Physical Therapy During Stroke Rehabilitation for People With Different Walking Abilities

Stroke rehabilitation: from diagnosis to therapy

Stroke remains a significant global health burden, necessitating comprehensive and innovative approaches in rehabilitation to optimize recovery outcomes. This paper provides a thorough exploration of rehabilitation strategies in stroke management, focusing on diagnostic methods, acute management, and diverse modalities encompassing physical, occupational, speech, and cognitive therapies. Emphasizing the importance of early identification of rehabilitation needs and leveraging technological advancements, including neurostimulation techniques and assistive technologies, this manuscript highlights the challenges and opportunities in stroke rehabilitation. Additionally, it discusses future directions, such as personalized rehabilitation approaches, neuroplasticity concepts, and advancements in assistive technologies, which hold promise in reshaping the landscape of stroke rehabilitation. By delineating these multifaceted aspects, this manuscript aims to provide insights and directions for optimizing stroke rehabilitation practices and enhancing the quality of life for stroke survivors.

Implementation of a unilateral hip flexion exosuit to aid paretic limb advancement during inpatient gait retraining for individuals post-stroke: a feasibility study

BACKGROUND

During inpatient rehabilitation, physical therapists (PTs) often need to manually advance patients' limbs, adding physical burden to PTs and impacting gait retraining quality. Different electromechanical devices alleviate this burden by assisting a patient's limb advancement and supporting their body weight. However, they are less ideal for neuromuscular engagement when patients no longer need body weight support but continue to require assistance with limb advancement as they recover. The objective of this study was to determine the feasibility of using a hip flexion exosuit to aid paretic limb advancement during inpatient rehabilitation post-stroke.

METHODS

Fourteen individuals post-stroke received three to seven 1-hour walking sessions with the exosuit over one to two weeks in addition to standard care of inpatient rehabilitation. The exosuit assistance was either triggered by PTs or based on gait events detected by body-worn sensors. We evaluated clinical (distance, speed) and spatiotemporal (cadence, stride length, swing time symmetry) gait measures with and without exosuit assistance during 2-minute and 10-meter walk tests. Sessions were grouped by the assistance required from the PTs (limb advancement and balance support, balance support only, or none) without exosuit assistance.

RESULTS

PTs successfully operated the exosuit in 97% of sessions, of which 70% assistance timing was PT-triggered to accommodate atypical gait. Exosuit assistance eliminated the need for manual limb advancement from PTs. In sessions with participants requiring limb advancement and balance support, the average distance and cadence during 2-minute walk test increased with exosuit assistance by 2.2 ± 3.1 m and 3.4 ± 1.9 steps/min, respectively (p < 0.017). In sessions with participants requiring balance support only, the average speed during 10-meter walk test increased with exosuit by 0.07 ± 0.12 m/s (p = 0.042). Clinical and spatiotemporal measures of independent ambulators were similar with and without exosuit (p > 0.339).

CONCLUSIONS

We incorporated a unilateral hip flexion exosuit into inpatient stroke rehabilitation in individuals with varying levels of impairments. The exosuit assistance removed the burden of manual limb advancement from the PTs and resulted in improved gait measures in some conditions. Future work will understand how to optimize controller and assistance profiles for this population.

Effects of robot-assisted gait training using the Welwalk on gait independence for individuals with hemiparetic stroke: an assessor-blinded, multicenter randomized controlled trial

BACKGROUND

Gait disorder remains a major challenge for individuals with stroke, affecting their quality of life and increasing the risk of secondary complications. Robot-assisted gait training (RAGT) has emerged as a promising approach for improving gait independence in individuals with stroke. This study aimed to evaluate the effect of RAGT in individuals with subacute hemiparetic stroke using a one-leg assisted gait robot called Welwalk WW-1000.

METHODS

An assessor-blinded, multicenter randomized controlled trial was conducted in the convalescent rehabilitation wards of eight hospitals in Japan. Participants with first-ever hemiparetic stroke who could not walk at pre-intervention assessment were randomized to either the Welwalk group, which underwent RAGT with conventional physical therapy, or the control group, which underwent conventional physical therapy alone. Both groups received 80 min of physical therapy per day, 7 days per week, while the Welwalk group received 40 min of RAGT per day, 6 days per week, as part of their physical therapy. The primary outcome was gait independence, as assessed using the Functional Independence Measure Walk Score.

RESULTS

A total of 91 participants were enrolled, 85 of whom completed the intervention. As a result, 91 participants, as a full analysis set, and 85, as a per-protocol set, were analyzed. The primary outcome, the cumulative incidence of gait-independent events, was not significantly different between the groups. Subgroup analysis revealed that the interaction between the intervention group and stroke type did not yield significant differences in either the full analysis or per-protocol set. However, although not statistically significant, a discernible trend toward improvement with Welwalk was observed in cases of cerebral infarction for the full analysis and per-protocol sets (HR 4.167 [95%CI 0.914-18.995], p = 0.065, HR 4.443 [95%CI 0.973-20.279], p = 0.054, respectively).

CONCLUSIONS

The combination of RAGT using Welwalk and conventional physical therapy was not significantly more effective than conventional physical therapy alone in promoting gait independence in individuals with subacute hemiparetic stroke, although a trend toward earlier gait independence was observed in individuals with cerebral infarction.

TRIAL REGISTRATION

This study was registered with the Japan Registry of Clinical Trials ( https://jrct.niph.go.jp ; jRCT 042180078) on March 3, 2019.

Towards meaningful community ambulation in individuals post stroke through use of a smart hip exoskeleton: A preliminary investigation

Stroke is the leading cause of long-term disability in the United States, leaving survivors with profound mobility challenges that impact independent community ambulation. Evidence shows assistance at the hip during walking may be beneficial for stroke survivors. In this cross-over design study, we examine the impact of a novel hip exoskeleton on both functional and patient reported outcomes measuring speed, fall risk, gait symmetry, energy expenditure and perceived walking ability during both indoors and outdoors in single and serial counting dual task paradigms. Nine ambulatory stroke survivors with hemiplegia were included. No differences were seen between the exoskeleton and baseline conditions for any outcomes. Only the patient reported outcome in which subjects were asked to rate their ability to walk outdoors approached statistical significance (p = 0.051) with greater improvement reported for the exoskeleton condition. When asked to rate several key factors about the exoskeleton, weight and assistance emerged as primary perceived negative factors of the exoskeleton underscoring the need for improvements to the technology in this area. Despite lack of differences across groups, some individuals responded positively to the exoskeleton for several functional outcomes measured, highlighting the need for additional exploration into the use of personalized hip exoskeletons for post-stroke rehabilitation.

Lower limb vertical stiffness and frontal plane angular impulse during perturbation-induced single limb stance and their associations with gait in individuals post-stroke

After stroke, deficits in paretic single limb stance (SLS) are commonly observed and affect walking performance. During SLS, the hip abductor musculature is critical in providing vertical support and regulating balance. Although disrupted paretic hip abduction torque production has been identified in individuals post-stroke, interpretation of previous results is limited due to the discrepancies in weight-bearing conditions. Using a novel perturbation-based assessment that could induce SLS by removing the support surface underneath one limb, we aim to investigate whether deficits in hip abduction torque production, vertical body support, and balance regulation remain detectable during SLS when controlling for weight-bearing, and whether these measures are associated with gait performance. Our results showed that during the perturbation-induced SLS, individuals post-stroke had lower hip abduction torque, less vertical stiffness, and increased frontal plane angular impulse at the paretic limb compared to the non-paretic limb, while no differences were found between the paretic limb and healthy controls. In addition, vertical stiffness during perturbation-induced SLS was positively correlated with single support duration during gait at the paretic limb and predicted self-selected and fast walking speeds in individuals post-stroke. The findings indicate that reduced paretic hip abduction torque during SLS likely affects vertical support and balance control. Enhancing SLS hip abduction torque production could be an important rehabilitation target to improve walking function for individuals post-stroke.

Physiotherapy practices in acute and sub-acute stroke in a low resource country: A prospective observational study in Benin

BACKGROUND AND OBJECTIVE

Physiotherapy is highly recommended for early recovery from stroke. This study aimed to document physiotherapy practices for people with acute and early sub-acute stroke in Benin.

METHODS

In this prospective observational study, physiotherapists working with acute stroke people documented the content of their treatment from six hospitals in Benin during the first session, at 2-week, and 1-month post-stroke with a standardized physiotherapy documentation form. We used the motricity index (MI) and trunk control test (TCT) to assess impairments, and the 10-meter walk test (10mWT), functional independence measure (FIM), walking, stair climbing, and dressing upper body subscales were used for activity limitations.

RESULTS

Fifteen physiotherapists (60 % male, mean±SD age=31.3±5.8 years) recorded treatment sessions for 77 stroke participants (53.2 % male, mean±SD age=57.7±12.5 years). Physiotherapists focused on conventional physiotherapy approaches, including musculoskeletal (67 % of pre-functional activity time) and neuromuscular (53 % of sitting activity time) interventions. A significant difference was found between the therapy time delivered for people with mild, moderate, and severe stroke (p < 0.001). The MI (p= 0.033) and TCT (p= 0.002) measures showed significant improvement at 2-week and 1-month (p< 0.001) post-stroke, while 10mWT, FIM walking, stair climbing, and dressing upper body items significantly increased at 1-month (p< 0.001) but not at 2-week post-stroke.

CONCLUSION

Physiotherapists working with acute stroke patients in Benin mainly use conventional neuromuscular and musculoskeletal interventions. In contrast, aerobic exercises were rarely employed regardless of stroke severity. Furthermore, our findings showed that the volume of physiotherapy sessions varied by stroke severity.

Lower Limb Vertical Stiffness and Frontal Plane Angular Impulse during Perturbation-Induced Single Limb Stance and Their Associations with Gait in Individuals Post-Stroke

Background

After stroke, deficits in paretic single limb stance (SLS) are commonly observed and affect walking performance. During SLS, the hip abductor musculature is critical in providing vertical support and regulating balance. Although disrupted paretic hip abduction torque production has been identified in individuals post-stroke, interpretation of previous results is limited due to the discrepancies in weight-bearing conditions.

Objective

To investigate whether deficits in hip abduction torque production, vertical body support, and balance regulation remain during SLS when controlling for weight-bearing using a perturbation-based assessment, and whether these measures are associated with gait performance.

Methods

We compared hip abduction torque, vertical stiffness, and frontal plane angular impulse between individuals post-stroke and healthy controls when SLS was induced by removing the support surface underneath one limb. We also tested for correlations between vertical stiffness and angular impulse during perturbation-induced SLS and gait parameters during overground walking.

Results

During the perturbation-induced SLS, lower hip abduction torque, less vertical stiffness, and increased frontal plane angular impulse were observed at the paretic limb compared to the non-paretic limb, while no differences were found between the paretic limb and healthy controls. Vertical stiffness during perturbation-induced SLS was positively correlated with single support duration during gait at the paretic limb and predicted self-selected and fast walking speeds in individuals post-stroke.

Conclusions

Reduced paretic hip abduction torque during SLS likely affects vertical support and balance control. Enhancing SLS hip abduction torque production could be an important rehabilitation target to improve walking function for individuals post-stroke.

Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review

Background

Use of standardized tools to assess balance and mobility limitations is a recommended practice in stroke rehabilitation. The extent to which clinical practice guidelines (CPGs) for stroke rehabilitation recommend specific tools and provide resources to support their implementation is unknown.

Purpose

To identify and describe standardized, performance-based tools for assessing balance and/or mobility and describe postural control components challenged, the approach used to select tools, and resources provided for clinical implementation, in CPGs for stroke.

Methods

A scoping review was conducted. We included CPGs with recommendations on the delivery of stroke rehabilitation to address balance and mobility limitations. We searched seven electronic databases and grey literature. Pairs of reviewers reviewed abstracts and full texts in duplicate. We abstracted data about CPGs, standardized assessment tools, the approach for tool selection, and resources. Experts identified postural control components challenged by each tool.

Results

Of the 19 CPGs included in the review, 7 (37%) and 12 (63%) were from middle- and high-income countries, respectively. Ten CPGs (53%) recommended or suggested 27 unique tools. Across 10 CPGs, the most commonly cited tools were the Berg Balance Scale (BBS) (90%), 6-Minute Walk Test (6MWT) (80%), Timed Up and Go Test (80%) and 10-Meter Walk Test (70%). The tool most frequently cited in middle- and high-income countries was the BBS (3/3 CPGs), and 6MWT (7/7 CPGs), respectively. Across 27 tools, the three components of postural control most frequently challenged were underlying motor systems (100%), anticipatory postural control (96%), and dynamic stability (85%). Five CPGs provided information in varying detail on how tools were selected; only 1 CPG provided a level of recommendation. Seven CPGs provided resources to support clinical implementation; one CPG from a middle-income country included a resource available in a CPG from a high-income country.

Conclusion

CPGs for stroke rehabilitation do not consistently provide recommendations for standardized tools to assess balance and mobility or resources to facilitate clinical application. Reporting of processes for tool selection and recommendation is inadequate. Review findings can be used to inform global efforts to develop and translate recommendations and resources for using standardized tools to assess balance and mobility post-stroke.

Systematic Review Registration

https://osf.io/, identifier: 10.17605/OSF.IO/6RBDV.

Referrals from Healthcare Professionals to Community-Based Exercise Programs Targeting People with Balance and Mobility Limitations: An Interviewer-Administered Survey

Purpose:

To describe program representatives’ perceptions of the: (1) type and work setting of healthcare professionals who refer to community-based exercise programs with healthcare-community partnerships (CBEP-HCPs) by community size; (2) nature, frequency, and utility of strategies used to promote referral from healthcare professionals to CBEP-HCPs; and (3) facilitators and barriers to CBEP-HCP promotion.

Method:

We invited individuals involved with the Together in Movement and Exercise (TIME™) program in 48 centres to participate in a cross-sectional survey. TIME™ is a group, task-oriented CBEP-HCP taught by fitness instructors; healthcare partners promote referrals. Data were summarized using frequencies and percentages. Content analysis was used for open-ended questions.

Results:

Twenty-three representatives of 27 TIME™ programs (56% response rate) participated. Out of 26 healthcare partners identified, 69% were physical therapists. We report the most common findings: programs received referrals from physical therapists ( n = 16, 70%); programs gave healthcare partners promotional materials (e.g., flyers) to facilitate referrals ( n = 17, 63%); strong relationships with healthcare partners facilitated promotion ( n = 18, 78%); and representatives perceived their lack of credibility challenged promotion ( n = 3, 23%).

Conclusions:

Physical therapists were the most common referral source. Healthcare partners were instrumental in program promotion. Future research is needed to leverage referrals from physical therapists in settings other than hospitals and to better understand the role of healthcare partners in CBEP-HCPs.

Relationship between daily rehabilitation time and functional gain in inpatient rehabilitation medicine of hospitalized older adults with subacute stroke

Igarashi T, Hayashi S, Ogawa K, Matsui S, Nishimatsu T. Relationship between daily rehabilitation time and functional gain in inpatient rehabilitation medicine of hospitalized older adults with subacute stroke. Jpn J Compr Rehabil Sci 2022; 13: 56-63.

Objective

Although there have been reports examining the relationship between daily rehabilitation time and functional gain, few have fully considered background factors such as severity of motor paralysis and comorbidities. This study aimed to examine the relationship between the daily rehabilitation time and improvement in functional status, longitudinally in hospitalized older adults with subacute stroke.

Method

From the results of the Functional Independence Measure (FIM), we calculated the FIM gain and FIM effectiveness, a measure that is less sensitive to the ceiling effect of FIM. Adjusted for covariates, multiple regression analysis was performed for daily rehabilitation time and FIM gain and effectiveness.

Results

This study enrolled 298 hospitalized older adults with subacute stroke (mean age, 78.1 ± 8.1 years, 112 females). The total scores of functional independence measure gain and effectiveness were 31.6 ± 22.5 points and 54.4 ± 35.2%, respectively. There was an association between FIM gain (total score) and total rehabilitation time (β = 0.29, p < 0.01) and between FIM effectiveness (total score) and total rehabilitation time (β = 0.22, p < 0.01).

Conclusions

Although prognosis after stroke is poorer in older adults than in young adults, this study shows that increased daily rehabilitation time may improve functional status.

A novel gait analysis system for detecting abnormal hemiparetic gait patterns during robot-assisted gait training: A criterion validity study among healthy adults

INTRODUCTION

Robot-assisted gait training has been reported to improve gait in individuals with hemiparetic stroke. Ideally, the gait training program should be customized based on individuals' gait characteristics and longitudinal changes. However, a gait robot that uses gait characteristics to provide individually tailored gait training has not been proposed. The new gait training robot, "Welwalk WW-2000," permits modification of various parameters, such as time and load of mechanical assistance for a patient's paralyzed leg. The robot is equipped with sensors and a markerless motion capture system to detect abnormal hemiparetic gait patterns during robot-assisted gait training. Thus, it can provide individually tailored gait training. This study aimed to investigate the criterion validity of the gait analysis system in the Welwalk WW-2000 in healthy adults.

MATERIALS AND METHODS

Twelve healthy participants simulated nine abnormal gait patterns that were often manifested in individuals with hemiparetic stroke while wearing the robot. Each participant was instructed to perform a total of 36 gait trials, with four levels of severity for each abnormal gait pattern. Fifteen strides for each gait trial were recorded using the markerless motion capture system in the Welwalk WW-2000 and a marker-based three-dimensional (3D) motion analysis system. The abnormal gait pattern index was then calculated for each stride from both systems. The correlation of the index values between the two methods was evaluated using Spearman's rank correlation coefficients for each gait pattern in each participant.

RESULTS

Using the participants' index values for each abnormal gait pattern obtained using the two motion analysis methods, the median Spearman's rank correlation coefficients ranged from 0.68 to 0.93, which corresponded to moderate to very high correlation.

CONCLUSION

The gait analysis system in the Welwalk WW-2000 for real-time detection of abnormal gait patterns during robot-assisted gait training was suggested to be a valid method for assessing gait characteristics in individuals with hemiparetic stroke.

CLINICAL TRIAL REGISTRATION

[https://jrct.niph.go.jp], identifier [jRCT 042190109].

Community-based exercise programs incorporating healthcare-community partnerships to improve function post-stroke: feasibility of a 2-group randomized controlled trial

Background

Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke.

Methods

We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function.

Results

Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1–2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health.

Conclusion

The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial.

Trial registration

ClinicalTrials.gov, NCT03122626. Registered April 21, 2017 — retrospectively registered.

Quantifying the amount of physical rehabilitation received by individuals living with neurological conditions in the community: a scoping review

Background

Physical rehabilitation is often prescribed immediately following a neurological event or a neurological diagnosis. However, many individuals require physical rehabilitation after hospital discharge. The purpose of this scoping review was to determine the amount of physical rehabilitation that individuals living in the community with neurological conditions receive to understand current global practices and assess gaps in research and service use.

Methods

This scoping review included observational studies that 1) involved adults living with a neurological condition, and 2) quantified the amount of rehabilitation being received in the community or outpatient hospital setting. Only literature published in English was considered. MEDLINE, EMBASE, AMED, CINAHL, Cochrane Library, and PEDro databases were searched from inception. Two independent reviewers screened titles and abstracts, followed by full texts, and data extraction. Mean annual hours of rehabilitation was estimated based on the amount of rehabilitation reported in the included studies.

Results

Overall, 18 studies were included after screen 14,698 articles. The estimated mean annual hours of rehabilitation varied greatly (4.9 to 155.1 h), with individuals with spinal cord injury and stroke receiving the greatest number of hours. Participants typically received more physical therapy than occupational therapy (difference range: 1 to 22 h/year). Lastly, only one study included individuals with progressive neurological conditions, highlighting a research gap.

Discussion

The amount of rehabilitation received by individuals with neurological conditions living in the community varies greatly. With such a wide range of time spent in rehabilitation, it is likely that the amount of rehabilitation being received by most individuals in the community is insufficient to improve function and quality of life. Future work should identify the barriers to accessing rehabilitation resources in the community and how much rehabilitation is needed to observe functional improvements.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07754-4.

Effect of Treadmill Training Interventions on Spatiotemporal Gait Parameters in Older Adults with Neurological Disorders: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective: Treadmill interventions have been shown to promote ‘normal’ walking patterns, as they facilitate the proper movement and timing of the lower limbs. However, prior reviews have not examined which intervention provides the most effective treatment of specific gait impairments in neurological populations. The objective of this systematic review was to review and quantify the changes in gait after treadmill interventions in adults with neurological disorders. Data Sources: A keyword search was performed in four databases: PubMed, CINAHL, Scopus, and Web of Science (January 2000−December 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 (RCT); adults ≥55 years old with a neurological disorder; treadmill 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 including stride length, stride time, step length, step width, step time, stance time, swing time, single support time, double support time, or cadence. Data Synthesis: We found a total of 32 studies to be included in our systematic review through keyword search, out of which 19 studies included adults with stroke and 13 studies included adults with PD. We included 22 out of 32 studies in our meta-analysis that examined gait in adults with neurological disorders, which only yielded studies including Parkinson’s disease (PD) and stroke patients. A meta-analysis was performed among trials presenting with similar characteristics, including study population and outcome measure. If heterogeneity was >50% (denoted by I2), random plot analysis was used, otherwise, a fixed plot analysis was performed. All analyses used effect sizes and standard errors and a p < 0.05 threshold was considered statistically significant (denoted by *). Overall, the effect of treadmill intervention on cadence (z = 6.24 *, I2 = 11.5%) and step length (z = 2.25 *, I2 = 74.3%) in adults with stroke was significant. We also found a significant effect of treadmill intervention on paretic step length (z = 2.34 *, I2 = 0%) and stride length (z = 6.09 *, I2 = 45.5%). For the active control group, including adults with PD, we found that overground physical therapy training had the largest effect on step width (z = −3.75 *, I2 = 0%). Additionally, for PD adults in treadmill intervention studies, we found the largest significant effect was on step length (z = 2.73 *, I2 = 74.2%) and stride length (z = −2.54 *, I2 = 96.8%). Conclusion: Treadmill intervention with sensory stimulation and body weight support treadmill training were shown to have the largest effect on step length in adults with PD and stroke.

The Relationship Between Strength of the Affected Leg and Walking Speed After Stroke Varies According to the Level of Walking Disability: A Systematic Review

OBJECTIVE

The objectives of this review were to determine the relationship between muscle strength of the affected leg and walking speed after stroke and whether this relationship varied according to muscle group or level of walking disability.

METHODS

This systematic review with meta-analysis focused on observational studies of adult survivors of stroke. Muscle strength had to be measured as maximum voluntary force production during an isometric contraction of the affected leg. Walking had to be measured as walking speed. Studies had to report correlations between muscle strength and walking speed.

RESULTS

Thirty studies involving 1001 participants were included. Pooled mean correlations between muscle strength of the affected leg and walking speed was 0.51 (95% CI = 0.45 to 0.57). Pooled correlations between the strength of individual muscle groups and walking speed ranged from 0.42 (for the hip abductors) to 0.57 (for the ankle dorsiflexors). The correlation between level of walking disability and the mean correlation between muscle strength and walking speed was -0.70 (95% CI = -0.42 to -0.86).

CONCLUSION

After stroke, there is a strong relationship between strength of the affected leg and walking speed, with little variability across individual muscle groups. However, the level of walking disability of people with stroke does make a difference such that the more disabled people are, the stronger the relationship is between strength of the affected leg and walking speed.

IMPACT

This study suggests that the strength of all muscles of the affected leg is important for walking after stroke. It appears that increasing strength in the affected leg could be most important in people who are more disabled.

LAY SUMMARY

After stroke, the speed at which a person can walk is highly associated with the muscle strength of their affected leg. In people whose walking speed is severely affected, this association is stronger, and the physical therapist might focus on strengthening that leg so the individual can walk faster.

Post-stroke gait training practices in a low resource setting: a cross-sectional survey among Indian physiotherapists

BACKGROUND

Independent mobility is the most important determinant of quality of life after stroke and it is vital that training aimed at restoration of gait is based on contemporary evidence. Despite several practice guidelines for gait rehabilitation after stroke existing globally, their feasibility of application in low-resource settings is often questionable.

OBJECTIVE

To investigate the current practices in gait training among Indian physiotherapists involved in the rehabilitation of stroke survivors.

METHODS

A questionnaire on the various aspects of gait training was developed and the content was validated by experts. The survey was made available online and distributed among Indian physiotherapists working in the field of stroke rehabilitation, using snowball sampling. Frequency distribution was used to summarize responses to each component of the questionnaire.

RESULTS

Responses were obtained from 250 practicing physiotherapists. The majority of the respondents (55%) reported that they initiate gait training within seven days after stroke. Gait training sessions ranged from 15-30 minutes (55%), once every day (44%), and the majority (89%) reported use of subjective outcome measures to evaluate gait. Although most respondents agreed on the use of assistive aids, 24% indicated that their use may deter gait, rather than improve it. Nearly 86% of the respondents reported that they do not follow standard guidelines pertaining to gait rehabilitation for stroke survivors.

CONCLUSION

The findings of the study point toward a lack of evidence-based practice among Indian physiotherapists while training gait after stroke. This implied the urgent need for development and implementation of country specific guidelines for stroke rehabilitation.

The rehabilitation of physical function after severely disabling stroke: a survey of UK therapist practice

Background/aims

Individuals who are severely disabled from stroke (survivors of severely disabling stroke) experience poorer outcomes compared to those who are less disabled from stroke. However, there is a paucity of evidence describing current therapy practice in the management of severely disabling stroke. The aim of the study was to describe intervention and outcome measure use by physiotherapists and occupational therapists in the rehabilitation of physical function of survivors of severely disabling stroke.

Methods

A mixed-methods survey was conducted, involving an online questionnaire and follow-up interviews. Survey participants were UK-based physiotherapists and occupational therapists with experience treating stroke. Questionnaire data were analysed with descriptive and inferential statistics. Interview data were analysed using content analysis.

Results

A total of 452 therapists (59% physiotherapists) responded to the questionnaire. Out of the respondents, 18 self-selected therapists participated in follow-up interviews to explain questionnaire data. Whole body positioning, training of upper limb handling and positioning, and sitting balance practice were the most frequently used interventions. Inpatient-based therapists performed more active rehabilitation interventions, whereas community-based therapists performed more training and education. The Barthel Index, Modified Rankin Scale and National Institutes for Health Stroke Scale were the most frequently used outcome measures. Outcome measure use was generally low and was more likely to be completed when it was part of a national audit. Reasons for low outcome measure use were perceived lack of time and insensitivity to detect clinical change.

Conclusions

A variety of interventions and outcome measures are used in the rehabilitation of survivors of severely disabling stroke. There is a need to evaluate the effectiveness of frequently used interventions and identify outcome measures that are sensitive to the needs of survivors of severely disabling stroke.

Perceptions of an over-ground induced temporal gait asymmetry by healthy young adults

Nearly 60% of individuals with stroke walk with temporal gait asymmetry (TGA; a phase inequality between the legs during gait). About half of individuals with TGA are unable to correctly identify the presence or direction of their asymmetry. If patients are unable to perceive their gait errors, it will be harder to correct them to improve their gait pattern. Perception of gait pattern error may be affected by the stroke itself; therefore, the objectives of this study were to determine how the gait of neurotypical individuals changes with an induced temporal asymmetry, and how perception of that TGA compares to actual asymmetry both before and after 15-min of exposure to the induced asymmetry. After baseline symmetry (measured as symmetry index (SI)) was assessed with a pressure sensitive mat, participants (n = 29) walked for 15 min over-ground with cuff weights (7.5% of body weight) on their non-dominant leg to induce TGA. Presence, direction, and magnitude of TGA was measured at five time points: 1) baseline, 2) immediately after unilateral loading (early adaptation (EA)), 3) at the end of 15 min of walking (late adaptation (LA)), 4) immediately after load removal (early deadaptation (EDA)), and 5) after the participant indicated that their gait had returned to baseline symmetry (late deadaptation (LDA). Presence, direction, and magnitude of perceived TGA was measured by self-report. Measured and perceived TGA changes over time were assessed with separate one-way repeated measures analyses of variance. Agreement between measured and perceived TGA was assessed. During EA, all participants walked asymmetrically, spending more time on the non-loaded limb compared to baseline (-12.67 [95%CI -14.56, -10.78], p < 0.0001). All but one participant perceived this TGA, however only fifteen (52%) correctly perceived both TGA presence and direction. At LA, the group remained asymmetric (-9.22 [95%CI -11.32, -7.12], p < 0.0001), but only 9 participants (31%) correctly perceived both the presence and direction of their TGA. Visual inspection of the data at each time point revealed most participants perceived TGA magnitude as greater than actual TGA. Overall, we find that TGA can be induced and maintained in neurotypical young adults. Perception of TGA direction is inaccurate and perception of TGA magnitude is grossly overestimated. Perceptions of TGA do not improve after a period of exposure to the new walking pattern. These preliminary findings indicate that accurately perceiving an altered gait pattern is a difficult task even for healthy young adults.

Implicit and Explicit Motor Learning Interventions Have Similar Effects on Walking Speed in People After Stroke: A Randomized Controlled Trial

OBJECTIVE

Clinicians may use implicit or explicit motor learning approaches to facilitate motor learning of patients with stroke. Implicit motor learning approaches have shown promising results in healthy populations. The purpose of this study was to assess whether an implicit motor learning walking intervention is more effective compared with an explicit motor learning walking intervention delivered at home regarding walking speed in people after stroke in the chronic phase of recovery.

METHODS

This randomized, controlled, single-blind trial was conducted in the home environment. The 79 participants, who were in the chronic phase after stroke (age = 66.4 [SD = 11.0] years; time poststroke = 70.1 [SD = 64.3] months; walking speed = 0.7 [SD = 0.3] m/s; Berg Balance Scale score = 44.5 [SD = 9.5]), were randomly assigned to an implicit (n = 38) or explicit (n = 41) group. Analogy learning was used as the implicit motor learning walking intervention, whereas the explicit motor learning walking intervention consisted of detailed verbal instructions. Both groups received 9 training sessions (30 minutes each), for a period of 3 weeks, targeted at improving quality of walking. The primary outcome was walking speed measured by the 10-Meter Walk Test at a comfortable walking pace. Outcomes were assessed at baseline, immediately after intervention, and 1 month postintervention.

RESULTS

No statistically or clinically relevant differences between groups were obtained postintervention (between-group difference was estimated at 0.02 m/s [95% CI = -0.04 to 0.08] and at follow-up (between-group difference estimated at -0.02 m/s [95% CI = -0.09 to 0.05]).

CONCLUSION

Implicit motor learning was not superior to explicit motor learning to improve walking speed in people after stroke in the chronic phase of recovery.

IMPACT

To our knowledge, this is the first study to examine the effects of implicit compared with explicit motor learning on a functional task in people after stroke. Results indicate that physical therapists can use (tailored) implicit and explicit motor learning strategies to improve walking speed in people after stroke who are in the chronic phase of recovery.

The Actuation System of the Ankle Exoskeleton T-FLEX: First Use Experimental Validation in People with Stroke

Robotic devices can provide physical assistance to people who have suffered neurological impairments such as stroke. Neurological disorders related to this condition induce abnormal gait patterns, which impede the independence to execute different Activities of Daily Living (ADLs). From the fundamental role of the ankle in walking, Powered Ankle-Foot Orthoses (PAFOs) have been developed to enhance the users’ gait patterns, and hence their quality of life. Ten patients who suffered a stroke used the actuation system of the T-FLEX exoskeleton triggered by an inertial sensor on the foot tip. The VICONmotion capture system recorded the users’ kinematics for unassisted and assisted gait modalities. Biomechanical analysis and usability assessment measured the performance of the system actuation for the participants in overground walking. The biomechanical assessment exhibited changes in the lower joints’ range of motion for 70% of the subjects. Moreover, the ankle kinematics showed a correlation with the variation of other movements analyzed. This variation had positive effects on 70% of the participants in at least one joint. The Gait Deviation Index (GDI) presented significant changes for 30% of the paretic limbs and 40% of the non-paretic, where the tendency was to decrease. The spatiotemporal parameters did not show significant variations between modalities, although users’ cadence had a decrease of 70% of the volunteers. Lastly, the satisfaction with the device was positive, the comfort being the most user-selected aspect. This article presents the assessment of the T-FLEX actuation system in people who suffered a stroke. Biomechanical results show improvement in the ankle kinematics and variations in the other joints. In general terms, GDI does not exhibit significant increases, and the Movement Analysis Profile (MAP) registers alterations for the assisted gait with the device. Future works should focus on assessing the full T-FLEX orthosis in a larger sample of patients, including a stage of training.

Predictors of Daily Steps at 1-Year Poststroke: A Secondary Analysis of a Randomized Controlled Trial

[Figure: see text].

Gait training interventions for patients with stroke in India: A systematic review

BACKGROUND

Gait is considered to be the most important determinant of functional independence in activities of daily living. The challenges faced by stroke survivors in India differ from the western population due to economic, cultural, and geographical factors and this, in turn, may influence the choice of intervention. Hence, there is a need to understand the current gait training trends for stroke survivors in low resource settings like India.

RESEARCH QUESTION

To systematically review the literature on interventional strategies for improving gait among stroke survivors in India.

METHODS

Six databases were searched to identify RCTs delivering gait training to stroke survivors having some gait deficits in terms of speed or any other kinematic parameters. Studies of the English language from India were included. Two independent reviewers screened, extracted data, and assessed the study quality. A descriptive synthesis was undertaken and the data was summarized.

RESULTS

Of 2112 potentially relevant articles, 12 studies with a total of 412 participants were included after title, abstract and full-text screening. Studies tested the efficacy of interventions such as mirror therapy, motor imagery, transcutaneous electrical nerve stimulation, strengthening, and task-based training. The outcome measures were kinematic gait-analysis, gait velocity, Functional Ambulation Categories, Timed Up and Go, Fugl-Meyer Assessment. From the results of this review, active task-based gait training and strengthening along with motor priming seems to be the most tested interventions. Future studies may need to design interventions targeting both impairment and function to bring about maximum improvement in gait after stroke.

SIGNIFICANCE

Reviews addressing gait practices in developing countries for people with stroke are scarce. The present review would assist physiotherapists in developing countries to utilize evidence-based criteria for the selection of gait training approaches post-stroke. Due to the environmental and contextual demands, the effect of interventions for recovery among stroke survivors should be improvised in low resource settings. This review can be a source of recommendation in giving effective strategies for clinical practice.

Validity and Reliability of The 3-Meter Backward Walk Test in Individuals with Stroke

OBJECTIVES

The 3-m backward walk test (3MBWT) is used to evaluate neuromuscular control, proprioception, protective reflexes, fall risk and balance. The aim of our study was to reveal the test-retest reliability and validity of the 3MBWT in stroke patients.

MATERIALS AND METHODS

This study included a total of 41 stroke patients [age 59 (35-78) years]. 3MBWT, Berg Balance Scale (BBS), Timed Up and Go test (TUG) were applied to the patients. The second evaluation (retest) was carried out by the same physiotherapist two days following the first evaluation (test) in order to measure test-retest reliability.

RESULTS

Cronbach's alpha coefficient was found to be 0.974 (excellent). For intra-rater agreement, the ICC values in the individual test were 0.985. The SEM value was 1.11 sec, the MDC value was found to be 1.57 sec. A moderate correlation was revealed between the 3 m-backward walking speed and BBS (r: -0.691, p: 0.001) and TUG (r: 0.849, p: 0.001).

CONCLUSIONS

The 3MBWT was observed to be valid and reliable in stroke individuals. It is an effecive and reliable tool for measuring dynamic balance and falls in stroke.

Evaluating a novel MR-compatible foot pedal device for unipedal and bipedal motion: Test-retest reliability of evoked brain activity

The purpose of this study was to develop and evaluate a new, open‐source MR‐compatible device capable of assessing unipedal and bipedal lower extremity movement with minimal head motion and high test–retest reliability. To evaluate the prototype, 20 healthy adults participated in two magnetic resonance imaging (MRI) visits, separated by 2–6 months, in which they performed a visually guided dorsiflexion/plantar flexion task with their left foot, right foot, and alternating feet. Dependent measures included: evoked blood oxygen level‐dependent (BOLD) signal in the motor network, head movement associated with dorsiflexion/plantar flexion, the test–retest reliability of these measurements. Left and right unipedal movement led to a significant increase in BOLD signal compared to rest in the medial portion of the right and left primary motor cortex (respectively), and the ipsilateral cerebellum (FWE corrected, p < .001). Average head motion was 0.10 ± 0.02 mm. The test–retest reliability was high for the functional MRI data (intraclass correlation coefficients [ICCs]: >0.75) and the angular displacement of the ankle joint (ICC: 0.842). This bipedal device can robustly isolate activity in the motor network during alternating plantarflexion and dorsiflexion with minimal head movement, while providing high test–retest reliability. Ultimately, these data and open‐source building instructions will provide a new, economical tool for investigators interested in evaluating brain function resulting from lower extremity movement.

Video Game-Based Therapy on Balance and Gait of Patients with Stroke: A Systematic Review

Background: Stroke patients with motor, sensory and cognitive diseases can take profits from information and communication technologies—in particular, from the latest commercial video consoles, which are based on motion capture. These technologies are positioning themselves as complementary therapeutic tools for treating gait and balance disorders. In this paper, a systematic review of the effect of video game-based therapy on balance and gait in stroke patients is shown and compared with other types of treatments. Methods: A systematic review of prospective controlled clinical trials published in the main biomedical databases in English and Spanish between 2005 and 2020 was performed. The systematic review presented in this paper has been done following the Cochrane Manual recommendations and the PRISMA Declaration by two independent reviewers. Data about participants, intervention, outcome measurements and outcome measurement results were extracted. The quality of evidence of each study was assessed using Cochrane’s standard quality assessment format, which includes a description of the risk of bias. Additionally, the Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of each paper. Results: A total of 18 papers, including 479 patients, were included in this systematic review, in which the use of video consoles (in combination with conventional rehabilitation or exclusively) was compared with conventional rehabilitation to treat balance or gait in post-stroke patients. In all studies, a tendency to improve balance was found in both intervention groups, finding, in 10 of 17 studies that analysed it, a better capacity in the experimental group that included video consoles compared to the conventional rehabilitation control group. Regarding gait, in six of seven studies that analysed it, improvements were found in both intervention groups, and these improvements were greater in the experimental group than compared to the control group in three of them. Conclusions: Commercial video game systems, in combination with conventional rehabilitation, have shown positive results on balance and gait in post-stroke patients. There were variations between the trials in terms of the video consoles used and the duration, frequency and number of sessions with commercial video games. Future studies should compare the effects of commercial video game treatments on balance and gait in stroke patients with a nonintervention group to know their real efficacy.

Does the Environment Cause Changes in Hemiparetic Lower Limb Muscle Activity and Gait Velocity During Walking in Stroke Survivors?

Stroke survivors often face difficulty in community ambulation though they attain steady-state walking in clinical setups. Compliance and unpredictability of the environment may alter the muscle activity and challenge the individual's gait. Successful reintegration into the community requires gait assessment and training in a real-life challenging environment. Little is known about the assessment and training of gait in the community environment under challenging mobility dimensions. Hence, we aimed to study the changes that real-life environmental dimensions have on the activity of selected muscles in hemiparetic lower limb and gait velocity in stroke survivors.

METHODS

An observational cross-sectional study was conducted on 16 ambulatory stroke survivors to assess the hemiparetic lower limb muscle activity during walking in real-life environmental dimensions. Participants were made to walk in the community on a walkway consisting of even surface, ramp, stairs, uneven terrain and obstacles. They were also made to manoeuvre through traffic and pick a load while walking for a distance in the walkway. Muscle activity of Rectus Femoris, Biceps Femoris, Gastrocnemius Medialis and Tibialis Anterior of the paretic lower limb were continuously recorded while walking using wireless surface electromyography. Gait velocity for the entire walkway and level of perceived difficulty while walking in different dimensions were also measured. Paired t-test was used to compare the percentage Maximum Voluntary Contraction (%MVC) of lower limb muscles between even surface and real-life environment dimensions while walking. One sample t-test was used to compare the gait velocity in real-life dimensions versus gait velocity in even surface measured in an earlier study.

RESULTS

There was a significant reduction (p < 0.01) in the activity of all four hemiparetic lower limb muscles while walking under the influence of real-life environmental dimensions compared to even surface. Gait velocity (0.33 ± 0.17 m/s) was significantly lower than that is essential to be a community ambulator. The level of perceived difficulty across all dimensions was reported qualitatively with the highest difficulty reported during stair and obstacle clearance.

CONCLUSION

Real-life environmental dimensions lead to the reduction of paretic lower limb muscle activities and gait velocity during walking in community-dwelling stroke survivors. Stroke survivors perceived more difficulty while walking in real-life environment dimensions particularly while negotiating stairs and obstacles.

SIGNIFICANCE

Knowledge about the influence of real-life environmental dimensions will help the clinicians to target rehabilitation methods to improve walking adaptability.

The effect of additional neuromuscular electrical stimulation applied to erector spinae muscles on functional capacity, balance and mobility in post-stroke patients

OBJECTIVE

The aim of this study was to investigate the effects of neuromuscular electric stimulation applied to the erector spinae on balance, motor function and functional capacity in patients with stroke in a randomized controlled trial.

METHODS

Sixty patients with stroke were recruited and randomly distributed into two groups: control group and neuromuscular electric stimulation group. All participants underwent conventional physical therapy five times a week for six weeks. The neuromuscular electric stimulation group received additional electrical stimulation. Outcome measures were evaluated with Brunnel Balance Assessment, Stroke Rehabilitation Movement Assessment, Functional Ambulation Classification, Adapted Patient Evaluation and Conference System, Postural Assesment Scale for Stroke patients, Short Form-36, and Minimental State Examination scales.

RESULTS

Significant differences were observed in all scores at the end of the study in both groups. Postural Assesment Scale for Stroke patients and Stroke Rehabilitation Movement Assessment scores were higher in the neuromuscular electric stimulation group compared to the control group (p < 0.05). All the other scores were not statistically significant.

CONCLUSION

It is recommended to evaluate and treat trunk muscle, which is usually neglected in treatment, and to consider the combination of conventional treatment and neuromuscular electric stimulation when designing an ideal rehabilitation program.

Lower limb muscle activity underlying temporal gait asymmetry post-stroke

OBJECTIVE

Asymmetric walking after stroke is common, detrimental, and difficult to treat, but current knowledge of underlying physiological mechanisms is limited. This study investigated electromyographic (EMG) features of temporal gait asymmetry (TGA).

METHODS

Participants post-stroke with or without TGA and control adults (n = 27, 8, and 9, respectively) performed self-paced overground gait trials. EMG, force plate, and motion capture data were collected. Lower limb muscle activity was compared across groups and sides (more/less affected).

RESULTS

Significant group by side interaction effects were found: more affected plantarflexor stance activity ended early (p = .0006) and less affected dorsiflexor on/off time was delayed (p < .01) in persons with asymmetry compared to symmetric and normative controls. The TGA group exhibited fewer dorsiflexor bursts during swing (p = .0009).

CONCLUSIONS

Temporal patterns of muscular activation, particularly about the ankle around the stance-to-swing transition period, are associated with TGA. The results may reflect specific impairments or compensations that affect locomotor coordination.

SIGNIFICANCE

Neuromuscular underpinnings of spatiotemporal asymmetry have not been previously characterized. These novel findings may inform targeted therapeutic strategies to improve gait quality after stroke.

The effects of different attentional focus on poststroke gait

Attention may influence the motor performance of poststroke patients. The attentional focus implies “where” attention is focused while performing a specific movement. Focusing attention on the inside of the body while performing a specific exercise is called an internal focus (IF) and focus on the external environment is called an external focus (EF). This study examined the effect of attention on the gait of patients with chronic stroke. Sixteen subjects voluntarily participated in the study. The subjects were guided to walk while maintaining the required attentional focus, which is control, IF, and EF condition. Dependent variables were as follows: step length, stride length, step width, 10-m walk time, and weight distribution on the paretic limb. The results are as follows. First, the step length and the stride length were observed to be longer in the EF condition. Second, 10-m walk time was faster in EF condition. Third, under the EF condition, more weight was applied to the paretic limb. We suggest that EF instruction useful to improve the poststroke gait.

A Systematic Review of Paired Associative Stimulation (PAS) to Modulate Lower Limb Corticomotor Excitability: Implications for Stimulation Parameter Selection and Experimental Design

Non-invasive neuromodulatory interventions have the potential to influence neural plasticity and augment motor rehabilitation in people with stroke. Paired associative stimulation (PAS) involves the repeated pairing of single pulses of electrical stimulation to a peripheral nerve and single pulses of transcranial magnetic stimulation over the contralateral primary motor cortex. Efficacy of PAS in the lower limb of healthy and stroke populations has not been systematically appraised. Optimal protocols including stimulation parameter settings have yet to be determined. This systematic review (a) examines the efficacy of PAS on lower limb corticomotor excitability in healthy and stroke populations and (b) evaluates the stimulation parameters employed. Five databases were searched for randomized, non-randomized, and pre-post experimental studies evaluating lower limb PAS in healthy and stroke populations. Two independent reviewers identified eligible studies and assessed methodological quality using a modified Downs and Blacks Tool and the TMS Checklist. Intervention stimulation parameters and TMS measurement details were also extracted and compared. Twelve articles, comprising 24 experiments, met the inclusion criteria. Four articles evaluated PAS in people with stroke. Following a single session of PAS, 21 experiments reported modulation of corticomotor excitability, lasting up to 60 min; however, the research lacked methodological rigor. Intervention stimulation parameters were highly variable across experiments, and whilst these appeared to influence efficacy, variations in the intervention and outcome assessment methods hindered the ability to draw conclusions about optimal parameters. Lower limb PAS research requires further investigation before considering its translation into clinical practice. Eight key recommendations serve as guide for enhancing future research in the field.

Daytime physical activity at admission is associated with improvement of gait independence 1 month later in people with subacute stroke: a longitudinal study

Background: Little is known about the benefits of daytime physical activity on gait ability in subacute stroke.Objectives: We investigated association between daytime physical activity at hospital admission and improvement of gait independence 1 month later in subacute stroke.Methods: Thirty-four participants with subacute stroke who could not walk independently were assessed. An accelerometer (HJA 350-IT, OMRON) was used to record the mean duration of light-intensity physical activity (LIPA) and moderate-to-vigorous-intensity physical activity (MVPA). LIPA and MVPA were recorded for 12 h per day for 7 consecutive days, and at three different time periods (daytime, therapy time, non-therapy time) at rehabilitation hospital admission (baseline). Gait independence was assessed by the functional ambulation category (FAC) at baseline and 1 month later. Participants were categorized into two groups based on the change of gait independence, as follows: the improved group, in which the FAC increased by ≥1; the non-improved group, in which the FAC did not increase.Results: Compared with the non-improved group, the improved group demonstrated significantly higher values of all physical activity variables, except for non-therapy time MVPA (p < .05). Logistic regression analysis showed that higher daytime LIPA was significantly associated with FAC improvement (OR = 1.068, 95% CI 1.009 to 1.140). In particular, higher non-therapy time LIPA was closely associated with FAC improvement (OR = 1.253, 95% CI 1.002 to 1.568).Conclusions: To promote recovery of gait independence in first month from admission, increasing daytime physical activity, especially LIPA during daytime or non-therapy time, is an important treatment target in subacute stroke.

Assessment of backward walking unmasks mobility impairments in post-stroke community ambulators

Background: While over half of stroke survivors recover the ability to walk without assistance, deficits persist in the performance of walking adaptations necessary for safe home and community mobility. One such adaptation is the ability to walk or step backward. Post-stroke rehabilitation rarely includes backward walking (BW) assessment and BW deficits have not been quantified in post-stroke community ambulators. Objective: To quantify spatiotemporal and kinematic BW characteristics in post-stroke community ambulators and compare their performance to controls. Methods: Individuals post-stroke (n = 15, 60.1 ± 12.9 years, forward speed: 1.13 ± 0.23 m/s) and healthy adults (n = 12, 61.2 ± 16.2 years, forward speed: 1.40 ± 0.13 m/s) performed forward walking (FW) and BW during a single session. Step characteristics and peak lower extremity joint angles were extracted using 3D motion analysis and analyzed with mixed-method ANOVAs (group, walking condition). Results: The stroke group demonstrated greater reductions in speed, step length and cadence and a greater increase in double-support time during BW compared to FW (p < .01). Compared to FW, the post-stroke group demonstrated greater reductions in hip extension and knee flexion during BW (p < .05). The control group demonstrated decreased plantarflexion and increased dorsiflexion during BW, but these increases were attenuated in the post-stroke group (p < .05). Conclusions: Assessment of BW can unmask post-stroke walking impairments not detected during typical FW. BW impairments may contribute to the mobility difficulties reported by adults post-stroke. Therefore, BW should be assessed when determining readiness for home and community ambulation.

The Effectiveness of Driving Game on Trunk Control and Gait Ability in Stroke

Patients who require neurological rehabilitation often do not comply with conventional programs because they find the therapy uninteresting. As a result, specialized interactive video games have been designed to be more enjoyable than conventional therapy (CT) tasks. This study aimed to assess the trunk control and gait ability of patients with chronic stroke after participation in driving-based interactive video games (DBIVG). Participants included 24 chronic stroke patients allocated to an experimental group (n = 13, CT + DBIVG) or a control group (n = 11, CT + treadmill walking training). Both groups received CT five days/week; the experimental and control groups participated in DBIVG and treadmill walking training, respectively, three days/week for four weeks. The primary outcome of trunk control was measured by the trunk impairment scale (TISall) and TIS subscales, including static sitting balance (TISssb), dynamic sitting balance (TISdsb), and trunk co-ordination (TISco). Gait ability was measured by the dynamic gait index (DGI), timed walking test (TWT), and time up and go test (TUGT). Both groups demonstrated significant improvements in TISall, TISdsb, and TUGT results. The experimental group showed significantly greater improvement in TISssb, TISco, and DGI than the control group. Our findings indicate that DBIVG can improve trunk control and gait ability in patients with chronic stroke.

Side does not matter in healthy young and older individuals - Examining the importance of how we match limbs during gait studies

BACKGROUND

Various methods exist when comparing gait data between groups and include the analysis of a single limb, or taking an average of both limbs. Evidence exists suggesting that both limbs are not symmetrical, so statistical differences may exist in biomechanical variables when comparing gait with different limb-matching methods.

RESEARCH QUESTION

Does limb-matching method have an effect on statistical outcome when comparing biomechanical variables during a gait task?

METHODS

This retrospective study compared forty participants separated into a younger and older group as they completed a gait task. Twenty-five commonly used biomechanical variables were compared between the two groups using four different limb-matching methods: (i) average of both limbs; (ii) dominant limb; (iii) non-dominant limb; (iv) random limb. A mixed linear model was used to compare all the biomechanical variables between the younger and older group using the different limb-matching methods.

RESULTS

Limb-matching methods only had a significant effect for 1/25 variables examined. Group effects between the younger and older groups were more prevalent, with the most significant effects occurring at the ankle joint.

SIGNIFICANCE

Limb-matching methods do not have a direct effect on biomechanical outcomes when comparing gait in healthy young and old groups. Gait is cyclical, so limb symmetry is often assumed. However, if the complexity of the task increases, or when comparing against groups with impaired gait, both limbs may behave differently, so limb-matching method may become more crucial.

Physiological Responses and Perceived Exertion During Robot-Assisted and Body Weight-Supported Gait After Stroke

INTRODUCTION

Physiological responses are rarely considered during walking after stroke and if considered, only during a short period (3-6 minutes). The aims of this study were to examine physiological responses during 30-minute robot-assisted and body weight-supported treadmill and overground walking and compare intensities with exercise guidelines.

METHODS

A total of 14 ambulatory stroke survivors (age: 61 ± 9 years; time after stroke: 2.8 ± 2.8 months) participated in 3 separate randomized walking trials. Patients walked overground, on a treadmill, and in the Lokomat (60% robotic guidance) for 30 minutes at matched speeds (2.0 ± 0.5 km/h) and matched levels of body weight support (BWS; 41% ± 16%). Breath-by-breath gas analysis, heart rate, and perceived exertion were assessed continuously.

RESULTS

Net oxygen consumption, net carbon dioxide production, net heart rate, and net minute ventilation were about half as high during robot-assisted gait as during body weight-supported treadmill and overground walking ( P < .05). Net minute ventilation, net breathing frequency, and net perceived exertion significantly increased between 6 and 30 minutes (respectively, 1.8 L/min, 2 breaths/min, and 3.8 units). During Lokomat walking, exercise intensity was significantly below exercise recommendations; during body weight-supported overground and treadmill walking, minimum thresholds were reached (except for percentage of heart rate reserve during treadmill walking).

CONCLUSION

In ambulatory stroke survivors, the oxygen and cardiorespiratory demand during robot-assisted gait at constant workload are considerably lower than during overground and treadmill walking at matched speeds and levels of body weight support. Future studies should examine how robotic devices can be Future studies should examine how robotic devices can be exploited to induce aerobic exercise.

The difficulty of studying race-ethnic stroke rehabilitation disparities in a community

OBJECTIVE

Minority populations have worse stroke outcomes compared with non-Hispanic whites (NHWs). One possible explanation for this disparity is differential allocation of stroke rehabilitation. We utilized a population-based stroke study to determine the feasibility of studying Mexican American-NHW differences in stroke rehabilitation in a population-based design including identification of community partners, development of standardized data collection instruments, and collection of pilot data.

METHODS

As part of the Brain Attack Surveillance in Corpus Christi project, we followed 48 patients for the first 90 days after stroke, and attempted to work with community partners to garner information on rehabilitation modalities used. With input from local occupational and physical therapists and speech language pathologists, we created data collection forms to capture rehabilitation activities and time spent on these activities and conducted a 3-month data collection pilot.

RESULTS

Of the 79 rehabilitation venues in the community, 63 (80%) agreed to participate. During the pilot, 545 data forms from 20 stroke patients were collected corresponding to ~18% of stroke patients. Forms were used by 13 partners during the pilot including 3 of 4 inpatient rehabilitation facilities, 4 of 13 skilled nursing facilities, 4 of 26 home health agencies, and 2 of 36 outpatient rehabilitation providers.

CONCLUSIONS

Initial agreement from rehabilitation providers to participate in research was excellent, but completion of study related data collection forms was sub-optimal suggesting this approach is not feasible for a future population-based stroke rehabilitation study. Further methods to study post-stroke rehabilitation disparities in communities are needed.

The effect of haptic interaction between balance assessment robot and pelvis on muscle activation of leg muscles

Admittance control is considered as a promising paradigm in rehabilitation that provides us with means to establish well controlled and adjustable interaction and cooperation between rehabilitation devices and patients. Recently we developed balance assessment robot (BAR) for studying postural responses during walking as well as for pelvis manipulation during walking that implements admittance control as a mean of interaction with user. In this study we evaluated the characteristics of transparent haptic interaction and investigated whether transparent haptic interaction induces adaptations in muscle activation patterns with respect to free walking. In one neurologically intact individual we measured interaction forces, ground reaction forces and center of pressure as well as EMG of selected leg muscles while walking free and while walking with BAR. Results show that the amplitude of interaction forces in transparent mode of operation remained below levels that could have imposed considerable adjustments in muscle activation patterns of leg muscles.

Dance for the rehabilitation of balance and gait in adults with neurological conditions other than Parkinson's disease: A systematic review

PURPOSE

To conduct a systematic review that examined the effect of dance interventions on balance, gait and functional mobility outcomes in adults with neurological conditions other than Parkinson's disease.

METHODS

A systematic search of relevant databases was conducted. Data extraction and methodological appraisal were performed by two independent authors.

RESULTS

Nine studies were included (4 pre-post studies with no control group, 3 case reports, and 2 controlled studies) and results of the methodological quality assessment ranged from poor to good. Study groups included stroke, multiple sclerosis, spinal cord injury, and Huntington's disease. Dance interventions varied in frequency, type and duration, and only 1 study reported intensity. Study dropout rates ranged from 20-44%, and 88-100% of dance classes were attended. Only 3 studies mentioned adverse events, of which there were none. A summary of results revealed significant changes in spatiotemporal gait parameters, Berg Balance Scale scores, Timed Up and Go test and six-minute walk test that were similar to or greater than those previously reported in a review of dance for individuals with Parkinson's disease.

CONCLUSIONS

There is emerging evidence to support the use of dance as a feasible intervention for adults with neurological conditions. Further investigation of the effects of dance with randomized controlled trials using larger sample sizes and better reporting of the intervention, participant tolerance, and adverse events is warranted.

Stroke

Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.

Walking on uneven terrain in healthy adults and the implications for people after stroke

BACKGROUND

One third of individuals after stroke report an inability to walk in the community. Community mobility requires walking adaptability - the ability to adjust one's stepping pattern to meet environmental demands and task goals. Walking on uneven terrain (e.g. grass, gravel) has unique requirements and is a critical component of walking adaptability that has not been investigated in the post-stroke population.

OBJECTIVE

To summarize current knowledge of biomechanical and neuromuscular modifications during uneven terrain negotiation in healthy individuals and discuss implications of post-stroke impairments.

METHODS

Review of eleven studies, identified through a search of relevant literature on PubMed and CINAHL.

RESULTS

On uneven terrain, healthy adults demonstrate numerous gait modifications including a lowered center of mass, increased muscle co-contraction during stance and exaggerated or increased toe clearance during swing. After stroke, changes in muscle activity and limb coordination will likely result in difficulty or inability performing these modifications that healthy adults use to maintain stability and safety when walking on uneven terrain.

CONCLUSIONS

Studies of biomechanical and neuromuscular control of walking on uneven terrain are needed to quantify mobility limitations in adults post-stroke. Such investigations will contribute to the understanding of mobility impairments after stroke and the design of critically important intervention strategies.

The comparison of stepping responses following perturbations applied to pelvis during overground and treadmill walking

BACKGROUND

Treadmills are used frequently in rehabilitation enabling neurologically impaired subjects to train walking while being assisted by therapists. Numerous studies compared walking on treadmill and overground for unperturbed but not also perturbed conditions.

OBJECTIVE

The objective of this study was to compare stepping responses (step length, step width and step time) during overground and treadmill walking in a group of healthy subjects where balance assessment robots applied perturbing pushes to the subject's pelvis in sagittal and frontal planes.

METHODS

During walking in both balance assessment robots (overground and treadmill-based) with applied perturbations the stepping responses of a group of seven healthy subjects were assessed with a motion tracking camera.

RESULTS

The results show high degree of similarity of stepping responses between overground and treadmill walking for all perturbation directions. Both devices reproduced similar experimental conditions with relatively small standard deviations in the unperturbed walking as well as in perturbed walking.

CONCLUSIONS

Based on these results we may conclude that stepping responses following perturbations can be studied on an instrumented treadmill where ground reaction forces can be readily assessed which is not the case during perturbed overground walking.

Detecting voluntary gait intention of chronic stroke patients towards top-down gait rehabilitation using EEG

One of the recent trends in gait rehabilitation is to incorporate bio-signals, such as electromyography (EMG) or electroencephalography (EEG), for facilitating neuroplasticity, i.e. top-down approach. In this study, we investigated decoding stroke patients' gait intention through a wireless EEG system. To overcome patient-specific EEG patterns due to impaired cerebral cortices, common spatial patterns (CSP) was employed. We demonstrated that CSP filter can be used to maximize the EEG signal variance-ratio of gait and standing conditions. Finally, linear discriminant analysis (LDA) classification was conducted, whereby the average accuracy of 73.2% and the average delay of 0.13 s were achieved for 3 chronic stroke patients. Additionally, we also found out that the inverse CSP matrix topography of stroke patients' EEG showed good agreement with the patients' paretic side.

Increased Energy Cost of Mobility in Chronic Stroke

The purpose of this study was to compare the energy cost of completing mobility-related activities in chronic stroke to the estimated energy cost found in the compendium of physical activities, a resource that estimates and classifies energy cost of various human physical activities. Men (n=18) and women (n=10) with chronic hemiparetic gait (stroke latency: 4 ± 2 years, age: 60.4 ± 1.6 years, BMI: 31.5 ± 1.1 kg/m²) participated in the study. Portable energy cost monitoring (COSMED K4b2) was performed during five mobility activities of varying intensity to determine metabolic equivalents (METs, or oxygen consumption in multiples of resting level) for each activity. The METs achieved during the five activities were compared to the following compendium MET values for: 1) floor sweeping; 2) stepping in place; 3) over-ground walking; 4) lower speed treadmill walking (1.0 mph at 4% incline); and 5) higher speed treadmill walking (2.0 mph at 4% incline). Measurements were obtained for 10 min at rest and 5 minutes during each of the five activities. The energy cost of rest was only 85% of Compendium METS, while mobility-related activities were ~1.25-1.50 fold greater when measured in stroke vs. Compendium METS for all measures (P's<0.05), except floor sweeping, which was similar between groups. These data indicate that MET levels provided in the compendium are not applicable to chronic stroke survivors as they overestimate energy expenditure at rest and underestimate energy expenditure during physical activity, indicating poor efficiency in movement, thus elevating the oxygen cost of completing general daily activities.

Relationship between dynamic balance and spatiotemporal gait symmetry in hemiplegic patients with chronic stroke

Background

Poor dynamic balance, which is common after stroke, may affect gait function. In particular, spatiotemporal asymmetrical gait patterns may occur in hemiplegic patients after stroke.

Objective

This study aimed to assess the relationship between dynamic balance and spatiotemporal gait symmetry in patients with chronic hemiplegic stroke.

Methods

To calculate symmetry ratios for step length (spatial parameter) and swing time (temporal parameter), 41 patients with chronic stroke walked at a comfortable speed. The dynamic balance measures included limit of stability (LOS) during standing and heel-to-heel base of support (H-H BOS) during gait. Analysis of correlations between various measures was performed.

Results

The overall LOS score correlated with temporal gait symmetry (r = 0.66). The forward, backward, paretic, and non-paretic direction LOS scores were related to temporal gait symmetry (r = 0.38-0.62). The H-H BOS was correlated with temporal (r = -0.63) and spatial (r = -0.36) gait symmetries. Other dynamic balance variables were not significantly correlated with spatial gait symmetry.

Conclusion

Thus, control of dynamic balance abilities is related to the magnitude of temporal gait symmetry. This observation suggests that rehabilitation strategies that improve dynamic balance may enhance temporal gait symmetry in post-stroke patients.

Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties

BACKGROUND AND PURPOSE

Systematic reviews of research evidence describing the quality and methods for administering standardized outcome measures are essential to developing recommendations for their clinical application. The purpose of this systematic review was to synthesize the research literature describing test protocols and measurement properties of time-limited walk tests in people poststroke.

METHODS

Following an electronic search of 7 bibliographic data-bases, 2 authors independently screened titles and abstracts. One author identified eligible articles, and performed quality appraisal and data extraction.

RESULTS

Of 12 180 records identified, 43 articles were included. Among 5 walk tests described, the 6-minute walk test (6MWT) was most frequently evaluated (n = 36). Only 5 articles included participants in the acute phase (<1 month) poststroke. Within tests, protocols varied. Walkway length and walking aid, but not turning direction, influenced 6MWT performance. Intraclass correlation coefficients for reliability were 0.68 to 0.71 (12MWT) and 0.80 to 1.00 (2-, 3-, 5- and 6MWT). Minimal detectable change values at the 90% confidence level were 11.4 m (2MWT), 24.4 m (5MWT), and 27.7 to 52.1 m (6MWT; n = 6). Moderate-to-strong correlations (≥0.5) between 6MWT distance and balance, motor function, walking speed, mobility, and stair capacity were consistently observed (n = 33). Moderate-to-strong correlations between 5MWT performance and walking speed/independence (n = 1), and between 12MWT performance and balance, motor function, and walking speed (n = 1) were reported.

DISCUSSION AND CONCLUSIONS

Strong evidence of the reliability and construct validity of using the 6MWT poststroke exists; studies in the acute phase are lacking. Because protocol variations influence performance, a standardized 6MWT protocol poststroke for use across the care continuum is needed.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A150).

Development of a Questionnaire to Investigate Study Design Factors Influencing Participation in Gait Rehabilitation Research by People with Stroke: A Brief Report

PURPOSE

The main objective of this study was to evaluate the feasibility of a newly developed questionnaire to assess the influence of study design on participation in gait rehabilitation research in a pilot test with individuals with stroke. A secondary objective was to investigate the relationship between participation in gait rehabilitation research and social and clinical factors of interest after stroke.

METHODS

A questionnaire was developed with expert opinion and guidance from related previous research. The questionnaire was pilot tested in a group of 21 people with stroke, and social and clinical factors (including gait function) were collected. Gait function was assessed using a pressure-sensitive mat; social and clinical characteristics were extracted from patient charts. Correlations were performed to investigate relationships between questionnaire responses and gait function, motor impairment, and chronicity; t-tests were used to examine response differences between people with a caregiver at home and those without.

RESULTS

A total of 21 people with stroke completed the questionnaire without difficulty; mean completion time was 7.2 (SD 3.5) minutes, with a range of responses across participants. Borderline significant associations were found between gait function and the number of studies in which a person would participate and between stroke chronicity and the location of studies in which a person would participate.

CONCLUSIONS

A questionnaire to investigate the influence of study design factors on participation in rehabilitation research is feasible for administration in the post-stroke population and has potential to inform the design of future studies.