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SYSTEMATIC REVIEW   Free accessfree

European Journal of Physical and Rehabilitation Medicine 2021 April;57(2):246-53

DOI: 10.23736/S1973-9087.21.06692-2


language: English

What is the impact of robotic rehabilitation on balance and gait outcomes in people with multiple sclerosis? A systematic review of randomized control trials

Thomas BOWMAN 1, 2 , Elisa GERVASONI 1, Angelo P. AMICO 3, Roberto ANTENUCCI 4, Paolo BENANTI 5, Paolo BOLDRINI 6, 7, Donatella BONAIUTI 6, Angelo BURINI 8, Enrico CASTELLI 9, Francesco DRAICCHIO 10, Vincenzo FALABELLA 11, Silvia GALERI 1, Francesca GIMIGLIANO 12, Mauro GRIGIONI 13, Stefano MAZZON 14, Stefano MAZZOLENI 2, 15, Fabiola G. MESTANZA MATTOS 1, Franco MOLTENI 16, Giovanni MORONE 17, Maurizio PETRARCA 18, Alessandro PICELLI 19, Federico POSTERARO 20, Michele SENATORE 21, Giuseppe TURCHETTI 22, Simona CREA 1, 2, Davide CATTANEO 1, Maria C. CARROZZA 1, 2, on behalf of “CICERONE” Italian Consensus Group for Robotic Rehabilitation 

1 IRCCS Fondazione Don Carlo Gnocchi ONLUS, Milan, Italy; 2 The BioRobotics Institute, Scuola Superiore Sant’Anna, Pontedera, Pisa, Italy; 3 Spinal Unit, Policlinico di Bari University Hospital, Bari, Italy; 4 Unit of Rehabilitation Medicine, Hospital of Castelsangiovanni, AUSL, Piacenza, Italy; 5 Department of Moral Theology, Pontifical Gregorian University, Rome, Italy; 6 Italian Society of Physical and Rehabilitation Medicine (SIMFER), Rome, Italy; 7General Secretary European Society of Physical and Rehabilitation Medicine (ESPRM), Rotterdam, the Netherlands; 8Humantech, Confapi, Milan, Italy; 9Department of Intensive Neurorehabilitation and Robotics, Bambino Gesù Children’s Hospital, Passoscuro Fiumicino, Rome, Italy; 10Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, INAIL, Rome, Italy; 11Italian Federation of Persons with Spinal Cord Injuries (Faip Onlus), Rome, Italy; 12Department of Mental and Physical Health and Preventive Medicine, Luigi Vanvitelli University of Campania, Naples, Italy; 13National Center for Innovative Technologies in Public Health, Italian National Institute of Health, Rome, Italy; 14Unit of Rehabilitation, ULSS (Local Health Authority) Euganea - Camposampiero Hospital, Padua, Italy; 15Department of Electrical and Information Engineering (DEI), Polytechnic University of Bari, Bari, Italy; 16Valduce Villa Beretta Hospital, Costa Masnaga, Lecco, Italy; 17Santa Lucia Foundation IRCCS, Rome, Italy; 18Department of Neurorehabilitation and Robotics, Movement Analysis and Robotics Laboratory (MARlab), Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy; 19Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; 20Department of Rehabilitation, Versilia Hospital, AUSL Toscana Nord Ovest, Camaiore, Lucca, Italy; 21Italian Association of Occupational Therapists (AITO), Rome, Italy; 22Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy

INTRODUCTION: In recent years, robot-assisted gait training (RAGT) has been proposed as therapy for balance and gait dysfunctions in people with multiple sclerosis (PwMS). Through this systematic review, we aimed to discuss the impact of RAGT on balance and gait outcomes. Furthermore, characteristics of the training in terms of robots used, participants characteristics, protocols and combined therapeutic approaches have been described.
EVIDENCE ACQUISITION: As part of the Italian Consensus on robotic rehabilitation “CICERONE” a systematic search was provided in PubMed, the Cochrane Library and PEDro to identify relevant studies published before December 2019. Only randomized control trials (RCT) involving RAGT for PwMS were included. PEDro scale was used to assess the risk of bias and the Oxford Center for Evidence-Based Medicine (OCEBM) was used to assess level of evidence of included studies.
EVIDENCE SYNTHESIS: The search on databases resulted in 336 records and, finally, 12 studies were included. RAGT was provided with Exoskeleton in ten studies (6-40 session, 2-5 per week) and with end-effector in two studies (12 sessions, 2-3 per week) with large variability in terms of participants’ disability. All the exoskeletons were combined with bodyweight support treadmill and movement assistance varied from 0% to 100% depending on participants’ disability, two studies combined exoskeleton with virtual reality. The end-effector speed ranged between 1.3 and 1.8 km/h, with bodyweight support starting from 50% and progressively reduced. In seven out of twelve studies RAGT was provided in a multimodal rehabilitation program or in combination with standard physical therapy. There is level 2 evidence that RAGT has positive impact in PwMS, reaching the minimally clinically importance difference in Berg Balance Scale, six-minute walking test and gait speed.
CONCLUSIONS: In available RCT, RAGT is mostly provided with exoskeleton devices and improves balance and gait outcomes in a clinically meaningful way. Considering several advantages in terms of safety, motor assistance and intensity of training provided, RAGT should be promoted for PwMS with severe disability in a multimodal rehabilitation context as an opportunity to maximize recovery.

KEY WORDS: Rehabilitation; Robotics; Multiple sclerosis; Gait

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