Beyond human or robot administered treadmill training

The demand for rehabilitation services is growing apace with the graying of the population. This situation creates both a need and an opportunity to deploy technologies such as rehabilitation robotics, and in the last decade and half, several research groups have deployed variations of this technology. Results so far are mixed with the available evidence demonstrating unequivocally that some forms of robotic therapy can be highly effective, even for patients many years post-stroke, while other forms of robotic therapy have been singularly ineffective. The contrast is starkest when we contrast upper-extremity and lower-extremity therapy. In fact, 2010 Stroke Care Guidelines of the American Heart Association (AHA) and of the Veterans Administration/Department of Defense (VA/DoD) endorsed the use of the rehabilitation robotics for upper-extremity post- stroke care, but concluded that lower-extremity robotic therapy is much less effective as compared to usual care practices in the USA and declared “still in its infancy." We submit that the contrasting effectiveness of upper- and lower-extremity therapies arises from neural factors, not technological factors. Though, no doubt, it might be improved, the technology deployed to date for locomotor therapy is elegant and sophisticated. Unfortunately, it may be misguided, providing highly repeatable control of rhythmic movement but ultimately doing the wrong thing. The technology we have deployed to date for upper-extremity therapy is firmly based on an understanding of how upper-extremity behavior is neurally controlled and derived from decades of neuroscience research. The limitations of lower-extremity robotic therapy lie not in the robotic technology but in its incompatibility with human motor neuroscience. In this chapter we briefly review the evidence supporting such negative views, and based on our experience with upper-extremity robotic therapy, we describe what we are presently investigating to revert and work toward a future endorsement of the AHA and VA/DoD for rehabilitation robotics for lower-extremity post-stroke care.