [17, 18], to developing software algorithms to analyze captured data to recognize movements patterns specific to stroke [19,20,21]. The advances in wearable monitoring have reached a point at which designing stroke-specific wearable monitoring technology is a realistic priority to assess outcome and enhance rehabilitation interventions .
Much of the efforts to design stroke-specific wearable monitoring technology has so far focused on the hemiparetic upper limb [23,24,25,26]. This is unsurprising, as many individuals with stroke report long-term upper limb deficits or disability , and upper limb recovery has been identified as a top research priority from the perspective of individuals with stroke and their health professionals . Conversely, limited efforts have been made in applying sensing technology to design stroke-specific wearable monitors for the hemiparetic lower limb. Research has shown that accelerometry can be reliable and valid in measuring physical activity after stroke , and new technologies to quantify foot pressure, leg motion, and muscle activity are being shown to be applicable to stroke [30, 31]. Thus, there is a gap in wearable monitoring technology for individuals with stroke, between what can be designed to improve rehabilitation of the lower extremity and what is currently available.
In order to develop devices that fill this niche, it is important to involve end-users in the development process from the onset to ensure initial efforts are relevant to the individuals who will ultimately use them, [32, 33] which inevitably are individuals with stroke and their physical therapists. This user-centered design approach is optimal for identifying relevant factors and technical aspects that should inform design choices [32, 33]. Thus, the objective of the current study was to identify important considerations in the future development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke.[…]
Virtual reality video games, activity monitors, and handheld computer devices can help people stand as well as walk, according to an Australia-based study published in PLoS Medicine looking at the effects of digital devices in rehabilitation.
The trial took place in Sydney’s Liverpool Hospital, Bankstown-Lidcombe Hospital, and Adelaide’s Repatriation General Hospital, and included 300 participants ranging in age from 18 to 101 years old who were recovering from strokes, brain injuries, falls, and fractures.
Participants used on average four different devices while in hospital and two different devices when at home. Fitbits were the most commonly used digital device, but also tested on people in hospital and at home were a suite of devices like Xbox, Wii and iPads, making the exercises more interactive and enabling remote connection with their physiotherapist.
The digital devices included virtual reality video games, activity monitors, and handheld computer devices aimed at enabling a higher dose of therapy.
Those who exercised using digital devices in addition to their usual rehabilitation were found to have better mobility (walking, standing up and balance) after 3 weeks and 6 months, according to a media release from University of Sydney.
Patients using the digital devices in rehabilitation reported benefits including variety, fun, feedback about performance, cognitive challenge, enabled additional exercise, and potential to use the devices with others (eg, family, therapists, and other patients), the study’s lead author, Dr Leanne Hassett from the University of Sydney, notes in the release.
“These benefits meant patients were more likely to continue their therapy when and where it suited them, with the assistance of digital health care,” says Hassett, from the university’s Faculty of Medicine and Health.
People were young at heart when it came to devices, she adds.
“Participants loved Fitbits; one woman would demand to put it on in the middle of the night before she went to the toilet, to make sure all her steps were counted,” shares Hassett, who is a Senior Research Fellow in the Institute for Musculoskeletal Health and Senior Lecturer in the Discipline of Physiotherapy.
“This model of rehabilitation therapy proved to be feasible and enjoyable, and demonstrated that it could be used across different care settings, such as post-hospital rehabilitation, with mostly remote support by the physiotherapist.
“The study shows that future physical rehabilitation models should look at including digital devices to improve both inpatient and post-hospital rehabilitation,” she suggests.
The next step will be to trial the approach into clinical practice by incorporating it into the work of physiotherapists; recruitment for this is likely in 12 to 18 months, the release concludes.
The aim of this study was to evaluate the effects of ankle-foot orthoses on speed walking in patients with stroke.
PubMed, Embase, Web of Science, Scopus, CENTRAL, PEDro, RehabData, RECAL, and ProQuest were searched from inception until 30 September 2019.
This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline statement. Risk of bias assessment was performed using the Cochrane Risk of Bias Tool. Begg’s test and Egger’s regression method were used to assess the publication bias. Trim and fill analysis was also used to adjust any potential publication bias. Sensitivity analysis was performed to evaluate the effect of individual studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.
Overall, 14 studies were included with a total of 1186 participants. A small-to-moderate and non-significant improvement in favor of the ankle-foot orthosis versus without ankle-foot orthosis (standardized mean difference (SMD) = 0.41, 95% confidence interval = −0.15 to 0.96), similar effects of ankle-foot orthosis and functional electrical stimulation (SMD = 0.00, 95% confidence interval = −0.16 to 0.16), and a small and non-significant improvement in favor of ankle-foot orthosis versus another type of ankle-foot orthosis (SMD = 0.22, 95% confidence interval = −0.05 to 0.49) in walking speed were found. However, the quality of evidence for all comparisons was low or very low.
Despite reported positive effects in some studies, there is no firm evidence of any benefit of ankle-foot orthoses on walking speed.
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Gait disorders are major symptoms of neurological diseases affecting the quality of life. Interventions that restore walking and allow patients to maintain safe and independent mobility are essential. Robot-assisted gait training (RAGT) proved to be a promising treatment for restoring and improving the ability to walk. Due to heterogenuous study designs and fragmentary knowlegde about the neural correlates associated with RAGT and the relation to motor recovery, guidelines for an individually optimized therapy can hardly be derived. To optimize robotic rehabilitation, it is crucial to understand how robotic assistance affect locomotor control and its underlying brain activity. Thus, this study aimed to investigate the effects of robotic assistance (RA) during treadmill walking (TW) on cortical activity and the relationship between RA-related changes of cortical activity and biomechanical gait characteristics.
Twelve healthy, right-handed volunteers (9 females; M = 25 ± 4 years) performed unassisted walking (UAW) and robot-assisted walking (RAW) trials on a treadmill, at 2.8 km/h, in a randomized, within-subject design. Ground reaction forces (GRFs) provided information regarding the individual gait patterns, while brain activity was examined by measuring cerebral hemodynamic changes in brain regions associated with the cortical locomotor network, including the sensorimotor cortex (SMC), premotor cortex (PMC) and supplementary motor area (SMA), using functional near-infrared spectroscopy (fNIRS).
A statistically significant increase in brain activity was observed in the SMC compared with the PMC and SMA (p < 0.05), and a classical double bump in the vertical GRF was observed during both UAW and RAW throughout the stance phase. However, intraindividual gait variability increased significantly with RA and was correlated with increased brain activity in the SMC (p = 0.05; r = 0.57).
On the one hand, robotic guidance could generate sensory feedback that promotes active participation, leading to increased gait variability and somatosensory brain activity. On the other hand, changes in brain activity and biomechanical gait characteristics may also be due to the sensory feedback of the robot, which disrupts the cortical network of automated walking in healthy individuals. More comprehensive neurophysiological studies both in laboratory and in clinical settings are necessary to investigate the entire brain network associated with RAW.
Safe and independent locomotion represents a fundamental motor function for humans that is essential for self-contained living and good quality of life [1,2,3,4,5]. Locomotion requires the ability to coordinate a number of different muscles acting on different joints [6,7,8], which are guided by cortical and subcortical brain structures within the locomotor network . Structural and functional changes within the locomotor network are often accompanied by gait and balance impairments which are frequently considered to be the most significant concerns in individuals suffering from brain injuries or neurological diseases [5, 10, 11]. Reduced walking speeds and step lengths  as well as non-optimal amount of gait variability [13,14,15] are common symptoms associated with gait impairments that increase the risk of falling .
In addition to manual-assisted therapy, robotic neurorehabilitation has often been applied in recent years [17, 18] because it provides early, intensive, task-specific and multi-sensory training which is thought to be effective for balance and gait recovery [17, 19, 20]. Depending on the severity of the disease, movements can be completely guided or assisted, tailored to individual needs , using either stationary robotic systems or wearable powered exoskeletons.
Previous studies investigated the effectiveness of robot-assisted gait training (RAGT) in patients suffering from stroke [21, 22], multiple sclerosis [23,24,25,26], Parkinson’s disease [27, 28], traumatic brain injury  or spinal cord injury [30,31,32]. Positive effects of RAGT on walking speed [33, 34], leg muscle force  step length, and gait symmetry [29, 35] were reported. However, the results of different studies are difficult to summarize due to the lack of consistency in protocols and settings of robotic-assisted treatments (e.g., amount and frequency of training sessions, amount and type of provided robotic support) as well as fragmentary knowledge of the effects on functional brain reorganization, motor recovery and their relation [36, 37]. Therefore, it is currently a huge challenge to draw guidelines for robotic rehabilitation protocols [22, 36,37,38]. To design prologned personalized training protocols in robotic rehabilitation to maximize individual treatment effects , it is crucial to increase the understanding of changes in locomotor patterns  and brain signals  underlying RAGT and how they are related [36, 41].
A series of studies investigated the effects of robotic assistance (RA) on biomechanical gait patterns in healthy people [39, 42,43,44]. On one side, altered gait patterns were reported during robot-assisted walking (RAW) compared to unassisted walking (UAW), in particular, substantially higher muscle activity in the quadriceps, gluteus and adductor longus leg muscles and lower muscle activity in the gastrocnemius and tibialis anterior ankle muscles [39, 42] as well as reduced lower-body joint angles due to the little medial-lateral hip movements [45,46,47]. On the other side, similar muscle activation patterns were observed during RAW compared to UAW [44, 48, 49], indicating that robotic devices allow physiological muscle activation patterns during gait . However, it is hypothesized that the ability to execute a physiological gait pattern depends on how the training parameters such as body weight support (BWS), guidance force (GF) or kinematic restrictions in the robotic devices are set [44, 48, 50]. For example, Aurich-Schuler et al.  reported that the movements of the trunk and pelvis are more similar to UAW on a treadmill when the pelvis is not fixed during RAW, indicating that differences in musle activity and kinematic gait characteristics between RAW and UAW are due to the reduction in degrees of freedom that user’s experience while walking in the robotic device . In line with this, a clinical concern that is often raised with respect to RAW is the lack of gait variability [45, 48, 50]. It is assumed that since the robotic systems are often operated with 100% GF, which means that the devices attempt to force a particular gait pattern regardless of the user’s intentions, the user lacks the ability to vary and adapt his gait patterns . Contrary to this, Hidler et al.  observed differences in kinematic gait patterns between subsequent steps during RAW, as demonstrated by variability in relative knee and hip movements. Nevertheless, Gizzi et al.  showed that the muscular activity during RAW was clearly more stereotyped and similar among individuals compared to UAW. They concluded that RAW provides a therapeutic approach to restore and improve walking that is more repeatable and standardized than approaches based on exercising during UAW .
In addition to biomechanical gait changes, insights into brain activity and intervention-related changes in brain activity that relate to gait responses, will contribute to the optimization of therapy interventions [41, 51]. Whereas the application of functional magnetic resonance imaging (fMRI), considered as gold standard for the assessment of activity in cortical and subcortical structures, is restricted due to the vulnerability for movement artifacts and the range of motion in the scanner , functional near infrared spectroscopy (fNIRS) is affordable and easily implementable in a portable system, less susceptible to motion artifacts, thus facilitation a wider range of application with special cohorts (e.g., children, patients) and in everyday environments (e.g., during a therapeutic session of RAW or UAW) [53, 54]. Although with lower resolution compared to fMRI , fNIRS also relies on the principle of neurovascular coupling and allows the indirect evaluation of cortical activation [56, 57] based on hemodynamic changes which are analogous to the blood-oxygenation-level-dependent responses measured by fMRI . Despite limited depth sensitivity, which restricts the measurement of brain activity to cortical layers, it is a promising tool to investigate the contribution of cortical areas to the neuromotor control of gross motor skills, such as walking . Regarding the cortical correlates of walking, numerous studies identified either increaesed oxygenated hemoglobin (Hboxy) concentration changes in the sensorimotor cortex (SMC) by using fNIRS [53, 57,58,59] or suppressed alpha and beta power in sensorimotor areas by using electroencephalography (EEG) [60,61,62] demonstrating that motor cortex and corticospinal tract contribute directly to the muscle activity of locomotion . However, brain activity during RAW [36, 61, 64,65,66,67,68], especially in patients [69, 70] or by using fNIRS [68, 69], is rarely studied .
Analyzing the effects of RA on brain activity in healthy volunteers, Knaepen et al.  reported significantly suppressed alpha and beta rhythms in the right sensory cortex during UAW compared to RAW with 100% GF and 0% BWS. Thus, significantly larger involvement of the SMC during UAW compared to RAW were concluded . In contrast, increases of Hboxy were observed in motor areas during RAW compared UAW, leading to the conclusion that RA facilitated increased cortical activation within locomotor control systems . Furthermore, Simis et al.  demonstrated the feasibility of fNIRS to evaluate the real-time activation of the primary motor cortex (M1) in both hemispheres during RAW in patients suffering from spinal cord injury. Two out of three patients exhibited enhanced M1 activation during RAW compared with standing which indicate the enhanced involvement of motor cortical areas in walking with RA .
To summarize, previous studies mostly focused the effects of RA on either gait characteristics or brain activity. Combined measurements investigating the effects of RA on both biomechanical and hemodynamic patterns might help for a better understanding of the neurophysiological mechanisms underlying gait and gait disorders as well as the effectiveness of robotic rehabilitation on motor recovery [37, 71]. Up to now, no consensus exists regarding how robotic devices should be designed, controlled or adjusted (i.e., device settings, such as the level of support) for synergistic interactions with the human body to achieve optimal neurorehabilitation [37, 72]. Therefore, further research concerning behavioral and neurophysiological mechanisms underlying RAW as well as the modulatory effect of RAGT on neuroplasticy and gait recovery are required giving the fact that such knowledge is of clinical relevance for the development of gait rehabilitation strategies.
Consequently, the central purpose of this study was to investigate both gait characteristics and hemodynamic activity during RAW to identify RAW-related changes in brain activity and their relationship to gait responses. Assuming that sensorimotor areas play a pivotal role within the cortical network of automatic gait [9, 53] and that RA affects gait and brain patterns in young, healthy volunteers [39, 42, 45, 68], we hypothesized that RA result in both altered gait and brain activity patterns. Based on previous studies, more stereotypical gait characteristics with less inter- and intraindividual variability are expected during RAW due to 100% GF and the fixed pelvis compared to UAW [45, 48], wheares brain activity in SMC can be either decreased  or increased .
This study was performed in accordance with the Declaration of Helsinki. Experimental procedures were performed in accordance with the recommendations of the Deutsche Gesellschaft für Psychologie and were approved by the ethical committee of the Medical Association Hessen in Frankfurt (Germany). The participants were informed about all relevant study-related contents and gave their written consent prior to the initiation of the experiment.
Twelve healthy subjects (9 female, 3 male; aged 25 ± 4 years), without any gait pathologies and free of extremity injuries, were recruited to participate in this study. All participants were right-handed, according to the Edinburg handedness-scale , without any neurological or psychological disorders and with normal or corrected-to-normal vision. All participants were requested to disclose pre-existing neurological and psychological conditions, medical conditions, drug intake, and alcohol or caffeine intake during the preceding week.
The Lokomat (Hocoma AG, Volketswil, Switzerland) is a robotic gait-orthosis, consisting of a motorized treadmill and a BWS system. Two robotic actuators can guide the knee and hip joints of participants to match pre-programmed gait patterns, which were derived from average joint trajectories of healthy walkers, using a GF ranging from 0 to 100% [74, 75] (Fig. 1a). Kinematic trajectories can be adjusted to each individual’s size and step preferences . The BWS was adjusted to 30% body weight for each participant, and the control mode was set to provide 100% guidance .
Montage and Setup. a Participant during robot-assisted walking (RAW), with functional near-infrared spectroscopy (fNIRS) montage. b fNIRS montage; S = Sources; D = Detectors c Classification of regions of interest (ROI): supplementary motor area/premotor cortex (SMA/PMC) and sensorimotor cortex (SMC)
The purpose of this paper is to discuss how knowledge of the biomechanics of walking can be used to inform the prescription of resistance exercises for people with mobility limitations. Muscle weakness is a key physical impairment that limits walking in commonly occurring neurologic conditions such as cerebral palsy, traumatic brain injury, and stroke. Few randomized trials to date have shown conclusively that strength training improves walking in people living with these conditions. This appears to be because
(1) the most important muscle groups for forward propulsion when walking have not been targeted for strengthening, and
(2) strength training protocols have focused on slow and heavy resistance exercises, which do not improve the fast muscle contractions required for walking.
We propose a theoretical framework to improve exercise prescription by integrating the biomechanics of walking with the principles of strength training outlined by the American College of Sports Medicine to prescribe exercises that are specific to improving the task of walking. The high angular velocities that occur in the lower limb joints during walking indicate that resistance exercises targeting power generation would be most appropriate. Therefore, we propose the prescription of plyometric and ballistic resistance exercise, applied using the American College of Sports Medicine guidelines for task specificity, once people with neurologic conditions are ambulating, to improve walking outcomes. This new theoretical framework for resistance training ensures that exercise prescription matches how the muscles work during walking.
People with vision impairment who are also Google Maps users are in for a nice surprise! Starting October 10, which was also World Sight Day, Google announced a new update to Google Maps that will provide more detailed voice guidance and verbal announcements while walking from point A to point B.
This feature will provide a lot more confidence to blind people while navigating busy streets and areas. While walking, Google Maps will proactively tell the user if they are on the correct route, the direction the person is walking in, distance from the next turn, etc. If a person misses their turn, Google Maps will announce that it is re-routing the person. Through this detailed voice guidance, people with vision impairment can not only navigate in a “screen free” way with ease, they can also explore places they have not been to before.
Currently, this feature is rolled out in the US and Japan in English and Japanese respectively on iOS and Android. Roll out for other languages is on the way.
Watch the following video to learn more about voice guidance in maps.
Detailed voice guidance can be turned on by going to Settings, Navigation (under walking Options)
Stroke survivors who completed group-based aerobic exercise programs similar in design and duration to cardiac rehabilitation programs significantly improved their aerobic endurance and walking ability, according to a recent study.
Stroke remains the leading cause of disability in the US, and physical therapy is often prescribed to improve physical impairments after stroke. Most current rehabilitation care following stroke has little to no focus on aerobic fitness, and when continued rehabilitation activity is suggested patients often fail to keep active without any support or guidance, according to an analysis of 19 published studies to assess the impact of aerobic exercise programs on endurance and walking ability after stroke.
“The physical therapy we currently provide to patients after a stroke focuses more on improving the ability to move and move well rather than on increasing how far and long you can move,” says Elizabeth Regan, DPT, study lead author, and PhD candidate in Exercise Science at the University of South Carolina, in a media release from the American Heart Association.
“It doesn’t matter how well you can walk if your endurance level keeps you at home.”
The study included nearly 500 adults (average ages between 54-71) who completed aerobic exercise programs similar in structure to cardiac rehabilitation. Participants attended two to three sessions per week for about three months. Of nearly two dozen different exercise groups, walking was the most common type of activity, followed by stationary cycling and then mixed mode aerobic exercise. Physical abilities were tested before and after the intervention.
Looking at results by activity type, researchers found:
Mixed aerobic activity provides the best result (four treatment groups) followed by walking (12 treatment groups).
Cycling or recumbent stepping (machine that allows stepping while in seated position) while still significant was the least effective (seven treatment groups).
Overall, participants significantly improved their endurance level and walking speed.
On average, participants walked almost half the size of a football field farther during a six-minute walking test. Participants with mild movement impairments benefited the most.
“These benefits were realized regardless of how long it had been since their stroke,” Regan comments, in the release. “Our analysis included stroke survivors across a wide range, from less than six months to greater than a year since their stroke, and the benefits were seen whether they started an aerobic exercise program one month or one year after having a stroke.”
“Cardiac rehab programs may be a viable option for patients after a stroke who have health risks and endurance losses similar to traditional cardiac rehab participants,” states Stacy Fritz, PhD, PT, the study’s co-author and associate professor of exercise science in the Physical Therapy Program at the University of South Carolina.
“Almost every hospital has a cardiac rehab program, so it’s an existing platform that could be used for stroke survivors. Funneling patients with stroke into these existing programs may be an easy, cost-effective solution with long-term benefits.”
While this study suggests group-based aerobic exercise programs improve health and endurance in stroke survivors, no control group analysis was performed for results comparison. Limited follow-up data were available to determine whether the health benefits persisted.
[Source(s): American Heart Association, Science Daily]