[ARTICLE] Improvement of Gait in Patients with Stroke Using Rhythmic Sensory Stimulation: A Case-Control Study – Full Text

Abstract

Patients with stroke suffer from impaired locomotion, exhibiting unstable walking with increased gait variability. Effects of rhythmic sensory stimulation on unstable gait of patients with chronic stroke are unclear. This study aims to determine the effects of rhythmic sensory stimulation on the gait of patients with chronic stroke. Twenty older adults with stroke and twenty age- and gender-matched healthy controls walked 60 m under four conditions: normal walking with no stimulation, walking with rhythmic auditory stimulation (RAS) through an earphone in the ear, walking with rhythmic somatosensory stimulation (RSS) through a haptic device on the wrist of each participant, and walking with rhythmic combined stimulation (RCS: RAS + RSS). Gait performance in the stroke group significantly improved during walking with RAS, RSS, and RCS compared to that during normal walking (p < 0.008). Gait variability significantly decreased under the RAS, RSS, and RCS conditions compared to that during normal walking (p < 0.008). Rhythmic sensory stimulation is effective in improving the gait of patients with chronic stroke, regardless of the type of rhythmic stimuli, compared to healthy controls. The effect was greater in patients with reduced mobility, assessed by the Rivermead Mobility Index (RMI).

1. Introduction

Stroke is a neurological disorder caused by ischemic and hemorrhagic damage to the cerebrovascular vessels [1,2,3,4,5]. The most common symptom of stroke is a movement disorder defined as loss or limitation of muscle control and motor function [6,7,8,9]. Patients with stroke suffer from impaired locomotion in their daily lives due to movement disorders [10] and exhibit unstable walking with increased gait variability [8,11,12]. Unstable gait with increased gait variability increases the risk of falling [13,14,15,16,17,18]. Falls in patients with stroke is one of the most serious problems, causing reduced mobility, limited function, serious injury, and death [19].

Compared with healthy controls, patients with stroke have decreased gait performance (generally expressed as the mean of spatiotemporal parameters) [20,21,22,23], and increased gait variability (expressed using the standard deviations (SD) or coefficients of variation (CV) of the gait spatiotemporal variables) [13]. Gait performance in individuals with post-stroke hemiparesis is characterized by reduction in the following: walking speed, cadence, stride length, hip joint angle at peak extension, knee joint angle at toe-off or during swinging [24,25,26], and increased foot lateral displacement during swinging [25,27,28]. Changes in walking variability, known as physiological signals that reflect alterations in walking characteristics due to aging and disease [29,30] are pronounced in patients with stroke [13]. For example, Balasubramanian et al. [13] reported that the SD of the spatiotemporal gait parameters, including the step length, swing, and stride time for patients with stroke were greater than those of healthy individuals in the same age group. Kao et al. [14] also reported significant increases in the SD of step length, step width, and margin of stability compared to those of healthy controls, while patients with stroke walked at four different speeds (60%, 80%, 100% of their preferred speeds, and as fast as possible). These results indicate that increased walking variability is closely related to walking in patients with stroke. Therefore, reducing such variability should be considered to improve walking in patients with stroke.

Rhythmic sensory stimulation, which can be used to improve the gait of persons with stroke, Parkinson’s disease, or the elderly, includes sensory feedback utilizing auditory, somatosensory, and external visual stimuli that provide spatial and temporal information to promote locomotion [31,32,33,34,35,36,37]. Rhythmic auditory stimulation (RAS), which stimulates hearing with fixed rhythms; rhythmic somatosensory stimulation (RSS), which provokes the somatosensory system with rhythmic vibrations; and rhythmic visual stimuli, which stimulate vision with constant patterns, affect the motor system of the human body [33,34,38,39,40,41]. This rhythmic sensory stimulation enhances the walking ability of patients with motion impairments and reduces walking variability. For example, RAS has been shown to increase gait speed [35,42] and stride length [36,43] but reduces the CV of stance time and double support time in a patient with stroke [11]. RSS has been shown to increase the stride length of patients with Parkinson’s disease [44]. Rhythmic auditory or somatosensory input appears to induce a constant locomotion pattern in this gait improvement mechanism by regularly stimulating the central nervous system (CNS), which controls the central pattern generator [45].

Considering these results, applying rhythmic sensory stimulation to patients with stroke could potentially reduce gait variability and improve gait performance [11,46,47,48,49,50,51,52,53]. Nevertheless, the effects of RAS, RSS, or rhythmic combined stimulation (RCS: RAS + RSS) on the gait of patients with stroke are unclear and remain unknown. Similar to previous studies [34,54], which used a mixture of auditory and visual stimulation, the main concern of this study was how the combined effects of auditory and somatosensory stimuli affected the walking of patients with stroke. Therefore, this study aimed to determine whether RAS, RSS, or RCS could improve the walking ability of persons with stroke. We hypothesized that individuals with stroke will have worse walking performance and greater gait variability than healthy controls and that RCS will induce greater gait improvement in individuals with stroke than RAS or RSS alone.[…]

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Figure 2. Example of a gait protocol using rhythmic sensory stimulation. (a) Experimental scene of a patient with stroke during a 60 m walk; (b) rhythmic auditory stimulation (RAS) condition; (c) rhythmic somatosensory stimulation (RSS) condition; (d) raw data extracted from 7D IMU sensor.

[WEB] GaitBetter + Clalit Health Services Introduce New VR Gait Training System to Improve Rehabilitation Outcomes

by Debbie Overman

Clalit Health Services, an HMO in Israel, and GaitBetter, a provider of a motor-cognitive intervention for gait rehabilitation and fall prevention, are partnering to bring GaitBetter’s innovative system to Clalit’s 4.7 million patients. Clalit will use GaitBetter’s systems in locations across Israel.

The GaitBetter system offers a solution that fits many of their patients’ indications, Clalit notes.

“We are happy to add GaitBetter’s motor-cognitive therapy to our rehabilitation and physical therapy clinics. This is another step in our continuous commitment to provide the best technologies and rehabilitation services to our members and communities.”

— Igal Lebran, Chief Physiotherapist of the Clalit Health Services

This follows GaitBetter’s recent US market launch, where a growing number of leading rehabilitation centers, physical therapy clinics, assisted living facilities, and continuing care retirement communities are already using GaitBetter’s solution.

Adds VR to Treadmills

The GaitBetter digital therapeutic solution adds a virtual reality (VR) experience to any treadmill and provides a personalized and clinically validated motor-cognitive intervention that results in improved gait and brain functions leading to fewer falls and better quality of life. In over 18 peer-reviewed studies, GaitBetter demonstrated its efficacy and benefits in neurologic and orthopedic gait disorder rehabilitation.

“It was great working with the Clalit team during their evaluation process. They are professional and dedicated to a high level of care. We’re looking forward to a continued collaboration in the years to come.”

— Idan Abukassis, GaitBetter’s Chief Operating Officer

“Between the two largest HMO providers in Israel, Clalit Health Services and Maccabi Healthcare Services, more than 80% of Israel’s adult population now have access to GaitBetter’s digital therapeutic gait rehabilitation and fall prevention solution.”

— Hilik Harari, Co-founder/CEO, GaitBetter

”We are geared to achieve the same success in the USA in 2022,” adds Hilik.

GaitBetter adds a virtual reality component to treadmill training to allow patients to practice real-life situations such as walking in a park or busy city streets while in the safety of the clinic.

GaitBetter’s “personalized exercise” approach combines virtual obstacles with decision-making, memory, and attention skills to improve dynamic balance, endurance, gait strategies, and cognitive abilities. In combination with other product features, GaitBetter increases gait and cognitive skills, improves self-confidence, and decreases accidental falls, according to the company.

[Source(s): GaitBetter, PRWeb]

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[Abstract] Association of lower-limb focal spasticity with kinematic variables during walking in traumatic brain injury

By Gavin Williams; Megan Banky

Provisional Abstract

Background and Purpose
Focal muscle spasticity is defined as spasticity that affects a localised group of muscles. It is prevalent in many adult-onset neurological conditions yet the relationship with focal muscle spasticity with walking remains unclear. Therefore, the aim of this study was to determine the relationship of focal muscle spasticity with the kinematics of walking in traumatic brain injury (TBI).
Methods
Ninety-one participants with TBI underwent clinical gait analysis and assessment of focal lower-limb muscle spasticity in a prospective cross-sectional study. A matched group of 25 healthy controls (HC) were recruited to establish a reference dataset. Kinematic data for each person with and without focal muscle spasticity following TBI were compared to the HC cohort at a matched walking speed.
Results
The TBI and HC cohorts were well matched. Only those with focal hamstring muscle spasticity walked significantly different to those without. They had significantly greater knee flexion (23.4° compared with 10.5°, p < .01) at initial contact. There were no other significant differences in kinematic variables between those with and without focal muscle spasticity. There was no significant association between focal muscle spasticity and walking speed.
Discussion and Conclusions
Focal muscle spasticity and abnormal kinematics whilst walking was common in this cohort of people with TBI. However, focal muscle spasticity had little relationship with kinematic variables, and no significant relationship with walking speed. This finding has implications for the treatment of focal muscle spasticity to improve walking following TBI. Focal muscle spasticity had little relationship with kinematic variables and walking speed in this cohort of people with TBI who could walk without assistance.

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[Abstract] Telephone-Delivered Physiotherapy Interventions Improve Physical Function for Adults With a Chronic Condition: A Systematic Review and Meta-analysis

Abstract

Objective: To investigate the efficacy of telephone-delivered physiotherapy interventions to improve lower extremity physical function and walking in adults aged ≥45 years with a chronic condition.

Data sources: A literature search was conducted using health databases (MEDLINE, PsychINFO, EMBASE, The Allied and Complementary Medicine Database, Web of Science, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature) up to April 26, 2020. Reference lists of relevant studies were explored to identify additional studies.

Study selection: The original search resulted in 3465 studies. Five other studies were included from hand searches. After duplicates were removed, 2820 studies remained. Title and abstract screening was completed independently by 2 authors and resulted in the exclusion of 2596 studies. The full-texts of the remaining 224 articles were assessed and 204 studies were excluded. Twenty articles were examined.

Data extraction: Data were extracted independently by 2 authors, including study, population, and intervention details; assessment timings; outcome characteristics; appropriateness of statistical methods; adverse events; and reasons for loss to follow-up. Study quality was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Data synthesis: Twenty studies were included in the systematic review. One study was not meta-analyzed owing to insufficient data. Telephone-delivered physiotherapy had a small to moderate effect on distance walked compared with control groups with no exercise intervention (standardized mean difference [SMD], 0.28; 95% confidence interval [CI], 0.00-0.56; I², 45%) and no effect when compared with control groups with an exercise intervention not delivered by telephone (SMD, 0.08; 95% CI, -0.19 to 0.36; I², 0%).

Conclusion: Telephone-delivered physiotherapy may be an effective method to improve walking. Further research is required to validate these findings.

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[ARTICLE] Effects of Lower Limb Constraint Induced Movement Therapy in People With Stroke: A Systematic Review and Meta-Analysis – Full Text

Abstract

Background: Constraint induced movement therapy (CIMT) is effective at improving upper limb outcomes after stroke.

Aim: The aim of this study was to carry out a systematic review and meta-analysis of the effects of lower limb CIMT studies of any design in people with stroke.

Materials/ Method: PubMED, PEDro, OTSeeker, CENTRAL, and Web of Science were searched from their earliest dates to February 2021. Lower limbs CIMT studies that measured outcomes at baseline and post-intervention were selected. Sample size, mean, and standard deviation on the outcomes of interest and the protocols of both the experimental and control groups were extracted. McMaster Critical Review Form was used to assess the methodological quality of the studies.

Result: Sixteen studies with different designs were included in this review. The result showed that lower limb CIMT improves functional, physiological and person’s reported outcomes including motor function, balance, mobility, gait speed, oxygen uptake, exertion before and after commencement of activities, knee extensor spasticity, weight bearing, lower limb kinematics and quality of life in people with stroke post intervention. However, there were only significant differences in quality of life in favor of CIMT post-intervention [mean difference (MD) = 16.20, 95% CI = 3.30–29.10, p = 0.01]; and at follow-up [mean difference (MD) = 14.10, 95% CI = 2.07–26.13, p = 0.02] between CIMT and the control group. Even for the quality of life, there was significant heterogeneity in the studies post intervention (I² = 84%, p = 0.01).

Conclusion: Lower limb CIMT improves motor function, balance, functional mobility, gait speed, oxygen uptake, weigh bearing, lower limb kinematics, and quality of life. However, it is only superior to the control at improving quality of life after stroke based on the current literature.

Introduction

Constraint Induced Movement Therapy (CIMT) is a translational motor rehabilitation technique following injury of the Central Nervous System (CNS). The technique originated many decades ago from use in primates; and was translated to humans following stroke and other neurological conditions (1). The original concept involved constraint of the unaffected limb and forced use of the affected one (2). Subsequent studies in humans involved voluntary massed tasks or shaping practices with the affected limb. Consequently, CIMT has been reported to be effective at improving real world arm use, motor function, and kinematic outcomes by inducing changes in the functions and structures of the brain (3–7). However, there have been many modifications over the years of the original protocol of CIMT, including but not limited to the length of time for the tasks practice, the constraint, and the use of a transfer package (7–9).

The effects of CIMT on the recovery of motor function of the upper limb have been well-investigated (7, 10). The practicability of the protocol for upper limbs could be because of the unilateral nature of the use of these limbs in most of our activities of daily living (ADL). For the lower limbs, this may seem difficult since humans are bipedal, and this requires them to use the two limbs simultaneously for ADL especially during walking. However, the positive results in the recovery of motor function of the upper limb following CIMT persuaded the neuroscientific community to consider translating the technique to the lower limbs. Consequently, a lower limb CIMT protocol was designed to comprise mainly of intensive practice with the affected limb, shaping activities, transfer package, and encouraging the increased use of the affected limb (11). So far, there are several small sample size studies that have investigated the effects of lower limb CIMT on gait parameters, balance, and motor function using different study designs such as case reports, experimental studies, quasi-experimental studies, and randomized controlled trials (RCTs) (12). These studies reported that lower limbs CIMT improved gait speed, step length, motor function, functional mobility, balance, and kinematic outcomes. However, small sample size studies may overestimate the effect of an intervention (13–15). Second, the only difference in the protocols of the CIMT and control groups was the use of a constraint in the CIMT group, with no difference in the types of tasks used in most of these studies, including the intensity. According to Abdullahi, task practice is the most important component of CIMT (16, 17). Therefore, it is possible that the effects of lower limb CIMT reported in those studies were overestimated.

In addition, in upper limb CIMT constraint is used to immobilize the unaffected limb to prevent movement at joints essential for the functioning of the limb. This is to done to maximize the use of the affected limb, and to help recover function. However, for lower limb CIMT, the types of constraints used include encouraging weight bearing on the affected limb, the use of an insole in the affected limb, the use of knee braces or a splint, and attaching weight to the ankle of the affected limb (12). Constraining one of the limbs may cause asymmetry which could negatively affect normal functions such as walking, especially since humans are bipedal. The aim of this study was to therefore carry out a systematic review and meta-analysis on the effects of lower limb CIMT on outcomes after stroke such as gait parameters, balance, motor function, functional mobility, and quality of life. This review sought to answer this question: What are the effects of lower limb CIMT on this information is important as, to date, there does not seem to be any review and/ or meta-analysis on the effects of lower limb CIMT following stroke.

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[WEB] Feasibility Study of Cionic’s Neural Sleeve Suggests Gait Improvement

by Debbie Overman

Participants in a gait study of the Neural Sleeve by Cionic demonstrated, on average, an improvement in their foot drop of 143%, Cionic reports.

The Neural Sleeve is an algorithm-powered bionic clothing designed to help those with cerebral palsy, multiple sclerosis, stroke, and other neurological disorders regain functional movement in their everyday activities, a media release from the company explains.

“It’s been incredible to see participants not just walk more confidently but also show quantitative improvements in their gait. Our participants are seeing 1.5x gain in dorsiflexion at heel strike, which means they’re clearing their foot through swing better, have a better chance to avoid falls, and have a more natural gait cycle. This is a tremendous step in building a scalable neuromodulation platform to help people with movement disorders leverage their own bodies and rebuild neural pathways for greater independence.”

— Jeremiah Robison, Founder and CEO of Cionic

“This month, we completed both our human factors and efficacy testing and we are now ready to submit our Neural Sleeve to the FDA,” Robison continues. “This is a huge milestone for the company. So much invention and hard work has gone into this first product, and we cannot wait to bring it to the many people living with a gait impairment.”

Trial participant Patricia Allen survived a stroke in 2019 that drastically affected her mobility, especially the ability to negotiate stairs. She has used a quad-cane and an ankle-foot orthotic with less than satisfactory results. During one of her trial sessions, Cionic recorded Patricia’s data while she walked outside in San Francisco.

“They’re just a great group of people. What Cionic is doing is a garment-type design so it’s not so obtrusive when you’re wearing it,” Allen shares. “My last visit I actually went out on the streets in North Beach in San Francisco, heavy population, all the flavors of San Francisco, and it was a feeling of inspiration for me that I haven’t felt for two and a half years. It was an impactful moment for me, and I am encouraged by what they’re doing, what the product is, and how it’s developing.”

How it Works

The Cionic Neural Sleeve analyzes, predicts, and augments a person’s movement. Using advanced algorithms, the system reads the signal sent from the brain to the muscles and can predict a person’s movement 1/10th of a second before their foot lifts off the ground.

The lower-leg Neural Sleeve uses a dense array of sensors to measure how the body is positioned and how individual muscles fire during movement, predicts intended movement by measuring the electrical signal from the brain, and then algorithms analyze this data in real time to determine optimal muscle activation patterns.

Cionic delivers Functional Electrical Stimulation to sequence proper muscle firing for natural movement. It is an adaptive system that provides real-time augmentation and adjustment of the participant’s movement, providing necessary assistance based on what can be measured of the participant’s neurological feedback that adjusts stimulation based on measured gait kinematics to optimize performance.

[Source(s): Cionic, Business Wire]

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[Abstract] OAR@UM: Gait rehabilitation in post-stroke patients : functional electrical stimulation vs standard care

Abstract

Synopsis of the topic: Stroke is a prevalent occurrence that causes disability, compromised quality of life, together with premature death. With the inclusion of FES in rehabilitation therapies, faster and more efficient rehabilitation of gait can be rendered. Research Question: Is FES more effective than Standard therapy in Improving Gait Retraining in PostStroke Patients? PICO Elements: Population Post-stroke Patients Intervention Functional Electrical Stimulation Comparison intervention Standard care Outcome Gait Retraining Methodology: Multiple search terms were defined then merged with search tools together with limiters to construct specific search tactics for every database/ platform. Examples of the databases used are PubMed and HyDi. Unpublished literature was also sought. The PRISMA framework was utilised. To facilitate the recruitment of key studies; comprehensive eligibility criteria were established and used. RCTs, systematic reviews, and meta-analyses were all suitable for incorporation. However, articles must have been written in English and published after 1995. The assessment method was directed by CASP tools and the Cochrane Collaboration’s tool for assessing the risk of bias. Results: This review lineated the provisional evidence in support of FES as a gait rehabilitation intervention. These findings justify further research in this field. Implications and recommendations: Recommendations for future research and recommendations for practice were provided. These generally related to the reinforcement of adequate blinding, longer-term intervention duration periods, larger study analyses and further local research.

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[Abstract] Design of Lower Limb Exoskeleton for Stroke Patients Gait Rehabilitation – Conference Publication

Abstract

The possible gap as the number of stroke patients outgrows the number of therapists encourages the development of the exoskeleton as a multiplier for the therapists. The objective of this study is to design a lower limb exoskeleton for stroke patients’ gait therapy. The design method was started with assessing previous studies, to search for design references and issues of the technology. The previous studies provide information on the brief history of the exoskeleton for gait rehabilitation as well as the various structural, mechanical, and control designs of exoskeletons. Based on the references, we design a simple lower limb exoskeleton and formulate the prototyping and testing plan, from CAD modeling, followed by 3D printing of the model, mockup testing, until prototyping and the clinical test of the prototype. This article describes the preliminary stage of exoskeleton design especially the design process and the results in the form of exoskeleton conceptual design and scale model 1:2. The scale model improves the efficacy of the design study.

Published in: 2021 International Conference on Radar, Antenna, Microwave, Electronics, and Telecommunications (ICRAMET)

[ARTICLE] Performance in complex life situations: effects of age, cognition, and walking speed in virtual versus real life environments – Full Text

Abstract

Background

Virtual reality (VR) enables objective and accurate measurement of behavior in ecologically valid and safe environments, while controlling the delivery of stimuli and maintaining standardized measurement protocols. Despite this potential, studies that compare virtual and real-world performance of complex daily activities are scarce. This study aimed to compare cognitive strategies and gait characteristics of young and older healthy adults as they engaged in a complex task while navigating in a real shopping mall and a high-fidelity virtual replica of the mall.

Methods

Seventeen older adults (mean (SD) age = 71.2 (5.6) years, 64% males) and 17 young adults (26.7 (3.7) years, 35% males) participated. In two separate sessions they performed the Multiple Errands Test (MET) in a real-world mall or the Virtual MET (VMET) in the virtual environment. The real-world environment was a small shopping area and the virtual environment was created within the CAREN™ (Computer Assisted Rehabilitation Environment) Integrated Reality System. The performance of the task was assessed using motor and physiological measures (gait parameters and heart rate), MET or VMET time and score, and navigation efficiency (cognitive performance and strategy). Between (age groups) and within (environment) differences were analyzed with ANOVA repeated measures.

Results

There were no significant age effects for any of the gait parameters but there were significant environment effects such that both age groups walked faster (F_(1,32) = 154.96, p < 0.0001) with higher step lengths (F_(1,32) = 86.36, p < 0.0001), had lower spatial and temporal gait variability (F_(1,32) = 95.71–36.06, p < 0.0001) and lower heart rate (F_(1,32) = 13.40, p < 0.01) in the real-world. There were significant age effects for MET/VMET scores (F_(1,32) = 19.77, p < 0.0001) and total time (F_(1,32) = 11.74, p < 0.05) indicating better performance of the younger group, and a significant environment effect for navigation efficiency (F_(1,32) = 7.6, p < 0.01) that was more efficient in the virtual environment.

Conclusions

This comprehensive, ecological approach in the measurement of performance during tasks reminiscent of complex life situations showed the strengths of using virtual environments in assessing cognitive aspects and limitations of assessing motor aspects of performance. Difficulties by older adults were apparent mainly in the cognitive aspects indicating a need to evaluate them during complex task performance.

Background

By 2035, twenty percent of the population will be 65 years or older [1]. This group strives for “successful aging” by aiming to maintain an active life style [2]. Models of successful aging recognize three main components including the prevention of diseases, good cognitive and physical functioning and engagement with life i.e. participation in daily activities [3, 4].

Older adults report that maintaining their ability to perform instrumental activities of daily living (IADL) such as driving and shopping are highly meaningful [5]. Eriksson et al. reported that IADL activities such as shopping in a store or for groceries were identified as important activities performed by more than 50% of older adults across Asian and Western countries [6]. The assessment of such complex tasks is challenging for many reasons including safety, accessibility, weather conditions and liability. As predicted by the models and supported by the empirical findings, physical and cognitive functions play a crucial role in aging successfully [7, 8]. Participation in daily activities, specifically those with high complexity such as shopping or driving are thus of great importance [9]. Participation restrictions in older adults has been associated with age-related physiological, cognitive and sensory-motor changes [10].

Evaluation of cognitive and motor functions in routine clinical procedures is based on a wide array of standardized clinical tests. However, such testing has limited ecological validity (i.e., minimal resemblance to everyday life demands) as it focuses on each motor or cognitive sub-domain in isolation, with little regard for ‘real-life’ demands and responses. Contrary to this ‘isolated’ approach, dual-task paradigms that assess concurrent motor-cognitive tasks such as texting [11] or calculating [12] while walking more closely replicate real-life activities, although such paradigms have been criticized for insufficient ecological validity [13,14,15] since they are often conducted in laboratory settings or entail non-functional tasks. We contend that a more valid evaluation of motor (specifically gait) and cognitive functions should be performed within the context of tasks that are relevant to older adult’s ‘real-life’ interests and activities, and should be documented via simultaneous recordings of both cognitive and motor performance. To date, neither of these recommendations has been sufficiently explored in the literature.

Assessment of an older person’s performance within simulations of daily life settings by means of laboratory-based virtual reality (VR) may overcome many of the above-mentioned barriers. VR enables objective and accurate measurement of behavior in ecologically valid and safe environments, while controlling the delivery of stimuli and maintaining standardized measurement protocols [15,16,17]. Despite this potential, studies that compared virtual and real-world performance of complex daily activities are scarce. Rand and colleagues [18], for example, examined the relationship between performance in the real world (via the Multiple Errands Test (MET) [19]) versus performance in a virtual shopping mall with an adapted version of the MET; the Virtual Multiple Errands Test (VMET) [18]. Both the MET and VMET assess executive functions during the performance of a complex shopping task. High, significant correlations were found between the performances of these two tasks, thus establishing the ecological validity of the VMET as a tool to assess executive functions. Nir-Hadad et al. [20] showed similar results when comparing a virtual shopping task to performance of the same task in the real environment. However, these studies focused on the cognitive aspect of performance and not gait or any other motor aspect.

In the study presented in this paper, we carried out a comprehensive, ecological approach that incorporated motor, cognitive and physiological aspects in the measurement of older adult’s performance during tasks reminiscent of complex life situations. The findings may lead to the development of ecologically valid assessments and interventions during in-situ daily life tasks [21] to maintain older adults’ participation in complex tasks in the community. The specific objectives were to: (1) compare performance (cognitive strategy and gait characteristics) of a complex task while navigating in a real shopping mall (MET) and a high-fidelity virtual replica of the mall (VMET); (2) to compare MET and VMET performance of young and older healthy adults; and (3) to examine within-group correlations between executive functions and performance scores in the MET and VMET. This work will lead to validation of the VMET relative to the MET.[…]

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[ARTICLE] Acceptability and deliverability of an auditory rhythmical cueing (ARC) training programme for use at home and outdoors to improve gait and physical activity post-stroke – Full Text

Abstract

Background

Although laboratory studies demonstrate that training programmes using auditory rhythmical cueing (ARC) may improve gait post-stroke, few studies have evaluated this intervention in the home and outdoors where deployment may be more appropriate. This manuscript reports stakeholder refinement of an ARC gait and balance training programme for use at home and outdoors, and a study which assessed acceptability and deliverability of this programme.

Methods

Programme design and content were refined during stakeholder workshops involving physiotherapists and stroke survivors. A two-group acceptability and deliverability study was then undertaken. Twelve patients post-stroke with a gait related mobility impairment received either the ARC gait and balance training programme or the gait and balance training programme without ARC. Programme provider written notes, participant exercise and fall diaries, adverse event monitoring and feedback questionnaires captured data about deliverability, safety and acceptability of the programmes.

Results

The training programme consisted of 18 sessions (six supervised, 12 self-managed) of exercises and ARC delivered by a low-cost commercially available metronome. All 12 participants completed the six supervised sessions and 10/12 completed the 12 self-managed sessions. Provider and participant session written records and feedback questionnaires confirmed programme deliverability and acceptability.

Conclusion

An ARC gait and balance training programme refined by key stakeholders was feasible to deliver and acceptable to participants and providers.

What’s already known about this topic

Auditory rhythmical cueing improves walking following stroke when delivered in the laboratory or clinical settings. Limited research exists, however, on the use of ARC in the home and outdoors where deployment may be more appropriate.What does the study add (one or two sentences)

The study demonstrated that an ARC gait and balance training programme can be delivered in the home and outdoors. The programme was acceptable to both stroke survivors and therapists.

Background

Although up to 80% of stroke survivors may eventually recover their ability to walk short distances [1], many do not achieve the locomotor capacity necessary for ‘real-world’ walking [2]. Gait impairments can limit household and outdoor ambulation post-stroke [3] and are associated with increased dependency in activities of daily living and reduced quality of life [4]. Typical impairments commonly observed post-stroke include reduced walking speed, decreased stride length/cadence and increased temporal asymmetry [5, 6]. The ability to walk safely and unsupervised around the home and outdoors is fundamental to independent living and as such is an important topic in stroke rehabilitation [7]. Stroke survivors view the ability to walk safely and effectively outdoors as a top priority [8], but unfortunately this is unachievable for many who as a result are confined to home [7, 9].

A potential method of enhancing the efficacy of gait rehabilitation post-stroke is auditory rhythmical cueing (ARC). ARC provides auditory feedback to target gait and physical activity. A metronome beat or music is delivered during exercise training in order to normalise and entrain stepping [10]. The efficacy of ARC has been well established in Parkinson’s disease over the last 20 years [11], and this intervention has more recently been utilised in stroke.

ARC gait training may confer benefits including increased practice of walking which is a recognized key component in recovery post-stroke [10, 12]. A recent systematic review [13] reported significant improvements in gait velocity, cadence and stride length following an ARC intervention compared to control groups receiving other types of rehabilitation. Whilst this suggests promise for ARC as a tool for improving gait, much of this work on ARC in stroke was ward or laboratory based which limits application of findings to ‘real world’ walking. Real world walking requires the ability to change speed and direction, for example, when walking in crowds or across roads, endurance to enable participation in community settings, and the ability to negotiate different terrains during different weather or ambient conditions [14]. Rather than using ARC to target aspects of efficient and effective walking, the studies in the review predominantly targeted laboratory based overground indoor walking in a straight line. The studies included in the review were also limited by size, bias (e.g., only 25% of the studies had blinded outcome assessments) and a large proportion were conducted over 10 years ago.

One recent study has examined the use of ARC within the home for stroke survivors [15]. This small pilot study (n = 12) evaluated ARC delivered whilst the stroke survivors stepped on the spot and reported that this programme was feasible, well-tolerated and improved walking ability. Whilst this is promising early data to support the use of ARC in the home, bigger studies and those which include different aspects of walking e.g., turning, and outdoor walking are needed to evaluate this treatment further.

To inform the design of a pilot randomised controlled trial of an ARC gait and balance training programme for use by stroke survivors in the home and outdoors, we undertook the work reported in this manuscript which aimed to refine a prototype ARC programme and then to assess whether the programme was acceptable and deliverable.[…]

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