Gait Training with Robotic Exoskeleton: A Case Report on the Treatment of Neurological Patients with Ataxia

To assess treatment of gait instability in the subacute and chronic phase after a cerebral infarction as well as chronic brain injury following tumor removal, by focusing on postural impairment and gait ataxia, with the use of robotic overground ambulation. Treatments such as virtual reality, biofeedback, and postural stability training have shown some promise to treat ataxia, but specific efficacy needs to be further investigated (Marquer 2014). Santos et al looked at therapist-assisted gait training vs bodyweight supported robotic-assisted gait training, which concluded that one was not better than the other (Santos 2018). No current studies have looked at the efficacy of robotic-assisted overground gait training without body weight support when not done in the intensive (five days per week) setting. This is a two-subject qualitative case study. There was no follow-up after discharge. Both patients participated in outpatient neurological physical therapy. Two patients with subacute cerebral infarction and chronic brain injury participated in this observational study. Over the span of twelve weeks, patients underwent an Ekso training program that included 10 sessions walking with decreasing assistance levels followed by overground ambulation between 100-200 feet each session. Ataxia deficits were quantified by ataxia scores on the Scale for the assessment and rating of ataxia (SARA), performed at every eighth to tenth visit. Standing balance and gait were also assessed through the Berg Balance Scale (BBS), Six Minute Walk Test (6MWT), and the Ten Meter Walk Test (10MWT). In the subacute and chronic phase, patients showed severe ataxia through the use of the SARA. Subject 2 was formally assessed and scored 21/50. Both subjects were initially non-ambulatory, or required maximum assistance to stand and walk. After twelve-weeks between the start of treatment with the exoskeleton and the re-evaluation of patients, the patients demonstrated meaningful improvement on the BBS, 6MWT, and 10MWT. Subject 1 improved his BBS from 16/56 to 23/56, meeting MDC of 4 points. Subject 2 did not meet MDC for the BBS (3 point improvement). However, Subject 2 did increase 6MWT distance from 0 feet at initial evaluation to 198 feet. Both subjects discharged as household ambulators. SARA scores remained unchanged. While gait training with robotics for ataxia has promising preliminary results to decrease fall risk, future studies are needed to investigate efficacy of this treatment.