[ARTICLE] Walking Training with a Weight Support Feedback Cane Improves Lower Limb Muscle Activity and Gait Ability in Patients with Chronic Stroke: A Randomized Controlled Trial – Full Text

Abstract

Background

Induction of proper weight transfer to the affected lower limb should be considered the most essential factor for successful stroke cane gait training. This study aimed to investigate the effect of walking training with a weight support feedback cane on lower limb muscle activity and gait ability of chronic stroke patients.

Material/Methods

Thirty stroke patients were randomized into 2 groups: a weight support feedback cane gait training group (WSFC group, n=15) and a conventional cane gait training group (CC group, n=15). All subjects were enrolled in standard rehabilitation programs for 4 weeks. Additionally, the WSFC group participated in WSFC gait training and the CC group participated in conventional cane gait training for 4 weeks. During WSFC gait training, the weight support rate loaded on the cane was reduced by 10% every week from 60% to 30% based on the measured initial cane dependence, while the CC group participated in conventional cane gait training with verbal instruction to reduce cane dependence. Lower limb muscle activity and gait ability were measured using wireless surface electromyography and a 3-axis accelerometer during walking.

Results

The WSFC group showed significantly greater improvement than the CC group in lower limb muscle activity and gait ability (P<0.05).

Conclusions

Cane gait training significantly improved lower limb muscle activity and gait ability in stroke regardless of the training method; however, the addition of real-time weight support feedback to cane gait training appears to provide further benefit compared with conventional cane gait training in chronic stroke patients.

Background

Stroke is classified as ischemic, caused by blockage of blood vessels supplying blood to the brain, and hemorrhagic, caused by rupture of blood vessels in the brain [1]. Stroke is a leading cause of death and dysfunction worldwide [2] and in general, it is associated with muscle weakness, decreased sensation, decreased cognitive function, depression, and decreased quality of life [3–5]. In particular, muscle weakness in the affected side causes overuse and asymmetrical weight shift to the non-affected lower limb [6], leading to an increased risk of falls, decreased independence in daily life, decreased postural control, and asymmetrical walking pattern [7,8]. Therefore, rehabilitation for symmetrical weight transfer and gait enhancement is fundamental to improve the independence and quality of life of patients with stroke [9,10].

In clinical practice, various assistive devices, such as parallel bars, walker, and cane, are used for balance and gait training of stroke patients. Among them, a cane can help to increase the base of support for stroke patients to provide postural stability and improves weight transfer ability in the standing position and walking [11–13]. Using a cane during the single-limb stance phase helps to retrain weight transfer to the affected lower limb and provides tactile information about the ground [14,15]. In addition, using a cane can contribute to stable postural control by controlling the rapid movement of the center of gravity during the stance phase [16]. Park reported that the use of a cane is effective in improving the weight support rate of the affected lower limb in patients with stroke [17]. Moreover, Boonsinsukh et al reported that cane training with auditory feedback according to the weight support rate of the affected lower limb leads to improvement of muscle activity in the affected tensor fasciae latae and vastus medialis [18]. In contrast, several studies have shown that the use of a cane in the early rehabilitation period caused a decrease in muscle activity of the affected lower limb [12,19] and it interferes with symmetrical weight distribution, which ultimately interferes with acquisition of independent gait ability [20,21]. Although the main purpose of using a cane is to help weight distribution to the affected lower limb, improper use of a cane can contribute to an asymmetrical gait pattern by inducing excessive weight support to the non-affected lower limb [16].

Therefore, for successful cane gait training, induction of proper weight transfer to the affected lower limb should be considered the most essential factor [6,22]. However, in clinical practice, it is difficult to quantitatively monitor the weight carried on the cane during cane gait training due to technical problems. Additionally, it is difficult for patients to receive accurate feedback on weight support on the paretic lower limb during cane gait training [23]. Moreover, there is insufficient information on the effects of progressive weight support induction on the affected lower limb during cane gait training on muscle activity and gait in patients with stroke.

Thus, this study aimed to investigate the effect of weight support feedback cane gait training that provided real-time feedback of the user’s weight support loaded on a cane on the lower limb muscle activity and gait ability of patients with chronic stroke. We hypothesized that 4 weeks of weight support feedback cane gait training would show improvements in lower limb muscle activity and gait ability in chronic stroke patients. […]

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Figure 2
A weight support feedback cane (WSFC). The WSFC measures the cane dependence by a load cell located at the bottom of the WSFC handle, and the measured cane dependence is displayed on the WSFC handle (A) and smartphone application in real time (B).