Gait training after stroke: a critical reprisal

The contributions of balance to gait capacity and motor function in chronic stroke

[Purpose] The aim of this study was to identify the contributions of balance to gait and motor function in chronic stroke. [Subjects and Methods] Twenty-three outpatients participated in a cross-sectional assessment. Gait ability was assessed using the functional ambulation category, self-paced 10-m walking speed, and fastest 10-m walking speed. Standing balance and trunk control measures included the Berg Balance Scale and the Trunk Impairment Scale. Univariate and multivariate regression analyses were performed. [Results] Balance was the best predictor of the FAC, self-paced walking speed, and fastest walking speed, accounting for 57% to 61% of the variances. Additionally, the total score of TIS was the only predictor of the motor function of the lower limbs and the dynamic balance of TIS was a predictor of the motor function of the upper limbs, accounting for 41% and 29% of the variance, respectively. [Conclusion] This study demonstrated the relative contribution of standing balance and trunk balance to gait ability and motor function. They show that balance has a high power of explanation of gait ability and that trunk balance is a determinant of motor function rather than gait ability.

The relationship between motor recovery and gait velocity during dual tasks in patients with chronic stroke

[Purpose] The aims of this study were to identify the relationship between motor recovery and gait velocity during dual tasks in patients with chronic stroke and determine automatic gait ability following stroke. [Subjects and Methods] Thirty-three outpatients and twelve healthy subjects participated in a cross-sectional assessment. Community ambulation was assessed using a self-administered questionnaire. Outcome measures included the Motricity index, Berg Balance Scale, and gait speed under three conditions (self-paced ambulation for 10 m, ambulation while performing dual cognitive tasks, and ambulation while performing dual manual tasks). Gait automaticity was calculated. [Results] No significant differences were observed for muscle strength or balance between the limited community ambulation and the community ambulation groups. However, a significant difference in gait velocity was observed between the groups under the three conditions. In particular, a significant difference was detected only in the limited community ambulation group depending on the level of motor function recovery during cognitive and manual dual task ambulation. Additionally, we revealed that the community ambulation group had a lower level of gait automaticity compared with that in the normal group. [Conclusion] Our results show the influence of motor recovery on the change in gait velocity depending on the task if a patient is limitedly ambulatory. We revealed that community ambulators did not have a sufficient level of gait automaticity.

Varied overground walking-task practice versus body-weight-supported treadmill training in ambulatory adults within one year of stroke: a randomized controlled trial protocol

BACKGROUND

Although task-oriented training has been shown to improve walking outcomes after stroke, it is not yet clear whether one task-oriented approach is superior to another. The purpose of this study is to compare the effectiveness of the Motor Learning Walking Program (MLWP), a varied overground walking task program consistent with key motor learning principles, to body-weight-supported treadmill training (BWSTT) in community-dwelling, ambulatory, adults within 1 year of stroke.

METHODS/DESIGN

A parallel, randomized controlled trial with stratification by baseline gait speed will be conducted. Allocation will be controlled by a central randomization service and participants will be allocated to the two active intervention groups (1:1) using a permuted block randomization process. Seventy participants will be assigned to one of two 15-session training programs. In MLWP, one physiotherapist will supervise practice of various overground walking tasks. Instructions, feedback, and guidance will be provided in a manner that facilitates self-evaluation and problem solving. In BWSTT, training will emphasize repetition of the normal gait cycle while supported over a treadmill, assisted by up to three physiotherapists. Outcomes will be assessed by a blinded assessor at baseline, post-intervention and at 2-month follow-up. The primary outcome will be post-intervention comfortable gait speed. Secondary outcomes include fast gait speed, walking endurance, balance self-efficacy, participation in community mobility, health-related quality of life, and goal attainment. Groups will be compared using analysis of covariance with baseline gait speed strata as the single covariate. Intention-to-treat analysis will be used.

DISCUSSION

In order to direct clinicians, patients, and other health decision-makers, there is a need for a head-to-head comparison of different approaches to active, task-related walking training after stroke. We hypothesize that outcomes will be optimized through the application of a task-related training program that is consistent with key motor learning principles related to practice, guidance and feedback.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT00561405.

Mechanically assisted walking with body weight support results in more independent walking than assisted overground walking in non-ambulatory patients early after stroke: a systematic review

QUESTION

Does mechanically assisted walking with body weight support result in more independent walking and is it detrimental to walking speed or capacity in non-ambulatory patients early after stroke?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Non-ambulatory adult patients undergoing inpatient rehabilitation up to 3 months after stroke.

INTERVENTION

Mechanically assisted walking (eg, treadmill, electromechanical gait trainer, robotic device, servo-motor) with body weight support (eg, harness with or without handrail, but not handrail alone) versus assisted overground walking of longer than 15 min duration.

OUTCOME MEASURES

The primary outcome was the proportion of participants achieving independent walking. Secondary outcomes were walking speed measured as m/s during the 10-m Walk Test and walking capacity measured as distance in m during the 6-min Walk Test.

RESULTS

Six studies comprising 549 participants were identified and included in meta-analyses. Mechanically assisted walking with body weight support resulted in more people walking independently at 4 weeks (RD 0.23, 95% CI 0.15 to 0.30) and at 6 months (RD 0.23, 95% CI 0.07 to 0.39), faster walking at 6 months (MD 0.12 m/s, 95% CI 0.02 to 0.21), and further walking at 6 months (MD 55 m, 95% CI 15 to 96) than assisted overground walking.

CONCLUSION

Mechanically assisted walking with body weight support is more effective than overground walking at increasing independent walking in non-ambulatory patients early after stroke. Furthermore, it is not detrimental to walking speed or capacity and clinicians should therefore be confident about implementing this intervention.

Virtual reality-enhanced partial body weight-supported treadmill training poststroke: feasibility and effectiveness in 6 subjects

Walker ML, Ringleb SI, Maihafer GC, Walker R, Crouch JR, Van Lunen B, Morrison S. Virtual reality-enhanced partial body weight-supported treadmill training poststroke: feasibility and effectiveness in 6 subjects.

OBJECTIVE

To determine whether the use of a low-cost virtual reality (VR) system used in conjunction with partial body weight-supported treadmill training (BWSTT) was feasible and effective in improving the walking and balance abilities of patients poststroke.

DESIGN

A before-after comparison of a single group with BWSTT intervention.

SETTING

University research laboratory.

PARTICIPANTS

A convenience sample of 7 adults who were within 1 year poststroke and who had completed traditional rehabilitation but still exhibited gait deficits. Six participants completed the study.

INTERVENTION

Twelve treatment sessions of BWSTT with VR. The VR system generated a virtual environment that showed on a television screen in front of the treadmill to give participants the sensation of walking down a city street. A head-mounted position sensor provided postural feedback.

MAIN OUTCOME MEASURES

Functional Gait Assessment (FGA) score, Berg Balance Scale (BBS) score, and overground walking speed.

RESULTS

One subject dropped out of the study. All other participants made significant improvements in their ability to walk. FGA scores increased from mean of 13.8 to 18. BBS scores increased from mean of 43.8 to 48.8, although a ceiling effect was seen for this test. Overground walking speed increased from mean of .49m/s to .68m/s.

CONCLUSIONS

A low-cost VR system combined with BWSTT is feasible for improved gait and balance of patients poststroke.

Effects of Training With a Robot-Virtual Reality System Compared With a Robot Alone on the Gait of Individuals After Stroke

Background and Purpose— Training of the lower extremity (LE) using a robot coupled with virtual environments has shown to transfer to improved overground locomotion. The purpose of this study was to determine whether the transfer of training of LE movements to locomotion was greater using a virtual environment coupled with a robot or with the robot alone.

Methods— A single, blind, randomized clinical trial was conducted. Eighteen individuals poststroke participated in a 4-week training protocol. One group trained with the robot virtual reality (VR) system and the other group trained with the robot alone. Outcome measures were temporal features of gait measured in a laboratory setting and the community.

Results— Greater changes in velocity and distance walked were demonstrated for the group trained with the robotic device coupled with the VR than training with the robot alone. Similarly, significantly greater improvements in the distance walked and number of steps taken in the community were measured for the group that trained with robot coupled with the VR. These differences were maintained at 3 months’ follow-up.

Conclusions— The study is the first to demonstrate that LE training of individuals with chronic hemiparesis using a robotic device coupled with VR improved walking ability in the laboratory and the community better than robot training alone.