Skip to main content

Energy cost and psychological impact of robotic-assisted gait training in people with spinal cord injury: effect of two different types of devices

Neurological Sciences volume 42, pages 3357–3366 (2021)Cite this article

Abstract

Background

In the last years, there has been an intense technological development of robotic devices for gait rehabilitation in spinal cord injury (SCI) patients. The aim of the present study was to evaluate energy cost and psychological impact during a rehabilitation program with two different types of robotic rehabilitation systems (stationary system on a treadmill, Lokomat, and overground walking system, Ekso GT).

Methods

Fifteen SCI patients with different injury levels underwent robot-assisted gait training sessions, divided into 2 phases: in the first phase, all subjects completed 3 sessions both Lokomat and Ekso GT. Afterwards, participants were randomly assigned to Lokomat or the Ekso for 17 sessions. A questionnaire, investigating the subjective psychological impact (SPI) during gait training, was administered. The functional outcome measures were oxygen consumption (VO2), carbon dioxide production (VCO2), metabolic equivalent of task (MET), walking economy, and heart rate (HR).

Results

The metabolic responses (7.73 ± 1.02 mL/kg/min) and MET values (3.20 ± 1.01) during robotic overground walking resulted to be higher than those during robotic treadmill walking (3.91 ± 0.93 mL/kg/min and 1.58 ± 0.44; p < 0.01). Both devices showed high scores in emotion and satisfaction. Overground walking resulted in higher scores of fatigue, mental effort, and discomfort while walking with Lokomat showed a higher score in muscle relaxation. All patients showed improvements in walking economy due to a decrease in energy cost with increased speed and workload.

Conclusions

Overground robotic-assisted gait training in rehabilitation program needs higher cognitive and cardiovascular efforts than robot-assisted gait training on a treadmill.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. Hachem LD, Ahuja CS, Fehlings MG (2017) Assessment and management of acute spinal cord injury: from point of injury to rehabilitation. J Spinal Cord Med 40:665–675

    Article  Google Scholar 

  2. Sun X, Jones ZB, Chen X-m, Zhou L, So K-F, Ren Y (2016) Multiple organ dysfunction and systemic inflammation after spinal cord injury: a complex relationship. J Neuroinflammation 13:260

    Article  Google Scholar 

  3. Jain NB, Higgins LD, Katz JN, Garshick E (2010) Association of shoulder pain with the use of mobility devices in persons with chronic spinal cord injury. PM R 2:896–900

    Article  Google Scholar 

  4. Calabrò RS, Cacciola A, Bertè F, Manuli A, Leo A, Bramanti A, Naro A, Milardi D, Bramanti P (2016) Robotic gait rehabilitation and substitution devices in neurological disorders: where are we now? Neurol Sci 37:503–514

    Article  Google Scholar 

  5. Rutović S, Glavić J, Cvitanović NK (2019) The effects of robotic gait neurorehabilitation and focal vibration combined treatment in adult cerebral palsy. Neurol Sci 40:2633–2634

    Article  Google Scholar 

  6. Schwartz I, Meiner Z (2015) Robotic-assisted gait training in neurological patients: who may benefit? Ann Biomed Eng 43:1260–1269

    Article  Google Scholar 

  7. Hayes SC, James Wilcox CR, Forbes White HS, Vanicek N (2018) The effects of robot assisted gait training on temporal-spatial characteristics of people with spinal cord injuries: a systematic review. J Spinal Cord Med 41:529–543

    Article  Google Scholar 

  8. Fritz H, Patzer D, Galen SS (2019) Robotic exoskeletons for reengaging in everyday activities: promises, pitfalls, and opportunities. Disabil Rehabil 41:560–563

    Article  Google Scholar 

  9. Kirshblum S, Waring W 3rd (2014) Updates for the international standards for neurological classification of spinal cord injury. Phys Med Rehabil Clin N Am 25(505–517):vii

    Google Scholar 

  10. Vertesi A, Lever JA, Molloy DW, Sanderson B, Tuttle I, Pokoradi L, Principi E (2001) Standardized mini-mental state examination. Use and interpretation. Can Fam Physician 47:2018–2023

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Yusuf S, Wittes J, Probstfield J, Tyroler HA (1991) Analysis and interpretation of treatment effects in subgroups of patients in randomized clinical trials. JAMA 266:93–98

    CAS  Article  Google Scholar 

  12. Heinemann AW, Jayaraman A, Mummidisetty CK, Spraggins J, Pinto D, Charlifue S, Tefertiller C, Taylor HB, Chang SH, Stampas A, Furbish CL, Field-Fote EC (2018) Experience of robotic exoskeleton use at four spinal cord injury model systems centers. J Neurol Phys Ther 42:256–267

    Article  Google Scholar 

  13. Borg G (1990) Psychophysical scaling with applications in physical work and the perception of exertion. Scand J Work Environ Health 16:55–58

    Article  Google Scholar 

  14. Borg G (1998) Borg’s perceived exertion and pain scales. Human kinetics, Champaign

    Google Scholar 

  15. Tanaka H, Monahan KD, Seals DR (2001) Age-predicted maximal heart rate revisited. J Am Coll Cardiol 37:153–156

    CAS  Article  Google Scholar 

  16. Brockway JM (1987) Derivation of formulae used to calculate energy expenditure in man. Hum Nutr Clin Nutr 41:463–471

    CAS  PubMed  Google Scholar 

  17. Stampacchia G, Rustici A, Bigazzi S, Gerini A, Tombini T, Mazzoleni S (2016) Walking with a powered robotic skeleton: subjective experience, spasticity and pain in spinal cord injured persons. NeuroRehabilitation 39:277–283

    Article  Google Scholar 

  18. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, O’Brien WL, Bassett DR Jr, Schmitz KH, Emplaincourt PO, Jacobs DR Jr, Leon AS (2000) Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 32:S498–S504

    CAS  Article  Google Scholar 

  19. Collins EG, Gater D, Kiratli J, Butler J, Hanson K, Langbein WE (2010) Energy cost of physical activities in persons with spinal cord injury. Med Sci Sports Exerc 42:691–700

    Article  Google Scholar 

  20. Monroe MB, Tataranni PA, Pratley R, Manore MM, Skinner JS, Ravussin E (1998) Lower daily energy expenditure as measured by a respiratory chamber in subjects with spinal cord injury compared with control subjects. Am J Clin Nutr 68:1223–1227

    CAS  Article  Google Scholar 

  21. Gorgey AS, Dolbow DR, Dolbow JD, Khalil RK, Castillo C, Gater DR (2014) Effects of spinal cord injury on body composition and metabolic profile - part I. J Spinal Cord Med 37:693–702

    Article  Google Scholar 

  22. Levine JA (2004) Non-exercise activity thermogenesis (NEAT). Nutr Rev 62:S82–S97

    Article  Google Scholar 

  23. Saeidifard F, Medina-Inojosa JR, Supervia M, Olson TP, Somers VK, Erwin PJ, Lopez-Jimenez F (2018) Differences of energy expenditure while sitting versus standing: a systematic review and meta-analysis. Eur J Prev Cardiol 25:522–538

    Article  Google Scholar 

  24. Pescatello LS, Arena R, Riebe D, Thompson PD (2014) ACSM’s guidelines for exercise testing and prescription, 9th edn. Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, p 456

  25. Seelen HA, Potten YJ, Huson A, Spaans F, Reulen JP (1997) Impaired balance control in paraplegic subjects. J Electromyogr Kinesiol 7:149–160

    CAS  Article  Google Scholar 

  26. Alamro RA, Chisholm AE, Williams AMM, Carpenter MG, Lam T (2018) Overground walking with a robotic exoskeleton elicits trunk muscle activity in people with high-thoracic motor-complete spinal cord injury. J Neuroeng Rehabil 15:109

    Article  Google Scholar 

  27. Aaslund MK, Moe-Nilssen R (2008) Treadmill walking with body weight support. Gait Posture 28:303–308

    Article  Google Scholar 

  28. Hornby TG, Kinnaird CR, Holleran CL, MR MRR, Rodriguez KS, Cain JB (2012) Kinematic, muscular and metabolic responses during exoskeletal-, elliptical-, or therapist-assisted stepping in people with incomplete spinal cord injury. Phys Ther 92:1278–1291

    Article  Google Scholar 

  29. Israel JF, Campbell DD, Kahn JH, Hornby TG (2006) Metabolic costs and muscle activity patterns during robotic-and therapist-assisted treadmill walking in individuals with incomplete spinal cord injury. Phys Ther 86:1466–1478

    Article  Google Scholar 

  30. Evans N, Hartigan C, Kandilakis C, Pharo E, Clesson I (2015) Acute cardiorespiratory and metabolic responses during exoskeleton-assisted walking overground among persons with chronic spinal cord injury. Topics Spinal Cord Inj Rehabil 21:122–132

    Article  Google Scholar 

  31. Kressler J, Thomas CK, Field-Fote EC, Sanchez J, Widerström-Noga E, Cilien DC, Gant K, Ginnety K, Gonzalez H, Martinez A, Anderson KD, Nash MS (2014) Understanding therapeutic benefits of overground bionic ambulation: exploratory case series in persons with chronic, complete spinal cord injury. Arch Phys Med Rehabil 95:1878–1887

    Article  Google Scholar 

  32. van den Berg R, de Groot S, Swart KM, van der Woude LHP (2010) Physical capacity after 7 weeks of low-intensity wheelchair training. Disabil Rehabil 32:2244–2252

    Article  Google Scholar 

  33. Ginis KA, Hicks AL, Latimer AE, Warburton DE, Bourne C, Ditor DS, Goodwin DL, Hayes KC, McCartney N, McIlraith A, Pomerleau P, Smith K, Stone JA, Wolfe DL (2011) The development of evidence-informed physical activity guidelines for adults with spinal cord injury. Spinal Cord 49:1088–1096

    Article  Google Scholar 

  34. Kozlowski AJ, Bryce TN, Dijkers MP (2015) Time and effort required by persons with spinal cord injury to learn to use a powered exoskeleton for assisted walking. Top Spinal Cord Inj Rehabil 21:110–121

    Article  Google Scholar 

  35. Hoekstra F, van Nunen MP, Gerrits KH, Stolwijk-Swüste JM, Crins MH, Janssen TW (2013) Effect of robotic gait training on cardiorespiratory system in incomplete spinal cord injury. J Rehabil Res Dev 50:1411–1422

    Article  Google Scholar 

  36. Teasell RW, Arnold JMO, Krassioukov A, Delaney GA (2000) Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury. Arch Phys Med Rehabil 81:506–516

    CAS  Article  Google Scholar 

  37. Dela F, Mohr T, Jensen CM, Haahr HL, Secher NH, Biering-Sørensen F, Kjaer M (2003) Cardiovascular control during exercise: insights from spinal cord-injured humans. Circulation 107:2127–2133

    Article  Google Scholar 

  38. Gandevia SC (2001) Spinal and supraspinal factors in human muscle fatigue. Physiol Rev 81:1725–1789

    CAS  Article  Google Scholar 

Download references

Funding

The study was partly funded within the research project “Clinical and healthcare strategies for improving quality of life in persons affected by spinal cord injuries: Tuscany regional network and use of innovative technological devices” (RF-2011-02346770) by the Italian Ministry of Health under “Ricerca Finalizzata e Giovani Ricercatori 2011–2012.”

Author information

Authors and Affiliations

  1. Interdepartmental Research Centre on Biology and Pathology of Aging, University of Pisa, via Roma 55, I-56126, Pisa, Italy

    Silvia Corbianco, Gabriella Cavallini & Marco Dini

  2. Human Movement and Rehabilitation Research Laboratory, Pisa, Italy

    Silvia Corbianco & Marco Dini

  3. Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy

    Ferdinando Franzoni

  4. Spinal Cord Unit, Pisa University Hospital, Pisa, Italy

    Carla D’Avino, Adriana Gerini & Giulia Stampacchia

Authors
  1. Silvia Corbianco
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gabriella Cavallini
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marco Dini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ferdinando Franzoni
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Carla D’Avino
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Adriana Gerini
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Giulia Stampacchia
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Silvia Corbianco.

Ethics declarations

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

The study was approved by the local Ethical Committee of Pisa University Hospital in accordance with the code of Ethics of the World Medical Association (Declaration of Helsinki).

Informed consent

Written informed consent was obtained prior to participation in the study and after an explanation of the protocol.

Additional information

The authors declare that the results of this study are presented clearly, honestly, and without fabrication, falsification, or inappropriate data manipulation.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Corbianco, S., Cavallini, G., Dini, M. et al. Energy cost and psychological impact of robotic-assisted gait training in people with spinal cord injury: effect of two different types of devices. Neurol Sci 42, 3357–3366 (2021). https://doi.org/10.1007/s10072-020-04954-w

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10072-020-04954-w

Keywords

  • Spinal cord injury
  • Robotic rehabilitation
  • Lokomat
  • Ekso
  • Oxygen consumption
  • Psychological impact