Among the lost functions, the ability to walk again is the function that the patients in need of neurological rehabilitation want to recover the most
12. The goal of neurological rehabilitation should be to stimulate the central nervous system plasticity as early as possible and in order to strengthen the natural healing process through customized therapies
13. Locomotor exercises focus on the retraining of lost motor function through the stimulation of central nervous system plasticity
14-16. Therefore, our goal is to help the formation of locomotor memory and eliminate disconnection in task-specific definitions. It is known that motor relearning is a necessary factor for stimulating central nervous system plasticity. Repetition is thought to play a major role in the central nervous system’s learning process and in retaining the learned information. However, excessive intensity of exercises or frequent repetitions of exercises alone are not enough for ideal motor learning. The administration of frequent repetitive task-specific therapies is required for stimulating central nervous system plasticity
15-17.
In patients in need of neurological rehabilitation, conventional walking exercises, body weight-assisted treadmill exercises, manual-supported or unsupported functional electrical stimulation (FES), treadmill exercise, manual support and/or walking training with FES, and walking training with robotic systems are the frequently applied methods 18,19. Among these, conventional rehabilitation methods (stretching, strengthening, balance, posture, transfer training, and joint mobility exercises) are dependent on the therapist, and these are the methods that require intensive manpower and whose gains can be measured subjectively. After many years of using conventional methods, different requirements were needed, and the adoption of new technologies has been an indispensable element in the field of medical rehabilitation. Robots developed for this purpose are multifunctional, programmable devices that carry out the specified movements to perform any task and have differences related to shape, size, and systems. Robotic systems are used in walking rehabilitation to ensure intensive, fast, and task-specific exercises are performed using rhythmic sensorial input 20.
Robotic-assisted gait training is used in the treatment of a wide range of neurological diseases. Studies related to these diseases report different results. In some studies, it has been reported that exoskeleton wearable robots are safe, tolerable, and easy to learn. It was emphasized that patients had improvements in pain, bladder-bowel function, and spasticity, and high emotional-psychosocial satisfaction was achieved 21,22. In a study by Esclarín-Ruz et al. 23 where they cate-gorized injuries as upper and lower motor neuron-related diseases, better functional results were obtained in patients in both the groups who underwent robotic therapy. It is believed that providing robotic-assisted gait training in combination with other correctly and adequately performed rehabilitation methods will prove to be beneficial. In a review by Datteri's, it was menti-oned that robotic therapy is just as effective as conventional therapy 24. As a result, it is important to provide mission-specific and high-intensity work when therapeutic robotic devices are used for rehabilitation to ensure the interactive participation and motivation of the patient, obtain feedback, perform measurements, and measure progress objectively.
In another review, 270 acute stroke, 114 chronic stroke patients were evaluated. It was reported that more improvements were observed in acute patients receiving body weight-supported treadmill exercise and robotic training. Although more improvements were observed in walking speed and distance in chronic patients than in acute patients, no difference was detected in terms of treatment methods, and it was emphasized that all treatment methods administered as a result had a potential effect 25. In a study of patients with subacute stroke, the efficacy of robotic-assisted gait therapy administered in addition to conventional treatment was analyzed, and it was determined that there was a significant improvement in Functional Ambulation Scala values of independent walking; however, it was concluded that robotic therapy had no additional advantage in timed up and go test, 10-meter walking test 26,27. In another study, they found that conventional therapy and robotic-assisted combined therapy were more effective in improving patients’ functionality and showed that this effect continued during their 2-year clinical follow-up 28.
Although there were studies on cerebral palsy in which significant improvement in rough motor functions after treatment compared to that before robotic-assisted walking therapy 29,30, Gillaux et al.31 did not find any statistically significant difference in the study, which examined the effect of upper extremity robotic rehabilitation on functional status in children with cerebral palsy. Smania et al. 32 evaluated the functional status using the Pediatric Functional Independence Scale (PFIS) before and after treatment in their study to examine the effect of robot-assisted recurrence walking exercises on walking and functional condition in children with SP, and did not find a significant increase in PFIS score.
In our study, we aimed to investigate the effectiveness of Lokomat treatment in three disease groups that most often need neurological rehabilitation. In all three patient groups, we found a statistically significant increase in walking time, distance and speed as much as the patient could tolerate at the onset and end of treatment.
Even if robotic rehabilitation systems do not show functional gain, it is reported in many studies that neurorehabilitation, which has a very long treatment period and progress is relatively slow, improves the quality of life, happiness, motivation, hope and self-confidence in the patient group, and reduces stress and pain 33.
Robotic rehabilitation in neurorehabilitation contributes a lot to the health system by requiring fewer therapists, reducing the therapist's workforce, being action-specific, providing more effective rehabilitation, reducing hospital stay time and creating more independent patients 33. Recording the parameters related to wal-king in robotic rehabilitation and thus offering the opportunity for more objective evaluation of the treatment process of patients is one of the important advantages 34. Moreover, with the virtual reality applications integrated into the system, both patient motivation is increased and frequent repetitive movements specific to the task are supported 35. In conventional methods, the experience of the therapist and the success of treatment are associated with each other, but it can also be difficult to carry out high-intensity and frequent repetition trainings 36. Although robotic rehabilitation is useful in this regard, it is difficult to talk about a completely trouble-free treatment process. In conventional treatment, spasticity and contracture are suitable for recognition and intervention by the therapist. While robotic treatment contributes better to the repetitive and high-intensity training process, the differences that may arise during the treatment process are difficult to feel due to the lack of therapist and patient contact 36,37. The robotic system must have a mechanism that can recognize and direct spasticity and contracture. The robotic system should be applicable to provide active assisted exercise or resistance to the weak muscle group of the patient and active resistant exercise options 36. Whether the robot to be selected for the patient will be an end effector or exoskeleton type is associated with the clinical condition of the patient and his ability to apply commands 35.
It is a fact that there are different results regarding the effectiveness of lokomat therapy in neurological disorders. Certain earlier reviews 38,39 compiled the available evidence on robot-assisted gait training; however, firm conclusions could not be drawn due to insufficient evidence owing to the heterogeneity of the studies, small samples, and identified limitations of the trials. Gait velocity was employed in earlier investigations to evaluate total motor function and gait recovery. Gait training in a robotic orthosis, according to Aguirre-Güemez et al. 38, showed positive impacts solely on gait performance, strength, and functioning, but not on speed. However, the 10-m walk test (10-MWT) and 6-min walk test (6-MWT) are still the most often used measures for evaluating individuals with SCI, according to the most recent review 40, as more and more research have shown that RAGT improves walking performance. However, there was a paucity of information on the most effective RAGT for enhancing locomotor results in SCI patients. Additionally, there is no research comparing overground wearable exoskeletons to conventional gait therapies, particularly for people with SCI. There is some evidence to suggest that stroke patients with more severe impairments may recover more quickly than those with less severe impairments 41. Children with CP have experienced similar outcomes 42, while these findings are debatable 43,44. Other investigations explore the relationships between responsiveness and stroke diagnostic variables 30-45,46.
The most important limitations are the retrospective nature of the study, the low number of cases, and the lack of detailed analysis based on subgroups. However, we think that our article will contribute to the literature since robotic treatment is not common, promising and there are not many studies on the subject.