Posts Tagged walking speed

[Abstract + References] The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials

Abstract

Objective:

The aim of this study was to evaluate the effects of ankle-foot orthoses on speed walking in patients with stroke.

Data sources:

PubMed, Embase, Web of Science, Scopus, CENTRAL, PEDro, RehabData, RECAL, and ProQuest were searched from inception until 30 September 2019.

Review methods:

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline statement. Risk of bias assessment was performed using the Cochrane Risk of Bias Tool. Begg’s test and Egger’s regression method were used to assess the publication bias. Trim and fill analysis was also used to adjust any potential publication bias. Sensitivity analysis was performed to evaluate the effect of individual studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Results:

Overall, 14 studies were included with a total of 1186 participants. A small-to-moderate and non-significant improvement in favor of the ankle-foot orthosis versus without ankle-foot orthosis (standardized mean difference (SMD) = 0.41, 95% confidence interval = −0.15 to 0.96), similar effects of ankle-foot orthosis and functional electrical stimulation (SMD = 0.00, 95% confidence interval = −0.16 to 0.16), and a small and non-significant improvement in favor of ankle-foot orthosis versus another type of ankle-foot orthosis (SMD = 0.22, 95% confidence interval = −0.05 to 0.49) in walking speed were found. However, the quality of evidence for all comparisons was low or very low.

Conclusion:

Despite reported positive effects in some studies, there is no firm evidence of any benefit of ankle-foot orthoses on walking speed.

References

1.Kelly-Hayes, M, Beiser, A, Kase, CS, et al. The influence of gender and age on disability following ischemic stroke: the Framingham study. J Stroke Cerebrovasc Dis 2003; 12(3): 119–126.
Google Scholar | Crossref | Medline
2.Patterson, SL, Forrester, LW, Rodgers, MM, et al. Determinants of walking function after stroke: differences by deficit severity. Arch Phys Med Rehabil 2007; 88(1): 115–119.
Google Scholar | Crossref | Medline | ISI
3.Hyndman, D, Ashburn, A, Stack, E. Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers. Arch Phys Med Rehabil 2002; 83(2): 165–170.
Google Scholar | Crossref | Medline
4.Graham, J . Foot drop: explaining the causes, characteristics and treatment. Br J Neurosci Nurs 2010; 6: 168–172.
Google Scholar | Crossref
5.Hebert, D, Lindsay, MP, McIntyre, A, et al. Canadian stroke best practice recommendations: stroke rehabilitation practice guidelines, update 2015. Int J Stroke 2016; 11(4): 459–484.
Google Scholar | SAGE Journals | ISI
6.Winstein, CJ, Stein, J, Arena, R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2016; 47: e98–e169.
Google Scholar | Crossref | Medline | ISI
7.Dworzynski, K, Ritchie, G, Fenu, E, et al. Rehabilitation after stroke: summary of NICE guidance. BMJ 2013; 346: f3615.
Google Scholar | Crossref | Medline
8.Daryabor, A, Arazpour, M, Aminian, G. Effect of different designs of ankle-foot orthoses on gait in patients with stroke: a systematic review. Gait Posture 2018; 62: 268–279.
Google Scholar | Crossref | Medline
9.Everaert, DG, Thompson, AK, Chong, SL, et al. Does functional electrical stimulation for foot drop strengthen corticospinal connections. Neurorehabil Neural Repair 2010; 24(2): 168–177.
Google Scholar | SAGE Journals | ISI
10.Tyson, SF, Kent, RM. Effects of an ankle-foot orthosis on balance and walking after stroke: a systematic review and pooled meta-analysis. Arch Phys Med Rehabil 2013; 94(7): 1377–1385.
Google Scholar | Crossref | Medline | ISI
11.Prenton, S, Hollands, KL, Kenney, LPJ, et al. Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: a meta-analysis providing direction for future research. J Rehabil Med 2018; 50(2): 129–139.
Google Scholar | Crossref | Medline
12.Prenton, S, Hollands, KL, Kenney, LP. Functional electrical stimulation versus ankle foot orthoses for foot-drop: a meta-analysis of orthotic effects. J Rehabil Med 2016; 48(8): 646–656.
Google Scholar | Crossref | Medline
13.Moher, D, Liberati, A, Tetzlaff, J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009; 151: 264–269.
Google Scholar | Crossref | Medline | ISI
14.Shea, BJ, Reeves, BC, Wells, G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017; 358: j4008.
Google Scholar | Crossref | Medline
15.Tomioka, K, Matsumoto, S, Ikeda, K, et al. Short-term effects of physiotherapy combining repetitive facilitation exercises and orthotic treatment in chronic post-stroke patients. J Phys Ther Sci 2017; 29(2): 212–215.
Google Scholar | Crossref | Medline
16.Higgins, JP, Altman, DG. Assessing risk of bias in included studies. In: Higgins, JPT, Green, S (eds) Cochrane handbook for systematic reviews of interventions (Cochrane Book Series). West Sussex, UK: Wiley, 2008, pp.187–241.
Google Scholar | Crossref
17.Verhagen, AP, de Vet, HC, de Bie, RA, et al. The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus. J Clin Epidemiol 1998; 51(12): 1235–1241.
Google Scholar | Crossref | Medline | ISI
18.Altman, D . Practical statistics for medical research. London: Chapman & Hall, 1991.
Google Scholar
19.Wan, X, Wang, W, Liu, J, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol 2014; 14: 135.
Google Scholar | Crossref | Medline | ISI
20.DerSimonian, R, Laird, N. Meta-analysis in clinical trials. Control Clin Trials 1986; 7: 177–188.
Google Scholar | Crossref | Medline
21.Cohen, J . A power primer. Psychol Bull 1992; 112: 155–159.
Google Scholar | Crossref | Medline | ISI
22.Hatala, R, Keitz, S, Wyer, P, et al. Tips for learners of evidence-based medicine: 4. Assessing heterogeneity of primary studies in systematic reviews and whether to combine their results. CMAJ 2005; 172(5): 661–665.
Google Scholar | Crossref | Medline | ISI
23.Begg, CB, Mazumdar, M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 1088–1101.
Google Scholar | Crossref | Medline | ISI
24.Egger, M, Smith, GD, Schneider, M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ 1997; 315: 629–634.
Google Scholar | Crossref | Medline
25.Duval, S, Tweedie, R. Trim and fill: a simple funnel-plot–based method of testing and adjusting for publication bias in meta-analysis. Biometrics 2000; 56(2): 455–463.
Google Scholar | Crossref | Medline | ISI
26.Schunemann, H . GRADE handbook for grading quality of evidence and strength of recommendation (version 3.2.), 2008, http://www.cc-ims.net/gradepro
Google Scholar
27.Bethoux, F, Rogers, HL, Nolan, KJ, et al. The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial. Neurorehabil Neural Repair 2014; 28(7): 688–697.
Google Scholar | SAGE Journals | ISI
28.De Seze, MP, Bonhomme, C, Daviet, JC, et al. Effect of early compensation of distal motor deficiency by the Chignon ankle-foot orthosis on gait in hemiplegic patients: a randomized pilot study. Clin Rehabil 2011; 25(11): 989–998.
Google Scholar | SAGE Journals | ISI
29.Erel, S, Uygur, F, Engin Simsek, I, et al. The effects of dynamic ankle-foot orthoses in chronic stroke patients at three-month follow-up: a randomized controlled trial. Clin Rehabil 2011; 25(6): 515–523.
Google Scholar | SAGE Journals | ISI
30.Everaert, DG, Stein, RB, Abrams, GM, et al. Effect of a foot-drop stimulator and ankle-foot orthosis on walking performance after stroke: a multicenter randomized controlled trial. Neurorehabil Neural Repair 2013; 27(7): 579–591.
Google Scholar | SAGE Journals | ISI
31.Farmani, F, Mohseni Bandpei, MA, Bahramizadeh, M, et al. The effect of different shoes on functional mobility and energy expenditure in post-stroke hemiplegic patients using ankle-foot orthosis. Prosthet Orthot Int 2016; 40(5): 591–597.
Google Scholar | SAGE Journals | ISI
32.Kluding, PM, Dunning, K, O’Dell, MW, et al. Foot drop stimulation versus ankle foot orthosis after stroke: 30-week outcomes. Stroke 2013; 44(6): 1660–1669.
Google Scholar | Crossref | Medline | ISI
33.Kottink, AI, Tenniglo, MJ, de Vries, WH, et al. Effects of an implantable two-channel peroneal nerve stimulator versus conventional walking device on spatiotemporal parameters and kinematics of hemiparetic gait. J Rehabil Med 2012; 44(1): 51–57.
Google Scholar | Crossref | Medline
34.Morone, G, Fusco, A, Di Capua, P, et al. Walking training with foot drop stimulator controlled by a tilt sensor to improve walking outcomes: a randomized controlled pilot study in patients with stroke in subacute phase. Stroke Res Treat 2012; 2012: 523564.
Google Scholar | Medline
35.Nikamp, CD, Buurke, JH, van der Palen, J, et al. Early or delayed provision of an ankle-foot orthosis in patients with acute and subacute stroke: a randomized controlled trial. Clin Rehabil 2017; 31: 798–808.
Google Scholar | SAGE Journals | ISI
36.Salisbury, L, Shiels, J, Todd, I, et al. A feasibility study to investigate the clinical application of functional electrical stimulation (FES), for dropped foot, during the sub—acute phase of stroke—a randomized controlled trial. Physiother Theory Pract 2013; 29(1): 31–40.
Google Scholar | Crossref | Medline | ISI
37.Sheffler, LR, Taylor, PN, Bailey, SN, et al. Surface peroneal nerve stimulation in lower limb hemiparesis: effect on quantitative gait parameters. Am J Phys Med Rehabil 2015; 94(5): 341–357.
Google Scholar | Crossref | Medline
38.Tyson, SF, Vail, A, Nessa, T, et al. Bespoke versus off-the-shelf ankle-foot orthosis for people with stroke: randomized controlled trial. Clin Rehabil 2018; 32: 367–376.
Google Scholar | SAGE Journals | ISI
39.Yamamoto, S, Tanaka, S, Motojima, N. Comparison of ankle-foot orthoses with plantar flexion stop and plantar flexion resistance in the gait of stroke patients: a randomized controlled trial. Prosthet Orthot Int 2018; 42(5): 544–553.
Google Scholar | SAGE Journals | ISI
40.Karniel, N, Raveh, E, Schwartz, I, et al. Functional electrical stimulation compared with ankle-foot orthosis in subacute post stroke patients with foot drop: a pilot study. Assist Technol. Epub ahead of print 4 April 2019. DOI: 10.1080/10400435.2019.1579269.
Google Scholar | Crossref
41.Bethoux, F, Rogers, HL, Nolan, KJ, et al. Long-term follow-up to a randomized controlled trial comparing peroneal nerve functional electrical stimulation to an ankle foot orthosis for patients with chronic stroke. Neurorehabil Neural Repair 2015; 29(10): 911–922.
Google Scholar | SAGE Journals | ISI
42.Kottink, AI, Hermens, HJ, Nene, AV, et al. A randomized controlled trial of an implantable 2-channel peroneal nerve stimulator on walking speed and activity in poststroke hemiplegia. Arch Phys Med Rehabil 2007; 88(8): 971–978.
Google Scholar | Crossref | Medline
43.Nikamp, CDM, van der Palen, J, Hermens, HJ, et al. The influence of early or delayed provision of ankle-foot orthoses on pelvis, hip and knee kinematics in patients with sub-acute stroke: a randomized controlled trial. Gait Posture 2018; 63: 260–267.
Google Scholar | Crossref | Medline
44.Nikamp, CDM, Buurke, JH, van der Palen, J, et al. Effect of providing ankle-foot orthoses in patients with acute and subacute stroke: a randomized controlled trial. In: Ibáñez, J, González-Vargas, J, Azorín, J, et al. (eds) Converging clinical and engineering research on neurorehabilitation II (Biosystems & Biorobotics). Cham: Springer, 2017, pp.305–309.
Google Scholar | Crossref
45.Sheffler, LR, Bailey, SN, Wilson, RD, et al. Spatiotemporal, kinematic, and kinetic effects of a peroneal nerve stimulator versus an ankle foot orthosis in hemiparetic gait. Neurorehabil Neural Repair 2013; 27(5): 403–410.
Google Scholar | SAGE Journals | ISI
46.Perry, J, Garrett, M, Gronley, JK, et al. Classification of walking handicap in the stroke population. Stroke 1995; 26(6): 982–989.
Google Scholar | Crossref | Medline | ISI
47.Ferreira, LA, Neto, HP, Grecco, LA, et al. Effect of ankle-foot orthosis on gait velocity and cadence of stroke patients: a systematic review. J Phys Ther Sci 2013; 25(11): 1503–1508.
Google Scholar | Crossref | Medline
48.Fatone, S, Gard, SA, Malas, BS. Effect of ankle-foot orthosis alignment and foot-plate length on the gait of adults with poststroke hemiplegia. Arch Phys Med Rehabil 2009; 90(5): 810–818.
Google Scholar | Crossref | Medline | ISI
49.Berenpas, F, Schiemanck, S, Beelen, A, et al. Kinematic and kinetic benefits of implantable peroneal nerve stimulation in people with post-stroke drop foot using an ankle-foot orthosis. Restor Neurol Neurosci 2018; 36: 547–558.
Google Scholar | Crossref | Medline
50.Pereira, S, Mehta, S, McIntyre, A, et al. Functional electrical stimulation for improving gait in persons with chronic stroke. Top Stroke Rehabil 2012; 19(6): 491–498.
Google Scholar | Crossref | Medline | ISI
51.Robbins, SM, Houghton, PE, Woodbury, MG, et al. The therapeutic effect of functional and transcutaneous electric stimulation on improving gait speed in stroke patients: a meta-analysis. Arch Phys Med Rehabil 2006; 87(6): 853–859.
Google Scholar | Crossref | Medline | ISI
52.Haruna, H, Sugihara, S, Kon, K, et al. Change in the mechanical energy of the body center of mass in hemiplegic gait after continuous use of a plantar flexion resistive ankle-foot orthosis. J Phys Ther Sci 2013; 25(11): 1437–1443.
Google Scholar | Crossref | Medline
53.Kobayashi, T, Orendurff, MS, Singer, ML, et al. Contribution of ankle-foot orthosis moment in regulating ankle and knee motions during gait in individuals post-stroke. Clin Biomech 2017; 45: 9–13.
Google Scholar | Crossref | Medline

Via https://journals.sagepub.com/doi/abs/10.1177/0269215519887784

, , , , ,

Leave a comment

[WEB SITE] New APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

(Journal of Neurologic Physical Therapy, January, 2020)

The message
A new clinical practice guideline (CPG) supported by APTA and developed by the APTA Academy of Neurologic Physical Therapy concludes that when it comes to working with individuals who experienced an acute-onset central nervous system (CNS) injury 6 months ago or more, aerobic walking training and virtual reality (VR) treadmill training are the interventions most strongly tied to improvements in walking distance and speed. Other interventions such as strength training, circuit training, and cycling training also may be considered, authors write, but providers should avoid robotic-assisted walking training, body-weight supported treadmill training, and sitting/standing balance that doesn’t employ augmented visual inputs.

The study
The final recommendations in the CPG are the result of an extensive process that began with a scan of nearly 4,000 research abstracts and subsequent full-text review of 234 articles, further narrowed to 111 randomized controlled trials (RCTs), all focused on interventions related to CNS injuries, with outcome data that included measures of walking distance and speed. CPG panelists evaluated the data and developed recommendations, which were informed by data on patient preferences and submitted for expert and stakeholder review.

Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Academy of Neurologic Physical Therapy — in the development stages such as drafting, appraisal, planning, and external review (for more detail on the program, visit APTA’s CPG Development webpage).

Findings

  • Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate maximum) walking training was associated with the strongest evidence for improvements in walking speed and distance.
  • Walking training using VR also fared well, due in part to the ability of a VR treadmill system to allow “safe practice of challenging walking activities,” something that’s hard to do in a more traditional hospital or clinic setting.
  • Strength training, while not included among the interventions that should be performed, was designated as an intervention that may be considered. Authors cite inconsistent evidence on the connection between strength training and improved walking speed and distance, but they acknowledge potential benefits.
  • Also among the list of interventions that “may be considered”: circuit training, as well as cycling training. In both cases, authors cite a paucity of evidence related to how the interventions affect walking speed and distance. They note that these interventions may be revisited during a future reevaluation of the CPG.
  • Body-weight supported treadmill training was labeled as an intervention that should not be performed in order to increase walking speed and distance, with authors finding little evidence supporting the approach, which is often associated with a greater cost. However, they write, the individuals included in the studies reviewed for the CPT were able to ambulate over ground without the use of a body-weight support device, and “different results may occur in those who are nonambulatory or unable to ambulate without the use of [body-weight support].”
  • Both static and dynamic (nonwalking) balance training and robotic-assisted walking training were also characterized as interventions that should not be performed. Authors acknowledge the ways that postural stability and balance are associated with fall risk and reduced participation, but they were unable to find sufficient evidence to support these particular interventions as effective in increasing walking speed and distance (although static and dynamic balance training with VR fared a bit better). As for robotic-assisted walking training, CPG authors note that while ineffective for individuals with CNS who were already ambulatory, “this recommendation … may not apply to nonambulatory individuals or those who require robotic assistance to ambulate.”

Why it matters
Authors note that “the implementation of evidence-based interventions in the field of rehabilitation has been a challenge,” and they believe that the new CPG offers a real opportunity for clinicians to “integrate available research into their practice patterns.” Further, they believe that the CPG has arrived at an important moment in the evolution of health care, with its greater emphasis on evidence for the cost-effectiveness and outcomes of various interventions.

More from the study
The CPG also offers tips for clinicians to implement its recommendations, including acquiring equipment to help providers monitor vital signs, implementing “automatic prompts in electronic medical records that will facilitate obtaining orders to attempt higher-intensity training strategies,” providing training sessions for clinicians, establishing organizational policies to promote use and documentation of the recommended interventions, and simply keeping a few copies of the study on hand for easy reference.

Keep in mind …
Authors acknowledged that the CPG has a few limitations. While the review of RCTs only is a strength, they write, some of those studies involved small sample sizes, and many lacked details on intervention dosage. Additionally, the CPG does not fully address the potential costs associated with its recommendations — specifically VR — which could impact a clinic’s ability to implement a particular intervention. Authors also acknowledge that walking speed and distance are not the only important outcomes related to mobility among individuals with CNS injury, and that other factors such as dynamic stability while walking, peak walking capacity, and community mobility may be incorporated in an assessment of walking function.

via New APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

, , , , , ,

Leave a comment

[ARTICLE] The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials – Full Text

The aim of this study was to evaluate the effects of ankle-foot orthoses on speed walking in patients with stroke.

PubMed, Embase, Web of Science, Scopus, CENTRAL, PEDro, RehabData, RECAL, and ProQuest were searched from inception until 30 September 2019.

This study was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline statement. Risk of bias assessment was performed using the Cochrane Risk of Bias Tool. Begg’s test and Egger’s regression method were used to assess the publication bias. Trim and fill analysis was also used to adjust any potential publication bias. Sensitivity analysis was performed to evaluate the effect of individual studies. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria.

Overall, 14 studies were included with a total of 1186 participants. A small-to-moderate and non-significant improvement in favor of the ankle-foot orthosis versus without ankle-foot orthosis (standardized mean difference (SMD) = 0.41, 95% confidence interval = −0.15 to 0.96), similar effects of ankle-foot orthosis and functional electrical stimulation (SMD = 0.00, 95% confidence interval = −0.16 to 0.16), and a small and non-significant improvement in favor of ankle-foot orthosis versus another type of ankle-foot orthosis (SMD = 0.22, 95% confidence interval = −0.05 to 0.49) in walking speed were found. However, the quality of evidence for all comparisons was low or very low.

Despite reported positive effects in some studies, there is no firm evidence of any benefit of ankle-foot orthoses on walking speed.

A total of 50% of patients with stroke suffer from diminished mobility due to hemiparesis.1 Impaired walking is one of the major problems occurring for stroke patients;2 although 70% of patients regain their ability for walking, they experience functional constraints due to spasticity, muscle weakness, and poor balance.3 Foot drop is among main causes of improper walking related to affected individuals. In response to this abnormality, clearance in swing phase and stability in stance phase are impaired, resulting in reduced walking speed and increased risk of falling.4

The use of ankle-foot orthosis and functional electrical stimulation as two major rehabilitation interventions is propounded to improve walking speed of individuals with stroke.5 An ankle-foot orthosis contributes to stabilization of the foot and ankle in stance phase, keeping the toes up while taking steps, and improving heel strike.6,7 Ankle-foot orthoses are used in different models and designs such as articulated, non-articulated, rigid, and dynamic.8 Functional electrical stimulation refers to the usage of musculoskeletal electrical stimulation to activate the muscles while performing functional tasks,9 which has been established as an alternative to ankle-foot orthoses for patients with stroke.

To the best of our knowledge, a limited systematic review and meta-analysis has also been performed in 2013,10 aimed at investigating the effects of ankle-foot orthosis on balance and gait after stroke. In that review, different study designs were included with heterogeneous methodologies, and short-term effects were only assessed. Although the study was published in 2013, the authors only included the studies published until 2011. In recent years, two meta-analyses11,12 have been carried out which aimed at comparing the therapeutic effects of ankle-foot orthoses and functional electrical stimulation on drop foot in central nervous system (CNS) diseases. In these reviews, stroke was considered along with other CNS diseases, and ankle-foot orthoses and functional electrical stimulation were found to have the same effects. Lack of publication bias assessment, quality of evidence evaluation, and combined different types of interventions resulted in inconclusive findings in these meta-analyses.

The primary objective of this up-to-date study is systematically reviewing the literature with regard to the effects of ankle-foot orthoses on walking speed of patients with stroke.[…]

 

Continue —->  The effects of ankle-foot orthoses on walking speed in patients with stroke: a systematic review and meta-analysis of randomized controlled trials – Saeed Shahabi, Hosein Shabaninejad, Mohammad Kamali, Maryam Jalali, Ahmad Ahmadi Teymourlouy,

, , , ,

Leave a comment

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

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

, , , , , , , ,

Leave a comment

[ARTICLE] Speed-adaptive control of functional electrical stimulation for dropfoot correction – Full Text

Abstract

Background

Functional electrical stimulation is an important therapy technique for dropfoot correction. In order to achieve natural control, the parameter setting of FES should be associated with the activation of the tibialis anterior.

Methods

This study recruited nine healthy subjects and investigated the relations of walking speed with the onset timing and duration of tibialis anterior activation. Linear models were built for the walking speed with respect to these two parameters. Based on these models, the speed-adaptive onset timing and duration were applied in FES-assisted walking for nine healthy subjects and ten subjects with dropfoot. The kinematic performance of FES-assisted walking triggered by speed-adaptive stimulation were compared with those triggered by the heel-off event, and no-stimulation walking at different walking speeds.

Results

Higher ankle dorsiflexion angle was observed in heel-off stimulation and speed-adaptive stimulation conditions than that in no-stimulation walking condition at all the speeds. For subjects with stroke, the ankle plantarflexion angle in speed-adaptive stimulation condition was similar to that in no-stimulation walking condition, and it was significant larger than that in heel-off stimulation condition at all speeds.

Conclusions

The improvement in ankle dorsiflexion without worsening ankle plantarflexion in speed-adaptive stimulation condition could be attributed to the appropriate stimulation timing and duration. These results provide evidence that the proposed stimulation system with speed-related parameters is more physiologically appropriate in dropfoot correction, and it may have great potential value in future clinical applications.

 

Background

About three quarters of stroke survivors experience different levels of brain dysfunction and movement disorder [1], which result in lower living quality and limited ability in social activities [2]. Of these subjects, 20% suffer from impaired motor function in the lower extremities. One of such impairments is dropfoot, which is characterized by poor ankle dorsiflexion during the swing phase and an inability to achieve heel strike at the initial contact [34]. Abnormal gaits such as circumduction gait and abnormal foot clearance on the affected side are often found as a method of compensating for excessive hip abduction and pelvis elevation on the unaffected side [5]. This results in gait asymmetry and slow walking speed [6].

Functional electrical stimulation was a representative intervention to correct dropfoot and Liberson et al. first introduced functional electrical stimulation (FES) to correct dropfoot for chronic hemiplegic subjects in the 1960s [7]. An electrical charge is delivered via a pair of electrodes to activate the tibialis anterior (TA), which results in ankle dorsiflexion. Yan et al. applied two dual-channel stimulators to the quadriceps, hamstring, gastrocnemius, and TA to recover motor function of the lower extremities in an early stage after stroke [8]. The stimulation was followed by a predetermined sequence of muscle activations that mimic a healthy gait cycle [9]. The duration of stimulation was five seconds in Yan et al.’s study. However, subjects with different severities of impairment might have different walking speeds [10], which means that a fixed stimulation duration might not be able to account for different walking patterns.

Liberson et al. used the heel-off event detected by a footswitch to trigger the stimulation [7]. However, the reliability of the footswitch controller was significantly reduced when subjects who dragged their feet during walking encountered a slope or an obstacle [11]. Bhadra et al. proposed a manual switch to trigger stimulation as a walking aid for subjects with spinal cord injury (SCI) [12]. However, manual control may distract subjects from maintaining balance and lead to an increased risk of falls [1314]. Furthermore, the cable between the control sensor and stimulator was inconvenient for walking [15].

Instead of a footswitch, Mansfield et al. [16] and Monaghan et al. [17] detected the heel event of the gait cycle in FES-assisted walking using an accelerometer and a uniaxial gyroscope, respectively. The commercially available product WalkAide also uses an accelerometer for this purpose [18]. Electromyography (EMG) signal is also applied as a control source in FES-assisted walking for the detection of volitional intent of muscle [19]. Yeom et al. amplified the EMG signal of the TA and modulated the stimulation intensity in proportion to the integrated EMG envelope. The electrical pulses are then sent to the common peroneal nerve for dropfoot correction [20].

In these studies, FES applied to the TA was mainly triggered by the heel-off event. However, this event occurs during the push-off phase and before TA activation [17]. An earlier start of TA stimulation results in reduced ankle plantarflexion [21]. Spaich et al. suggested implementing a constant time interval before the onset timing of TA stimulation to extend the push-off phase before the ankle dorsiflexion [21]. Some studies have found that walking speed can affect the activation of TA [2223]. Shiavi et al. found that the duration of EMG activity decreased as speed increased [22]. In Winter et al.’s study, the shape of the EMG patterns generally remained similar at the different walking speeds and the duration of EMG activity was closely related to the normalized stride time [23]. Although the duration of TA activation changes with the walking speeds has been reported [24], the selection of speed-adaptive FES parameters for TA has not been investigated.

The objective of this study is to find a more physiologically appropriate FES design for dropfoot correction. Firstly, speed-related changes in onset timing and the duration of TA activation were examined. Next, linear models were built for the walking speed and time interval from the heel-off event to the onset timing of TA activation, as well as for the walking speed and the duration of the TA activation. The speed-adaptive stimulation (SAS) timing and duration were then calculated based on the two models and applied for FES-assisted walking. Finally, the performance of stimulation triggered by SAS, heel-off event (HOS) and no stimulation (NS) were compared during FES-assisted walking on both subjects with stroke and healthy subjects at different walking speeds.[…]

 

Continue —->  Speed-adaptive control of functional electrical stimulation for dropfoot correction | Journal of NeuroEngineering and Rehabilitation | Full Text

 

Fig. 1a The experiment setup of SAS condition; b one healthy subject on the treadmill for system evaluation; c the position of five markers on the right leg

, , , , , ,

Leave a comment

[WEB SITE] Stroke survivors may benefit from magnetic brain stimulation

A new meta-analysis of existing studies shows that a technique called repetitive transcranial magnetic stimulation might be a useful tool to help stroke survivors regain the ability to walk independently.

senior woman learning to walk again after stroke

A brain stimulation technique may help stroke survivors walk faster and more easily.

Repetitive transcranial magnetic stimulation (rTMS) is a noninvasive brain stimulation technique; magnetic coils are placed on a person’s scalp, and short electromagnetic pulses are delivered to specific brain areas through the coil.

Although these pulses only cause an almost imperceptible “knocking or tapping” sensation for the patient undergoing the procedure, they reach into the brain, triggering electric currents that stimulate neurons.

rTMS has mainly been used to treat psychosisdepressionanxiety, and other mood disorders with a fair degree of success. In a recent study, more than one third of people living with auditory verbal hallucinations — a marker of schizophrenia — reported a reduction in their symptoms following the procedure.

But researchers have also been delving into the potential that the technique has for improving life after stroke. Four years ago, for instance, a team of researchers at The Ohio State University Wexner Medical Center in Columbus used rTMS to improve arm movement in people who had experienced a stroke, and more studies have explored this therapeutic potential since.

Now, a team of researchers — jointly led by Dr. Chengqi He, of Sichuan University in the People’s Republic of China, and Shasha Li, of Massachusetts General Hospital and Harvard Medical School, both in Boston, MA — set out to review these studies.

Dr. He and colleagues wanted to see if the technique improved motor skills for people who had stroke; to do so, the researchers examined the impact rTMS has on walking speed, balance, and other key factors for post-stroke rehabilitation.

The findings were published in the American Journal of Physical Medicine & Rehabilitation, the official journal of the Association of Academic Physiatrists.

rTMS ‘significantly improves walking speed’

Dr. He and team reviewed nine studies of rTMS — including five randomized controlled trials — which were published between 2012 and 2017.

The people who participated in these studies had either had an ischemic stroke — that is, a stroke caused by a blood clot in one of the brain’s arteries — or a hemorrhagic stroke — that is, one caused by bleeding within the brain.

Of the nine studies, six included data on the walking speed of 139 stroke survivors. The researchers carried out a pooled analysis of these studies, and the results revealed that rTMS “significantly improves walking speed.”

This improvement was greater among people who received stimulation on the same side of the brain that the stroke occurred. By contrast, those who received rTMS on the opposite side did not see any improvement.

Other key health outcomes for stroke survivors such as balance, motor function, or brain responsiveness did not show any improvement as a result of rTMS.

In the United States, it is estimated that almost 800,000 people annually have a stroke, which makes the condition a leading cause of long-term disability in the country. More than half of the seniors who survived a stroke have reduced mobility as a result.

Although the review shows that rTMS is a promising strategy for restoring independent walking, the authors say that more research is needed. Dr. He and colleagues conclude:

Future studies with larger sample sizes and an adequate follow-up period are required to further investigate the effects of rTMS on lower limb function and its relationship with changes in cortical excitability with the help of functional neuroimaging techniques.”

via Stroke survivors may benefit from magnetic brain stimulation

, , , , ,

Leave a comment

[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

, , , , , , , , ,

Leave a comment

[ARTICLE] Effectiveness of a multimodal exercise rehabilitation program on walking capacity and functionality after a stroke – Full Text

Abstract

The aim of this study was to determine the effectiveness of a 12-week multimodal exercise rehabilitation program on walking speed, walking ability and activities of daily living (ADLs) among people who had suffered a stroke. Thirty-one stroke survivors who had completed a conventional rehabilitation program voluntarily participated in the study. Twenty-six participants completed the multimodal exercise rehabilitation program (2 days/wk, 1 hr/session). Physical outcome measures were: walking speed (10-m walking test), walking ability (6-min walking test and functional ambulation classification) and ADLs (Barthel Index). The program consisted on: aerobic exercise; task oriented exercises; balance and postural tonic activities; and stretching. Participants also followed a program of progressive ambulation at home. They were evaluated at baseline, postintervention and at the end of a 6-month follow-up period. After the intervention there were significant improvements in all outcomes measures that were maintained 6 months later. Comfortable and fast walking speed increased an average of 0.16 and 0.40 m/sec, respectively. The walking distance in the 6-min walking test increased an average of 59.8 m. At the end of the intervention, participants had achieved independent ambulation both indoors and outdoors. In ADLs, 40% were independent at baseline vs. 64% at the end of the intervention. Our study demonstrates that a multimodal exercise rehabilitation program adapted to stroke survivors has benefits on walking speed, walking ability and independence in ADLs.
Keywords: Exercise, Physical activity, Stroke rehabilitation, Walking speed, Activities of daily living

INTRODUCTION

As life expectancy increases, a larger number of persons may suffer from stroke. Stroke mortality rates have decreased, but the burden of stroke is increasing in terms of stroke survivors per year, correlated deaths and disability-adjusted life-years lost. These deficiencies are further highlighted by a trend towards more strokes in younger people (Feigin et al., 2014). Stroke not only causes permanent neurological deficits, but also a profound degradation of physical condition, which worsens disability and increases cardiovascular risk. Stroke survivors are likely to suffer functional decline due to reduction of aerobic capacity. This may involve further secondary complications such as progressive muscular atrophy, osteoporosis, peripheral circulation worsening and increased cardiovascular risk (Ivey et al., 2006). All these factors cause increased dependency, need of assistance from third parties in activities of daily living (ADLs) and a restriction on participation that can have a profound psychosocial impact (Carod-Artal and Egido, 2009). Gait capacity is one of the main priorities of persons who have suffered a stroke, but is often limited due to the high energy demands of hemiplegic gait and the poor physical condition of these persons (Ivey et al., 2006). Gait speed is a commonly used measure in patients who have suffered a stroke to differentiate the functional capacity to walk indoors or outdoors. Gait speed has been classified as: allowing indoor ambulation (<0.4 m/sec), limited outdoor ambulation (0.4–0.8 m/sec), and outdoor functional ambulation (>0.8 m/sec) (Perry et al., 1995). Gait speed can also help to establish the functional prognosis of the patient. It has been stated that improvements in walking speed correlate with improved function and quality of life (QoL) (Schmid et al., 2007). It is essential to achieve a proper gait speed for outdoors functional ambulation.
Falls are common among stroke survivors and are associated with a worsening of disability and QoL. Balance is a complex process that involves the reception and integration of afferent inputs and the planning and execution of movement. Stroke can impact on different systems involved in postural control. Multifactorial falls risk assessment and management, combined with fitness programs, are effective in reducing risk of falls and fear of falling (Stroke Foundation of New Zealand and New Zealand Guidelines Group, 2010). Falls often occur when getting in and out of a chair (Brunt et al., 2002). The 2013 Cochrane review (Saunders et al., 2013) recommends the repetitive practice of sit-to-stand in order to promote an ergonomic and automatic pattern of this movement. Recent studies demonstrate that exercises that improve trunk stability and balance provide a solid base for body and leg movements that entail an improved gait in people affected by stroke (Sharma and Kaur, 2017). Conventional rehabilitation programs after stroke focus on the subacute period. The aim is to recover basic ADLs, but they do not provide maintenance exercises to provide long-term health gains. Cardiac monitoring demonstrates that conventional physiotherapy exercises do not regularly provide adequate exercise intensity to modify the physical deconditioning, nor sufficient exercise repetition to improve motor learning (Ivey et al., 2006). Therapeutic physical exercise to optimize function, physical condition and cardiovascular health after a stroke is an emerging field within neurorehabilitation (Teasell et al., 2009). The wide range of difficulties experienced by stroke survivors justify the need to explore rehabilitation programs designed to promote an overall improvement and to maintain the gains obtained after rehabilitation programs. Numerous studies have demonstrated the efficacy of aerobic exercise (Saunders et al., 2016), but there are few data on the long term effects of multimodal programs that incorporate aerobic exercise, complemented by task-oriented training and balance exercises. Consequently, the aim of this study is to analyse the impact of a multimodal exercise rehabilitation program tailored to stroke survivors on walking speed, walking ability and ADLs. […]

Continue —> Effectiveness of a multimodal exercise rehabilitation program on walking capacity and functionality after a stroke

, , , ,

Leave a comment

[ARTICLE] Effects of dual-task and walking speed on gait variability in people with chronic ankle instability: a cross-sectional study – Full Text

Abstract

Background

Recent evidence suggests that impaired central sensorimotor integration may contribute to deficits in movement control experienced by people with chronic ankle instability (CAI). This study compared the effects of dual-task and walking speed on gait variability in individuals with and without CAI.

Methods

Sixteen subjects with CAI and 16 age- and gender-matched, able-bodied controls participated in this study. Stride time variability and stride length variability were measured on a treadmill under four different conditions: self-paced walking, self-paced walking with dual-task, fast walking, and fast walking with dual-task.

Results

Under self-paced walking (without dual-task) there was no difference in stride time variability between CAI and control groups (P = 0.346). In the control group, compared to self-paced walking, stride time variability decreased in all conditions: self-paced walking with dual-task, fast speed, and fast speed with dual-task (P = 0.011, P = 0.016, P = 0.001, respectively). However, in the CAI group, compared to self-paced walking, decreased stride time variability was demonstrated only in the fast speed with dual-task condition (P = 1.000, P = 0.471, P = 0.008; respectively). Stride length variability did not change under any condition in either group.

Conclusions

Subjects with CAI and healthy controls reduced their stride time variability in response to challenging walking conditions; however, the pattern of change was different. A higher level of gait disturbance was required to cause a change in walking in the CAI group compared to healthy individuals, which may indicate lower adaptability of the sensorimotor system. Clinicians may use this information and employ activities to enhance sensorimotor control during gait, when designing intervention programs for people with CAI.

The study was registered with the Clinical Trials network (registration NCT02745834, registration date 15/3/2016).

Background

Recurrent ankle sprains occur in up to 40% of individuals who have previously experienced a lateral ankle sprain [1, 2]. Individuals who report residual symptoms, which include repetitive episodes of ‘giving way’ and subjective feeling of ankle joint instability are termed as having chronic ankle instability (CAI) [3]. The cause of these symptoms and the high frequency of recurrent ankle sprain is not fully understood [4]. It has been suggested that the residual joint instability and the high reoccurrence rates can be attributed to loss of sensory input from articular mechano-receptors, decreased muscle strength, mechanical instability of the ankle joint, and reduced ankle range of motion [5, 6].

Recent evidence suggests that deficits in central neural sensorimotor integration can contribute to impaired movement control in people with CAI [7, 8, 9, 10, 11, 12, 13, 14]. For example, Springer et al. [8] assessed the correlation between single-limb stance postural control (Overall Stability Index) and shoulder position sense (Absolute Error Score) among people with CAI and healthy controls. Correlations between the lower and upper limbs were observed only in the healthy controls, indicating altered sensorimotor integration in the CAI group. Several studies have observed altered gait mechanism in people with CAI, which was explained by compromised central nervous system (CNS) control [9, 14, 15, 16]. It was shown that people with CAI have a typical gait pattern of increased inversion kinematics and kinetics, lateral shift of body weight, increased hip flexion during terminal swing to mid stance, reduced hip extension and increased knee flexion during terminal stance to initial swing, and slow weight transfer at the beginning and end of the stance [15, 16, 17]. Altered biomechanical strategies during gait initiation and termination tasks (e.g., reduced center of pressure displacement), have also been demonstrated in this population [9, 14]. Studies that assessed movement variability, such as knee and hip joint motions during single leg jump landing, identified differences between individuals with and without CAI, which may also indicate central motor programming deficits [10, 11, 12, 13]. Hence, further investigation of motor control adaptations may contribute to understanding the underlying neurophysiologic mechanisms of CAI.

Gait speed and other spatio-temporal parameters during daily activities should reflect behavioral goals and environmental conditions [18]. Studies revealed that walking speed has a significant effect on joint coordination pattern and gait variability [18, 19, 20]. Therefore, assessing gait variability under challenging situations such as walking at different speeds might test CNS flexibility in controlling gait [19, 20]. Moreover, based on the understanding that for many daily activities even a fully intact motor control system requires attention and cognitive resources [21], the dual-task paradigm has been used to provide insight into the demands of postural control and gait on attention. Performance of a cognitive task has been shown to decrease postural control in participants with CAI as compared to healthy controls [7, 22]. However, no previous study examined the impact of cognitive task and walking speed on gait performance in subjects with CAI.

Balance during walking is reflected by precise spatial and temporal control of foot placement. Stride to stride fluctuations in time and length are related to control of the rhythmic walking mechanism. Thus, previous research has suggested that studying gait variability is a reliable way to quantify locomotion [23]. The mechanism of adjusting movement variability is considered beneficial for coping with changes, maintaining stability, preventing injury, and attaining higher motor skills [24]. Performing a cognitive task while walking or while altering self-paced walking speed has been related to changes in gait variability in populations with neurological and musculoskeletal pathologies, as well in healthy young individuals [25, 26, 27, 28]. Yet, there is no consensus in the literature as to how to interpret these changes. Decreased variability while performing demanding gait tasks may reflect voluntary gait adaptation toward a more conservative gait pattern [26]. Alternatively, it has been suggested that increased variability may indicate CNS flexibility and adaptability to changes in task demands [29]. A possible central sensorimotor control deficit in people with CAI may constrain the ability of the CNS to adjust to different task demands; thus, affecting central control over gait variability and reducing the ability to cope with varied tasks. Consequently, testing the mechanism of adjusting gait variability as a response to complex walking conditions in people with CAI compared to healthy controls may provide more information on sensorimotor control in this population.

The present study was designed to compare the effects of dual-task and walking speed on gait variability in individuals with and without CAI. Previous reports, including a meta-analysis, indicated that simple postural tasks do not always discriminate between participants with CAI and those without [6, 8, 30]. Consequently, we hypothesized that gait variability among individuals with and without CAI will be similar during “normal” self-paced walking, whereas gait will vary under complex walking conditions.[…]

Continue —> Effects of dual-task and walking speed on gait variability in people with chronic ankle instability: a cross-sectional study | BMC Musculoskeletal Disorders | Full Text

Fig. 1 Stride time variability results of the two groups under all gait conditions. CAI- chronic ankle instability, SP- self-paced, DT- dual task

, , , , , ,

Leave a comment

[ARTICLE] Sustained effects of once-a-week gait training with hybrid assistive limb for rehabilitation in chronic stroke: case study

Abstract.

[Purpose] The purpose of this study was to investigate the accumulated and sustained effects of oncea-week gait training with a powered exoskeleton suit, Hybrid Assistive Limb, in a subject with chronic stroke.

[Subject and Methods] The subject was a woman in her early sixties who had stroke onset approximately 5 years ago. A single-case ABA design was used. A 2-month baseline period was followed by an 8-week period of weekly gait training and a subsequent 2-month follow-up period. Throughout the study period, she underwent conventional physiotherapy. Outcome measures were the 10-meter walking test, timed up and go test, functional reach test, twostep test, and Berg Balance Scale.

[Results] Significant improvements were seen in all outcome measures during the gait training period. Improvements in all outcome measures except walking speed were maintained at follow-up.

[Conclusion] Continued gait training with Hybrid Assistive Limb once a week can improve gait and balance performance in patients with chronic stroke, and these improvements are maintained at least for two months.

Download Full Text PDF

, , , , , ,

Leave a comment

%d bloggers like this: