[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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