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Stress urinary incontinence (SUI) represents one of the most common subtypes of urinary incontinence (UI) reported by women. Studies have shown an association of SUI with nonspecific low back pain (NSLBP). The primary aim of the present study was to explore the long-term effects of a combined treatment of manual techniques and pelvic floor muscle (PFM) training in women suffering from SUI associated with NSLBP. The secondary aim was to evaluate which manual approach combined with PFM rehabilitation is more effective in improving symptoms related to SUI and in reducing pain perception related to NSLBP. Twenty-six patients suffering from SUI associated with chronic NSLBP were randomly assigned to one of two groups: the postural rehabilitation group (PRg) or the spinal mobilization group (SMg). Both groups performed a manual approach combined with PFM rehabilitation. All patients were evaluated before the treatment (T0), after 10 sessions (T1) and after 30 days from the end of the treatment (T2). The results showed an improvement in both groups in all of the investigated outcomes. Combining manual therapy and PFM training within the same therapy session may be useful for improving both SUI and NSLBP and increasing the quality of life of women suffering from SUI associated with NSLBP.

In this paper, we present the design, control, and preliminary evaluation of the Symbitron exoskeleton, a lower limb modular exoskeleton developed for people with a spinal cord injury. The mechanical and electrical configuration and the controller can be personalized to accommodate differences in impairments among individuals with spinal cord injuries (SCI). In hardware, this personalization is accomplished by a modular approach that allows the reconfiguration of a lower-limb exoskeleton with ultimately eight powered series actuated (SEA) joints and high fidelity torque control. For SCI individuals with an incomplete lesion and sufficient hip control, we applied a trajectory-free neuromuscular control (NMC) strategy and used the exoskeleton in the ankle-knee configuration. For complete SCI individuals, we used a combination of a NMC and an impedance based trajectory tracking strategy with the exoskeleton in the ankle-knee-hip configuration. Results of a preliminary evaluation of the developed hardware and software showed that SCI individuals with an incomplete lesion could naturally vary their walking speed and step length and walked faster compared to walking without the device. SCI individuals with a complete lesion, who could not walk without support, were able to walk with the device and with the support of crutches that included a push-button for step initiationOur results demonstrate that an exoskeleton with modular hardware and control allows SCI individuals with limited or no lower limb function to receive tailored support and regain mobility.

Background: Neurogenic bowel dysfunction (NBD) indicates bowel dysfunction due to a lack of nervous control after a central nervous system lesion. Bowel symptoms, such as difficulties with evacuation, constipation, abdominal pain and swelling, are experienced commonly among individuals with spinal cord injury (SCI). Consequentially, individuals with SCI experience a general dissatisfaction with the lower perceived quality of life (QoL). Several studies have demonstrated the positive effects of manual therapies on NBD, including Osteopathic Manipulative Treatment (OMT). This study aimed to explore OMT effects on NBD in individuals with SCI compared with Manual Placebo Treatment (MPT). Methods: The study was a double-blind randomized controlled trial composed of three phases, each one lasting 30 days (i: NBD/drugs monitoring; ii: four OMT/MPT sessions; iii: NBD/drug monitoring and follow-up evaluation). Results: the NBD scale, the QoL on worries and concerns sub-questionnaire, and the perception of abdominal swelling and constipation significantly improved after treatments compared to baseline only for individuals who underwent OMT. Conclusion: These preliminary results showed positive effects of OMT on bowel function and QoL in individuals with SCI, but further studies are needed to confirm our results.

BACKGROUND: Balance is a crucial function of basic Activities of Daily Living (ADL) and is often considered the priority in Spinal Cord Injury (SCI) patients’ rehabilitation. Technological devices have been developed to support balance assessment and training, ensuring an earlier, intensive, and goal-oriented motor therapy. OBJECTIVE: The aim of this systematic review is to explore the technology-assisted strategies to assess and rehabilitate balance function in persons with SCI. METHODS: A systematic review was conducted in the databases PubMed, Scopus, IEEE Xplore, Cochrane Library, and Embase. Full reports on Randomized Clinical Trials (RCTs) of parallel-group or cross-over design and non-RCTs were included according to the following criteria: i) publication year from 1990 to 2021; ii) balance considered as a primary or secondary outcome; iii) population of individuals with SCI with age over 18 years old, regardless of traumatic or non-traumatic lesions, Time Since Injury, lesion level, Asia Impairment Scale score and gender. The methodological quality was determined for each included study according to the recognized Downs and Black (D&B) tool. RESULTS: Nineteen articles met the inclusion criteria and were included in the analysis. Four articles focused on balance assessment while 15 targeted rehabilitation interventions to improve balance by using Treadmill-Based Devices (TBD), OverGround Devices (OGD) and Tilt Table Devices (TTD). Statistically significant effects on balance can be found in TBD subcategory, in the hip-knee guidance subcategory of OGD and in the study of TTD category. CONCLUSION: Although different studies reported positive effects, improvements due to technology-assisted rehabilitation were not greater than those obtained by means of other rehabilitation therapies. The heterogeneity, low methodological quality, and the small number of the studies included do not allow general conclusions about the usefulness of technology-assisted balance assessment and training in individuals with SCI, even if significant improvements have been reported in some studies.

Background: Osteopathic manipulative treatment (OMT) is a patient-centred, whole-body intervention aimed at enhance the person’s self-regulation. OMT interventions are focused on somatic dysfunctions (SD) that can be defined as an altered regulative function associated with inflammatory signs palpable in the body framework in different body regions. The conceptual model that sustains SD, as well as its usefulness for the osteopathic profession, is still being discussed by the osteopathic community. Understanding the role and the application of SD is the aim of this scoping review. Methods: A literature search was carried out through the main biomedical databases: Pubmed (Medline), Cochrane, Central (Cochrane), Embase, PEDro and Scopus. Grey literature was considered via Google Scholar and the Osteopathic Research Web. The review was prepared by referring to the “Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews” (PRISMA-ScR). Results: A total of 37,279 records were identified through database searching and other sources. After the duplicates were removed, 27,023 titles and abstracts were screened. A total of 1495 full-text articles were assessed for eligibility. The qualitative synthesis included 280 studies. Conclusions: Treating SD is an important part of osteopathic practice that varies from country to country. SD should be considered as a clinical value that assists in the clinical assessment and guides the decision-making process of osteopathic practitioners. Further studies should be designed to better understand why and how to choose the different assessment and intervention modalities to approach SD and to evaluate new osteopathic models.

Overground powered lower limb exoskeletons (EXOs) have proven to be valid devices in gait rehabilitation in individuals with spinal cord injury (SCI). Although several articles have reported the effects of EXOs in these individuals, the few reviews available focused on specific domains, mainly walking. The aim of this systematic review is to provide a general overview of the effects of commercial EXOs (i.e. not EXOs used in military and industry applications) for medical purposes in individuals with SCI. This systematic review was conducted following the PRISMA guidelines and it referred to MED-LINE, EMBASE, SCOPUS, Web of Science and Cochrane library databases. The studies included were Randomized Clinical Trials (RCTs) and non-RCT based on EXOs intervention on individuals with SCI. Out of 1296 studies screened, 41 met inclusion criteria. Among all the EXO studies, the Ekso device was the most discussed, followed by ReWalk, Indego, HAL and Rex devices. Since 14 different domains were considered, the outcome measures were heterogeneous. The most investigated domain was walking, followed by cardiorespiratory/metabolic responses, spasticity, balance, quality of life, human–robot interaction, robot data, bowel functionality, strength, daily living activity, neurophysiology, sensory function, bladder functionality and body composition/bone density domains. There were no reports of negative effects due to EXOs trainings and most of the significant positive effects were noted in the walking domain for Ekso, ReWalk, HAL and Indego devices. Ekso studies reported significant effects due to training in almost all domains, while this was not the case with the Rex device. Not a single study carried out on sensory functions or bladder functionality reached significance for any EXO. It is not possible to draw general conclusions about the effects of EXOs usage due to the lack of high-quality studies as addressed by the Downs and Black tool, the heterogeneity of the outcome measures, of the protocols and of the SCI epidemiological/neurological features. However, the strengths and weaknesses of EXOs are starting to be defined, even considering the different types of adverse events that EXO training brought about. EXO training showed to bring significant improvements over time, but whether its effectiveness is greater or less than conventional therapy or other treatments is still mostly unknown. High-quality RCTs are necessary to better define the pros and cons of the EXOs available today. Studies of this kind could help clinicians to better choose the appropriate training for individuals with SCI.

we present the design, control, and preliminary evaluation of the Symbitron exoskeleton, a lower limb modular exoskeleton developed for people with a spinal cord injury. The mechanical and electrical configuration and the controller can be personalized to accommodate differences in impairments among individuals with spinal cord injuries (SCI). In hardware, this personalization is accomplished by a modular approach that allows the reconfiguration of a lower-limb exoskeleton with ultimately eight powered series actuated (SEA) joints and high fidelity torque control. For SCI individuals with an incomplete lesion and sufficient hip control, we applied a trajectory-free neuromuscular control (NMC) strategy and used the exoskeleton in the ankle-knee configuration. For complete SCI individuals, we used a combination of a NMC and an impedance based trajectory tracking strategy with the exoskeleton in the ankle-knee-hip configuration. Results of a preliminary evaluation of the developed hardware and software showed that SCI individuals with an incomplete lesion could naturally vary their walking speed and step length and walked faster compared to walking without the device. SCI individuals with a complete lesion, who could not walk without support, were able to walk with the device and with the support of crutches that included a push-button for step initiationOur results demonstrate that an exoskeleton with modular hardware and control allows SCI individuals with limited or no lower limb function to receive tailored support and regain mobility.

Rehabilitation robots are able to quantitatively assess biomechanical performance but they typically do not provide any information on the users’ subjective experience during the execution of motor tasks. In the framework of gait rehabilitation aided by treadmill-based exoskeletons, we developed a method for the assessment of the users’ psychophysiological state. By using a Fuzzy logic approach, four indicators can be estimated based on the recording of physiological signals. The method was tested on a group of four healthy participants walking with the Lokomat robotic gait trainer and the correlation among different pairs of indicators was evaluated., https://youtu.be/LiEwGdF5b28

The effects of osteopathic manipulative treatment (OMT) on functional brain connectivity in healthy adults is missing in the literature. To make up for this lack, we applied advanced network analysis methods to analyze resting state functional magnetic resonance imaging (fMRI) data, after OMT and Placebo treatment (P) in 30 healthy asymptomatic young participants randomized into OMT and placebo groups (OMTg, Pg). fMRI brain activity measures, performed before (T0), immediately after (T1) and three days after (T2) OMT or P were used for inferring treatment effects on brain circuit functional organization. Repeated measures ANOVA and post-hoc analysis demonstrated that Right Precentral Gyrus (F (2, 32) = 5.995, p &lt, 0.005) was more influential over the information flow immediately after the OMT, while decreased betweenness centrality in Left Caudate (F (2, 32) = 6.496, p &lt, 0.005) was observable three days after. Clustering coefficient showed a distinct time-point and group effect. At T1, reduced neighborhood connectivity was observed after OMT in the Left Amygdala (L-Amyg) (F (2, 32) = 7.269, p &lt, 0.005) and Left Middle Temporal Gyrus (F (2, 32) = 6.452, p &lt, 0.005), whereas at T2 the L-Amyg and Vermis-III (F (2, 32) = 6.772, p &lt, 0.005) increased functional interactions. Data demonstrated functional connectivity re-arrangement after OMT.

This work was devoted to preliminary test the Achilles ankle exoskeleton and its NeuroMuscular Controller (NMC) with a test pilot affected by incomplete spinal cord injury. The customization of the robot controller, i.e. a subject-specific tailoring of the assistance level, was performed and a 10-session training to optimize human-robot interaction was finalized. Results demonstrated that controller tuning was in line with the functional clinical assessment. NMC adapted to the variable walking speed during the training and the test pilot was successfully trained in exploiting robotic support and also improved his performance in terms of walking speed and stability. After the training, a higher speed could also be achieved during free walking and hence a slight unexpected rehabilitation effect was evidenced.

Powered exoskeletons are among the emerging technologies claiming to assist functional ambulation. The potential to adapt robotic assistance based on specific motor abilities of incomplete spinal cord injury (iSCI) subjects, is crucial to optimize Human-Robot Interaction (HRI). Achilles, an autonomous wearable robot able to assist ankle during walking, was developed for iSCI subjects and utilizes a NeuroMuscular Controller (NMC). NMC can be used to adapt robotic assistance based on specific residual functional abilities of subjects. The main aim of this pilot study was to analyze the effects of the NMC-controlled Achilles, used as an assistive device, on chronic iSCI participants’ performance, by assessing gait speed during 10-session training of robot-aided walking. Secondary aims were to assess training impact on participants’ motion, clinical and functional features and to evaluate subjective perspective in terms of attitude towards technology, workload, usability and satisfaction. Results showed that 5 training sessions were necessary to significantly improve robot-aided gait speed on short paths and consequently to optimize HRI. Moreover, the training allowed participants who initially were not able to walk for 6 minutes, to improve gait endurance during Achilles-aided walking and to reduce perceived fatigue. Improvements were obtained also in gait speed during free walking, thus suggesting a potential rehabilitative impact, even if Achilles-aided walking was not faster than free walking. Participants’ subjective evaluations indicated a positive experience

Purpose: To examine physiological responses and perceived exertion during robot-assisted treadmill walking in non-ambulatory stroke survivors; compare these outcomes with aerobic exercise recommendations; and investigate the effect of robotic assistance. Materials and methods: Twelve non-ambulatory stroke survivors (67 ± 11 years-old, 84 ± 38 d post-stroke) participated. Subjects walked three times 20 min (1 session/day) in the Lokomat: once with conventional exercise parameters, once with 60% robotic assistance and once with 100% robotic assistance. Gas exchange and heart rate were monitored continuously. Perceived exertion was assessed every 3 min during walking. Results: During conventional robot-assisted treadmill walking, net perceived exertion (0–14 scale) significantly increased between minute 6 (median = 2, interquartile range = 4) and 18 (median = 5, interquartile range = 4). Net physiological responses did not significantly change over time. Throughout exercise, percentage of predicted heart rate reserve was significantly below the 40% threshold (medians: 11–14%) and percentage of predicted maximum heart rate reached the 55% threshold (medians: 59–60%). Perceived exertion reached the 11-point threshold halfway. Net physiological responses and perceived exertion did not significantly differ between 60% and 100% robotic assistance. Conclusions: The assistance level that non-ambulatory stroke survivors require at their highest tolerable walking speed seems too high to sufficiently stress the cardiorespiratory system during robot-assisted treadmill walking.Implications for rehabilitationThe exercise intensity of 20-minute conventional robot-assisted treadmill walking can be low, and might be too low to challenge the cardiorespiratory system of non-ambulatory stroke survivors.Lowering the level of robotic assistance from 100% to 60% does not seem to increase the exercise intensity of 20-minute robot-assisted treadmill walking. The exercise intensity of 20-minute conventional robot-assisted treadmill walking can be low, and might be too low to challenge the cardiorespiratory system of non-ambulatory stroke survivors. Lowering the level of robotic assistance from 100% to 60% does not seem to increase the exercise intensity of 20-minute robot-assisted treadmill walking.

In this study, our goal was to improve the standing balance of people with a spinal cord injury by using a wearable exoskeleton that has ankle and knee actuation in the sagittal plane. Three test-pilots that have an incomplete spinal cord injury wore the exoskeleton and tried to maintain standing balance without stepping while receiving anteroposterior pushes. Two balance controllers were tested: One providing assistance based on the subject's body sway and one based on the whole body momentum. For both controllers, the balance performances of the test-pilots wearing the exoskeleton were assessed based on the center of mass kinematics and compared to the condition in which the device did not provide any assistance. One of the test-pilots was not able to maintain balance without assistance, but could withstand small pushes when any of the balance controllers was implemented. For this test-pilot the recovery time and sway amplitude hardly varied with the type of balance controller that was used. For the other two test-pilots the recovery time and the sway amplitude were smallest using the body sway controller. In conclusion, the wearable exoskeleton with balance controller was able to improve the balance performance of the test-pilots by reducing the recovery time after a perturbation and by enabling one of the test-pilots to maintain balance, who could not maintain balance by himself.

In 1700 BC, the Edwin Smith Papyrus, an ancient Egyptian medical text, described spinal cord injury (SCI) as an “ailment not to be treated.” (Silva et al. in Progress in neurobiology 2014;114:25–57, [1]) SCI can actually be defined as a lesion that occurs in any portion of the spinal cord and results in complete or incomplete impairment of motor, sensory and autonomic functions below the level of the injury [1]. The aetiology of SCI may be traumatic (TSCI) or non-traumatic (NTSCI).

Spinal cord injury (SCI) is a traumatic event with a global incidence of 23 cases per million, representing 180,000 cases per annum worldwide. Recovery of locomotion is a main priority for spinal cord-injured patients. In addition to overcoming the obvious mobility and social issues related to the inability to stand or walk, regular ambulation may profoundly combat secondary medical problems associated with lack of weight-bearing activity in SCI patients. Lower limb exoskeletons (EXOs) may be devised as an ambulation device, as a rehabilitation tool or may be aimed at allowing both objectives living. Regarding rehabilitation, it is worth noticing that EXOs also provide a perfect environment for precise assessing of rehabilitation protocols and effects. Different is the case of EXO for mobility, where the old wheelchair is still largely winning the challenge: existing exoskeletons have limitations with respect to affordability, size, weight, speed, and efficiency, which may reduce their functional application. In all functional areas (velocity, safety, portability, acceptance as well as autonomy in the ADL) none of today EXOs can compete with the performances of an average wheelchair. However, EXO usage requires learning, and brain changes associated with tool usage introduce the human in the loop concept, a key aspect of clinical relevance for EXO usage. At present, interesting data on the biological mechanisms and rehabilitation relevance of embodiment are providing hints for guiding rehabilitation. In this chapter, these challenges will be presented from a clinical rehabilitation perspective and expectations and critics discussed.

This work presents a wearable device and the algorithms for quantitative modelling of joint spasticity and its application in a pilot group of subjects with different levels of spinal cord injury. The device comprises light-weight instrumented handles to measure the interaction force between the subject and the physical therapist performing the tests, EMG sensors and inertial measurement units to measure muscle activity and joint kinematics. Experimental tests included the passive movement of different body segments, where the spasticity was expected, at different velocities. Tonic stretch reflex thresholds and their velocity modulation factor are computed, as a quantitative index of spasticity, by using the kinematics data at the onset of spasm detected through thresholding the EMG data. This technique was applied to two spinal cord injury subjects. The proposed method allowed the analysis of spasticity at muscle and joint levels. The obtained results are in line with the expert diagnosis and qualitative spasticity characterisation on each individual.

[Background]: Spasticity is a motor disorder that is commonly treated manually by a physical therapist (PhT) stretching the muscles. Recent data on learning have demonstrated the importance of human-to-human interaction in improving rehabilitation: cooperative motor behavior engages specific areas of the motor system compared with execution of a task alone., [Objectives]: We hypothesize that PhT-guided therapy that involves active collaboration with the patient (Pt) through shared biomechanical visual biofeedback (vBFB) positively impacts learning and performance by the Pt during ankle spasticity treatment. A sensorized ankle foot orthosis (AFO) was developed to provide online quantitative data of joint range of motion (ROM), angular velocity, and electromyographic activity to the PhT and Pt during the treatment of ankle spasticity., [Methods]: Randomized controlled clinical trial. Ten subacute stroke inpatients, randomized into experimental (EXP) and control (CTRL) groups, underwent six weeks of daily treatment. The EXP group was treated with an active AFO, and the CTRL group was given an inactive AFO. Spasticity, ankle ROM, ankle active and passive joint speed, and coactivation index (CI) were assessed at enrollment and after 15–30 sessions., [Results]: Spasticity and CI (p < 0.005) decreased significantly after training only in the EXP group, in association with a significant rise in active joint speed and active ROM (p < 0.05). Improvements in spasticity (p < 0.05), active joint speed (p < 0.001), and CI (p < 0.001) after treatment differed between the EXP and CTRL groups., [Conclusions]: PhT–Pt sharing of exercise information, provided by joint sensorization and vBFB, improved the efficacy of the conventional approach for treating ankle spasticity in subacute stroke Pts.

Lower limb exoskeletons (EXOs) may be devised as an ambulation device, as a rehabilitation tool or may be aimed at allowing both objectives. Regarding rehabilitation, it is worth noticing that EXOs also provide a perfect environment for precise assessing of rehabilitation protocols and effects. Different is the case of EXO for mobility, in this area the old wheelchair is still largely winning the challenge. In all functional areas: velocity, safety, portability, acceptance as well as autonomy in the ADL none of today EXOs can compete with the performances of an average wheelchair. EXO usage requires learning, and brain changes associated with tool usage introduce the human in the loop concept, a key aspect of clinical relevance for EXO usage. At present, interesting data on the biological mechanisms and rehabilitation relevance of embodiment are providing hints for guiding rehabilitation. These challenges will be presented from a clinical rehabilitation perspective and expectations and critics discussed.

This paper presents MINDWALKER, which is an ambitious EC funded research project coordinated by Space Applications Services aiming at the development of novel Brain Neural Computer Interfaces (BNCI) and robotics technologies, with the goal of obtaining a crutch-less assistive lower limbs exoskeleton, with non-invasive brain control approach as main strategy. Complementary BNCI control approaches such as arms electromyograms (EMG) are also researched. In the last phase of the project, the developed system should undergo a clinical evaluation with Spinal Cord Injured (SCI) subjects at the Fondazione Santa Lucia, Italy.

Funding. LG is supported by the EU Project “Integrative approach for the emergence of human like locomotion” (H2R; contract #600698).

The recovery of walking function is considered of extreme relevance both by patients and physicians. Consequently, in the recent years, recovery of locomotion become a major objective of new pharmacological and rehabilitative interventions. In the last decade, several pharmacological treatment and rehabilitative approaches have been initiated to enhance locomotion capacity of SCI patients. Basic science advances in regeneration of the central nervous system hold promise of further neurological and functional recovery to be studied in clinical trials. Therefore, a precise knowledge of the natural course of walking recovery after SCI and of the factors affecting the prognosis for recovery has become mandatory. In the present work we reviewed the prognostic factors for walking recovery, with particular attention paid to the clinical ones (neurological examination at admission, age, etiology gender, time course of recovery). The prognostic value of some instrumental examinations has also been reviewed. Based on these factors we suggest that a reliable prognosis for walking recovery is possible. Instrumental examinations, in particular evoked potentials could be useful to improve the prognosis.

Impairments in balance are highly predictive of functional recovery in patients with spinal cord injury (SCI) and thus merit evaluation. An objective balance evaluation can be implemented by analyzing center of pressure (COP) parameters using stabilometric platforms (SPs). Specifically, concerning subjects with SCI, no studies addressed reliability, validity, or responsiveness of this measure. The objective of the serial cross-sectional study was to analyze the reliability, validity, and responsiveness of COP parameters under various conditions in 23 incomplete SCI subjects, examined 111 times for 1 year. Each session comprised: Berg Balance scale, Tinetti and WISCI scale, stabilometry performed under various sensory conditions (open and closed feet (OF - CF); open and closed eyes (OE - CE). COP parameters analyzed (L: path length; V: velocity, VAP and VLL: anteroposterior and laterolateral velocity, A: ellipse area, SA1 and SA2: x and y-axis of A). V and arithmetically related measures had the highest reliability, validity, and effectiveness scores. Of all test conditions, OE-OF was the most valid, whereas CE-OF was the most responsive. The assessment of balance in SCI subjects can be reliable, valid, and effective on acquisition of V data, based on OF-OE and OF-CE conditions and heel distance values.

Gait Trainer (GT) and the Lokomat (Loko) are two commercial robotic devices developed for assist task-oriented, intensive practice of walking in neurological patients. Despite the many studies involving these devices, there are not specific studies comparing electromyography (EMG) activity during sessions of walking training performed using these devices. This study aimed to explore the differences in the EMG patterns between these two devices and in respect over-ground walking. EMG of eight lower limb muscles were bilaterally recorded and analyzed in one healthy subject. Thigh muscles were more active during GT-session, whereas shank muscles during Loko-session. Furthermore, decreasing the guidance assistance of Loko (i.e. the percentage of force applied by the robot in respect to that needed for following the predetermined trajectory, training), all the muscles showed an increment of the EMG signal. These results showed clear differences in muscle activation patterns between the two systems and, as expected, quite different from the pattern observed in over-ground locomotion. These results are of importance for the correct use of robotic devices in gait rehabilitation and would represent the preliminary step to address their correct use in neurologically impaired subjects.

Powered exoskeletons can empower paraplegics to stand and walk. Actively controlled hip ab/adduction (HAA) is needed for weight shift and for lateral foot placement to support dynamic balance control and to counteract disturbances in the frontal plane. Here, we describe the design, control, and preliminary evaluation of a novel exoskeleton, MINDWALKER. Besides powered hip flexion/extension and knee flexion/extension, it also has powered HAA. Each of the powered joints has a series elastic actuator, which can deliver 100 Nm torque and 1 kW power. A finite-state machine based controller provides gait assistance in both the sagittal and frontal planes. State transitions, such as stepping, can be triggered by the displacement of the Center of Mass (CoM). A novel step-width adaptation algorithm was proposed to stabilize lateral balance. We tested this exoskeleton on both healthy subjects and paraplegics. Experimental results showed that all users could successfully trigger steps by CoM displacement. The step-width adaptation algorithm could actively counteract disturbances, such as pushes. With the current implementations, stable walking without crutches has been achieved for healthy subjects but not yet for SCI paraplegics. More research and development is needed to improve the gait stability.

Although no data are available on the effects of water environment on the gait of subjects with spinal cord injury (SCI), hydrotherapy is used in the rehabilitation protocols of SCI patients. The aim of this study was to characterize gait features of subjects with incomplete SCI walking in water and on land in comparison with healthy controls (CTRLs) to identify the specificity of water environment on influencing gait in SCI subjects.This is a matched case-control study.Kinematic gait parameters and range of motion of joint angles of 15 SCI subjects and 15 CTRLs were analyzed. Compared with gait on land, gait in water of the SCI patients was characterized by speed and stance phase reduction, gait cycle time increment, and invariance of stride length and range of motion values. Comparison with CTRL data remarked that walking in water reduces gait differences between the groups. Furthermore, in water, the SCI subjects presented a reduction in variability of the hip and knee joint angles, whereas in the CTRLs, a larger variability was observed.Gait in water of the SCI subjects is associated with kinematic parameters more similar to those of the CTRLs, particularly regarding speed, stride length, and stance phase, supporting the idea that walking in a water environment may be of rehabilitative significance for SCI subjects.

Background The effects of multiple injuries on the neurological and functional outcomes of patients with traumatic spinal cord injury (SCI) are debated—some groups have shown that subjects with multiple injuries have the same neurological and functional outcomes of those without them, whereas others have found that SCI patients with associated traumatic brain injury have worse functional status at admission and discharge and longer rehabilitation stays than patients without brain injury. Thus, the aim of this study was to compare the outcomes of SCI subjects with or without multiple injuries. Methods A total of 245 patients with a traumatic SCI during the first rehabilitation stay after the development of the lesion (202 males and 43 females; age 39.8 ± 17 years; lesion to admission time 51.1 ± 58 days) were examined on a referral basis. Patients were assessed using the following measures: American Spinal Injury Association standards, Barthel Index, Rivermead Mobility Index, and Walking Index for Spinal Cord Injury. The statistical analysis comprised Poisson regression models with relative risks and 95% confidence intervals, adjusted for the following confounders: age, sex, lesion level, and ASIA impairment scale (AIS) grade. Student’s T test was used to compare the outcomes of patients divided by AIS impairment and lesion level. Results SCI patients with and without multiple injuries differed significantly with regard to the level and completeness of the lesion. Overall, patients with multiple injuries had worse functional status at admission and discharge than monotraumatic subjects. However, when adjusted for neurological features, the populations had comparable functional and neurological status at admission and discharge and similar rates of complications and discharge destinations. The separate analysis per each level of lesion/AIS grade showed that in some groups, patients with multiple injuries had a significant longer length of stay or worse functional status at rehabilitation admission (but not at discharge) than their monotraumatic counterparts. Conclusions Multiple injuries do not affect the neurological or rehabilitative prognosis of spinal cord injuries. At discharge, patients with spinal cord injuries with and without multiple injuries achieved similar results with regard to neurological and functional improvement. Some groups of patients with multiple injuries had a longer length of stay.

To calculate the clinical significance of the SCIM III according to distribution-based approaches.Retrospective review of the charts of 255 patients with registration of the total SCIM and of the four subscales. Clinical significance was calculated per several distribution-based approaches. The calculated clinical significance was compared with improvements by the patients to determine the percentage of patients who achieved significant improvement.An improvement of at least 4 points of the total SCIM is needed to obtain a small significant improvement and of 10 points to obtain a substantial improvement. Based on these results, the percentages of patients who achieved an improvement varied from 60% to 100%.The results provide benchmarks for clinicians and researchers to interpret whether patients' change score on the SCIM III can be interpreted as true or clinically meaningful and to make clinical judgments about the patients' progress.An improvement of at least four points of the total SCIM is needed to obtain a small significant improvement and of 10 points to obtain a substantial improvement. The results provide benchmarks for clinicians and researchers to interpret whether patients' change score on the SCIM III can be interpreted as true or clinically meaningful and to make clinical judgments about the patients' progress.

The modular control of movement is a popular concept in the neurophysiologic community much less among clinicians. In clinical setting, when designing a rehab protocol for a neurologically motor disabled patient residual abilities and functions, kinematic as well as muscular tone and force parameters are among the main factors taken into account, while little consideration is given to muscles co-activation patterns. Possibly, the only parameter considered is the interplay between agonist and antagonist muscles. Muscle synergies are still far from becoming an everyday clinical tool in neurorehabilitation. Goals and challenges on the road map for adding muscle synergies to the tool-box of neurorehabilitation professionals are the focus of this presentation.

During robotic assisted gait rehabilitation, give feedback to the patient has become essential to inform him/her about his/her performance, in order to motivate him/her and enhance his/her rehabilitation. We performed a study to determine if there are differences in patient’s performance receiving two different types of feedback (biomechanical and EMG based), when trained with the driven gait orthosis (DGO) Lokomat (Hocoma AG, Volketswil, Switzerland). We compared the biomechanical data (joint forces) recorded by Lokomat’s sensors during training. Preliminary findings obtained shown that different feedbacks produce meaningful biomechanical differences.