Posts Tagged exercise movement techniques
[ARTICLE] The Use of Rhythmic Auditory Stimulation to Optimize Treadmill Training for Stroke Patients: A Randomized Controlled Trial – Full Text
The use of functional music in gait training termed rhythmic auditory stimulation (RAS) and treadmill training (TT) have both been shown to be effective in stroke patients (SP). The combination of RAS and treadmill training (RAS-TT) has not been clinically evaluated to date. The aim of the study was to evaluate the efficacy of RAS-TT on functional gait in SP. The protocol followed the design of an explorative study with a rater-blinded three arm prospective randomized controlled parallel group design. Forty-five independently walking SP with a hemiparesis of the lower limb or an unsafe and asymmetrical walking pattern were recruited. RAS-TT was carried out over 4 weeks with TT and neurodevelopmental treatment based on Bobath approach (NDT) serving as control interventions. For RAS-TT functional music was adjusted individually while walking on the treadmill. Pre and post-assessments consisted of the fast gait speed test (FGS), a gait analysis with the locometre (LOC), 3 min walking time test (3MWT), and an instrumental evaluation of balance (IEB). Raters were blinded to group assignments. An analysis of covariance (ANCOVA) was performed with affiliated measures from pre-assessment and time between stroke and start of study as covariates. Thirty-five participants (mean age 63.6 ± 8.6 years, mean time between stroke and start of study 42.1 ± 23.7 days) completed the study (11 RAS-TT, 13 TT, 11 NDT). Significant group differences occurred in the FGS for adjusted post-measures in gait velocity [F(2, 34) = 3.864, p = 0.032; partial η2 = 0.205] and cadence [F(2, 34)= 7.656, p = 0.002; partial η2 = 0.338]. Group contrasts showed significantly higher values for RAS-TT. Stride length results did not vary between the groups. LOC, 3MWT, and IEB did not indicate group differences. One patient was withdrawn from TT because of pain in one arm. The study provides first evidence for a higher efficacy of RAS-TT in comparison to the standard approaches TT and NDT in restoring functional gait in SP. The results support the implementation of functional music in neurological gait rehabilitation and its use in combination with treadmill training.
About 60% of all stroke patients (SP) have difficulties with walking (1). These are often caused by hemiparesis and/or sensory deficits of the lower extremity and/or trunk and are also due to uncoordinated movements. In addition to motor and sensory dysfunctions, symptoms such as spasticity, somato-sensory neglect, and cognitive malfunctioning may further impede walking. Thus, the restoration of gait is often a key focus of rehabilitation efforts, enhancing not only physical activity but also autonomy and participation in everyday life (2, 3).
Treadmill training (TT) with and without body weight support has been shown to improve functional gait in stroke patients effectively. A meta-analysis comparing 44 trials (n = 2,658 patients) revealed clear therapeutic effects on gait velocity and walking endurance, the latter only for TT with body weight support (1). However, the improvements were identified only for independent walkers while patients who walked with assistance did not show an additional benefit from TT (1). Lee’s work (4) provided evidence that TT with a high walking velocity at the beginning of training is more effective when compared to a stepwise increase in velocity.
Rhythmic-auditory stimulation (RAS) is defined as a therapeutic application of pulsed rhythmic or musical stimulation in order to improve gait or gait related aspects of movement (5). It has been demonstrated that SP are able to synchronize their gait pattern to auditory stimulation using music with an embedded metronome (6–8). This led to immediate improvements in stride time and stride length symmetry as well as weight bearing time on the paretic side, while EMG showed a more balanced muscular activation pattern between the paretic and non-paretic sides (6). Training effects of RAS for SP were confirmed in a meta-analysis comparing 7 randomized controlled studies (n = 197) that showed improvements in functional gait performance (velocity, cadence, and stride length) (9). This work also gave evidence, that a musical stimulation is more effective in improving gait velocity and cadence then the metronome (9). Hayden et al. found that RAS became more effective when it is implemented earlier in the rehabilitation program. This provides evidence that the variation in time of the RAS-training during the rehabilitation process may affect the success of the treatment (10). The application of RAS on the treadmill (RAS-TT) was evaluated over a 3-week training period by Park et al. In that study metronome stimulation was used for 9 patients with chronic stroke. The results were compared with a group of 10 patients performing over ground RAS walking training (11). The RAS-TT group experienced greater improvements in gait velocity (11).
While RAS and TT have proven to be effective for gait training in SP, the efficacy of its combination (RAS-TT) in the early course of rehabilitation in SP has not been investigated to date. Therefore, we hypothesized that RAS-TT in the early course of rehabilitation would improve the clinical efficacy of TT for SP. The purpose of the present study was to investigate the functional improvements of gait using a rehabilitation therapy combining RAS and TT in order to assess its clinical efficacy for patients suffering the aftermaths of a stroke.
Materials and methods
The study protocol was approved by the state authorization association for medical issues in Brandenburg, that determined on the 21st of January 2010 that no formal ethics approval was required. Patients gave their informed consent according to the Helsinki declaration.
The study was designed as a prospective, single center three arm clinical study with parallel groups. We enrolled patients who performed either RAS on the treadmill (RAS-TT) or treadmill training alone (TT). A third group that received neurodevelopmental treatment following the Bobath approach (NDT) served as a control group. The patients were randomly assigned to the three training interventions by a person not involved in the study using a block randomization (software randlist). Allocations were placed in sealed sequentially numbered envelopes and were not opened until the actual study inclusion. Thus, the patients, the responsible doctor, the assessing physiotherapist, and study manager were not informed beforehand regarding the group assignment.
We included stroke patients with a hemiparesis of the lower limb (at least 1 muscle group with muscle strength grade <5 as defined by the British Medical Research Council) or with an unsafe and asymmetrical walking pattern (by assessment of a physiotherapist). The patients had to be able to walk independently with assistive devices if necessary for at least 3 min.
Criteria for exclusion were the following: significantly disturbed language perception (marked by either the Aachener Aphasietest or Token Test), cognitive impairment (Mini Mental Status Test <26), major depression or productive psychosis, adjustment disorder with a need for medical treatment, peripheral arterial occlusive disease with walking distance <100 m, and coronary heart disease (instable angina pectoris).
After having passed the diagnostics patients underwent a screening session on the treadmill. There they had to demonstrate a stable and sufficiently ergonomic gait. Candidates with insufficient quality of gait on the treadmill (multimodal neglect or spasticity as assessed by a physiotherapist) were postponed and re-screened every week (Figure (Figure11).
[Abstract] Interventions for Improving Upper Limb Function after Stroke – Cochrane Database Syst Rev.
Impairment of the upper limbs is quite frequent after stroke, making rehabilitation an essential step towards clinical recovery and patient empowerment. This review aimed to synthetize existing evidence regarding interventions for upper limb function improvement after Stroke and to assess which would bring some benefit. The Cochrane Database of Systematic Reviews, the Database of Reviews of Effects and PROSPERO databases were searched until June 2013 and 40 reviews have been included, covering 503 studies, 18 078 participants and 18 interventions, as well asdifferent doses and settings of interventions. The main results were:
- Information currently available is insufficient to assess effectiveness of each intervention and to enable comparison of interventions;
- Transcranial direct current stimulation brings no benefit for outcomes of activities of daily living;
- Moderate-quality evidence showed a beneficial effect of constraint-induced movement therapy, mental practice, mirror therapy, interventions for sensory impairment, virtual reality and repetitive task practice;
- Unilateral arm training may be more effective than bilateral arm training;
- Moderate-quality evidence showed a beneficial effect of robotics on measures of impairment and ADLs;
- There is no evidence of benefit or harm for technics such as repetitive transcranial magnetic stimulation, music therapy, pharmacological interventions, electrical stimulation and other therapies.
Currently available evidence is insufficient and of low quality, not supporting clear clinical decisions. High-quality studies are still needed.
Background: Health care environments are continuously improving conditions, especially regarding the use of current technology. In the field of rehabilitation, the use of video games and related technology has helped to develop new rehabilitation procedures. Patients are able to work on their disabilities through new processes that are more motivating and entertaining. However, these patients are required to leave their home environment to complete their rehabilitation programs.
Objective: The focus of our research interests is on finding a solution to eliminate the need for patients to interrupt their daily routines to attend rehabilitation therapy. We have developed an innovative system that allows patients with a balance disorder to perform a specific rehabilitation exercise at home. Additionally, the system features an assistive tool to complement the work of physiotherapists. Medical staff are thus provided with a system that avoids the need for them to be present during the exercise in specific cases in which patients are under suitable supervision.
Methods: A movement-based interaction device was used to achieve a reliable system for monitoring rehabilitation exercises performed at home. The system accurately utilizes parameters previously defined by the specialist for correct performance of the exercise. Accordingly, the system gives instructions and corrects the patient’s actions. The data generated during the session are collected for assessment by the specialist to adapt the difficulty of the exercise to the patient’s progress.
Results: The evaluation of the system was conducted by two experts in balance disorder rehabilitation. They were required to verify the effectiveness of the system, and they also facilitated the simulation of real patient behavior. They used the system freely for a period of time and provided interesting and optimistic feedback. First, they evaluated the system as a tool for real-life rehabilitation therapy. Second, their interaction with the system allowed us to obtain important feedback needed to improve the system.
Conclusions: The system improves the rehabilitation conditions of people with balance disorder. The main contribution comes from the fact that it allows patients to carry out the rehabilitation process at home under the supervision of physiotherapists. As a result, patients avoid having to attend medical centers. Additionally, medical staff have access to an assistant, which means their presence is not required in many exercises that involve constant repetition.