Posts Tagged gait

[NEWS] Controlling Foot Drop – Physical Therapy Products

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Uzo Igwegbe, PT, MPT, fitting a stroke survivor with the thigh component of the Bioness L300 Go, targeted at stimulating the L hamstrings to minimize L knee hyperextension in stance during ambulation.

Uzo Igwegbe, PT, MPT, fitting a stroke survivor with the thigh component of the Bioness L300 Go, targeted at stimulating the L hamstrings to minimize L knee hyperextension in stance during ambulation.

By Uzo Igwegbe, PT, MPT

Foot drop, a gait abnormality, is an insufficient ability to dorsiflex or clear the foot/feet during the swing phase of gait, causing an increased risk for stumbling, falls, or injury. In a normal gait cycle, initial foot contact occurs with the heel; however, an individual with foot drop may drag the foot and/or make initial contact with the forefoot or foot flat. To compensate they may excessively flex the hip and knee, or circumduct the affected limb, or increase time spent in swing phase of the affected extremity.

The cause of drop foot is due to damage to the common fibular (peroneal) nerve (inclusive of the sciatic nerve), weakness or paralysis of the tibialis anterior, extensor halluces longus and extensor digitorum longus. Foot drop is associated with cerebrovascular accident/stroke, brain injury, multiple sclerosis, cerebral palsy, spinal cord injury, spinal stenosis, disc herniation, poliomyelitis, diabetes mellitus, Charcot-Marie-Foot Disease, muscular dystrophy, Amyotrophic Lateral Sclerosis, or direct injury to the peroneal nerve.

Ankle foot orthotics (AFOs) and Functional Electric Stimulation (FES) technologies are used in the management and treatment of drop foot in physical therapy. These two approaches strive to facilitate a natural gait with increased speed, improved balance, confidence, safety, and independence with ambulation and functional mobility.

Product ResourcesThe following companies provide products to treat ankle injuries, foot drop and other aspects of stroke and neurological rehabilitation:

Active Ankle

Allard USA Inc


GAITRite/CIR Systems Inc

Gorbel Medical/SafeGait

Mobility Research

Motorika Medical Ltd



Saebo Inc



Vista Medical

Woodway USA

Orthotic Management

Ankle foot orthotics, the most common approach used, support neutral foot position to facilitate clearance during swing and provide ankle stability during loading response.1 AFOs are either off the shelf (for short-term use) or custom made from a cast (for complex cases or long-term use). These L-shaped braces are worn in footwear and, in most cases, a larger shoe size of one half to a full shoe size may be required due to the bulk of the orthosis. To obtain an AFO, a correct foot drop diagnosis by the therapist/physician and a physician’s AFO prescription is needed to proceed with a comprehensive assessment, with recommendations of treatment options from a licensed orthotist. A cast impression of the foot and leg is done for custom AFO. Follow-up appointments are done after reception of the AFO for re-evaluation of fit and function. The AFOs prescribed for drop foot include:

1) Posterior Leaf Spring AFO:This prefabricated, semi-rigid, polypropylene AFO supports individuals with mild foot drop and knee instability. It provides dorsiflexion during swing and controls plantarflexion at heel strike. Resistance to plantarflexion can be controlled by modifying the ankle and footplate trim lines. This AFO is the initial “go-to” brace for physical therapists because they are readily available, lightweight, inexpensive, and can provide initial ankle stability early in rehabilitation; however, there are newer, lighter, more comfortable, user-friendly and functional models available. Sources for these types of AFOs include Orthotic & Prosthetic Lab Inc, Webster Groves, Mo, which makes the Dynamic ROM AFO, and Orange County, Calif-headquartered, Össur Americas, which offers a prefabricated, polypropylene AFO Leaf Spring.

2) Solid AFO: This custom-fabricated plastic AFO prevents plantarflexion and prevents/limits dorsiflexion. It supports the ankle-foot complex in the coronal and sagittal planes in individuals with complete or nearly complete loss of dorsiflexion and mild to moderate knee hyperextension. Although bulky, it provides significant ankle support. It is contraindicated in individuals with fluctuating edema due to its rigid structure. Its bulk, difficulty obtaining properly fitted footwear, and general discomfort due to heat generated from continuous use can be barriers to utilization. One source for these devices is Kiser’s Orthotic and Prosthetic Services Inc, Keene, NH, which manufactures its solid ankle AFO to help combat spasticity, help the toe to clear, and prevent the Achilles tendon from tightening.



3) Free Motion Articulating AFO: The ankle joint here is activated, so the individual must have active ankle motion. It is commonly prescribed for individuals with some dorsiflexion, but who still need frontal plane stability. It is not recommended for patients with significant quadriceps weakness. Among the products available in this category is the Exos Free Motion Ankle from DJO Global Inc, Vista, Calif; a prefabricated AFO made to be moldable, adjustable, and can be custom fit. Becker Orthopedic, Troy, Mich, also offers a plastic AFO with articulating ankle, which can be used with a variety of the company’s thermoplastic ankle joints and posterior stops.

4) Short Leg AFO with Fixed Hinge: A good option for people who have flatfoot and drop foot, this AFO holds the foot at 90 degrees to the lower leg and controls unwanted inward rotation of the foot, which is common in stroke and Charcot-Marie Tooth patients. It is relatively light and easily fits footwear. A disadvantage of this brace, and the solid AFO, is its failure to provide a natural gait. Among the sources that offer this type of orthoses is New Linox, Ill-headquartered Rinella Orthotics & Prosthetics Inc.

5) Dorsiflexion Assist AFO: This has a spring-like hinge which assists the ankle with dorsiflexion as the foot comes off the ground for those with mild to moderate drop foot, and a flat or unstable foot as it offers a more natural gait pattern. The short lower leg length of this brace and the Short Leg AFO fails to provide adequate support in people over 6 feet or 225 pounds.

6) Plantarflexion Stop AFO: This brace prevents plantarflexion and has a hinge that facilitates normal dorsiflexion. Due to its cumbersome size, it is not utilized often but can be effective in people with more severe or spastic drop foot. Orthotic & Prosthetic Lab Inc provides plantarflexion stop AFOs that are designed to prevent unwanted plantarflexion while permitting free dorsiflexion. These AFOs are also available from Yakima, Wash-headquartered Yakima Orthotics & Prosthetics, and are designed to provide medial/lateral stability and plantarflexion/dorsiflexion control.

7) Energy Return AFO: This prefabricated, lightweight AFO is made of carbon graphite material. It provides assistance in dorsiflexion and energy return at push-off to propel the individual forward with plantarflexors. It provides stability only in the sagittal plane; however, a foot orthotic can be placed on the flat foot for frontal plane stability. In stroke and spina bifida patients, carbon-fiber AFOs increased walking speed and decreased energy cost when compared to unbraced walking.2 Research suggests that Energy Return AFOs facilitate plantar flexor muscle regeneration and prevents atrophy.3,4

Therapists have a number of choices in this category, including the ToeOff carbon composite dynamic response floor reaction AFO from Allard USA Inc, Rockaway, NJ; designed to keep the foot up during swing phase as well as provide soft heel strike and stability in stance. In addition to providing good toe-off to the wearer, the company recommends this AFO for foot drop in combination with no spasticity to moderate spasticity. The Ypsilon, also from Allard, is made to provide toe-off assistance to stable ankles while also allowing natural ankle movement, while the company’s BlueROCKER provides more rigid orthopedic control and was developed for bilateral foot drop. It can be used for foot drop in combination with no spasticity to severe spasticity, as well as partial foot amputations, impaired balance, and weakness or impairment in multiple leg muscle groups. The Peromax carbon fiber AFO and Trulife Matrix Max carbon fiber AFO are two other options available to the PT market in this category.

Users with big toe plantar ulcerations who are unable to cope with the plastic AFO due to skin breakdown from continuous pushing off the foot plate can have the addition of a custom foot orthotic, which can help offload those areas. Items like a heel lift can be placed under the foot plate to control for knee hyperextension. Despite their advantages, this AFO is not ideal for individuals with large calves or very tall individuals, as their long stride repeatedly overextend and weaken the AFO, or individuals with spastic drop foot or tight Achilles tendon, as the overactivity of the muscle pushes down on the foot plate, excessively hyperextending the knee.

Therapist is shown fitting a stroke survivor with the lower leg cuff of the Bioness L300 Go to stimulate the tibialis anterior muscle to improve L foot clearance during ambulation.

Therapist is shown fitting a stroke survivor with the lower leg cuff of the Bioness L300 Go to stimulate the tibialis anterior muscle to improve L foot clearance during ambulation. 

Performing the initial stimulation testing to determine whether the desired muscle activation is elicited prior to ambulation.

Performing the initial stimulation testing to determine whether the desired muscle activation is elicited prior to ambulation.

Functional Electrical Stimulation Management

The L300 Foot Drop System and WalkAide are approved medical devices for foot drop by the US Food and Drug Administration and are used in rehabilitation hospitals. The Bioness Legacy L300, L300 Go, and WalkAide consist of a lower leg cuff which holds electrode(s), providing low-level electrical stimulation to an intact peroneal nerve. The L300 Go and WalkAide use advance tilt sensor technology to monitor movement in all three kinematic planes, providing stimulation to lift the foot at the appropriate time. This makes foot clearance at various cadence and terrains feasible. They do not require a foot sensor like the Legacy L300, decreasing setup time and allowing users to ambulate with or without footwear. They can be used if knee instability and foot drop are present, promoting clinical application as majority of individuals present with both. Patients work alongside a clinician to obtain training for home use or utilize these technologies in the clinical setting.


The options available in the treatment and management of foot drop are numerous. The path to obtaining the right product involves a joint partnership between the patient, physical therapist, physician, and orthotist. The clinician must draw from the patient’s needs, abilities, facets of gait needing improvement, and special conditions specific to the patient to recommend the optimal product. In the choice between an AFO and FES device, the ultimate goal is to provide a product that will yield compliance, a normalized gait, and contribute to independent function. PTP

Uzo Igwegbe, PT, MPT, is outpatient physical therapist, senior, at HealthSouth Rehabilitation Hospital of Cypress, located in Houston, Texas. She earned her master’s degree in physical therapy at The Robert Gordon University in Aberdeen, Scotland, in February 2010. She joined HealthSouth Rehabilitation Hospital in January 2012, starting at the City View location in Fort Worth, Texas, working in both inpatient and outpatient settings, developing treatment plans for pulmonary, brain injury and orthopedics patients. Igwegbe joined the HealthSouth Cypress team in September 2013, where she primarily worked with outpatients with a wide range of neuromuscular and musculoskeletal conditions, as well as post-orthopedic surgery patients. For more information, contact


  1. Farley J. Controlling drop foot: Beyond standard AFOs. Lower Extremity Review. 2009.
  2. Danielsson A, Sunnerhagen K. Energy expenditure in stroke subjects looking with a carbon composite ankle foot orthosis. J Rehabil Med. 2004;36(4):165-168.

  3. Wolf SI, Alimusaj M, Rettig O, Doderlein L. Dynamic assist by carbon fiber spring AFOs for patients with myelomeningocele. Gait Posture. 2008;28(1):175-177.

  4. Meier RH, Ruthsatz DC, Cipriani D. Impact of AFO (ankle foot orthosis) design on calf circumference. Lower Extremity Review. 2014;6(10):29-35.

via Controlling Foot Drop – Physical Therapy Products


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[Abstract] Novel multi-pad functional electrical stimulation in stroke patients: A single-blind randomized study

via Novel multi-pad functional electrical stimulation in stroke patients: A single-blind randomized study – IOS Press

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[ARTICLE] Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients – Full Text


The purpose of this study was to critically evaluate the effects of robot-assisted gait training (RAGT) on gait-related function in patients with acute/subacute stroke. We conducted a systematic review of randomized controlled trials published between May 2012 and April 2016. This search included 334 articles (Cochrane, 51 articles; Embase, 175 articles; PubMed, 108 articles). Based on the inclusion and exclusion criteria, 7 studies were selected for this review. We performed a quality evaluation using the PEDro scale. In this review, 3 studies used an exoskeletal robot, and 4 studies used an end-effector robot as interventions. As a result, RAGT was found to be effective in improving walking ability in subacute stroke patients. Significant improvements in gait speed, functional ambulatory category, and Rivermead mobility index were found with RAGT compared with conventional physical therapy . Therefore, aggressive weight support and gait training at an early stage using a robotic device are helpful, and robotic intervention should be applied according to the patient’s functional level and onset time of stroke.

1. Introduction

Stroke is a common disease [1]. In most patients, disabilities remain after stroke, and long-lasting disability requires continuous management and intensive rehabilitation [12]. Furthermore, the economic burden on the patient increases because of the prolonged rehabilitation period. Therefore, the application of intensive and efficient rehabilitation programs and techniques is an urgent need after stroke [3].

Gait impairment is one of the most important problems after stroke and is associated with activities of daily living and mobility issues [4]. Therefore, recovery of gait function is an important goal of rehabilitation for independent living [5]. Interventions to enhance gait function require repetitive task training with high intensity, and extensive effort by physical therapists is essential [5]. Moreover, the most effective rehabilitation intervention, including gait training, must be performed shortly after stroke and in an intensive and task-oriented manner and should include multisensory stimulation [3].

Robot-assisted gait training (RAGT) for patients in the acute/subacute stage who are nonambulatory is effective at reeducating motor control function through repetitive training of a specific task [6]; RAGT provides intensive therapy, which reduces the burden on therapists, and enhances motor reeducation with multisensory stimulation [3]. Several previous studies reported that gait training using robotic devices is effective at enhancing muscular activity patterns [7], muscle tone, joint range of motion [8], gait speed, functional gait capability [79], gait independence, and mobility in the community [1011]. Moreover, patients who received RAGT and conventional physical therapy had a higher chance of regaining independent gait function than those who received only conventional gait training [12]. However, owing to studies that suggested RAGT is ineffective [13], the effect on gait and gait-related function in subacute stroke remains unclear. In a previous review of effectiveness in stroke patients, the RAGT group showed significant improvement in balance and balance-related activity function, but the comparison between the groups was not significant [14]. These results show that RAGT is effective, but whether it is more effective than other gait-related rehabilitation interventions is still unclear. In this context, the effect of RAGT is still not clearly demonstrated, and reviews that have recently demonstrated the effect of RAGT on gait-related outcome measures in patients with acute/subacute stroke are also limited.

Therefore, the aim of this systematic review was to investigate the effects of RAGT on acute/subacute stroke. The specific goals included identifying the effects of RAGT using assessment tools associated with gait and gait-related function in patients with acute/subacute stroke.[…]

Continue —>  Systematic Review of Appropriate Robotic Intervention for Gait Function in Subacute Stroke Patients

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[ARTICLE] Neural predictors of gait stability when walking freely in the real-world – Full Text



Gait impairments during real-world locomotion are common in neurological diseases. However, very little is currently known about the neural correlates of walking in the real world and on which regions of the brain are involved in regulating gait stability and performance. As a first step to understanding how neural control of gait may be impaired in neurological conditions such as Parkinson’s disease, we investigated how regional brain activation might predict walking performance in the urban environment and whilst engaging with secondary tasks in healthy subjects.


We recorded gait characteristics including trunk acceleration and brain activation in 14 healthy young subjects whilst they walked around the university campus freely (single task), while conversing with the experimenter and while texting with their smartphone. Neural spectral power density (PSD) was evaluated in three brain regions of interest, namely the pre-frontal cortex (PFC) and bilateral posterior parietal cortex (right/left PPC). We hypothesized that specific regional neural activation would predict trunk acceleration data obtained during the different walking conditions.


Vertical trunk acceleration was predicted by gait velocity and left PPC theta (4–7 Hz) band PSD in single-task walking (R-squared = 0.725, p = 0.001) and by gait velocity and left PPC alpha (8–12 Hz) band PSD in walking while conversing (R-squared = 0.727, p = 0.001). Medio-lateral trunk acceleration was predicted by left PPC beta (15–25 Hz) band PSD when walking while texting (R-squared = 0.434, p = 0.010).


We suggest that the left PPC may be involved in the processes of sensorimotor integration and gait control during walking in real-world conditions. Frequency-specific coding was operative in different dual tasks and may be developed as biomarkers of gait deficits in neurological conditions during performance of these types of, now commonly undertaken, dual tasks.


Recent developments in mobile technologies enable the design of experiments describing behavioural and neural responses of subjects performing commonly observed tasks in real-world scenarios outside of the experimental lab environment [1]. Such tasks may include artistic performance such as dancing and music playing [2], dealing with stressful situations [3] and evaluating changes in the levels of “excitement”, “engagement” and “frustration” when walking within different city areas [45]. An interesting aspect of these novel experimental approaches is the possibility to correlate brain activity and natural behaviour, in both healthy and neurologically impaired populations [1]. For example, recent evidence has suggested that the pre-frontal cortex (PFC) is involved in multitasking behaviours [678] and that the posterior parietal cortex (PPC) is engaged in motor adaptation during walking in health [91011]. These regions have also been shown to be involved in different attentional [12] and executive function networks [13]. Gait initiation failure (GIF) and freezing of gait (FoG) episodes in freely walking Parkinson’s disease (PD) patients have been correlated with increased neural activity and connectivity between different cortical regions such as occipital, parietal and frontal regions [1415]. Clinically, difficulties in free walking are observed to increase with the severity of PD due to damage in the cortical-striatal locomotor network [16]. Ambulatory abilities of PD patients are impaired by muscular hypertonia and hypokinesia, which induce asymmetries and reduce speed, as well as FoG [17]. PD patients have less control of their posture when standing, walking and compensating for an external perturbation and this may lead to an increased magnitude of postural sway [18]. Specifically, the magnitude of medio-lateral sway was shown to be highly sensitive to postural impairments during both standing and over-ground free walking and this progressed with the severity of PD [1920].

In ths study, we used a smartphone to measure the acceleration root mean square index (RMS) as an indication of the magnitude of movements or sway at the pelvis in any of the three movement directions (i.e., vertical, antero-posterior and medio-lateral) [18212223]. Previous investigations have shown that RMS increases at the level of the pelvis when walking on an insidious surface (i.e., more difficult) compared to smooth conditions, but not at the head [2124]. Normalization procedures have also been developed for RMS data to reliably compare the quality and variability of real-world gait between different populations (healthy young vs. elderly vs. neurologically impaired) and at different gait speeds [22252627].

Whilst RMS has been correlated with age or level/type of neurological impairments, there have been no models of how neural activation can predict gait stability [20]. We hypothesised that in healthy young subjects, neural activity in the PFC and PPC regions would predict gait stability, specifically measured with the acceleration RMS index. To test our hypothesis, we investigated the relationships between neural activity and RMS index during different ambulatory conditions outside the laboratory using real life tasks. We studied three common ambulatory tasks, namely self-paced free walking, walking whilst conversing and walking whilst texting on a smartphone in order to better understand the neural correlates underlying human natural behaviours.[…]


Continue —> Neural predictors of gait stability when walking freely in the real-world | Journal of NeuroEngineering and Rehabilitation | Full Text


Fig. 1 Mobile Setup for real-world experiments. Brain activity was recorded by a 64 channel EEG Waveguard cap connected to the EEGoPro amplifier placed into a backpack together with a tablet on which the recording software ran. Contact Switches were placed underneath the subject’s heels and connected to a digital input of the MWX8 DataLog analog-to-digital converter fixed at the subject’s hips by an elastic belt. Elastic bands were also placed around the subject’s thighs to make sure cables did not disturb gait performance. A digital button was connected to the converter and pressed by the subject at specific time points. A Samsung Galaxy S4 mini was firmly placed at the subject’s lower back with the elastic belt. Author S.P. gave written informed consent for the usage of this picture

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[VIDEO] CVA/Drop Foot Patient Case Study & Casting – Arizona AFO – YouTube

Patient is a 48 year old male that suffered from a cerebrovascular accident which caused paralysis in the patients lower left extremity. This resulted the patient in having drop foot.

Patient was dispensed an Arizona Extended AFO which provided dorsi-flexion assist. For more information and other helpful videos, please visit us at

via CVA/Drop Foot Patient Case Study & Casting – Arizona AFO – YouTube

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[WEB SITE] Robot-Assisted Therapy: What Is Right for Your Clinic?

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One of the advantages of this gait training system is that it uses end-effector technology to assist patients in stepping, while a therapist provides manual facilitation. (Photo by Kevin Hentz)

by Rebecca Martin, OTR/L, OTD, and Dennis Tom-Wigfield, PT, DPT

Investment in therapeutic technologies spans a continuum from elastic bands that cost a few dollars to room-sized mobility and balance systems that require construction build-outs and additional staff. Inhabiting the middle to upper range of this continuum are robotic devices and associated technology, which have become increasingly popular. Though these advanced technologies deserve a thorough cost-benefit analysis and review of competing products prior to purchase, the payoff they may provide in outcomes and efficiency can make the investment well worth the effort.

Among the facility-based technologies that have grabbed recent headlines, robot-assisted therapy is one that may be attractive to healthcare organizations. Robot-assisted therapy is an efficacious method to remediate disability associated with a wide variety of neurological disorders, most notably stroke and spinal cord injury (SCI). Intensity and repetition has been repeatedly demonstrated to be necessary for central nervous system excitation and associated motor learning.1Massed practice, or high-volume repetition, has been shown to improve muscle strength and voluntary function.2 Robot-assisted therapy has the capacity to provide high numbers of specific movements with support or guidance as necessary, ensuring optimal conditions for motor learning and recovery of function.3 Changes can be observed in as little as 6 weeks and peak around 12 weeks of training.4

Nearly all robotic devices include some sort of computer interface, even a virtual reality component, providing the patient and therapist with real-time feedback to improve performance. Robotic devices also allow for quantitative monitoring; measuring changes in strength, range of motion, and trajectory; and illuminating patient engagement trends, time, and effort.3 As the body of literature expands and supports its use, patients are seeking clinics with these resources. Robotic technology has the potential to align patients’ interests in validated strategies with clinics’ interests in efficiency and payor-supported interventions. Clinics have an opportunity to improve patient outcomes and efficiency with which they reach those outcomes by investing in robotic devices. This investment is not trivial, however, and better understanding of the capacity and scope of different devices will help to make sure that everyone’s resources are utilized appropriately.

Assessment: Get the Complete Picture

Before it begins to investigate and trial devices, a clinic should do a careful self-assessment. Clinics should have a good understanding of their patient factors and needs: demographics, diagnoses, and payor mix. Equally important, clinics should have a good understanding of how much of their own resources—money, time, and space—they have to spend. Although money is often considered to be the limiting factor in the acquisition of technology, time and space deserve equal consideration. Nothing would be worse than investing in the perfect body weight support (BWS) gait trainer, only to find that your ceiling is too low to accommodate it. Similarly, clinics should anticipate that therapists will need time outside patient care to learn the devices and that efficiency will suffer in the early learning phase. Clinics will want to consider existing technology and therapist-driven interventions when deciding on their specific needs. Clinics would benefit from having a clear plan for acquisition and incorporation of robotic technology into existing practices. Acquiring too much technology too quickly is a sure way to reduce integration of devices and waste valuable resources.


Visit Site —> Robot-Assisted Therapy: What Is Right for Your Clinic? – Rehab Managment

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[ARTICLE] Adaptation of a smart walker for stroke individuals: a study on sEMG and accelerometer signals – Full Text



Stroke is a leading cause of neuromuscular system damages, and researchers have been studying and developing robotic devices to assist affected people. Depending on the damage extension, the gait of these people can be impaired, making devices, such as smart walkers, useful for rehabilitation. The goal of this work is to analyze changes in muscle patterns on the paretic limb during free and walker-assisted gaits in stroke individuals, through accelerometry and surface electromyography (sEMG).


The analyzed muscles were vastus medialis, biceps femoris, tibialis anterior and gastrocnemius medialis. The volunteers walked three times on a straight path in free gait and, further, three times again, but now using the smart walker, to help them with the movements. Then, the data from gait pattern and muscle signals collected by sEMG and accelerometers were analyzed and statistical analyses were applied.


The accelerometry allowed gait phase identification (stance and swing), and sEMG provided information about muscle pattern variations, which were detected in vastus medialis (onset and offset; p = 0.022) and biceps femoris (offset; p = 0.025). Additionally, comparisons between free and walker-assisted gaits showed significant reduction in speed (from 0.45 to 0.30 m/s; p = 0.021) and longer stance phase (from 54.75 to 60.34%; p = 0.008).


Variations in muscle patterns were detected in vastus medialis and biceps femoris during the experiments, besides user speed reduction and longer stance phase when the walker-assisted gait is compared with the free gait.

Keywords Stroke,sEMG,Smart walker,Gait,Accelerometer


Stroke is considered a major health issue worldwide, since it is a leading cause of motor disabilities, affecting the independence and ability to perform daily tasks in most cases (Belda-Lois et al., 2011World…, 2015). There are two distinct types of stroke: the ischemic and the hemorrhagic. The first one is the most common and is responsible for 85-90% of cases, while the second type occurs in a smaller number (10-15%). In contrast, the mortality rate ranges from 8 to 12% for the ischemic type, while the hemorrhagic type has more fatal outcomes with numbers varying between 33% and 45% (Ovbiagele and Nguyen-Huynh, 2011).

Aside from the stroke type, the location and extension of the brain lesions may lead to different sequels (Deb et al., 2010) and, due to this reason there is a high heterogeneity among stroke sequels (Belda-Lois et al., 2011), varying according to the brain lesion location and extension. A lesion that occurs in the anterior cerebral artery, for example, may cause motor injuries predominantly in the lower extremity of the contralateral side, which interfere in the gait and body balance (Pare and Kahn, 2012).

Patients that had stroke usually have spastic muscles in the quadriceps femoris (vastus medialis, vastus lateralis, vastus intermedius and rectus femoris) and triceps surae (gastrocnemius medialis, gastrocnemius lateralis and soleus) while the hamstrings (biceps femoris, semitendinosus and semimembranosus) and tibialis anterior are flaccid, hindering the knee flexion and dorsiflexion (Murray et al., 2014Sheffler and Chae, 2015). In spite of flexor weakness, stroke individuals present more co-contractions between agonist and antagonist muscles when compared with healthy subjects (Shao et al., 2009), which occur in order to avoid knee and plantar hyperflexion.

All these conditions create a tendency on stroke individuals to produce a compensatory movement in order to walk, which is known as hip circumduction, typical in stroke gait (Whittle, 2007), causing an asymmetric gait, and overloading the non-paretic limb.

Due to this asymmetry and lack of balance, about 75% of stroke patients need assistance for walking independently during the first three months after stroke onset (Verma et al., 2012). However, there are no evidence-based criteria for choosing the device to help the patient (Verma et al., 2012). Tyson and Rogerson (2009) evaluated the use of cane and foot-ankle orthosis, which provided confidence and safety to the patients (20 stroke patients; mean age: 65.6 ± 10.4 years; mean time since stroke: 6.5 ± 5.7 weeks), improving their functional mobility. On the other hand, Suica et al. (2016) analyzed the immediate effect using a rollator, although for healthy subjects (19 subjects; 22 to 70 years), identifying a reduced muscle activity of the lower limbs (gluteus medius and maximus, rectus femoris, semitendinosus, tibialis anterior and gastrocnemius) caused by the weight bearing imposed on the walker.

Most stroke individuals need rehabilitation, whose main goal is the movement recovery to allow them to carry out daily tasks independently (Dohring and Daly, 2008Roger et al., 2011). This rehabilitation depends on many factors: lesion severity, age, type of therapeutic intervention, and how complex the stroke was. However, in many cases, rehabilitation does not provide an efficient recovery, and sometimes worsening the clinical status and the damage in the non-paretic limb. In such cases, those therapeutic interventions may provoke decreased mobility and secondary complications (Allen et al., 2011). On the other hand, conventional gait training and rehabilitation, commonly used nowadays, may not provide a total restoration for most patients (Dohring and Daly, 2008Suica et al., 2016).

Many studies (Cifuentes et al., 2014Dohring and Daly, 2008Tan et al., 2013) used robotic devices for motor rehabilitation, to recover important features of the gait and maintain muscle integrity. However, to the extent of our knowledge, no neuromuscular analysis was performed using robotic walkers applied for stroke rehabilitation. The main goal of this paper is to analyze changes in the muscle pattern on paretic limb during free and walker-assisted gaits in stroke individuals, through accelerometry and surface electromyography (sEMG). Another important goal is to verify the volunteer adaptation to a smart walker in the first contact. Therefore, this study is focused on the pattern-variation analysis of the paretic limb muscles and the swing and stance phase duration, in addition to the walking speed during the use of robotic walker and in free gait.



Eight ischemic stroke individuals (4 males and 4 females; 65.75 ± 6.27 years old), from a rehabilitation institution of Espirito Santo state (Brazil), volunteered for the experiments. The number of volunteers generated a sample size for this study that has an effect size of 0.8, with statistical power of 50% and alpha equals 0.05. The research was previously approved by the Ethical Committee of Federal University of Espírito Santo (UFES/Brazil) and all volunteers signed the informed consent.

Eligibility criteria for inclusion in this study were: only one stroke that happened at least from 6 months up to 5 years before the tests; hemiparetic gait; Functional Ambulation Classification – FAC (Holden et al., 1984) in stage 2 or higher; ability to remain erect and with elbows at 90º while using the smart walker; age range from 50 to 80 years; enough cognitive skills and language to follow the experiment instructions. Individuals were excluded if they could not walk independently, had any musculoskeletal or neurological disorder limiting ambulation unrelated to the stroke, and if they had cardiorespiratory impairment, conditions that may prevent them from performing walking tests. Each volunteer was classified through a functional walking test (FAC) by the same physiotherapist, who has more than 20 years of experience.

sEMG and accelerometer data

All procedures for sEMG data acquisition and processing were based on recommendations of the “Standards for reporting EMG data” (Merletti and Torino, 2015). The kind of electrodes used was Ag/AgCl discoid shape, with 10 mm diameter, pre-gelled and with inter-electrode distance of 20 mm. Before the electrode placement, the skin was cleaned (alcohol 70%) and shaved to reduce impedance. Signals from four muscles of lower limb — vastus medialis (VM), biceps femoris (BF), tibialis anterior (TA) and gastrocnemius medialis (GM) — were acquired and analyzed. In addition, a reference electrode was placed on the medial malleolus. In all cases, the analyzed limb was the contralateral to the brain lesion. For better accuracy in electrode placement, two experts checked the electrode position placed on the muscles. Cables from the sEMG acquisition equipment were fixed on the limb using adhesive tape to minimize motion artifacts. In addition, a biaxial accelerometer was fixed using adhesive tape on the ankle of the contralateral limb, with the y-axis pointing cranially and x-axis pointing anteriorly.

Both sEMG and accelerometer data were recorded simultaneously using an acquisition equipment EMG 830C (EMG System do Brasil Ltda®) with 16-bit analog/digital conversion resolution, amplifier gain up to 2000V/V, common mode rejection > 100dB, input impedance of 109Ω, and maximum sampling frequency of 2 kHz. The measurement capacity ranged from -2000 to 2000 μV with sensitivity of 0.061 μV.

Smart walker

A smart walker from UFES/Brazil (Valadão et al., 2016) (Figure 1) was used in the experiments, which was built from a conventional four-legged walker adapted to a robotic mobile platform. The smart walker structure has forearm bars to provide weight support and comfort during its use, also allowing the user to guide it. The smart walker has also a height adjustment, which allows the user to stay in an upright posture. An onboard laser sensor is used to provide information about the distance from the walker to the user’s leg. By using the information provided by the laser sensor, the walker can adjust its speed through a proportional–integral–derivative controller (PID), with the goal of keeping the user at a predefined distance and angle, thus aiding him/her to maintain right posture (position and orientation) while using the device. […]

Figure 1 Smart Walker scheme: side view (left) and top view (middle). Stroke subject using the walker (right) in an experiment. Structure changes in the walker: (a) Handlebar; (b) Forearm support; (c) Stabilizer bars; (d) Laser sensor; (e) Pioneer 3-DX robot; (f) Free wheels; (g) Fixed distance (70 cm) from the user to laser sensor. 


Continue —> Adaptation of a smart walker for stroke individuals: a study on sEMG and accelerometer signals

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[BLOG] Complete Solution for Neurological Gait Rehabilitation

medica presents an efficient best-practice model for multi-phase group therapy

With the THERA-Trainer Complete Solution for gait rehabilitation, medica Medizintechnik GmbH brings a complete device-based concept for neurological rehabilitation onto the market. The company is thus addressing the challenge, faced by many hospitals, of offering scientifically established and effective therapies despite the lack of resources, cost pressures and time constraints.

With our Complete Solution, we are successfully implementing an evidence-based, clinically proven treatment concept for the rehabilitation of the lower extremities.

Jacob Tiebel, head of product management at medica

Many hospitals need tailored strategies to work efficiently, and medica Medizintechnik GmbH’s new solution concept meets this requirement. The THERA-Trainer Complete Solution for gait rehabilitation is developed individually with each customer and is tailored to the current operating reality of each hospital. An in-depth analysis of the initial situation and a customised design of the solution ensure that space issues are taken into account and that the training and therapy devices are properly utilised. The Complete Solution is not a substitute for therapists, but instead facilitates and supports their work. In addition, it enables a single therapist to treat several patients at the same time.

A complete solution, not a piecemeal offering

With the Complete Solution concept, THERA-Trainer primarily addresses the organisational and process weaknesses in hospitals. With this approach, medica intends to harness previously untapped economic potential in hospitals, while at the same time working sustainably towards better treatment outcomes. The focus is not on the individual products, but on an optimised therapy process and the full set of devices as a complete solution.
Last year, medica acquired an end-effector gait trainer through its merger with the Swiss company ability.

With the THERA-Trainer lyra, we now offer the full range of products for gait rehabilitation. The real innovation lies in integrating these products intelligently into a high-efficiency setting.

medica owner and managing director Peter Kopf

First pilot projects have been successful

The first pilot project was launched last year in collaboration with one of Germany’s largest hospital operators. The first THERA-Trainer Complete Solution was installed by medica in the neurological centre at the MEDIAN clinic in Madgeburg. This marked the beginning of intensive cooperation between the rehabilitation sector and industry.

Prof. Michael Sailer, medical director of the MEDIAN clinic in Madgeburg, is convinced: “Professional care allows us to develop a differentiated approach with the Complete Solution.” The process of carrying out a preliminary analysis of a hospital’s therapy processes, followed by the creation of new therapeutic pathways, is of vital importance for cost-effective use, Sailer continues.

With the Complete Solution for gait rehabilitation, medica is striving towards long-term cooperation and partnership with hospitals. The concept has already received positive feedback from experts, and official distribution of the THERA-Trainer Complete Solution is now underway.

via Complete Solution for Neurological Gait Rehabilitation | ACNR | Online Neurology Journal

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[Abstract] Effects of constraint-induced movement therapy for lower limbs on measurements of functional mobility and postural balance in subjects with stroke: a randomized controlled trial

Background: Constraint-induced movement therapy (CIMT) is suggested to reduce functional asymmetry between the upper limbs after stroke. However, there are few studies about CIMT for lower limbs.

Objective: To examine the effects of CIMT for lower limbs on functional mobility and postural balance in subjects with stroke.

Methods: A 40-day follow-up, single-blind randomized controlled trial was performed with 38 subacute stroke patients (mean of 4.5 months post-stroke). Participants were randomized into: treadmill training with load to restraint the non-paretic ankle (experimental group) or treadmill training without load (control group). Both groups performing daily training for two consecutive weeks (nine sessions) and performed home-based exercises during this period. As outcome measures, postural balance (Berg Balance Scale – BBS) and functional mobility (Timed Up and Go test – TUG and kinematic parameters of turning – Qualisys System of movement analysis) were obtained at baseline, mid-training, post-training and follow-up.

Results: Repeated-measures ANOVA showed improvements after training in postural balance (BBS: F = 39.39, P < .001) and functional mobility, showed by TUG (F = 18.33, P < .001) and by kinematic turning parameters (turn speed: F = 35.13, P < .001; stride length: F = 29.71, P < .001; stride time: F = 13.42, P < .001). All these improvements were observed in both groups and maintained in follow-up.

Conclusions: These results suggest that two weeks of treadmill gait training associated to home-based exercises can be effective to improve postural balance and functional mobility in subacute stroke patients. However, the load addition was not a differential factor in intervention.


via Effects of constraint-induced movement therapy for lower limbs on measurements of functional mobility and postural balance in subjects with stroke: a randomized controlled trial: Topics in Stroke Rehabilitation: Vol 24, No 8

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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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