Effect of Robot Technology for Post Stroke Gait Improvement

Effect of Robot Technology for Post Stroke Gait Improvement Introduction Stroke is a one of the most severe health problem worldwide; it is a syndrome characterised by signs and symptoms that develop rapidly resulting in focal and global loss of cerebral functions. These sign and symptoms resulting from vascular insufficiency last for over 24 hours eventually results in severe physical and functional disability or may also cause death. It has been also found that per year prevalence rate of stroke is high i.e. 2/1000. However, the mortality rate of stroke is reduce in past few years but it is still the second most cause of death worldwide following chronic heart disease and third-most leading cause of death in New Zealand following cancer at first and chronic heart disease at second. Moreover, because of the poor functional outcome in majority of post-stroke patients, makes stroke as an utmost cause of disability worldwide; as one-third of post stroke population suffers with severe functional disability even after five years of stroke. Besides, over 7000 stroke incident reports per year in New Zealand; 3/4th of this post stroke population have to live dependently on others for their Activities of daily living. Eventually, post-stroke functional disability and rehabilitation cost of post stroke victims results in increase holistic socioeconomic burden; in conjunction with victim and their respective family member, i ncreases the worldwide economic burden at 4% (Barker, 2010). According to previous studies; neuroplasticity mechanism plays an imperative role in post-stroke functional improvement. In an endeavour to achieve effective functional recovery, it is mandatory to use neuroplasticity mechanism effectively is an essential goal to include during the stroke rehabilitation (Pekna, 2012). Whilst, multidisciplinary treatment approach and task specific training embellish with consistent repetition or high intensity task practice are also vital for functional recovery after stroke1. Therefore, it is essential to include these fundamental principal during the goal setting of stroke rehabilitation (Langhorne, 2011). Furthermore previous studies reveals; coordinated reciprocal movements and pastoral tone is reduce or lost subsequently post-stroke. Therefore, gait alteration is one of the most common disability among post-stroke patient; as 30% of the stroke survivors have impaired walking ability i.e., slow walking velocity in conjunction with decrease endurance and poor ability to adopt constrains during walking (Tilling, 2001). Eventually, in an endeavour to improve activities of daily living and functional independence among stroke victim; an independent ambulation is an important goal to achieve during stroke rehabilitation. Kwakkel (1999), suggest the imperative role of motor control in improving the ability to control and regulate normal pattern of movement. Besides, it has been also found from studies that for an efficient motor relearning programme it is important to emphasize on the three essential components: Neural; Muscular and; Biomechanical . Therefore, it is essential to focus on high intensity and diversity of specific tasks during the post stroke relearning of skilful movements. Consequently, multidisciplinary approach is supposed to be more beneficial and important for the motor relearning of the stroke patients. Evidently it has been conclude from the previous studies; although innumerable of stroke victims reported worldwide; besides a huge variability in treatment approaches for post-stroke rehabilitation also exists. Therefore, in manoeuvre to reduce post-stroke disability, it is essential to have a reliable and effective rehabilitation treatment. In the recent years a new technology with the help of advance computational approaches and sophisticated electromechanical components has been developed and named as Robot. A robot is develop and design in such a way that it can be re-programmable and perform multi-functional tasks by moving specialize devices. Therefore, it can be used to accomplish a specific task by programming it to produce variable specific motion movements (Pignolo, 2009). As it has been already conclude that the utmost requirements are the consistent repetition or high intensity task practice in stroke rehabilitation; because of the available advancement in technology, it is advantageous to use robot as an effective intervention in stroke rehabilitation (Stein, 2012). Majority of studies have been done to determine the effect of conventional rehabilitation approaches on the variables (function and walking speed) associated with gait training of stroke patients. In most of these studies conventional physiotherapy treatment was included to rehabilitate the gait of the stroke patients therefore; the results of these studies is mainly based upon single treatment approach. Apparently, results of these single treatment approach studies may not be that much beneficial because of the diversity in post-stroke functional loss. Eventually, as soon as robot technology is accepted as an effective intervention for the rehabilitation for stroke; majority of studies are now focus on effectiveness of therapeutic rehabilitation robots surge dramatically. As it has been already found, that the high dosage intensive training and high intensity functional task practice plays an imperative role in stroke rehabilitation. Besides, it has been also reveal that robotic technology has the advantage of delivering this high dosage intensive training and consistent practice of specific functional task. Therefore robot technology as an intervention can play an imperative role in minimizing the adverse post stroke disability effect. Therefore, the aim of the current study is to compare the effect of robotic technology as an intervention on the functional improvement and gait training in the insight of evidence that; a robotic technology as an intervention enhances functional and gait improvement among post-stroke people. METHODS Search Strategy In the present study, a variety of electronic database were search for the initial literature search: EBSCO and Medline health database, Elsevier, PubMed, google, Pedro, AUT library database. Extensive key word were included for the initial search: Stroke; post-stroke disability; neuroplasticity; motor disorder; functional impairment; gait dysfunction; stroke rehabilitation; conventional treatment approach, robot intervention . In the manoeuvre of standardized approach during the search procedure; the list of keyword and all their combinations were used uniformly for searching the literature. Furthermore, additional keywords were added to the main keywords list included review,critical,meta and systematic review when searching for past review articles on stretching and exercise interventions. Study Selection Inclusion Criteria: There was not limitation on the date of publication but search was limited to articles publish in English language. The studies having randomized controlled trial and quasi-experimental studies; comparing either the experimental group with another intervention or with a control group were eligible to include in the present study. The study was restricted to those post-stroke patients who are in sub-acute or chronic stage, fully cooperative and able to follow command, having robot assisted rehabilitation for gait impairment and functional disability. Participants included in studies should not have any; pathological restricted ROM, amputation of any lower limb joint. Furthermore, pilot studies and single case studies were excluded in the present study. Data extraction Data from included studies were extracted for the variables of interest: Gait improvement and functional independence. Then for the tabulated presentation of data; it was then presented in the table 2, under the headings: Author; Study design; Intervention; Outcome measures and; Main findings. Internal validity of the studies The internal validity of the included studies for the appraisal and grading of intervention were checked through a modified version of the Cochrane Musculoskeletal Injuries Group (CMIG) scoring system that comprises of eleven items covering aspects of study design. A final overall score or quality rating (out of a possible 11) for all the included studies was then awarded to each intervention paper. Data synthesis In all the included studies; effect of the robot assisted intervention on post-stroke patients was analysed through gait improvement and functional independence. However, most of the studies included in this literature review also have a diversity in the variables of interest therefore, in an endeavour to check quality of the included studies; a pattern of evidence approach was thus used and marked accordingly on the basis of their design and consistency of finding: low quality if it scored 5 to 6; moderate quality if it scored 6 to 8 and; high quality if it scored 9 or above. Among the included eight studies; one found to be of high quality with score at 9 and remaining studies were of moderate quality with an average score at 6 to 8. RESULTS Initially after searching various database, two thousand articles were identified and out of these articles only twenty articles were found to be appropriate for the abstract review. Thereafter, only 10 papers were found to have the full paper review, and then out of these 8 intervention studies were selected on the basis of the inclusion criteria and were further subject to critical appraisal and scoring. The primary reasons for the rejection of papers were the intervention other than Robot. Secondly, remaining non-included studies were focused on the population having either acute phase of stroke, restricted rom and amputation of the lower limb. The information relating to each paper included in the review is shown Figure 1. Figure 1: Flowchart Efficacy of robot intervention in Stroke rehabilitation Selected variables – Robot intervention; Gait improvement and Functional independence Two thousand paper were found 100 articles identified, 20 were suitable for abstract review, 10 papers were selected for the full paper review 8 intervention studies were selected on the basis of the inclusion criteria and were further subject to critical appraisal and scoring Inclusion criteria-RCT; Quasi experimental; English language; Robot intervention; Stroke patients Exclusion criteria Restricted rom; Amputation, Pilot studies, Single case studies Results – One study include is of high quality score at 9 and seven are of moderate quality score at 6 to 8 Quality The scores related to the quality of the papers (QS) varied from 6 to 9. One paper attained a strong quality score each at 9, while all others were at moderate quality score at 6 to 8. The key elements associated with the quality of each paper (blinding of subjects and treatment providers etc.), that were not addressed well are presented in Table 1. Table 1: Internal validity of the studies S.N Author A B C D E F G H I J K Quality score 1 Bandy, W.D. (1994) Y Y Y Y Y N N Y Y Y Y 9 2 Bandy, W.D. (1997) Y Y Y N.P N N N.P Y Y Y Y 7 3 Baranda, P. S. (2010), Y Y Y N.P N.P N N.P Y Y Y Y 7 4 Feland, J. B. (1999). Y Y Y Y Y N N Y Y Y Y 9 5 Feland, J. B. (2001) Y Y Y N.P N.P N N Y Y Y Y 7 6 Ford, G. S. (2005) Y Y Y Y N N N.P N Y Y Y 7 7 Odunaiya, N.A. (2005) Y Y Y N N N.P N N.P Y Y Y 6 8 OHora, J. (2011) Y Y Y N N N N N Y Y Y 6 9 Zakas, A. B. (2013) Y Y Y Y N.P N.P N.P Y Y Y Y 8 Participants From the overall prospective, there were a total of 327 subjects in all the included studies. All the subject included in the studies were stroke patients, having gait impairments and functional dependency. Firstly, it has been found that in all the included studies; an informed consent form was gathered from subjects for their ethical approval. Moreover, in order to keep subjects blinded to the interventions; a randomization of subjects in different groups was done by an appropriate manner. Furthermore, in all the included studies Robot intervention was used as an intervention for the rehabilitation of gait and functional independence. The Robotic device used in all the included studies for the intervention was Lokomat.