Posts Tagged Balance

[Abstract] Effects of Robot-Aided Rehabilitation on Improving Ankle and Balance Performance of Stroke Survivors: A Randomized Controlled Trial


Background: Stroke survivors often experience abnormal posture control, which affects balance and locomotion. The ankle strategy is important in maintaining static balance. Prolonged spasticity may result in biomechanical changes at the ankle joint, which may cause balance disorders. The intelligent stretching device may decrease the stiffness of the ankle and improve balance. The purpose of this study was to investigate the effects of robot-aided ankle rehabilitation of stroke survivors with ankle spasticity and the correlations between biomechanical properties and balance in these patients.

Methods: Twenty inpatients post stroke with ankle spasticity performed 20 minutes of stretching treatment for 2 weeks. The study group used a rehabilitation robot to stretch the spastic ankle plantar flexors under intelligent control and the control group received manual stretching. Outcome measures included biomechanical, clinical evaluations and Pro-Kin balance test.

Results: After training, significant improvements were found in both groups in the active range of motion, muscle strength, Berg Balance Scale, Fugl-Meyer Motor Assessment of Lower Extremity, Postural Assessment Scale for Stroke Patients, 6-minute walk test, and Modified Barthel Index (P<0.05); significant decreases were found in the study group in dorsiflexion stiffness, Modified Ashworth Scale, trajectory lengths, elliptical trajectory, standard deviation medial/lateral, average speed forward/backward with eyes closed, and standard deviation forward/backward with eyes open (P=0.001, P=0.037, P=0.028, P=0.019, P=0.016, P=0.001, and P=0.033, respectively); dorsiflexion stiffness was positively correlated with the Pro-Kin balance test outcomes: ellipse area, trajectory length, average speed forward/backward, average speed medial/lateral with eyes open ( =0.352, P=0.026; =0.522, P=0.001; =0.045, P=0.004; =0.433, P=0.005, respectively); dorsiflexion stiffness was correlated with the Modified Ashworth Scale ( =0.265, P=0.041); the study group improved significantly more than the control group in the activities of daily living after training (P =0 .017).

Conclusions: The results suggested that robot-aided ankle rehabilitation had a positive effect on the biomechanical properties of the spastic ankle, and it may be feasible to improve balance post-stroke. Ankle dorsiflexion stiffness affected balance poststroke significantly; it may be a sensitive indicator for evaluating balance.

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[ARTICLE] Immersive Virtual Reality in Stroke Patients as a New Approach for Reducing Postural Disabilities and Falls Risk: A Case Series – Full Text HTML

Graphical abstract


Stroke is a neurologic disorder considered the first cause of disability worldwide due to motor, cognitive, and sensorial sequels. Balance dysfunctions in stroke survivors increase the risk of falls and physiotherapeutic rehabilitation is essential to reduce it. Virtual reality (VR) seems to be an alternative to conventional physiotherapy (CT), providing virtual environments and multisensorial inputs to train balance in stroke patients. The aim of this study was to assess if immersive VR treatment is more effective than CT to improve balance after stroke. This study got the approval from the Ethics Committee of the University of Almeria. Three chronic ischemic stroke patients were selected. One patient who received 25 sessions of immersive VR intervention for two months was compared with another patient who received equivalent CT and a third patient with no intervention. Balance, gait, risk of falling, and vestibular and visual implications in the equilibrium were assessed. After the interventions, the two patients receiving any of the treatments showed an improvement in balance compared to the untreated patient. In comparison to CT, our results suggest a higher effect of immersive VR in the improvement of balance and a reduction of falls risk due to the active upright work during the VR intervention.

1. Introduction

Stroke is considered the first cause of disability [1] and the third cause of death in westernized countries after cardiovascular diseases and cancer [2]. Stroke is a central nervous system disorder produced by a local interruption of the cerebral blood flow due to the occlusion (ischemic stroke) or rupture (hemorrhagic stroke) of a cerebral blood vessel [3]. As result of brain cortex injury, afferent and efferent neural pathways are affected, and motor, sensitive and cognitive functions become impaired. Motor and cognitive impairments observed in post-stroke patients reduce their functional capacity, their personal autonomy [4], and social abilities, which results in intensive care and rehabilitation needs with the subsequent economic burden to society and families [5].
Postural instability or poor balance is a relevant central vestibular symptom in neurologic disorders, such as stroke [6], in which approximately 83% of stroke survivors show balance impairments [7]. Proprioceptive visual and vestibular inputs to the central nervous system are essential to guarantee the upright position [8]. Thus, errors in the central integration of this postural information can induce gait difficulties with the subsequent increase in risk of falls [9]. In addition, stroke survivors show a number of neurological issues like visual neglect, sensory loss, reduced muscle strength and spasticity, which also increase the risk of fall 1.5–2 times more in post-stroke patients than older adults without brain damage [10]. This results in fractures, tissue injuries, immobility, and psychological fear of falling as additional consequences of falls in stroke patients [11]. Besides, large hospitalization periods due to injury falls are devastating for patient recovery [12].
The use of virtual reality (VR) has been booming during the last decade, becoming a potential tool in the field of stroke rehabilitation [13]. Virtual reality technology works by displaying a set of digital images that allow the user interacts with a virtual environment or situation that is perceived equivalent to the real physical world [14]. VR has been used in neurorehabilitation in order to encourage a higher number of exercise repetitions and their intensity, and enhances motor learning thanks to the quick feedback possibilities and the multisensorial stimulation [15]. This promotes neuronal plasticity, which would the responsible of VR-induced benefits in stroke rehabilitation [16]. Recent studies have shown that immersive VR protocols in a sitting position and Wii exergames (non-immersive VR) improve motor function, balance, and gait in stroke patients in comparison with conventional therapy (CT) [17]. However, other studies report no statistical differences when comparing immersive or non-immersive VR in a sitting position with CT [18,19]. Moreover, several studies suggest that a neurorehabilitation program combining VR and CT produces a greater improvement than each treatment separately [20].
Nevertheless, the majority of published works have used non-immersive VR therapies, such as Wii exergames for balance training [21,22]. Recently, improved versions of immersive VR have become available for clinical and research purposes in physical rehabilitation. Thus, immersive VR, thanks to the use of headsets that display 3D digital images that simulate any scenario with high realism, has the capability to make individuals feel as if they’re inside the virtual environment. Moreover, the use of hand-held controllers allows users to interact with virtual elements using their hands as they do real life, allowing exercise repetition, intensity variation, and task-oriented training. Thus, immersive VR postulates as a promising tool for the rehabilitation of motivated stroke patients. The aim of this study is to assess if an experimental protocol based on immersive VR therapy is valid for stroke rehabilitation and produces positive effects in balance and falls risk in comparisons to a CT protocol. For such a reason, two intervention protocols (immersive VR or CT) in comparison with the absence of treatment were tested in three patients diagnosed with ischemic stroke[…]

Continue —->  Brain Sciences | Free Full-Text | Immersive Virtual Reality in Stroke Patients as a New Approach for Reducing Postural Disabilities and Falls Risk: A Case Series | HTML

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[ARTICLE] Effect of Vojta Therapy on Balance and Walking of Community Dwelling Chronic Stroke Patients – Full Text PDF


Objectives: To evaluate effect of Vojta Therapy on balance and
walking of community dwelling chronic stroke patients.
Study design: Single group clinical trial with pre and post test.
Setting: VojtaTherapy clinic, Division of Physical Therapy,
Department of Rehabilitation Medicine, Trang Hospital.
Subjects: Community dwelling chronic stroke patients with
abnormal gait referred to the VojtaTherapy clinic.
Methods: Every participant did a timed up and go test (TUGT)
immediately before and after the VojtaTherapy. Techniques were
chosen according to response of patients with 30 minutes per
session. Treatment and assessment were repeated once a week
for three weeks.
Results: Twenty chronic stroke patients with average age of
63.1 (SD = 13.23) years and average duration after stroke of
58.35 (SD = 52.83) months were enrolled into the study. The
median TUGT scores of the first, second and third pre-treatment
were 28, 22 and 19.5 respectively. Friedman test demonstrated a
significant difference (p < 0.001). Median TUGT Score of the first,
second, and third post treatment TUGT score were 22.5, 18 and
18.5 respectively. Wilcoxon test showed significant difference of
pre versus post treatments in everysessions (p < 0.0001).
Conclusion: Once a week of VojtaTherapy for three weeks can
improve walking in community dwelling chronic stroke patients.
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[WEB PAGE] Physical Therapy at Home – Gorbel Rehab – Videos

Physical Therapy at Home

As rehab professionals around the world work to address patient needs during the COVID-19 pandemic, Gorbel is actively taking steps to improve efforts in delivering therapy during these difficult times. The Gorbel team of physical therapists have created a library of home exercise program videos for those patients who are now unable to receive therapy with the frequency or duration in which they normally would have. The current video categories are Strength, Range of Motion, Balance, and Caregiver Training. Each category has a ‘Playlist’ that includes multiple videos. We will continue to add categories and new videos in our commitment to assist your efforts to advance your patient’s recovery.

Stay safe, healthy and thank you for all you do.
Brian Reh, CEO Gorbel®


Physical Therapy Videos

Balance Videos Playlist  /  Caregiver Videos Playlist  /  Range of Motion Videos Playlist  /  Strength Videos Playlist

Balance Videos Playlist

Caregiver Videos Playlist

Range of Motion Videos Playlist

Strength Videos Playlist


Physical Therapist Bio

Matthew KlockMatthew Klock PT,DPT I am a licensed physical therapist in New York State and the Northeast Account Manager for Gorbel® Rehabilitation. Before joining Gorbel® I worked for Ochsner Health System in New Orleans, LA as the Supervisor of the Ochsner Sports Medicine Clinic. My passions include sports and orthopedics as well as new and emerging technologies. I believe that physical therapists should serve their patients by applying their wealth of knowledge in rehabilitation and pair it with the most cutting edge technologies to get the most out of every treatment.


Ramiro MaldonadoRamiro Maldonado PT, DPT I am a licensed Physical Therapist in New York State as well as the Clinical Business Development Specialist for Gorbel Rehabilitation. During my ten years as a clinician, my clinical interests lead me to specialize in vestibular and neuromuscular impairment, and I have completed the vestibular competency at Emory University. My passion now lies in helping patients and therapists by increasing awareness of rehabilitation technology and how it can improve patient outcomes. You can find out more about the products I represent, innovations in physical therapy, and me at or follow me on Twitter or Instagram @RamiroDPT. Thank you!! 

Heidi ShenkHeidi Shenk, PT I am a licensed Physical Therapist in the states of Ohio and Indiana as well as the Account Manager for the Great Lakes Region of Gorbel Rehabilitation. I am a graduate of the Doisy College of Health Sciences at St Louis University. During my twenty-seven years as a clinician, my clinical interests led me to specialize in occupational medicine, outpatient orthopedics and in women’s health. My lifelong interest in technology and in improving therapist safety and patient outcomes has led to a passion in increasing awareness of rehabilitation technology and how it can improve patient care.

via Physical Therapy at Home | Gorbel Rehab

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[ARTICLE] Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury – Full Text



To compare the efficacy of high- and low-frequency noninvasive translingual neurostimulation (TLNS) plus targeted physical therapy (PT) for treating chronic balance and gait deficits due to mild-to-moderate traumatic brain injury (mmTBI).


Participants were randomized 1:1 in a 26-week double-blind phase 1/2 study (NCT02158494) with 3 consecutive treatment stages: in-clinic, at-home, and no treatment. Arms were high-frequency pulse (HFP) and low-frequency pulse (LFP) TLNS.


TLNS plus PT training was initiated in-clinic and then continued at home.


Participants (N=44; 18-65y) from across the United States were randomized into the HFP and LFP (each plus PT) arms. Forty-three participants (28 women, 15 men) completed at least 1 stage of the study. Enrollment requirements included an mmTBI ≥1 year prior to screening, balance disorder due to mmTBI, a plateau in recovery with current PT, and a Sensory Organization Test (SOT) score ≥16 points below normal.


Participants received TLNS (HFP or LFP) plus PT for a total of 14 weeks (2 in-clinic and 12 at home), twice daily, followed by 12 weeks without treatment.

Main Outcome Measures

The primary endpoint was change in SOT composite score from baseline to week 14. Secondary variables (eg, Dynamic Gait Index [DGI], 6-minute walk test [6MWT]) were also collected.


Both arms had a significant (P<.0001) improvement in SOT scores from baseline at weeks 2, 5, 14 (primary endpoint), and 26. DGI scores had significant improvement (P<.001-.01) from baseline at the same test points; 6MWT evaluations after 2 weeks were significant. The SOT, DGI, and 6MWT scores did not significantly differ between arms at any test point. There were no treatment-related serious adverse events.


Both the HFP+PT and LFP+PT groups had significantly improved balance scores, and outcomes were sustained for 12 weeks after discontinuing TLNS treatment. Results between arms did not significantly differ from each other. Whether the 2 dosages are equally effective or whether improvements are because of provision of PT cannot be conclusively established at this time.

Traumatic brain injury (TBI) is a leading cause of injury-induced death and physical disability. Millions of people experience TBI every year,1,2 and an estimated 5.3 million people are living with TBI-related disabilities,3 with up to 57% of patients with TBI experiencing balance disorders.4 Mild-to-moderate traumatic brain injury (mmTBI) encompasses most of TBI cases (83%).5

For many people, the signs and symptoms of mmTBI resolve with time, allowing return to normal daily activities; however, 25%-50% of patients experience chronic symptoms.678910 Instability or imbalance can persist after mild TBI,11 which has a significant negative effect on functional status, capacity to return to work, and quality of life7,1213141516 and can increase the risk of falling and repeat injury.17 Rehabilitation techniques consist of basic gait and balance training, but may also include specialized therapies, such as vestibular rehabilitation therapy, vision therapy, motor control retraining, graded exercise, and others.18192021222324 Whereas some patients improve with these treatments, others do not.18,25,26

Neurostimulation combined with physical therapy (PT) can potentially affect rehabilitation outcomes,272829 and noninvasive brain stimulation can affect neural excitability and may facilitate motor skill learning.30 Cranial nerves V and VII in the tongue and associated neural projections in the brain can be stimulated through noninvasive translingual neurostimulation (TLNS).31 Clinical studies by our group and others indicate that TLNS with targeted PT, combined, can significantly improve outcomes in those with degenerative neurologic disease, spinal cord injury, or stroke.32333435 In a separate study, we treated 20 persons with multiple sclerosis and an identified gait disturbance with TLNS plus targeted PT.32 Over 14 weeks of treatment, Dynamic Gait Index (DGI) significantly improved from baseline.32 One group reported results from 2 people with chronic incomplete spinal cord injury who completed 12 weeks of TLNS plus balance or gait PT that indicated improvements in both walking speed and skilled walking function.34 Results from a separate randomized controlled trial demonstrated significant improvement in the Mini-Balance Evaluation Test after 2 weeks of TLNS plus targeted PT in 5 subacute stroke survivors.33 These results, as well as similarities in neural dysfunction mechanisms of stroke and TBI,35 support the possibility that TLNS plus targeted PT may be effective for treating chronic balance and gait deficits due to mmTBI.

This 26-week, randomized trial (Clinicaltrials.govNCT02158494) was developed to investigate high-frequency pulse (HFP) TLNS plus PT, as treatment for individuals with persistent balance deficit due to mmTBI, compared with low-frequency pulse (LFP) TLNS plus PT as a control. Since trial registration, notable difficulties in establishing controls in neurostimulation studies have become more prominent in the field, particularly focusing on how a low, minimally perceived stimulus serving as a sham can trigger neural activity and produce a response.3637383940 This determination of optimal stimulation parameters has proven challenging across the neurostimulation field, including studies with transcutaneous electrical nerve stimulation,36,37,414243 noninvasive trigeminal nerve stimulation,38,39,44 and TLNS.32 Because of these difficulties, the focus of this study shifted from using the LFP as a control to one of a comparison between the treatment arms (PT plus either HFP or LFP); balance assessment after 14 weeks of treatment was the primary outcome measure.

Continue —->  Translingual Neurostimulation for the Treatment of Chronic Symptoms Due to Mild-to-Moderate Traumatic Brain Injury – ScienceDirect

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[ARTICLE] Effects of Exoskeleton Gait Training on Balance, Load Distribution, and Functional Status in Stroke: A Randomized Controlled Trial – Full Text

Background: As a result of stroke, patients have problems with locomotion and transfers, which lead to frequent falls. Recovery after stroke is a major goal of rehabilitation, but it is difficult to choose which treatment method is most beneficial for stroke survivors. Recently, powered robotic exoskeletons are used in treatment to maximize the neural recovery of patients after stroke, but there are no studies evaluating the changes in balance among patients rehabilitated with an exoskeleton.

Purpose: The aim of this study was to evaluate the effects of Ekso GT exoskeleton-assisted gait training on balance, load distribution, and functional status of patients after ischemic stroke.

Methods: The outcomes are based on 44 patients aged 55–85 years after ischemic stroke who were previously randomly assigned into two groups: experimental (with Ekso GT rehabilitation) and control (with classical rehabilitation). At baseline and after 4 weeks of treatment, the patients were evaluated on balance, load distribution, and functional status using, respectively a stabilometric platform, the Barthel Index, and the Rivermead Mobility Index.

Results: In the experimental group, balance improved regarding the variables describing sway area as ellipse major and minor axes. In the control group, improvement was noted in sway velocity. After the therapy, total load distribution on feet in both groups showed a small and insignificant tendency toward reduction in the amount of uninvolved limb loading. In the control group, significant load transfer from the backfoot to the forefoot was noted. Both forms of rehabilitation caused significant changes in functional status.

Conclusions: Both training with the use of the Ekso GT exoskeleton and classical physiotherapy lead to functional improvement of patients after ischemic stroke. However, in the experimental group, improvement was observed in a larger number of categories, which may suggest potentially greater impact of treatment with the exoskeleton on functional status. Also, both forms of rehabilitation caused significant changes in balance, but we have noted some trends indicating that treatment with exoskeleton may be more beneficial for some patients. The load transfer from the backfoot to the forefoot observed in the control group was an unfavorable phenomenon. We suggest that the Ekso GT exoskeleton may be a promising tool in the rehabilitation of patients after stroke.


Stroke is the third leading cause of death worldwide and is the most common cause of disability among adults (12). As a result of stroke, patients have problems with locomotion and transfers, which lead to frequent falls. People with hemiparesis have uneven distribution of body mass between the sides of the body, causing balance and coordination disorders, deep and superficial sensation, increased muscle tone, and fear of falling (23). Patients have problems with lack of normal postural muscle tone, and proper reciprocal innervation as well as normal, automatic movement patterns and balance reactions (4). Some studies have reported that balance alterations significantly limit the physical activity of stroke patients, which may be the reason for deconditioning of patients in the chronic phase and reduction in their gait possibilities as well as other activities of daily living (5). That is why gait rehabilitation and also balance therapy are very important in improving the quality of everyday and social life of those patients (6).

Gait training may improve not only strength, endurance, and coordination of the lower limbs but also the entire body of the patient, influencing general fitness and endurance, balance, normalization of muscle tone, and functional improvement (7). The Barthel Index (BI) and Rivermead Mobility Index (RMI) tests are considered to be proper criteria for assessing a patient’s functional state after stroke and good indicators of the effectiveness of the applied therapy (89).

Recovery after stroke is a major goal of rehabilitation, but it is difficult to choose which treatment method is most beneficial for stroke survivors. Recently, powered robotic exoskeletons are used in treatment to maximize the neural recovery of patients after stroke (1011). However, in a review paper, Louie and Eng (12) have reported that only four different types of powered exoskeletons have been studied among a small number of stroke patients, and the published data were controversial. Moreover, in the available literature, there are no studies evaluating the changes in balance among patients rehabilitated with an exoskeleton. Most authors have reported various aspects of walking, and only a few papers have presented data concerning changes in balance. Additionally, most of the studies used subjective tools such as the Berg Balance Scale (1314). There is a lack of studies in which changes in balance and load distribution due to rehabilitation with the exoskeleton would be examined using an objective tool—stabilometric platform; therefore, this study undertakes this task for the first time.

The aim of this study was to evaluate the effectiveness of rehabilitation with Ekso GT exoskeleton in patients after ischemic stroke and to compare this type of therapy with the classical model of rehabilitation. The novelty of this study was the verification of the robot-assisted gait training effects on balance, load distribution, and functional status of stroke patients.[…]

Continue —-> Frontiers | Effects of Exoskeleton Gait Training on Balance, Load Distribution, and Functional Status in Stroke: A Randomized Controlled Trial | Neurology

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[WEB PAGE] Go Digital To Aid Standing and Walking in Rehab. Here’s How – Rehab Managment

Go Digital To Aid Standing and Walking in Rehab. Here’s How


Virtual reality video games, activity monitors, and handheld computer devices can help people stand as well as walk, according to an Australia-based study published in PLoS Medicine looking at the effects of digital devices in rehabilitation.

The trial took place in Sydney’s Liverpool Hospital, Bankstown-Lidcombe Hospital, and Adelaide’s Repatriation General Hospital, and included 300 participants ranging in age from 18 to 101 years old who were recovering from strokes, brain injuries, falls, and fractures.

Participants used on average four different devices while in hospital and two different devices when at home. Fitbits were the most commonly used digital device, but also tested on people in hospital and at home were a suite of devices like Xbox, Wii and iPads, making the exercises more interactive and enabling remote connection with their physiotherapist.

The digital devices included virtual reality video games, activity monitors, and handheld computer devices aimed at enabling a higher dose of therapy.

Those who exercised using digital devices in addition to their usual rehabilitation were found to have better mobility (walking, standing up and balance) after 3 weeks and 6 months, according to a media release from University of Sydney.

Patients using the digital devices in rehabilitation reported benefits including variety, fun, feedback about performance, cognitive challenge, enabled additional exercise, and potential to use the devices with others (eg, family, therapists, and other patients), the study’s lead author, Dr Leanne Hassett from the University of Sydney, notes in the release.

“These benefits meant patients were more likely to continue their therapy when and where it suited them, with the assistance of digital health care,” says Hassett, from the university’s Faculty of Medicine and Health.

People were young at heart when it came to devices, she adds.

“Participants loved Fitbits; one woman would demand to put it on in the middle of the night before she went to the toilet, to make sure all her steps were counted,” shares Hassett, who is a Senior Research Fellow in the Institute for Musculoskeletal Health and Senior Lecturer in the Discipline of Physiotherapy.

“This model of rehabilitation therapy proved to be feasible and enjoyable, and demonstrated that it could be used across different care settings, such as post-hospital rehabilitation, with mostly remote support by the physiotherapist.

“The study shows that future physical rehabilitation models should look at including digital devices to improve both inpatient and post-hospital rehabilitation,” she suggests.

The next step will be to trial the approach into clinical practice by incorporating it into the work of physiotherapists; recruitment for this is likely in 12 to 18 months, the release concludes.

[Source(s): University of Sydney, MedicalXPress]


via Go Digital To Aid Standing and Walking in Rehab. Here’s How – Rehab Managment

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[ARTICLE] The effects of Ai Chi for balance in individuals with chronic stroke: a randomized controlled trial – Full Text


This study investigated the effectiveness of Ai Chi compared to conventional water-based exercise on balance performance in individuals with chronic stroke. A total of 20 individuals with chronic stroke were randomly allocated to receive either Ai Chi or conventional water-based exercise for 60 min/time, 3 times/week, and a total of 6 weeks. Balance performance assessed by limit of stability (LOS) test and Berg balance scale (BBS). Fugl-Meyer assessment (FMA) and gait performance were documented for lower extremity movement control and walking ability, respectively. Excursion and movement velocity in LOS test was significantly increased in anteroposterior axis after receiving Ai Chi (p = 0.005 for excursion, p = 0.013 for velocity) but not conventional water-based exercise. In particular, the improvement of endpoint excursion in the Ai Chi group has significant inter-group difference (p = 0.001). Both groups showed significant improvement in BBS and FMA yet the Ai Chi group demonstrated significantly better results than control group (p = 0.025). Ai Chi is feasible for balance training in stroke, and is able to improve weight shifting in anteroposterior axis, functional balance, and lower extremity control as compared to conventional water-based exercise.


Stroke is a cerebral vascular disease caused by the interruption of the blood supply to the brain, cutting off the supply of oxygen and nutrients1. Damage to the brain tissue leads to sensory, motor, cognitive, and emotional deficits. With impaired motor and sensory functions, stroke patients suffer from deficits in balance control which plays crucial role in ambulatory function and thus as an important clinical indicator2,3,4,5. Balance is defined as the ability to maintain center of mass (COM) within the stability limits, the boundaries of the base of support (BOS)6. Balance control can be quantified by limit of stability (LOS) test, expressed by movement velocity, displacement excursion, and directional control7,8. Individuals with stroke usually show decline in the abovementioned balance performance9,10,11,12. Bohannon13 noted the correlation between static standing ability and independent mobility in stroke patients (r = 0.62). Lee et al.14 found that walking velocity is associated with maximal displacement excursion in LOS test (r = 0.68, p < 0.01) and Berg balance scale (r = 0.66, p < 0.01) in patients with stroke. In addition, the balance-related fall risks should also be addressed in people with chronic stroke15,16. Therefore, it is crucial to improve balance control in order to improve the balance-related activities for individuals with stroke.

Several elements, such as strengthening, postural control, weight shifting, and agility exercise, are necessary to be incorporated during balance training17. It has also been noted that increased somatosensory inputs and visual deprivation might exert positive effects on top of balance training, as well as enriched environment4,5,18,19. Water-based exercise, by utilizing the properties of water, including buoyancy, viscosity, turbulence, and hydrostatic pressure, has been suggested to improve balance control20,21. Two reviews summarized that the water-based exercise for neurological disorder covers a wide variety, including resistance training, movement facilitation, motor control training, balance training, coordination training and other specific techniques21,22. They indicated that stroke patients improved significantly more in weight shifting ability, dynamic balance, and functional mobility as compared with the land-based intervention21,22.

Ai Chi, first developed by Jun Konno in 1990s23, is one kind of water-based exercise emphasizing characteristics of balance training24. It resembles Tai Chi on land, complemented by Zen shiatzu and Watsu concepts25. Ai Chi is composed of 16 katas (movements), including breathing, upper extremity movements, lower extremity movements, trunk control, and coordinated movements23. With the properties and advantages of water, less weight bearing is required and larger displacement can be achieved. Currently, some studies have mentioned the benefits of Ai Chi for neurological involved patients21,22. Bayraktar et al. showed positive effects of 8 weeks of Ai Chi training on muscle strength, muscle endurance, functional mobility, and fatigue severity in patients with multiple sclerosis26. Noh et al. found that the balance performance and knee flexors strength improved more in the Ai Chi combining Halliwick therapy group than the conventional physiotherapy group in patients with stroke27. Pérez-de la Cruz et al. also showed the feasibility of Ai Chi on balance and functional capacity for people with Parkinson’s disease28.

Taking together, water-based exercise is beneficial for balance performance in patients with stroke. Ai Chi is a specific water-based exercise which emphasizes the characteristics of balance control. However, whether Ai Chi can exert better effect on balance performance than conventional water-based exercise in people with stroke is not known. The aim of this study was to compare the effects of Ai Chi training with conventional water-based exercise on balance performance in people with stroke. We hypothesized that Ai Chi can result in superior effects on balance control than conventional water-based exercise people with stroke. […]

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[ARTICLE] Does a novel exergame challenge balance and activate muscles more than existing off-the-shelf exergames? – Full Text



Novel balance-targeting exergames controlled with off-the-shelf hardware, were developed based on current recommendations for balance training in healthy older adults and documented shortcomings of existing games. The aim of this study was to explore the feasibility of these novel exergames as training tool for elderly and, more specifically whether these games can elicit more challenging weight shifts and higher levels of muscle activity compared to existing off-the-shelf exergames. Furthermore, the motivational pull in these new games was studied.


Sixteen healthy older adults were recruited to play the novel games and two reference games that were found to be the most challenging ones in terms of weight shifts or muscle activity in previous studies. Weight shifts were expressed relative to participants’ Functional Limits of Stability (FLOS). Muscular challenge of the games was quantified by dividing the signal into 200 ms blocks and determining the average muscle activity within these blocks. The muscle activity was normalized to maximal voluntary contractions (MVC) to categorize the blocks in zones of < 40, 40–60, 60–80 and > 80% MVC. Subsequently, the number of blocks per intensity level and the number of consecutive blocks above 40% were determined. Motivation to play the games was assessed using the Intrinsic Motivation Inventory (IMI) and scores between the games were analyzed using Generalized Estimated Equations (GEE).


The novel exergames successfully elicited center of mass (COM) displacements with medians of around 80% of FLOS or higher for all directions. Furthermore, the COM displacements in the novel games were larger for each direction than in the reference games, although for one game the sideward left direction reached significance only at the third trial. Compared to the existing games, longer blocks of muscle activation above 40% MVC were found, but overall intensity remained low. IMI scores were high on all subscales, indicating that older adults experienced the games as motivating.


We conclude that affordable hardware can be used to create challenging and enjoyable balance training programs using exergames. The exergames that were successful in eliciting challenging weight shifts and muscle activity should now be further studied in longitudinal randomized controlled interventions, to assess effects on balance, muscle strength and eventually fall risk in healthy older adults.


Studies report that 30–40% of people older than 65 will fall at least once per year and about 10–20% of these falls will result in hospitalization [12]. The number of people aged 65 and older will increase due to the demographic developments worldwide, which will further increase the total number of falls [3]. Major risk factors for falling are an age-related decrease in functional capabilities, especially in balance control and muscle strength [45]. Multidimensional training programs have been shown to ameliorate these risk factors and reduce fall risk in older adults. This is especially the case when strength training and sufficiently challenging balance exercises are provided for at least 3 h per week [1267]. However, ongoing participation in a training program is needed to prevent fading of the benefits due to the progressive strength and balance decline caused by aging [26]. As long-term, structural supervised training is costly, home-based training appears most promising for long-term effects. Sadly, adherence to traditional home-based training programs is low due to the repetitive nature of the exercises, lack of perceived usefulness and therefore motivation [89].

The use of computer games to aid in balance training for older adults, also called exergames balance training, receives increasing attention [10,11,12]. In this study, exergames are defined as computer games using commercial consoles as the Wii and the Kinect console and that are controlled with body movements. Different commercial games are already available that might have a balance training potential [10,11,12]. Potential benefits of exergames over conventional training are: an increase in motivation and thereby adherence [13], the option to offer dual task training [14], the option to provide different forms of feedback [15] and to adapt the training intensity to the skill level of the player so that individualized progression is possible. However, the latter is not always possible in commercial games. Despite these promising features, systematic reviews report varying results on balance [10,11,12], possibly due to the wide variability in games that have been studied and the fact that these games were not specifically developed with the aim to improve balance in older adults. In conventional balance training, strength and specific balance training were shown to be key elements in preventing falls [261617]. It is recommended that balance training is sufficiently challenging by requiring weight-shifts to the limits of stability, by reducingthe base of support (BOS) [6], or by adding a cognitive task. For strength training, it is recommended in literature that the muscles are sufficiently challenged by increasing the intensity of the exercises or the number of repetitions, so that the muscles will fatigue [18]. The American College of Sports Medicine defined the threshold for hypertrophy and strength gains to be 60% of the one-repetition maximum [19]. However, exercises with external weights are unpractical in VR training, which is often performed at home. Recent research showed that strength exercises at low loads, but with high velocities, can induce muscle activations comparable to training with high loads [20]. Furthermore, these low-load exercises also seem to induce benefits for strength and balance in older adults [21]. Finally, ongoing participation in the training program is recommended to prevent fading of the gained benefits [6]. A study that analysed the challenge of balance provided by off-the-shelf games showed that balance is challenged to a varying extent, but that ample room for improvements is left. Moreover, it was found that adaptation to or learning the game, as trials advanced, resulted in a decreasing challenge in some games [2223]. From the analysis of muscle activity in seven off-the shelf games, it was concluded that overall muscle activation was low and that longer periods of muscle activation were scarce [24]. Only the games that required faster movements elicited some muscle activity that seemed challenging enough to be considered as a training impulse [24].

The motivational pull of exergame balance training with off-the-shelf games, was assessed in older adults and results showed that playing exergames can lead to strong intrinsic motivation [25]. Especially games that provide positive feedback resulted in high intrinsic motivation. Furthermore, physically active games containing variation seemed to be the preferred game mechanics [25].

Based on the above summarized recommendations for balance training (e.g. sufficiently challenging balance tasks and strength exercises that lead to muscle fatigue), an exergame package for balance training for older adults was developed [246]. The aim of the current study was to evaluate whether the novel set of exergames (called Virbal), which are controlled with off-the-toy-shelf technologies, are feasible and well-suited from a content perspective for balance training in elderly. The novel games were evaluated to see whether they were more challenging in terms of balance movements and muscle activity than existing off-the shelf games. Furthermore, the novel exergames were evaluated on how motivating they are for older adults. Games were compared regarding the challenge imposed to balance in terms of magnitude of center of mass (COM) displacements and regarding the muscle activation elicited in terms of intensity and duration of muscle activation. Motivation was evaluated using questionnaires on motivation.



via Does a novel exergame challenge balance and activate muscles more than existing off-the-shelf exergames? | Journal of NeuroEngineering and Rehabilitation | Full Text


Screenshots of the mini games of the Virbal game. The overarching game is presented in the middle. From this overarching game different mini games are chosen

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[WEB SITE] Electrotherapy Exposed!

Electrotherapy Exposed!

by Kelly Armstrong, OTR/L, MPP-MPS

How Does Electrotherapy Actually Relieve Pain?

From a biomedical prospective, all cellular activity stems from the phenomenon of electrical charge, and all healing requires a change in cellular electrical activity for success. When a muscle or tissue is injured, the injury alters the bio-electrical state of the cells, called “the current of injury.” These electrically imbalanced cells disrupt the cellular exchange process (metabolism) and negatively influence the autonomic nervous system, causing sympathetic upregulation and imbalances of the autonomic nervous system. Cellular “current of injuries” lead to loss of ATP, muscle tonicity/spasm, and chronic pain.

Therefore, to understand how electrotherapy relieves pain is to understand how electrotherapy influences imbalances of the autonomic nervous system (ANS). There are two key branches of the ANS: parasympathetic (rest and healing) and sympathetic (flight/fight/stress). It is the sympathetic system in flight/fight phase that appears to causes most health problems in humans. During SNS flight/fight phase, hormones are released and blood moves from organs to muscles to prepare for engagement. Originally designed for short-term survival, in modern society long-term nervous system stress combined with trauma often produce a lengthened and elevated state of sympathetic upregulation, resulting in chronic pain and disease. Physical traumas to the body, such as surgical scars and injuries, misalignments of the sacrum, jaw, spine, tight muscles, and blocked energetics accumulatively upregulate the SNS. One key theory in managing chronic pain and improving functionality is to learn how to deregulate the sympathetic nervous system using electrotherapy.

Electrotherapy Modalities’ Influence On the Autonomic Nervous System

Why some devices are more successful at managing pain than others may have more to do with the strength of the stimulation they produce. And, it appears, stronger is not always better.

Discovered by 19th-century scientists, the “Arndt-Shultz Law” states that weak stimuli accelerates physiologic activity, and medium to strong stimuli inhibits or even halts physiologic activity.1 Applying this law to modern electro-physiology, some of the success of currents applied at low micro amperage levels is due to the ability to sympathetically deregulate the autonomic nervous system and place the patient into a self-healing parasympathetic state.

TENS: Transcutaneous electrical nerve stimulation (TENS). The United States Food and Drug Administration (FDA) classifies all electro-therapy devices as TENS, regardless of the range of electrical current applied through the skin. The traditional and popular TENS units are used as a prescription device for pain control in most clinics. Traditional TENS units are applied with AC current in the milliamperage.

TENS is usually applied at high frequency (>50 Hz) with an intensity below motor contraction (sensory intensity) or low frequency (<10 Hz) with an intensity that produces motor contraction.2-5 Frequency and amplitude of TENS produces “gate control theory of pain management,” and AC TENS has not been clinically documented to provide autonomic nervous system balance.

MENS: Microcurrent Electrical Nerve Stimulation (MENS) applies extremely small microcurrent (less than 1 milliamperage) electrical impulses to nerves using either pads or point stimulation. Microcurrent units are engineered and built to closely approximate the body’s naturally occurring bio-electric currents, and they produce electrical currents just above the levels of the electrical exchanges of the cellular level in the human body. The theory behind microcurrent therapy is that introducing micro impulses into the body restores cellular balance of positive and negative electrons, positively influencing the autonomic nervous system and accelerating the body’s own healing mechanisms.

Since microamperes are close to the electrical level of the body’s cells, when injured cells become electrically imbalanced, the application of microcurrent helps return the damaged cells to a normal bio-electrical state, re-initiating cellular activity. Research has shown that microcurrent impulses enhance three variables critical to healing: ATP (adenosine triphosphate), Protein synthesis, and Cellular Membrane transport.6-8

One detailed study by Cheng showed microcurrent applied at low levels (10 to 500 microamps) increased ATP production by 500%, protein synthesis by 70%, and metabolism (cell transport) by 40%.6-8 These three variables are critical to healing patients, and are triggered only in a parasympathetic phase. The same research documented that amplitude levels above 1 Ma inhibited ATP, protein synthesis, and cellular membrane transport, all of which are inhibited or blocked in a sympathetic state.

This documented phenomena suggests of a “sympathetic threshold” around 1 milliamperage, with current <1 Ma producing a healing parasympathetic state and current >1 Ma producing further sympathetic upregulation. Is it possible the Arndt-Shultz Law theorized 200 years ago may strongly apply to electro-therapy?

EA: Electro-acupuncture (EA) is a form of acupuncture electro-therapy where a small current, either DC or AC, is applied via point stimulation directly into acupuncture/trigger points without skin puncture. Electro-acupuncture is quite similar to traditional acupuncture in that the same points are often used during treatment, just without the use of needles.9-12 One advantage EA has over traditional acupuncture is that a practitioner does not have to be as precise as with needles, since almost all devices on the market have a “point locator” which measures variances in skin resistance and “detects” acupuncture and trigger points.

EA devices fall into two categories on the market. One category is AC point stimulators, which produce current levels well into the millamperage (Ma) range and frequencies in the 10-15 hz range. The second category is DC point stimulators, which deliver an impulse in the low to medium microcurrent (50-800 mca) range, usually in the 2-4 hz range.

Additionally, EA devices can provide the benefits of integrating traditional acupuncture principles into the clinical setting. Since acupuncture has now been clinically proven to provide “a significant tool for balancing the ANS,”13-16 integrating EA into any pain setting can often provide additional outcomes to suffering patients.

Additional Beneficial Pain Modalities

LASERS: Laser technology is another noninvasive form of treatment for healing local tissues. This technology consists of using red and infrared light to irradiate abnormal tissue with photons. The cellular molecules in the tissue will absorb the energy particles. This absorption will stimulate the cell to produce more energy and to speed up the healing process. When more energy is available to cells, it stimulates healing in the body. In typical treatments the laser is placed over the injured area. There are a variety of lasers that range in wavelengths and strength of applications, with class 4 and class 3b lasers used by therapists in rehab settings as pain-relief tools.

TAPING: Therapeutic tape is an elastic cotton strip with an acrylic adhesive that is used for the purposes of treating pain and disability. Taping is a popular technique that can be applied during a clinical treatment session to facilitate healing after manual therapy. Taping may help with acute soft-tissue injuries such as muscle strains, ligament sprains, and bruising or swelling. Therapists can use taping for muscle facilitation for weak or low tone as well as to help keep joints in alignment or stable. Taping is a great tool to follow therapeutic work to assist outside of the clinic with posture. Furthermore, taping is beneficial for a variety of other issues such as bone injuries, tendinopathies, fasciopathies, systemic conditions, swelling, and edema.

TA: Topical analgesics are analgesics applied to the skin surface and associated with a lower risk of side effects than oral analgesics. There are four types of topical analgesics: counter-irritants, topical NSAIDS, capsaicin creams, and local anesthetics. Some are available as over-the-counter products, while others are available by prescription. These products may be a beneficial addition for temporary pain relief during rehabilitation. Several topical agents have been shown to be useful in short-term relief.17

Hot and cold therapy can also be of assistance in healing tissues. Application of cold packs/ice slow down the blood flood or circulation to the injured tissues and reduces inflammation, muscle spasms, and pain. Cold should be applied in the first 24 to 48 hours after an injury to decrease pain, swelling, and inflammation. Heat opens up the blood flow to the area and promotes oxygen to the tissue to relax muscles and decrease pain. Heat can also be applied during the healing process before stretching and exercises to improve range of motion.

Achieve Balance to Optimize Healing

The bottom line in helping provide pain relief is a thorough knowledge of what causes the body to heal deep inside. Key in my own practice has been cultivating an understanding that the ultimate therapeutic goal is to “swing” patients into a parasympathetic state, and to do this, the “current of injury” has to be cellularly reversed. This is an important first step that sometimes is missed.

After ANS balance, all other therapeutic techniques/modalities will be much more effective. After SNS deregulation, apply hot/cold applications and topical analgesics for acute pain and muscle relaxation, then perform your stretches/exercises with more compliance, no guarding, and better outcomes. RM

Kelly Armstrong, OTR/L, MPP-MPS, has been a practicing occupational therapist for more than 23 years and holds a bachelor of science in occupational therapy from the University of Alabama at Birmingham. For more information, contact


  1. Arndt-Schulz law: the pharmacologic principle of homeopathy and healing, discovered by 19th century scientists, Hugo Schulz and Rudolf Arndt, stating that weak stimuli accelerate physiologic activity, medium stimuli inhibit physiologic activity, and strong stimuli halt physiologic activity.
  2. Ottoson D, Lundeberg T. Pain Treatment by Tens/Transcutaneous Electrical Nerve Stimulation: A Practical Manual. Springer-Verlag; 1988.
  3. Sjolund B, Eriksson M. Relief of Pain by Tens: Transcutaneous Electrical Nerve Stimulation
  4. Chen C, Tabasam G, Johnson M. Does the pulse frequency of transcutaneous electrical nerve stimulation (TENS) influence hypo analgesia? A systematic review of studies using experimental pain and healthy human participants. Physiotherapy. 29008;94(1):11-20.
  5. Chesterton LS, Barlas P, Foster NE, Lundeberg T, Wright CC, Baxter GD. Sensory stimulation (TENS): effects of parameter manipulation on mechanical pain thresholds in healthy human subjects. Pain. 2002;99:253-262.
  6. Cheng N, Van Hoof H, Bockx E, et al. The effects of electric currents on ATP generation, protein synthesis, and membrane transport in rat skin. Clin Orthop Relat Res. 1982;171:264-272.
  7. Carley PJ, Wainapel SF. Electrotherapy for acceleration of wound healing: low intensity direct current. Arch Phys Med Rehabil. 1985;66(7):443-446.
  8. Becker RO. Cross Currents: The Perils of Electropollution, the Promise of Electromedicine. G.P. Putnam’s Sons.
  9. Fisher HW. Acute low back pain treated by spinal manipulation and electronic acupuncture. J Manipulative Physiol Ther. 1992;15(3):199-202.
  10. Cheng R, McKibbon L, Roy B, Pomeranz B. Electroacupuncture elevates blood cortisol levels in naive horses; sham treatment has no effect. Int J Neurosci. 1980;10(2-3):95-97.
  11. Cheng RS, Pomeranz B, Yu G. Electroacupuncture treatment of morphine-dependent mice reduces signs of withdrawal, without showing cross-tolerance. Eur J Pharmacol. 1980;68(4):477-481.
  12. Imai K, Ariga H, Takahashi T. Electroacupuncture improves imbalance of autonomic function under restraint stress in conscious rats. Am J Chin Med. 2009;37(1):45–55
  13. Noguchi E. Acupuncture regulates gut motility and secretion via nerve reflexes. Auton Neurosci. 2010;156(1-2):15-18.
  14. Sakatani K, Kitagawa T, Aoyama N, Sasaki M. Effects of acupuncture on autonomic nervous function and prefrontal cortex activity. Adv Exp Med Biol. 2010;662:455-460.
  15. Uchida S, Kagitani F, Hotta H. Neural mechanisms of reflex inhibition of heart rate elicited by acupuncture-like stimulation in anesthetized rats. Auton Neurosci. 2010;157(1-2):18–23.
  16. Li QQ, Shi GX, Xu Q, Wang J, Liu CZ, Wang LP. Acupuncture effect and central autonomic regulation. Evid Based Complement Alternat Med. 2013;2013:267959. doi: 10.1155/2013/267959. Epub 2013 May 26.
  17. Gibbs M. The role of transdermal fentanyl patches in the effective management of cancer pain. Int J Palliat Nurs. 2009;15(7):354–359.

This article originally appeared in the January/February print issue of Rehab Management, and posted online January 22, 2016.


via Electrotherapy Exposed! – Rehab Managment

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