Robotic Rehabilitation Benefits

Authors:
Helena López (Clinical Manager), Erika Porras (Clinical Affairs Specialist)

Robot-Assisted Gait Training

Research has demonstrated that robotic rehabilitation, combined with conventional therapy, is more effective than gait training without these devices¹. Robots enable higher intensity, longer training sessions, more physiological and reproducible gait patterns, and the ability to measure patient performance^2,3. These factors contribute to neuroplasticity and align with the basic principles of motor learning (specificity, repetition, and intensity) after a neurological injury⁴. Robotic rehabilitation not only benefits the patient but also the therapist, allowing for a higher dosage of gait training with less effort⁵.

Compared to stationary gait training devices (such as Lokomat), wearable exoskeletons have the advantage of engaging the trunk muscles through weight-shifting movements necessary for initiating steps, potentially improving postural control in sitting and coordination, developing new motor control strategies, and promoting independence in daily activities⁶,⁷. Wearable exoskeletons are more physically demanding than stationary systems, leading to significant increases in metabolic and cardiac responses, which suggests cardiopulmonary benefits⁸.

Clinical Benefits of Robotic Rehabilitation

The loss of mobility negatively impacts patients’ ability to perform daily tasks, reducing their independence. A randomized controlled trial (RCT) evaluated levels of ambulation (WISCI-II, Walking Index for Spinal Cord Injury II) and functional independence (FIM, Functional Independence Measure) in two groups of patients with spinal cord injury: one undergoing conventional rehabilitation (control group) and the other receiving robot-assisted rehabilitation. After rehabilitation, there was a significant improvement in both indicators in the robotic rehabilitation group compared to the control group. For the WISCI-II scale, the robotic rehabilitation group showed a 5.0% improvement, while the control group showed no improvement (0%). In the FIM scale, the robotic rehabilitation group improved by 4.0%, compared to 2.0% in the control group³.

Neuroplasticity plays a crucial role in the rehabilitation of these patients by enabling the brain to relearn how to walk. To promote neuroplasticity, intensive and repetitive training is essential—something difficult to achieve with conventional rehabilitation. Robotic devices facilitate this process by allowing high-intensity training with repetitive, task-oriented movements⁴. In this context, a study evaluated the effects of robotic training on the brain by measuring brain activity using an electroencephalogram (EEG). Results showed an increase in effective frontoparietal connectivity, suggesting an improvement in brain plasticity¹².

People who have suffered a spinal cord injury can lose 3% to 4% of bone mineral density per month due to inactivity in their lower limbs. Therefore, a study examined changes in body composition and bone mineral density during the use of a robotic exoskeleton. The results showed a 14.5% increase in tibial bone density, which is clinically significant⁹.

Another common symptom after a spinal cord injury is spasticity, characterized by increased muscle tone and tendon reflexes, representing a significant problem for patients. Robotic gait rehabilitation has proven to be effective in reducing spasticity. Several studies measured this parameter, mostly through questionnaires in which patients reported reduced spasticity after rehabilitation¹⁰.

Additionally, people with spinal cord injuries are at an elevated risk of developing cardiovascular diseases due to their limited or inability to perform upright physical activity. Several studies have demonstrated that robotic rehabilitation increases heart rate and oxygen consumption, making it an effective form of cardiovascular exercise¹⁰.

Finally, the psychological impact of robotic exoskeletons has also been investigated. These devices allow patients to stand and interact with others at eye level, rather than looking up from a seated position. Studies have shown that the use of robotic devices improves patients’ quality of life as well as their psychological and emotional well-being¹⁰,¹¹.

The evidence suggests that exoskeletons are an innovative method for helping paraplegic individuals meet the physical activity guidelines recommended by the World Health Organization. This can reduce their risk of cardiovascular diseases, improve their gait, and positively impact their physical and mental health, ultimately leading to a better quality of life.

References:

1. Electromechanical-assisted training for walking after stroke. Mehrholz J, Thomas S, Kugler J, Pohl M, Elsner B. Cochrane Database Syst Rev. 2020;10(10):CD006185. doi:10.1002/14651858.CD006185.pub5
2. Robot-assisted gait training (Lokomat) improves walking function and activity in people with spinal cord injury: a systematic review. Nam KY, Kim HJ, Kwon BS, Park JW, Lee HJ, Yoo A. J NeuroEngineering Rehabil. 2017;14(1):24. doi:10.1186/s12984-017-0232-3
3. Early term effects of robotic assisted gait training on ambulation and functional capacity in patients with spinal cord injury. Yildirim MA, Öneş K, Gökşenoğlu G.Turk J Med Sci. 2019;49(3):838-843. doi:10.3906/sag-1809-7
4. Wearable exoskeleton control modes selected during overground walking affect muscle synergies in adults with a chronic incomplete spinal cord injury. Escalona MJ, Bourbonnais D, Goyette M, Duclos C, Gagnon DH. Spinal Cord Ser Cases. 2020;6(1):26. doi:10.1038/s41394-020-0269-6
5. Sistemas robotizados para la reeducación de la marcha en la lesión medular: una revisión sistemática. Gándara Sambade T, Fernández Pereira M, Rodríguez Sotillo A. Rev Neurol. 2017;64(05):205. doi:10.33588/rn.6405.2016200
6. Overground vs. treadmill-based robotic gait training to improve seated balance in people with motor-complete spinal cord injury: a case report. Chisholm AE, Alamro RA, Williams AMM, Lam T. J Neuroengineering Rehabil. 2017;14(1):27. doi:10.1186/s12984-017-0236-z
7. Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics. Bach Baunsgaard C, Vig Nissen U, Katrin Brust A, et al. Spinal Cord. 2018;56(2):106-116. doi:10.1038/s41393-017-0013-7
8. Energy cost and psychological impact of robotic-assisted gait training in people with spinal cord injury: effect of two different types of devices. Corbianco S, Cavallini G, Dini M, et al. Neurol Sci. 2021;42(8):3357-3366. doi:10.1007/s10072-020-04954-w
9. Karelis AD, Carvalho LP, Castillo MJ, Gagnon DH, Aubertin-Leheudre M. Effect on body composition and bone mineral density of walking with a robotic exoskeleton in adults with chronic spinal cord injury. J Rehabil Med. 2017 Jan 19;49(1):84-87. doi: 10.2340/16501977-2173. PMID: 27973679.
10. Robotic Rehabilitation and Spinal Cord Injury: a Narrative Review. Mekki M, Delgado AD, Fry A, Putrino D, Huang V.Neurotherapeutics. 2018;15(3):604-617. doi:10.1007/s13311-018-0642-3
11. Heinemann AW, Kinnett-Hopkins D, Mummidisetty CK, Bond RA, Ehrlich-Jones L, Furbish C, Field-Fote E, Jayaraman A. Appraisals of robotic locomotor exoskeletons for gait: focus group insights from potential users with spinal cord injuries. Disabil Rehabil Assist Technol. 2020 Oct;15(7):762-772. doi: 10.1080/17483107.2020.1745910. Epub 2020 Apr 7. PMID: 32255369.
12. Calabrò, R.S., Naro, A., Russo, M. et al. Shaping neuroplasticity by using powered exoskeletons in patients with stroke: a randomized clinical trial. J NeuroEngineering Rehabil 15, 35 (2018). https://doi.org/10.1186/s12984-018-0377-8