Posts Tagged gait

[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] Virtual reality for stroke rehabilitation – Review


Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

Randomised and quasi-randomised trials of virtual reality (“an advanced form of human-computer interface that allows the user to ‘interact’ with and become ‘immersed’ in a computer-generated environment in a naturalistic fashion”) in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Update of
Virtual reality for stroke rehabilitation. [Cochrane Database Syst Rev. 2015]

via Virtual reality for stroke rehabilitation. – PubMed – NCBI

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[ARTICLE] A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity – Full Text



Improved walking is one of the highest priorities in people living with stroke. Post-stroke lower limb spasticity (PSLLS) impedes walking and quality of life (QOL). The understanding of the evidence of improved walking and QOL following botulinum toxin (BoNTA) injection is not clear. We performed a systematic review of the randomized control trials (RCT) to evaluate the effectiveness of BoNTA injection on walking and QOL in PSLLS.


We searched PubMed, Web of Science, Embase, CINAHL, ProQuest Thesis and Dissertation checks, Google Scholar, WHO International Clinical Trial Registry Platform,, Cochrane, and ANZ and EU Clinical Trials Register for RCTs looking at improvement in walking and QOL following injection of BoNTA in PSLLS. The original search was carried out prior to 16 September 2015. We conducted an additional verifying search on CINHAL, EMBASE, and MEDLINE (via PubMed) from 16 September 2015 to 6 June 2017 using the same clauses as the previous search. Methodological quality of the individual studies was critically appraised using Joanna Briggs Institute’s instrument. Only placebo-controlled RCTs looking at improvement in walking and QOL were included in the review.


Of 2026 records, we found 107 full-text records. Amongst them, we found five RCTs qualifying our criteria. No new trials were found from the verifying search. Two independent reviewers assessed methodological validity prior to inclusion in the review using Joanna Briggs Institute’s appraisal instrument. Two studies reported significant improvement in gait velocity (p = 0.020) and < 0.05, respectively. One study showed significant improvement in 2-min-walking distance (p < 0.05). QOL was recorded in one study without any significant improvement. Meta-analysis of reviewed studies could not be performed because of different methods of assessing walking ability, small sample size with large confidence interval and issues such as lack of power calculations in some studies. Findings from our systematic and detailed study identify the need for a well-designed RCT to adequately investigate the issues highlighted.


This review could not conclude there was sufficient evidence to support or refute improvement on walking or QOL following BoNTA injection. Reasons for this are discussed, and methods for future RCTs are developed.


Stroke is a common cause of adult disability worldwide [1]. More than two thirds of the stroke survivors develop post-stroke sequelae including impaired motor functions and spasticity [2]. The prevalence of post-stroke spasticity ranges from 19.0 to 42.6% [3]. There have been many recent developments in diagnosis, management, and prevention of stroke, while advances in rehabilitation have been modest [4]. There has, however, been progress with the use of botulinum toxin (BoNTA) as a treatment to improve spasticity in the upper limb [567]. Three systematic reviews [8910] have addressed research progress on both the upper and lower limbs, with the conclusion from two of these that the effect on the upper and lower limbs spasticity favored BoNTA [89]; however, these reviews did not fulfill the criteria for inclusion in this study.

As far as the lower limb is concerned, improvement in spasticity while important is only a first stage in post-stroke improvement, and the aim of RCTs should be to address the more important questions of functional activity including walking. How well this outcome has been addressed is the aim of this study. This is also an important question for many countries to resolve, because to date, botulinum toxin A is not approved for use in the post-stroke lower limb spasticity (PSLLS) by the pharmaceutical authorities except in the USA [11].

Lower limb spasticity most commonly involves the foot and the ankle leading to equinovarus (plantarflexion and inversion) deformity. Post-stroke patients with equinovarus deformity fail to achieve optimal contact with the ground leading to a poor stance, loss of heel to toe rhythm while walking and post-stroke patients walk predominantly with plantarflexion/inversion of the foot. Transfers and walking are essentially bipedal activity involving phases like balancing on one leg and swinging the other leg forward. The awkward position of the foot in addition to spasticity impairs balance, transfer, stride, gait, and mobility, besides causing spasm and pain. In many cases, complications like falls, fractures, deep vein thrombosis, and pressure ulcers may also result [12]. Inability to walk is associated with loss of independence and premature residential aged care placement [1314] and in the older population contributes substantially to adverse health outcomes including activities of daily living and mortality [15]. Improving and maintaining walking ability and activities of daily living are therefore vital for post-stroke survivors [16] and a major contributor to functional improvements. The overall human and economic cost of spasticity is, therefore, considerable, and interventions potentially can deliver significant benefits [17].

Given the evidence for efficacy of BoNTA in reducing spasticity, the objective of this review was to assess the available evidence of BoNTA injection: (1) to improve mobility (using gait velocity and walking distance as measuring parameters) and quality of life (QOL) and (2) to make appropriate recommendations for further research regarding these questions. […]


Continue —> A systematic review: efficacy of botulinum toxin in walking and quality of life in post-stroke lower limb spasticity | Systematic Reviews | Full Text

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[Abstract] Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial

Objective: To determine the effect of activity-based mirror therapy (MT) on motor recovery and gait in chronic poststroke hemiparetic subjects.

Design: A randomised, controlled, assessor-blinded trial.

Setting: Rehabilitation institute.

Participants: Thirty-six chronic poststroke (15.89 ± 9.01 months) hemiparetic subjects (age: 46.44 ± 7.89 years, 30 men and functional ambulation classification of median level 3).

Interventions: Activity-based MT comprised movements such as ball-rolling, rocker-board, and pedalling. The activities were provided on the less-affected side in front of the mirror while hiding the affected limb. The movement of the less-affected lower limb was projected as over the affected limb. Conventional motor therapy based on neurophysiological approaches was also provided to the experimental group. The control group received only conventional management.

Main outcome measures: Brunnstrom recovery stages (BRS), Fugl-Meyer assessment lower extremity (FMA-LE), Rivermead visual gait assessment (RVGA), and 10-metre walk test (10-MWT).

Results: Postintervention, the experimental group exhibited significant and favourable changes for FMA-LE (mean difference = 3.29, 95% CI = 1.23–5.35, p = .003) and RVGA (mean difference = 5.41, 95% CI = 1.12–9.71, p = .015) in comparison to the control group. No considerable changes were observed on 10-MWT.

Conclusions: Activity-based MT facilitates motor recovery of the lower limb as well as reduces gait deviations among chronic poststroke hemiparetic subjects.


via Effect of activity-based mirror therapy on lower limb motor-recovery and gait in stroke: A randomised controlled trial: Neuropsychological Rehabilitation: Vol 0, No 0

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[Abstract+References] Transcutaneous electrical nerve stimulation improves walking capacity and reduces spasticity in stroke survivors: a systematic review and meta-analysis

To evaluate (1) the effectiveness of transcutaneous electrical nerve stimulation (TENS) at improving lower extremity motor recovery in stroke survivors and (2) the optimal stimulation parameters for TENS.

A systematic search was conducted for studies published up to October 2017 using eight electronic databases (CINAHL,, the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PEDro, PubMed and Web of Science). Randomized controlled trials that evaluated the effectiveness of the application of TENS at improving lower extremity motor recovery in stroke survivors were assessed for inclusion. Outcomes of interest included plantar flexor spasticity, muscle strength, walking capacity and balance.

In all, 11 studies met the inclusion criteria which involved 439 stroke survivors. The meta-analysis showed that TENS improved walking capacity, as measured by either gait speed or the Timed Up and Go Test (Hedges’ g = 0.392; 95% confidence interval (CI) = 0.178 to 0.606) compared to the placebo or no-treatment control groups. TENS also reduced paretic plantar flexor spasticity, as measured using the Modified Ashworth Scale and Composite Spasticity Scale (Hedges’ g = –0.884; 95% CI = –1.140 to −0.625). The effect of TENS on walking capacity in studies involving 60 minutes per sessions was significant (Hedges’ g = 0.468; 95% CI = 0.201–0.734) but not in study with shorter sessions (20 or 30 minutes) (Hedges’ g = 0.254; 95% CI = –0.106–0.614).

The results support the use of repeated applications of TENS as an adjunct therapy for improving walking capacity and reducing spasticity in stroke survivors.

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via Transcutaneous electrical nerve stimulation improves walking capacity and reduces spasticity in stroke survivors: a systematic review and meta-analysisClinical Rehabilitation – Patrick WH Kwong, Gabriel YF Ng, Raymond CK Chung, Shamay SM Ng, 2017

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[ARTICLE] The immediate effect of FES and TENS on gait parameters in patients after stroke – Full Text PDF


[Purpose] This study was conducted to compare the immediate effects of different electrotherapies on the gait parameters for stroke patients.

[Subjects and Methods] Thirty patients with stroke were randomly assigned either to the functional electrical stimulation group or the transcutaneous electrical nerve stimulation group, with 15 patients in each group. Each electrotherapy was performed for 30 minutes simultaneously with the therapeutic exercise, and the changes in the spatial and temporal parameters of gait were measured.

[Results] After the intervention, a significant, immediate improvement in cadence and speed was observed only in the functional electrical stimulation group.

[Conclusion] Based on this study, functional electrical stimulation that stimulates motor nerves of the dorsiflexor muscles on the paretic side is recommended to achieve immediate improvement in the gait ability of stroke patients.[…]

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[ARTICLE] Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial – Full Text

Purpose: The purpose of this study was to compare the effects of the FES-gait with augmented feedback training to the FES alone on the gait and functional performance in individuals with chronic stroke.
Methods: This study used a pretest and posttest randomized control design. The subjects who signed the agreement were randomly divided into 12 experimental groups and 12 control groups. The experimental groups performed two types of augmented feedback training (knowledge of performance and knowledge of results) together with FES, and the control group performed FES on the TA and GM without augmented feedback and then walked for 30 minutes for 40 meters. Both the experimental groups and the control groups received training five times a week for four weeks.
Results: The groups that received the FES with augmented feedback training significantly showed a greater improvement in single limb  support (SLS) and gait velocity than the groups that received FES alone. In addition, timed up and go (TUG) test and six minute walk test (6MWT) showed a significant improvement in the groups that received FES with augmented feedback compared to the groups that received FES alone.
Conclusion: Compared with the existing FES gait training, augmented feedback showed improvements in gait parameters, walking ability, and dynamic balance. The augmented feedback will be an important method that can provide motivation for motor learning to stroke patients.

Continue —>  Functional Electrical Stimulation with Augmented Feedback Training Improves Gait and Functional Performance in Individuals with Chronic Stroke: A Randomized Controlled Trial (PDF Download Available)

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[ARTICLE] The effect of newly designed multi joint ankle foot orthosis on the gait and dynamic balance of stroke patients with foot drop – Full Text PDF


[Purpose] The purpose of this study is to investigate the effect of the newly designed multi joint anklefoot orthosis on the gait and dynamic balance of stroke patients having foot drop.

[Subjects and Methods] This study was conducted with 15 subjects who were diagnosed with stroke. 10-meter walk test, functional reaching test and timed up and go test were measured after each subjects wore a plastic ankle-foot orthosis and a multi joint anklefoot orthosis that consists of orthosis joints (having free joint, anterior-stop joint, poster-stop joint, and Klenzak joint functions). In the case of the newly developed multi joint ankle-foot orthosis, the experiments were performed using posterior-stop joint and Klenzak joint.

[Results] 10-meter walk test, functional reaching test and timed up and go test showed significant differences in the orthosis using posterior joint-stop function and Klenzak joint function.

[Conclusion] The appropriate use of the four functions of the newly designed multi joint ankle-foot orthosis is expected to have a positive effect on improving the gait and balancing ability of stroke patients having foot drop.

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[Abstract] Sensing motion and muscle activity for feedback control of functional electrical stimulation: Ten years of experience in Berlin


After complete or partial paralysis due to stroke or spinal cord injury, electrical nerve stimulation can be used to artificially generate functional muscle contractions. This technique is known as Functional Electrical Stimulation (FES). In combination with appropriate sensor technology and feedback control, FES can be empowered to elicit also complex functional movements of everyday relevance. Depending on the degree and phase of impairment, the goal may be temporary support in a rehabilitation phase, e.g. during re-learning of gait after a stroke, or permanent replacement/support of lost motor functions in form of assistive devices often referred to as neuro-prostheses.

In this contribution a number of real-time capable and portable approaches for sensing muscle contractions and motions are reviewed that enable the realization of feedback control schemes. These include inertial measurement units (IMUs), electromyography (EMG), and bioimpedance (BI). This contribution further outlines recent concepts for movement control, which include e.g. cascaded control schemes. A fast inner control loop based on the FES-evoked EMG directly controls the amount of recruited motor units. The design and validation of various novel FES systems are then described that support cycling, walking, reaching, and swallowing. All methods and systems have been developed at the Technische Universität Berlin by the Control Systems Group within the last 10 years in close cooperation with clinical and industrial partners.

Source: Sensing motion and muscle activity for feedback control of functional electrical stimulation: Ten years of experience in Berlin – ScienceDirect

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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.[…]

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