Posts Tagged Balance

[Abstract] Validity and reproducibility of the Functional Gait Assessment in persons after stroke


To evaluate construct validity and reproducibility of the Functional Gait Assessment (FGA) for measuring walking balance capacity in persons after stroke.

Cross-sectional study.

Inpatient and outpatient rehabilitation center.

Fifty-two persons post-stroke (median (25% and 75% percentiles)) time post-stroke 6 (5–10) weeks) with independent walking ability (mean gait speed 1.1 ± .4 m/s).

Subjects completed a standardized FGA twice within one to eight days by the same investigator. Validity was evaluated by testing hypotheses on the association with two timed walking tests, Berg Balance Scale, and the mobility domain of the Stroke Impact Scale using correlation coefficients (r), and with Functional Ambulation Categories using the Kruskal–Wallis test. Reproducibility of FGA scores was assessed with intraclass correlation coefficient and standard error of measurement.

Subjects scored a median of 22 out of 30 points at the first FGA. Moderate to high significant correlations (r .61–.83) and significant differences in FGA median scores between the Functional Ambulation Categories were found. Eight hypotheses (80%) could be confirmed. Inter-rater, intra-rater, and test–retest reliability of the total scores were excellent. The standard error of measurement and minimal detectable change were 2 and 6 points, respectively. No relevant ceiling effect was observed.

The FGA demonstrated good measurement properties in persons after stroke and yielded no ceiling effect in contrast to other capacity measures. In clinical practice, a measurement error of 6 points should be taken into account in interpreting changes in walking balance.

via Validity and reproducibility of the Functional Gait Assessment in persons after stroke – Maijke Van Bloemendaal, Walter Bout, Sicco A Bus, Frans Nollet, Alexander CH Geurts, Anita Beelen, 2018

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[WEB SITE] Effects of Mirror Therapy on Walking Ability, Balance and Lower Limb Motor Recovery After Stroke

Leanne Loranger, PT, Manager Policy and Practice    August 2, 2018

Full Citation

Li Y, Wei Q, Gou W, He C. Effects of mirror therapy on walking ability, balance and lower limb recovery after stroke: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation 2018; DOI: 10.1177/0269215518766642.1


“Stroke is the leading cause of death and disability in Canada.”2 Up to half of people with stroke-related hemiplegia cannot walk independently after rehabilitation;1 however, independent mobility is often a priority for people following stroke.

Mirror therapy involves the use of a mirror placed in the mid-sagittal plane to create the illusion that the affected limb is performing the movements that the unaffected limb is performing. It has been theorized that the visual feedback can help to prevent or reduce learned non-use of the affected limb. Mirror therapy first became common in the rehabilitation of stroke-related upper extremity dysfunction, but more recently has been used in the rehabilitation of lower limbs.

The authors conducted a systematic review and meta-analysis of randomized controlled trials of the use of mirror therapy in the rehabilitation of stroke-related lower-limb impairments.


  • Systematic search of MEDLINE, EMBASE, Web of Science, CENTRAL, Physiotherapy Evidence Database, CNKI, VIP, Wan Fang,, and Current Controlled Trials, conducted according to PRISMA guidelines.
  • Study Inclusion Criteria:
    • Randomized Controlled Trials
    • Patients > 18 years of age with stroke
    • More than five subjects in the study
    • Compared mirror to no intervention, a different intervention, or a control group with the same therapeutic intervention minus mirror therapy
    • Provided original data or sufficient information about at least one outcome to allow inclusion in Meta-analysis
    • Published in English or Chinese
  • The PEDro Scale was used to assess quality of included studies.
    • Scores ranged from five to eight points
    • Six studies were rated “good quality” while seven were rated “fair quality”
  • Meta-analysis was conducted using RevMan 5.3.
  • Subgroup analysis was conducted to establish the effectiveness of treatment depending on recovery stage (acute, subacute, or chronic) and nature of the treatment intervention (movement of unaffected limb only, or bilateral movement).
  • A total of 13 studies, representing 572 patients were included in the meta-analysis.
  • Timing of interventions ranged from six days to 16 months post-stroke.
  • Six studies involved bilateral movements, while in seven only the unaffected side was moved.
  • Frequency ranged from three to six days per week.
  • Duration of treatment ranged from two weeks to three months.


  • Significant improvement in walking speed compared with control group, measured by 10-meter walk test.
    • Both bilateral and unilateral movements led to improved walking speed.
  • No significant improvement in mobility, measured by Timed Up and Go or Functional Ambulatory Category.
  • Significant treatment effect for balance, measured by the Berg Balance Scale or Brunnel Balance Assessment.
  • Significant effect on lower limb motor recovery, measured by the Fugl-Meyer or Brunnstrom Scale.
  • No significant effect on spasticity of ankle muscles.
  • Significant improvement in PROM of ankle dorsiflexion.


The main finding of this systematic review and meta-analysis was that “patients with stroke who received mirror therapy had significant improvements in walking speed, balance, lower limb motor recovery and passive range of motion of ankle dorsiflexion.”1 However, although the findings were statistically significant, they “seemed to have little clinical significance.” For example, the average improvement in walking speed after mirror therapy treatment would not lead to a change in patient categorization from “house-hold ambulator” to “limited community ambulator.”


  • Considerable study heterogeneity regarding treatment frequency and duration may have impacted on the strength of the study findings.
  • Relatively small number of studies and total patients included.

Relevance to physiotherapy practice in Alberta

Mirror therapy shows some promise for lower limb rehabilitation of people who have experienced a stroke, leading to statistically significant changes in gait speed, balance, motor recovery and range of motion. However, current research findings show that effects may have limited clinically significance. More research is needed to determine the frequency, duration, timing and parameters of mirror therapy that may result in clinically significant effects, and the patient populations that derive greatest benefit from the intervention, if any.


The purpose of this summary is to highlight recently published research findings that are not openly accessible. Every effort is made to ensure accuracy and clarity of the summary. Readers are encouraged to review the published article in full for further information.


  1. Li Y, Wei Q, Gou W, He C. Effects of mirror therapy on walking ability, balance and lower limb recovery after stroke: A systematic review and meta-analysis of randomized controlled trials. Clinical Rehabilitation 2018; DOI: 10.1177/0269215518766642
  2. Physiotherapy Alberta – College + Association. Physiotherapy Works for Stroke. Available at Accessed July 13, 2018.

via Physiotherapy Alberta College + Association : The Movement Specialists: Research in Focus: Effects of Mirror Therapy on Walking Ability, Balance and Lower Limb Motor Recovery After Stroke

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[Abstract] Effects of mirror therapy on walking ability, balance and lower limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials

To investigate the effects of mirror therapy on walking ability, balance and lower limb motor recovery in patients with stroke.

MEDLINE, EMBASE, Web of Science, CENTRAL, PEDro Database, CNKI, VIP, Wan Fang,, Current controlled trials and Open Grey were searched for randomized controlled trials that investigated the effects of mirror therapy on lower limb function through January 2018. The primary outcomes included were walking speed, mobility and balance function. Secondary outcomes included lower limb motor recovery, spasticity and range of motion. Quality assessments were performed with the PEDro scale.

A total of 13 studies (n = 572) met the inclusion criteria. A meta-analysis demonstrated a significant effect of mirror therapy on walking speed (mean difference (MD) 0.1 m/s, 95% confidence interval (CI): 0.08 to 0.12, P < 0.00001), balance function (standard mean difference (SMD) 0.66, 95% CI: 0.43 to 0.88, P < 0.00001), lower limb motor recovery (SMD 0.83, 95% CI: 0.62 to 1.05, P < 0.00001) and passive range of motion of ankle dorsiflexion (MD 2.07°, 95% CI: 082 to 3.32, P = 0.001), without improving mobility (SMD 0.43, 95% CI: −0.12 to 0.98, P = 0.12) or spasticity of ankle muscles (MD −0.14, 95% CI: −0.43 to 0.15, P = 0.35).

The systematic review demonstrates that the use of mirror therapy in addition to some form of rehabilitation appears promising for some areas of lower limb function, but there is not enough evidence yet to suggest when and how to approach this therapy.


via Effects of mirror therapy on walking ability, balance and lower limb motor recovery after stroke: a systematic review and meta-analysis of randomized controlled trials – Yi Li, Qingchuan Wei, Wei Gou, Chengqi He, 2018

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[Fact Sheet] Recovery After Stroke: Movement And Balance – PDF file

Moving around safely and easily may not be something you think about, unless you’ve had a stroke. Many stroke survivors have trouble moving around. These problems range from balance issues to arm or leg paralysis. As a result, about 40 percent of stroke survivors have serious falls within a year of their strokes. But, there is good news. Rehab and therapy may improve your balance and ability to move.

Download this fact sheet

via National Stroke Association at

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[Abstract] Cranial nerve non-invasive neuromodulation improves gait and balance in stroke survivors: A pilot randomised controlled trial

First page of article

Cranial nerve non-invasive neuromodulation (CN-NINM) is delivered using a Portable Neuromodulation Stimulation (PoNS™) device that stimulates two cranial nerve nuclei (trigeminal and facial nerve nuclei) using electrodes embedded in a mouthpiece that rests on the tongue. Danilov and colleagues reported that prolonged and repetitive (20 minutes or more) tongue stimulation coupled with specific training of balance and gait can initiate long-lasting neuronal reorganization that can be measured in participants’ behaviour [1].

via Cranial nerve non-invasive neuromodulation improves gait and balance in stroke survivors: A pilot randomised controlled trial – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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[Abstract] Stabilometric analysis of the effect of postural insoles on static balance in patients with hemiparesis: A randomized, controlled, clinical trial



Stroke is one of the main causes of disability among adults.


The aim of the present study was to analyze the effect of postural insoles on static balance in individuals with stroke.


Twenty-four strokes survivors with hemiparesis were recruited from the rehabilitation clinics of the university and randomly allocated to two groups: experimental and control group. The subjects were analyzed for stabilometry, immediately following insole placement and after three months of insole usage, with eyes open and eyes closed.


A significant difference was found immediately after postural insole placement regarding anteroposterior range of movement (p < 0.05). Moreover, significant reductions were found in the inter-group analysis after three months of insole usage.


Based on the present findings, postural insoles combined with conventional physical therapy offer significant benefits regarding static postural control among stroke victims after three months of use, as demonstrated by computerized stabilometry.

via Stabilometric analysis of the effect of postural insoles on static balance in patients with hemiparesis: A randomized, controlled, clinical trial – Journal of Bodywork and Movement Therapies

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[Brochure] THE FUTURE IS MOVING – Revolutionizing Functional Movement Therapy – HOCOMA


Conventional therapy today is limited—by time, by number of repetitions, by
the lack of reproducible movement quality and by the fact that it is strenuous for both therapists and patients. In other words: there is a disbalance between the therapy we know we should provide according to motor learning principles and all the factors that prevent us from reaching this goal.[…]

Download Brochure (PDF file)

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[WEB SITE] AFOs and balance issues in peripheral neuropathy


At a symposium in Cape Town, South Africa, an orthotist demonstrated his technique for treating balance issues in patients with peripheral neuropathy using ankle foot orthoses (AFOs), and a team of researchers theorized about evidence-based concepts that could help explain his findings.

By Cary Groner

A symposium at the recent 2017 World Congress of the International Society for Prosthetics and Orthotics (ISPO)1 shed new light on a long-vexing question: How can clinicians help patients with peripheral neuropathy improve their balance using ankle foot orthoses (AFOs)?

People with severe neuropathy typically have trouble with balance and gait, partly because they receive little or none of the sensory information the rest of us get from the plantar surfaces of the feet. That input helps most people manage the body’s ever-swaying center of mass, much of which is controlled at the ankle. If the ankle lacks the necessary plantar feedback, the whole kinetic chain is destabilized, and people must compensate with movements at the knee, hip, and trunk. The result is often difficulty maintaining balance while standing and walking.

Unfortunately, there’s a paucity of research on interventions that might address the problem, so clinicians have largely been left to their own devices. AFOs are often prescribed for conditions that affect joint stability and positioning, pressure distribution, and neuro­muscular issues, and research suggests they can be effective for adjusting various gait parameters.2 A 2010 systematic review in the Journal of Prosthetics & Orthotics (JPO), moreover, reported that although rigid AFOs seemed to facilitate static balance, dynamic balance problems were usually better treated with more flexible leaf-spring devices.2 But unfortunately, little of this research is directly applicable to patients with neuropathy, whose concerns include the risk of falls.

LER has previously reported that, although AFOs can be helpful for improving balance, their utility for preventing falls is open to question—and, for most patients with impaired balance, falls present the biggest danger.3 Part of the issue is that balance itself is achieved via a complex system of visual, cognitive, motor, vestibular, proprioceptive, and neurological functions at both the central and peripheral levels.3 The goal is to maintain the body’s center of gravity within the base of support while a patient is stationary (static balance), and to control the center of mass in dynamic situations such as walking (dynamic balance).2

Applying constraint theory to AFOs for peripheral neuropathy, one reduces the degrees of freedom at the ankle to let the patient control what they can easily control.

So, when Paul Charlton, MSc, a senior orthotist at Peacocks Medical Group in Newcastle Upon Tyne, UK, showed Stefania Fatone, PhD, BPO(Hons) some of the results he was getting by treating patients with neuropathy using rigid AFOs, she took notice. Fatone, an associate professor in physical medicine and rehabilitation at Northwestern University in Chicago, put together a team of researchers to examine Charlton’s methods and consider a theoretical underpinning that could help explain his findings.

The ISPO symposium was the result; it included Charlton and Fatone, as well as Cleveland Barnett, PhD, a senior lecturer in biomechanics at Nottingham Trent University in the UK, and Nerrolyn Ramstrand, PhD, BPO(Hons), an associate professor of prosthetics and orthotics at Jonkoping University in Sweden and coauthor of the 2010 review in JPO.

Paul Charlton, MSc, and a healthy volunteer demonstrate his technique for assessing balance in patients with peripheral neuropathy. He starts by asking patients to stand still, to establish a baseline (left). He then has the patient sit. He sits opposite them and positions his knees just below theirs, at the top of their tibias. He grasps the back of the patient’s calves near the top and pulls them toward him, so the tibias are slightly inclined. He has the patient stand as he does this—essentially mimicking the effects of a rigid AFO (center and right). (Photos courtesy of Paul Charlton, MSc.)


“Paul’s videos of his patients’ results are really startling, because you see dramatic changes,” Fatone said. “We wanted to try to elucidate the mechanism by which he was getting those effects.”

Charlton’s four presented case studies comprised different diagnostic pathologies, Fatone explained, but all the patients had peri­pheral neuropathy in common.

“Initially, we wanted to talk about orthotic function with regard to a diagnosis; if you have a stroke you do this, if you have Parkinson’s you do this, if you have MS [multiple sclerosis] you do this,” she continued. “But Paul’s approach was less about diagnosis and more about evaluating the person’s sensation and how that influenced balance. He developed a way to assess whether the peripheral neuro­pathy is the primary contributor to balance problems.”

Charlton explained his process (see images above) to LER.

“Balance is so complex that as a clinician, I have to start by determining which mechanism is affecting it,” he said. “I can’t address all of those causes, but I know I can have an impact on peripheral neuropathy. So, I want to start by confirming that condition and assessing their proximal control.”

He starts by asking his patients to stand still; it’s difficult for many of them, but those who do it more easily are then asked to move their feet closer together, which increases the postural challenge. Those who manage that reasonably well are then asked to close their eyes.

“That baseline isn’t just for me,” Charlton said. “It also gives the patient a better understanding of their level of impairment, of how poor their balance is. If they can stand still with their feet together and their eyes closed, the [rigid] AFO intervention I use is probably too aggressive.”

Once he’s established the baseline, Charlton has the patients sit. He sits opposite them and positions his knees just below theirs, at the top of their tibias. He then grasps the back of the patient’s calves near the top and pulls them toward him, so the tibias are slightly inclined forward and clamped between his hands and his knees. He then has the patient stand as he does this—essentially mimicking the effects of a rigid AFO.

Patients with peripheral neuropathy are usually much steadier during this process than when standing on their own, he said.

“They’ll say, ‘Well of course I’m steadier, you’re holding me still,’ but I’m only holding them below the knees,” Charlton said. “The point is that if I make their ankle rigid this way, then they can more effectively use the balance mechanisms at their knees, hips, and proximally, because they’re on a stable base. My proposition is that their balance is actually normal, apart from that distal segment. When their ankle is stabilized, they use their knees more effectively, and they become less dependent on their eyesight to maintain their balance.”

Charlton emphasized the importance of the forward tibial incline, as well.

“It doesn’t have to include ankle dorsiflexion,” he said. “I usually use heel lifts to pitch them forward to what I feel is optimal, which is usually around seven degrees. My feeling is that the ground reaction force [GRF] vector should be posterior to the center of the knee joint through midstance. I think what we’re doing with alignment is putting more appropriate demands on the neuromuscular system; you want a flexion moment at the knee, so you’re using your quadriceps and gluteals to keep yourself up.”

Charlton explained, further, that the tibial incline angle varies with the length of the shank; if the ideal is to position the knee joint 1 cm ahead of the GRF vector, a long-shanked person would require a smaller inclination angle to achieve that position than someone with a shorter shank.

“That’s my hypothesis, anyway, for which I have no proof,” he said with a laugh.

But there’s proof, and then there’s proof. Does Charlton have randomized controlled trials? No. But he does have compelling videos of patients walking with dramatically more normalized gait.

“I can show what I see clinically, anyway,” he added. “Then I ask the academics to prove it.”


At the ISPO symposium, the academics did their best to comply.

“My role was to look at things from a theoretical perspective,” said Cleveland Barnett. “I’m a biomechanist by trade, so I was trying to explain Paul’s results using biomechanical principles and motor control theories. My orientation is dynamical-systems theory, which is based on the constraints-led approach.”

Briefly, the approach notes humans have “motor abundance”—that is, lots of ways to achieve a given task. If you want to scratch your nose, there are essentially infinite ways in which you can bring the tip of your fingernail to the skin atop your alar cartilage, involving positional changes at the hand, wrist, elbow, and shoulder. A “constraint,” in this context, is just what it sounds like—the placing of a restriction on one or more aspects of that movement menu.

Does Charlton have randomized controlled trials? No. But he has compelling videos of patients with peripheral neuropathy walking with dramatically more normalized gait.

“If you have peripheral neuropathy, you’ll have poor control at the ankle, but your more proximal control may be very good,” Barnett said. “If you fix the ankle joint with an AFO, you reduce the need for neuromuscular control at that joint. When we’re learning something, we are usually quite rigid and stiff; then, as we get better at it, we loosen up, allow for more variation. So, if someone finds a given task difficult, you can help by imposing a constraint, which helps them explore how to coordinate their other movements. Paul freezes the ankle joint with an AFO, which allows patients to stop worrying about controlling the ankle and use the control they have at the knee and hip. In watching his videos, I’ve never seen interventions work so quickly.”

Stef Fatone concurred.

“If you can reduce a task to its least complex form and block redundant degrees of freedom, then people can learn the task more easily,” Fatone said. “In Paul’s approach, we’re using constraint theory to reduce the degree of freedom at the ankle joint and let the person control what they can easily control, where they have feedback and sensation. We’re not necessarily training them, but we’re taking away the thing they can’t control and letting them work with everything else more effectively.”

The literature

Part of the challenge involved in conducting a broad theoretical inquiry into the problem is that what scant literature there is tends to be uneven in its findings. As LER has reported previously, for example, researchers aren’t always certain whether AFOs work by affecting gait mechanics, sensory feedback, or both.3-5

“It’s really difficult to divorce those two things,” Fatone acknowledged. “If someone was completely paralyzed, with no sensation, and the AFO provided a corrective response to postural perturbations, you could say, ‘OK, we’re definitely seeing a mechanical input.’ I suppose you could test that using a nerve block, but does the benefit of what you might learn from that outweigh the risks? It’s a tough study to do. We know that our population of neuropathy patients has diminished sensation, but the amount and kind of sensation loss varies. Is it proprioceptive, touch-receptive, mechanoreceptive— what, exactly, is diminished? It’s very hard to discriminate. The orthosis could be acting in different ways, and teasing those out in any given study is extremely challenging.”

Fatone argues the lack of appropriate studies doesn’t mean researchers are flying completely blind, however.

“We haven’t found any studies that investigated rigid AFOs directly in patients with peripheral neuropathy,” she said. “The study that would test the scenarios Paul is enacting in his clinic, with the exact kind of people he works with, hasn’t been done. But we do have studies that have investigated rigid AFOs more broadly, in mixed populations, and we can infer certain things from that—
including that it’s not unreasonable that rigid AFOs would facilitate static balance in those with neuropathy, because they’ve done it in other populations.”

For example, some studies have shown that AFOs have positive effects on gait regularity6 and postural stability5 in neuropathic patients, and one found that auxiliary sensory cues improved automatic postural responses in those with diabetic neuropathy.7 However, a 2016 systematic review reported that in the absence of randomized controlled trials, the literature offered little consistent evidence of efficacy.8

Since coauthoring the 2010 review mentioned earlier, Nerrolyn Ramstrand has continued to monitor the literature, and she told LER that it offers little justification for changing her conclusions.

“We said that the rigid AFO was good for static balance, and that a leaf-spring design was better for dynamic balance, and I think the literature still supports those conclusions,” Ramstrand said. “I’m a researcher, I’m interested in evidence-based practice, and from a purely academic point of view, there’s no evidence to support the theory that rigid AFOs will help neuropathic patients with dynamic balance. But the modern definition of evidence-based practice includes both the literature and individual clinical experience, and obviously Paul can’t ignore his own experience. You have to consider that, as well as the patient’s desires, in addition to the literature.”

Ramstrand noted, too, that there’s an inherent tension between the demands of a research environment, in which conclusions can be drawn only in the presence of experimental uniformity across a cohort of participants, and the practical exigencies of a clinic, where treatments must be customized according to the clinician’s experience and the patient’s needs.

“People haven’t been using rigid AFOs in neuropathy patients because they didn’t think they were useful,” Ramstrand said. “But now we may need to go back and say, ‘OK, there are people having success with these, so why is that?’”

She noted, too, that clinicians may need to distinguish pathology from clinical presentation in their patient evaluations.

“We have to stop talking about pathologies with this cookbook approach to orthotic prescription,” she said. “Instead, we need to ask what’s behind the patient’s clinical presentation—muscle strength, range of motion, all those things. Then we can consider what might be the most appropriate orthosis for that condition: How well are its mechanical properties suited to managing the clinical presentation of that patient? Different orthosis designs can achieve the exact same goal. There’s lots to figure out, and I think we’ve really just started to identify some of the problems.”

Barnett agreed.

“Instead of talking about individual AFOs, you may say that this type of AFO may have this type of effect,” he said. “But beyond that, I think one of Paul’s points is that a given patient’s treatment depends very much on how that patient presents. Two people with different diagnoses can have similar functional deficits, and for the deficits Paul was seeing, I think rigid AFOs are definitely beneficial; they clearly allow people to do things they couldn’t do before. Never mind the intricacies of the biomechanics: If they’re able to walk farther or faster, it’s likely they’re going to feel better about themselves. If they’re able to walk to the shops unaided with a rigid AFO rather than a flexible one, it’s better for their physical and mental health.”


In Barnett’s presentation, he suggested that once patients become comfortable and better balanced with rigid AFOs, it might be possible to loosen them up and allow more of their natural flexibility.

“Long-term, my feeling is that if you put a constraint like that on someone and they make progress, it’s a question of how long you let them use that before you try to challenge them again,” he said. “The theory would suggest that if you slowly allow an increase in articulation, reduce the rigidity of the AFO, they would start to learn to control that to some extent. They might find it difficult at first—their neuro­pathy might limit them—but they could gradually get used to it.”

Paul Charlton respectfully differed, however.

“I’m slightly skeptical of that,” he acknowledged. “If the patient has a range of motion in a joint that they can’t control, then I see benefit from fixing them in an optimum position. If you give them more movement, it’s fine if they have the control to use it, but if they don’t, you’re not doing them any favors. It depends on the pathology and the patient’s potential. Some peripheral neuropathies can improve, such as in Guillain-Barré syndrome, or in patients with an insult to the central nervous system such as a stroke or a brain injury. For such patients to progress, they should be given more range of movement by reducing the stiffness of the AFO. But in patients where there isn’t that potential for improvement, I doubt if it would work.”

Fatone emphasized the degree to which Charlton customizes his AFOs, for that matter. In his presentation, only one of the cases involved a patient with diabetic peripheral neuropathy, for example, and he fabricated a specially designed external orthosis for her.

“In that case, he made an AFO with a rigid, lateral carbon-fiber strut that attached to the base of her diabetic footwear,” Fatone explained. “The others had more typical AFOs that went into the shoe and had plastic directly in contact with the foot, but in her case he used a completely different strategy to achieve the same control, so that it didn’t change the pressure experienced by her foot. The only problem was that she started walking so much more that her shoes weren’t able to protect her from the increased activity level, and she started to have tissue breakdown in her feet. So you can never win, right?”

Charlton acknowledged another problem, as well: His patients are sometimes intimidated by their new capabilities.

“Quite often the patients have developed a lot of compensations in their gait,” he said. “Then, suddenly, they’re in a situation where they get a real heel strike. They go from that to foot flat, and their tibia is pushed forward, and it’s a shock to their system. They’re walking more normally, but it’s scary, it takes practice, and I really have to persuade them to stay with it. But if I can convince them to do that, a more normal gait comes very quickly.”

Charlton emphasized that his approach isn’t out of the reach of most clinicians.

“None of this is high-tech,” he said. “It’s simple, it’s practical, and it uses existing technology. And it provides a framework as to the patients for whom it might best be applied.”

Down the road

Fatone said that Charlton’s work, along with the admittedly vague messages from the literature, are pointing a way forward for future research.

“I think we’re evolving a theoretical framework for the kinds of hypotheses we want to test,” she said. “We know what the gaps in the literature are, and by looking at those, as well as at the work that’s been done well, it allows you to design a better research project. That, coupled with the fact that we now have a good hypothesis based on a theoretical understanding of what we think is going on, puts us in a better position to design a study to answer the question of how Paul is getting such good results.”

Cary Groner is a freelance writer in the San Francisco Bay Area.

Source: AFOs and balance issues in peripheral neuropathy | Lower Extremity Review Magazine

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[ARTICLE] Feasibility and Effectiveness of Virtual Reality Training on Balance and Gait Recovery Early after Stroke: A Pilot Study – Full Text


Objective: To investigate the feasibility and effectiveness of virtual reality training for improving balance and/or gait during inpatient rehabilitation of patients within 12 weeks after stroke.

Methods: Sixteen patients within 12 weeks after stroke and dependent gait as categorised with a Functional Ambulation Category score of 2 or 3 were included in this longitudinal pilot study. Participants received eight 30-min sessions of virtual reality training during four weeks as part of the regular inpatient rehabilitation program. Feasibility was assessed using compliance with the training, adverse events, experiences of the participants and the physiotherapists; and effectiveness with the Berg Balance Scale, centre of pressure velocity, Functional Ambulation Category and 10-meter walking test.

Results: Participants positively evaluated the intervention and enjoyed the training sessions. Also, physiotherapists observed the training as feasible and beneficial for improving balance or gait. Compliance with the training was 88% and no serious adverse events occurred. The Berg Balance Scale, anterior-posterior centre of pressure velocity, Functional Ambulation Category and 10-meter walking test showed significant improvement after four weeks of training (p<0.05).

Conclusion: This study demonstrates that virtual reality training in patients early after stroke is feasible and may be effective in improving balance and/or gait ability.


Balance and gait recovery are considered as key aspects in stroke rehabilitation [13]. To date, physiotherapy and occupational therapy focus on high intensity, repetitive and task-specific practice, which are important principles of motor learning, to elicit improvements in the early rehabilitation phase [1,4,5]. In addition to high intensity, repetitive and task-specific training, variability in practice is important for motor learning. Also, cognitive involvement, functional relevance and the presence of feedback enhance learning [5]. In current physiotherapy or occupational therapy it is difficult to meet all of these above-mentioned training characteristics as therapy may be tedious and resource-intensive [69]. In addition, the frequency and intensity of current therapies have been indicated as insufficient to achieve maximum recovery in the early phase of rehabilitation [8,10]. There is need for engaging, motivating and varied therapy that achieves maximal recovery [11].

In recent years, virtual reality (VR) is introduced in the field of balance and gait rehabilitation after stroke [12]. Since VR training is characterised by individualised, high intensity training in a variety of virtual environments with a high amount of real-time feedback [1315] it might be valuable in stroke rehabilitation. This is confirmed by recent studies [12,1518]. However, almost all studies on the effect of VR on balance and/or gait ability were conducted in the chronic phase after brain injury [9,12,16,17,1923]. Because of the potential relevant characteristics of VR for motor learning and neuroplasticity [14], VR may be of even more added value during the earlier rehabilitation phase. Three studies [2426] that investigated the effect of VR in this time period after stroke indicated a positive effect of commercially available VR systems (Nintendo Wii Fit or IREX) on balance and/or gait recovery. However, the results of these studies cannot be generalised to the whole population of patients with stroke because included participants had a relatively high functional level regarding balance and gait at the start of the VR intervention. A lack of studies including patients with lower functional status after stroke might be caused by the idea that the feasibility of using advanced VR technology may be restricted because of visual, cognitive and/or endurance impairments. These impairments are more often present in the more impaired patients early after stroke [2729]. Because of the expected promising effects of VR training for the recovery of balance and gait in patients with low functional level early after stroke, it is important to investigate the feasibility of this innovative form of training and to determine whether the above-mentioned impairments interfere with the use of VR training early after stroke.

Therefore, the aim of the present study was to investigate the feasibility and effectiveness of VR training for improving balance and/or gait during the inpatient rehabilitation of patients with stroke. The specific research questions were:

• What is the feasibility, from the perspective of patients and physiotherapists, of VR training aimed to improve balance and gait ability?

• What is the effectiveness of VR training, embedded within an inpatient rehabilitation program, on balance and gait ability in people with impaired balance and dependent gait within 12 weeks after stroke?


Study design

This longitudinal pilot study involved two assessments, one before and one after a four-week VR training intervention, performed within the inpatient rehabilitation program of patients with stroke at (Revant Rehabilitation Centres, Breda, the Netherlands).


Patients with stroke who were following an inpatient rehabilitation program with a treatment goal to improve balance and/or gait. They received balance and/or gait training with VR as part of their regular rehabilitation program. Besides the VR training, the regular rehabilitation program could include therapy given by a physiotherapist, occupational therapist, speech therapist, psychomotor therapist, psychologist and social worker, depending on the goals of the patient with stroke. Inclusion criteria consisted of hemiplegia resulting from a stroke, a time since stroke of less than 12 weeks, a Berg Balance Scale (BBS) score of at least 20, i.e. the minimum level of balance deemed safe for balance interventions [30], and a Functional Ambulation Category (FAC) score of 2 or 3 out of 5 [31]. Exclusion criteria were patients with stroke with terminal diseases, lower-limb impairments not related to stroke, severe cognitive impairments, severe types of expressive or receptive aphasia, visual impairments, age over 80 years and experiencing epileptic seizures. All participants provided written consent to use data obtained during the rehabilitation program for research, and anonymity was assured. The study procedures follow the principles of the Declaration of Helsinki.

VR training intervention

The intervention consisted of balance and gait training using the recently developed treadmill based Gait Real-time Analysis Interactive Lab (GRAIL, Motekforce Link, Amsterdam, The Netherlands). The GRAIL comprises a dual-belt treadmill with force platform, a motion-capture system (Vicon, Oxford, UK) and speed-matched virtual environments projected on a 180° semi-cylindrical screen (Figure 1) [32].


Continue —> Feasibility and Effectiveness of Virtual Reality Training on Balance and Gait Recovery Early after Stroke: A Pilot Study | Open Access Journals

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Objective: To evaluate the influence of transcutaneous electrical nerve stimulation in patients with stroke through a systematic review and meta-analysis.

Methods: PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases were searched systematically. Randomized controlled trials assessing the effect of transcutaneous electrical nerve stimulation vs placebo transcutaneous electrical nerve stimulation on stroke were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome was modified Ashworth scale (MAS). Meta-analysis was performed using the random-effect model.

Results: Seven randomized controlled trials were included in the meta-analysis. Compared with placebo transcutaneous electrical nerve stimulation, transcutaneous electrical nerve stimulation supplementation significantly reduced MAS (standard mean difference (SMD) = –0.71; 95% confidence interval (95% CI) = –1.11 to –0.30; p =0.0006), improved static balance with open eyes (SMD = –1.26; 95% CI = –1.83
to –0.69; p<0.0001) and closed eyes (SMD = –1.74; 95% CI = –2.36 to –1.12; p < 0.00001), and increased walking speed (SMD = 0.44; 95% CI = 0.05 to 0.84; p = 0.03), but did not improve results on the Timed Up and Go Test (SMD = –0.60; 95% CI=–1.22 to 0.03; p = 0.06).

Conclusion: Transcutaneous electrical nerve stimulation is associated with significantly reduced spasticity, increased static balance and walking speed, but has no influence on dynamic balance.

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