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European Journal of Physical and Rehabilitation Medicine 2021 October;57(5):841-9

DOI: 10.23736/S1973-9087.21.06915-X


language: English

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

Rocco S. CALABRÒ 1 , Anna CASSIO 2, Davide MAZZOLI 3, Elisa ANDRENELLI 4, Emiliana BIZZARINI 5, Isabella CAMPANINI 6, Simona M. CARMIGNANO 7, Simona CERULLI 8, Carmelo CHISARI 9, Valentina COLOMBO 10, Stefania DALISE 9, Cira FUNDARÒ 11, Valeria GAZZOTTI 12, Daniele MAZZOLENI 13, Miryam MAZZUCCHELLI 13, Corrado MELEGARI 14, Andrea MERLO 3, 6, Giulia STAMPACCHIA 15, Paolo BOLDRINI 16, Stefano MAZZOLENI 17, Federico POSTERARO 18, Paolo BENANTI 19, Enrico CASTELLI 20, Francesco DRAICCHIO 21, Vincenzo FALABELLA 22, Silvia GALERI 23, Francesca GIMIGLIANO 24, Mauro GRIGIONI 25, Stefano MAZZON 26, Franco MOLTENI 27, Maurizio PETRARCA 28, Alessandro PICELLI 29, Michele SENATORE 30, Giuseppe TURCHETTI 31, Giovanni MORONE 32, Donatella BONAIUTI 33, on behalf of the Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE)

1 IRCCS Centro Neurolesi “Bonino-Pulejo”, Messina, Italy; 2 Spinal Cord and Intensive Rehabilitation Medicine Unit, AUSL Piacenza, Castel San Giovanni, Piacenza, Italy; 3 OPA Sol et Salus Gait and Motion Analysis Laboratory, Torre Pedrera, Rimini, Italy; 4 Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy; 5 Spinal Cord Unit, Department of Rehabilitation Medicine, Gervasutta Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; 6 LAM-Motion Analysis Laboratory, Department of Neuromotor and Rehabilitation Sciences, AUSL-IRCCS Reggio Emilia, Reggio Emilia, Italy; 7 Rehabilitation Therapeutic Center, Tramutola, Potenza, Italy; 8 University Polyclinic Foundation A. Gemelli IRCCS, Rome, Italy; 9 Section of Neurorehabilitation, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy; 10 Montecatone Rehabilitation Institute, Imola, Bologna, Italy; 11 Unit of Neurophysiopathology, Istituti Clinici Scientifici Maugeri IRCCS, Montescano, Pavia, Italy; 12 Vigorso Prostheses Center, National Institute for Insurance against Accidents at Work (INAIL), Budrio, Bologna, Italy; 13 School of Physical and Rehabilitation Medicine, Bicocca University of Milan, Milan, Italy; 14 Elias Neuroriabilitazione, Parma, Italy; 15 Spinal Cord Unit, Pisa University Hospital, Pisa, Italy; 16 Italian Society of Physical and Rehabilitation Medicine (SIMFER), Rome, Italy; 17 Department of Electrical and Information Engineering, Polytechnical University of Bari, Bari, Italy; 18 Department of Rehabilitation, ASL12, Viareggio, Lucca, Italy; 19 Pontifical Gregorian University, Rome, Italy; 20 Department of Pediatric Neurorehabilitation, Bambino Gesù Children’s Hospital, Rome, Italy; 21 Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, National Institute for Insurance against Accidents at Work (INAIL), Monte Porzio Catone, Rome, Italy; 22 Italian Federation of Persons with Spinal Cord Injuries (FAIP Onlus), Rome, Italy; 23 IRCCS Don Gnocchi Foundation, Florence, Italy; 24 Department of Mental and Physical Health and Preventive Medicine, Luigi Vanvitelli University of Campania, Naples, Italy; 25 National Center for Innovative Technologies in Public Health, Italian National Institute of Health, Rome, Italy; 26 Rehabilitation Unit, ULSS Euganea, Camposampiero Hospital, Padua, Italy; 27 Villa Beretta Rehabilitation Center, Valduce Hospital, Costa Masnaga, Lecco, Italy; 28 The Movement Analysis and Robotics Laboratory, Bambino Gesù Children’s Hospital, Rome, Italy; 29 Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy; 30 Italian Association of Occupational Therapists (AITO), Rome, Italy; 31 Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy; 32 Santa Lucia Foundation IRCCS, Rome, Italy; 33 Piero Redaelli Geriatric Institute, Milan, Italy

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 1st, 2010 and December 31st, 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.

KEY WORDS: Gait; Rehabilitation; Robotics; Lower extremity; Multiple sclerosis

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