The Effect Of Exoskeleton Robot-assisted Walking Training On Constipation Symptoms In Patients With Spinal Cord Injury From The Perspective Of Intestinal Microflora

Objective:To observe the clinical effectiveness of exoskeleton-assisted walking(ERAW)training on patients with spinal cord injury(SCI)constipation,and the affect of ERAW training on the intestinal microflora of patients with SCI constipation,and to preliminarily probe the probable mechanism of ERAW training to ameliorate the symptoms of constipation in patients with SCI.Methods:Twenty cases of SCI constipation patients with complete sports injuries(AISA grades A and B)were selected from the General Hospital of the Western Theater Command,Bayi Rehabilitation Center of Sichuan Province,and Jinchen Rehabilitation Hospital of Chengdu,and were stochasticly divided into an exoskeleton group and a waiting treatment group,and healthy volunteers matching the gender and age of the SCI subjects were recruited.Finally,8 cases were included in the exoskeleton group and waiting for treatment 8 cases were included in the group and 10 cases were included in the healthy group.All SCI subjects were evaluated by the physician in charge and therapist based on their condition,and the corresponding routine rehabilitation training program was drawn up.The exoskeleton group received additional ERAW training(5times/week,40 minutes/time,8 weeks in total);the waiting treatment group did not undergo any additional intervention.The exoskeleton group,the waiting treatment group and the healthy group kept their diet and living habits unchanged.The exoskeleton group and the waiting treatment group received the International SCI Intestinal Function Basic Data Set,Wexner Constipation Score,Neurogenic Bowel Dysfunction(NBD)Score,ASIA Lower Extremity Sports Score,and WHOQOL-BREF Scale before intervention and after 8 weeks of intervention,respectively.Evaluation and detection of intestinal flora and other indicators;the healthy group only conducts intestinal flora detection once.Results:1.Baseline data analysis resultsThe demographic data(age,education,height,weight)of the three groups of subjects had no significant differences,and the exoskeleton group and the waiting-fortreatment group had no statistically significant differences in the course of disease and ASIA grading level,and they were comparable.2.Results of main efficacy indicatorsThe results of the International SCI Intestinal Function Basic Data Set showed that after the intervention,the number of Kaiserlu used in the exoskeleton group was significantly reduce than that before the intervention(P<0.05),and the finger assistance,defecation time,lactulose and defecation frequency were higher the improvement trend was not statistically significant(P>0.05);the use of lactulose in the waiting treatment group was maekedly higher than before the intervention(P<0.05).After the training,the decrease in the use of lactulose in the exoskeleton group was noticeably different than the increase in the use of lactulose in the waiting treatment group(P<0.05).3.Results of secondary efficacy indicators(1)NBD scoreAfter the train,the NBD score of the exoskeleton group tended to decrease,and the NBD score of the waiting treatment group increased,but there was no significant diversification(P>0.05);there was no noticeable difference among the two groups of NBD scores(P>0.05).(2)Wexner constipation scoreBefore and after intervention,there was no noticeable diversification in Wexner constipation scores within and between the two groups.(3)LEMS scoreCompared with before the intervention,the LEMS scores of the exoskeleton group increased obviously after train(P<0.05).There was no statistical divergence in the LEMS scores between the exoskeleton group with the waiting therapy group.(4)WHOQOL-BREF scale scoreAfter the train,the scores of the psychology,physiology and social relations in the WHOQOL-BREF scale of the exoskeleton group increased compared with that before the train,but there was no statistical difference,and there was no significant change in the environmental field;There was no significant difference in the scores of each field of the WHOQOL-BREF scale.4.Intestinal flora index results(1)Analysis of flora diversityCompared with the healthy group,the Alpha diversity of the exoskeleton group and the waiting treatment group did not change significantly(P>0.05),while the Beta diversity had a statistical difference(P<0.05).After the train,the Beta diversity and Alpha diversity of the exoskeleton group and the waiting treatment group were not significantly different from those before the intervention(P>0.05).(2)Differential species analysis1)Analysis of differences in intestinal flora of the three groups of subjects before interventionAt the phylum level,compared with the healthy group,the abundance of Bacteroides was conspicuously reduced,and the abundance of Verrucomicrobia was conspicuously added(P<0.05)in the waiting treatment group;and the abundance of Bacteroides,Firmicutes,Verrucomicrobia and Actinobacteria in the exoskeleton group were no statistical difference.In contrast to the waiting treatment group,the abundance of Bacteroides in the exoskeleton group was conspicuously added(P<0.05).At the genus level,in contrast to healthy volunteers,in the exoskeleton group and the waiting group,abundance of Akkermansia and Escherichia-Shigella was conspicuously added(P<0.05),and the abundance of Megamonas was conspicuously reduced(P<0.05).The abundance of Blautia in the waiting treatment group was less than in the healthy group(P<0.05).2)The influence of ERAW training on the relative abundance of intestinal flora in patients with SCIAt the phylum level,compared with before the train,the abundances of Bacteroides and Verrucomicrobia in the exoskeleton group after train have a tendency to decrease,and the abundances of Firmicutes,Actinobacteria,and Proteobacteria have a tendency to increase,but there are no significant differences.In the genus level,after the train,the abundance of Ralstonia in the exoskeleton group was conspicuously better than that in the waiting treatment group(P<0.05).The abundance of Parabacteroides,Prevotella 9,and Akkermansia after the train of the exoskeleton group lessened compared with that before the train.Ruminococcus UCG-002,Ruminococcus 1,Ralstonia and Bifidobacterium have an increasing trend compared with before the train,but there is no conspicuous difference.(3)Correlation analysis of the test group’s community composition and defecation indicatorsThe difference analysis after the treatment and before the treatment showed that the difference of Bifidobacterium in the exoskeleton group was positively correlated with the difference of Wexner score,and the difference of Faecalibacterium was negatively correlated with the difference of lactulose use(P<0.05).5.Safety evaluationThere were no adverse events or serious adverse events in each group of the study,and no adverse events related to lower limb walking exoskeleton,such as falls,skin damage/blisters,and joint contractures,occurred in the experimental group.Conclusion:1.Exoskeleton-assisted walking training can effectively reduce the use of glycerini enema in patients with SCI constipation.It has potential benefits in bowel functions such as defecation time,defecation frequency,and finger assistance,and not adverse events occurred.2.The mechanism of Exoskeleton-assisted walking training to ameliorate the symptoms of constipation in patients with SCI might be related to Faebacterium and Akkermansia.