EFFECT OF ROBOTIC TILT TABLE VERS US CONVENTIONAL EXERCIS ES ON REHABILITATION OUTCOME IN STROKE PATIENTS: A FOLLOW UP STUDY

Suraj Kumar 1 , Ramakant Yadav 2 and Aafreen 3 . 1. Associate Professor and Head, Department of Physiotherapy, UPUMS, Saifai, Etawah, UP, India . 2. Professor and Head, Department of Neurology, UPUMS, Saifai, Etawah, UP, India . 3. Senior Research Fellow, Department of Physiotherapy, UPUMS, Saifai, Etawah, UP, India . ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 09 September 2018 Final Accepted: 11 October 2018 Published: November 2018

The subjects were randomized into two groups by lottery method (Kumar S et al., 2009), Group A for Conventional physiotherapy and Group B for Robotic t ilt-table rehabilitation. The clin ical demographic characteristics were reported (age, height, weight, systolic and diastolic blood pressure). Both treatments were given as individual treatment by same physiotherapist with same intensity and capacity on 30 regular days (except Sunday) and reassessment was done after 30 days and 90 days. The subjects were also informed about the experimental risks, if any. The duration of each individual treatment session was about 50 to 60 minutes per day. All subjects were allo wed to take treatment for their comorbid condition like hypertension, dyslipidemia, hypothyroidism, cardiac problem in both the conditions under supervision of Neurologist. No other treat ment will be allo wed other than mention above.

Apparatus
The Erigo is a tilt table with integrated leg drives and can be tilted between 0°-80°. It supports and facilitates the mobilization of bed-bound patients, thus contributing to the prophylaxis of secondary complications caused by a prolonged period of immobility. The Erigo allows patients to be placed in a vertical position, while the patient' s legs are moved in a physiological movement pattern and have a load applied to them.

Trai ning protocols Conventi onal physiotherapy (Group A)
All the exercises were done for 10 repetition, 2 sets with 10 seconds hold ones in a day under the supervision of physiotherapist which includes following: 1. Full range of motion (ROM) exercisespassive and active assisted range of motion exercises for upper limb included shoulder (flexion, extension, abduction and adduction), elbow (flexion and extension), forearm (supination and pronation), wrist (flexion, extension, radial and ulnar deviation), and for lower limb included hip (flexion, extension, abduction and adduction), knee (flexion and extension), ankle (dorsiflexion, planterflexion, eversion and inversion). 2. To prevent spasticity -Positioning of the limb, quick icing, brushing, gentle stroking, and gentle tapping. 3. The common mat activities include turning from supine to side-lying to prone and vice versa, prone to prone on elbow, prone on elbow to prone on hand; prone on hand to quadripud; quadripud to kneeling; kneeling to half kneeling; half kneeling to standing with support; standing with support to the standing withou t support. 4. Bridging exercises. 5. Prolonged and gradually progressive stretching of hamstring, calf and wrist. 6. Strengthening exercises included isometrics of back, quadriceps, grip ing exercises. 7. The gentle and controlled weight bearing exercises. 8. Balance and coordination exercises.

Robotic tilt-table therapy (Group B )
Robotic tilt-table therapy was ad min istered according to the following protocol. Pat ient received treat ment session of 40 minutes, 6 times per week (Janice J Eng et al., 2001) for about 4 weeks (Ben M et al., 2005). The National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS) is a tool used by healthcare providers to objectively quantify the impairment caused by a stroke. The NIHSS is composed of 11 items, each of wh ich scores a specific ability between a 0 and 4. For each item, a score of 0 typically indicates normal function in that specific ability, while a h igher score is indicative of some level of impairment. The individual scores fro m each item are summed in order to calculate a patient's total NIHSS score. The maximu m possible score is 42, with the minimu m score being a 0 (W illiams L S et al., 2000).
The Mini-Mental State Examination (MMSE) or Folstein test is a 30-point questionnaire that is used extensively in clin ical and research settings to measure cognitive impairment. Administration of the test takes between 5 and 10 minutes and examines functions including registration (repeating named pro mpts), attention and calculation, recall, language, ability to follow simp le co mmands and orientation. Any score greater than or equal to 24 points (out of 30) indicates a normal cognition. Below this, scores can indicate severe (≤9 points), moderate (10-18 points) or mild (19-23 points) cognitive impairment (Zwecker M et al., 2002).
The Modified Ashworth Scale is a 6-point rat ing scale that is used to measure muscle tone with rat ings from 0 indicating no increase in tone to 5 indicating limb rigid in flexion or extension (Gregson J M et al., 1999) Statistical Analysis:-One way repeated measures ANOVA, with treatments as a between subjects variable (CONV vs. Tilt Table) and time as a repeated measures variable (baseline vs. fo llo w-up) was used to analyse theoutcome variables. MS EXCEL (MS Office 97-2013) was used for the analysis. Probability (P) value between 0.05 (P <0.05) & 0.01 was considered statistically significant; P <0.01 as highly significant and P >0.05 had no significance (ns).   Table 2 shows the Independent t-test for between group comparisons of the baseline data, that there was no significant difference between the baseline scores. It shows that both the groups (robotic tilt table and conventional physiotherapy) were homogenous at baseline and there was very little possibility that the any improvement/deterioration in the scores with time could be due to group characteristics.

Discussion:-
This study hypothesized that the exercise by robotic tilt table will be beneficial than the conventional physiotherapy in imp roving the rehabilitation outcomes in acute stroke patients was found to be true.
Thisstudy emphasises that the performance of the Conventional Physiotherapy group and Robotic tilt table therapy group shows imp roved for all variables with time. It was also found in a study ERIGO training could be a valuable tool for the adaptation to the vertical position with a better global function improvement, as also suggested by the sensory-motor and vestibular system plasticity induction in post-stroke patients (Calabro R et al., 2015).
Rehabilitation on a tilt-table has been reported to be a useful way to mobilize severely impaired or non -cooperating patients, since it improves circulation, prevents contractures, and increases pulmonary ventilation (Chang AT et  In our study it was found that in "0 versus 30 days" comparison all variables imp roved in both the groups but robotic tilt table group shown higher improvement in all the variables except muscle strength of upper limb. Whereas, it has been suggested that verticalizat ion (VT) may play a role in stimulating cortical areas involved in trunk and lower limb control, so that deafferentation and learned non-use can be contrasted (Pittaccio S et al., 2013). VT may actively contribute to enhance cognitive performances through an increase in cerebral blood flow with a consequent induction of cortical plasticity, especially in frontal lobes (Reinstrup P et al., 1994). Robotic verticalizat ion inc lude increased ventilation, increased arousal, imp roved weight bearing of the lower limbs, and facilitation of antigravity exercise of the limbs (Dean E and Ross J. 1992).
For "30 th day versus 90 th day comparison" all variables improved in both the groups except Ashworth scores. It could be the reason that exercises prevent developing or reducing spasticity. The study also suggested that the two primary physical treatments applied to patients with involuntary muscle contractions have been described are electrical stimulat ion and long-term stretch. When applied to the ankle plantar flexo r muscles, the benefits of longterm stretch, seem to be augmented by weight loading (Odeen I et al., 1981). Th is finding, and a personal impression that extensor spasms are sometimes reduced after tilt table standing, prompted a monitored trial of a tilt table standing regimen for a patient with intractable extensor spasms of the lower extremities ( Bohannon RW. 1993).
Whereas, on "0 day versus 90 th day" comparison, it was found that all variab les improved in both the groups. But robotic tilt table group shown higher improvement in QOL, NIHSS, Ashworth and muscle strength of lower limb while MMSE and muscle strength of upper limb imp roved equally in both groups. The improvemen t could be related to the fact that robotic rehabilitation may offer standardized, intensive and repetitive exercises, a proper body weight support, with an appropriate sensory feedback amount and a controlled progressive verticalization. As the study also suggested that Robotic verticalization maximizes the potential for longitudinal weight bearing through the lower ext remities in a position of hip-extension/knee-extension/ankle-dorsiflexion, wh ich is difficu ltly obtained in the physiotherapy verticalizat ion setting. Moreover, Robotic verticalization allows strengthen exercises of body weight shifting fro m one leg to the other, wh ich is not simply carried out in severe post-stroke patients (Calabro R et al., 2015).
Some studies found that greater cerebral blood flow modulation during Robotic VT in co mparison to physiotherapy VT could further support plastic changes within sensory -motor areas and vestibular system, with the consequent motor and cognitive function ameliorat ion (Raethjen J et  Another study showed that there was a significantly greater increase in the EMG patterns of the extensors and flexo rs of the affected leg muscles during flexion and extension movements of both legs and clinical scores in patients undergoing the progressive task-oriented training on the tilt table compared to the other groups ( Kim CY et al., 2015).
Mobilizat ion into a standing position, e.g., with a tilt table, has been shown to imp rove arousal and awareness in small groups of vegetative state and min imally conscious state patients (Elliot L et  Thus, robotic tilt table can be used by clinicians for effect ive and safe management of acute stroke patients.

Conclusion:-
The study concluded that the rehabilitation outcomes were improved both by the conventional physiotherapy and tilt table intervention in post-stroke patients. But the Robotic tilt table exercises proved to be more effective and beneficial for acute hemipleg ic patients.