Gait disturbances in patients with stroke

A non-immersive virtual reality-based intervention to enhance lower-extremity motor function and gait in patients with subacute cerebral infarction: A pilot randomized controlled trial with 1-year follow-up

Introduction

This study was conducted to evaluate whether a non-immersive virtual reality (VR)-based intervention can enhance lower extremity movement in patients with cerebral infarction and whether it has greater short-term and long-term effectiveness than conventional therapies (CTs).

Materials and methods

This was a single-blinded, randomized clinical controlled trial. Forty-four patients with subacute cerebral infarction were randomly allocated to the VR or CT group. All intervention sessions were delivered in the inpatient unit for 3 weeks. Outcomes were measured before (baseline) and after the interventions and at 3-month, 6-month and 1-year follow-ups. The outcomes included clinical assessments of movement and balance function using the Fugl–Meyer Assessment of Lower Extremity (FMA-LE) and Berg Balance Scale (BBS), and gait parameters in the sagittal plane.

Results

In the VR group, the walking speed after intervention, at 3-month, 6-month, and 1-year follow-ups were significantly greater than baseline (p = 0.01, <0.001, 0.007, and <0.001, respectively). Compared with baseline, BBS scores after intervention, at 3-month, 6-month, and 1-year follow-ups were significantly greater in both the VR group (p = 0.006, 0.002, <0.001, and <0.001, respectively) and CT group (p = <0.001, 0.002, 0.001, and <0.001, respectively), while FMA-LE scores after intervention, at 3-month, 6-month, and 1-year follow-ups were significant increased in the VR group (p = 0.03, <0.001, 0.003, and <0.001, respectively), and at 3-month, 6-month, and 1-year follow-ups in the CT group (p = 0.02, 0.004 and <0.001, respectively). In the VR group, the maximum knee joint angle in the sagittal plane enhanced significantly at 6-month follow-up from that at baseline (p = 0.04).

Conclusion

The effectiveness of the non-immersive VR-based intervention in our study was observed after the intervention and at the follow-ups, but it was not significantly different from that of CTs. In sum, our results suggest that non-immersive VR-based interventions may thus be a valuable addition to conventional physical therapies to enhance treatment efficacy.

Clinical trial registration

http://www.chictr.org.cn/showproj.aspx?proj=10541, ChiCTR-IOC-15006064.

Recording context matters: Differences in gait parameters collected by the OneStep smartphone application

BACKGROUND

Detailed understanding of impairments that underlie walking dysfunction through objective measures is essential to diagnosis, evaluation and care planning. Despite significant developments in motion tracking technologies, there is a dearth of research about the influence of remote monitoring context on performance. The objective of this study was to determine whether gait parameters collected by the OneStep smartphone application differ based on the recording condition.

METHODS

Retrospective repeated measures univariate analysis was performed on data extracted based on detected activity, either spontaneous (background recording) or consciously initiated (in app) walks, of 25 patients enrolled in a physical therapy program.

FINDINGS

Across 7227 walking bouts, significant differences between the two paradigms in velocity (g = 0.48), double support (g = 0.37), stride length (g = 0.37) and step length of the affected side (g = 0.32) were revealed. Overall, the passively recorded walks presented a less clinically favorable spatiotemporal pattern for each of these variables.

INTERPRETATION

The recording context of walks that were used for analysis appears to significantly affect the biomechanical output of the OneStep application. It is unclear whether the disparity found would impact functional recovery of individuals undergoing rehabilitation due to neurological or musculoskeletal disorder. Clinicians may consider this information when incorporating remotely-acquired quantitative gait analysis and interpreting care outcomes as part of therapeutic practice. Future work can further investigate the behavioral and environmental factors contributing to how movement occurs in specific clinical populations when monitored via mobile health systems.

Sex Differences in Functional Capacity in Older Adults With Stroke: An Analysis of Data From the National Health and Aging Trends Study

OBJECTIVE

Women experience greater disability following stroke, but biological sex differences in both overall and specific domains of functional capacity are not well understood. The primary objective of this study was to examine sex differences in overall functional capacity (Short Physical Performance Battery [SPPB] score) cross-sectionally and longitudinally over a 3-year follow-up period. The secondary objective was to determine whether sex differences exist in specific domains of functional capacity of walking speed and lower extremity functional strength.

METHODS

This study was a secondary analysis of data of individuals with stroke from the National Health and Aging Trends Study. For the cross-sectional analyses, general linear models were used to examine differences between 293 men and 427 women in SPPB, walking speed, and the 5-Times Sit-to-Stand Test (5XSST). For the longitudinal analysis, survey-weighted, multivariable-adjusted generalized linear mixed models were used to compare 3-year trajectories in SPPB scores between the sexes (87 men, 153 women).

RESULTS

Women had lower SPPB scores at baseline (difference = 0.9, linearized SE = 0.3) and over 3 years. SPPB scores declined similarly between men and women. Women had lower walking speed (difference = 0.08 m/s, SE = 0.02) as compared with men, but men and women had similar 5XSST scores (difference = 0.6 seconds, SE = 0.5).

CONCLUSION

Older women with stroke have clinically meaningfully lower overall functional capacity as compared with older men but decline at a similar rate over time. Walking speed was lower in older women with stroke, but similar between sexes in 5XSST.

IMPACT

Women with stroke have poorer functional capacity compared with men, which reinforces the importance of targeted stroke rehabilitation strategies to address these sex-specific disparities.

LAY SUMMARY

Women with stroke have poorer outcomes in terms of their ability to move around the community when compared with men. However, both men and women with stroke have similar physical functioning over time.

A Pneumatic Artificial Muscle and Spring Combination System that Assists Ankle Rocker and Transforms Energy into Push-Off Support: A Feasibility Study in Heathy Participants

Insufficient push-off is a common problem for stroke hemiplegia patients. Assistive systems using extension spring to store energy during stance phase of gait to provide push-off assistance have been developed. However, patients could also suffer poor ankle rocker function; that is, poor dorsiflexion movement in stance phase. In such case, the spring could reversely become a burden for ankle movement. In this research, we proposed a system that combines a pneumatic artificial muscle and a tension spring. The artificial muscle mimics a human's tibialis anterior muscle, while the spring mimicking the Achilles tendon. Upon foot flat event of gait, the artificial muscle contracted to assist ankle rocker function and stretched the spring to store energy simultaneously. After heel off, the artificial muscle extended and the spring was released to provide push-off assistance. A feasibility study in seven healthy participants was conducted to verify assistance effects on their ankle rocker function and push-off movements. The results show significant increase in ankle rocker angle, push-off angle, and push-off torque compared with those during normal walk when the participants were assisted by our system. Therefore, we believe that the proposed system has great potential to assist stroke survivors with problems of poor ankle rocker function and push-off movements.

A Framework for Determining the Performance and Requirements of Cable-Driven Mobile Lower Limb Rehabilitation Exoskeletons

The global increase in the number of stroke patients and limited accessibility to rehabilitation has promoted an increase in the design and development of mobile exoskeletons. Robot-assisted mobile rehabilitation is rapidly emerging as a viable tool as it could provide intensive repetitive movement training and timely standardized delivery of therapy as compared to conventional manual therapy. However, the majority of existing lower limb exoskeletons continue to be heavy and induce unnecessary inertia and inertial vibration on the limb. Cable-driven exoskeletons can overcome these issues with the provision of remote actuation. However, the number of cables and routing can be selected in various ways posing a challenge to designers regarding the optimal design configuration. In this work, a simulation-based generalized framework for modelling and assessment of cable-driven mobile exoskeleton is proposed. The framework can be implemented to identify a ‘suitable’ configuration from several potential ones or to identify the optimal routing parameters for a given configuration. For a proof of concept, four conceptual configurations of cable-driven exoskeletons (one with a spring) were developed in a manner where both positive and negative moments could be generated for each joint (antagonistic configuration). The models were analyzed using the proposed framework and a decision metric table has been developed based on the models’ performance and requirements. The weight of the metrics can be adjusted depending on the preferences and specified constraints. The maximum score is assigned to the configuration with minimum requirement or error, maximum performance, and vice versa. The metric table indicated that the 4-cable configuration is a promising design option for a lower limb rehabilitation exoskeleton based on tracking performance, model requirements, and component forces exerted on the limb.

Brain Asymmetry and Its Effects on Gait Strategies in Hemiplegic Patients: New Rehabilitative Conceptions

Brain asymmetry is connected with motor performance, suggesting that hemiparetic patients have different gait patterns depending on the side of the lesion. This retrospective cohort study aims to further investigate the difference between right and left hemiplegia in order to assess whether the injured side can influence the patient’s clinical characteristics concerning gait, thus providing insights for new personalized rehabilitation strategies. The data from 33 stroke patients (17 with left and 16 with right hemiplegia) were retrospectively compared with each other and with a control group composed of 20 unaffected age-matched individuals. The 3D gait analysis was used to assess kinematic data and spatio-temporal parameters. Compared to left hemiplegic patients, right hemiplegic patients showed worse spatio-temporal parameters (p < 0.05) and better kinematic parameters (p < 0.05). Both pathological groups were characterized by abnormal gait parameters in comparison with the control group (p < 0.05). These findings show an association between the side of the lesion—right or left—and the different stroke patients’ gait patterns: left hemiplegic patients show better spatio-temporal parameters, whereas right hemiplegic patients show better segmentary motor performances. Therefore, further studies may develop and assess new personalized rehabilitation strategies considering the injured hemisphere and brain asymmetry.

Muscle contributions to pre-swing biomechanical tasks influence swing leg mechanics in individuals post-stroke during walking

Background

Successful walking requires the execution of the pre-swing biomechanical tasks of body propulsion and leg swing initiation, which are often impaired post-stroke. While excess rectus femoris activity during swing is often associated with low knee flexion, previous work has suggested that deficits in propulsion and leg swing initiation may also contribute. The purpose of this study was to determine underlying causes of propulsion, leg swing initiation and knee flexion deficits in pre-swing and their link to stiff knee gait in individuals post-stroke.

Methods

Musculoskeletal models and forward dynamic simulations were developed for individuals post-stroke (n = 15) and healthy participants (n = 5). Linear regressions were used to evaluate the relationships between peak knee flexion, braking and propulsion symmetry, and individual muscle contributions to braking, propulsion, knee flexion in pre-swing, and leg swing initiation.

Results

Four out of fifteen of individuals post-stroke had higher plantarflexor contributions to propulsion and seven out of fifteen had higher vasti contributions to braking on their paretic leg relative to their nonparetic leg. Higher gastrocnemius contributions to propulsion predicted paretic propulsion symmetry (p = 0.005) while soleus contributions did not. Higher vasti contributions to braking in pre-swing predicted lower knee flexion (p = 0.022). The rectus femoris had minimal contributions to lower knee flexion acceleration in pre-swing compared to contributions from the vasti. However, for some individuals with low knee flexion, during pre-swing the rectus femoris absorbed more power and the iliopsoas contributed less power to the paretic leg. Total musculotendon work done on the paretic leg in pre-swing did not predict knee flexion during swing.

Conclusions

These results emphasize the multiple causes of propulsion asymmetry in individuals post-stroke, including low plantarflexor contributions to propulsion, increased vasti contributions to braking and reliance on compensatory mechanisms. The results also show that the rectus femoris is not a major contributor to knee flexion in pre-swing, but absorbs more power from the paretic leg in pre-swing in some individuals with stiff knee gait. These results highlight the need to identify individual causes of propulsion and knee flexion deficits to design more effective rehabilitation strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01029-z.

Effects of ankle-foot orthoses on the stability of post-stroke hemiparetic gait

BACKGROUND

Ankle-foot orthoses are used to improve gait stability in patients with post-stroke gait; however, there is not enough evidence to support their beneficial impact on gait stability.

AIM

To investigate the effects of ankle-foot orthoses on post-stroke gait stability.

DESIGN

An experimental study with repeated measurements of gait parameters with and without orthosis.

SETTING

Inpatients and outpatients in the Fujita Health University Hospital, Toyoake, Japan.

POPULATION

Thirty-two patients (22 males; mean age 48.3±20.0 years) with post-stroke hemiparesis participated in the study.

METHODS

Three-dimensional treadmill gait analysis was performed with and without ankle-foot orthosis for each participant. Spatiotemporal parameters, their coefficient of variation, and margin of stability were evaluated. Toe clearance, another major target of orthosis, was also examined. The effect of orthosis in the patients with severe (not able to move within the full range of motion, defying gravity) and mild ankle impairment (able to move within the full range but have problem with speed and/or smoothness of the ankle movement) was compared.

RESULTS

In the total group comparison, the decrease in the coefficient of variation of step width (P=0.012), and margin of stability on the paretic side (P=0.023) were observed. In the severe ankle impairment groups, the decreased in the coefficient of variation of the non-paretic step length (P=0.007), stride length (P=0.037), and step width (P=0.033) and margin of stability on the paretic side (P=0.006) were observed. No significant effects were observed in the mild ankle impairment group; rather, the coefficient of variation of non-paretic step length increased with the use of orthosis in this group (P=0.043); however, toe clearance increased with the use of ankle-foot orthosis (P=0.041).

CONCLUSIONS

Ankle-foot orthoses improved gait stability indices; however, the effect was either not significant or showed possible worsening in the patients with mild ankle impairment, while the effect on toe clearance was significant. These results suggest that the effects of using orthoses in patients with mild impairment should be carefully evaluated.

CLINICAL REHABILITATION IMPACT

Understanding the effects of ankle-foot orthoses on the stability of post-stroke gait and their relationship with ankle impairment severity may support clinical decision-making while prescribing orthosis for post-stroke hemiparesis.

Measurement, Evaluation, and Control of Active Intelligent Gait Training Systems—Analysis of the Current State of the Art

Gait recognition and rehabilitation has been a research hotspot in recent years due to its importance to medical care and elderly care. Active intelligent rehabilitation and assistance systems for lower limbs integrates mechanical design, sensing technology, intelligent control, and robotics technology, and is one of the effective ways to resolve the above problems. In this review, crucial technologies and typical prototypes of active intelligent rehabilitation and assistance systems for gait training are introduced. The limitations, challenges, and future directions in terms of gait measurement and intention recognition, gait rehabilitation evaluation, and gait training control strategies are discussed. To address the core problems of the sensing, evaluation and control technology of the active intelligent gait training systems, the possible future research directions are proposed. Firstly, different sensing methods need to be proposed for the decoding of human movement intention. Secondly, the human walking ability evaluation models will be developed by integrating the clinical knowledge and lower limb movement data. Lastly, the personalized gait training strategy for collaborative control of human–machine systems needs to be implemented in the clinical applications.

Effect of trim line on stiffness in dorsi- and plantarflexion of posterior leaf spring ankle-foot orthoses

[Purpose] This study aimed to objectively clarify the effect of the trim line setting on the stiffness of posterior leaf spring ankle-foot orthoses. [Participant and Methods] Posterior leaf spring ankle-foot orthoses were fabricated with two thickness levels and three trim line conditions for the posterior upright width and the dorsi- and plantarflexion moments and stiffness exhibited by the orthoses were measured using an evaluation tester. [Results] The trim line of the posterior upright width affected the dorsiflexion moment generated by the orthoses in plantarflexion. [Conclusion] A strong linear correlation was found between posterior upright width and orthotic stiffness, suggesting that it is highly feasible to standardize orthotic settings according to individual conditions of patients after stroke, even for posterior leaf spring ankle-foot orthoses.

Altered Muscle Contributions are Required to Support the Stance Limb During Voluntary Toe-Walking

Toe-walking characterizes several neuromuscular conditions and is associated with a reduction in gait stability and efficiency, as well as in life quality. The optimal choice of treatment depends on a correct understanding of the underlying pathology and on the individual biomechanics of walking. The objective of this study was to describe gait deviations occurring in a cohort of healthy adult subjects when mimicking a unilateral toe-walking pattern compared to their normal heel-to-toe gait pattern. The focus was to characterize the functional adaptations of the major lower-limb muscles which are required in order to toe walk. Musculoskeletal modeling was used to estimate the required muscle contributions to the joint sagittal moments. The support moment, defined as the sum of the sagittal extensive moments at the ankle, knee, and hip joints, was used to evaluate the overall muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Compared to a normal heel-to-toe gait pattern, toe-walking was characterized by significantly different lower-limb kinematics and kinetics. The altered kinetic demands at each joint translated into different necessary moment contributions from most muscles. In particular, an earlier and prolonged ankle plantarflexion contribution was required from the soleus and gastrocnemius during most of the stance phase. The hip extensors had to provide a higher extensive moment during loading response, while a significantly higher knee extension contribution from the vasti was necessary during mid-stance. Compensatory muscular activations are therefore functionally required at every joint level in order to toe walk. A higher support moment during toe-walking indicates an overall higher muscular effort necessary to maintain stance limb stability and prevent the collapse of the knee. Higher muscular demands during gait may lead to fatigue, pain, and reduced quality of life. Toe-walking is indeed associated with significantly larger muscle forces exerted by the quadriceps to the patella and prolonged force transmission through the Achilles tendon during stance phase. Optimal treatment options should therefore account for muscular demands and potential overloads associated with specific compensatory mechanisms.

Walk-IT: An Open-Source Modular Low-Cost Smart Rollator

Rollators are widely used in clinical rehabilitation for gait assessment, but gait analysis usually requires a great deal of expertise and focus from medical staff. Smart rollators can capture gait parameters autonomously while avoiding complex setups. However, commercial smart rollators, as closed systems, can not be modified; plus, they are often expensive and not widely available. This work presents a low cost open-source modular rollator for monitorization of gait parameters and support. The whole system is based on commercial components and its software architecture runs over ROS2 to allow further customization and expansion. This paper describes the overall software and hardware architecture and, as an example of extended capabilities, modules for monitoring dynamic partial weight bearing and for estimation of spatiotemporal gait parameters of clinical interest. All presented tests are coherent from a clinical point of view and consistent with input data.

Core Sets of Kinematic Variables to Consider for Evaluation of Gait Post-stroke

Background

Instrumented gait analysis post-stroke is becoming increasingly more common in research and clinics. Although overall standardized procedures are proposed, an almost infinite number of potential variables for kinematic analysis is generated and there remains a lack of consensus regarding which are the most important for sufficient evaluation. The current aim was to identify a discriminative core set of kinematic variables for gait post-stroke.

Methods

We applied a three-step process of statistical analysis on commonly used kinematic gait variables comprising the whole body, derived from 3D motion data on 31 persons post-stroke and 41 non-disabled controls. The process of identifying relevant core sets involved: (1) exclusion of variables for which there were no significant group differences; (2) systematic investigation of one, or combinations of either two, three, or four significant variables whereby each core set was evaluated using a leave-one-out cross-validation combined with logistic regression to estimate a misclassification rate (MR).

Results

The best MR for one single variable was shown for the Duration of single-support (MR 0.10) or Duration of 2nd double-support (MR 0.11) phase, corresponding to an 89–90% probability of correctly classifying a person as post-stroke/control. Adding Pelvis sagittal ROM to either of the variables Self-selected gait speed or Stride length, alternatively adding Ankle sagittal ROM to the Duration of single-stance phase, increased the probability of correctly classifying individuals to 93–94% (MR 0.06). Combining three variables decreased the MR further to 0.04, suggesting a probability of 96% for correct classification. These core sets contained: (1) a spatial (Stride/Step length) or a temporal variable (Self-selected gait speed/Stance time/Swing time or Duration of 2nd double-support), (2) Pelvis sagittal ROM or Ankle plantarflexion during push-off, and (3) Arm Posture Score or Cadence or a knee/shoulder joint angle variable. Adding a fourth variable did not further improve the MR.

Conclusion

A core set combining a few crucial kinematic variables may sufficiently evaluate post-stroke gait and should receive more attention in rehabilitation. Our results may contribute toward a consensus on gait evaluation post-stroke, which could substantially facilitate future diagnosis and monitoring of rehabilitation progress.

Optimal Assistance Timing to Induce Voluntary Dorsiflexion Movements: A Preliminary Study in Healthy Participants

Swing-phase dorsiflexion assistance with robotic ankle–foot orthosis could improve toe clearance and limb shortening such that compensatory movements are suppressed. However, facilitating voluntary effort under assistance remains a challenge. In our previous study, we examined assistance effects of swing-phase dorsiflexion with different delay times after toe-off on a dorsiflexion-restricted gait with a high-dorsiflexion assistive system. Results showed that later dorsiflexion assistance could lead to an increase in the tibialis anterior’s surface electromyography but could also deteriorate compensatory movement. Thus, we concluded that there is a suitable assistance timing to simultaneously achieve voluntary effort and optimal gait. In the present research, we derived a method to identify a suitable dorsiflexion assistance delay time via a multiple linear regression analysis on ankle data of stroke patients with a pathological gait with insufficient dorsiflexion. With the identification method, an experiment was conducted on six healthy participants with restricted dorsiflexion. Results showed that the identified assistance timing improved the amplitude of the tibialis anterior’s surface electromyography while also suppressing limb shortening during circumduction and hip hiking. Although a practical study of stroke survivors is required, observations from this research indicate the potential to successfully induce voluntary efforts with the identified dorsiflexion assistance timing.

Can prior exposure to repeated non-paretic slips improve reactive responses on novel paretic slips among people with chronic stroke?

This study examined if people with chronic stroke (PwCS) could adapt following non-paretic overground gait-slips and whether such prior exposure to non-paretic slips could improve reactive responses on novel paretic slip. Forty-nine PwCS were randomly assigned to either adaptation group, which received eight unexpected, overground, nonparetic-side gait-slips followed by two paretic-side slips or a control group, which received two paretic-side slips. Slip outcome, recovery strategies, center of mass (CoM) state stability, post-slip stride length and slipping kinematics were analyzed. The adaptation group demonstrated fall-reduction from first to eighth non-paretic slips, along with improved stability, stride length and slipping kinematics (p < 0.05). Within the adaptation group, on comparing novel slips, paretic-side demonstrated comparable pre-slip stability (p > 0.05); however, lower post-slip stability, increased slip velocity and falls was noted (p < 0.05). There was no difference in any variables between the novel paretic slips of adaptation and control group (p > 0.01). However, there was a rapid improvement on the 2nd slip such that adaptation group demonstrated improved performance from the first to second paretic slip compared to that in the control group (p < 0.01). PwCS demonstrated immediate proactive and reactive adaptation with overground, nonparetic-side gait-slips. However, PwCS did not demonstrate any inter-limb performance gain on the paretic-side after prior nonparetic-side adaptation when exposed to a novel paretic-side slip; but they did show significant positive gains with single slip priming on the paretic-side compared to controls without prior adaptation.Clinical registry number: NCT03205527.

Title: Assessment of VO2peak and Exercise Capacity after Stroke: a Validity Study of the Human Activity Profile Questionnaire

OBJECTIVE

to investigate, in individuals after stroke, the concurrent validity of the Human Activity Profile (HAP) to provide the VO_2peak and the construct validity of the HAP to assess exercise capacity; and to provide equations based upon the HAP outcomes to estimate the distance covered in the Incremental Shuttle Walking Test (ISWT).

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Fifty-seven individuals (54±11 years) after stroke.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Agreement between the VO_2peak provided by the HAP (lifestyle energy consumption (LEC) outcome, in mL.kg^-1.min^-1) and the gold standard measure of the VO_2peak (mL.kg^-1.min^-1), obtained through the symptom-limited Cardiopulmonary Exercise Test (CPET). Correlation between the HAP outcomes (LEC; the maximum activity score (MAS) and the adjusted activity score (AAS)) and the construct measure: the distance covered (in meters) in the ISWT. An equation to estimate the distance covered in the ISWT was determined.

RESULTS

High magnitude agreement was found between the VO_2peak, in mL.kg^-1.min^-1, obtained by the symptom-limited CPET and the value of VO_2peak, in mL.kg^-1.min^-1, provided by the HAP (LEC) (ICC=0.75;p<0.001). Low to moderate magnitude correlations were found between the distance covered in the ISWT and the HAP (LEC/MAS/AAS) (0.34≤rho≤0.58). The equation to estimate the distance covered in the ISWT explained 31% of the variability of the ISWT (ISWT_estimated=-361.91+(9.646xAAS)).

CONCLUSION

The HAP questionnaire is a clinically applicable way to provide a valid value of VO_2peak (in mL.kg^-1.min^-1) and to assess the exercise capacity of individuals after stroke. Furthermore, an equation to estimate the distance covered in the submaximal field exercise test (ISWT) based on the result of the AAS (in points) was provided.

Reliability of IMU-Based Gait Assessment in Clinical Stroke Rehabilitation

Background: Gait is often impaired in people after stroke, restricting personal independence and affecting quality of life. During stroke rehabilitation, walking capacity is conventionally assessed by measuring walking distance and speed. Gait features, such as asymmetry and variability, are not routinely determined, but may provide more specific insights into the patient’s walking capacity. Inertial measurement units offer a feasible and promising tool to determine these gait features. Objective: We examined the test–retest reliability of inertial measurement units-based gait features measured in a two-minute walking assessment in people after stroke and while in clinical rehabilitation. Method: Thirty-one people after stroke performed two assessments with a test–retest interval of 24 h. Each assessment consisted of a two-minute walking test on a 14-m walking path. Participants were equipped with three inertial measurement units, placed at both feet and at the low back. In total, 166 gait features were calculated for each assessment, consisting of spatio-temporal (56), frequency (26), complexity (63), and asymmetry (14) features. The reliability was determined using the intraclass correlation coefficient. Additionally, the minimal detectable change and the relative minimal detectable change were computed. Results: Overall, 107 gait features had good–excellent reliability, consisting of 50 spatio-temporal, 8 frequency, 36 complexity, and 13 symmetry features. The relative minimal detectable change of these features ranged between 0.5 and 1.5 standard deviations. Conclusion: Gait can reliably be assessed in people after stroke in clinical stroke rehabilitation using three inertial measurement units.

Treatment of knee hyperextension in post-stroke gait. A systematic review

BACKGROUND

Post-stroke, patients exhibit considerable variations in gait patterns. One of the variations that can be present in post-stroke gait is knee hyperextension in the stance phase.

RESEARCH QUESTION

What is the current evidence for the effectiveness of the treatment of knee hyperextension in post-stroke gait?

METHODS

MEDLINE, EMBASE, PEDro, CINAHL, and the Cochrane library were searched for relevant controlled trials. Two researchers independently extracted the data and assessed the methological quality. A best evidence synthesis was conducted to summarize the results.

RESULTS

Eight controlled trials (5 RCTs, 3 CCTs) were included. Three types of interventions were identified: proprioceptive training, orthotic treatment, and functional electrostimulation (FES). In the included studies, the time since the stroke occurrence varied from the (sub)acute phase to the chronic phase. Only short-term effects were investigated. The adjustment from a form of proprioceptive training to physiotherapy training programs seems to be effective (moderate evidence) for treating knee hyperextension in gait, as applied in the subacute phase post-stroke. Neither evidence for effects on gait speed nor gait symmetry were found as a result of proprioceptive training. Orthoses that cover the knee have some effects (limited evidence) on knee hyperextension and gait speed. No evidence was found for FES.

SIGNIFICANCE

This is the first systematic literature review on the effectiveness of interventions on knee hyperextension in post-stroke gait. We found promising results (moderate evidence) for some "proprioceptive approaches" as an add-on therapy to physiotherapy training programs for treating knee hyperextension during the subacute phase post-stroke, in the short-term. Therefore, initially, clinicians should implement a training program with a proprioceptive approach in order to restore knee control in these patients. Because only studies reporting short-term results were found, more high-quality RCTs and CCTs are needed that also study mid- and long-term effects.

The effect of anterior ankle-foot orthosis and posterior ankle-foot orthosis on functional ambulation in stroke patients

Background

The goal of rehabilitation after stroke is to restore safe and sufficient function to hemiplegic patients, and prescription of an ankle-foot orthosis (AFO) to improve speed and functional ambulation is a part of this program.

Objective

This crossover randomized interventional study aimed to evaluate the effect of an anterior ankle-foot orthosis (AAFO) and posterior leaf-spring ankle-foot orthosis (PLS AFO) on speed and functional ambulation in hemiplegic stroke patients.

Method

Clinical assessments were performed on 11 hemiplegic stroke patients by the AAFO, PLS AFO, and wearing shoes. Functional ambulation was measured by the 6-min walking test, Timed Up and Go Test, Time Up and Down Stair Test, and Functional Ambulation Category. Walking speed was measured by the 10-m test.

Results

Both PLS AFO and AAFO significantly improved the performance of TUDS and TUG tests in hemiplegic patients. However, by using PLS AFO, walking distance was significantly greater than walking with shoes. There was no significant effect on the walking speed improvement using PLS AFO or AAFO compared to wearing shoes.

Conclusions

The positive effects of the AAFO and PLS AFO on functional ambulation were significant. By using PLS AFO, hemiplegic patients could walk a longer distance than wearing shoes.

Real-Time Exercise Feedback through a Convolutional Neural Network: A Machine Learning-Based Motion-Detecting Mobile Exercise Coaching Application

PURPOSE

Mobile applications are widely used in the healthcare market. This study aimed to determine whether exercise using a machine learning-based motion-detecting mobile exercise coaching application (MDMECA) is superior to video streaming-based exercise for improving quality of life and decreasing lower back pain.

MATERIALS AND METHODS

The same 14-day daily workout program consisting of five exercises was performed by 104 participants using the MDMECA and another 72 participants using video streaming. The Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) and lower back pain scores were assess as pre- and post-workout measurements. Scores for the treatment-satisfaction subscale of the visual analog scale (TS-VAS), intention to use a disease-oriented exercise program, intention to recommend the program to others, and available expenses for a disease-oriented exercise program were determined after the workout.

RESULTS

The MDMECA group showed a higher increase in SF-36 score (MDMECA, 9.10; control, 1.09; p<0.01) and a greater reduction in lower back pain score (MDMECA, -0.96; control, -0.26; p<0.01). Scores for TS-VAS, intention to use a disease-oriented exercise program, and intention to recommend the program to others were all higher (p<0.01) in the MDMECA group. However, the available expenses for a disease-oriented program were not significantly different between the two groups.

CONCLUSION

The MDMECA is more effective than video streaming-based exercise in increasing exercise adherence, improving QoL, and reducing lower back pain. MDMECAs could be promising tools of use to achieve better medical outcomes and higher treatment satisfaction.

Effects of robot (SUBAR)-assisted gait training in patients with chronic stroke: Randomized controlled trial

BACKGROUND

SUBAR is a new ground walking exoskeletal robot. The objective of this study is to investigate SUBAR-assisted gait training's effects in patients with chronic stroke.

METHODS

This preliminary study is a prospective randomized controlled trial. Thirty adults were enrolled 6 months after the onset of stroke with functional ambulation category scores ≥ 3. Patients were randomly assigned to receive robot-assisted gait training (SUBAR group, n = 15) or conventional physiotherapy (control group, n = 15). All patients received a total of 10 treatment sessions of 30 minutes each for 3 weeks. Before and after the 10-treatment sessions, patients were evaluated. The primary outcome is the 10 meter walk test and the secondary outcomes were the functional ambulation category scale, the Motricity Index-Lower, Modified Ashworth Scale (MAS), timed up and go, Rivermead Mobility Index, Berg Balance Scale (BBS), and gait analysis.

RESULTS

In the SUBAR group, MAS and step length were significantly improved between pre- and posttreatment measurements (Δmean ± SD: -1.1 ± 1.6 and 5.5 ± 7.6, P = .019 and .016, respectively). The SUBAR group improved the stride length and step length of the affected limb but not significantly. The control group had significant improvements in the BBS, MAS, and stride length between pre- and posttreatment measurements (Δmean ± SD: 3.5 ± 4.6, -0.8 ± 1.5, and 6.5 ± 9.5; P = .004, .031, and .035, respectively). The BBS improved more in the control group than in the SUBAR group. There were no other differences between the SUBAR group and the control group.

CONCLUSION

Our results suggest that SUBAR-assisted gait training improved gait parameters in patients with chronic stroke. However, there was no significant difference in most outcome measures compared to conventional physiotherapy. Further research is warranted to measure the effects of SUBAR-assisted gait training.

Abnormal synergistic gait mitigation in acute stroke using an innovative ankle-knee-hip interlimb humanoid robot: a preliminary randomized controlled trial

Abnormal spasticity and associated synergistic patterns are the most common neuromuscular impairments affecting ankle–knee–hip interlimb coordinated gait kinematics and kinetics in patients with hemiparetic stroke. Although patients with hemiparetic stroke undergo various treatments to improve gait and movement, it remains unknown how spasticity and associated synergistic patterns change after robot-assisted and conventional treatment. We developed an innovative ankle–knee–hip interlimb coordinated humanoid robot (ICT) to mitigate abnormal spasticity and synergistic patterns. The objective of the preliminary clinical trial was to compare the effects of ICT combined with conventional physical therapy (ICT-C) and conventional physical therapy and gait training (CPT-G) on abnormal spasticity and synergistic gait patterns in 20 patients with acute hemiparesis. We performed secondary analyses aimed at elucidating the biomechanical effects of Walkbot ICT on kinematic (spatiotemporal parameters and angles) and kinetic (active force, resistive force, and stiffness) gait parameters before and after ICT in the ICT-C group. The intervention for this group comprised 60-min conventional physical therapy plus 30-min robot-assisted training, 7 days/week, for 2 weeks. Significant biomechanical effects in knee joint kinematics; hip, knee, and ankle active forces; hip, knee, and ankle resistive forces; and hip, knee, and ankle stiffness were associated with ICT-C. Our novel findings provide promising evidence for conventional therapy supplemented by robot-assisted therapy for abnormal spasticity, synergistic, and altered biomechanical gait impairments in patients in the acute post-stroke recovery phase.

Trial Registration: Clinical Trials.gov identifier NCT03554642 (14/01/2020).

Motor-cognitive intervention concepts can improve gait in chronic stroke, but their effect on cognitive functions is unclear: A systematic review with meta-analyses

Motor-cognitive intervention concepts are promising to counteract residual gait and cognitive impairments in chronic stroke. There is, however, considerable variation in motor-cognitive intervention types, which may lead to different effects. This systematic review strived to summarize and compare the effects of different motor-cognitive intervention concepts on gait and cognitive functions in chronic stroke. The systematic search identified twenty-nine articles, which were allocated to three types of motor-cognitive training concepts; SEQUENTIAL, SIMULTANEOUS-ADDITIONAL, and SIMULTANEOUS-INCORPORATED. Random-effects meta-analyses revealed that motor-cognitive interventions may be better than non-combined training approaches for improving gait function in chronic stroke (e.g. gait speed: g = 0.43, 95 % CI [0.22, 0.64], p < 0.0001). SIMULTANEOUS-INCORPORATED motor-cognitive training seems the most promising concept. As very few articles measured both, spatiotemporal gait parameters and cognitive outcomes, future studies are warranted to investigate the effects of motor-cognitive intervention concepts on gait control and cognitive functions in chronic stroke.

Analysis of Gait Characteristics Using Hip-Knee Cyclograms in Patients with Hemiplegic Stroke

Gait disturbance is a common sequela of stroke. Conventional gait analysis has limitations in simultaneously assessing multiple joints. Therefore, we investigated the gait characteristics in stroke patients using hip-knee cyclograms, which have the advantage of simultaneously visualizing the gait kinematics of multiple joints. Stroke patients (n = 47) were categorized into two groups according to stroke severity, and healthy controls (n = 32) were recruited. An inertial measurement unit sensor-based gait analysis system, which requires placing seven sensors on the dorsum of both feet, the shafts of both tibias, the middle of both femurs, and the lower abdomen, was used for the gait analysis. Then, the hip-knee cyclogram parameters (range of motion, perimeter, and area) were obtained from the collected data. The coefficient of variance of the cyclogram parameters was obtained to evaluate gait variability. The cyclogram parameters differed between the stroke patients and healthy controls, and differences according to stroke severity were also observed. The gait variability parameters mainly differed in patients with more severe stroke, and specific visualized gait patterns of stroke patients were obtained through cyclograms. In conclusion, the hip-knee cyclograms, which show inter-joint coordination and visualized gait cycle in stroke patients, are clinically significant.

Virtual Reality and Physiotherapy in Post-Stroke Functional Re-Education of the Lower Extremity: A Controlled Clinical Trial on a New Approach

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP.

Effect of Customized Insoles on Gait in Post-Stroke Hemiparetic Individuals: A Randomized Controlled Trial

Background: Insoles have been widely applied to many diseases, but stroke involves complex problems and there is a paucity of research on the application of insoles in stroke patients. Aim: To evaluate the effect of customized insoles on gait in patients with hemiplegia. Design: A randomized controlled trial. Setting: Rehabilitation department of a hospital. Population: A total of 50 stroke patients were randomized into an experimental group (n = 25) or a control group (n = 25). Methods: Both groups received conventional gait training, which was conducted five times a week, every 40 min for four weeks and patients in the experimental group were required to wear customized insoles for at least 1 h per day for four weeks. The primary outcome measure was the Tinetti Gait Scale (TGS) and the secondary outcome measures were the plantar pressure test, 6-min walking test (6MWT), lower extremity Fugl-Meyer assessment (FMA-LE), Berg Balance Scale (BBS), and the modified Barthel index (MBI). Results: Compared to the control group, there were significant increases in the experimental group after four weeks (p = 0.014) and at the four week follow-up (p = 0.001) in the change in TGS, weight-bearing on the involved side (p = 0.012) or forefoot (p = 0.028) when standing, weight-bearing on the involved side (p = 0.01 6) or forefoot (p = 0.043) when walking, early stance phase (p = 0.023) and mid stance phase (p = 0.013) on the involved side, FMA-LE (p = 0.029), BBS (p = 0.005), and MBI (p = 0.009), but there were no differences in the late stance phase (p = 0.472) on the involved side when walking or in the 6MWT (p = 0.069). Conclusions: Customized insoles had great efficacy in enhancing gait performance in stroke patients.

Developing and exploring a methodology for multi-modal indoor and outdoor gait assessment

Gait assessment is emerging as a prominent way to understand impaired mobility and underlying neurological deficits. Various technologies have been used to assess gait inside and outside of laboratory settings, but wearables are the preferred option due to their cost-effective and practical use in both. There are robust conceptual gait models developed to ease the interpretation of gait parameters during indoor and outdoor environments. However, these models examine uni-modal gait characteristics (e.g., spatio-temporal parameters) only. Previous studies reported that understanding the underlying reason for impaired gait requires multi-modal gait assessment. Therefore, this study aims to develop a multi-modal approach using a synchronized inertial and electromyography (EMG) signals. Firstly, initial contact (IC), final contact (FC) moments and corresponding time stamps were identified from inertial data, producing temporal outcomes e.g., step time. Secondly, IC/FC time stamps were used to segment EMG data and define onset and offset times of muscle activities within the gait cycle and its subphases. For investigation purposes, we observed notable differences in temporal characteristics as well as muscle onset/offset timings and amplitudes between indoor and outdoor walking of three stroke survivors. Our preliminary analysis suggests a multi-modal approach may be important to augment and improve current inertial conceptual gait models by providing additional quantitative EMG data.

Predictive simulation of post-stroke gait with functional electrical stimulation

Post-stroke patients present various gait abnormalities such as drop foot, stiff-knee gait (SKG), and knee hyperextension. Functional electrical stimulation (FES) improves drop foot gait although the mechanistic basis for this effect is not well understood. To answer this question, we evaluated the gait of a post-stroke patient walking with and without FES by inverse dynamics analysis and compared the results to an optimal control framework. The effect of FES and cause-effect relationship of changes in knee and ankle muscle strength were investigated; personalized muscle–tendon parameters allowed the prediction of pathologic gait. We also predicted healthy gait patterns at different speeds to simulate the subject walking without impairment. The passive moment of the knee played an important role in the estimation of muscle force with knee hyperextension, which was decreased during FES and knee extensor strengthening. Weakening the knee extensors and strengthening the flexors improved SKG. During FES, weak ankle plantarflexors and strong ankle dorsiflexors resulted in increased ankle dorsiflexion, which reduced drop foot. FES also improved gait speed and reduced circumduction. These findings provide insight into compensatory strategies adopted by post-stroke patients that can guide the design of individualized rehabilitation and treatment programs.

Training muscle activation patterns of the lower paretic extremity using directional exertion improves mobility in persons with hemiparesis: a pilot study

Background

Controlled static exertion performed in the sagittal plane on a transducer attached to the foot requires coordinated moments of force of the lower extremity. Some exertions and plantarflexion recruit muscular activation patterns similar to synergies previously identified during gait. It is currently unknown if persons with hemiparesis following stroke demonstrate similar muscular patterns, and if force feedback training utilizing static exertion results in improved mobility in this population.

Methods

Electromyographic (EMG) activity of eight muscles of the lower limb were recorded using surface electrodes in healthy participants (n = 10) and in persons with hemiparesis (n = 8) during an exertion exercise (task) performed in eight directions in the sagittal plane of the foot and a plantarflexion exercise performed at 20 and 40% maximum voluntary effort (MVE). Muscle activation patterns identified during these exertion exercises were compared between groups and to synergies reported in the literature during healthy gait using cosine similarities (CS). Functional mobility was assessed in four participants with hemiparesis using GAITRite® and the Timed Up and Go (TUG) test at each session before, during and after static force feedback training. Tau statistics were used to evaluate the effect on mobility before and after training. Measures of MVE and the accuracy of directional exertion were compared before and after training using ANOVAs. Spearman Rho correlations were also calculated between changes in these parameters and changes in mobility before and after the training.

Results

Muscle activation patterns during directional exertion and plantarflexion were similar for both groups of participants (CS varying from 0.845 to 0.977). Muscular patterns for some of the directional and plantarflexion were also similar to synergies recruited during gait (CS varying from 0.847 to 0.951). Directional exertion training in hemiparetic subjects resulted in improvement in MVE (p < 0.040) and task performance accuracy (p < 0.001). Hemiparetic subjects also demonstrated significant improvements in gait velocity (p < 0.032) and in the TUG test (p < 0.022) following training. Improvements in certain directional efforts were correlated with changes in gait velocity (p = 0.001).

Conclusion

Static force feedback training following stroke improves strength and coordination of the lower extremity while recruiting synergies reported during gait and is associated with improved mobility.

Effects of Assisted Dorsiflexion Timing on Voluntary Efforts and Compensatory Movements: A Feasibility Study in Healthy Participants

In previous research, we found that modulating the assistance timing of dorsiflexion may affect a user's voluntary efforts. This could constitute a focus area based on assistive strategies that could be developed to foster patients' voluntary efforts. In this present study, we conducted an experiment to verify the effects of ankle dorsiflexion assistance under different timings using a high-dorsiflexion assistive system. Nine healthy and young participants wore a dorsiflexion-restrictive device that enabled them to use circumduction or steppage gaits. On the basis of the transition from the stance to the swing phase of the gait, the assistance timings of the high-dorsiflexion assistive system were set to have delays, which ranged from 0 to 300 ms. The index results from eight out of nine participants evaluated compensatory movements and revealed positive strong/moderate correlations with assistance delay times (r = 0.627-0.965, p <.001), whereas the other participants also performed compensatory movement when dorsiflexion assistance timing was late. Meanwhile, the results from tibialis anterior surface electromyography from six out of nine participants showed positive strong/moderate correlations with dorsiflexion assistance delay times (r = 0.598-0.922, p <.001), indicating that tuning the assistance timing did foster these participants' voluntary dorsiflexion movements. This result indicates that there should be a trade-off between ensuring voluntary dorsiflexion movements and preventing incorrect gait patterns at different assistance timings. The findings of this feasibility study indicate the potential of developing an adaptive control method to ensure voluntary efforts during robot-assisted gait rehabilitation based on assistance timing modification. A new assistance mechanism should also be required to stimulate and motivate a patient's voluntary efforts and should reinforce the effects of active gait rehabilitation.

Temporal But Not Spatial Gait Parameters Associated With Lower Balance Capacity in Moderate-High Functioning Persons With Stroke

BACKGROUND AND PURPOSE

Falls are a major health concern after stroke. Spatial and temporal gait asymmetry and variability can contribute to instability and increased fall risk in persons with stroke (PwS). We aimed to quantify gait spatiotemporal symmetry and variability parameters in PwS undergoing rehabilitation in the subacute stage of the disease, by comparison to healthy participants, and to examine the associations between these parameters and patients' reactive and proactive balance capacity.

METHODS

Twenty-two PwS and 12 healthy adults walked over a computerized treadmill system at their self-selected walking speed. Symmetry and variability of gait parameters (step length, swing time, and stance time) as well as upper extremity and lower extremity angular range of motion in the sagittal plane were extracted. In addition, the Berg Balance Scale (BBS) and the fall threshold in response to sudden surface translations at increasing intensities were assessed.

RESULTS

PwS demonstrated significantly higher asymmetry in all gait parameters in comparison to controls. Also, PwS demonstrated increased stance time variability in comparison to healthy controls and increased swing time variability in the paretic lower extremity. Significant negative associations were found between fall threshold and stance time asymmetry in PwS (r = -0.48, P = 0.022), between the BBS and swing time asymmetry (r = -0.50, P = 0.018), and between the BBS and stance time variability of the paretic lower extremity (r = -0.56, P = 0.006).

DISCUSSION AND CONCLUSIONS

Findings highlight the importance of gait temporal symmetry and variability measures for dynamic balance control after stroke. These parameters should be considered when assessing gait recovery and safety in PwS.Video Abstract available for more insight from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A355).

Kinematics, Speed, and Anthropometry-Based Ankle Joint Torque Estimation: A Deep Learning Regression Approach

Powered Assistive Devices (PADs) have been proposed to enable repetitive, user-oriented gait rehabilitation. They may include torque controllers that typically require reference joint torque trajectories to determine the most suitable level of assistance. However, a robust approach able to automatically estimate user-oriented reference joint torque trajectories, namely ankle torque, while considering the effects of varying walking speed, body mass, and height on the gait dynamics, is needed. This study evaluates the accuracy and generalization ability of two Deep Learning (DL) regressors (Long-Short Term Memory and Convolutional Neural Network (CNN)) to generate user-oriented reference ankle torque trajectories by innovatively customizing them according to the walking speed (ranging from 1.0 to 4.0 km/h) and users’ body height and mass (ranging from 1.51 to 1.83 m and 52.0 to 83.7 kg, respectively). Furthermore, this study hypothesizes that DL regressors can estimate joint torque without resourcing electromyography signals. CNN was the most robust algorithm (Normalized Root Mean Square Error: 0.70 ± 0.06; Spearman Correlation: 0.89 ± 0.03; Coefficient of Determination: 0.91 ± 0.03). No statistically significant differences were found in CNN accuracy (p-value > 0.05) whether electromyography signals are included as inputs or not, enabling a less obtrusive and accurate setup for torque estimation.

Efficacy of a novel walking assist device with auxiliary laser illuminator in stroke Patients~ a randomized control trial

BACKGROUND/PURPOSE

Task-oriented functional walking is important in stroke patients. We aimed to investigate effects of a quad-cane with auxiliary laser illuminator (laser-cane) among stroke patients.

METHODS

This was a randomized-prospective study. Patients in the experimental group (EG) received 15-min of walking training with laser-cane and 15-min of traditional physical therapy. Patients in the control group (CG) received the same rehabilitation without laser-cane. The rehabilitation lasted for 4 weeks, twice per week. Primary outcome were gait parameters. Secondary outcomes were Berg Balance Scale (BBS), Timed Up and Go Test (TUG), and Barthel index (BI). Outcomes were measured at baseline, at the end of the rehabilitation (visit-1), and 4 weeks later (visit-2).

RESULTS

Both the groups (both n = 15) showed improvement of cadence, relative stance and swing phase duration of non-paretic side, BBS, and TUG at both visits. In the intragroup comparison, the EG additionally improved at stride length, relative stance and swing phase duration of paretic side, and gait speed at both visits; temporal swing symmetry, and toe-off angle of non-paretic side at the visit-2. Intergroup comparing for changing of outcomes with the CG, stride length and gait speed increased, relative stance phase duration of the non-paretic site decreased, and the temporal swing symmetry improved at the visit-1; relative stance phase duration of the paretic side decreased and the temporal stance symmetry improved at the visit-2 in the EG.

CONCLUSION

Rehabilitation with laser-cane improved the balance, activity of daily living, gait symmetry and gait parameters of stroke patients.

The Effects of Transcranial Direct Current Stimulation on Balance and Gait in Stroke Patients: A Systematic Review and Meta-Analysis

Objective: Balance dysfunction after stroke often results in individuals unable to maintain normal posture, limits the recovery of gait and functional independence. We explore the short-term effects of transcranial direct current stimulation (tDCS) on improving balance function and gait in stroke patients.

Methods: We systematically searched on PubMed, Web of Science, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar for studies that explored the effects of tDCS on balance after stroke until August 2020. All involved studies used at least one measurement of balance, gait, or postural control as the outcome.

Results: A total of 145 studies were found, of which 10 (n = 246) met the inclusion criteria and included in our studies. The present meta-analysis showed that active tDCS have beneficial effects on timed up and go test (TUGT) [mean difference (MD): 0.35; 95% confidence interval (CI): 0.11 to 0.58] and Functional Ambulation Category (FAC) (MD: −2.54; 95% CI: −3.93 to −1.15) in stroke patients. However, the results were not significant on the berg balance scale (BBS) (MD: −0.20; 95% CI: −1.44 to 1.04), lower extremity subscale of Fugl-Meyer Assessment (FMA-LE) (MD: −0.43; 95% CI: −1.70 to 0.84), 10-m walk test (10 MWT) (MD: −0.93; 95% CI: −2.68 to 0.82) and 6-min walking test (6 MWT) (MD: −2.55; 95% CI: −18.34 to 13.23).

Conclusions: In conclusion, we revealed that tDCS might be an effective option for restoring walking independence and functional ambulation for stroke patients in our systematic review and meta-analysis.

Systematic Review Registration: CRD42020207565.

Single-session training on an ascending treadmill slope: effects on gait parameters in persons with stroke. A pilot study

OBJECTIVE

Treadmill training with an upward incline could improve gait parameters altered in persons with stroke, especially lower limb flexion. This study aimed to determine the effects of a treadmill single-session training with a 10% upward incline on biomechanical gait parameters in persons with stroke.

METHODS

Fifteen persons with stroke-related hemiparesis performed a 20-min treadmill training session with a 10% ascending incline in this interventional pilot study. Spatiotemporal, kinematic and kinetic parameters were evaluated, overground, with a tridimensional optoelectronic system, before the session, immediately after and after a 20-min rest period.

RESULTS

The single-session training on a treadmill with a 10% incline has significantly increased hip flexion peak on the paretic side (39.8°± 8.1 in baseline to 42.7°± 8.6 after the session, P < 0.001, large effect size) and knee flexion peak on the paretic side (39.9°± 11.6 in baseline to 43.1°± 11.7 after the session, P = 0.004, large effect size). Gait speed, other spatiotemporal gait parameters and propulsion on the paretic side were also significantly increased (P < 0.05, all large effects size). These short-term changes were maintained after the break.

CONCLUSIONS

A treadmill single-session training with a 10% upward incline induces biomechanical changes in people with stroke. The environmental constraints of this training could explain these biomechanical adaptations, concerning especially paretic hip and knee flexion.

Wearable Devices for Biofeedback Rehabilitation: A Systematic Review and Meta-Analysis to Design Application Rules and Estimate the Effectiveness on Balance and Gait Outcomes in Neurological Diseases

Wearable devices are used in rehabilitation to provide biofeedback about biomechanical or physiological body parameters to improve outcomes in people with neurological diseases. This is a promising approach that influences motor learning and patients' engagement. Nevertheless, it is not yet clear what the most commonly used sensor configurations are, and it is also not clear which biofeedback components are used for which pathology. To explore these aspects and estimate the effectiveness of wearable device biofeedback rehabilitation on balance and gait, we conducted a systematic review by electronic search on MEDLINE, PubMed, Web of Science, PEDro, and the Cochrane CENTRAL from inception to January 2020. Nineteen randomized controlled trials were included (Parkinson's n = 6; stroke n = 13; mild cognitive impairment n = 1). Wearable devices mostly provided real-time biofeedback during exercise, using biomechanical sensors and a positive reinforcement feedback strategy through auditory or visual modes. Some notable points that could be improved were identified in the included studies; these were helpful in providing practical design rules to maximize the prospective of wearable device biofeedback rehabilitation. Due to the current quality of the literature, it was not possible to achieve firm conclusions about the effectiveness of wearable device biofeedback rehabilitation. However, wearable device biofeedback rehabilitation seems to provide positive effects on dynamic balance and gait for PwND, but higher-quality RCTs with larger sample sizes are needed for stronger conclusions.

Effects of gait rehabilitation on motor coordination in stroke survivors: an UCM-based approach

Post-stroke locomotion is usually characterized by asymmetrical gait patterns, compensatory movements of trunk and nonparetic limb, altered motor coordination, and wide inter-stride variability. This pilot study was designed to test a twofold hypothesis: post-stroke survivors can exploit the redundancy of the segmental angles to stabilize the 3D footpath trajectory during the swing phase, in accordance with the Uncontrolled Manifold (UCM) theory; an intense rehabilitative treatment improves both motor performance and outcomes of the UCM analysis. Ten stroke survivors underwent two evaluation sessions, before and after a conventional multidisciplinary intensive rehabilitation program, encompassing clinical tests and gait analysis, both overground and on treadmill. In addition, the UCM analysis was implemented to investigate whether variance of segmental angles is structured to minimize the inter-stride variability of the 3D footpath during the swing phase of treadmill locomotion. Both clinical and spatio-temporal parameters improved after the treatment, even if the statistical significance was reached for a limited set of them. The UCM analysis suggested that post-stroke survivors exploit the redundancy of lower limbs segmental angles mainly during the late swing, without significant differences between affected and unaffected sides. Thereafter, the main significant effects of the rehabilitative treatment consisted in strengthening the synergistic organization of the redundant segmental angles involving a more accurate control of the 3D footpath. Concluding, the UCM theory can be a promising tool to appraise the effects of a specific rehabilitative protocol on motor coordination in post-stroke survivors.

An Intelligent In-Shoe System for Gait Monitoring and Analysis with Optimized Sampling and Real-Time Visualization Capabilities

The deterioration of gait can be used as a biomarker for ageing and neurological diseases. Continuous gait monitoring and analysis are essential for early deficit detection and personalized rehabilitation. The use of mobile and wearable inertial sensor systems for gait monitoring and analysis have been well explored with promising results in the literature. However, most of these studies focus on technologies for the assessment of gait characteristics, few of them have considered the data acquisition bandwidth of the sensing system. Inadequate sampling frequency will sacrifice signal fidelity, thus leading to an inaccurate estimation especially for spatial gait parameters. In this work, we developed an inertial sensor based in-shoe gait analysis system for real-time gait monitoring and investigated the optimal sampling frequency to capture all the information on walking patterns. An exploratory validation study was performed using an optical motion capture system on four healthy adult subjects, where each person underwent five walking sessions, giving a total of 20 sessions. Percentage mean absolute errors (MAE%) obtained in stride time, stride length, stride velocity, and cadence while walking were 1.19%, 1.68%, 2.08%, and 1.23%, respectively. In addition, an eigenanalysis based graphical descriptor from raw gait cycle signals was proposed as a new gait metric that can be quantified by principal component analysis to differentiate gait patterns, which has great potential to be used as a powerful analytical tool for gait disorder diagnostics.

Effect of robotic-assisted gait training on objective biomechanical measures of gait in persons post-stroke: a systematic review and meta-analysis

BACKGROUND

Robotic-Assisted Gait Training (RAGT) may enable high-intensive and task-specific gait training post-stroke. The effect of RAGT on gait movement patterns has however not been comprehensively reviewed. The purpose of this review was to summarize the evidence for potentially superior effects of RAGT on biomechanical measures of gait post-stroke when compared with non-robotic gait training alone.

METHODS

Nine databases were searched using database-specific search terms from their inception until January 2021. We included randomized controlled trials investigating the effects of RAGT (e.g., using exoskeletons or end-effectors) on spatiotemporal, kinematic and kinetic parameters among adults suffering from any stage of stroke. Screening, data extraction and judgement of risk of bias (using the Cochrane Risk of bias 2 tool) were performed by 2-3 independent reviewers. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria were used to evaluate the certainty of evidence for the biomechanical gait measures of interest.

RESULTS

Thirteen studies including a total of 412 individuals (mean age: 52-69 years; 264 males) met eligibility criteria and were included. RAGT was employed either as monotherapy or in combination with other therapies in a subacute or chronic phase post-stroke. The included studies showed a high risk of bias (n = 6), some concerns (n = 6) or a low risk of bias (n = 1). Meta-analyses using a random-effects model for gait speed, cadence, step length (non-affected side) and spatial asymmetry revealed no significant differences between the RAGT and comparator groups, while stride length (mean difference [MD] 2.86 cm), step length (affected side; MD 2.67 cm) and temporal asymmetry calculated in ratio-values (MD 0.09) improved slightly more in the RAGT groups. There were serious weaknesses with almost all GRADE domains (risk of bias, consistency, directness, or precision of the findings) for the included outcome measures (spatiotemporal and kinematic gait parameters). Kinetic parameters were not reported at all.

CONCLUSION

There were few relevant studies and the review synthesis revealed a very low certainty in current evidence for employing RAGT to improve gait biomechanics post-stroke. Further high-quality, robust clinical trials on RAGT that complement clinical data with biomechanical data are thus warranted to disentangle the potential effects of such interventions on gait biomechanics post-stroke.

Change in Center of Pressure Progression in the Foot Provides Clues for Functional Improvement of the More Affected Lower Limb During Post-stroke Gait Rehabilitation

OBJECTIVE

The aim of this study was to determine the clinical significance of the anterior-posterior displacement of the center of pressure in the foot (apCoP) in post-stroke gait rehabilitation.

DESIGN

This observational study was conducted in a tertiary hospital. Forty-two subacute post-stroke patients were included. The apCoP was measured twice with a wearable insole foot pressure measurement system, time interval more than 7 days. The results were compared between the first and second tests. The relationship between apCoP changes and spatiotemporal parameter changes were investigated.

RESULTS

The apCoP increased significantly between tests. The change in walking speed was significantly predicted by the change in the apCoP on the less affected side. The change in asymmetry of the single support phase was significantly correlated with the change in the apCoP on the more affected side.

CONCLUSION

The change in apCoP provides information about the restoration of body support, body forward progression control, and propulsion in the more affected lower limb during early post-stroke rehabilitation. The apCoP can be a useful parameter for the monitoring of functional changes in the more affected lower limb during post-stroke gait rehabilitation.

Exploring the predictive value of lesion topology on motor function outcomes in a porcine ischemic stroke model

Harnessing the maximum diagnostic potential of magnetic resonance imaging (MRI) by including stroke lesion location in relation to specific structures that are associated with particular functions will likely increase the potential to predict functional deficit type, severity, and recovery in stroke patients. This exploratory study aims to identify key structures lesioned by a middle cerebral artery occlusion (MCAO) that impact stroke recovery and to strengthen the predictive capacity of neuroimaging techniques that characterize stroke outcomes in a translational porcine model. Clinically relevant MRI measures showed significant lesion volumes, midline shifts, and decreased white matter integrity post-MCAO. Using a pig brain atlas, damaged brain structures included the insular cortex, somatosensory cortices, temporal gyri, claustrum, and visual cortices, among others. MCAO resulted in severely impaired spatiotemporal gait parameters, decreased voluntary movement in open field testing, and higher modified Rankin Scale scores at acute timepoints. Pearson correlation analyses at acute timepoints between standard MRI metrics (e.g., lesion volume) and functional outcomes displayed moderate R values to functional gait outcomes. Moreover, Pearson correlation analyses showed higher R values between functional gait deficits and increased lesioning of structures associated with motor function, such as the putamen, globus pallidus, and primary somatosensory cortex. This correlation analysis approach helped identify neuroanatomical structures predictive of stroke outcomes and may lead to the translation of this topological analysis approach from preclinical stroke assessment to a clinical biomarker.

Effect of assist-as-needed robotic gait training on the gait pattern post stroke: a randomized controlled trial

Background

Regaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AAN_mDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AAN_mDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation.

Methods

Thirty-four participants with unilateral, supratentorial stroke were enrolled (< 10 weeks post onset, Functional Ambulation Categories 3–5) and randomly assigned to six weeks of AAN_mDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3–5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (W_EXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2).

Results

Two participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AAN_mDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, W_EXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0–T1) and paretic step length (T0–T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AAN_mDOF robotic group compared to the conventional group (T0–T2).

Conclusions

Generally, AAN_mDOF robotic training was not superior to conventional training for improving gait pattern in subacute stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AAN_mDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing.

Trial registration Registry number Netherlands Trial Register (www.trialregister.nl): NTR5060. Registered 13 February 2015.

Feasibility and Preliminary Efficacy of Gait Training Assisted by Multichannel Functional Electrical Stimulation in Early Stroke Rehabilitation: A Pilot Randomized Controlled Trial

Background. Many stroke survivors suffer from leg muscle paresis, resulting in asymmetrical gait patterns, negatively affecting balance control and energy cost. Interventions targeting asymmetry early after stroke may enhance recovery of walking. Objective. To determine the feasibility and preliminary efficacy of up to 10 weeks of gait training assisted by multichannel functional electrical stimulation (MFES gait training) applied to the peroneal nerve and knee flexor or extensor muscle on the recovery of gait symmetry and walking capacity in patients starting in the subacute phase after stroke. Methods. Forty inpatient participants (≤31 days after stroke) were randomized to MFES gait training (experimental group) or conventional gait training (control group). Gait training was delivered in 30-minute sessions each workday. Feasibility was determined by adherence (≥75% sessions) and satisfaction with gait training (score ≥7 out of 10). Primary outcome for efficacy was step length symmetry. Secondary outcomes included other spatiotemporal gait parameters and walking capacity (Functional Gait Assessment and 10-Meter Walk Test). Linear mixed models estimated treatment effect postintervention and at 3-month follow-up. Results. Thirty-seven participants completed the study protocol (19 experimental group participants). Feasibility was confirmed by good adherence (90% of the participants) and participant satisfaction (median score 8). Both groups improved on all outcomes over time. No significant group differences in recovery were found for any outcome. Conclusions. MFES gait training is feasible early after stroke, but MFES efficacy for improving step length symmetry, other spatiotemporal gait parameters, or walking capacity could not be demonstrated. Trial Registration. Netherlands Trial Register (NTR4762).

IMU-Based Gait Normalcy Index Calculation for Clinical Evaluation of Impaired Gait

Inertial measurement units (IMU) have been used for gait analysis in many clinical studies, as a more convenient, low cost and less restricted alternative to the laboratory-based motion capture systems or instrumented walkways. Spatial-temporal gait parameters such as gait cycle duration and stride length calculated from the IMUs were often used in these studies for evaluating the impaired gait. However, the spatial-temporal information provided by IMUs is limited, and sometime suffers incomplete and less effective evaluation. In this study, we develop a novel IMU-based method for clinical gait evaluation. Nine gait variables including three spatial-temporal parameters and six kinematic parameters are extracted from two shank-mounted IMUs for quantifying patient's gait deviations. Based on those parameters, an IMU-based gait normalcy index (INI) is derived to evaluate the overall gait performance. Eight inpatient subjects with gait impairments caused by n-hexane neuropathy and ten healthy subjects were recruited. The proposed gait variables and INI were examined on the inpatients at three to five time instants during the rehabilitation process until being discharged. A comparison with healthy subjects and statistical analysis for the changes of gait variables and INI demonstrated that the proposed new set of gait variables and INI can provide adequate and effective information for quantifying gait abnormalities, and help understanding the progress of gait and effectiveness of therapy during rehabilitation process.

Intracisternal administration of tanshinone IIA-loaded nanoparticles leads to reduced tissue injury and functional deficits in a porcine model of ischemic stroke

Background

The absolute number of new stroke patients is annually increasing and there still remains only a few Food and Drug Administration (FDA) approved treatments with significant limitations available to patients. Tanshinone IIA (Tan IIA) is a promising potential therapeutic for ischemic stroke that has shown success in pre-clinical rodent studies but lead to inconsistent efficacy results in human patients. The physical properties of Tan-IIA, including short half-life and low solubility, suggests that Poly (lactic-co-glycolic acid) (PLGA) nanoparticle-assisted delivery may lead to improve bioavailability and therapeutic efficacy. The objective of this study was to develop Tan IIA-loaded nanoparticles (Tan IIA-NPs) and to evaluate their therapeutic effects on cerebral pathological changes and consequent motor function deficits in a pig ischemic stroke model.

Results

Tan IIA-NP treated neural stem cells showed a reduction in SOD activity in in vitro assays demonstrating antioxidative effects. Ischemic stroke pigs treated with Tan IIA-NPs showed reduced hemispheric swelling when compared to vehicle only treated pigs (7.85 ± 1.41 vs. 16.83 ± 0.62%), consequent midline shift (MLS) (1.72 ± 0.07 vs. 2.91 ± 0.36 mm), and ischemic lesion volumes (9.54 ± 5.06 vs. 12.01 ± 0.17 cm³) when compared to vehicle-only treated pigs. Treatment also lead to lower reductions in diffusivity (-37.30 ± 3.67 vs. -46.33 ± 0.73%) and white matter integrity (-19.66 ± 5.58 vs. -30.11 ± 1.19%) as well as reduced hemorrhage (0.85 ± 0.15 vs 2.91 ± 0.84 cm³) 24 h post-ischemic stroke. In addition, Tan IIA-NPs led to a reduced percentage of circulating band neutrophils at 12 (7.75 ± 1.93 vs. 14.00 ± 1.73%) and 24 (4.25 ± 0.48 vs 5.75 ± 0.85%) hours post-stroke suggesting a mitigated inflammatory response. Moreover, spatiotemporal gait deficits including cadence, cycle time, step time, swing percent of cycle, stride length, and changes in relative mean pressure were less severe post-stroke in Tan IIA-NP treated pigs relative to control pigs.

Conclusion

The findings of this proof of concept study strongly suggest that administration of Tan IIA-NPs in the acute phase post-stroke mitigates neural injury likely through limiting free radical formation, thus leading to less severe gait deficits in a translational pig ischemic stroke model. With stroke as one of the leading causes of functional disability in the United States, and gait deficits being a major component, these promising results suggest that acute Tan IIA-NP administration may improve functional outcomes and the quality of life of many future stroke patients.

A Subject-Specific Analysis of the Kinematic Constraint Imposed by the Relink Trainer

The relink trainer (RLT) is a novel end-effector device designed for gait-retraining poststroke. The user's foot is constrained to a specific kinematic trajectory relative to the trainer, while the hip and knee are unconstrained. As the RLT only fixes the footplate trajectory, the expected constraint on the hip and knee angles will be subject-specific due to individual lower limb geometries. This study had two objectives (1) to calculate the subject-specific theoretical joint angle trajectories, the RLT should constrain the hip and knee angle to using computer simulation, assuming a fixed hip position relative to the RLT, and (2) experimentally determine the actual hip and knee joint angle trajectories of healthy users walking in the RLT, and compare them to the theoretical joint angle trajectories. The root-mean-square (RMS) error between joint trajectories obtained from motion capture and simulation ranged from 4.31 deg to 20.51 deg for the hip and between 4.48 deg and 22.58 deg for the knee, suggestive of moderate to poor accuracy and distinct kinematic adaptation strategies when using the RLT. A linear fit method (LFM) was used to determine the similarity between the obtained and simulated joint angle trajectories. LFM results would suggest that users' hip and knee joint angles follow the simulated joint angle trajectories when walking in the RLT; however, the actual joint angle trajectories are offset from the simulation trajectories. Post hoc analyses suggest hip motion when using the RLT influences the hip and knee angle trajectory differences for participants.

Estimulação elétrica nervosa transcutânea e crioterapia no tratamento de estudantes com dismenorreia primária: estudo piloto

Objetivo: Comparar os efeitos da Estimulação Elétrica Nervosa Transcutânea (TENS) e da crioterapia no alívio da sintomatologia dolorosa de estudantes com dismenorreia primária (DP). Métodos: Estudo transversal e quantitativo, com 20 mulheres universitárias aleatoriamente divididas em dois grupos: Grupo TENS (GT) cujas participantes foram submetidas a uma sessão de 45 min de TENS com frequência de 120 Hz e duração de pulso de 100 µs e Grupo Crioterapia (GC) cujas participantes foram submetidas a sessão de crioterapia por 20 min. Foram incluídas mulheres com ciclos menstruais regulares, nuligestas, sem relato de doença pélvica e com dismenorreia com nível de dor entre 4 e 10 durante os três primeiros dias de menstruação. Foram excluídas aquelas com contraindicação ao uso da TENS e crioterapia ou que fizeram uso de medicamentos até 24 h antes da intervenção. Foi registrado o nível de dor das participantes antes e logo depois da intervenção. Resultados: Foram avaliadas mulheres com idade variando entre 18 e 27 anos (média 22,8 ± 2,4 anos). Todas apresentaram além dos sintomas dolorosos algum outro sintoma associado, sendo os mais comuns diarreia e fadiga (80%, cada). O teste ANOVA two-way de medidas repetidas considerando como fatores grupo e avaliação, revelou efeito apenas para o fator avaliação (p < 0,001), não apresentando efeito para a interação grupo/avaliação (p = 0,09). Conclusão: TENS e crioterapia são recursos eficientes para o alívio dos sintomas álgicos de mulheres com DP, não havendo superioridade entre as abordagens.

Motor Impairment and Its Influence in Gait Velocity and Asymmetry in Community Ambulating Hemiplegic Individuals

Objectives

To determine the most important motor impairments that are predictors of gait velocity and spatiotemporal symmetrical ratio in patients with stroke.

Design

Cross-sectional, descriptive analysis study.

Setting

Human performance laboratory of the University of Santo Tomas.

Participants

Individuals with chronic stroke (N=55; 34 men, 21 women) who are community dwellers.

Interventions

Not applicable.

Main Outcome Measures

The gait velocity and spatiotemporal symmetrical ratio (step length; step, stance, swing, single-leg support, and double-leg support stance times) was determined using Vicon motion capture. We also calculated motor impairment of the leg and foot using Brunnstrom’s stages of motor recovery, evaluated muscle strength using the scoring system described by Collin and Wade, and assessed spasticity using by the modified Ashworth Scale.

Results

Regression analysis showed that plantarflexor strength is a predictor of gait velocity and all temporospatial symmetry ratio. Knee flexor and extensor strength are predictors in single-leg support time and double-leg support time symmetry ratio, respectively. On the other hand, hip adductor and quadriceps spasticity are predictors of swing time and step length symmetry ratio.

Conclusion

Different motor impairments are predictors of stroke gait abnormality. Interventions should be focused on these motor impairments to allow for optimal gait rehabilitation results.