[ARTICLE] Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

Abstract

Background:

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

Methods:

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

Results:

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality–based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality–based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight–supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

Discussion:

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient’s engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

Limitations:

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

Summary:

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

Disclaimer:

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

TABLE OF CONTENTS

INTRODUCTION AND METHODS

Summary of Action Statements………………………………………………..53

Levels of Evidence and Grade of Recommendations…………………54

Methods………………………………………………………………………………….57

ACTION STATEMENTS AND RESEARCH RECOMMENDATIONS

Action Statements…………………………………………………………………..63

Discussion…………………………………………………………………………….79

Conclusions…………………………………………………………………………..82

Summary of Research Recommendations……………………………….83

ACKNOWLEDGMENTS AND REFERENCES

Acknowledgments…………………………………………………………………84

References……………………………………………………………………………84

TABLES AND FIGURE

Table 1: Levels of Evidence for Studies……………………………………54

Table 2: Standard and Revised Definitions for Recommendations………………..54

Table 3: Example of PICO Search Terms for Strength Training………………….58

Table 4: Survey Results………………………………………………….59

Figure 1: Flow chart for article searches and appraisals…………………….60

Table 5: Final Recommendations for Clinical Practice Guideline on Locomotor Function…..79

APPENDIX: EVIDENCE TABLES

Appendix Table 1: Walking Training at Moderate to High Aerobic Intensities…….91

Appendix Table 2: Walking Training With Augmented Feedback/Virtual Reality…….92

Appendix Table 3: Strength Training……………………………………….93

Appendix Table 4: Cycling and Recumbent Stepping Training……………………94

Appendix Table 5: Circuit and Combined Exercise Training…………………….95

Appendix Table 6A: Balance Training: Sitting/Standing With Altered Feedback/Weight Shift……..96

Appendix Table 6B: Balance Training: Augmented Feedback With Vibration………..97

Appendix Table 6C: Balance Training: Augmented Visual Feedback……………….98

Appendix Table 7: Body Weight–Supported Treadmill Walking………………99

Appendix Table 8: Robotic-Assisted Walking Training………………………..100

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Continue —-> Clinical Practice Guideline to Improve Locomotor Function Fo… : Journal of Neurologic Physical Therapy

[Abstract] Compensation or Recovery? Altered Kinetics and Neuromuscular Synergies Following High-Intensity Stepping Training Poststroke

Abstract

Background. High-intensity, variable stepping training can improve walking speed in individuals poststroke, although neuromuscular strategies used to achieve faster speeds are unclear. We evaluated changes in joint kinetics and neuromuscular coordination following such training; movement strategies consistent with intact individuals were considered evidence of recovery and abnormal strategies indicative of compensation.

Methods. A total of 15 individuals with stroke (duration: 23 ± 30 months) received ≤40 sessions of high-intensity stepping in variable contexts (tasks and environments). Lower-extremity kinetics and electromyographic (EMG) activity were collected prior to (BSL) and following (POST) training at peak treadmill speeds and speeds matched to peak BSL (MATCH). Primary measures included positive (concentric) joint and total limb powers, measures of interlimb (paretic/nonparetic powers) and intralimb compensation (hip/ankle or knee/ankle powers), and muscle synergies calculated using nonnegative matrix factorization.

Results. Gains in most positive paretic and nonparetic joint powers were observed at higher speeds at POST, with decreased interlimb compensation and limited changes in intralimb compensation. There were very few differences in kinetic measures between BSL to MATCH conditions. However, the number of neuromuscular synergies increased significantly following training at both POST and MATCH conditions, indicating gains from training rather than altered speeds. Despite these results, speed improvements were associated primarily with changes in nonparetic versus paretic powers.

Conclusion. Gains in locomotor function were accomplished by movement strategies consistent with both recovery and compensation. These and other data indicate that both strategies may be necessary to maximize walking function in patients poststroke.

via Compensation or Recovery? Altered Kinetics and Neuromuscular Synergies Following High-Intensity Stepping Training Poststroke – Marzieh M. Ardestani, Catherine R. Kinnaird, Christopher E. Henderson, T. George Hornby, 2019

[Clinical Study] Exploiting Interlimb Arm and Leg Connections for Walking Rehabilitation: A Training Intervention in Stroke. – Full Text

Abstract

Rhythmic arm and leg (A&L) movements share common elements of neural control. The extent to which A&L cycling training can lead to training adaptations which transfer to improved walking function remains untested. The purpose of this study was to test the efficacy of A&L cycling training as a modality to improve locomotor function after stroke. Nineteen chronic stroke (>six months) participants were recruited and performed 30 minutes of A&L cycling training three times a week for five weeks. Changes in walking function were assessed with (1) clinical tests; (2) strength during isometric contractions; and (3) treadmill walking performance and cutaneous reflex modulation. A multiple baseline (3 pretests) within-subject control design was used. Data show that A&L cycling training improved clinical walking status increased strength by ~25%, improved modulation of muscle activity by ~25%, increased range of motion by ~20%, decreased stride duration, increased frequency, and improved modulation of cutaneous reflexes during treadmill walking. On most variables, the majority of participants showed a significant improvement in walking ability. These results suggest that exploiting arm and leg connections with A&L cycling training, an accessible and cost-effective training modality, could be used to improve walking ability after stroke.

1. Introduction

Body weight supported treadmill training therapy can be used for the recovery of walking after neurological damage. In this rehabilitation paradigm, participants walk on a motorized treadmill with a harness system allowing the weakened leg muscles to be freed from the necessity of body weight support and stepping is performed with the help of robotic interfaces or therapists. This protocol was initially utilized after spinal cord injury and may be equally beneficial for recovery of walking after stroke [1–5].

Results from this therapy are positive, but there are significant limitations that limit access for the broader stroke population. Body weight supported treadmill training therapy has significant labour requirements, requires specialized equipment, and is typically only available in restricted environments such as in rehabilitation centers [6, 7]. In addition, body weight supported treadmill training offers no additional benefit over conventional physical therapy, as demonstrated in a large randomized clinical trial [2]. A more cost-effective and generally accessible protocol based upon a device (e.g., arm and leg ergometer or a recumbent stepper) that could be more readily used in therapy would be of great benefit where less training is required for physical therapists to supervise training and participants may be more likely to comply with a community-based training regimen [2, 8].

In addition to finding a rehabilitation program that is widely accessible, exploiting the neural and mechanical linkages between the arms and legs that are inherent parts of human locomotion could enhance the recovery of walking [6, 9, 10]. Therefore, incorporating rhythmic arm movement paradigms for locomotor rehabilitation, such as with arm and leg (A&L) cycling, could be very beneficial to stroke locomotor recovery. Although there are differences in kinematics, balance requirements, and loading of the arms between walking and A&L cycling, this type of training activates similar neural networks that are engaged during walking [11]. We have recently shown that, even following a stroke, neural commonalities between A&L cycling and walking persist, despite altered descending supraspinal input from the stroke lesion [12]. Given that A&L cycling and walking share common neural elements and that this persists following stroke, there is a reasonable basis for expectation of training transfer to improve walking.

The extent to which A&L cycling training can lead to training adaptations which transfer to improved walking function remains untested. Thus, the objective of this project was to test the efficacy of A&L cycling training to enhance walking after stroke. Given that A&L cycling and walking share a common core of subcortical regulation, we hypothesize that A&L cycling training will transfer to an improvement in walking. Improvements in walking function were gauged by changes in clinical walking status, strength, and walking performance. If indirect training with A&L cycling does improve walking function, this adjunct therapy could be used as an additional modality to improve walking ability after stroke.

Continue —> Exploiting Interlimb Arm and Leg Connections for Walking Rehabilitation: A Training Intervention in Stroke