Objective: To investigate the clinical impact of robotic body weight support gait training using the ZeroG overground system in paraplegic patients with chronic spinal cord injury, assessing neurological recovery and functional improvements
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Eight paraplegic patients with chronic spinal cord injury (>1 year duration, seven complete and one incomplete) were enrolled. Clinical protocol (Walk Again Neurorehabilitation, WA-NR) was approved by local ethics committee and Brazilian federal government ethics committee. All participants signed written informed consent.
Note: Ethics approval from Associação de Assistência à Criança Deficiente, Sao Paulo (#364.027) and CONEP (CAAE: 13165913.1.0000.0085)
“Eight paraplegic patients, suffering from chronic (>1 year) spinal cord injury (SCI, seven complete and one incomplete)”
Comprehensive clinical assessments performed on Day 0 (first day of training) including ASIA Impairment Scale, Semmes-Weinstein Monofilament Test, temperature/vibration/proprioception/deep pressure sensitivity evaluation, muscle strength test, trunk control assessment, walking index, independence measurement, pain evaluation, range of motion, spasticity assessment, quality of life, self-esteem, and depression inventory.
Note: Baseline measurements before any training begins
“Such clinical evaluation started on the first day patients began training (Day 0)”
Initial training phase with patients upright and supported by stand-in-table device. Patients interact with virtual environment using 16-channel EEG to control human body avatar movements while receiving visuo-tactile feedback.
Note: Starting point of progressive complexity increase; patients imagine arm movements to modulate EEG activity for high-level motor commands
“identical interaction with the same virtual environment and BMI protocol while patients were upright, supported by a stand-in-table device”
Patients train on Lokomat robotic gait trainer (Hocoma AG, Switzerland) with integrated body weight support system on treadmill. No tactile feedback provided for this component.
Note: Component 3 of protocol; no continuous tactile feedback provided
“training on a robotic body weight support (BWS) gait system on a treadmill (Lokomat, Hocoma AG, Switzerland)”
Patients train with body weight support gait system fixed on overground track using ZeroG 19 system (Aretech LLC., Ashburn, VA). No mechanical barriers between patient and physical therapist. Requires patient to manage postural control, trunk control, upper limb strength, and dynamic balance.
Note: Component 4 of protocol; no continuous tactile feedback provided; more challenging than treadmill-based systems due to lack of mechanical constraints
“training with a BWS gait system fixed on an overground track (ZeroG, Aretech LLC., Ashburn, VA)”
Patients train with custom-built robotic exoskeleton (50-80 kg weight range, autonomous power, self-stabilization, full lower limb hydraulic actuation) controlled via EEG signals. Exoskeleton used in conjunction with ZeroG 19 overground body weight support system. Patients receive continuous tactile feedback via haptic display on forearms synchronized with robotic foot rolling.
Note: Component 6 of protocol; 12 degrees of freedom; sensorized system; requires patients to imagine leg movements to control individual stepping
“gait training with a brain-controlled, sensorized 12 degrees of freedom robotic exoskeleton”
Throughout training protocol, complexity of activities is progressively increased over time to ensure cardiovascular stability and improve postural control. Progression from orthostatic training at stand-in-table through various robotic gait training systems.
Note: Complexity increased gradually; cardiovascular function monitored before and after every activity
“the complexity of activities was increased over time to ensure cardiovascular system stability and better patient postural control; starting with orthostatic training at a stand-in-table and progressing all the way to the different gait training robotic systems”
Before and after every activity, routine general clinical evaluations performed including cardiovascular function assessment, intestinal and urinary emptying evaluation, skin inspection, and spasticity handling. Long-term osteoporosis treatment provided.
Note: Ongoing monitoring throughout entire protocol duration
“In addition to routine general clinical evaluations (i.e. cardiovascular function, intestinal and urinary emptying, skin inspection, spasticity handling), before and after every activity”
Comprehensive clinical evaluations repeated at 4, 7, 10, and 12 months using same assessment battery as baseline: ASIA Impairment Scale, Semmes-Weinstein Monofilament Test, sensory evaluations, muscle strength test (Lokomat L-force Evaluation), trunk control assessment, walking index, independence measurement, pain scales, range of motion, spasticity assessment (Lokomat L-stiff Evaluation), quality of life, self-esteem, and depression inventory.
Note: Periodic assessments to identify changes in neurological status and assess psychological/physical conditions
“were repeated after 4, 7, 10, and 12 months”
Throughout training, patients instructed to imagine movements of their own legs while EEG signals recorded from 11 scalp electrodes positioned over leg primary somatosensory and motor cortical areas. Recordings performed before and after training months to evaluate functional cortical plasticity.
Note: Longitudinal analysis of EEG recordings; 11 electrodes over leg representation areas
“patients were instructed to imagine movements of their own legs while EEG signals from 11 scalp electrodes were recorded over the leg primary somatosensory and motor cortical areas”
Independent Component Analysis (ICA) employed on EEG recordings to determine potential cortical sources (individual independent components) of novel leg representations in primary motor and somatosensory cortices and detect functional changes of these representations over time.
Note: Analysis of longitudinal EEG data to assess cortical plasticity
“Independent Component Analysis (ICA) was employed to determine potential cortical sources, represented by individual independent components (ICs), of novel leg representations in the primary motor and somatosensory cortices”
For each independent component, Event Related Spectral Perturbations (ERSPs) calculated with respect to 1-second baseline prior to event and normalized by average power across trials at each frequency. Performed before and after many months of training.
Note: Baseline period: 1 second prior to event
“we calculated for each IC the Event Related Spectral Perturbations (ERSPs) with respect to a baseline of 1 second prior to the event and normalized by the average power across trials at each frequency”
Event Related Potentials (ERPs) sampled from two EEG electrodes located over leg representation area, averaged over all patients before and after training, calculated and used for statistical comparison.
Note: Two electrodes over leg representation area; data averaged across all patients
“Event Related Potentials (ERPs), sampled from two EEG electrodes located over the leg representation area, averaged over all patients, before and after training, were also calculated and used for statistical comparison”
Eight paraplegic patients with chronic (>1 year) spinal cord injury (SCI), seven complete and one incomplete lesion