ZeroG is an FDA-listed robotic body weight support system (BWSS). Mounted on an overhead track, patients are fitted in a harness system tethered to said track, and are able to practice gait and balance activities without the risk of falling. This compensates for ineffective postural control permitting intensive therapy sessions earlier in recovery. The purpose of this study is to determine if inducing effective and safe balance perturbations during standing and walking in the BWSS more effectively improve postural control than the BWSS without perturbations. The target population are those patients in the post-acute phase of stroke admitted for inpatient rehabilitation of balance impairments. Site investigators and/or research staff will obtain names of potential subjects from internal reporting identifying inpatients who may qualify for the study based on the inclusion criteria. Trained site investigators will meet with potential subjects to explain the study, complete a screening interview for exclusion and inclusion criteria, answer any questions, obtain informed consent and HIPAA authorization, and schedule the study therapy sessions involving the protocol. Based on the randomization scheme provided by the lead site, consented subjects will be randomized to either the BWSS with perturbations (BWSS-P) or standard BWSS control without perturbations. Subjects will perform 2 to 6 sessions in their designated intervention using a structured protocol for each session. To compare differences between treatment groups, outcome measures will be collected at baseline before any BWSS sessions are performed and within 48 hours after completing the final treatment session.
Each year, more than 795,000 people experience a stroke. Stroke, or cerebral vascular accident, is a devastating neurological event that can lead to physical and cognitive deficits, such as the inability to ambulate, impaired balance regulation, loss of coordination, and impaired communication. Due to the physical and cognitive deficits experienced following a stroke, many require admission to an inpatient rehabilitation facility with the goal of maximizing their independence before returning to the home setting. Gait and balance dysfunction are common secondary impairments to stroke, usually requiring specific rehabilitative interventions. Following a stroke, motion analysis has observed patients navigating obstacles more conservatively and with abnormal gait patterns. One associated factor is the loss of muscle-strength secondary to stroke, which could increase the risk of falling. Within six-months of discharge, falls occur in up to 70% of patients post-stroke, highlighting the importance and urgency to improve patients' balance and gait during the rehabilitation phase. As patients may better understand their capabilities/limitation than what the physical tests demonstrate, patient self-assessments can be important indicators of fall risk. In fact, it is estimated that over 90% of stroke survivors would report that the fear of falling negatively impacts their performance of daily living activities. Fear of falling has been shown to influence balance and gait control in older adults, supporting the theory that balance and gait should be taken into account during rehabilitative methods. These psychological factors are strong predictors of falling compared to physical factors or the presence of pathology. Patient self-assessments are important indicators of fall risk, as patients may understand their capabilities/limitation better than what physical tests can demonstrate. The ability to walk, stand, and climb stairs are examples of mobility-related functional tasks that are critical for achieving functional independence. With those with stroke related balance and gait impairments, early and frequent balance and gait training are essential to maximizing functional ability and independence. However, it is often difficult for post-stroke patients with these impairments to safely undergo the necessary balance and gait training without putting both therapists and patients at risk for injury. It is also reasonable to suspect that any injurious falls that occur during rehabilitation would reinforce, or create, a psychological fear of falling that would impede the recovery of the patient. Furthermore, injurious falls can prolong a patient's length of stay, increasing the economic and financial strain both to the individual and their family as the patient is out work. Any falls, but especially injurious falls, can also increase the financial burden of an institution. In some cases, patients need to be carefully examined and imaged to confirm the presence or absence of injury. If the necessary imaging equipment isn't available, a patient may need to be taken to an outside location or even emergently transferred. Improving a patient's gait and balance earlier in their stay may also prevent other injurious falls outside of therapy as well. It could also improve a patient's fall risk, meaning that resources, such as safety sitters, can be minimized, further improving the financial burden of the institution. These benefits can be achieved, in part, by focusing on and improving a patient's balance and gait status. Incorporating robotic technologies to neurological rehabilitation can play a critical role in delivering safe and effective gait and balance therapy sooner in a patient's stay. Body-weight support systems (BWSS) are either stationary or track-mounted suspended-harnesses that support a patient's body-weight. This permits those with significant weakness and poor coordination to ambulate and perform more intensive therapy sessions sooner in their recovery, with minimal risk of injurious fall. In addition to BWSSs, balance perturbation systems have been used to improve gait and balance-control after stroke, or other age and disease related balance impairments. Balance perturbation systems purposefully unbalance patients in order to rehabilitate their postural control. Conventional balance perturbation training, including modified treadmills, tilt-tables, or external force provided by the therapist directly, can pose an injury risk to the therapist and the patient. While incorporation of stationary BWSSs over modified treadmills can decrease the injury risk, ambulation over treadmills is not typically representative of a patients' functional ambulation in their home environment. Systems such as these may also limit the participation of patients who would otherwise benefit from balance perturbation training, but are uncomfortable or unable to ambulate on a treadmill. Direct integration of the balance perturbation modules to the BWSS can resolve many of these issues. The goal of this multisite study is to build upon a recent pilot study and further evaluate the efficacy of this newly developed BWSS integrated balance perturbation system in rehabilitating patient gait and balance after stroke, compared to standard BWSS training without perturbations. In the pilot study, 32 participants were recruited, half of whom were unbalanced during stationary and ambulatory activities to train their balance-control and balance-reactions. Both the BWSS and BWSS with perturbation groups demonstrated significant improvements in balance-related confidence and balance performance outcome measures (Berg Balance Scale) in comparison to both their baseline and a historic control. However, when compared to the BWSS control, the outcomes of the BWSS-P group only trended in the predicted positive direction, and were not significantly different. The investigators believe this was, in part, due to the small sample size and variation in timing of the post-assessment Berg Balance scales. It is hypothesized that by increasing the sample size to achieve the appropriate power for the effect size observed in the pilot study, the BWSS with balance perturbation intervention will improve patient outcomes more than the BWSS treatment alone. Further, with the data collected from the larger sample size, it is proposed to conduct correlative analysis to determine what, if any, variables influence participant response to treatment. To address these hypotheses, these are the proposed research aims: Research Aim 1: Conduct an unblinded multisite randomized-control trial to evaluate the effectiveness and appropriate dose requirements of a track-mounted BWSS perturbation module to improve balance and gait impairments in patients receiving inpatient rehabilitation services for stroke with a BBS score ≥21/56 (n=214). Hypothesis: Post-intervention balance and gait assessments will show that BWSS-P participants improved more than participants receiving BWSS alone. Research Aim 2: Conduct post hoc correlative analyses to identify what affect participant variability, such as differences in stroke lesion laterality/location, age, sex, number of BWSS sessions, and time since stroke, may have on participant response to treatment. Hypothesis: Participant specific variables will impact the efficacy and participant response to treatment.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
114
Participants will complete the physical therapy exercises as described previously, without experiencing, therapist induced, balance perturbations.
Participants will complete the physical therapy exercises as described previously, while experiencing intermittent, therapist induced, balance perturbations aimed at training the participant's balance-control and balance-reactions. With the ZeroG BWSS integrated TRiP module, therapist's are able to induce safe lateral, anterior, or posterior perturbations via a Wi-Fi-enabled handheld device. The force, or level, of perturbation can be adjusted from 1 (least amount of force) up to 10 (highest amount of force) using the same handheld device,
Gaylord Hospital
Wallingford, Connecticut, United States
MedStar National Rehabilitation Hospital
Washington D.C., District of Columbia, United States
Spaulding Rehabilitation Hospital
Sandwich, Massachusetts, United States
Providence St. Luke's Rehabilitation Medical Center
Spokane, Washington, United States
Berg Balance Scale Pre-intervention Assessment Scores
The Berg Balance Scale is a standardized objective measure of a subject/participant's balance. It is scored on a scale of 0 to 56, with 56 being the best score possible.
Time frame: Baseline (within 72 hours of admission)
Berg Balance Scale Post-intervention Assessment Scores
The Berg Balance Scale is a standardized objective measure of a subject/participant's balance. It is scored on a scale of 0 to 56, with 56 being the best score possible.
Time frame: The post-assessment BBS will be collected within 48 hours of the last study session or discharge from the health system, on average, 17 days.
Difference in Berg Balance Scale Pre-Intervention and Post-Intervention Assessment Scores
The Berg Balance Scale is a standardized objective measure of a subject/participant's balance. It is scored on a scale of 0 to 56, with 56 being the best score possible. Admission and discharge Berg scores are collected from a chart review within 48 hours of participant discharge. The change in Berg score is calculated by subtracting the participants admission or pre-assessment score from their discharge or post-assessment score: (Post assessment)-(Pre assessment)
Time frame: The baseline pre-assessment BBS score will be collected within 72 hours of admission, as part of their normal care. The post-assessment will be collected within 48 hours of the last study session or discharge from the health system, on average, 17 days.
Activities Specific Balance Scale (ABC) Pre-intervention Scores
The ABC scale is a 16-item patient reported outcome measure that subjectively measures ones self-perceived balance-confidence. The ABC achieves this by asking the user to consider various hypothetical situations and tasks and if the participants could perform the tasks without losing balance or experiencing a sense of unsteadiness; it is based on a rating scale from 0% (no confidence) to 100% (completely confident).
Time frame: The pre-assessment ABC Scale will be collected within 48 hours of the first study session.
Activities Specific Balance Scale (ABC) Post-intervention Scores
The ABC scale is a 16-item patient reported outcome measure that subjectively measures ones self-perceived balance-confidence. The ABC achieves this by asking the user to consider various hypothetical situations and tasks and if the participants could perform the tasks without losing balance or experiencing a sense of unsteadiness; it is based on a rating scale from 0% (no confidence) to 100% (completely confident).
Time frame: The post-assessment ABC Scale will be collected within 48 hours of the last study session or discharge from the health system, on average, 17 days.
Difference in Activities-Specific Balance Confidence (ABC) Scale Score Change
The ABC scale is a 16-item patient reported outcome measure that subjectively measures ones self-perceived balance-confidence. The ABC achieves this by asking the user to consider various hypothetical situations and tasks and if the participants could perform the tasks without losing balance or experiencing a sense of unsteadiness; it is based on a rating scale from 0% (no confidence) to 100% (completely confident).
Time frame: The pre-assessment ABC Scale will be conducted within 48 hours prior to the first study session. The post-assessment ABC scale will be collected within 48 hours of the last study session or discharge from the health system, on average, 17 days.
10 Meter Walk Test (10MWT) Pre-intervention Scores
The 10MWT is used to assess walking speed in meters/second (m/s) over 10 meters (m). The time is started when any part of the leading foot crosses the plane of the 2 m mark. Time is stopped when any part of the leading foot crosses the plane of the 8 m mark. The total time taken to ambulate the central 6 m is recorded to the nearest hundredth of a second. 6 m is then divided by the total time and recorded in m/s (the faster the participant traverses 6 meters the better).
Time frame: The pre-assessment 10MWT will be conducted by site investigators within 48 hours prior to the first study session.
10 Meter Walk Test (10MWT) Post-intervention Scores
The 10MWT is used to assess walking speed in meters/second (m/s) over 10 meters (m). The time is started when any part of the leading foot crosses the plane of the 2 m mark. Time is stopped when any part of the leading foot crosses the plane of the 8 m mark. The total time taken to ambulate the central 6 m is recorded to the nearest hundredth of a second. 6 m is then divided by the total time and recorded in m/s (the faster the participant traverses 6 meters the better).
Time frame: The post-assessment 10MWT will be collected within 48 hours of the last study session or discharge from the health system, on average, 17 days.
Difference in 10 Meter Walk Test (10MWT) Pre-Intervention and Post-Intervention Assessment Scores
The 10MWT is used to assess walking speed in meters/second (m/s) over 10 meters (m). The time is started when any part of the leading foot crosses the plane of the 2 m mark. Time is stopped when any part of the leading foot crosses the plane of the 8 m mark. The total time taken to ambulate the central 6 m is recorded to the nearest hundredth of a second. 6 m is then divided by the total time and recorded in m/s (the faster the participant traverses 6 meters the better). The change in 10MWT score is calculated by subtracting the participants admission or pre-assessment score from their discharge or post-assessment score: (Post assessment)-(Pre assessment)
Time frame: The pre-assessment 10MWT will be conducted within 48 hours prior to the first study session. The post-assessment 10MWT will be collected within 48 hours of the last study session or discharge from the health system, on average, 17 days.
Pre-Intervention Mobility Admission Z-Scores
The CARE Item Set and Patient Assessment Instrument measure the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. The CARE Item Set and Patient Assessment Instrument are designed to standardize assessment of patients' medical, functional, cognitive, and social support status across acute and post-acute settings.) These two outcomes measure the same concept, but across different healthcare institutions, so a z-score transformation was used. This outcome looked at total mobility score. The Z-score was calculated by taking the raw score, subtracting the population mean of pre- and post-intervention scores, and dividing it by the population standard deviation. A Z-score of 0 represents the population mean. A higher score represents a better score than the mean of the population, and a negative score represents a lower score than the mean of the population.
Time frame: Baseline (within 72 hours of admission).
Post-Intervention Mobility Discharge Z-Scores
The CARE Item Set and Patient Assessment Instrument measure the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. The CARE Item Set and Patient Assessment Instrument are designed to standardize assessment of patients' medical, functional, cognitive, and social support status across acute and post-acute settings.) These two outcomes measure the same concept, but across different healthcare institutions, so a z-score transformation was used. This outcome looked at total mobility score. The Z-score was calculated by taking the raw score, subtracting the population mean of pre- and post-intervention scores, and dividing it by the population standard deviation. A Z-score of 0 represents the population mean. A higher score represents a better score than the mean of the population, and a negative score represents a lower score than the mean of the population.
Time frame: The post-intervention mobility discharge scores will be collected within 48 hours before discharge from the health system, on average, 17 days.
Difference in Pre-Intervention and Post-Intervention Mobility Admission and Discharge Z-Scores
The CARE Item Set and Patient Assessment Instrument measure the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. The CARE Item Set and Patient Assessment Instrument are designed to standardize assessment of patients' medical, functional, cognitive, and social support status across acute and post-acute settings.) These two outcomes measure the same concept, but across different healthcare institutions, so a z-score transformation was used. This outcome looked at total mobility score. The Z-score was calculated by taking the raw score, subtracting the population mean of pre- and post-intervention scores, and dividing it by the population standard deviation. A Z-score of 0 represents the population mean. A higher score represents a better score than the mean of the population, and a negative score represents a lower score than the mean of the population.
Time frame: Baseline (within 72 hours of admission), and Post-intervention (within 48 hours of discharge from the health system, on average, 17 days).
Pre-Intervention Self-Care Admission Z-Scores
The CARE Item Set and Patient Assessment Instrument measure the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. The CARE Item Set and Patient Assessment Instrument are designed to standardize assessment of patients' medical, functional, cognitive, and social support status across acute and post-acute settings.) These two outcomes measure the same concept, but across different healthcare institutions, so a z-score transformation was used. This outcome looked at total Self-Care score. The Z-score was calculated by taking the raw score, subtracting the population mean of pre- and post-intervention scores, and dividing it by the population standard deviation. A Z-score of 0 represents the population mean. A higher score represents a better score than the mean of the population, and a negative score represents a lower score than the mean of the population.
Time frame: Baseline (within 72 hours of admission).
Post-Intervention Self-Care Discharge Z-Scores
The CARE Item Set and Patient Assessment Instrument measure the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. The CARE Item Set and Patient Assessment Instrument are designed to standardize assessment of patients' medical, functional, cognitive, and social support status across acute and post-acute settings.) These two outcomes measure the same concept, but across different healthcare institutions, so a z-score transformation was used. This outcome looked at total Self-Care score. The Z-score was calculated by taking the raw score, subtracting the population mean of pre- and post-intervention scores, and dividing it by the population standard deviation. A Z-score of 0 represents the population mean. A higher score represents a better score than the mean of the population, and a negative score represents a lower score than the mean of the population.
Time frame: The post-intervention self-care discharge scores will be collected within 48 hours before discharge from the health system, on average, 17 days.
Difference in Pre-Intervention and Post-Intervention Self-Care Admission and Discharge Z-Scores
The CARE Item Set and Patient Assessment Instrument measure the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. The CARE Item Set and Patient Assessment Instrument are designed to standardize assessment of patients' medical, functional, cognitive, and social support status across acute and post-acute settings.) These two outcomes measure the same concept, but across different healthcare institutions, so a z-score transformation was used. This outcome looked at total Self-Care score. The Z-score was calculated by taking the raw score, subtracting the population mean of pre- and post-intervention scores, and dividing it by the population standard deviation. A Z-score of 0 represents the population mean. A higher score represents a better score than the mean of the population, and a negative score represents a lower score than the mean of the population.
Time frame: Baseline (within 72 hours of admission), and Post-intervention (within 48 hours of discharge from the health system, on average, 17 days).
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