Posts Tagged gait
[Preprint] Feasibility of Simultaneous Transcranial Direct Current Stimulation During Gait Training in Chronic Stroke Patients: A Randomized Double-blind Pilot Clinical Trial
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, tDCS/rTMS on April 2, 2024
Abstract
Background
Transcranial direct current stimulation (tDCS) is a therapeutic tool for improving post-stroke gait
disturbances, with ongoing research focusing on specific protocols for its application. We evaluated the
feasibility of a rehabilitation protocol that combines tDCS with conventional gait training.
Methods
This was a randomized, double-blind, single-center pilot clinical trial. Patients with unilateral hemiplegia
due to ischemic stroke were randomly assigned to either the tDCS with gait training group or the sham
stimulation group. The anodal tDCS electrode was placed on the tibialis anterior area of the precentral
gyrus while gait training proceeded. Interventions were administered 3 times weekly for 4 weeks.
Outcome assessments, using the 10-meter walk test, Timed Up and Go test, Berg Balance Scale,
Functional Ambulatory Scale, Modified Barthel Index, and EQ-5D-3L, were conducted before and after the
intervention and again at the 8-week mark following its completion. Repeated-measures ANOVA was used for comparisons between and within groups.
Results
Twenty-six patients were assessed for eligibility, and 20 were enrolled and randomized. No significant
differences were observed between the tDCS with gait training group and the sham stimulation group in
gait speed after the intervention. However, the tDCS with gait training group showed significant
improvement in balance performance in both within-group and between-group comparisons. In the
subgroup analysis of patients with elicited motor-evoked potentials, comfortable pace gait speed
improved in the tDCS with gait training group. No serious adverse events occurred throughout the study.
Conclusions
Simultaneous tDCS during gait training is a feasible rehabilitation protocol for chronic stroke patients
with gait disturbances.
Introduction
Impairment of independent gait is one of the most disabling consequences after a stroke [1]. Gait
abnormality in stroke patients arises from a complex interplay of factors, including lower limb motor
weakness and decreased balance. Some individuals may not be entirely incapable of walking, but they
may still require gait aids or assistance from caregivers. Gait disturbances pose a greater risk of further
injury due to falls. It is well known that fall-associated fractures result in significant socioeconomic costs
[2]. Additionally, gait disturbances lead to limitations in social activity, thereby reducing the quality of life
of stroke patients. Therefore, improving gait performance in stroke patients has long been a desire shared
by patients and physicians.
Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that aims to
modulate the human brain by delivering low-intensity electrical current through the scalp. The mechanism of tDCS is explained by 2 principles: (1) the enhancement of cortical activity through a polarity shift in the resting membrane potential and (2) the upregulation of neural plasticity through long-term potentiation [3]. Applying anodal tDCS to patients with subacute stroke has been associated with beneficial effects on motor function [4]. However, inconsistent results have emerged across studies, with some failing to observe significant improvements in patients who underwent tDCS compared to sham stimulation [5].
Additionally, there has been substantial variability in factors, such as stimulation area, intensity, duration,
and the number of sessions among different tDCS protocols, highlighting the need for further research to
establish an optimal tDCS protocol for maximizing the effect of conventional gait training methods.
Studies focusing on stimulation timing suggest that combining tDCS with gait training simultaneously
shows more promising results in improving gait performance compared to protocols that administer gait
training and tDCS separately [6].
This study aimed to evaluate the feasibility of a rehabilitation protocol that combines simultaneous tDCS
with conventional gait training and to investigate its impact on gait performance in chronic stroke
patients.[…]
[Abstract + References] Effects of robotic-assisted gait training on physical capacity, and quality of life among chronic stroke patients: A randomized controlled study
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, Rehabilitation robotics on January 24, 2024
Abstract
Background
Even though robotic therapy is becoming more commonly used in research protocols for lower limb stroke rehabilitation, there still is a significant gap between research evidence and its use in clinical practice. Therefore, the present study was designed assuming that the wearable mobile gait device training for chronic stroke patients might have different effects on functional independence when compared to training with a stationary gait device. The present study aims to examine the effects of gait training with ExoAthlet exoskeleton and Lokomat Free-D on functional independence, functional capacity, and quality of life in chronic stroke patients.
Methods
The present study included 32 chronic stroke patients. Participants were randomly divided into two groups. Functional independence of patients was evaluated by using Functional Independence Measure (FIM), physical function was assessed by using the 30-second chair stand test (30-CST), functional capacity was measured by using the 6-Minute Walk Test (6MWT), and quality of life was assessed by using Short Form 36 (SF36). All participants underwent a conventional physiotherapy program for eight weeks, three sessions per week, and each session lasted 60 min. After the physiotherapy program, one group received gait training by using ExoAthlet exoskeleton (ExoAtlet 1 model/2019, Russia), while the other group received training by using Lokomat Free-D (Hocoma, Lokomat Pro Free-D model/2015, Switzerland). Participants were assessed at baseline and post-intervention.
Results
Results achieved in this study revealed that there was a statistically significant difference between FIM, 30-CST, 6MWT, and SF36 scores before and after the treatment in both groups (p < 0.05).There was no difference in FIM, 30-CST, and 6MWT results between Exoskeleton ExoAthlet and Lokomat Free-D groups (p > 0.05). However, there was a statistically significant difference between Exoskeleton ExoAthlet and Lokomat Free-D groups in terms of SF-36 sub-parameters “vitality”, “mental health”, “bodily pain”, and “general health perception” (p < 0.05).
Conclusions
This study demonstrated that the use of ExoAthlet exoskeleton and Lokomat Free-D in addition to conventional physiotherapy, was effective in improving functional independence, physical function, functional capacity, and quality of life among chronic stroke patients. Incorporation of robotic gait aids into rehabilitation for chronic stroke patients might offer significant advantages.
Introduction
Stroke is defined as a condition that develops due to a disturbance in brain functions, either in a specific location or in the whole brain, rapidly manifests symptoms, and these symptoms persist for one day or longer, or result in death [1]. Motor functions are affected in 65 % of chronic stroke patients, and the majority of these patients experience a reduced level of functional independence [2]. It is believed that the most prominent challenges faced by chronic stroke patients are the distance walked in 6 min and the decrease in functional capacity [3]. In addition, cohort studies also reported that 22 % of chronic stroke patients did not regain any walking function [4].
A significant portion of chronic stroke patients suffer not only from physical disability but also from cognitive and emotional disorders [5]. General predictors of the poor quality of life after a stroke were reported to include medical comorbidities, loss of physical function, social role difficulties, emotional involvement, and depression [6], [7], [8].
In recent years, robotic technology has exhibited notable advancement thanks to faster and more powerful computers, innovative computational methodologies, and a broader range of electromechanical components. This technological advancement also made robotics suitable for rehabilitation interventions, and robotic rehabilitation is a promising method for treating patients with motor disorders. Its significance lies in its the potential to increase and carefully control the dosage of therapy [9], [10]. However, robotic rehabilitation does not solely focus on augmenting the quantity and intensity of treatment.
Robotic systems not only generate simple and repetitive stereotypical movement patterns but can also be utilized in order to provide patients with more intricate and controlled multisensory stimuli [11]. It can be seen that the effect of rehabilitation technology on functional outcomes can be optimized by affording the nervous system greater opportunities to experience genuine activity-related sensorimotor input [12]. Nevertheless, there are ongoing studies examining the therapeutic effectiveness of robotic rehabilitation. In clinical rehabilitation practices addressing chronic stroke patients, robotic technologies are employed for gait training, providing opportunities to move freely on a stationary or mobile basis. Robotic devices are utilized as assistive, rehabilitative, and augmentative instruments in lower extremity rehabilitation for neurological conditions [13]. Considering the lower extremity rehabilitation, the Lokomat, utilized as a stationary device, was demonstrated to be effective in improving walking quality, speed, and balance in conditions such as Multiple Sclerosis, Cerebral Palsy, Parkinson’s disease, Brown-Sequard syndrome, and vascular dementia [14]. Moreover, Lokomat was also reported to be an effective approach used in the rehabilitation of chronic stroke patients. In the literature, a retrospective case-control study examined the efficacy of Lokomat Free-D on functional independence, functional capacity, and balance in chronic stroke patients [15]. It was also reported that Lokomat Free-D is effective in chronic stroke individuals, not only affecting motor functions such as walking, balance, muscle strength, walking ability, and speed but also cognitive and emotional status. [14]. However, to the best of our knowledge, there is no study examining the effectiveness of Lokomat on the quality of life in chronic stroke individuals could be found. Another method utilized for lower extremity rehabilitation is the use of mobile gait devices. Devices such as MIRAD, XoR, and ExoAthlet exoskeleton are some of them [13]. The ExoAthlet exoskeleton was found to increase gait speed and stability, as well as reducing body sway, in conditions such as Multiple Sclerosis and spinal cord injuries [16], [17]. In a randomized controlled study comparing ExoAthlet exoskeleton and traditional physiotherapy in chronic stroke patients, the ExoAthlet exoskeleton group exhibited significant improvements when compared to the traditional physiotherapy group. The ExoAthlet exoskeleton group had a decrease in hemiparesis severity, an increase in paretic limb muscle strength, improvement in balance, and notable enhancements in the walking process and speed [18]. However, there is no study available that examines the effectiveness of the ExoAthlet exoskeleton on quality of life in chronic stroke patients. In both literature and clinical practice, there are gaps concerning the effectiveness of Lokomat Free-D and ExoAthlet exoskeleton on different parameters. There is no study available that has comparing these two different methods among chronic stroke patients. Finally, this study aims to examine the effects of gait training with the ExoAthlet exoskeleton and Lokomat Free-D on functional independence, functional capacity, and quality of life in chronic stroke patients, as well as to investigate whether there are any different effects.
Section snippets
Study design and ethics
Study design: Randomized Controlled Study.
Ethics: The study protocol was approved by from the institutional ethics board of Üsküdar University’s Non-Interventional Ethics Committee (Approval no = 61351342/February 2021-66/26.02.2021). The present study was carried out in accordance with the principles outlined in the Declaration of Helsinki. Participants, who voluntarily agreed to participate in this study, signed a written consent form. The paper is registered with ClinicalTrials.gov, and the
Results
Initially, 40 chronic stroke patients were involved in the study, and 8 individuals did not meet the inclusion criteria. Thus, the study was completed with a total of 32 individuals. The flow chart of the study is presented in Fig. 3.
The sociodemographic characteristics of the chronic stroke patients included in the study are shown in Table 1.
The results of this study showed that there was a statistically significant difference between functional independence, functional capacity, and quality
Discussion
Significant advancements have been achieved in robotic technology, especially in the last ten years, and the use of robotic technology in healthcare has increased. The use of robotic technology increased in post-stroke rehabilitation due to its advantages such as performing movements very similar to normal activity, providing continuous stimulation of the central nervous system, and creating treatment options with appropriate intensity and dosage for the patient during the rehabilitation
Limitations and future directions
The study has some limitations. The long-term effects of robotic-assisted gait training were not evaluated in this study. Additionally, different psychometric properties that would affect the quality of life were ignored. Future studies taking these parameters into consideration may provide different perspectives on the interpretation of results.
Conclusion
In conclusion, the results achieved in this study showed that gait training with Exoskeleton ExoAthlete and gait training with Lokomat Free-D for eight weeks administered in addition to conventional physiotherapy have positive effects on functional independence, functional capacity, and quality of life parameters in post-stroke patients. Training with Exoskeleton ExoAthlet had a more positive effect on the quality-of-life sub-parameters, such as vitality, mental health, bodily pain, and general
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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[WEB] Physical therapy clinical trial demonstrates meaningful gains for stroke survivors
Posted by Kostas Pantremenos in REHABILITATION on January 20, 2024
by Amy Cherry, University of Delaware
It was 3 o’clock in the morning when Larry Christian awoke to sudden pain in his left hand and arm. He didn’t think much of it and managed to fall back asleep. The next day, he got up, and his wife noticed he was bouncing off the walls.
“I couldn’t keep my balance at all. My wife said, ‘There’s something wrong with you,’ and obviously there was,” he said.
An MRI determined the 67-year-old from Wilmington suffered a hemorrhagic stroke. He was referred to the University of Delaware’s Physical Therapy Clinic for rehabilitation.
“Initially, I had a lot of balance problems that we worked pretty intensely to correct,” Christian said.
He enrolled in a clinical trial at UD, led by co-investigator Darcy Reisman, professor and chair of the Department of Physical Therapy, that sought to explore whether high-intensity interval training (HIIT) aids in improved gait post-stroke. UD was one of three sites selected for the clinical trial led by primary investigator and associate professor Pierce Boyne of the University of Cincinnati. Sandra Billinger, professor and vice chair of stroke translation research at the University of Kansas Medical Center, is also a co-investigator and represents the third site involved in the clinical trial.
Now, seven years later, Christian is walking better.
“Participating in this study got me to a point where I could walk better and even take a walk outside,” Christian said. “I’ve been pretty healthy all my life, and while I can’t play volleyball anymore, walking again made me feel great.”
Christian is among the lucky ones. Among 7 million stroke survivors in the U.S., fewer than 10% have adequate walking speed and endurance to complete normal daily activities like grocery shopping.
Reisman said the results of the multi-million-dollar, five-year clinical trial showed HIIT helped more people than just Christian. The results, published in JAMA Neurology, show that chronic stroke survivors who engaged in high-intensity exercise with bursts of maximum-speed walking alternated with recovery periods saw a significant difference in their walking capacity over 12 weeks. The improvements were so dramatic Boyne and Reisman have secured a clinical trial grant renewal for more than $3.4 million from the National Institutes of Health (NIH) to triple the size of their study to 165 participants.
“We need a larger sample because the more people you sample, the more closely the results represent the population,” Reisman said.
She added HIIT looks different for each stroke survivor, and the optimal exercise program for each person with stroke remains unknown.
“We want them to train at the fastest possible speed, which varies from person to person,” Reisman said. “But we don’t want them running.”
For those already walking at a reasonably fast pace, research associate Henry Wright in Reisman’s lab will add an incline or a weighted vest or wrap a bungee cord around their waist to create resistance.
“It’s self-reported data, but participants tell me they have more energy, or they’re able to do more around the house, or they’re not winded when they go shopping,” Wright said. “By the end of the training, I can see their walking is smoother, they’re getting farther on clinical testing, and it’s rewarding to see their gains.”
The results from the initial clinical trial showed Reisman and collaborators that HIIT was feasible and safe in a small group of stroke survivors, who saw sustained gains in walking capacity, more so than patients engaged in moderate-intensity exercise.
However, further study of the intervention in larger populations is crucial to change the standard of care.
“Many physical therapists were trained during a time when patients with neurologic conditions, particularly stroke, were treated with kid gloves, partly because they say stroke is the heart attack of the brain,” Reisman said. “It’s common they also have cardiovascular conditions, so people tend to be extra careful with those patients in terms of pushing them.
“But what we know now is at least moderate-intensity, and likely high-intensity interval training, is essential not only for stroke survivors’ cardiovascular system but also for their brain,” Reisman said. “The evidence shows that intensity is linked to the release of neurotrophins in the brain that help the brain remodel after a stroke.”
Kiersten McCartney, a physical therapist obtaining her doctorate in biomechanics and movement science, worked on the clinical trial with Reisman. She spent the 2022 Winter Session at Magee Rehabilitation Hospital in Philadelphia, helping them implement moderate-to-high-intensity exercise and saw the benefits first-hand.
“I’ll never be able to say there’s no risk of heart attack. Even the fittest people can have a heart attack when exercising,” McCartney said. “Still, the data points to the idea that you’re doing more harm than good by not engaging your patients with stroke in high-intensity exercise when we talk about those longer-term outcomes.
“When patients tell me they went for a longer walk in the park or didn’t get as tired when playing with their grandkids, it shows they’re doing the things they want to do in their life, and to me, that’s a sign of their hard work paying off.”
The HIIT-Stroke Trial 2 will continue to examine dosing to confirm whether a full 12 weeks of vigorous exercise is needed to see significant improvements in walking. Reisman and collaborators will identify whether differences in sex, gender and other factors played a role in rehabilitation. If the five-year study results are similar and show significant gains from high-intensity interval exercise in a larger population, investigators would next work with NIH Strokenet to launch a nationwide clinical trial in people with stroke.
“We’ve known about the value of moderate-intensity exercise for more than a decade, and it’s still not the standard of care,” Reisman said. “If we find that HIIT is the optimal intervention, the next phase would be the knowledge translation phase, where we’d systematically develop a methodology to get HIIT into clinics.”
For HIIT to work as an intervention, Reisman said therapists will need the proper tools. She’s been pushing for commercially available heart rate monitors, placed around the chest during exercise, to be the standard of care in clinics for years.
“They’re already a standard of care for people in the community,” Reisman said. “Getting them into clinics is imperative so PTs can monitor patients’ heart rate the entire time they exercise. That constant monitoring gives therapists data on how a person is responding beyond visible signs and symptoms, and in turn, more peace of mind.”
But beyond tools and training, Reisman said, it comes down to evidence and education.
“If we have hundreds and hundreds of stroke survivors who’ve gone through our high-intensity exercise intervention, and we’ve seen no major adverse events—that will help,” Reisman said. “The more data we have to show therapists, the better we can implement this intervention that will change lives.”
More information: Pierce Boyne et al, Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke, JAMA Neurology (2023). DOI: 10.1001/jamaneurol.2023.0033
Journal information: Archives of Neurology
Provided by University of Delaware
[WEB] Revolutionizing Stroke Recovery: The iStride Device
Posted by Kostas Pantremenos in Assistive Technology, Gait Rehabilitation - Foot Drop, Rehabilitation robotics on January 19, 2024
The story of Maria Magdalena Valencia Juares, fondly known as Elena, is a testament to the power of innovation and the resilience of the human spirit. In 2021, Elena experienced a stroke that left her with muscle weakness and a decline in mental health, a situation further intensified by the isolation brought about by the COVID-19 pandemic. With her family residing thousands of miles away, they sought a solution to Elena’s predicament, and their answer came in the form of the iStride device. This ground-breaking tool, designed to help stroke survivors improve their walking ability, brought about incredible changes in Elena’s life, enabling her to climb stairs and dance again. The iStride device didn’t just offer her a solution; it provided hope and a renewed sense of independence.
The iStride Device: A New Hope for Stroke Survivors
The iStride device is a wearable technology designed to help stroke survivors regain their walking capability. Its real-time feedback mechanism supports users during walking exercises, leading to significant improvements in walking speed and endurance. As a result, stroke survivors gain better overall mobility and independence, as was the case with Elena.
Not only is the iStride device designed for functionality, but it is also built for comfort and adaptability. As a wearable ankle robot, it provides adjustable assistance to the user’s ankle, aiding in the regaining of strength and balance. Clinical studies corroborate the effectiveness of the iStride, with users reporting notable enhancements in their walking speed and endurance.
How the iStride Works
At its core, the iStride device is an assistive technology that aims to reduce the risk of falls in stroke survivors by providing targeted electrical stimulation to the muscles in the affected leg. This stimulation aids in improving strength and coordination, resulting in significant increases in walking speed and endurance, which in turn lead to greater independence and improved quality of life.
The iStride device employs a unique combination of visual and auditory cues to help patients improve their gait and balance. Its non-invasive nature and wearability ensure that it provides electrical stimulation to the leg muscles in a way that enhances mobility and minimises the risk of falls. The benefits of using the iStride device are not only immediate but also long-term, with studies showing sustained improvements in walking ability for stroke survivors, even one year after therapy.
iStride: Shifting the Paradigm of Stroke Recovery
The remarkable story of Elena serves as an inspiring testament to the potential of the iStride device. It is not just a rehabilitation tool; it is a device that promises a shift in the paradigm of stroke recovery. The iStride device offers a beacon of hope to stroke survivors, enabling them to regain their independence and significantly improve their quality of life.
As we move forward, it is clear that the iStride device will continue to empower stroke survivors, offering them a chance to reclaim their mobility, independence, and ultimately, their lives. Through technology and innovation, we can look forward to a future where stroke recovery is not just possible, but also achievable and sustainable.
[ARTICLE] Robotic gait training and botulinum toxin injection improve gait in the chronic post-stroke phase: A randomized controlled trial
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, Pharmacological, Rehabilitation robotics on December 23, 2023
Abstract
Background
Improving walking ability is one of the main goals of rehabilitation after stroke. When lower limb spasticity increases walking difficulty, botulinum toxin type A (BTx-A) injections can be combined with non-pharmacologic interventions such as intensive rehabilitation using a robotic approach. To the best of our knowledge, no comparisons have been made between the efficacy of robotic gait training and conventional physical therapy in combination with BTx-A injections.
Objective
To conduct a randomized controlled trial to compare the efficacy on gait of robotic gait training versus conventional physiotherapy after BTx-A injection into the spastic triceps surae in people after stroke.
Method
Thirty-three participants in the chronic stroke phase with triceps surae spasticity inducing gait impairment were included. After BTx-A injection, participants were randomized into 2 groups. Group A underwent robotic gait training (Lokomat®) for 2 weeks, followed by conventional physiotherapy for 2 weeks (n = 15) and Group B underwent the same treatment in reverse order (n = 18). The efficacy of these methods was tested using the 6-minute walk test (6MWT), comparing post-test 1 and post-test 2 with the pre-test.
Results
After the first period, the 6MWT increased significantly more in Group A than in Group B: the mean difference between the interventions was 33 m (95%CI 9; 58 p = 0.007; g = 0.95), in favor of Group A; after the second period, the 6MWT increased in both groups, but the 30 m difference between the groups still remained (95%CI 5; 55 p = 0.019; g = 0.73).
Conclusion
Two weeks of robotic gait training performed 2 weeks after BTx-A injections improved walking performance more than conventional physiotherapy. Large-scale studies are now required on the timing of robotic rehabilitation after BTx-A injection.
Introduction
Stroke is a major cause of death and disability in adults worldwide [1]. It results in spastic paresis which leads to motor impairment. Among survivors, 65% to 85% are able to walk during the first 6 months after stroke, but the functional limitations which often persist impact their quality of life [2,3]. Improving walking ability is one of the main goals of rehabilitation after stroke [4,5]. Both pharmacological and non-pharmacological treatments could be used to reduce the activity limitation caused by spastic paresis [6,7].
Intramuscular injection of botulinum toxin type A (BTx-A) performed under electromyographic or ultrasound guidance has proved to be a safe and effective means of pharmacologically reducing spasticity locally (Grade A according to the French National Health Agency). When lower limb spasticity increases individuals’ walking difficulties, BTx-A can be combined with non-pharmacological interventions as part of a multidisciplinary rehabilitation program to optimize individuals’ walking abilities [8]. Intensive rehabilitation using repetitive task training methods has been found to improve walking performance [4,9]. Robotic gait training (RGT) can be used as a repetitive, intensive, single-task method of gait training with body weight unloading and variable motor assistance, resulting in longer walking times at higher speeds [10], [11], [12]. In an international group consensus on interventions to optimize the benefits of BTx-A after stroke, Francisco et al. wrote that since repetition is important in rehabilitation, robotics are likely to gain more importance in the future [7].
Two studies have addressed the effects of combined treatment with BTx-A and robotic gait training in individuals in the chronic post-stroke phase. Picelli et al. compared the effects on spasticity of combined treatment with BTx-A and RGT with a Lokomat versus BTx-A injection alone [13]. The results showed that RGT did not enhance the antispastic effect of BTx‑A, as measured using the modified Ashworth scale and the Tardieu scale. Interestingly the latter author reported the occurrence of a significant improvement in the distance covered in the 6-minute walk test after combined treatment versus BTx-A alone. Erbil et al. observed greater benefits in terms of individuals’ walking and balance abilities after treatment with physical therapy and RGT with the Robogait as compared with physical therapy alone in individuals in the chronic post-stroke phase previously injected with BTx-A [14].
It was proposed here to test the hypothesis that RGT performed after injection of BTx-A into the triceps surae muscle would improve the walking performance of participants in the chronic post-stroke phase with spastic hemiparesis more than conventional physiotherapy (CP). The chronic phase was chosen to avoid fluctuations in performance caused by natural recovery during the first 6 months post stroke. The second argument for choosing the chronic phase was to reduce the contribution of balance disorders to walking disorders and to increase the contribution of intra-limb coordination and propulsion, which can be trained using a robotic exoskeleton [15,16].
To our knowledge, this is the first comparison of the effects of RGT and CP after BTx-A injection on gait performance in participants in the chronic post-stroke phase. The aims of the present study were as follows:
- -To compare the efficacy of RGT using the Lokomat with that of conventional physiotherapy after triceps surae BTx-A injection in participants with chronic stroke sequelae
- -To assess whether the time elapsed between BTx-A injection and RGT may contribute significantly to the gait improvements observed.
Section snippets
Materials and methods
This manuscript follows the 2017 CONSORT guidelines for reporting randomized trials evaluating non-pharmacological treatments [17].
Results
The flowchart of the results obtained is presented in Fig. 2. A total of 34 participants were enrolled and randomized into 2 groups from February 2019 to May 2021. One participant from Group A was excluded from the analysis because the investigator realized at the end of the assessments that he had been included by mistake. The analysis was based on 15 and 18 participants in Group A and Group B, respectively (Fig. 2). No significant differences were observed between the 2 groups (see Table 1).
Discussion
The aim of this study was to assess the effects of RGT treatment using a fixed exoskeleton combined with BTx-A on the walking performances of people in the chronic post-stroke phase, in comparison with CP combined with BTx-A. To our knowledge, no previous studies have addressed the question of the timing of RGT after botulinum toxin injection. The results presented here show that between W4 and W0, participants’ performances improved in the 6MWT tests more clearly after undergoing RGT than CP.
Conclusion
Our results support the hypothesis that 2 weeks of RGT with a fixed exoskeleton performed 2 weeks after BTx-A improved the walking ability of individuals in the chronic post-stroke phase more than CP. Participants with a spontaneous gait speed between 0.4 and 0.8 m/s appeared to benefit most from RGT performed between W2 and W4 after BTx-A injection. Further studies with groups paired on the basis of gait speed are now required in order to confirm this finding.
Declaration of conflicts of interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jean Michel VITON reports financial support was provided by French government ministry of health (PHRC). Jean Michel Viton reports a relationship with Allergan France and Merz Pharma that includes support for attending meetings and travel reimbursement. Maëva COTINAT reports a relationship with Ipsen Pharma and Allergan France that includes support for attending
Funding
This study was sponsored by Assistance Publique – Hôpitaux de Marseille (DRCI).
Acknowledgement
The authors thank the participants in this study and the rehabilitation teams for their invaluable assistance, Pr. Julien Mancini for his help with statistics and Mrs. Jessica Blanc for her English writing correction.
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- J. Eng et al.Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidenceExpert Rev Neurother(2007)
- D. Wade et al.Walking after stroke. Measurement and recovery over the first 3 monthsScand J Rehabil Med(1987)
View more references
[VIDEO] Post Stroke Foot Dorsiflexion: Using Electrical Stimulation to Reduce Tone & Promote Plasticity – YouTube
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, Neuroplasticity, Video on December 22, 2023
Further reading on electrophysiology and muscle contractions: https://strokesciences.com/post-strok…
StrokeSciences.Com
[ARTICLE] Validating the Safe and Effective Use of a Neurorehabilitation System (InTandem) to Improve Walking in the Chronic Stroke Population: Usability Study. – Full Text
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, Neuroplasticity on November 27, 2023
Abstract
Background:Persistent walking impairment following a stroke is common. Although rehabilitative interventions exist, few exist for use at home in the chronic phase of stroke recovery. InTandem (MedRhythms, Inc) is a neurorehabilitation system intended to improve walking and community ambulation in adults with chronic stroke walking impairment.
Objective:Using design best practices and human factors engineering principles, the research presented here was conducted to validate the safe and effective use of InTandem.
Methods:In total, 15 participants in the chronic phase of stroke recovery (≥6 months after stroke) participated in this validation study. Participants were scored on 8 simulated use tasks, 4 knowledge assessments, and 7 comprehension assessments in a simulated home environment. The number and types of use errors, close calls, and operational difficulties were evaluated. Analyses of task performances, participant behaviors, and follow-up interviews were conducted to determine the root cause of use errors and difficulties.
Results:During this validation study, 93% (14/15) of participants were able to successfully complete the critical tasks associated with the simulated use of the InTandem system. Following simulated use task assessments, participants’ knowledge and comprehension of the instructions for use and key safety information were evaluated. Overall, participants were able to find and correctly interpret information in the materials in order to answer the knowledge assessment questions. During the comprehension assessment, participants understood warning statements associated with critical tasks presented in the instructions for use. Across the entire study, 3 “use errors” and 1 “success with difficulty” were recorded. No adverse events, including slips, trips, or falls, occurred in this study.
Conclusions:In this validation study, people in the chronic phase of stroke recovery were able to safely and effectively use InTandem in the intended use environment. This validation study contributes to the overall understanding of residual use–related risks of InTandem in consideration of the established benefits.
Introduction
Stroke is a major cause of disability and the second leading cause of death worldwide, with its incidence and prevalence expected to increase due to an aging population [1,2]. Many people in the chronic phase of stroke recovery (commonly defined as ≥6 months after stroke) experience walking impairment [3] and consider the ability to walk in their community as “either essential or very important” [4]. Walking rehabilitation can positively impact the well-being of stroke survivors and their families. It can also restore independence—a prospective study in the chronic stroke population reported that better walking ability was positively correlated with quality of life and the ability to live independently [5]. Clinical practice guidelines recommend various interventions for walking impairment, including physical therapy and braces such as an ankle foot orthosis [6–8]. Rhythmic auditory stimulation (RAS) is another clinically effective intervention for the rehabilitation of movements that are naturally rhythmic (eg, walking) [9]. RAS draws on a naturally occurring phenomenon called auditory-motor entrainment. During entrainment, an external auditory rhythm enables subconscious synchronization between the auditory and motor systems to drive coordinated movement patterns [10,11]. RAS has shown clinical benefits related to walking for patients with stroke across the subacute and chronic phases in many studies, several of which are randomized controlled trials (RCTs) [12–18]. In particular, speed, step length, cadence, balance, and dynamic postural stability [12,19,20] have been shown to improve in people who have had a stroke and receive RAS. In addition, the US Department of Veterans Affairs incorporated rhythmic auditory cueing into its clinical practice guidelines for the management of stroke rehabilitation in 2019 [21].
Currently, clinicians administer the RAS protocol in rehabilitation hospitals or clinics, while accessible at-home RAS-based interventions are nonexistent. Rehabilitation at home can carry benefits including half the risk of readmission, lower caregiver strain [22], reduced cost, and greater patient satisfaction [23] relative to hospital rehabilitation. For those in the chronic phase of stroke recovery, physical therapy and to a greater extent RAS can be difficult to access due to limited insurance coverage and the limited number of neurologic music therapists who deliver RAS. The lack of a solution for at-home walking rehabilitation is a critical gap in chronic stroke recovery, and it is imperative that solutions that are safe and effective to use are developed and delivered to address this unmet need.
To help close this gap, MedRhythms has designed MR-001 (InTandem, MedRhythms, Inc), a neurorehabilitation system that delivers a RAS-based intervention for chronic stroke walking impairment and is intended to be used independently at home. […]
[ARTICLE] A multi-degree-of-freedom reconfigurable ankle rehabilitation robot with adjustable workspace for post-stroke lower limb ankle rehabilitation – Full Text
Posted by Kostas Pantremenos in Gait Rehabilitation - Foot Drop, Rehabilitation robotics on November 25, 2023
Introduction: A multi-degree-of-freedom ankle rehabilitation robot with an adjustable workspace has been designed to facilitate ankle joint rehabilitation training. It features a rotation center adapted to the human body, making it suitable for patients with ankle dysfunction following a stroke.
Method: In this study, a multi-degree-of-freedom reconfigurable ankle rehabilitation robot (RARR) with adaptable features, based on the principles of ergonomics, has been proposed to cater to the varying needs of patients. This robot offers an adjustable workspace, allowing for different types of ankle joint rehabilitation exercises to be performed. By adjusting the assembly of the RARR, personalized and targeted training can be provided to patients, circumventing issues of redundancy in degrees of freedom during its use. A kinematic model of the robot has been established, and finite element simulation has been employed to analyze the strength of critical components, ensuring the safety of the robot. An experimental platform has been set up to assess the smoothness of the rehabilitation process with RARR, with angle measurements conducted using an Inertial Measurement Unit (IMU).
Results and discussion: In conclusion, both simulation and experimental results demonstrate that the robot offers an adjustable workspace and exhibits relatively smooth motion, thereby confirming the safety and effectiveness of the robot. These outcomes align with the intended design goals, facilitating ankle joint rehabilitation and advancing the field of reconfigurable robotics. The RARR boasts a compact structure and portability, making it suitable for various usage scenarios. It is easily deployable for at-home use by patients and holds practical application value for wider adoption in rehabilitation settings.
1 Introduction
Stroke is an acute cerebrovascular disorder characterized by a high incidence rate, elevated mortality, and a range of complications (Feigin et al., 2021; Markus, 2022). In recent years, the issue of post-stroke motor dysfunction has become increasingly pressing due to the growing number of stroke patients, with data indicating that approximately 65% of survivors require rehabilitation (Miao et al., 2023). Traditional rehabilitation is labor-intensive, and associated with limitations such as the inability to quantify rehabilitation data, strained medical resources, inconsistent training, and high costs (Gittler and Davis, 2018; Gao et al., 2023). Robot-assisted therapy has emerged as a solution to address these challenges. As the fields of rehabilitation medicine and robotics continue to integrate, various models of ankle rehabilitation robots have been designed to address ankle joint dysfunction resulting from strokes (Dao et al., 2022; Meng et al., 2023a). These diverse rehabilitation robots possess unique potential, offering the promise of more effective and consistent rehabilitation solutions for these patients, thereby positively impacting their quality of life and rehabilitation outcomes.
Ankle rehabilitation robots have extensive applications in the field of rehabilitation medicine, including but not limited to ankle injury rehabilitation, athlete rehabilitation, and elderly population rehabilitation, among other application contexts. Traditionally, ankle rehabilitation robots can be categorized into two main types: wearable and platform-based systems (Jiang et al., 2019; Li et al., 2020). Platform-based ankle rehabilitation robots are fixed devices consisting of a base and a footplate. The base incorporates control and power systems, while the patient places their foot on the footplate. The robot then moves the footplate within predefined parameters, assisting patients in recovering ankle joint strength and flexibility. Zou et al. (2022) proposed a 3-RRS (where R and S denote revolute and spherical joints, respectively) parallel ankle rehabilitation robot (PARR) with low mobility parallel mechanisms. Tsoi et al. (2009) presented an approach that aligns the rotation center by using the patient’s ankle as a part of the robot’s kinematic constraints, including the selection of four linear actuators to control platform tilt. However, this approach may inadvertently impose unexpected loads, leading to discomfort and safety concerns. Zhang et al. (2019) developed a parallel ankle rehabilitation robot (PARR) with three rotational degrees of freedom around the virtual stationary center of the ankle joint. They also established a comprehensive information acquisition system to enhance human-machine interaction among the robots, patients, and healthcare providers. These studies emphasize the importance of considering compatibility, convenience, and safety in the design process. Nonetheless, the mentioned rehabilitation devices are often unable to provide targeted treatment solutions to users, leading to unnecessary movements during the rehabilitation process, resulting in redundancy of degrees of freedom. Additionally, their complex structures increase the cost of robot design. To address these issues, Zhang et al. (2017) introduced a redundant-driven reconfigurable robot structure called the Compliance Ankle Rehabilitation Robot (CARR). This robot is powered by four Festo pneumatic muscles, offering an adjustable workspace and actuator torque to meet the range of motion and muscle strengthening requirements for training. However, this rehabilitation equipment is relatively large in size, involves complex setup and adjustments, and has limited applicability in various environments. Furthermore, rehabilitation devices developed using flexible actuators and materials are still in the experimental stage and are primarily found in laboratories (Meng et al., 2023b). Wang et al. (2022) designed a novel reconfigurable ankle rehabilitation exoskeleton capable of static and dynamic rehabilitation exercises and real-time adaptation to the rotation center of the human ankle-foot complex. Yoon and Ryu (2005) developed a reconfigurable ankle rehabilitation robot with multiple rehabilitation modes. This robot can be reconfigured from a range of motion (ROM) or strengthening exercise device by simply adding extra boards to a balance or proprioceptive exercise device.
When developing ankle rehabilitation devices, it is essential to prioritize user needs, such as device adjustability and adaptability, the capability for personalized rehabilitation plans, a comfortable user experience, and low usage costs, among other aspects. However, this presents several challenges: 1. Precision and Safety: Precision and safety are fundamental prerequisites for designing such devices. The robot must ensure the effectiveness and safety of the equipment. 2. Cost and Accessibility: The manufacturing cost of the robot and the accessibility of the equipment pose a challenge. Rehabilitation robots need to be produced within a reasonable price range to ensure widespread availability to medical institutions and patients. 3. Software Development and Algorithm Design: Complex control algorithms need to be developed to enable the robot to provide personalized rehabilitation plans. The causes of ankle injuries in patients are diverse, and each patient may require different rehabilitation approaches. Therefore, the development of a personalized and reconfigurable ankle rehabilitation robot tailored to individual patient needs holds significant importance.
This study presents a multi-degree-of-freedom ankle rehabilitation robot with an adjustable workspace for post-stroke lower limb ankle rehabilitation. The key feature of this robot is its ability to be personalized and assembled according to the specific rehabilitation needs of different users, involving the selection of varying numbers of actuators and assembly modes to achieve different workspaces for the robot. This customization aims to provide personalized treatment, avoid redundancy of degrees of freedom, and alleviate the financial burden on users. The organization of the remainder of this study is as follows: Section 2 provides an overview of the robot’s design, including different assembly modes. Section 3 conducts a theoretical analysis of the robot, including the establishment of the robot’s kinematic model, the construction of the robot’s workspaces in various modes, and finite element simulation analysis to verify the strength of critical robot components, ensuring the robot’s safety and effectiveness. Section 4 establishes an experimental platform and conducts passive control rehabilitation motion experiments with the robot prototype, analyzing the experimental results to validate the feasibility of the robot. Finally, in Section 5, a summary and outlook for this study are provided. […]
[NEWS] Intensive rehabilitation can provide improvements long after stroke event
Posted by Kostas Pantremenos in Constraint induced movement therapy CIMT, Gait Rehabilitation - Foot Drop on November 25, 2023
by Claes Björnberg, Umea University
Lower-extremity constraint-induced movement therapy (LE-CIMT), i.e., high-intensity treatment with exercise six hours a day for two weeks, appears to improve the function of the leg and the ability to walk and move in its environment. The improvements are seen even if a long time has passed since the stroke, and the achieved effects were maintained, as shown in a new thesis by Ingela Marklund.
LE-CIMT is a treatment option that can be performed both in day rehabilitation in hospital and in outpatient care. People with stroke treated with LE-CIMT were interviewed for the study. Based on the patient’s ability to walk a distance of six minutes, their health-related quality of life in terms of physical function can be predicted, emphasizing the importance of walking and locomotion training in post-stroke rehabilitation.
“We found that the high-intensity treatment produced significant improvements in leg function with increased strength, improved balance and the ability to walk and do two things at the same time,” says Marklund, Department of Community Medicine and Rehabilitation.
Remaining improvements
In addition, walking speed and the ability to walk a longer distance improved in people with stroke. They maintained or even improved their weight bearing on the more affected leg to a more symmetrical load in standing. The improvements achieved were maintained at follow-up three and six months after the end of treatment.
“We also found a strong correlation between time since illness and age in the functional tests that were carried out. Those who completed LE-CIMT within six months of their illness improved their walking speed to a greater degree than those who completed LE-CIMT after seven months or more. Younger participants had better balance than older ones in one of the balance tests.”
Analysis of the interviews conducted about the participants’ experiences generated an overarching theme, that the LE-CIMT gave them knowledge about themselves and how their body works. This knowledge facilitated the possibility of living life more easily. They felt that there was still hope and opportunity for functional improvement, which gave them increased independence and self-esteem. Although the treatment was intense and challenging, it was felt to be absolutely necessary.
Increased participation
Compared to the general population in Sweden, the participants had a significantly lower health-related quality of life in terms of physical function, physical capacity, general health and social function. There was a strong correlation between their results on the six-minute walk test and the physical function domain.
“With increased function in the affected leg, conditions are created for increased participation in society for those who suffer a stroke. Strength, balance and the ability to walk and do two things at the same time are important factors in reducing the risk of falling,” says Marklund.
More information: Lower-extremity constraint-induced movement therapy in individuals with stroke—Improvements, experiences and health-related quality of life. umu.diva-portal.org/smash/record.jsf?pid=diva2%3A1807834&dswid=3870
Provided by Umea University
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