Weakness of the ankle plantarflexors after a stroke results in impaired forward propulsion
during walking, which consequently impacts walking efficiency and speed - parameters that are
necessary for community participation. Next-generation soft, wearable robots, known as soft
robotic exosuits, were developed to assist paretic ankle dorsiflexion during its swing phase
and paretic ankle plantarflexion during push off. Prior observational studies of the exosuit
technology have culminated in strong evidence of immediate gait-restorative effects for
patients post-stroke through improved forward propulsion, and faster and farther walking. The
investigators posit that gait training using exosuits will leverage these immediate
gait-restorative effects to facilitate gait training at higher intensities without
compromising gait quality. This type of training will facilitate lasting rehabilitative
effects that persist beyond the use of exosuit. Leveraging a systematic approach in the
staging of pilot studies toward larger clinical trials, this clinical validation was
initiated with a single-subject study design followed by a case series, which both provided
early evidence for the potential of gait training with exosuits in restoring propulsion and
speed. As a next step, the investigators seek to examine the efficacy of these interventions
under more robust terms by implementing a randomized clinical trial (RCT).
The primary aim of the current study seeks to understand the rehabilitative effects of a
Robotic Exosuit Augmented Locomotion (REAL) gait training program relative to matched gait
training without exosuits (Control) on walking and propulsion function after stroke. It is
hypothesized that REAL training will result in clinically meaningful improvements in walking
speed that are greater than the speed gains following Control training. Further, this study
seeks to examine whether training-related changes in propulsion function following both
interventions (REAL, Control) influence the training-induced effects on walking function. The
investigators hypothesize that REAL training will result in substantial gains in walking
function that are achieved through improved propulsion function, while Control training will
have modest gains in walking function that are not related to changes in propulsion.
A secondary aim of this study is to evaluate single day changes in neuromuscular control
following both interventions (REAL, Control), as measured by muscle synergies and the dynamic
motor control index. The investigators hypothesize that neuromuscular control will
immediately improve during powered use of a soft-robotic exosuit (i.e., immediate) and
exosuit-induced improvements in neuromuscular control will show continued improvement over a
single session of REAL gait training (i.e., adaptation), and persisting improvement to
unassisted walking after a single session of REAL gait training (i.e., retention). In
contrast, the Control training will show no changes in neuromuscular control. An additional
secondary aim is to identify neuromuscular predictors of training-related improvements in
walking and propulsion function. It is hypothesized that positive relationships will be
observed between single-day changes in neuromuscular control and training-induced
improvements in walking and propulsion function after 12 sessions of gait training. Moreover,
the investigators hypothesize that regardless of baseline walking speed, individuals with
higher baseline neuromuscular control will have the greatest training-induced improvements in
propulsion and walking function after 12 sessions of gait training.
For this protocol, exosuits developed in collaboration with an industry partner (ReWalk™
Robotics) will be used. To examine the effects of REAL gait training, the investigators will
use clinical measures of motor and gait function, locomotor mechanics, and physiologic
measures that may infer on motor learning. The spectrum of behavioral and physiologic data
that will be collected will enable a more comprehensive understanding of the gait-restorative
effects of REAL.
This study will be implemented by carrying out the following study visits: (1) Primary screen
over the phone, (2) Clinical screen & fit, (3) Exposure, (4) Pre-training evaluations, (5)
Training (12 sessions)(6) Post-training evaluation, and (7) Retention evaluation.
Randomization to either REAL or Control will occur after Pre-training evaluation. A washout
period up to 4 weeks will precede Retention evaluation.
