The effects of robot-assisted gait training using virtual reality and auditory stimulation on balance and gait abilities in persons with stroke.

1. Journal club
Presentar : Ashik Dhakal
Moderator : Mr. Sydney Roshan Rebello

2. Title
The effects of robot-assisted gait training using virtual reality and
auditory stimulation on balance and gait abilities in persons with
stroke.

3. • Author : Jaeho Park and Yijung Chung
• Publication : Neurorehabilitation
• Publishing year : 2018
• Journal impact factor : 0.84
• Author impact factor : 0/2, 195/32= 6.09

4. Key words used :
• Stroke
• Rehabilitation
• Gait
• Balance
• Muscular strength

5. PICO
• Population : 40 patients with stroke who were admitted to Chung-Nam national
university in Daejeon.
• Intervention : virtual reality robot-assisted gait training and Auditory stimulation
robot-assisted gait training
• Comparison : control group (conventional physical therapy).

6. • Outcomes :
1. Medical Research Council (MRC)
2. Berg Balance Scale (BBS)
3. Timed up and Go Test (TUG)
4. 10 meter Walk Test (10MWT)
5. Fugl-Myer Assessment (FMA)

7. Search strategy
Search was conducted in
• PubMed and Google scholar
Boolean logic
• AND

8. Abstract
• Background : Robot- assisted gait training provide a big therapeutic advantage
in functional mobility for postural control.
• Objectives : To investigate the effects of robot-assisted gait training using
virtual reality and auditory stimulation on balance and gait abilities in stroke
patients.

9. Methods :
• Patients received virtual reality and auditory stimulation while
undergoing robot assisted gait training for 45 minutes, three times a week
for 6 weeks.
• All have received general physical therapy for 30 mins, five times a week
for 6 weeks.
• All subjects were assessed with MRC, BBS, TUG, 10MWT, FMA, MBI,
pre and post intervention.

10. Results :
• BBS, TUG, and 10MWT scores significantly improved post- intervention
in all three groups,
• VRGT had significantly improved in MRC and FMA scores compared
with ARGT and also significantly improved in MRC,BBS, TUG,
10MWT and FMA compared to control group.

11. • Conclusion : result of this study showed improve balance and gait
abilities after VRGT compared with general physical therapy and were
found to be effective in enhancing the functional activity of persons with
stroke.

12. Introduction
• In patients with stroke, balance is compromised due to muscle weakness
and asymmetric muscle tension.
• The use of compensatory movements exhibits abnormal gait form, which
causes higher energy consumption.
• 75 % of the patients with stroke represent gait disorders.

13. • Also in these patients, slow gait cycle and gait speed, difference in stride
between the affected and unaffected side steps, a short stance phase on the
affected side and a relatively long swing phase are present which limits
functional mobility.
• Therefore proper exercise method is needed.

14. • Robot-rehabilitation is found to be advantageous and also helps to
perform safer gait training by repetitive task training with high intensity.
• These trainings, which requires repetitive tasks, can increase the neuro-
plasticity and motor learning that focus on reorganisation of brain tissue,
resulting in better balance and faster walking speed.
• Many studies are conducted to find it’s effectiveness and they have
shown positive results.

15. • Robot-assisted gait training using virtual reality has been continuously
studied as a way to bring about active movement.
• Virtual Reality has been developed as a tool for evaluation and treatment
of rehabilitation in the late 20th century.
• Now it has been developed as a stage to acquire various skills through
interacting and feedback based on realistic user experience.

16. • In the study by Lee et al. (2013) and Ham et al. (2016) on robot-assisted
gait training applied based on virtual reality reported significant effects on
functional performance according to the positive change of balance
ability and walking ability.

17. • Other than VR, auditory stimulation training leads to the active
movement of the patients.
• This auditory stimulation training provides an auditory signal that
immediately leads to the synchronisation of neurological movements.
• It has been reported that by structuring the movement pattern in time,
it can perform efficient re-education and functional motor learning,
thereby improving the spatiotemporal factors of movement, leading to
more normal and rhythmical movement pattern.

18. • In the study of Jeong et al. (2007) showed that gait training using
regular auditory stimulation improves the angle and flexibility of the
joints in stroke patients.
• Roeldink et al. (2007) reported that the positive change was due to the
improvement of gait ability with symmetrical spatiotemporal change
as well as the improvement of joint angle and flexibility of stroke
patients using auditory stimulation.

19. Methods
1. Participants
• The subjects of this study were, 40 patients who were admitted to Chung-
Nam national university hospital in Daejeon.
• The subjects did not have experience in robot-assisted gait training before.
• The stroke patients were composed of patients who had no overlapping
diseases within the past 6 months after the onset of stroke.
• Subjects were randomly divided into three groups.

20. • General characteristics of patients

21. • The inclusion criteria were as follows:
1. Diagnosis of stroke (after minimum 6months)
2. Ability to walk 10 minutes with or without an assistive device.
3. Impairment of balance ability (maximum BBS score 45)
4. Cognitive abilities enabling communication
5. Medically stable and free of major cardiovascular or other medical condition
6. No history of orthopaedic surgery within the past 6 months and seizure.

22. Protocol
• This study included a pretest - post test control group design where the subjects
were divided according to intervention such as VRGT, ARGT, or control group.
• All groups measured all outcomes before the intervention.
• A single blinded method was used to train and evaluate different physiotherapists
who had at least five years of experience in each of the trainers and evaluators.

23. • This study was approved by the Institutional Review Board of Sahmyook
University.
• All participants signed informed consent forms after receiving a detailed
explanation of the study.

24. Intervention
1. VRGT
• Patient performs gait training on the treadmill using robotic device (Lokomat Pro).
• Exoskeletal type robot that can effectively simulate normal gait pattern was
applied.
• The control of the angle and force of the hip joints and the knee joints of the robot
is controlled by sensors embedded in each joint.
• The intensity of movement is controlled by walking speed, BWS (body weight
support) and guidance force.

25. -In order to control the movement of progressive intensity,
• Gait training was increased as the rate of 5% of the initial applied speed in the
3rd and 5th weeks.
• The BWS was also decreased by 5%.
-In case of the guiding force, intensity of exercise was controlled by applying the
robot-assisted gait training with the intensity (of guidance) decreased by 10%.
-The intervention periods for the subjects were 6 weeks, 3 times a week, for 45
minutes each.

26. • VRGT used a virtual reality program called Augmented feedback, which is
software embedded in the walking robot.
• In this virtual reality program, the degree of mutual force between the patient and
the robot is represented by the movement of the avatar in the screen through the
sensor response.
• This program can lead to the patient’s reaction and motivation.

27. ARGT
• ARGT is a method of adjusting the walking speed to the regular rhythm of the
metronome producing the auditory signal.
• The regular rhythm of metronome is a method to train the patient to set the
auditory signal at the initial contact, and to walk according to the signal.
• ARGT also performed gait training using the rehabilitation robot used in
VRGT.
• In order to control the movement of progressive intensity, the rhythm of the
metronome was adjusted at the speed increased by 5% of walking speed.

28. Control group (General gait training)
• The control group performed general gait training using a treadmill.
• The training was conducted for 45minutes three times a week for 6 weeks in same
manner as the experimental group.
• All patients who participated in the study were conducted conventional physical
therapy for 6 weeks, 5 times a week.

29. Outcome measures
1. Medical research Council
• MRC is the clinical method for evaluating muscle strength as a sequence
scale.
• The MRC is divided into six grades:
Normal 5, Good 4, Fair 3, Poor 2, Trace 1, Zero 0.
• The mean value was taken from three measurements, and to minimize the
degree of fatigue, there was a 30 second rest period between measurements.

30. 2. Berg Balance Scale
• The BBS is composed of 14 different items that can quantitatively evaluate the degree of
balance and fall risk through direct observation.
• Items can be classified into three regions of sitting, standing, and postural changes, and each
of the 14 items can be scored between 0–4 points, with 56 points being the maximum score.
• A score of
A. 45 or less — need for the use of a cane or other gait assistive devices,
B. 41–44 — low fall-risk,
C. 21–40 — higher fall risk,
D. 0–20 — very high risk for falls and injuries.

31. 3. Timed Up and Go Test
• The TUG measures the time it takes for a subject to rise from a seated
position at the “start” signal, walk up to the 3m mark, and then return back to
the chair until they are completely seated.
• The mean value was obtained from a total of three measurements.

32. 4. 10 Meter Walk Test
• The 10MWT is a standard test used to investigate the extent of gait ability.
• 10M Walking test measures the walking speed walked at the maximum speed
and is measured 2 times and selected the highest one.

33. 5. Fugl Myer Test
• FMA is a method of assessing motor impairment with a total score of 100
points for motor function, 66 points for upper limbs, and 34 points for
lower limbs, giving a score of 0 ∼ 2, where a higher score indicates better
exercise control.
• In this study, a total of 34 points were used for evaluation of FMA lower
limbs during exercise performance evaluation.

34. 6. Modified Barthel Index
• MBI is an evaluation method that reflects changes in the patient’s functional
improvement.
• It is a valuable, reliable and change-sensitive evaluation method that indicates
the level of competence in performing daily living activities.

35. Data Analysis
• This study used the PASW Statistics ver. 19.0 program.
• A normality analysis was performed on the general characteristics of subjects
and a paired t-test was performed to examine for changes pre and post-
intervention for each group.
• A one-way ANOVA was used to determine for statistically significant
differences in balance and walking ability between groups after six weeks,

36. Results
• The general characteristics and medical characteristics of all subjects in the
VRGT, ARGT, and control were all homogenous.
• The MRC, BBS, TUG, 10MWT and FMA in the VRGT, ARGT and control
group were significantly increased post intervention.
• The MRC and FMA of the outcome measures showed a greater significant
increase in VRGT compared to ARGT.
• However, there was a significant difference in the results when comparing
VRGT and ARGT with the control group.

38. Discussion
• The weakness of lower extremity muscles in stroke patients is one of the limiting
factors for functional restoration.
• It causes asymmetrical posture and physical imbalance, which greatly affects the
balance ability.
• Anat et al. (2010) and Celine et al. (2014) suggested that robot-assisted gait
training is a very effective method for restoring asymmetric walking ability due to
muscle weakness.
• Dias et al. (2007) and Wong et al. (2012) stated that robot-assisted gait training
gave a functional improvement to stroke patients with an effective change in
balance ability.

39. • VRGT plays an important role in enhancing the active movement and
participation of the patient by using the virtual reality program as a way of
carrying out and interacting with the task through his or her representation on
screen.
• In this study, a virtual reality program called ‘Augmented feedback’ provided a
realistic environment, helping patients to participate enthusiastically and actively.

40. • In the study of Deutsch et al. (2004), active movement was induced by applying
virtual reality and ankle rehabilitation system using robots, resulting in
improvement of walking speed and muscle endurance.
• After that, Lee et al. (2013) and Ham et al. (2016) also demonstrated that robot-
assisted gait training using virtual reality was very effective in restoring balance
and gait ability of stroke patients.

41. • Regularly auditory stimuli improve the pattern of muscle activation.
• This periodicity of auditory stimulation regularly regulates motor neuron activity —
leading to neuronal activation pattern — leading to consistent time control and more
motor neuron mobilization.
• Jeong et al. and Roerdink et al. reported that these regular auditory stimuli
improved symmetrical gait ability and walking speed with improved coordination
ability as well as improved joint angle and flexibility.
• It was reported that the gait training by using the progressive change of the speed of
auditory stimulation positively influenced gait ability such as walking speed and
stride length.

42. • It is believed that repetitive tasks such as virtual reality and auditory stimuli
stimulate long-term structural changes by promoting remapping of the sensory and
motor cortex by promoting neuroplasticity.
• That leads to a positive effect on walking speed and balance ability by exercise
relearning in limbs.

43. • Yang et al. (2013) also showed symmetrical gait changes based on effective body
weight shifting through changes in foot pressure after robot-assisted gait training.
• This suggests the improvement of the over all function of the lower extremity, as
well as muscle strength.
• Robot-assisted gait training can be said to have a very positive effect on the
improvement of motor function as well as on balance and gait ability.

44. Limitations
• First, there is a limit to generalising the results of the study because it does not
involve a large number of subjects.
• Second, there is a limit to represent various characterised stroke patients with
balance and gait abilities.
• Third, the study period is set at six weeks, and there is a limit to reflect the
difference in effectiveness with short-term training.

45. Appraisal - tools
• PEDro
• CONSORT

46. PEDro

47. 1. Eligibility criteria were specified
❑ Yes
2. Subjects were randomly allocated to groups (in a crossover study, subjects were
randomly allocated an order in which treatments were received)
❑ Yes
3. Allocation was concealed
❑ No
4. The groups were similar at baseline regarding the most important prognostic
indicators
❑ Yes

48. 5. There was blinding of all subjects
❑ No
6. There was blinding of all therapists who administered the therapy
❑ No
7. There was blinding of all assessors who measured at least one key outcome
❑ No
8. Measures of at least one key outcome were obtained from more than 85% of the
subjects initially allocated to groups
❑ Yes

49. 9. All subjects for whom outcome measures were available received the treatment or
control condition as allocated or, where this was not the case, data for at least one key
outcome was analyzed by “intention to treat”
❑ No
10. The results of between-group statistical comparisons are reported for at least one
key outcome
❑ Yes
11. The study provides both point measures and measures of variability for at least one
key outcome.
❑ No

50. PEDRO SCORE:5/10

51. Consort

52. 1. TITLE & ABSTRACT
POSITIVE NEGATIVE
Not mentioned as RCT in the title
Structured abstract is given

53. 2. INTRODUCTION
POSITIVE NEGATIVE
Specific background and
rationale given
Objectives of the study
mentioned

54. 3. METHOD – trial design
POSITIVE NEGATIVE
• Randomisation is
mentioned.
• Type of trial design and
allocation ratio not
mentioned

55. 4. METHOD- participants
POSITIVE NEGATIVE
Inclusion criteria mentioned
clearly
Exclusion criteria not mentioned
Setting and location where the
study was conducted is given

56. 5. INTERVENTION
POSITIVE NEGATIVE
• Detailed description of
intervention is stated
including how and when it
was administered.

57. 6. OUTCOMES
POSITIVE NEGATIVE
• Outcome measures are clearly
mentioned.
• Pre and post test measurements
are clearly mentioned

58. 7. SAMPLE SIZE
POSITIVE NEGATIVE
• How sample size was
calculated is not mentioned
• No mention of stopping
guidelines

59. 8. RANDOMIZATION
POSITIVE NEGATIVE
Randomisation not explained

60. 9. ALLOCATION CONCEALMENT MECHANISM
POSITIVE NEGATIVE
Allocation was not concealed

61. 10.IMPLEMENTATION
POSITIVE NEGATIVE
Who generated the random allocation
sequence not mentioned

62. 11. BLINDING
POSITIVE NEGATIVE
• Patients were not blinded
• Treating therapists were not blinded
• Assessor were not blinded

63. 12. STATISTICAL METHODS
POSITIVE NEGATIVE
Statistical methods used to compare
groups for outcome measures
Methods of additional analysis was
not mentioned.

64. 13. RESULTS
POSITIVE NEGATIVE
• participants who were randomly
assigned, received intended
treatment, and were analysed for all
outcomes.
Not mentioned about exclusion after
randomisation

65. 14. RECRUITMENT
POSITIVE NEGATIVE
• period of study is not
mentioned
• Why the trial ended is not
mentioned

66. 15. BASELINE DATA
POSITIVE NEGATIVE
• Base line data is provided

67. 16. NUMBERS ANALYSED
POSITIVE NEGATIVE

68. 17. OUTCOMES AND ESTIMATION
POSITIVE NEGATIVE
• The outcome measure calculation
per group and its precision clearly
mentioned

69. 18. HARMS
POSITIVE NEGATIVE
• Harms not mentioned

70. 19. DISCUSSION
POSITIVE NEGATIVE
• Limitations given
• Suggestions for future researches
is given
• Considered other relevant
evidences

71. OTHER - INFORMATION
POSITIVE NEGATIVE
• Protocol • Funding
Trial registration not given

72. THANK YOU