Research Article| Volume 29, ISSUE 6, 104758, June 2020

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Augmented Performance Feedback during Robotic Gait Therapy Results in Moderate Intensity Cardiovascular Exercise in Subacute Stroke



      Low cardiovascular fitness is common poststroke. Conventional subacute stroke rehabilitation does not meet Australian National Stroke Guidelines for cardiovascular exercise, particularly in mobility-dependent patients. Walking robotics can potentially achieve recommended cardiovascular exercise with these patients.


      The primary aim was to determine whether sustained moderate intensity cardiovascular exercise can be achieved using 3 Lokomat Augmented Performance Feedback activities in mobility-dependent adults with subacute stroke. Secondary aims were to assess if cardiovascular workload was influenced by the activity completed, participants motivation or enjoyment, or changes in Lokomat settings.


      Ten patients with subacute stroke (mean (SD) age: 63.4 (13) years) participated in 6x20-minute Lokomat study sessions. Each study session involved a warm-up and 3x5-minute APF activities presented in a random order. Metabolic data were collected using the COSMED-K5. Participants rated their perceived exertion on the BORG CR10 scale and Lokomat settings of body-weight support, guidance force, and speed were recorded.


      Moderate intensity cardiovascular exercise was achieved and maintained over the 15 minutes of exercise, objectively demonstrated by a mean (SD) Metabolic Equivalent Task of 3.1 (1.3), and mean (SD) oxygen consumption of 8.0 (3.8) ml/kg/min, estimated as 52% VO2max. This was subjectively confirmed by exertion scores between 3 and 5. The cardiovascular workload was not affected by which activity was completed, participant motivation or enjoyment, or significant progression of Lokomat settings between study sessions.


      Mobility-dependent patients with subacute stroke can achieve sustained moderate intensity cardiovascular exercise on the Lokomat when using APF activities.


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      1. Australian Institute of Health and Welfare 2016. Australia's health 2016. Australia's Health Series No. 15. Cat. No. AUS 199. Canberra: AIHW.

        • Australasian Rehabilitation Outcomes Centre
        AROC impairment specific report on stroke (inpatient - pathway 3), January 2016 - December 2016.
        Australasian Rehabilitation Outcomes Centre, 2017 (Anywhere Hospital; 2017)
        • Smith A.C.
        • Saunders D.H.
        • Mead G.
        Cardiorespiratory fitness after stroke: a systematic review.
        Int J Stroke. 2012; 7: 499-510
        • Barclay R.
        • Ripat J.
        • Mayo N.
        Factors describing community ambulation after stroke: a mixed-methods study.
        Clin Rehabil. 2015; 29: 509-521
        • Delussu A.S.
        • Morone G.
        • Iosa M.
        • et al.
        Physiological responses and energy cost of walking on the Gait Trainer with and without body weight support in subacute stroke patients.
        J Neuroeng Rehab. 2014; 11: 54
        • Michael K.M.
        • Allen J.K.
        • Macko R.F.
        Reduced ambulatory activity after stroke: the role of balance, gait, and cardiovascular fitness.
        Arch Phys Med Rehabil. 2005; 86: 1552-1556
        • Shephard R.J.
        Maximal oxygen intake and independence in old age.
        Br J Sports Med. 2009; 43: 342-346
        • Marsden D.L.
        • Dunn A.
        • Callister R.
        • et al.
        Characteristics of exercise training interventions to improve cardiorespiratory fitness after stroke: a systematic review with meta-analysis.
        Neurorehabil Neural Repair. 2013; 27: 775-788
        • Stroke Foundation
        Clinical guidelines for stroke management.
        2017 (Melbourne Australia)
        • Billinger S.A.
        • Arena R.
        • Bernhardt J.
        • et al.
        Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association.
        Stroke. 2014; 45: 2532-2553
        • Pescatello L.S.
        • Arena R.
        • Riebe D.
        American College of Sports Medicine.
        ACSM's guidelines for exercise testing and prescription. 9th ed. Wolters Kluwer/Lippincott Williams & Wilkins Health, Philadelphia (PA)2014
        • Norton K.
        • Norton L.
        • Sadgrove D.
        Position statement on physical activity and exercise intensity terminology.
        J Sci Med Sport. 2010; 13: 496-502
        • Kaur G.
        • English C.
        • Hillier S.
        How physically active are people with stroke in physiotherapy sessions aimed at improving motor function? A systematic review.
        Stroke Res Treat. 2012; 2012 ( 820673
        • Prajapati S.K.
        • Mansfield A.
        • Gage W.H.
        • et al.
        Cardiovascular responses associated with daily walking in subacute stroke.
        Stroke Res Treat. 2013; 2013: 612458
        • Billinger S.A.
        • Mattlage A.E.
        • Ashenden A.L.
        • et al.
        Aerobic exercise in subacute stroke improves cardiovascular health and physical performance.
        J Neurol Phys Ther. 2012; 36: 159-165
        • Lefeber N.
        • Swinnen E.
        • Kerckhofs E.
        The immediate effects of robot-assistance on energy consumption and cardiorespiratory load during walking compared to walking without robot-assistance: a systematic review.
        Disabil Rehabil Assist Technol. 2017; 12: 657-671
        • Stoller O.
        • de Bruin E.D.
        • Schindelholz M.
        • et al.
        Efficacy of feedback-controlled robotics-assisted treadmill exercise to improve cardiovascular fitness early after stroke: a randomized controlled pilot trial.
        J Neurol Phys Ther. 2015; 39: 156-165
        • Sandberg K.
        • Kleist M.
        • Falk L.
        • et al.
        Effects of twice-weekly intense aerobic exercise in early subacute stroke: a randomized controlled trial.
        Arch Phys Med Rehabil. 2016; 97: 1244-1253
        • Saunders D.H.
        • Sanderson M.
        • Brazzelli M.
        • et al.
        Physical fitness training for stroke patients.
        Cochrane Database Syst Rev. 2013; (CD003316)
        • Mehrholz J.
        • Thomas S.
        • Werner C.
        • et al.
        Electromechanical‐assisted training for walking after stroke.
        Cochrane Database of Systematic Reviews, 2017 (CD006185)
        • Schindelholz M.
        • Stoller O.
        • Hunt K.J.
        A software module for cardiovascular rehabilitation in robotics-assisted treadmill exercise.
        Biomed Signal Process Control. 2014; 10: 296-307
        • Stoller O.
        • de Bruin E.D.
        • Schindelholz M.
        • et al.
        Evaluation of exercise capacity after severe stroke using robotics-assisted treadmill exercise: a proof-of-concept study.
        Technol Health Care. 2013; 21: 157-166
        • van Nunen M.P.M.
        • Gerrits K.H.L.
        • de Haan A.
        • et al.
        Exercise intensity of robot-assisted walking versus overground walking in nonambulatory stroke patients.
        J Rehab Res Dev. 2012; 49: 1537
        • Chang W.H.
        • Kim M.S.
        • Huh J.P.
        • et al.
        Effects of robot-assisted gait training on cardiopulmonary fitness in subacute stroke patients: a randomized controlled study.
        Neurorehabil Neural Repair. 2012; 26: 318-324
        • David D.
        • Regnaux J.P.
        • Lejaille M.
        • et al.
        Oxygen consumption during machine-assisted and unassisted walking: a pilot study in hemiplegic and healthy humans.
        Arch Phys Med Rehabil. 2006; 87: 482-489
        • Lefeber N.
        • De Keersmaecker E.
        • Henderix S.
        • et al.
        Physiological responses and perceived exertion during robot-assisted and body weight–supported gait after stroke.
        Neurorehabil Neural Repair. 2018; 32: 1043-1054
        • Stoller O.
        • de Bruin E.D.
        • Schindelholz M.
        • et al.
        Cardiopulmonary exercise testing early after stroke using feedback-controlled robotics-assisted treadmill exercise: test-retest reliability and repeatability.
        J Neuroeng Rehabil. 2014; 11: 145
        • Stoller O.
        • Schindelholz M.
        • Bichsel L.
        • et al.
        Feedback-controlled robotics-assisted treadmill exercise to assess and influence aerobic capacity early after stroke: a proof-of-concept study.
        Disabil Rehabil Assist Technol. 2014; 9: 271-278
        • Riener R.
        • Lünenburger L.
        • Maier I.C.
        • et al.
        Locomotor training in subjects with sensori-motor deficits: an overview of the robotic gait orthosis lokomat.
        J Healthc Eng. 2010; 1: 197-216
        • Koenig A.
        • Omlin X.
        • Bergmann J.
        • et al.
        Controlling patient participation during robot-assisted gait training.
        J Neuroeng Rehabil. 2011; 8: 14
        • Stookey A.D.
        • McCusker M.G.
        • Sorkin J.D.
        • et al.
        Test-retest reliability of portable metabolic monitoring after disabling stroke.
        Neurorehabil Neural Repair. 2013; 27: 872-877
        • Borg E.
        • Kaijser L.
        A comparison between three rating scales for perceived exertion and two different work tests.
        Scand J Med Sci Sports. 2006; 16: 57-69
        • Pageaux B.
        Perception of effort in exercise science: definition, measurement and perspectives.
        Eur J Sport Sci. 2016; 16: 885-894
        • Sage M.
        • Middleton L.E.
        • Tang A.
        • et al.
        Validity of rating of perceived exertion ranges in individuals in the subacute stage of stroke recovery.
        Top Stroke Rehabil. 2013; 20: 519-527
        • Kwan M.
        • Woo J.
        • Kwok T.
        The standard oxygen consumption value equivalent to one metabolic equivalent (3.5 ml/min/kg) is not appropriate for elderly people.
        Int J Food Sci Nutr. 2004; 55: 179-182
        • Krewer C.
        • Muller F.
        • Husemann B.
        • et al.
        The influence of different Lokomat walking conditions on the energy expenditure of hemiparetic patients and healthy subjects.
        Gait Posture. 2007; 26: 372-377
        • Riedo J.
        • Hunt K.J.
        Feedback control of oxygen uptake during robotics-assisted end-effector-based stair climbing.
        Syst Sci Control Eng. 2017; 5: 142-155
        • Borg G.A.
        Psychophysical bases of perceived exertion.
        Med Sci Sports Exerc. 1982; 14: 377-381
        • Lunenburger L.
        • Colombo G.
        • Riener R.
        • Dietz V.
        Biofeedback in gait training with the robotic orthosis Lokomat.
        in: Engineering in Medicine and Biology Society, 2004 IEMBS'04 26th annual international conference of the IEEE. 2004
        • Banz R.
        • Bolliger M.
        • Colombo G.
        • et al.
        Computerized visual feedback: an adjunct to robotic-assisted gait training.
        Phys Therapy. 2008; 88: 1135-1145
        • Macko R.F.
        • Smith G.V.
        • Dobrovolny C.L.
        • et al.
        Treadmill training improves fitness reserve in chronic stroke patients.
        Arch Phys Med Rehabil. 2001; 82: 879-884