What does evidence tell us about the use of gait robotic devices in patients with multiple sclerosis? A comprehensive systematic review on functional outcomes and clinical recommendations

Abstract

INTRODUCTION: There is growing evidence on the efficacy of gait robotic rehabilitation in patients with multiple sclerosis (MS), but most of the studies have focused on gait parameters. Moreover, clear indications on the clinical use of robotics still lack. as part of the cicEroNE italian consensus on robotic rehabilitation, the aim of this systematic review was to investigate the existing evidence concerning the role of lower limb robotic rehabilitation in improving functional recovery in patients with Ms. EVidENcE acQuisitioN: We searched for and systematically reviewed evidence-based studies on gait robotic rehabilitation in Ms, between January 1 st , 2010 and december 31 st , 2020, in the following databases: cochrane library, pEdro, pubMed and Google scholar. the study quality was assessed by the 16-item assessment of multiple systematic reviews 2 (aMstar 2) and the 10-item pEdro scale for the other research studies. EVidENcE syNthEsis: after an accurate screening, only 17 papers were included in the review, and most of them (13 rct) had a level ii evidence. Most of the studies used the Lokomat as a grounded robotic device, two investigated the efficacy of end-effectors and two powered exoskeletons. Generally speaking, robotic treatment has beneficial effects on gait speed, endurance and balance with comparable outcomes to those of conventional treatments. however, in more severe patients (Edss >6), robotics leads to better functional outcomes. Notably, after gait training with robotics (especially when coupled to virtual reality) Ms patients also reach better non-motor outcomes, including spasticity, fatigue, pain, psychological well-being and quality of life. unfortunately, no clinical indications emerge on the treatment protocols. CONCLUSIONS: The present comprehensive systematic review highlights the potential beneficial role on functional outcomes of the lower limb robotic devices in people with Ms. future studies are warranted to evaluate the role of robotics not only for walking and balance outcomes, but also for other gait-training-related benefits, to identify appropriate outcome measures related to a specific subgroup of MS subjects' disease severity.(Cite this article as: calabrò rs, cassio a, Mazzoli d, andrenelli E, bizzarini E, campanini i, et al.; italian consensus conference on robotics in Neurorehabilitation (cicEroNE). What does evidence tell us about the use of gait robotic devices in patients with multiple sclerosis? a comprehensive systematic review on functional outcomes and clinical recommendations.

Exoskeletons in MS rehabilitation are ready for widespread use in clinical practice: No

“…1 Another important aspect to consider before we start the widespread use of exoskeletons in MS relates to the specific patient subgroup that may benefit. Indeed, it is suggested that clinical effects of robot-assisted gait training are superior to conventional treatment in severely (but not in moderately) affected people with MS. 1,2 These results were implemented in the figure published by Calabro et al, 3 where patients gait deficits (based on Expanded Disability Status Scale (EDSS) scores) were plotted relative to the type of the therapy and devices (from overground walking training to powered exoskeletons to grounded exoskeletons).…”

“…2 Combination of exoskeleton therapy with virtual reality, can increase the impact on motor and non-motor outcomes such as psychological well-being and quality of life. 3,8 Third, although there is progress related to the usability of exoskeletons there is still a lot of improvement possible. For stationary and mobile exoskeletons, patients and therapists reported high levels of satisfaction.…”

Finding the Way to Improve Motor Recovery of Patients with Spinal Cord Lesions: A Case-Control Pilot Study on a Novel Neuromodulation Approach

“…Therefore, RAR combined with CPT offers some valuable clinical benefits. Contrarily, other studies showed no significant difference between RAR and CPT [ 9 , 10 , 11 , 12 , 40 ]. Therefore, further investigation is necessary to find additional strategies to RAR that may further promote rehabilitation outcome achievement.…”

“…Many promising RAR interventions have been shown to improve the mobility, function, and quality of life of individuals with SCI, in particular regarding lower extremity robotic exoskeletons. However, the majority of the available works have methodological and rehabilitation paradigm differences, thus being unable to demonstrate the superiority of one gait training strategy over another in counteracting the loss of muscle strength and trophism, walking disability and mobility, sensory dysfunction, autonomic disorders, spasticity, pain, and overall quality of life [ 9 , 10 , 11 , 12 , 13 , 14 , 15 ]. Therefore, more extensive studies are required to prove RAR’s benefits definitively [ 4 ].…”

Exoskeletons in MS rehabilitation are ready for widespread use in clinical practice: Yes

“…In the last few years, different authors have attempted to demonstrate the clinical efficacy of robotics in patients with MS, mainly focusing on motor outcomes. [7][8][9] In their recent systematic review, Bowman et al found that RAGT, provided with exoskeleton devices, improves balance and gait outcomes in a clinically meaningful way, thanks to their several advantages in terms of safety, motor assistance, and intensity of training. Then, the authors concluded that RAGT should be used in patients with MS and severe disability in a multimodal rehabilitation context as an opportunity to maximize their functional recovery.…”