Effects of robotic-assisted body weight supported treadmill training (BWSTT) on walking and cardiopulmonary function in people with incomplete spinal cord injury

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Effects of robotic-assisted body weight supported treadmill training (BWSTT) on walking and cardiopulmonary function in people with incomplete spinal cord injury

 

Author: Cheung, Yu Yeung Eddy
Title: Effects of robotic-assisted body weight supported treadmill training (BWSTT) on walking and cardiopulmonary function in people with incomplete spinal cord injury
Degree: M.Phil.
Year: 2016
Subject: Spinal cord -- Wounds and injuries -- Exercise therapy.
Spinal cord -- Wounds and injuries -- Patients -- Effect of exercise on
Robotics in medicine.
Hong Kong Polytechnic University -- Dissertations
Department: Dept. of Rehabilitation Sciences
Pages: xxviii, 214 pages : color illustrations
Language: English
InnoPac Record: http://library.polyu.edu.hk/record=b2925500
URI: http://theses.lib.polyu.edu.hk/handle/200/8684
Abstract: Spinal cord regulates descending nerve impulses and control autonomic reflexes, injury to spinal cord leads to distortion of neural transmission and coordination. Limitation in mobility is one of the commonest consequences of spinal cord injury (SCI), which leads to poor self-care ability and social participation. A decrease in mobility performance would cause various complications including development of pressure injuries and decreased cardiopulmonary fitness. Therefore, functional trainings especially walking training are foci of rehabilitation for people with SCI. However, it is unclear what are the optimal training strategies for walking rehabilitation for this group of clients. Body weight supported treadmill training (BWSTT) is a frequently used approach for restoration of walking ability after SCI. The technique aims at maximizing the remaining neural structures and promoting neuroplasticity through high repetition and sufficient afferent input from peripheral joints (Dietz, Muller, &amp; Colombo 2002). However, BWSTT usually requires manual assistance from therapists, which limits the treatment duration due to fatigue from both therapists and patients. Robotic-assisted body weight supported treadmill training (RABWSTT) was developed to tackle the aforesaid limitation. Computerized motor orthoses are designed to replace manual assistance that allows prolonged assisted walking training with normal gait pattern. Study I: Method and result: Systematic review has been done to investigate the effects of RABWSTT on SCI patients. A total of 2176 articles were identified and 10 randomized controlled trial (RCT) studies fulfilled all the inclusion criteria. It was found that RABWSTT led to better improvement in walking independence (3.73 with 95% CI -4.92 to -2.53; P<0.00001; I2=38%) and endurance (53.32 m with 95% CI - 73.15 to -33.48; P<0.00001; I2=0%) in SCI patients as compared with conventional physiotherapy treatment alone. It was also found that RABWSTT showed similar effects on walking ability as compared with traditional BWSTT or overground walking training (Field-Fote &amp; Roach, 2011; Nooijen, Hoeve, & Field-Fote, 2009; Hornby, Campbell, Zemon, &amp; Kahn, 2005). However, no study has investigated the effects of RABWSTT on subacute (duration of injury from 6-24 months) SCI subjects, which is the golden time for neurological rehabilitation. Also, none of these RCTs has monitored muscle activation during RABWSTT, note that a lack of active participation from subjects may end up in using RABWSTT as a passive exercise training. Besides, only one RCT study investigated the effect of RABWSTT on cardiopulmonary function in SCI subjects which showed limited improvement. Therefore, the aim of the studies II and III is to investigate the effects of RABWSTT with monitoring of muscle activation in walking ability and cardiopulmonary function on patients suffering from subacute SCI. Study II: Method and result: Ten SCI subjects were recruited to analyze the test-retest reliability and inter-rater reliability of assessments on maximal isometric strength and joint stiffness of a rehabilitation robot. Force measured by Lokomat (L-force) assessing maximal isometric muscle strength of hip and knee muscles in Nm and joint stiffness of hip and knee joints (L-stiff) were measured by two different assessors on day 1 for analyzing inter-rater reliability and the first assessor performed the two measurements again on day 2 for test-retest reliability. Our findings showed that both L-force and L-stiff had excellent test-retest reliability (ICC(3,1)=0.886-0.968 and ICC(3,2)=0.861-0.950 respectively, p&lt;0.001) and inter-rater reliability (ICC(2,1)=0.864-0.980 and ICC(2,2)=0.803-0.924 respectively, p&lt;0.001). Our results demonstrated that L-force and L-stiff are reliable tools in measuring maximal isometric muscle strength and joint stiffness of lower limb joints.
Study III: Method and result: Part I: A pilot study involving 6 incomplete SCI subjects were conducted. Half of them were allocated into intervention group while the other half were allocated to control group. Conventional physiotherapy training was given to each group three times a week. In addition, 30 minutes of RABWSTT or passive lower limbs mobilization exercise were given to subjects based on their group allocation. Outcome measures included Walking Index for Spinal Cord Injury version II (WISCI II) and Spinal Cord Independence Measures version III (SCIM III) for walking and functional independence; 10-meter walk test (10MWT) for walking speed; Lower extremity motor score (LEMS) and L-force for muscle strength over lower limbs; Modified Ashworth Scale and L-stiff for lower limb muscles spasticity and stiffness respectively; submaximal exercise stress test with gas analysis for cardiopulmonary fitness. The changes in outcome measures in each group were compared by using independent-t test. It was found that RABWSTT showed better improvement in WISCI II (3.3 vs 0.0, p=0.010) and 10MWT (6.2 vs 0.4, p=0.046). Also trend of better improvement was suggested for maximal oxygen consumption (1.5 vs 0.3, p=0.189) in RABWSTT group. Part II: Sixteen incomplete SCI subjects were recruited from a rehabilitation hospital in Hong Kong. They were randomly allocated into intervention group or control group. One-hour of conventional physiotherapy training were given to subjects three times a week. On top of this the intervention group received 30 minutes of RABWSTT with EMG biofeedback system over vastus lateralis muscle to enhance active participation of subjects. Dose equivalent passive lower limbs mobilization exercise was provided to subjects in the control group. Outcome measures included Walking Index for Spinal Cord Injury version II (WISCI II) and Spinal Cord Independence Measures version III (SCIM III) for walking and functional independence; Lower extremity motor score (LEMS) and L-force for muscle strength over lower limbs; Modified Ashworth Scale and L-stiff for lower limb muscles spasticity and stiffness respectively; submaximal exercise stress test with gas analysis for cardiopulmonary fitness; gait analysis for spatiotemporal gait parameters; spirometry for pulmonary muscle strength and function. Two-way repeated measures ANOVA was used for interaction analysis. Our results showed significant time-group interaction in WISCI II (p=0.020), SCIM III mobility sub-score (p<0.001), bilateral symmetry (p=0.048), maximal oxygen consumption (p=0.014) and peak expiratory flow rate (p=0.048). Paired-t test showed that the intervention group had significant improvement in the five above-mentioned outcomes after the intervention (WISCI II: 14.6 vs 16.3, p=0.014; SCIM III mobility: 24.0 vs 28.6, p<0.001; bilateral symmetry: 0.80 vs 0.88, p=0.042; maximal oxygen consumption: 25.7 vs 26.4, p=0.010; peak expiratory flow: 5.03 vs 5.73, p=0.037 respectively). In contrast, no significant changes were observed in the control group (WISCI II: 17.0 vs 17.1, p=0.351; SCIM III mobility: 28.4 vs 28.6, p=0.351; bilateral symmetry: 0.95 vs 0.96, p=0.233; maximal oxygen consumption: 20.5 vs 20.5, p=0.941; peak expiratory flow: 4.74 vs 4.70, p=0.841 respectively) after the 8-week intervention period. The present study showed that the use of EMG biofeedback can enhance the walking performance for SCI subjects with RABWSTT and also improve cardiopulmonary function. Positive outcomes reflect that RABSTT training may be able to enhance their physical fitness.

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