Does robotic gait training improve balance in Parkinson's disease? A randomized controlled trial

doi:10.1016/j.parkreldis.2012.05.010

Parkinsonism & Related Disorders

Volume 18, Issue 8, September 2012, Pages 990-993

https://doi.org/10.1016/j.parkreldis.2012.05.010 Get rights and content

Abstract

Background

Treadmill training (with or without robotic assistance) has been reported to improve balance skills in patients with Parkinson's disease (PD). However, its effectiveness on postural instability has been evaluated mainly in patients with mild to moderate PD (Hoehn & Yahr stage ≤3). Patients with more severe disease may benefit from robot-assisted gait training performed by the Gait-Trainer GT1, as a harness supports them with their feet placed on motor-driven footplates. The aim of this study was to determine whether robot-assisted gait training could have a positive influence on postural stability in patients with PD at Hoehn & Yahr stage 3–4.

Methods

Thirty-four patients with PD at Hoehn & Yahr stage 3–4 were randomly assigned into two groups. All patients received twelve, 40-min treatment sessions, three days/week, for four consecutive weeks. The Robotic Training group (n = 17) underwent robot-assisted gait training, while the Physical Therapy group (n = 17) underwent a training program not specifically aimed at improving postural stability. Patients were evaluated before, immediately after and 1-month post-treatment. Primary outcomes were: Berg Balance scale; Nutt's rating.

Results

A significant improvement was found after treatment on the Berg Balance Scale and the Nutt's rating in favor of the Robotic Training group (Berg: 43.44 ± 2.73; Nutt: 1.38 ± 0.50) compared to the Physical Therapy group (Berg: 37.27 ± 5.68; Nutt: 2.07 ± 0.59). All improvements were maintained at the 1-month follow-up evaluation.

Conclusions

Robot-assisted gait training may improve postural instability in patients with PD at Hoehn & Yahr stage 3–4.

Introduction

Postural instability is highly disabling in Parkinson's disease (PD) [1]. It has been partially determined that postural abnormalities may not be related to dopamine depletion. Indeed, medications aimed at increasing dopamine in the brain only slightly improve postural instability [1].

Physiotherapy complements pharmacological and neurosurgical treatments in PD [2]. Interestingly, there are indications that treadmill training (TT), with or without robot-assistance, may have beneficial effects on balance in PD [3], [4], [5], [6]. However, its effectiveness on postural instability has mainly been evaluated in PD patients whose balance impairment is a minor problem, probably because TT may be difficult to carry out in patients with advanced PD. The Gait-Trainer GT1 (Reha-Stim, Berlin, Germany) allows for robot-assisted gait training (RAGT), with patients supported by a harness and their feet placed on motor-driven footplates. Its effectiveness for improving gait skills in patients with PD at Hoehn & Yahr (H&Y) stage <3 has recently been reported in the literature [7]. Considering the GT1 machine characteristics, it may be useful for treating patients with advanced phase PD.

The main aim of this study was to evaluate whether RAGT could have a positive influence on postural stability in patients with advanced PD. The secondary aim was to examine whether RAGT could have a positive impact not only on the level of confidence perceived during those activities of dialing living requiring balance, functional mobility but also on severity of disease.

Section snippets

Methods

This study was performed in the Neurological Rehabilitation Unit of the University Hospital of Verona, Italy. Inclusion criteria [2]: a confirmed medical diagnosis of PD; H&Y stage of 3 or 4 (determined in the “on” phase); Mini Mental State Examination > 23. Exclusion criteria: severe dyskinesias or “on-off” fluctuations; the need to modify PD medication during the study; need for assistive devices to rise from chairs or beds; deficits of somatic sensation involving the legs; vestibular

Results

Thirty-four subjects (20 males, 14 females; mean age: 68.3 years) with idiopathic PD (mean disease duration: 7.5 years; mean H&Y stage: 3.45) were selected from all outpatients with H&Y 3–4 consecutively admitted to our Neurorehabilitation Unit from October 2008 to July 2010. Seventeen patients were allocated in each group. Three patients withdrew from the study. No adverse events occurred in either group. The mean step-length on the GT1 machine for the RT Group was 40.17 ± 5.87 cm. The flow

Discussion

We showed that RAGT could improve balance in patients with advanced PD suffering from postural instability (H&Y 3–4). Interestingly, our results regarding gait speed are in line with those reported in a previous study conducted by our research group on patients with PD and H&Y <3 [7].

Ability to maintain the upright position is a challenge for all humans, which becomes even more challenging when negotiating the environment and following complex trajectories (i.e. going from sitting to standing,

Financial disclosure/conflict of interest

The authors received no financial support for the research or authorship of this article.

No commercial party having a direct financial interest in the results of the research supporting this manuscript has or will confer a benefit on the authors or on any organization with which the authors are associated.

Acknowledgments

The authors would like to thank Patrizia Ianes for her technical assistance in preparation of the manuscript.

References (12)

G. Kwakkel et al.
Impact of physical therapy for Parkinson's disease: a critical review of the literature
Parkinsonism Relat Disord
(2007)
M. Visser et al.
Clinical tests for the evaluation of postural instability in patients with Parkinson's disease
Arch Phys Med Rehabil
(2003)
N. Smania et al.
Effect of balance training on postural instability in patients with idiopathic Parkinson's disease
Neurorehabil Neural Repair
(2010)
T. Toole et al.
The effects of loading and unloading treadmill walking on balance, gait, fall risk, and daily function in Parkinsonism
NeuroRehabilitation
(2005)
E.J. Protas et al.
Gait and step training to reduce falls in Parkinson's disease
NeuroRehabilitation
(2005)
B.D. Cakit et al.
The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinson's disease
Clin Rehabil
(2007)

There are more references available in the full text version of this article.

Cited by (49)

Evidence for gait improvement with robotic-assisted gait training of children with cerebral palsy remains uncertain
2023, Gait and Posture
Cerebral palsy (CP) is a group of neuromotor diseases that develops as a result of damage to the developing central nervous system during the perinatal period. The condition is usually accompanied by musculoskeletal problems resulting in movement disorders. Gait improvement therefore, is an important part of its treatment. Roboticassisted gait training (RAGT) is a new potential rehabilitation tool for CP patients, however there is no clear evidence for the effectiveness of this method.
Can robotic-assisted gait training improve walking function in children with CP?
A systematic search was performed in five databases: MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), Embase, Scopus, and Web of Science. Eligible studies were randomized controlled trials (RCT) with CP patients under the age of 18. Gross motor function and kinematic gait parameters of patients were the main outcomes.
Two authors determined the risk of bias of the RCTs independently using the revised Risk of Bias 2 (ROB 2) tool.
Mean Differences (MDs) along with their 95% Confidence Interval (CI) were calculated when at least three studies were present for an outcome, subgroup analysis was performed based on the treatment of the control group.
Of the 7363 screened articles, 13 papers met our inclusion criteria and among them, 7 studies could be used in our meta-analyses. The results related to RAGT suggest nonsignificant improvement in standing and walking function (Gross Motor Function Measure D, E), moreover changes in gait speed, step length, and in cadence were also only comparable to controls.
The results indicate that there is a trend in some gait parameters where the improvement was higher in the intervention group than in control group. The therapeutic effect of RAGT was probably not superior to physiotherapy combined with treadmill training.
Efficacy of rehabilitation robot-assisted gait training on lower extremity dyskinesia in patients with Parkinson's disease: A systematic review and meta-analysis
2023, Ageing Research Reviews
Robot-assisted training is used as a new rehabilitation training method for the treatment of motor dysfunction in neurological diseases. Robot-assisted gait training (RAGT) has been reported to treat motor dysfunction in patients with Parkinson's disease (PD). The purpose of this study was to summarize previous clinical studies comparing the effectiveness of RAGT and conventional training for lower extremity dyskinesia in PD patients.
PubMed, Cochrane library, Scopus, Embase, EBSCO, Web of Science, CNKI, and Wanfang databases were searched. This study included all randomized controlled trials (RCTs) compared lower extremity RAGT with conventional training on motor impairment in PD patients. The retrieval time limit is from the establishment of the database to October 2022. Two researchers independently screened the literature, extracted data, assessed the risk of bias of included studies, and then used RevMan 5.3 software for meta-analysis.
A total of 14 RCTs with 572 patients were included. The results showed that compared with the control group, RAGT significantly improved the motor function evaluation-related indicators 10MWT, 6MWT, TUG and UPDRS III, 10MWT [MD = 0.08, 95 % CI (0.01, 0.14), P = 0.03], 6MWT [MD = 42.83, 95 % CI (22.05, 63.62), P < 0.0001], TUG[MD = −1.81, 95 % CI (−2.55, −1.08), P < 0.0001], UPDRS III [MD = - 3.82, 95 % CI (−4.27, −3.37), P < 0.00001]; For the balance function evaluation index BBS [MD = 3.33, 95 % CI (2.76, 3.89), P < 0.00001], the above results were significantly different significance.
The currently limited evidence suggests that RAGT provides evidence for the effectiveness of lower extremity motor function and balance dysfunction, and RAGT can significantly improve motor and balance function in PD patients.
Use of artificial intelligence in assistive devices
2023, Artificial Intelligence in Tissue and Organ Regeneration
The quality of life (QOL) of people is greatly affected by the various diseases that affect them. Disorders such as Parkinson's disease, cerebral palsy, spinal cord Injuries, and tumor formation greatly affect the population. This chapter focuses on the overview of the application of artificial intelligence (AI) in the identification, management, and devising treatment regimens for people suffering from Parkinson's disorder, cerebral palsy, or spinal cord Injuries. In addition, AI has been applied to analyze and identify the results in tissue to identify tumors and the effects of different drugs in managing them. Timely sharing of information between patients and clinicians will, however, even more increase the efficiency of these systems and help the clinicians make the most of the technology and make an informed decision.
Artificial intelligence in elderly healthcare: A scoping review
2023, Ageing Research Reviews
The ageing population has led to a surge in the adoption of artificial intelligence (AI) technologies in elderly healthcare worldwide. However, in the advancement of AI technologies, there is currently a lack of clarity about the types and roles of AI technologies in elderly healthcare. This scoping review aimed to provide a comprehensive overview of AI technologies in elderly healthcare by exploring the types of AI technologies employed, and identifying their roles in elderly healthcare based on existing studies. A total of 10 databases were searched for this review, from January 1 2000 to July 31 2022. Based on the inclusion criteria, 105 studies were included. The AI devices utilized in elderly healthcare were summarised as robots, exoskeleton devices, intelligent homes, AI-enabled health smart applications and wearables, voice-activated devices, and virtual reality. Five roles of AI technologies were identified: rehabilitation therapists, emotional supporters, social facilitators, supervisors, and cognitive promoters. Results showed that the impact of AI technologies on elderly healthcare is promising and that AI technologies are capable of satisfying the unmet care needs of older adults and demonstrating great potential in its further development in this area. More well-designed randomised controlled trials are needed in the future to validate the roles of AI technologies in elderly healthcare.
Body Weight Support Gait Training for Patients With Parkinson Disease: A Systematic Review and Meta-analyses
2021, Archives of Physical Medicine and Rehabilitation
Citation Excerpt :
The search retrieved 348 results, 12 of which were included in this systematic review (supplemental fig S1, available online only at http://www.archives-pmr.org/). All included studies were randomized controlled trials,25-36 and 1 was a crossover design.25 All of them were published between 2000 and 2019.
To determine the effectiveness of body weight support (BWS) gait training to improve the clinical severity, gait, and balance in patients with Parkinson disease (PD).
A literature search was conducted until July 2020 in MEDLINE, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature.
Randomized controlled trials that aimed at determining the effectiveness of physical activity interventions with BWS during gait training in patients with PD.
The methodological quality of randomized controlled trials was assessed using the Cochrane risk of bias tool (RoB 2.0). Effect size (ES) and 95% confidence intervals [CIs] were calculated for the Unified Parkinson Disease Rating Scale (UPDRS), the UPDRS section III, the 6-minute walk test (6MWT), gait parameters (ie, velocity, cadence, stride length), and the Berg Balance Scale (BBS).
Twelve studies were included in the systematic review. The pooled ES for the effect of BWS on total UPDRS was −0.35 (95% CI, -0.57 to −0.12; I²=1.9%, P=.418), whereas for UPDRS III it was −0.35 (95% CI, -0.68 to −0.01; I²=66.4 %, P<.001). Furthermore, the pooled ES for 6MWT was 0.56 (95% CI, −0.07 to 1.18; I²=77.1%, P=.002), for gait velocity was 0.37 (95% CI, −0.10 to 0.84); I²=78.9%, P<.001), for cadence was 0.03 (95% CI, −0.25 to 0.30; I²=0.0%, P=.930), for stride length was 1.00 (95% CI, 0.23 to 1.78; I²=79.5%, P=.001), and for BBS was 0.65 (95% CI, 0.30, 0.99; I²=51.8%, P=.042).
Interventions with BWS could improve the general and motor clinical severity of patients with PD, as well as other parameters such as stride length and balance. However, the effect does not appear to be statistically significant in improving gait parameters such as velocity, cadence, and distance.
Clinical effects of robot-assisted gait training and treadmill training for Parkinson's disease. A randomized controlled trial
2019, Annals of Physical and Rehabilitation Medicine
Although gait disorders strongly contribute to perceived disability in people with Parkinson's disease, clinical trials have failed to identify which task-oriented gait training method can provide the best benefit. Freezing of gait remains one of the least investigated and most troublesome symptoms.
We aimed to compare the effects of robot-assisted gait training and treadmill training on endurance and gait capacity in people with Parkinson disease; the secondary aim was to compare the effect of the treatments in people with freezing and/or severe gait disability and assess changes in overall disease-related disability and quality of life.
Outpatients with Parkinson disease (Hoehn and Yahr stage ≥ 2) were randomly assigned to receive 20 sessions of 45-min gait training assisted by an end-effector robotic device (G-EO System) or treadmill training. Outcome assessments were the 6-min walk test, Timed Up and Go test, Freezing of Gait Questionnaire, Unified Parkinson's Disease Rating Scales and Parkinson's Disease Quality of Life Questionnaire-39 administered before (T0) and after treatment (T1).
We included 96 individuals with Parkinson disease: 48 with robot-assisted gait training and 48 treadmill training. Both groups showed significant improvement in all outcomes. As compared with baseline, with robot-assisted gait training and treadmill training, endurance and gait capacity were enhanced by 18% and 12%, respectively, and motor symptoms and quality of life were improved by 17% and 15%. The maximum advantage was observed with the Freezing of Gait Questionnaire score, which decreased by 20% after either treatment. On post-hoc analysis, dependent walkers benefited more than independent walkers from any gait training, whereas freezers gained more from robot-assisted than treadmill training in terms of freezing reduction.
Repetitive intensive gait training is an effective treatment for people with Parkinson disease and can increase endurance and gait velocity, especially for those with severe walking disability. Advantages are greater with robot-assisted gait training than treadmill training for individuals with freezing of gait – related disability.

View all citing articles on Scopus

View full text

Short communicationDoes robotic gait training improve balance in Parkinson's disease? A randomized controlled trial

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Financial disclosure/conflict of interest

Acknowledgments

Parkinsonism Relat Disord

Arch Phys Med Rehabil

Effect of balance training on postural instability in patients with idiopathic Parkinson's disease

Neurorehabil Neural Repair

The effects of loading and unloading treadmill walking on balance, gait, fall risk, and daily function in Parkinsonism

NeuroRehabilitation

Gait and step training to reduce falls in Parkinson's disease

NeuroRehabilitation

The effects of incremental speed-dependent treadmill training on postural instability and fear of falling in Parkinson's disease

Clin Rehabil

Short communication
Does robotic gait training improve balance in Parkinson's disease? A randomized controlled trial