One of the most important consequences of stroke is a person’s reduced mobility. The rate of patients achieving independence in self-care activities such as toilet, dressing, and feeding is around 60-80% 1 year after stroke. According to a scientific study in 2008, about half of stroke patients were discharged from the hospital in a wheelchair, less than 15% were able to walk indoors unaided, less than 10% were able to walk outside, and less than 5% were able to climb stairs.
Why robotic rehabilitation?
Due to the aging population and developments in acute phase stroke treatment, the number of stroke patients who continue their lives with functional limitations is increasing every year. For this reason, there is an intense effort all over the world for stroke rehabilitation to give more successful results. Intensive rehabilitation and the use of new technologies in the early period are prominent approaches in this regard. According to current scientific data, early, intense, task-specific, multi-sensory stimulation and rehabilitation treatments that strengthen brain plasticity by involving both top-down and bottom-up integration from the brain to the end organs are more effective. The first 3 months after stroke is the period when brain plasticity is strongest and intensive rehabilitation is most beneficial. An example of top-down and bottom-up integration is non-invasive brain stimulation (e.g.TMS ) and robotic therapy combined can be used.
Neuroplasticity triggers healing mechanisms and functional adaptation processes and can create general changes in nerve cell organization. Neuroplasticity is related to concepts such as arousal/suppression balance, breadth and activation of brain shell maps, and structural remodeling.
When robotic rehabilitation is applied in an integrated manner with the treatment principles we mentioned, it can improve certain abilities of stroke patients.
The figure shows the determinants of using robotic rehabilitation for stroke patients to walk. Robotic rehabilitation can be integrated with computer games and augmented reality feedback technologies.
Robotic walking devices
Many different machines are produced and tested for robotic rehabilitation and robotic physical therapy all over the world. These devices can be classified according to the movement they apply to the body. For example, exoskeleton type devices move the hip, knee, and ankle joints during walking. “End-effector” devices usually move only the foot on support and thus simulate the oscillation and pressure phases of walking. Another classification for robotic devices is based on the principle that the patient can move or navigate in a fixed environment. Accordingly, the devices can be divided into two as static and dynamic robotic devices.
Robotic devices and exercises that can be used according to the walking condition of the stroke patient. FAC: Functional walking classification
Static devices, that is, the most commonly used types of robotic rehabilitation in which the patient performs the movement in a fixed place, are the Lokomat, a kind of robotic exoskeleton, and the Gait Trainer and G-EO, which are end-effector devices.
Lokomat is a robotic walking orthosis that works in combination with a bodyweight sling system and a treadmill. The main difference from the bodyweight supported treadmill is that the patient’s leg joints are moved in a pre-programmed pattern.
In the gait trainer device, the stance and swing phases of walking are simulated with the help of footplates. The distinguishing feature of this system is that the feet are always in contact with the platform.
In recent years, there have been intense efforts to develop dynamic exoskeleton types. These robots can also be used for military applications (increasing the mobility of soldiers) besides neurorehabilitation. Robotic hip-knee-ankle exoskeleton orthoses are commercially available and can be used for stroke patients to stand up and walk again. For now, almost all functional exoskeletons require additional supports such as crutches to maintain balance.
Benefits of robotic physical therapy
Robotic systems facilitate the intensive application of task-specific movements under the supervision of the therapist. It strengthens the effect of more traditional rehabilitation methods.
For patients who cannot stand alone or with the help of a person after a stroke, robotic physical therapy enables intensive and safe walking rehabilitation in the early period. The weight of the patient is supported by robotic devices. The workload of the physiotherapist is reduced, and the device performs tasks such as supporting the trunk or positioning the paralyzed leg. The physiotherapist can concentrate on the functional part of the therapy. With the movements provided by robotic rehabilitation, the stroke patient gains form in terms of heart and respiratory capacity in the early period. Using robotic devices to stand up prevents excessive contraction of the body’s muscles that normally stand against gravity ( spasticity ).
An advantage of robotic devices is that they allow objective measurement and monitoring of patient performance from various aspects. Parameters such as range of motion, speed of movement, fluency of movement, the force can be measured.
The combination of robotic rehabilitation with classical physical therapy contributes to the recovery of independent walking after stroke. Although the most appropriate starting time, duration, and frequency of robotic treatment are still discussed, it is known that the first 3 months after stroke benefit most. It should be known that robotic rehabilitation alone is not a solution for stroke treatment. Robotic treatments are in use as a useful tool in a wide range of rehabilitation methods.
- Morone G, Paolucci S, Cherubini A, et al. Robot-assisted gait training for stroke patients: current state of the art and perspectives of robotics. Neuropsychiatr Dis Treat. 2017; 13: 1303-1311. Published 2017 May 15.