Journal of Rehabilitation Medicine 51-10

J Rehabil Med 2019; 51: 723–733 REVIEW ARTICLE EFFECTIVENESS OF OVER-GROUND ROBOTIC LOCOMOTOR TRAINING IN IMPROVING WALKING PERFORMANCE, CARDIOVASCULAR DEMANDS, SECONDARY COMPLICATIONS AND USER-SATISFACTION IN INDIVIDUALS WITH SPINAL CORD INJURIES: A SYSTEMATIC REVIEW Claire SHACKLETON, BSc (HONS) 1 , Robert EVANS, MPhil 1 , Delva SHAMLEY, PhD 2 , Sacha WEST, PhD 3 and Yumna ALBERTUS, PhD 1 From the 1 Division of Exercise Science and Sports Medicine, Department of Human Biology, Faculty of Health Science, FIMS International Collaborating Centre of Sports Medicine, 2 Clinical Research Centre, University of Cape Town and 3 Department of Sports Management, Cape Peninsula University of Technology, Cape Town, Western Cape, South Africa Objectives: To evaluate the effectiveness of over- ground robotic locomotor training in individuals with spinal cord injuries with regard to walking perfor- mance, cardiovascular demands, secondary health complications and user-satisfaction. Data sources: PubMed, Cochrane, Web of Science, Scopus, EBSCOhost and Engineering Village. Study selection: Trials in which robotic locomotor training was used for a minimum of 3 participants with spinal cord injury. Data extraction: Independent extraction of data by 2 reviewers using a pre-established data abstraction table. Quality of evidence assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Data synthesis: Total of 27 non-controlled studies representing 308 participants. Most studies showed decreases in exertion ratings, pain and spasticity and reported positive well-being post-intervention. Seven studies were included in meta-analyses on walking performance, showing significant impro- vements post-intervention (p < 0.05), with pooled effects for the 6-min walking test and 10-metre walking test of–0.94 (95% confidence interval (95% CI) –1.53,–0.36) and –1.22 (95% CI –1.87,–0.57), respectively. The Timed Up and Go Test showed a positive pooled effect of 0.74 (95% CI 0.36, 1.11). Improvements in walking parameters were seen with an increase in session number; however, no significant cardiovascular changes were found over time. Conclusion: Robotic locomotor training shows pro- mise as a tool for improving neurological rehabilita- tion; however, there is limited evidence regarding its training benefits. Further high-powered, randomized controlled trials, with homogenous samples, are re- quired to investigate these effects. Key words: spinal cord injury; over-ground robotic locomotor training; exoskeleton device; exercise therapy; gait; blood pressure; muscle spasticity; pain. Accepted Aug 30, 2019; Epub ahead of print Sep 11, 2019 J Rehabil Med 2019; 51: 723–733 Correspondence address: Yumna Albertus, Division of Exercise Sci- ence & Sports Medicine Division, University of Cape Town, Boundary Road, Newlands, Cape Town, South Africa. E-mail: yumna.albertus@ uct.ac.za LAY ABSTRACT The benefits of using robotic suits for rehabilitation in patients with spinal cord injury have been tested in many studies. This review assessed the findings of these studies with regards to how over-ground robotic train- ing could improve walking parameters, cardiovascular fitness and health outcomes for people with spinal cord injuries. Twenty-seven studies met the inclusion crite- ria for an in-depth analysis. The results showed that walking parameters were improved after the training interventions, but that there were no changes in car- diovascular outcomes. Health outcomes, including pain and muscle spasms, decreased after the intervention. This highlights that robotic walking has the potential to advance care for patients with spinal cord injuries by improving walking capacity, reducing pain and mus- cle tightness, and improving psychological well-being. However, the available evidence could be enhanced by further research using larger sample sizes, randomized control designs, sensitive interventions and tests. S pinal cord injury (SCI) is a devastating and life- altering condition. The primary neurological effects can lead to serious disability by impacting on physical functioning and independence and increasing the risk of secondary complications associated with a lack of weight-bearing activity (1). Secondary complications include osteoporosis, cardiovascular disease, spasticity, pain, pressure ulcers and depression (1, 2). In order to combat the negative health outcomes associated with SCI and to improve daily independence and social rein- tegration, recovery of locomotion and functional ability is a top priority for individuals with SCI (3). SCI reha- bilitation should not focus primarily on compensation for impairment, but also on maximizing the individual’s potential for recovery through neuroplasticity changes in the central nervous system (CNS). Retraining of motor function and recovery via neuroplasticity is the focus of recently developed locomotor training techniques, which involve the use of wearable robotic exoskeletons (3, 4). The first widely adopted powered exoskeleton, the Lokomat (Hocoma, Switzerland), is a fixed exoskeleton suspended over a treadmill. Robot-assisted technology has advanced in recent years to move away from body- weight supported treadmill training (BWSTT) to over- This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm Journal Compilation © 2019 Foundation of Rehabilitation Information. ISSN 1650-1977 doi: 10.2340/16501977-2601

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