Restoration of the nervous system for complex neurological states relies on training that is systematic, has clear goals, and corresponds with the deficiency, the needs in respect of safety, and the stage of recovery of each individual patient. For those who have a great problem of walking, training in walking may require more than verbal recommendations or manual support alone. A controlled environment may be necessary, in order to direct the repetition, the alignment of the trunk and the legs, the bearing of weight, and the careful increasing of the level of the training
This is the important role that robotic gait training may have within a plan of restoration led by specialists. For patients affected by cerebrovascular disease, Parkinson's disease, a severe deficiency of walking, or another neurological state, training in walking with a robot to help may support training in walking that is more consistent, more repeatable, and more measurable
The evidence must be interpreted separately according to the diagnosis and the equipment. The Cochrane review on electromechanical-assisted training for walking after cerebrovascular disease (opens in a new tab) found that when used together with physiotherapy it may increase the chance of walking independently, but the effect on the speed and the ability in walking is still not clear. This result does not confirm the same benefit in every disease or in every person
Robotic gait training is not a treatment on its own or a replacement for the therapist. The walking, the balance, the bearing of weight, the stability of the trunk, the endurance, the medical stability, and the goals of living must be assessed before choosing and increasing the level of the training
Why recovery of walking from a problem of the nervous system is complex
Walking is not only a movement of the legs; it relies on coordination between the brain, the spinal cord, the peripheral nerves, the muscles, the joints, the system of balance, the seeing, the posture, and the endurance of the heart and the blood vessels. After an injury or an abnormality of the nervous system, many of these systems may be affected at the same time
The patient may have weakness on one side of the body, reduced balance, poor control of the trunk, tight and spastic muscles, an abnormal tone of the muscles, changed sensation, exhaustion, fear of falling, or difficulty transferring the weight from one leg to the other. These problems may make training in walking unsafe, inconsistent, or too effortful if there is no suitable help
For this reason, complex recovery of the nervous system should begin from a systematic assessment. The specialist team of rehabilitation medicine must understand how much help the patient needs, which patterns of movement must be given importance, how much repetition should be trained, and which goals of use are the most important to daily life
How technology can support training in walking under the care of the therapist
Traditional physiotherapy is still an important part of the restoration of the nervous system. The therapist helps direct the quality of the movement, assesses the clinical response, adjusts the level of the training, and connects the training with use in real life. However, in patients who have a great deficiency of walking, training in walking with the therapist helping may have limitations in practice
Patients who still cannot stand, bear weight, or step safely may need a great deal of manual support, which may limit the number of steps that can be trained in one session, and make it difficult to keep the rhythm, the alignment of the body, the support of the weight, and the quality of the movement consistent throughout many sessions of the training
Robotic gait training may help deal with this limitation, by opening the opportunity for selected patients to train the movements for walking in an environment that is controlled and supported. It may help increase both the quality and the quantity of the training of the step, while the therapist can focus attention on the posture, the taking part, the response, and the increasing of the level of the training
The plasticity of the nervous system: why intensive task-specific training is important
The foundation of the restoration of the nervous system is the plasticity of the nervous system, or the ability of the brain and the nervous system to adapt to meaningful training. In restoration, the plasticity of the nervous system does not arise from random movement; it relies on training that has a goal, is repeated, is suitably challenging, and is connected with real use
For the recovery of walking, this means that the patient must have the opportunity to train tasks connected with walking with sufficient frequency and quality. The nervous system receives sensory input and motor commands repeatedly from stepping, transferring the weight, controlling the balance, moving the joints, and adjusting the posture. As time passes, this repeated input may help strengthen patterns of movement that are more effective, depending on the state and the potential for restoration of the patient
Restoration that uses technology to help may have clinical value when it helps increase training that is safe, systematic, and task-specific. The intensity of the training is also important, but it must be planned responsibly. More treatment is not always better, unless it is specific, safe, and corresponds with the tolerance and the goals of the patient
How robotic gait training helps the nervous system relearn movement through repetition
Robotic gait training supports the restoration of the nervous system by helping the patient train walking more consistently and more measurably. The system can lead patterns of stepping repeatedly, while giving support to the body and assisting force that can be controlled when it is needed
Systematic repetition of the pattern of walking
Repeated training is one of the important principles of motor learning. A system of robotic gait training helps the patient carry out the movements for walking repeatedly, with a pattern that is more constant than manual help alone may be able to achieve
The goal is not only to "move the legs", but to support purposeful training in walking under clinical guidance. During the training, the team of restoration may give importance to the rhythm of the step, the alignment of the body, the transfer of weight, the posture, the endurance, and the active taking part of the patient
The control of the bearing of weight, the rhythm, and the alignment of the body
A large number of neurological patients have a problem of uneven bearing of weight, poor control of the knee, reduced movement of the hip, difficulty lifting the toes clear of the ground, or difficulty coordinating the timing of each step. Training in walking with a robot to help may help direct these components within an environment that is safer and more controlled
This approach may be of benefit especially when the patient is not yet ready for walking on the ground by themselves. By adjusting the level of the assisting force and of the support, the treating team can help the patient train a pattern of walking that is closer to the goal that has been set, while reducing unnecessary compensating movements
Increasing the level in a way that can be followed and measured as time passes
Because robotic gait training has a clear structure, it helps the team of restoration observe the progress more clearly. The time in the training, the level of the assisting force, the quality of the step, the tolerance, the exhaustion, the readiness in respect of balance, and the response to the intensity of the training can be followed and adjusted
This supports a plan of restoration that is based more on clinical reasoning, instead of repeating the same routine of treatment. The programme can be changed when the patient improves, when the recovery stalls, when there is exhaustion, or when the focus must be changed
Integrating robotic gait training into the plan of restoration
Technology should support clinical decisions; it should not replace personnel. Robotic gait training may be a part of a plan that has medical assessment, physiotherapy, occupational therapy, speech therapy, training of balance, training of the routine, and following of the result as necessary
The dose and the components of the treatment must be adjusted specifically to the individual. More hours is not always better. The intensity depends on the diagnosis, the tolerance of the heart and the blood vessels, the fatigue, the cognition, the safety of the skin and the joints, the taking part, and the recovery between sessions
The goal of this model is to support the plasticity of the nervous system with restoration that is task-specific, has high intensity, and uses technology to help, instead of giving treatment session by session separately. The programme has been designed to create an environment of restoration that is more continuous, with therapy in several fields working towards shared goals of use
The programme of a patient may consist of robotic gait training, training of movement by the therapist, training of balance, restoration of the arm and the hand, support in the field of cognition or of communication, and training in doing the daily routine. The exact combination depends on the diagnosis, the tolerance, the safety, the response to the treatment, and what is important in daily life
Who may be considered for robotic gait training
Robotic gait training may be considered in selected patients who have a deficiency of walking from the nervous system, such as cerebrovascular disease, Parkinson's disease, a problem of walking connected with the spinal cord, an injury to the brain, or another neurological state that affects the ability to walk
However, this method does not suit every patient. The specialist team should assess the stability of the medical state, the state of the bones and the joints, the tone of the muscles, the state of the skin, the endurance of the heart and the blood vessels, the cognition, the ability to communicate, the balance, the risks in respect of safety, and the ability to take part in the training
Careful screening is important, because the robotic technology should be chosen to suit the patient; the patient should not have to be adjusted to suit the technology. In some cases there may need to be therapy preparing readiness before beginning robotic gait training. In other cases the robotic training may be combined with walking on the ground, training of balance, strengthening, occupational therapy, or other approaches of restoration
From training in walking to use in daily life
The ultimate goal of the restoration of walking is not only to make the walking better within the medical establishment, but to support movement in daily life so that it is safer and more purposeful
This may include standing with more confidence, transferring from the bed to the chair, better balance while turning the body, walking with a walking aid, reducing compensating movements, increasing endurance, or taking part in daily activities more. The progress may have a different character in each individual patient, particularly in complex neurological cases
The team should follow the response, adjust the assisting force and the intensity, and connect the training with technology to the goals of walking and of transferring the body outside the treatment room
Frequently asked questions
Is robotic gait training better than general physiotherapy
Robotic gait training should not be seen as a replacement for general physiotherapy, but it may be of benefit when used as part of a systematic plan of restoration of the nervous system, particularly for patients who need training in walking that is supported, repeatable, and controlled
Does robotic gait training guarantee faster recovery
No. The recovery depends on many factors, including the diagnosis, the severity of the deficiency, the length of time since the symptoms began, the medical state, the consistency of the treatment, and the response specific to the individual. Robotic gait training may support the recovery by increasing the quality and the intensity of the training when it is clinically suitable
Why is intensity important for the restoration of the nervous system
Intensity is important, because the nervous system usually needs training that is meaningful and repeated in order to learn movement anew. However, the intensity must be planned carefully. More treatment is not always better, if it is not safe, not specific, or does not correspond with the state of the patient
How does the team of restoration decide whether robotic gait training is suitable or not
The team assesses the ability in movement, the balance, the control of the bearing of weight, the safety, the tolerance, the state of the nervous system, and the goals of use. Robotic gait training will be recommended only when it corresponds with the clinical necessity and the plan of restoration of the patient
A summary
Robotic gait training is an important direction of modern restoration of the nervous system, because it helps training in walking have more structure, be more repeatable, be more measurable, and be more under clinical control. Its value is most apparent when it is used within a plan of restoration led by specialists, not as a technology on its own
For complex neurological states, the robot should be used when it supports clear task-specific goals, with an intensity that can be tolerated, regular reassessment, and continuous training of walking and of transferring the body in real situations