Walking with rhythmic auditory stimulation in chronic patients after stroke: A pilot randomized controlled trial

Effects of rehabilitation exercise program types on dynamic balance in patients with stroke: a meta-analysis of randomized controlled trials

PURPOSE

The purposes of meta-analysis are to evaluate evidence about the effects of Rehabilitation Exercise Program on the balance of post-stroke patients, evaluated by the Berg Balance Scale (BBS).

METHODS

The search was conducted 'stroke,' 'rehabilitation,' 'dynamic balance,' 'Berg Balance Scale,' 'exercise' and 'randomized controlled trial'using MEDLINE (accessed by PubMed), Web of Science (WoS), ProQuest, and Google Scholar for journal studies published from January 2018 to October 2022. Two independent reviewers performed the article selection, data extraction, and methodological quality assessment. The main outcome was dynamic balance assessed by the Berg Balance scale.

RESULTS

The review included 30 papers and a total of 540 patients. The overall effect size was 0.550, a medium effect size according to the Cohen's standard. It was observed that gender has moderate effect size in male (0.551), female (0.458) and higher in male. Exercise type results showed large effect sizes in balance training (0.966), and aquatic activities (0.830), moderate effect sizes in virtual reality (0.762), moderate effect sizes in physically active (0.581), gait training (0.541), dual-task (0.478), trunk control (0.284), and small effect sizes in resistance training (0.128).

CONCLUSIONS

Exercise programs are effective in improving dynamic balance in stroke patients. Especially, the meta-analysis showed higher Effect Size for balance training and virtual reality than for other programs making this relevant interventions for future head to head superiority studies that compare different balance interventions in stroke.

Challenges in applying minimal clinically important difference: a critical review

Healthcare clinicians strive to make meaningful changes in patient function and participation. A minimal clinically important difference (MCID) is an estimate of the magnitude of change needed to be meaningful to a patient. Clinicians and investigators may assume that a cited MCID is a valid and generalizable estimate of effect. There are, however, at least two concerns about this assumption. First, multiple methods exist for calculating an MCID that can yield divergent values and raise doubt as to which one to apply. Second, MCID values may be erroneously generalized to patients with dissimilar health conditions. With this in mind, we reviewed the methods used to calculate MCID and citations of reported MCID values for outcome measures commonly used in neurologic, orthopedic, and geriatric populations. Our goal was to assess whether the calculation methods were acknowledged in the cited work and whether the enrolled patients were similar to the sample from which the MCID estimate was derived. We found a concerning variation in the methods employed to estimate MCID. We also found a lack of transparency in identifying calculation methods and applicable health conditions in the cited work. Thus, clinicians and researchers must pay close attention and exercise caution in assuming changes in patient status that exceed a specific MCID reflect meaningful improvements in health status. A common standard for the calculation and reporting of an MCID is needed to address threats to the validity of conclusions drawn from the interpretation of an MCID.

The effects of rhythmic auditory stimulation on functional ambulation after stroke: a systematic review

BACKGROUND

Several studies have reported the effect of rhythmic auditory stimulation (RAS) on functional ambulation in stroke patients, yet no systematic overview has yet been published. This study aims to synthesize the available evidence describing changes in stroke patients after RAS intervention for functional ambulation and the use of walking assistive devices, and to find out if the effect of RAS and music-based RAS differs depending on the lesioned area.

METHODS

The PubMed, PEDro, Cochrane Central Register of Controlled Trials, Web of Science, Scopus and CINAHL electronic databases were searched for reports evaluating the effect of RAS on walking in stroke patients, applying the PICOS criteria for the inclusion of studies.

RESULTS

Twenty one articles were included (948 stroke survivors). Most studies were of good methodological quality according to the PEDro scale, but they had a high risk of bias. The most consistent finding was that RAS improves walking and balance parameters in stroke patients in all phases compared to baseline and versus control groups with conventional treatment. Functional ambulation and the use of walking assistive devices were inconsistently reported. Several studies also suggest that RAS may be as good as other complementary therapies (horse-riding and visual cueing).

CONCLUSIONS

Despite the beneficial effects of RAS, the question remains as to whether it is better than other complementary therapies. Given the heterogeneity of the interventions, the interventions in control groups, the varied durations, and the different outcome measures, we suggest that care should be taken in interpreting and generalizing findings.

PROSPERO REGISTRATION

CRD42021277940.

Validating the Safe and Effective Use of a Neurorehabilitation System (InTandem) to Improve Walking in the Chronic Stroke Population: Usability Study

BACKGROUND

Persistent walking impairment following a stroke is common. Although rehabilitative interventions exist, few exist for use at home in the chronic phase of stroke recovery. InTandem (MedRhythms, Inc) is a neurorehabilitation system intended to improve walking and community ambulation in adults with chronic stroke walking impairment.

OBJECTIVE

Using design best practices and human factors engineering principles, the research presented here was conducted to validate the safe and effective use of InTandem.

METHODS

In total, 15 participants in the chronic phase of stroke recovery (≥6 months after stroke) participated in this validation study. Participants were scored on 8 simulated use tasks, 4 knowledge assessments, and 7 comprehension assessments in a simulated home environment. The number and types of use errors, close calls, and operational difficulties were evaluated. Analyses of task performances, participant behaviors, and follow-up interviews were conducted to determine the root cause of use errors and difficulties.

RESULTS

During this validation study, 93% (14/15) of participants were able to successfully complete the critical tasks associated with the simulated use of the InTandem system. Following simulated use task assessments, participants' knowledge and comprehension of the instructions for use and key safety information were evaluated. Overall, participants were able to find and correctly interpret information in the materials in order to answer the knowledge assessment questions. During the comprehension assessment, participants understood warning statements associated with critical tasks presented in the instructions for use. Across the entire study, 3 "use errors" and 1 "success with difficulty" were recorded. No adverse events, including slips, trips, or falls, occurred in this study.

CONCLUSIONS

In this validation study, people in the chronic phase of stroke recovery were able to safely and effectively use InTandem in the intended use environment. This validation study contributes to the overall understanding of residual use-related risks of InTandem in consideration of the established benefits.

Effects of Therapeutic Intervention on Spatiotemporal Gait Parameters in Adults With Neurologic Disorder: Systematic Review and Meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to review and quantify the changes in gait parameters after therapeutic intervention in adults with neurologic disorders.

DATA SOURCES

A keyword search was performed in 4 databases: PubMed, CINAHL, Scopus, and Web of Science (01/2000-12/2021). We performed the search algorithm including all possible combinations of keywords. Full-text articles were examined further using forward/backward search methods.

STUDY SELECTION

Studies were thoroughly screened using the following inclusion criteria: Study design: randomized controlled trial; adults ≥55 years old with a neurologic disorder; therapeutic intervention; spatiotemporal gait characteristics; and language: English.

DATA EXTRACTION

A standardized data extraction form was used to collect the following methodological outcome variables from each of the included studies: author, year, population, age, sample size, and spatiotemporal gait parameters such as cadence, step length, step width, or double limb support. A meta-analysis was performed among trials presenting with similar characteristics, including study population and outcome measure. If heterogeneity was >50%, a random plot analysis was used; otherwise, a fixed plot analysis was done.

DATA SYNTHESIS

We included 25 out of 34 studies in our meta-analysis that examined gait in adults with neurologic disorders. All analyses used effect sizes and standard error and a P<.05(denoted by *) threshold was considered statistically significant. Overall, we found that sensory (SS) and electrical stimulation (ES) had the most significant effect on step length (SS: z=5.44*, ES: z=2.42*) and gait speed (SS: z=6.19*, ES: z=7.38*) in adults with Parkinson disease (PD). Although balance or physical activity interventions were not found to be effective in modifying step length in adults with PD, they showed a significant effect on gait speed. Further, physical activity had the most significant effect on cadence in adults with PD (z=2.84*) relative to sensory stimulation effect on cadence (z=2.59*). For stroke, conventional physical therapy had the most significant effect on step length (z=3.12*) and cadence (z=3.57*).

CONCLUSION

Sensory stimulation such as auditory and somatosensory stimulation while walking had the most significant effect on step length in adults with PD. We also found that conventional physical therapy did improve spatial gait parameters relative to other physical activity interventions in adults with PD and stroke.

Exercise dosage to facilitate the recovery of balance, walking, and quality of life after stroke

Background

Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting.

Objectives

Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors.

Method

PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs).

Results

Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings.

Conclusion

Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL.

Clinical implications

A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity.

Effect of Treadmill Training with Visual Biofeedback on Selected Gait Parameters in Subacute Hemiparetic Stroke Patients

BACKGROUND

Functional limitations after a stroke are unique to each person and often include impaired independent mobility. A reduction in existing gait deficits after a stroke is often one of the main goals of rehabilitation. Gait re-education after stroke is a complex process, which consists of the effects of many therapeutic interventions.

OBJECTIVE

The study aimed to analyze the effects of using a treadmill with visual feedback in gait re-education in the sub-acute stroke period and assess the impact of biofeedback treadmill training on selected gait parameters, improving static balance and reducing the need for orthopedic aids.

METHODS

The study included 92 patients (F: 45, M: 47) aged 63 ± 12 years, with post-ischemic sub-acute (within six months onset) stroke hemiparesis, treated at a neurological rehabilitation ward. All patients participated in a specific rehabilitation program, and in addition, patients in the study group (n = 62) have a further 10 min of treadmill training with visual feedback. Patients in the control group (n = 30) participated in additional conventional gait training under the direct supervision of a physiotherapist. The evaluation of static balance was assessed with the Romberg Test. A Biodex Gait Trainer 3 treadmill with biofeedback function was used to evaluate selected gait parameters (walking speed, step length, % limb loading, and traveled distance). The use of an orthopedic aid (walker or a crutch) was noted.

RESULTS

After four weeks of rehabilitation, step length, walking speed, traveled distance, and static balance were significantly improved for the study and control group (p < 0.05). Treadmill gait training yielded significantly better results than a conventional rehabilitation program. Only the study group observed a corrected walking base (p < 0.001). All participants showed a reduction in the use of walking aids (p = 0.006). There was no asymmetry in the % of limb loading for either group prior to or following rehabilitation.

CONCLUSIONS

The treadmill with visual biofeedback as conventional gait training has resulted in a significant improvement in parameters such as step length, walking speed, static balance, and a reduction in the use of locomotion aids. However, the achieved improvement in gait parameters is still not in line with the physiological norm.

Effects of rhythmic auditory stimulation on motor function and balance ability in stroke: A systematic review and meta-analysis of clinical randomized controlled studies

OBJECTIVE

Rhythmic auditory stimulation (RAS) belongs to neurologic music therapy, which has attracted clinical attention because of its efficacy in motor function after stroke. This study aimed to summarize the effectiveness of rhythmic auditory stimulation (RAS) for the treatment of motor function and balance ability in stroke through a systematic review and meta-analysis.

METHODS

All studies were retrieved from six databases. The effects of RAS on stroke were determined using the following indicators: motor function including step length, step cadence, velocity, Fugl-Meyer assessment (FMA); and balance ability including overall balance index (OBI) and Berg Balance Scale (BBS). The risk map of bias of the quality of the studies and the meta-analysis results of the indicators was prepared using RevMan 5.2 software.

RESULTS

A total of 1,363 abstracts were retrieved. Among them, 325 duplicate studies were eliminated, and 971 studies were excluded after reading the titles and abstracts. In addition, by downloading the full text for further reading and screening, 47 studies were excluded. A total of 22 studies were included in the systematic review, and 18 studies were included in the meta-analysis. Assessment of quality, based on the PEDro scale, two studies had low quality, three studies had excellent quality, and the other studies had good quality; based on the Cochrane Collaborative Network Bias Risk Assessment Scale. A total of 15 studies specifically explained the random methods used. Meanwhile, seven studies did not report random sequence generation. A total of 10 studies reported that the evaluation of experimental results was blinded. In the meta-analysis, the results of motor function [namely, velocity (SMD = 0.99, 95% CI (0.43, 1.55)), step length (SMD = 0.97, 95% CI (0.74, 1.20)), and step cadence (MD = 5.16, 95% CI (4.17, 6.14)), FMA (MD = 2.93, 95% CI (2.04, 3.83))], were statistically significant (P < 0.01). The results of balance ability [OBI (MD = -0.51, 95% CI (-0.86, -0.16)) and BBS (MD = 2.93, 95% CI (1.67, 4.20))], were also statistically significant (P < 0.01). Among all the outcome indicators, three indicators were included in more than 10 studies: these are step length, step cadence, and velocity. The results showed that the two sides of the funnel chart were asymmetrical, thus these results all showed heterogeneity. The GRADEpro GDT online tool was used to evaluate the quality of evidence for the outcome indicators in the included studies. Five outcome indicators were included, of which three were low-quality indicators and two were moderate-quality indicators.

CONCLUSIONS

RAS could improve gait parameters, walking function, and balance ability of individuals with stroke. However, studies or samples of outcome indicators for balance ability of stroke patients is relatively insufficient, which also requires further research in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier: CRD42021225102.

Improvement of Gait in Patients with Stroke Using Rhythmic Sensory Stimulation: A Case-Control Study

Patients with stroke suffer from impaired locomotion, exhibiting unstable walking with increased gait variability. Effects of rhythmic sensory stimulation on unstable gait of patients with chronic stroke are unclear. This study aims to determine the effects of rhythmic sensory stimulation on the gait of patients with chronic stroke. Twenty older adults with stroke and twenty age- and gender-matched healthy controls walked 60 m under four conditions: normal walking with no stimulation, walking with rhythmic auditory stimulation (RAS) through an earphone in the ear, walking with rhythmic somatosensory stimulation (RSS) through a haptic device on the wrist of each participant, and walking with rhythmic combined stimulation (RCS: RAS + RSS). Gait performance in the stroke group significantly improved during walking with RAS, RSS, and RCS compared to that during normal walking (p < 0.008). Gait variability significantly decreased under the RAS, RSS, and RCS conditions compared to that during normal walking (p < 0.008). Rhythmic sensory stimulation is effective in improving the gait of patients with chronic stroke, regardless of the type of rhythmic stimuli, compared to healthy controls. The effect was greater in patients with reduced mobility, assessed by the Rivermead Mobility Index (RMI).

Neurologic Music Therapy via Telehealth: A Survey of Clinician Experiences, Trends, and Recommendations During the COVID-19 Pandemic

This cross-sectional survey investigated the transition of Neurologic Music Therapy (NMT) services from in-person (pre-COVID-19) to telehealth (since COVID-19) to (1) determine whether the use of an NMT paradigm contributes to the successful transition of therapy services to telehealth, (2) identify which NMT domains and techniques are transferable from in-person to telehealth, (3) identify whether there are differences in the transition of NMT services across different employment settings, and (4) evaluate the potential benefits and challenges of telehealth NMT. An online survey comprised of 49 closed and open-ended questions was distributed by the Academy of Neurologic Music Therapy to 2,778 NMT affiliates worldwide. The survey sought information on demographics, telehealth perceptions, technology, assessment, clinical practice, safety, and caregiver involvement. Quantitative and qualitative analyses were applied. Eighty-one participants answered the survey and the 69 who completed the survey in its entirety were included in the analysis. Results indicated that the frequency of NMT technique usage had no impact on the overall number of clinical hours retained over telehealth. Correlation analysis revealed an association between more frequent NMT usage and perceived likelihood of using telehealth in the future (i.e., once COVID-19 is no longer a major threat), as well as with fewer group sessions lost over telehealth. All NMT domains transferred to telehealth, although within the sensorimotor domain, fewer therapists implemented rhythmic auditory stimulation for telehealth sessions compared to in-person. Overall, NMTs had fewer hours for telehealth compared to in-person regardless of employment setting. Technological challenges were notable drawbacks, while major benefits included the ability to continue providing NMT when in-person sessions were not possible, increased accessibility for remote clients, and positive outcomes related to increased caregiver involvement. Based on the results, our recommendations for implementing telehealth in Neurologic Music Therapy include integrating telehealth into routine care, mitigating safety concerns, identifying those who could benefit most from remote delivery, involving caregivers, and developing/sharing resources for telehealth NMT.