Posts Tagged Balance

[Abstract] Ergometer training in stroke rehabilitation: systematic review and meta-analysis

Abstract

Objective

Ergometer training is routinely used in stroke rehabilitation. How robust is the evidence of its effects?

Data source

The PubMed database and PEDro database were reviewed prior to 22/01/2019.

Study selection

Randomized controlled trials investigating the effects of ergometer training on stroke recovery were selected.

Data extraction

Two reviewers independently selected the studies, performed independent data extraction, and assessed the risk of bias.

Data synthesis

A total of 28 studies (including 1115 stroke subjects) were included. The data indicates that

(1) ergometer training leads to a significant improvement of walking ability, cardiorespiratory fitness, motor function and muscular force of lower limbs, balance and postural control, spasticity, cognitive abilities, as well as the brain’s resistance to damage and degeneration,

(2) neuromuscular functional electrical stimulation assisted ergometer training is more efficient than ergometer training alone,

(3) high-intensity ergometer training is more efficient that low-intensity ergometer training, and

(4) ergometer training is more efficient than other therapies in supporting cardiorespiratory fitness, independence in activities of daily living, and balance and postural control, but less efficient in improving walking ability.

Conclusion

Ergometer training can support motor recovery after stroke. However, current data is insufficient for evidence-based rehabilitation. More data is required about the effects of ergometer training on cognitive abilities, emotional status, and quality of life in stroke subjects.

via Ergometer training in stroke rehabilitation: systematic review and meta-analysis – Archives of Physical Medicine and Rehabilitation

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[Abstract] A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors

Abstract

BACKGROUND:

Stroke is a leading cause of death and disability in the Western world, and leads to impaired balance and mobility.

OBJECTIVE:

To investigate the feasibility of using a Virtual Reality-based dual task of an upper extremity while treadmill walking, to improve gait and functional balance performance of chronic poststroke survivors.

METHODS:

Twenty-two individuals chronic poststroke participated in the study, and were divided into 2 groups (each group performing an 8-session exercise program): 11 participated in dual-task walking (DTW), and the other 11 participated in single-task treadmill walking (TMW). The study was a randomized controlled trial, with assessors blinded to the participants’ allocated group. Measurements were conducted at pretest, post-test, and follow-up. Outcome measures included: the 10-m walking test (10 mW), Timed Up and Go (TUG), the Functional Reach Test (FRT), the Lateral Reach Test Left/Right (LRT-L/R); the Activities-specific Balance Confidence (ABC) scale, and the Berg Balance Scale(BBS).

RESULTS:

Improvements were observed in balance variables: BBS, FRT, LRT-L/R, (P < .01) favoring the DTW group; in gait variables: 10 mW time, also favoring the DTW group (P < .05); and the ABC scale (P < .01). No changes for interaction were observed in the TUG.

CONCLUSIONS:

The results of this study demonstrate the potential of VR-based DTW to improve walking and balance in people after stroke; thus, it is suggested to combine training sessions that require the performance of multiple tasks at the same time.

 

via A Preliminary Study of Dual-Task Training Using Virtual Reality: Influence on Walking and Balance in Chronic Poststroke Survivors. – PubMed – NCBI

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[Abstract] Effect of functional electrical stimulation plus body weight-supported treadmill training for gait rehabilitation in patients with poststroke – a retrospective case-matched study.

Abstract

BACKGROUND:

Functional electrical stimulation (FES) plus body weight-supported treadmill training (BWSTT) provide effective gait training for poststroke patients with abnormal gait. These features promote a successful active motor relearning of ambulation in stroke survivors.

AIM:

This is a retrospective study to assess the effect of FES plus BWSTT for gait rehabilitation in patients poststroke.

DESIGN:

A retrospective case-matched study.

SETTING:

Participants were recruited from a rehabilitation department in an acute university-affiliated hospital.

POPULATION:

Ninety patients poststroke from Yue Bei People’s Hospital underwent BWSTT (A: control group) were compared to an equal number of cross-matched patients who received FES plus BWSTT (B: FES plus BWSTT group).

METHODS:

While B group received FES for 45 minutes plus BSWTT for 30 minutes in the program, group A received time-matched BWSTT alone. The walking speed, step length, step cadence, Fugl-Meyer lower-limb scale (LL-FMA), composite spasticity scale (CSS), 10-Meter Walk Test (10MWT), Tinetti Balance Test (TBT) and nerve physiology testing were collected before and after intervention.

RESULTS:

One hundred and eighty patients with poststroke abnormal gait were chosen. There were significant differences in walking speed, step length, step cadence, LL-FMA, CSS, TBT, and 10MWT between baseline and post-intervention (P<0.05). There were significant differences in walking speed, step length, step cadence, LL-FMA, CSS, TBT, and 10MWT between two groups at the end of the eighth week (P<0.05), but not at baseline (P>0.05). In comparison with group A, the peak of somatosensory evoked potential (SEP) and motor evoked potential (MEP) amplitude increased, the latency was shortened, and the conduction velocity of sensory nerve (SCV) and motor nerve (MCV) was significantly increased in the group B (P < 0.05). No adverse events occurred during the study.

CONCLUSIONS:

This study suggests that FES plus BWSTT could be more effective than BWSTT alone in the improvement of gait, balance, spasticity, and function of the lower limb in patients poststroke.

CLINICAL REHABILITATION IMPACT:

Introduce effective rehabilitation strategies for poststroke patients with abnormal gait.

 

via Effect of functional electrical stimulation plus body weight-supported treadmill training for gait rehabilitation in patients with poststroke-a ret… – PubMed – NCBI

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[Abstract] Evaluating the effectiveness of aquatic therapy on mobility, balance, and level of functional independence in stroke rehabilitation: a systematic review and meta-analysis

To meta-analyze and systematically review the effectiveness of aquatic therapy in improving mobility, balance, and functional independence after stroke.

Articles published in Medline, Embase, CINAHL, PsycINFO, and Scopus up to 20 August 2019.

Studies met the following inclusion criteria: (1) English, (2) adult stroke population, (3) randomized or non-randomized prospectively controlled trial (RCT or PCT, respectively) study design, (4) the experimental group received >1 session of aquatic therapy, and (5) included a clinical outcome measure of mobility, balance, or functional independence.

Participant characteristics, treatment protocols, between-group outcomes, point measures, and measures of variability were extracted. Methodological quality was assessed using Physiotherapy Evidence Database (PEDro) tool, and pooled mean differences (MD) ± standard error and 95% confidence intervals (CI) were calculated for Functional Reach Test (FRT), Timed Up and Go Test (TUG), gait speed, and Berg Balance Scale (BBS).

Nineteen studies (17 RCTs and 2 PCTs) with a mean sample size of 36 participants and mean PEDro score of 5.6 (range 4–8) were included. Aquatic therapy demonstrated statistically significant improvements over land therapy on FRT (MD = 3.511 ± 1.597; 95% CI: 0.381–6.642; P = 0.028), TUG (MD = 2.229 ± 0.513; 95% CI: 1.224–3.234; P < 0.001), gait speed (MD = 0.049 ± 0.023; 95% CI: 0.005–0.094; P = 0.030), and BBS (MD = 2.252 ± 0.552; 95% CI: 1.171–3.334; P < 0.001).

While the effect of aquatic therapy on mobility and balance is statistically significant compared to land-based therapy, the clinical significance is less clear, highly variable, and outcome measure dependent.

via Evaluating the effectiveness of aquatic therapy on mobility, balance, and level of functional independence in stroke rehabilitation: a systematic review and meta-analysis – Alice Mary Iliescu, Amanda McIntyre, Joshua Wiener, Jerome Iruthayarajah, Andrea Lee, Sarah Caughlin, Robert Teasell,

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[Abstract] Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review

Abstract

BACKGROUND:

Virtual reality (VR) has emerged as a therapeutic tool facilitating motor learning for balance and gait rehabilitation. The evidence, however, has not yet resulted in standardized guidelines. The aim of this study was to systematically review the application of VR-based rehabilitation of balance and gait in 6 neurologic cohorts, describing methodologic quality, intervention programs, and reported efficacy.

METHODS:

This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. VR-based treatments of Parkinson disease, multiple sclerosis, acute and chronic poststroke, traumatic brain injury, and cerebral palsy were researched in PubMed and Scopus, including earliest available records. Therapeutic validity (CONTENT scale) and risk of bias in randomized controlled trials (RCT) (Cochrane Collaboration tool) and non-RCT (Newcastle-Ottawa scale) were assessed.

RESULTS:

Ninety-seven articles were included, 68 published in 2013 or later. VR improved balance and gait in all cohorts, especially when combined with conventional rehabilitation. Most studies presented poor methodologic quality, lacked a clear rationale for intervention programs, and did not utilize motor learning principles meticulously. RCTs with more robust methodologic designs were widely recommended.

CONCLUSION:

Our results suggest that VR-based rehabilitation is developing rapidly, has the potential to improve balance and gait in neurologic patients, and brings additional benefits when combined with conventional rehabilitation. This systematic review provides detailed information for developing theory-driven protocols that may assist overcoming the observed lack of argued choices for intervention programs and motor learning implementation and serves as a reference for the design and planning of personalized VR-based treatments.

 

via Advantages of virtual reality in the rehabilitation of balance and gait: Systematic review. – PubMed – NCBI

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[Abstract] Functional Balance and Postural Control Improvements in Patients with Stroke after Non-Invasive Brain Stimulation: A Meta-Analysis

Highlights

  • NIBS improved deficits in functional balance and postural control post stroke.
  • The treatment effects on postural imbalance were significant following rTMS.
  • The improvements after rTMS appeared in acute, subacute, and chronic patients.
  • A higher number of rTMS sessions significantly increased the treatment effects.

Abstract

Objectives

The postural imbalance post stroke limits individual’s walking abilities as well as increase the risk of falling. We investigated the short-term treatment effects of non-invasive brain stimulation (NIBS) on functional balance and postural control in patients with stroke.

Data Sources

We started the search via PubMed and ISI’s Web of Science on March 1, 2019 and concluded the search on April 30, 2019.

Study Selection

The meta-analysis included studies that used either repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) for the recovery of functional balance and postural control post stroke. All included studies used either randomized control trial or crossover designs with a sham control group.

Data Extraction

Three researchers independently performed data extraction and assessing methodological quality and publication bias. We calculated overall and individual effect sizes using random effects meta-analysis models.

Data Synthesis

The random effects meta-analysis model on the 18 qualified studies identified the significant positive effects relating to NIBS in terms of functional balance and postural control post stroke. The moderator variable analyses revealed that these treatment effects were only significant in rTMS across acute/subacute and chronic stroke patients whereas tDCS did not show any significant therapeutic effects. The meta-regression analysis showed that a higher number of rTMS sessions was significantly associated with more improvements in functional balance and postural control post stroke.

Conclusions

Our systematic review and meta-analysis confirmed that NIBS may be an effective option for restoring functional balance and postural control for patients with stroke.

via Functional Balance and Postural Control Improvements in Patients with Stroke after Non-Invasive Brain Stimulation: A Meta-Analysis – Archives of Physical Medicine and Rehabilitation

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[Abstract] Effects of Exergame on Patients’ Balance and Upper Limb Motor Function after Stroke: A Randomized Controlled Trial.

Abstract

BACKGROUND:

Stroke is a major cause of motor incapacity in adults and the elderly population, requiring effective interventions capable of contributing to rehabilitation. Different interventions such as use of exergames are being adopted in the motor rehabilitation and balance area, as they act as motivating instruments, making therapies more pleasurable.

OBJECTIVE:

The aim of this study was to investigate the effects of exergame on patients’ balance and upper limb motor function after stroke.

METHODS:

This study is a randomized controlled trial. Thirty-one participants of both genders, mean age of 76 years, were assigned to the experimental or control groups; the experimental group (n = 16) underwent exergame rehabilitation using Motion Rehab AVE 3D, and the control group (n = 15) underwent conventional physiotherapy. Both EG and GC sessions happened twice a week, for 30 minutes each, over a 12 weeks period, resulting in 24 sessions. All sessions were composed of similar exercises, with same purpose and elapsed time (5 minutes). Instruments applied to verify inclusion criteria were a sociodemographic questionnaire and clinical aspects and a Mini-Mental State Examination. At baseline and after 12 weeks of intervention, the Modified Ashworth Scale, the Fugl-Meyer Assessment, and the Berg Balance Scale were used.

RESULTS:

In both groups, patients obtained significant improvement from baseline values in all analyzed variables (shoulder, elbow, and forearm; wrist; hand; and balance) (P < .001). In the intergroup comparison, there were significant differences between the 2 groups for changes in values from preintervention to postintervention of shoulder, elbow and forearm (P = .001), and total (P = .002).

CONCLUSION:

Exergame rehabilitation in poststroke patients can be an efficient alternative for restoring balance and upper limb motor function and might even reduce treatment time.

via Effects of Exergame on Patients’ Balance and Upper Limb Motor Function after Stroke: A Randomized Controlled Trial. – PubMed – NCBI

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[BLOG POST] How To Cope with Sensory Overload after Brain Injury

How To Cope with Sensory Overload after Brain Injury

Sensory overload, also known as hypersensitivity, occurs when the brain’s filters no longer work properly. Unlike a healthy brain, which can identify and filter out irrelevant or unnecessary information, an injured brain often cannot.

As a result, normal, everyday stimuli can be uncomfortable, overwhelming, or unbearable. Sounds that before your injury were barely noticeable may be alarming and uncomfortable. Crowds may feel overwhelming. Clothing that was once comfortable may be irritating. Bright light can be distressing and might give you a headache.

Flooded is a word that is often used to describe the overstimulated brain. A brain that is flooded with information can shut down or freeze. It can become difficult or even impossible to continue a conversation or make a decision. Agitation and anxiety are common symptoms, but some may even experience panic attacks, nausea, or vomiting.

Hypersensitivity is more common after a mild brain injury, whereas people with severe brain injuries more often experience a loss of sensory function.

Types of Sensory Overload

Sensory overload can affect one, several, or all the senses.

  1. Sight (light intensity, light color)
  2. Sound
  3. Smell
  4. Touch (heat, cold, pressure)
  5. Taste
  6. Balance (movement, spatial awareness)

Factors that can Exacerbate Hypersensitivity

There are some factors that can stress your brain, lowering your ability to adapt to stimuli and exacerbating hypersensitivity. It is good to keep these in mind and plan accordingly.

  1. Fatigue
  2. Lack of sleep
  3. Pain
  4. Heat

Common Symptoms of Sensory Overload

  1. Fatigue
  2. Unable to think clearly
  3. Unable to respond/ feeling “frozen”
  4. Anxiety
  5. Agitation
  6. Panic attacks
  7. Difficulty breathing
  8. Migraine
  9. Nausea/vomiting

How to Deal with Sensory Overload

Common Triggers and Coping Suggestions

Note Hypersensitivity is not something that I personally deal with. If you feel that I have misrepresented any information please let me know. If you know other tips or strategies let that I have neglected to include let me know and I will promptly add them.

Light

  1. Try avoiding bright light and fluorescent lights
  2. Limit exposure to TV, phone, and computer screens
  3. Adjust electronics to display yellow light instead of blue light
  4. Wear sunglasses when needed, even indoors
  5. Wear syntonic light therapy glasses (see below)

Noise

  1. Limit time spent in noisy stores or at events
  2. Wear earplugs or noise cancelling earmuffs (see below)
  3. Ask family members to use headphones when listening to music or watching TV shows
  4. This may seem counter intuitive, but for some people adding quiet, calming background noise can help – sound machine, fan, or peaceful music
  5. When attending an event that you know will be taxing, plan to stay for a short time and/or plan time to rest afterwards
  6. If you feel a situation start to become overwhelming, excuse yourself to a quiet place like the bathroom, close your eyes, and take slow deep breaths

Crowds

  1. Go grocery shopping and run other errands early in the morning
  2. Eat at restaurants between meal times when they are less busy
  3. Plan time to rest after going out

How to Cope with Sensory Overload after Brain Injury - How To Brain

More General Coping Strategies

Planning

Plan any even that could potentially lead to overstimulation. You may need to plan time to rest before and after the event or plan to only stay for part of the event. Sometimes it may even be helpful to plan what you will do if things do not go as expected.

Make a grocery list before going shopping. If there is a chance that the store might not carry an item, consider if you will buy a substitute or go without.

If you are attending an event for the first time since your injury and do not know how it will affect you, explain this to the people joining you. When going to the movies, a concert, or a sporting event it may be a good idea to sit towards the back. It will be slightly less stimulating and you will be able to leave easily, if the need should arise.

Include other senses

Identify the stimuli that is bothering you and add in one that isn’t. For example, if a sound is bothersome try sucking on a peppermint or cinnamon candy. Or if a crowd is overwhelming squeezing a stress ball.

Syntonic light therapy glasses

I would love to get feedback from you guys on this one. Prior to researching for this post, I had not heard of syntonic therapy. But, if the claims made about it are true, it seems that many survivors could benefit from syntonic therapy.

Syntonic therapy glasses have colored lens. Depending on your symptoms, a certain color can be prescribed to alter signals the brain is sending and positively influence the vision system. They claim to be particularly beneficial for brain injury survivors, especially those suffering from light sensitivity and headaches.

If you are interested here is a little more information:

Explanation of Syntonic Therapy (article)
Explanation of Syntonic Therapy (short video)
Brain Injury Success Story

Musicians’ earplugs

I would suggest trying cheap foam ones from the grocery store first, as these seem to work well enough for most people. However, if you find that they do not block enough of the background noise, you can be prescribed custom earplugs by audiologist.

These custom earplugs are traditionally used by musicians but can be helpful for brain injury survivors with hypersensitivity to sound.  The article below explains the benefits of musicians’ earplugs over traditional earplugs for sound hypersensitivity resulting from brain injury.

Musicians’ Earplugs vs. Traditional Earplugs

Exposure

Try to slowly build up tolerance to the problematic stimuli. Though avoiding the stimulus entirely may be the most comfortable, doing so could increase your hypersensitivity to that stimulus overtime. When doing this pay close attention to your body and plan an “out” for yourself should you feel the need to rest.

Communication

You cannot expect family members, friends, and coworkers to know what you are going through if you have not told them. Let them know which stimuli are troublesome for you and what they can do to help – be as specific as possible.

What Can You do as a Loved One of a Survivor with Hypersensitivity?

The single biggest thing you can do is to be supportive. Ask your loved one what triggers sensory overwhelm for them and actively try to create an environment that is not overwhelming for them.

If they ask you to stop talking so that they can process what has already been said, listen to them. Do not continue talking until they are ready for you to do so.

When planning outings keep in mind that heat, pain, and lack of sleep can intensify hypersensitivity. Be understanding if they need to cut the outing short.

What coping strategies do you use to deal with hypersensitivity? 

How to Cope with Sensory Overload after Brain Injury - How To Brain

via How To Cope with Sensory Overload after Brain Injury – How To Brain

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[ARTICLE] Sensory retraining of the leg after stroke: systematic review and meta-analysis – Full Text

This systematic review aimed to investigate the effects of interventions intended for retraining leg somatosensory function on somatosensory impairment, and secondary outcomes of balance and gait, after stroke.

Databases searched from inception to 16 January 2019 included Cochrane Library, PubMed, MEDLINE, CINAHL, EMBASE, PEDro, PsycINFO, and Scopus. Reference lists of relevant publications were also manually searched.

All types of quantitative studies incorporating interventions that intended to improve somatosensory function in the leg post stroke were retrieved. The Quality Assessment Tool for Quantitative Studies was used for quality appraisal. Standardised mean differences were calculated and meta-analyses were performed using preconstructed Microsoft Excel spreadsheets.

The search yielded 16 studies, comprising 430 participants, using a diverse range of interventions. In total, 10 of the included studies were rated weak in quality, 6 were rated moderate, and none was rated strong. Study quality was predominantly affected by high risk of selection bias, lack of blinding, and the use of somatosensory measures that have not been psychometrically evaluated. A significant heterogeneous positive summary effect size (SES) was found for somatosensory outcomes (SES: 0.52; 95% confidence interval (CI): 0.04 to 1.01; I2 = 74.48%), which included joint position sense, light touch, and two-point discrimination. There was also a significant heterogeneous positive SES for Berg Balance Scale scores (SES: 0.62; 95% CI: 0.10 to 1.14; I2 = 59.05%). Gait SES, mainly of gait velocity, was not significant.

This review suggests that interventions used for retraining leg somatosensory impairment after stroke significantly improved somatosensory function and balance but not gait.

 

Somatosensory impairment is common after stroke, occurring in up to 89% of stroke survivors.1Proprioception and tactile somatosensation are more impaired in the leg than in the arm post stroke,2 with the frequency increasing with increasing level of weakness and stroke severity.2,3 Leg somatosensory impairment also has a significant impact on independence in daily activities3 and activity participation in stroke survivors,4 as well as predicts longer hospital stays and lower frequency of home discharges.5

Leg somatosensory impairment negatively influences balance and gait. Post-stroke plantar tactile deficits correlate with lower balance scores and greater postural sway in standing.6 Tactile and proprioceptive feedback provide critical information about weight borne through the limb.7 Accordingly, tactile and proprioceptive somatosensory deficits may hinder paretic limb load detection ability, potentially leading to reduced weight-bearing and contributing to balance impairment and falls post stroke.8 Indeed, stroke survivors with somatosensory impairment have a higher falls incidence compared to those without somatosensory impairment.3 In addition to reduced balance, impaired load detection may also contribute to gait asymmetry, particularly in the push-off phase.8 In addition, leg proprioception influences variance in stride length, gait velocity,9 and walking endurance in stroke survivors.10 In fact, leg somatosensory impairment has been shown to be the third most important independent factor for reduced gait velocity in stroke survivors.11

Two systematic reviews have previously investigated the effects of interventions for retraining somatosensory function after stroke.12,13 In the first review, published more than a decade ago, only four of the 14 included studies targeted the leg,12 while the second only included studies of the arm.13 Nevertheless, both reviews reported that there were insufficient data to determine the effectiveness of these interventions. A third systematic review evaluating the effectiveness of proprioceptive training14 only included 16 studies with stroke-specific populations, of which only two specifically addressed the leg. From these three reviews, the effects of interventions for post-stroke leg somatosensory impairment remain unclear. In addition, the first review12 was critiqued for including studies with participants without somatosensory impairment, and that did not report somatosensory outcomes.15 Therefore, a targeted systematic review, addressing the limitations of previous reviews, is required to elucidate the effects of interventions for post-stroke leg somatosensory impairment.

It is of interest to clinicians and researchers to evaluate the effects of leg somatosensory retraining on factors that may ultimately influence activity and participation, as this could change practice. Therefore, this systematic review aimed to examine the effects of post-stroke leg somatosensory retraining on somatosensory impairment, balance, gait, motor impairment, and leg function.[…]

 

Continue —> Sensory retraining of the leg after stroke: systematic review and meta-analysis – Fenny SF Chia, Suzanne Kuys, Nancy Low Choy, 2019

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[Abstract] Four-week training involving ankle mobilization with movement versus static muscle stretching in patients with chronic stroke: a randomized control trial.

Abstract

BACKGROUND:
Patients with stroke generally have diminished balance and gait. Mobilization with movement (MWM) can be used with manual force applied by a therapist to enhance talus gliding movement. Furthermore, the weight-bearing position during the lunge may enhance the stretch force.

OBJECTIVES:
This study aimed to compare the effects of a 4-week program of MWM training with those of static muscle stretching (SMS). Ankle dorsiflexion passive range of motion (DF-PROM), static balance ability (SBA), the Berg balance scale (BBS), and gait parameters (gait speed and cadence) were measured in patients with chronic stroke.

METHODS:
Twenty patients with chronic stroke participated in this study. Participants were randomized to either the MWM (n = 10) or the SMS (n = 10) group. Patients in both groups underwent standard rehabilitation therapy for 30 min per session. In addition, MWM and SMS techniques were performed three times per week for 4 weeks. Ankle DF-PROM, SBA, BBS score, and gait parameters were measured after 4 weeks of training.

RESULTS:
After 4 weeks of training, the MWM group showed significant improvement in all outcome measures compared with baseline (p < 0.05). Furthermore, SBA, BBS, and cadence showed greater improvement in the MWM group compared to the SMS group (p < 0.05).

CONCLUSIONS:
This study demonstrated that MWM training, combined with standard rehabilitation, improved ankle DF-PROM, SBA, BBS scores, and gait speed and cadence. Thus, MWM may be an effective treatment for patients with chronic stroke.

via Four-week training involving ankle mobilization with movement versus static muscle stretching in patients with chronic stroke: a randomized control… – PubMed – NCBI

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