The influence of walking-aids on the plasticity of spinal interneuronal networks, central-pattern-generators and the recovery of gait post-stroke. A literature review and scholarly discussion

Physiotherapy management focusing on proprioceptive impairment in a patient with gait and balance impairments following stroke: A case report

BACKGROUND

Proprioceptive impairment contributes to gait and balance impairments in patients with stroke. Diagnosis functional impairments and evaluation treatment efficacy require quantitative proprioception assessment. However, proprioception assessment has remained limited to ordinal scale measurement, with a lack of ratio scale measurements.

PURPOSE

This case report describes a physiotherapy management program focusing on proprioceptive impairment in patients with stroke using quantitative tests such as Threshold to Detect Passive Motion (TDPM) and Joint Position Sense (JPS).

CASE DESCRIPTION

A63-year-old male patient with an acute pontine lacunar infarction was admitted to our hospital. His muscle strength, selective movement, and trunk activity were preserved. However, the Berg Balance Scale (BBS) and Gait Assessment andIntervention Tool (GAIT) score were 42 and 9 points, observing balance impairment and the buckling knee pattern with hip ataxia during gait. Based on these, TDPM and JPS using image capture were performed. In physiotherapeuticdiagnosis, proprioceptive impairments in the hip and knee joints were the primary functional impairments related to balance and gait. To address these proprioceptive impairments, a 13-day treatment protocol incorporating transcutaneous electrical nerve stimulation (intensity: sensory threshold, frequency: 100 Hz) targeting the quadriceps femoris was performed.

OUTCOMES

The patient was discharged after achieving independent ambulation and improvement in BBS (56 points) and GAIT (2 points) scores, exceeding the minimum clinically important difference. Recovery of proprioceptive impairment corresponded withimproved balance and gait ability.

CONCLUSION

Quantitatively evaluating proprioceptive impairments may provide novel rehabilitation for patients with stroke who have proprioceptive impairments and contribute to clinical decision-making.

Gait Entrainment to Torque Pulses from a Hip Exoskeleton Robot

Robot-aided locomotor rehabilitation has proven challenging. To facilitate progress, it is important to first understand the neuro-mechanical dynamics and control of unimpaired human locomotion. Our previous studies found that human gait entrained to periodic torque pulses at the ankle when the pulse period was close to preferred stride duration. Moreover, synchronized gait exhibited constant phase relation with the pulses so that the robot provided mechanical assistance. To test the generality of mechanical gait entrainment, this study characterized unimpaired human subjects' responses to periodic torque pulses during overground walking. The intervention was applied by a hip exoskeleton robot, Samsung GEMS-H. Gait entrainment was assessed based on the time-course of the phase at which torque pulses occurred within each stride. Experiments were conducted for two consecutive days to evaluate whether the second day elicited more entrainment. Whether entrainment was affected by the difference between pulse period and preferred stride duration was also assessed. Results indicated that the intervention evoked gait entrainment that occurred more often when the period of perturbation was closer to subjects' preferred stride duration, but the difference between consecutive days was insignificant. Entrainment was accompanied by convergence of pulse phase to a similar value across all conditions, where the robot maximized mechanical assistance. Clear evidence of motor adaptation indicated the potential of the intervention for rehabilitation. This study quantified important aspects of the nonlinear neuro-mechanical dynamics underlying unimpaired human walking, which will inform the development of effective approaches to robot-aided locomotor rehabilitation, exploiting natural dynamics in a minimally-encumbering way.

Adjunct Non-Elastic Hip Taping Improves Gait Stability in Cane-Assisted Individuals with Chronic Stroke: A Randomized Controlled Trial

Cane-assisted individuals with chronic stroke may perform with an abnormal gait pattern. One of the important factors of gait training for cane-assisted individuals is inducing improvement in lower limb muscle activity of the paretic side. Non-elastic taping on the hip may be used as an adjunct therapy for improving gait. The objective of this study was to investigate effects of non-elastic hip taping combined with exercise on gait in cane-assisted individuals with chronic stroke. This study is a single-blinded, randomized controlled trial. A total of 21 cane-assisted ambulators with chronic stroke were enrolled. Participants in both groups received a therapeutic exercise program, with the experimental and control groups having adjunct non-elastic taping and sham taping on the hip, respectively. The gait, Berg Balance Scale, 6-min walk test, and Fall Efficacy Scale–International were measured at pre-intervention, post-intervention, and 1-month follow-up. The experimental group resulted in significantly better performance in double-support time compared with the control group. Furthermore, the experimental group showed a significant improvement in double-support time and spatial symmetry at post-intervention and 1-month follow-up compared with pre-intervention. This study demonstrated that non-elastic hip taping combined with exercise could improve gait stability in cane-assisted ambulators. Non-elastic hip taping would be a useful adjunct to rehabilitation strategies for individuals with chronic stroke.

Replacing canes with an elasticated orthotic-garment in chronic stroke patients - The influence on gait and balance. A series of N-of-1 trials

OBJECTIVE

To investigate the effect of replacing canes with an elasticated orthotic-garment on balance and gait-function in chronic stroke survivors.

DESIGN

Experimental, N-of-1 series with a replicated, ABC design with randomised phase duration in a home setting.

PARTICIPANTS

Four cane using chronic stroke survivors (P1-4).

INTERVENTIONS

Phase A (9-12 weeks) cane-walking "as usual" to establish baseline values; Phase B (9-16 weeks) intervention: orthotic-garment worn throughout the day with maximal cane-use reduction; Phase C (9-10 weeks) participant-determined follow-up: either no walking-aid, orthotic-garment or cane.

OUTCOME MEASURES

Primary: Functional-Gait-Assessment (FGA), Secondary: Trunk-sway during walking measured as Total-Angle-Area (TAA°²) in frontal and sagittal-planes, both measured weekly.

RESULTS

Visual and statistical analysis of results showed significant improvements in FGA from phase A to B in all participants. Improvement continued in phase C in P2, stabilized in P1 and P4 and deteriorated in P3. A Minimal-Clinical-Important-Difference of 6 points-change was achieved in P2 & P4. Trunk-sway reduced during walking, indicating increased stability, in two participants from phase A to B and in three participants from A to C but no TAA changes were statistically significant. In phase C participant-selected walking-aids were: P1 cane-usage reduced by 25%, P2 independent-walking with no assistive-device, S3 usual cane-usage, P4 orthotic-garment with reduced cane-usage 2-3 days-a-week, usual cane-usage 4-5 days.

CONCLUSIONS

Although walking ability is multifactorial these results indicate that the choice of walking-aids can have a specific and clinically relevant impact on gait following stroke. "Hands-free" assistive-devices may be more effective than canes in improving gait-function in some patients. CLINICALTRIALS.

GOV ID

NCT03642444.

Rehabilitation After Complete Hemisensory Loss: Report of Two Cases

The role and function that proprioception plays in movement and motor learning have been debated since the 19th century but can be difficult to isolate and study. Lesions at various points along the proprioceptive pathway result in afferent paresis that can be significantly disabling. Compensatory mechanisms can help with successful rehabilitation and provide an opportunity to study the role of these mechanisms in sensory feedback. Here, we present two cases of adult patients with complete hemisensory loss after a stroke: one patient with a cortical stroke and the other one with a thalamic stroke. First, we see that that motor learning can occur without proprioception, with the help of visual feedback. Second, proprioception plays an important role in movement: in the upper limb, it can facilitate individual finger movements, and in the lower limb, it maintains sufficient knee flexion to prevent the knee from going into recurvatum (backward bending) during ambulation.

Muscle synergies demonstrate only minimal changes after treatment in cerebral palsy

Background

Children with cerebral palsy (CP) have altered synergies compared to typically-developing peers, reflecting different neuromuscular control strategies used to move. While these children receive a variety of treatments to improve gait, whether synergies change after treatment, or are associated with treatment outcomes, remains unknown.

Methods

We evaluated synergies for 147 children with CP before and after three common treatments: botulinum toxin type-A injection (n = 52), selective dorsal rhizotomy (n = 38), and multi-level orthopaedic surgery (n = 57). Changes in synergy complexity were measured by the number of synergies required to explain > 90% of the total variance in electromyography data and total variance accounted for by one synergy. Synergy weights and activations before and after treatment were compared using the cosine similarity relative to average synergies of 31 typically-developing (TD) peers.

Results

There were minimal changes in synergies after treatment despite changes in walking patterns. Number of synergies did not change significantly for any treatment group. Total variance accounted for by one synergy increased (i.e., moved further from TD peers) after botulinum toxin type-A injection (1.3%) and selective dorsal rhizotomy (1.9%), but the change was small. Synergy weights did not change for any treatment group (average 0.001 ± 0.10), but synergy activations after selective dorsal rhizotomy did change and were less similar to TD peers (− 0.03 ± 0.07). Only changes in synergy activations were associated with changes in gait kinematics or walking speed after treatment. Children with synergy activations more similar to TD peers after treatment had greater improvements in gait.

Conclusions

While many of these children received significant surgical procedures and prolonged rehabilitation, the minimal changes in synergies after treatment highlight the challenges in altering neuromuscular control in CP. Development of treatment strategies that directly target impaired control or are optimized to an individual’s unique control may be required to improve walking function.

Immediate effect of hip taping on balance and walking ability in cane-dependent ambulators with chronic stroke: a randomized controlled trial

BACKGROUND

Previous studies showed that cane-dependent post-stroke ambulators have poor balance and gait performance. Adhesive taping on the hip may be used as a therapeutic modality for improving range of motion and muscle activity in individuals with stroke.

AIM

The objective of this study was to investigate the immediate effect of the hip extensor and abductor taping on balance and walking ability in cane-dependent ambulators with chronic stroke.

DESIGN

This study was a single-blinded, randomized controlled trial.

SETTING

Outpatients from a hospital rehabilitation department.

POPULATION

Twenty-eight cane-dependent ambulators with chronic stroke were recruited.

METHODS

Participants were randomized into either the control group with sham tape (N.=14) or experimental group with non-elastic tape (N.=14). The Berg Balance Scale, gait speed, 6-minute walk test, and Fall Efficacy Scale were measured with and without taping.

RESULTS

After taping, participants in the experimental group showed significant improvement in the Berg Balance Scale, gait speed, and 6-minute walk test. Furthermore, experimental group showed significant improvement in the Berg Balance Scale and 6-minute walk test compared with sham taping control group.

CONCLUSIONS

Non-elastic tape could immediately improve balance, gait speed, and endurance in cane-dependent ambulators with chronic stroke.

CLINICAL REHABILITATION IMPACT

Non-elastic tape may be a useful adjunct to current rehabilitation strategies for individuals with chronic stroke.