Responsiveness and predictability of gait speed and other disability measures in acute stroke

The NewGait Rehabilitative Device Corrects Gait Deviations in Individuals With Foot Drop

The purpose of this quasiexperimental study was to test the effects of wearing the NewGait rehabilitative device on walking abilities in individuals with foot drop. The study involved 16 participants with foot drops caused by stroke (11 participants), multiple sclerosis (one participant), and peripheral neuropathies (four individuals). During a single testing session, participants walked 12 m at their self-selected speed in four experimental conditions: walking without any orthotic device; walking while wearing a regular plastic posterior leaf ankle foot orthosis (AFO); walking with the NewGait device assisting ankle dorsiflexion only; and walking with the NewGait device assisting the hip, knee, and ankle joint motions. Body motions during walking were recorded using a 3D system for motion analysis and analyzed with a set of spatiotemporal and kinematic parameters and a gait decomposition index. The gait decomposition index indicated sagittal interjoint coordination in the three joint pairs (hip-knee, knee-ankle, and hip-ankle) of the paretic (foot drop) leg during walking and was validated in a previous study. Overall, wearing all three orthotic devices improved the gait velocity, ankle dorsiflexion, and foot clearance compared to gait trials in which no assistive devices were used. However, wearing the AFO significantly restricted the plantarflexion range of motion and decreased interjoint coordination as measured by joint decomposition. In contrast, the NewGait device altered the ankle plantarflexion motions but also increased coordinated movement (reduced the decomposition) in most lower-extremity joint pairs and conditions. Therefore, the NewGait rehabilitative device can be considered superior to a regular AFO in correcting gait deviations caused by foot drop.

Measurement properties of activity monitoring for a rehabilitation (AMoR) platform in post-stroke individuals in a simulated home environment

AIM

The aim of this study was to evaluate the measurement properties of activity monitoring for a rehabilitation (AMoR) platform for step counting, time spent in sedentary behavior, and postural changes during activities of daily living (ADLs) in a simulated home environment.

METHODS

Twenty-one individuals in the post-stroke chronic phase used the AMoR platform during an ADL protocol and were monitored by a video camera. Spearman's correlation coefficient, mean absolute percent error (MAPE), intraclass correlation coefficient (ICC), and Bland-Altman plot analyses were used to estimate the validity and reliability between the AMoR platform and the video for step counting, time spent sitting/lying, and postural changes from sit-to-stand (SI-ST) and sit-to-stand (ST-SI).

RESULTS

Validity of the platform was observed with very high correlation values for step counting (rs = 0.998) and time spent sitting/lying (rs = 0.992) and high correlation for postural change of SI-ST (rs = 0.850) and ST-SI (rs = 0.851) when compared to the video. An error percentage above 5% was observed only for the SI-ST postural change (7.13%). The ICC values show excellent agreement for step counting (ICC3, k = 0.999) and time spent sitting/lying (ICC3, k = 0.992), and good agreement for SI-ST (ICC3, k = 0.859) and ST-SI (ICC3, k = 0.936) postural change. Values of the differences for step counting, sitting/lying time, and postural change were within the limits of agreement according to the analysis of the Bland-Altman graph.

CONCLUSION

The AMoR platform presented validity and reliability for step counting, time spent sitting/lying, and identification of SI-ST and ST-SI postural changes during tests in a simulated environment in post-stroke individuals.

Overestimation associated with walking and balance function in individuals diagnosed with a stroke

BACKGROUND

An estimation error is the difference between motor imagery and actual motor time. Previous studies have reported that overestimation (motor imagery time < actual motor time) is related to physical functions in healthy individuals. However, this finding is unclear among individuals diagnosed with a stroke.

OBJECTIVE

We investigated whether overestimation is related to physical function in individuals diagnosed with a stroke.

METHODS

This study included 71 individuals diagnosed with a stroke (mean age, 67.2 ± 13.4 years; mean time since stroke, 68.4 ± 44.7 days). Imagined timed up and go test (iTUGT) was performed to assess the estimation error. First, the iTUGT was performed; subsequently, the TUGT was performed. The estimation error was calculated by subtracting the TUGT from the iTUGT, with two standard deviations (2 SDs) being calculated. Furthermore, patients were classified into appropriate estimation (AE, within ±2 SD) and overestimation (OE, over -2 SD) groups. Both groups were tested using the estimation error, iTUGT, TUGT, Berg Balance Scale (BBS), and Brunnstrom Recovery Stage (BRS). Subsequently, a correlation analysis was performed.

RESULTS

The OE group had a significantly higher estimation error than the AE group (OE: -7.08 ± 6.87 s, AE: -0.29 ± 1.53 s, P < .001). Moreover, the OE group had significantly lower TUGT and BBS than the AE group. The estimation error was correlated with the TUGT, BBS, and lower-limb BRS (ρ = -0.454, 0.431, 0.291, respectively; P < .05).

CONCLUSIONS

Overestimation was associated with TUGT and balance function in individuals diagnosed with a stroke.

High-intensity locomotor training during inpatient rehabilitation improves the discharge ambulation function of patients with stroke. A systematic review with meta-analysis

OBJECTIVE

To evaluate the evidence of high-intensity locomotor training on outcomes related to gait and balance for patients with stroke in inpatient rehabilitation.

METHODS

Four databases were searched (PubMed, CINAHL, Web of Science, and MedLINE) for articles published prior to 13 June 2023. Studies of adults (>18 years old) with a diagnosis of stroke who received a high-intensity locomotor intervention while admitted to an inpatient rehabilitation facility were included. A functional outcome in the domain of gait speed, gait endurance, or balance must have been reported. Following the screening of 1052 studies, 43 were selected for full-text review. Studies were assessed for risk of bias using the tool appropriate to the study type. Gait speed, gait endurance, and balance outcome data were extracted for further analysis.

RESULTS

Eight studies were selected with risk of bias ratings as moderate (4), high (2), and low (2). Six studies were analyzed in the meta-analysis (N = 635). A random-effects model analyzed between-group differences. Standard mean differences demonstrated that high-intensity locomotor training produces a moderate effect on gait endurance (0.50) and gait speed (0.41) and a negligible effect on balance (0.08) compared with usual care.

CONCLUSIONS

The meta-analysis supports the use of high-intensity locomotor training over usual care for improving gait speed and gait endurance during inpatient post-stroke. Future studies should investigate dose-response relationships of high-intensity locomotor training in this setting.

PROSPERO REGISTRATION

#CRD42022341329.

A single-center, assessor-blinded, randomized controlled clinical trial to test the safety and efficacy of a novel brain-computer interface controlled functional electrical stimulation (BCI-FES) intervention for gait rehabilitation in the chronic stroke population

BACKGROUND

In the United States, there are over seven million stroke survivors, with many facing gait impairments due to foot drop. This restricts their community ambulation and hinders functional independence, leading to several long-term health complications. Despite the best available physical therapy, gait function is incompletely recovered, and this occurs mainly during the acute phase post-stroke. Therapeutic options are limited currently. Novel therapies based on neurobiological principles have the potential to lead to long-term functional improvements. The Brain-Computer Interface (BCI) controlled Functional Electrical Stimulation (FES) system is one such strategy. It is based on Hebbian principles and has shown promise in early feasibility studies. The current study describes the BCI-FES clinical trial, which examines the safety and efficacy of this system, compared to conventional physical therapy (PT), to improve gait velocity for those with chronic gait impairment post-stroke. The trial also aims to find other secondary factors that may impact or accompany these improvements and establish the potential of Hebbian-based rehabilitation therapies.

METHODS

This Phase II clinical trial is a two-arm, randomized, controlled, longitudinal study with 66 stroke participants in the chronic (> 6 months) stage of gait impairment. The participants undergo either BCI-FES paired with PT or dose-matched PT sessions (three times weekly for four weeks). The primary outcome is gait velocity (10-meter walk test), and secondary outcomes include gait endurance, range of motion, strength, sensation, quality of life, and neurophysiological biomarkers. These measures are acquired longitudinally.

DISCUSSION

BCI-FES holds promise for gait velocity improvements in stroke patients. This clinical trial will evaluate the safety and efficacy of BCI-FES therapy when compared to dose-matched conventional therapy. The success of this trial will inform the potential utility of a Phase III efficacy trial.

TRIAL REGISTRATION

The trial was registered as "BCI-FES Therapy for Stroke Rehabilitation" on February 19, 2020, at clinicaltrials.gov with the identifier NCT04279067.

Can We Target Close Therapeutic Goals in the Gait Re-Education Algorithm for Stroke Patients at the Beginning of the Rehabilitation Process?

(1) Background: The study aimed to determine the most important activities of the knee joints related to gait re-education in patients in the subacute period after a stroke. We focused on the tests that a physiotherapist could perform in daily clinical practice. (2) Methods: Twenty-nine stroke patients (SG) and 29 healthy volunteers (CG) were included in the study. The patients underwent the 5-meter walk test (5mWT) and the Timed Up and Go test (TUG). Tests such as step up, step down, squat, step forward, and joint position sense test (JPS) were also performed, and the subjects were assessed using wireless motion sensors. (3) Results: We observed significant differences in the time needed to complete the 5mWT and TUG tests between groups. The results obtained in the JPS show a significant difference between the paretic and the non-paretic limbs compared to the CG group. A significantly smaller range of knee joint flexion (ROM) was observed in the paretic limb compared to the non-paretic and control limbs in the step down test and between the paretic and non-paretic limbs in the step forward test. (4) Conclusions: The described functional tests are useful in assessing a stroke patient's motor skills and can be performed in daily clinical practice.

Smartphone-based gait and balance assessment in survivors of stroke: a systematic review

PURPOSE

Gait and balance impairments are associated with falls and reduced quality of life among survivors of stroke (SS). Effective methods to assess these impairments at-home and in-clinic can help reduce fall risks and improve functional outcomes. Smartphone technology may be able to evaluate these impairments. This review aims to summarize the validity, reliability, sensitivity, and specificity of smartphone applications for determining gait and balance disorders in SS.

METHOD

Database search through PubMed, Web of Science, Scopus, CINAHL, and SportDiscuss was conducted to retrieve studies that explored the use of smartphone-based applications for assessing gait and balance disorders in SS. Two independent reviewers screened potential articles to determine eligibility for inclusion. Eligible studies were summarized for participant and study characteristics, validity, reliability, sensitivity, and specificity of smartphone assessments. Methodological quality assessment of studies was performed using the NIH Quality Assessment Tool.

RESULTS

Seven cross-sectional studies were included in the review. Quality assessment revealed all studies had low risk of bias. Three of the included studies examined the validity, four examined the reliability, and two examined the specificity and sensitivity of smartphone-based application assessments of gait and balance in SS. Studies revealed that smartphones were valid, reliable, specific, and sensitive. Six of the seven included studies intended their use for SS and one study for clinicians.

CONCLUSION

Preliminary evidence supports that smartphone-based gait and balance assessments are valid, reliable, sensitive, and specific in SS in laboratory settings. Future research is needed to test smartphone-based gait and balance assessments in home settings and determine optimal wear sites for assessments.IMPLICATIONS FOR REHABILITATIONSmartphone-based gait and balance assessments are feasible, valid and reliable for survivors of strokeThe findings may guide future research to standardize the use of smartphone to assess gait and balance in this population.The remote use of smartphone-based assessments to predict fall risk in survivors of stroke needs to be explored.

Acupuncture in the Treatment of a Series of Patients with Chronic Pain Associated with Hip Osteoarthritis

Objective  Hip osteoarthritis (HO) causes pain and deranges functioning. Surgical treatment is the preferred approach in severe cases, but clinical comorbidities, age and the long waiting list may compromise quality of life. This study aimed to describe the results of acupuncture for the control pain and improvement of functioning in subjects with HO. Method  Twelve severe HO patients were treated with ten weekly sessions of a standardized acupuncture point protocol. Pain intensity was assessed with the Visual Analog Pain Scale (VAS) and quality of life with WOMAC Index. Results  Pain intensity (VAS) reduced from 75.8 ± 18.8 mm to 20.0 ± 22.6 mm after 10 acupuncture sessions and 48.3 ± 26.6mm in the follow-up (ANOVA F = 7.99; p < 0.001). WOMAC Index values reduced from 74.7 ± 12.7 to 45.7 ± 22.1 and 54.6 ± 22.9 at the same timepoints. Conclusion  Acupuncture is an effective conservative rehabilitation strategy to reduce pain and improve quality of life in subjects with severe HO.

Effects of functional performance and national health insurance cost on length of hospitalization for postacute care in stroke: a retrospective observational study

BACKGROUND

The postacute care for cerebrovascular disease (PAC-CVD) program was launched in Taiwan nearly a decade ago. However, no clear regulations regarding length of stay (LOS) in the program and extension standards exist. Thus, the allocation of limited medical resources such as hospital beds is a major issue.

METHODS

This novel study retrospectively investigated the effects of functional performance and national health insurance (NHI) costs on PAC-CVD LOS. Data for 263 patients with stroke who participated in the PAC-CVD program were analysed. Hierarchical multiple regression was used to estimate the effects of functional performance and NHI costs on LOS at three time points: weeks 3, 6, and 9.

RESULTS

At week 3, age, NHI costs, modified Rankin scale score, and Barthel index significantly affected LOS, whereas at week 6, age and NHI costs were significant factors. However, functional performance and NHI costs were not significant factors at week 9.

CONCLUSIONS

The study provides crucial insights into the factors affecting LOS in the PAC-CVD program, and the results can enable medical decision-makers and health care teams to develop inpatient rehabilitation plans or provide transfer arrangements tailored to patients. Specifically, this study highlights the importance of early functional recovery and consideration of NHI costs when managing LOS in the PAC-CVD program.

Assessing Stroke-Related Sarcopenia in Chronic Stroke: Identification of Clinical Assessment Tools-A Pilot Study

Stroke-related sarcopenia has recently been defined as the muscle atrophy consequent to stroke and assessing it following the guidelines with simple clinical tools is crucial in chronic stroke survivors. The aim of this study was to determine the characteristics of patient-friendly instruments sarcopenia in a chronic stroke sample (SG) compared to non-stroke counterparts (CG). Each participant underwent a single assessment which consisted of: SARC-F questionnaire, assessment of muscle strength (hand grip and five-times sit-to-stand test, 5STS), the calf circumference (CC) of both legs, the short physical performance battery (SPPB), and the 10 m walk test. A total of 68 participants were included (SG, n = 34 and CG, n = 34). All variables showed statistical differences (p < 0.05) between the SG and the CG, except handgrip although it showed lower values for SG. The values of the 5STS (16.26 s) and the SPPB (7 points) were below to the cutoff values for the SG. The five-times sit-to-stand test, SPPB, and gait speed can lead clinicians to detect stroke-related sarcopenia. Maximum handgrip shows a trend of low values for men and women in the SG, however, CC did not detect sarcopenia in our sample.

Feasibility of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability: a randomized controlled trial

Background

Treadmill training shows advantages in the specificity, amount, and intensity of gait and balance practice for the rehabilitation of stroke patients.

Objective

To investigate the feasibility and effectiveness of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability.

Methods

For this randomized controlled trial (Chinese Clinical Trials.gov registration number ChiCTR-IOR-16009536) with blinded testers, we recruited 33 ambulatory stroke participants with restricted community ambulation capacity and randomly assigned them into two groups: the experimental group with 2 week treadmill speed-dependent gait training combined with 2 week treadmill perturbation-induced balance training (EXP) or the control group with traditional gait and balance training (CON). Various variables were recorded during EXP training, including the rating of perceived exertion, heart rate, causes of pauses, treadmill speed, and perturbation intensity. Outcome measures were examined before training and at 2 and 4 weeks after training. They included gait velocity during five-meter walk test at comfortable and fast speed and reactive balance ability in the compensatory stepping test as primary outcome measures, as well as dynamic balance ability (timed up-and-go test and 5 times sit-to-stand test) and balance confidence as secondary outcome measures.

Results

All participants completed the study. The treadmill speed and perturbation intensity significantly increased across training sessions in the EXP group, and no adverse effects occurred. The normal and fast gait velocities showed significant time and group interaction effects. They significantly increased after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05). Likewise, dynamic balance ability measured using the timed up-and-go test at a fast speed significantly improved after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05), although without a significant time and group interaction effect. Surprisingly, the reactive balance ability did not show improvement after treatment in the EXP group (p > 0.05).

Conclusion

Challenging treadmill speed-dependent gait and treadmill perturbation-induced balance training is feasible and effective to improve ambulation function in chronic stroke patients with low ambulation ability.

Automation of the Timed Up and Go Test Using a Doppler Radar System for Gait and Balance Analysis in Elderly People

The timed up and go (TUG) test is a simple, valid, and reliable clinical tool that is widely used to assess mobility in elderly people. Several research studies have been conducted to automate the TUG test using wearable sensors or motion-tracking systems. Despite their promising results, the adopted technological systems present inconveniences in terms of acceptability and privacy protection. In this work, we propose to overcome these problems by using a Doppler radar system set into the backrest of a chair in order to automate the TUG test and extract additional information from its phases (i.e., transfer, walk, and turn). We intend to segment its phases and extract spatiotemporal gait parameters automatically. Our methodology is mainly based on a multiresolution analysis of radar signals. We proposed a segmentation technique based on the extraction of limbs oscillations signals through a semisupervised machine learning approach, on the one hand, and the application of the DARC algorithm on the other hand. Once the speed signals of torso and limbs oscillations were detected, we suggested estimating 14 gait parameters. All our approaches were validated by comparing outcomes to those obtained from a reference Vicon system. High correlation coefficients were obtained by comparing the speed signals of the torso (ρ=0.8), the speed signals of limbs oscillations (ρ=0.91), the initial and final indices of TUG phases (ρ=0.95), and the extracted parameters (percentage error < 4.8) obtained after radar signal processing to those obtained from the Vicon system.

Dual-task versus single-task gait rehabilitation after stroke: the protocol of the cognitive-motor synergy multicenter, randomized, controlled superiority trial (SYNCOMOT)

BACKGROUND

Gait disorders and cognitive impairments are prime causes of disability and institutionalization after stroke. We hypothesized that relative to single-task gait rehabilitation (ST GR), cognitive-motor dual-task (DT) GR initiated at the subacute stage would be associated with greater improvements in ST and DT gait, balance, and cognitive performance, personal autonomy, disability, and quality of life in the short, medium and long terms after stroke.

METHODS

This multicenter (n=12), two-arm, parallel-group, randomized (1:1), controlled clinical study is a superiority trial. With p<0.05, a power of 80%, and an expected loss to follow-up rate of 10%, the inclusion of 300 patients will be required to evidence a 0.1-m.s-1 gain in gait speed. Trial will include adult patients (18-90 years) in the subacute phase (0 to 6 months after a hemispheric stroke) and who are able to walk for 10 m (with or without a technical aid). Registered physiotherapists will deliver a standardized GR program (30 min three times a week, for 4 weeks). The GR program will comprise various DTs (phasic, executive function, praxis, memory, and spatial cognition tasks during gait) in the DT (experimental) group and gait exercises only in the ST (control) group. The primary outcome measure is gait speed 6 months after inclusion. The secondary outcomes are post-stroke impairments (National Institutes of Health Stroke Scale and the motor part of the Fugl-Meyer Assessment of the lower extremity), gait speed (10-m walking test), mobility and dynamic balance (timed up-and-go test), ST and DT cognitive function (the French adaptation of the harmonization standards neuropsychological battery, and eight cognitive-motor DTs), personal autonomy (functional independence measure), restrictions in participation (structured interview and the modified Rankin score), and health-related quality of life (on a visual analog scale). These variables will be assessed immediately after the end of the protocol (probing the short-term effect), 1 month thereafter (the medium-term effect), and 5 months thereafter (the long-term effect).

DISCUSSION

The main study limitation is the open design. The trial will focus on a new GR program applicable at various stages after stroke and during neurological disease.

TRIAL REGISTRATION

NCT03009773 . Registered on January 4, 2017.

Efficacy and Cost over 12 Hospitalization Weeks of Postacute Care for Stroke

Few studies have investigated changes in functional outcomes and economic burden in patients in the postacute care cerebrovascular disease (PAC-CVD) program. We, for the first time, retrospectively investigated changes in functional performance and the national health insurance (NHI) cost over 12 PAC-CVD hospitalization weeks and evaluated the therapeutic effects of the PAC-CVD program on the NHI cost. Specifically, the functional outcomes and NHI cost of 263 stroke patients in the PAC-CVD program were analyzed. The repeated measures t test was used to compare functional performance over 0-3 weeks, and a one-way repeated measures multivariate analysis of variance was used to compare functional performance and NHI costs during weeks 0-6 and 0-9. The Wilcoxon signed-rank test was used to compare functional performance over weeks 9-12. Hierarchical multiple regression was used to estimate the effects of functional performance on NHI costs during weeks 3, 6, and 9. Over weeks 0-12, all functional performance measures demonstrated significant improvements. Changes in NHI costs varied depending on whether hospitalization was extended. At any time point, functional performance did not have a significant impact on NHI cost. Therefore, the PAC-CVD program may aid patients with stroke in sustainably regaining functional performance and effectively controlling economic burden.

Walking speed, hip muscles strength, aerobic capacity, and self-perceived locomotion ability most explain walking confidence after stroke: a cross-sectional experimental study

Identifying the determinants of walking confidence can be crucial in therapeutic terms. On these bases, interventions to improve these factors could improve, in turn, walking confidence. Objective is to explore the relationship between motor impairments and activity limitation measures and walking confidence in people with chronic stroke. Walking confidence was assessed using the modified Gait Efficacy Scale. The independent variables were: strength of the hip flexors and knee flexors/extensors (measured with a dynamometer), lower limb coordination (assessed by the Lower Extremity Motor Coordination Test), dynamic balance (assessed by the Four-Square Step Test), walking speed (from the 10-m Walk Test), aerobic capacity (from the 6-Minute Walk Test), and self-perceived locomotion ability (assessed by the ABILOCO). Pearson correlation was used to explore the relationships between the variables, and multiple linear regression to identify the independent explainers of walking confidence after stroke. Ninety chronic stroke individuals (35 men), with a mean age of 68 (SD 13) years were assessed. All independent variables were significantly correlated with walking confidence. Regarding the regression analysis, these measures explained 44% ( F = 9.21; P < 0.001) of the variance in walking confidence; however, only walking speed, strength of the hip flexor muscles, aerobic capacity, and perceived locomotion ability showed significance. All motor impairment and activity limitation measures correlated with walking confidence. However, the regression analysis highlighted that only walking speed, aerobic capacity, the strength of the hip flexor muscles, and perceived locomotion were independent explainers of walking confidence after stroke.

Effects of Combination of Functional Electric Stimulation and Robotic Leg Movement Using Dynamic Tilt Table on Walking Characteristics in Post-Stroke Patients with Spastic Hemiplegia: A Randomized Crossover-Controlled Trial

BACKGROUND

Spastic hemiplegia causes slow and unstable walking in post-stroke patients. Dynamic tilt table with robotic leg movement (DTTRLM) is safe and effective in improving walking. Functional electric stimulation (FES) improves walking speed in post-stroke patients with spastic hemiplegia. The aim of this study was to determine the effects of combined DTTRLM + FES on walking speed compared with DTTRLM alone.

METHODS

Twenty post-stroke patients were randomly assigned to receive either a single session of stepping + FES treatment or a single session of stepping alone treatment. After a one-week washout period, the same two groups underwent a single session of the other treatment, and the same measurements were taken. We measured walking speed, cadence, and the number of steps in a 10 m walking test (10MWT) and assessed Modified Ashworth Scale (MAS), Fugl-Meyer Assessment (FMA), and range of motion (ROM) before and after the intervention.

RESULTS

Stepping + FES significantly improved walking speed, number of steps, and ankle inversion ROM, compared with stepping alone. Adverse events were not observed in any subject.

CONCLUSIONS

Robotic stepping therapy combined with FES significantly improved 10 m walking speed (10MWS) compared with stepping only in patients with post-stroke and spastic hemiplegia. Further studies are needed to determine the long-term effects of the combination treatment.

Fully Immersive Virtual Reality Game-Based Training for an Adolescent with Spastic Diplegic Cerebral Palsy: A Case Report

BACKGROUND

Recently, virtual reality-based training (VR-based training) is receiving attention as greater emphasis is placed on the importance of interest and motivation in participation. However, studies investigating the effects of fully immersive VR-based training are insufficient.

CASE PRESENTATION

We report a case of using a fully immersive VR game-based training in a patient with cerebral palsy. A 15-year-old girl was diagnosed with spastic diplegia cerebral palsy Gross Motor Function Classification System level II. A six-week intervention (18 sessions) phase was performed with one fully immersive VR game using PlayStation^®VR in three sessions per week. After 18 sessions of training, the scores on the gross motor function measure-88 (Gross Motor Function Measure-88-GMFM-88), pediatric balance scale (PBS), timed up and go test (TUG), functional gait assessment (FGA), and 10 m walking test (10MWT) were improved: GMFM-88, 91.56 points (9.31 points increase); PBS, 45 points (6 points increase); TUG, 8.23 s (6.9 s decrease); FGA, 11 points (3 points increase); the 10 MWT, 5.27 s (6.59 s decrease).

CONCLUSIONS

This study found that a fully immersive VR game-based training using PlayStation^®VR may be an effective intervention for GMFCS level II adolescent, leading to some improvement of motor function, balance and gait skills in adolescents with cerebral palsy.

Walking speed at the acute and subacute stroke stage: A descriptive meta-analysis

Gait disorders are one of the leading patient complaints at the sub-acute stroke stage (SSS) and a main determinant of disability. Walking speed (WS) is a major vital and functional index, and the Ten-Meter Walk Test is considered the gold standard after stroke. Based on a systematic review of the literature, studies published between January 2000 and November 2021 were selected when WS was reported (ten-meter walk test for short distance and/or 6-min walking distance for long distance) within 6 months following a first ischemic and/or hemorrhagic stroke (SSS) in adults prior to receiving specific walking rehabilitation. Following PRISMA guidelines, a meta-analysis was conducted on two kinds of WS: the principal criterion focused on short-distance WS (ten-meter walking test) and the secondary criteria focused on long-distance WS (6-min test) and meta-regressions to study the association of WS with balance, cognitive disorders and autonomy. Nine studies comprising a total of 939 data on post-stroke patients were selected. The weighted average age was 61 years [95% IC [55-67] and males represented 62% ± 2.7 of patients [57-67]. Average short-distance WS was 0.36 ± 0.06 m.s-1 [95% CI (0.23-0.49)]. Average long-distance WS was 0.46 ± 0.1 m.s-1 [95% CI (0.26-0.66)]. The funnel plot revealed asymmetry of publication bias and high heterogeneity of the nine studies (I 2 index 98.7% and Q-test p < 0.0001). Meta-regressions of secondary endpoints could not be performed due to a lack of study data. At the SSS, WS would be lower than data in general population published in literature, but above all, lower than the WS required for safe daily autonomy and community ambulation after stroke. WS must be a priority objective of stroke rehabilitation to increase walking function but also for survival, autonomy, social participation and health-related quality of life.

A cohort study on longitudinal changes in postural balance during the first year after stroke

INTRODUCTION

Many patients with strokes report increased incidence of fall that can be due to impaired postural balance. The recovery of balance in patients with varying degrees of impairments and activity limitations is less studied, and whether individuals with mild paresis can recover their balance faster is unclear. Better knowledge about factors influencing the recovery of postural balance can be used to guide clinical management after stroke to provide the right rehabilitation to the right person at the right time, and thus to avoid potential fall incidences.

OBJECTIVE

This study aims to examine longitudinal changes in postural balance during the first year after stroke.

METHODS

Postural balance was assessed using the Berg Balance Scale (BBS) within 5 days, 1, 2, and 3 months and 1-year post-stroke. Stroke severity was stratified using a cluster analysis by including multidimensional baseline measures. A longitudinal mixed-effect model was constructed to analyze changes in proportional balance impairment by stroke severity over time. Individuals with a cut-off of BBS below 45 scores were identified through a classification algorithm using baseline predictors.

RESULTS

A total of 135 patients were stratified to mild stroke (77 [57%] patients) or moderate stroke (58 [43%] patients). Ninety-three patients were included in the longitudinal analysis. Significant recovery was found at 1-year for moderate stroke (48% recovery from the initial impaired postural balance, adjusted P < 0.001), but not for mild stroke, after adjusting for age and cognition. Both stroke severities had a maximal recovery in postural balance at 3 months post-stroke, but the moderate stroke group deteriorated after that. Patients with higher age and worse cognition had more severe balance impairments. The classification model achieved a sensitivity of 0.95 (95% confidence interval [CI]: 0.91-0.98) and a specificity of 0.99 (95% CI: 0.98-1.0) for classifying individuals with BBS below 45 points.

CONCLUSIONS

This study indicates that continuous improvements in postural balance ends at 3 months regardless for mild or moderate stroke groups, and patients with moderate stroke significantly deteriorate in postural balance after 3 months.

The Most Significant Factor Affecting Gait and Postural Balance in Patients’ Activities of Daily Living Following Corrective Surgery for Deformity of the Adult Spine

Background and Objectives: Gait ability and spinal postural balance affect ADL in patients who underwent adult spinal deformity (ASD) surgery. However, it is still unclear how to determine what the cause is. This study was done to investigate various factors affecting gait, postural balance and activities of daily living (ADL) in patients who were operated on for ASD over a period of one year, following corrective surgery. Materials and Method: A cohort of 42 (2 men, 40 women, mean age, 71.1 years) who were operated on for ASD were included in this study. According to Oswestry Disability Index (ODI), based on their ADL, patients were segregated into satisfied and unsatisfied groups. Gait and postural balance abilities were evaluated before and after the operative procedure. Radiographs of spine and pelvis as well as the rehabilitation data (static balance, standing on single-leg; dynamic postural adaptation, timed up and go test (TUG); Gait Capability, walk velocity for a distance of 10 m) were acquired 12 months after surgery and analyzed. Spinopelvic parameters such as (lumbar lordosis (LL), pelvic tilt (PT), sagittal vertical axis (SVA), pelvic incidence (PI)) were marked and noted. The factors which affect patients’ satisfaction with their ADL were evaluated. Results: The ADL satisfied group included 18 patients (1 man, 17 women, mean age 68.6 years) and the unsatisfied group included 24 patients (1 man, 23 women, mean age 73.1 years). One year after the surgery, the two groups were tested. TUG (8.5 s vs. 12.8 s), 10 m walk velocity (1.26 m/s vs. 1.01 m/s), and single leg standing test (25 s vs. 12.8 s) were regarded as notably different. According to logistic regression analysis, only TUG was extracted as a significant factor. The cut-off value was 9.7 s, with sensitivity 75%, specificity 83%, area under the curve 0.824, and a 95% confidence interval of 0.695–0.953. Conclusions: A significant factor among all evaluations in postoperative ASD patients was TUG, for which the cut-off value for ADL satisfaction was 9.7 s.

Assessment of Lower Limb Motor Function, Ambulation, and Balance After Stroke

Restoration of ambulation is important for stroke patients. Valid and reliable methods are required for the assessment of lower limb functional status. We reviewed the psychometric properties of methods employed to assess lower extremity motor function, ambulation, and balance, with a focus on stroke patients. We define "motor function" as the ability to produce bodily movements when the brain, motor neurons, and muscles interact. "Ambulation" is defined as the ability to walk with or without a personal assistive device, and "balance" as the ability to maintain stability (without falling) during various physical activities. The Motricity Index and Fugl-Meyer Assessment of Lower Extremities assess the motor function of the lower limbs. The Functional Ambulation Category, 10-m Walk Test, and 6-minute Walk Test assess ambulation. The Berg Balance Scale, Timed Up and Go Test, Functional Reach Test, and Trunk Impairment Scale explore balance. All these tests exhibit high-level validity and have good inter-rater and test-retest reliabilities. However, only 3 methods have been formally translated into Korean. The methods discussed here can be used for standardized assessment, personalized goal setting, rehabilitation planning, and estimation of therapeutic efficacy.

Chronological Evaluation of Gait Ability and Posture Balance after Adult Spinal Deformity Surgery

Adult spinal deformity (ASD) is highly prevalent in persons older than 65 years, affecting more than 30% of the total population. There are many important reports that describe excellent postoperative results for ASD surgery. However, there is no report that describes a chronological evaluation of gait ability and spinal balance after ASD surgery. The present prospective study aimed to determine the recovery time of gait and spinal balance ability after adult spinal deformity (ASD) surgery. Patients with ASD (n = 25: mean age, 73.0 years) who underwent corrective surgery and preoperative and postoperative gait and spinal balance ability evaluation. Spinal radiographs and gait analysis data (static balance; single-leg standing, dynamic balance; time-up and go test, gait ability; 10 m walk velocity) were acquired preoperatively, 1 month, 6 months, and 12 months after surgery. The radiographic parameters of the spine and pelvis (lumbar lordosis; LL, pelvic tilt; PT, sagittal vertical axis; SVA, pelvic incidence; PI) were measured. The mean postoperative SVA, LL, PT, and PI-LL became 30.0 mm, 50.1 degrees, 14.1 degrees, and 0.35 degrees, respectively. Preoperatively, all spinal balance and gait ability were worse than the normal threshold (one-leg standing; 14.2 s vs. 15.0 s, time-up and go test; 13.9 s vs. 13.5 s, 10-m walk speed; 0.91 m/s vs. 1.00 m/s). At 12 months after surgery, all spinal balance and gait ability became normal or improved (single-leg standing; 14.7 s, time-up and go test; 11.0 s, 10-m walk speed; 1.09 m/s). The ODI at one-year follow-up improved from 46.8 ± 12.6% to 27.8 ± 18.1%. In conclusion, gait and spinal balance analysis revealed that ASD patients could not recover gait and spinal balance ability one month after surgery. At 12 months after surgery, gait ability and dynamic spinal balance became better than preoperative levels. However, the static spinal balance was at the same level as that of preoperative status.

Prognostic value of balance performance for improvements of community ambulation among stroke patients: a cohort study

BACKGROUND

Despite the positive impact of improving the level of community ambulation among stroke patients, little prognostic research has focused on this indicator.

AIM

To investigate the prognostic value of the side-by-side, semi-tandem, and tandem standing balance positions and the five-sit-stand (5STS) test for discriminating patients undergoing physical rehabilitation who improve level of functional ambulation and predicting transition time.

DESIGN

A cohort study with assessments repeated monthly until discharge for classifying patients in a community ambulation class.

SETTING

A neurological rehabilitation unit of a hospital in Spain.

POPULATION

A consecutive sample of 109 stroke patients (68.5±12.0 years) was screened and included within four months post stroke. Of them no one refused, 3 died, and 5 were lost earlier to transition or discharge.

METHODS

Balance tests, the 5STS and gait speed were measured at the center at baseline and monthly until discharge. Transition from household or limited community ambulation to a higher ambulatory capacity or class. Area under the curve (AUC) were used to compare discriminative abilities of the tests and Cox regression analysis to evaluate the association between the tests and time of transition.

RESULTS

For household non-ambulators, the semi-tandem was the best discriminative test (AUC=0.850) and the three balance tests showed an association with time to transition. Among the limited community ambulators, the 5STS test also revealed discriminative ability (AUC: 0.822 [0.63-1.00]), with a good prognostic cut-off (14.8 seconds) and association with time to transition (Hazard Ratio: 1.22; 95%CI: 1.05-1.43).

CONCLUSIONS

Semi-tandem and the 5STS tests can discriminate patients who improve level of functional ambulation and predict transition times within three months in non-ambulators and limited community ambulation patients, respectively.

CLINICAL REHABILITATION IMPACT

The semi-tandem and the 5STS tests can be performed easily in clinical settings to predict improvement of functional ambulation level in patients following stroke.

Patients Surviving Critical COVID-19 have Impairments in Dual-task Performance Related to Post-intensive Care Syndrome

Objective

The purpose was to examine Dual Task (DT) performance in patients surviving severe and critical COVID-19 compared to patients with chronic lung disease (CLD). Secondarily, we aimed to determine the psychometric properties of the Timed Up and Go (TUG) test in patients surviving COVID-19.

Design

Prospective, cross-sectional, observational study.

Setting

Academic medical center within United States.

Patients

Ninety-two patients including 36 survivors of critical COVID-19 that required mechanical ventilation (critical-COVID), 20 patients recovering from COVID-19 that required supplemental oxygen with hospitalization (severe-COVID), and 36 patients with CLD serving as a control group.

Measurements and Main Results

Patients completed the TUG, DT-TUG, Short Physical Performance Battery (SPPB), and Six Minute Walk Test (6MWT) 1-month after hospital discharge. A subset of patients returned at 3-months and repeated testing to determine the minimal detectable change (MDC). Critical-COVID group (16.8 ± 7.3) performed the DT-TUG in significantly slower than CLD group (13.9 ± 4.8 s; P = .024) and Severe-COVID group (13.1 ± 5.1 s; P = .025). Within-subject difference between TUG and DT-TUG was also significantly worse in critical-COVID group (−21%) compared to CLD (−10%; P = .012), even despite CLD patients having a higher comorbid burden (P < .003) and older age (P < .001). TUG and DT-TUG demonstrated strong to excellent construct validity to the chair rise test, gait speed, and 6MWT for both COVID-19 groups (r = −0.84to 0.73, P < .05). One- and 3-months after hospital discharge there was a floor effect of 14% (n = 5/36) and 5.2% (n = 1/19), respectively for patients in the critical-COVID group. Ceiling effects were noted in four (11%) critical-COVID, six (30%) severe-COVID patients for the TUG and DT-TUG at 1-month.

Conclusion

The ability to maintain mobility performance in the presence of a cognitive DT is grossly impaired in patients surviving critical COVID-19. DT performance may subserve the understanding of impairments related to Post-intensive care syndrome (PICS) for survivors of critical illness.

Can telerehabilitation services combined with caregiver-mediated exercises improve early supported discharge services poststroke? A study protocol for a multicentre, observer-blinded, randomized controlled trial

BACKGROUND

Recovery of walking ability is an important goal for patients poststroke, and a basic level of mobility is critical for an early discharge home. Caregiver-mediated exercises could be a resource-efficient strategy to augment exercise therapy and improve mobility in the first months poststroke. A combination of telerehabilitation and face-to-face support, blended care, may empower patient-caregiver dyads and smoothen the transition from professional support to self-management. The Armed4Stroke study aims to investigate the effects of a caregiver-mediated exercise program using a blended care approach in addition to usual care, on recovery of mobility in the first 6 months poststroke.

METHODS

A multicentre, observer-blinded randomized clinical trial in which 74 patient-caregiver dyads will be enrolled in the first 3 months poststroke. Dyads are randomly allocated to a caregiver-mediated exercises intervention or to a control group. The primary endpoint is the self-reported mobility domain of the Stroke Impact Scale. Secondary endpoints include care transition preparedness and psychological functioning of dyads, length of inpatient stay, gait-related measures and extended ADL of patients, and caregiver burden. Outcomes are assessed at enrolment, end of treatment and 6 months follow-up.

RESULTS

During 8 weeks, caregivers are trained to become an exercise coach using a blended care approach. Dyads will receive a tailor-made, progressive training program containing task-specific exercises focusing on gait, balance, physical activity and outdoor activities. Dyads are asked to perform the training program a minimum of 5 times a week for 30 min per session, supported by a web-based telerehabilitation system with instruction videos and a messaging environment to communicate with their physiotherapist.

CONCLUSIONS

We hypothesize that the Armed4Stroke program will increase self-reported mobility and independence in ADL, facilitating an early discharge poststroke. In addition, we hypothesize that active involvement of caregivers and providing support using blended care, will improve the care transition when professional support tapers off. Therefore, the Armed4Stroke program may complement early supported discharge services.

TRIAL REGISTRATION

Netherlands Trial Register, NL7422 . Registered 11 December 2018.

Physical activity level of post-stroke individuals that use the Brazilian public health system

Abstract Introduction: According to studies from developed countries, post-stroke individuals commonly have a low level of physical activity. Considering the benefits of maintaining a good level of physical activity in these subjects, it is important to provide specific and complete information, based on the assessment of all dimensions of physical activity, which supports interventions. Objective: To compare the physical activity levels between individuals with stroke and matched healthy individuals that use the public health system in Brazil considering the different dimensions of physical activity. Methods: Individuals with stroke (n = 11) and matched healthy individuals (n = 11) were assessed. Physical activity levels, considering all dimensions -duration (> 3 MET), frequency (number of steps) and intensity (mean total energy expenditure per day) - were assessed using SenseWear® monitor for seven days. Descriptive statistics and between-groups comparisons were performed (α = 0.05). Results: The physical activity levels were significantly lower in individuals with stroke when compared to matched healthy individuals, considering all dimensions. The between-group differences in activity duration, frequency, and intensity were 74 minutes/day, 5,274 steps/day, and 2,134kJ/day, respectively. Conclusion: Individuals with stroke users of the Brazilian public health system have lower physical activity levels in different dimensions of physical activity than matched healthy individuals. The assessment of the physical activity level of post-stroke individuals is important for decision making in public health programs.

Measuring Balance Abilities of Transtibial Amputees Using Multiattribute Utility Theory

Background

Berg Balance Scale (BBS) can be considered the standard for assessment of functional balance but has a noted ceiling effect in active transtibial amputees (TTAs). Development of ceiling-free measures based on quantitative measurement techniques that is suitable for patients in any experience levels, yet sensitive enough to capture improvements in any stage of prosthetic rehabilitation, is needed. Research Question. Does a scoring scheme based on Multiattribute Utility (MAU) theory assess balance abilities of multileveled TTAs comparable to BBS?

Methods

A case-control study including 28 participants (8 novice TTAs, 10 experienced TTAs, and 10 healthy controls) was conducted. Guided by MAU theory, a novel balance model was developed and initially validated by Spearman correlation between index-generated scores and expert assigned scores, providing preliminary evidence of validity. Floor/ceiling effects were tested, and between-group comparisons of static/dynamic balance were conducted by paired t-test or Wilcoxon signed-rank test depending on data distribution normality.

Results

BBS score was correlated with computed balance index (r = 0.847, p < 0.001). The BBS score of novice/experienced TTAs was 39/54, and the computed balance index was 38/75. A ceiling effect of BBS (30%) was observed in the experienced TTA group, whereas no ceiling effects were found for the computed index in any combination of TTA groups. Group differences between novice and experienced TTAs were observed in center of pressure (COP) ellipse shift area, COP path length, COP average velocity, gait speed, and cadence (all p < 0.05). Significance. Evidence from first stage validation of the proposed MAU balance model indicated that the model performed well. This proposed method can monitor the progress of balance for varied experience-leveled TTAs and provide clinicians with useful information for assessing the rehabilitation training.

Increased Anxiety and Depression Symptoms in Post-Acute Care Patients with Stroke during the COVID-19 Pandemic

This study aimed to explore the quality and stability of post-acute care for patients with stroke, including their functional outcomes, mental health and medical care in Taiwan during the COVID-19 pandemic. In this retrospective case-control study-based on propensity score matching-we assessed 11 patients admitted during the pandemic period (in 2021) and 11 patients admitted during the non-pandemic period (in 2020). Functional outcomes, including the scores of the modified Rankin Scale, Barthel Index, EuroQoL-5 Dimension, Lawton-Brody instrumental activities of daily living, Berg Balance Scale, 5-metre walking speed and 6-min walking distance, were determined. Data on the length of acute care, length of post-acute care, destination after discharge and 14-days readmission were used to evaluate the quality of medical care. The Wilcoxon signed-rank test was used to compare functional performance before and after rehabilitation. The pandemic group showed no significant improvement in the scores of EuroQoL-5 Dimension, a self-reported health status assessment (p = 0.13), with the anxiety or depression dimension showing a negative effect (r = 0.21). Post-acute care programmes can efficiently improve the functional performance of patients with stroke during the COVID-19 pandemic in Taiwan. Mental health should therefore be simultaneously maintained while rehabilitating physical function.

Experiences of Physical Therapists and Professional Leaders With Implementing a Toolkit to Advance Walking Assessment Poststroke: A Realist Evaluation

OBJECTIVE

The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings.

METHODS

A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice.

RESULTS

Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m.

CONCLUSION

Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings.

IMPACT

This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

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

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

Classification of Limb and Mobility Impairments in Persons With Stroke Using the STREAM

BACKGROUND AND PURPOSE

Classification of functional impairment in persons with stroke can influence treatment planning but this information is missing in the Stroke Rehabilitation Assessment of Movement (STREAM) Scale. This study aimed to establish the classification of limb mobility impairments and item difficulty of the STREAM.

METHODS

Rasch analysis was conducted on the STREAM scores to examine the person and item reliability, the item difficulty, and level of impairments. A total of 240 participants were evaluated using the STREAM, the Fugl-Meyer Stroke Assessment (FM), and the Functional Ambulation Categories (FAC). The concurrent validity of the STREAM extremity (STREAM-E) category with the FM-motor category and the STREAM mobility (STREAM-M) category with the FAC category was analyzed using the Spearman rank-order correlation.

RESULTS

Person reliabilities of the STREAM-E and STREAM-M were 0.92 and 0.80, respectively. High-item reliability was observed in both STREAM-E (0.97) and STREAM-M (0.99). The STREAM items "flexes hip and knee in supine" and "rolls onto side" were the easiest items, whereas the "dorsiflexes affected ankle with knee extended" item was the most difficult item. The STREAM-E category demonstrated excellent concurrent validity with the FM-motor category (ρ = 0.83) in classifying individuals with stroke into 5 groups: mild, moderate, moderately severe, severe, and very severe limb impairment. The STREAM-M category showed a moderate correlation with the FAC category (ρ = 0.71) in categorizing persons with stroke into 3 groups: mild, moderate, and severe mobility impairment.

DISCUSSION AND CONCLUSIONS

Findings can be used in the assessment and treatment planning of persons with stroke.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A373).

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial

BACKGROUND

Individuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke.

METHODS

An assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months.

RESULTS

Thirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported.

CONCLUSIONS

This study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes. Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016).

Capacidade, desempenho e confiança da marcha como preditores de quedas em indivíduos pós-acidente vascular encefálico

RESUMO O objetivo deste estudo foi avaliar a correlação entre capacidade, desempenho e confiança da marcha e número de quedas em indivíduos após sofrerem acidente vascular encefálico (AVE), além de investigar quais dessas variáveis relacionadas à marcha poderiam predizer as quedas nessa população. Foram avaliados 95 indivíduos pós-AVE, de acordo com número de quedas no último ano e capacidade de marcha (por meio de teste de caminhada de 10 metros), desempenho na marcha (pela aplicação do questionário ABILOCO-Brasil) e confiança na marcha (pela análise de modified gait efficacy scale). O coeficiente de correlação de Pearson foi utilizado para avaliar as correlações entre as variáveis. A regressão linear múltipla foi aplicada para avaliar se as variáveis relacionadas à marcha são capazes de predizer as quedas em indivíduos pós-AVE. Não foram encontradas correlações significativas entre capacidade (p=0,87) e performance na marcha (p=0,06) e número de quedas. Correlação significativa, negativa, de magnitude moderada, foi encontrada somente entre confiança na marcha e quedas (r=−0,43; p<0,01). Na análise de regressão, apenas a confiança na marcha permaneceu no modelo (p<0,01) como preditora do número de quedas em indivíduos pós-AVE, sendo capaz, sozinha, de explicar 18% (R2=0,18) dessa variável. Assim, os achados do estudo demonstraram que apenas a confiança na marcha está diretamente relacionada com o número de quedas em indivíduos pós-AVE, sendo essa também a única variável que pode ser considerada preditora desse evento nessa população.

Home-based rehabilitation programs on postural balance, walking, and quality of life in patients with stroke: A single-blind, randomized controlled trial

BACKGROUND

The most challenging aspect of rehabilitation is the high costs of in-patient rehabilitation programs and poor continuity of care while patients are transferred to home. In this regard, numerous home-based rehabilitation programs have been developed. The purpose of this study was to investigate the effects of home-based rehabilitative programs on postural balance, walking, and quality of life in individuals with chronic hemiparetic stroke.

DESIGN

A CONSORT-compliant randomized controlled trial.

METHODS

Seventeen community-dwelling people diagnosed with a first stroke participated in this study. They randomly divided the home-based rehabilitative program (HBP) group (n = 9) and control group (n = 8). The HBP group received coordination exercises at home and the control group received clinic-based exercises. This study measured postural balance, walking, and quality of life using four outcome measures: 10-meter walk test, figure of 8 walk test, four-square step test, and 36 item short-form survey.

RESULTS

After analysis, it was found that the HBP improved postural balance, comfortable speed, and fast speed walking, and straight and curved walking for chronic stroke. Second, clinic-based rehabilitation services improved postural balance, comfortable speed, and fast speed walking abilities in patients with chronic stroke.

CONCLUSION

The results of this study suggest that the HBP group received positive benefits with regard to the postural balance and walking abilities of chronic hemiparetic stroke patients compared to the clinical setting exercise program.

Serum activity of matrix metalloproteinase-2 and -9 is increased in chronic post-stroke individuals: a cross-sectional exploratory study

BACKGROUND

High concentrations of matrix metalloproteinase-2 (MMP-2) and -9 (MMP-9) are associated with inflammation early after stroke. In chronic stages, the elevation of some cytokines is related to the presence of co-morbid conditions in these individuals. In addition to this, some characteristics such as sensorimotor impairment, atrophy, and sedentary lifestyle predispose the system to an inflammatory response.

OBJECTIVE

To quantify MMP-2 and -9 serum activity in chronic post-stroke individuals and correlate it with variables of physical activity level, body composition, functional and walking capacity, and with inflammatory biomarkers. Additionally, gelatinase activity was characterized according to motor impairment.

METHODS

Fourteen patients with stroke onset >6 months and seven healthy individuals were enrolled in this study. The clinical assessment included: body composition, measure by bioelectrical impedance analyzer; Fugl-Meyer Motor Assessment Scale; six-minute and ten-meter walk tests, and physical activity level assessed by the StepWatch® Activity Monitor. Blood samples were collected from antecubital vein and serum MMP-2 and -9 activity was analyzed using gelatin Zymography, and the TNFα, IL-6, IL-1β, IL-10 biomarkers using ELISA kits.

RESULTS

Chronic post-stroke individuals presented an increased activity of MMP-2 and -9 compared to healthy individuals. Positive correlations with time and steps in low cadence and negative ones with medium cadence and peak activity index were observed. According to the motor impairment, the MMP-2 activity was increased in the mild-moderate group compared to the control group.

CONCLUSION

Increased gelatinases in chronic post-stroke individuals could describe an inflammation process related to the limited capacity of walking in high intensities.

Sensory Stimulation of the Foot and Ankle Early Post-stroke: A Pilot and Feasibility Study

Background: Somatosensory stimulation of the lower extremity could improve motor recovery and walking post-stroke. This pilot study investigated the feasibility of a subsequent randomized controlled trial (RCT) to determine whether task-specific gait training is more effective following either (a) intensive hands-on somatosensory stimulation or (b) wearing textured insoles. Objectives: Determine recruitment and attrition rates, adherence to intervention, acceptability and viability of interventions and outcome measures, and estimate variance of outcome data to inform sample size for a subsequent RCT. Methods: Design: randomized, single-blinded, mixed-methods pilot study. Setting: In-patient rehabilitation ward and community. Participants: n = 34, 18+years, 42-112 days following anterior or posterior circulation stroke, able to follow simple commands, able to walk independently pre-stroke, and providing informed consent. Intervention: Twenty 30-min sessions of task-specific gait training (TSGT) (delivered over 6 weeks) in addition to either: (a) 30-60 min mobilization and tactile stimulation (MTS); or (b) unlimited textured insole (TI) wearing. Outcomes: Ankle range of movement (electrogoniometer), touch-pressure sensory thresholds (Semmes Weinstein Monofilaments), motor impairment (Lower Extremity Motricity Index), walking ability and speed (Functional Ambulation Category, 5-m walk test, pressure insoles) and function (modified Rivermead Mobility Index), measured before randomization, post-intervention, and 1-month thereafter (follow-up). Adherence to allocated intervention and actual dose delivered (fidelity) were documented in case report forms and daily diaries. Focus groups further explored acceptability of interventions and study experience. Analysis: Recruitment, attrition, and dose adherence rates were calculated as percentages of possible totals. Thematic analysis of daily diaries and focus group data was undertaken. Standard deviations of outcome measures were calculated and used to inform a sample size calculation. Results: Recruitment, attrition, and adherence rates were 48.57, 5.88, and 96.88%, respectively. Focus groups, daily-diaries and case report forms indicated acceptability of interventions and outcome measures to participants. The 5-m walk was selected as primary outcome measure for a future trial [mean (SD) at end of intervention: 16.86 (11.24) MTS group and 21.56 (13.57) TI group]; sample size calculation indicated 60 participants are required per group. Conclusion: Recruitment, attrition and adherence rates and acceptability of interventions and outcomes justify a subsequent powered RCT of MTS+TSGT compared with TI+TSGT.

Clinical value of assessing motor performance in postacute stroke patients

Background

Rehabilitative treatment plans after stroke are based on clinical examinations of functional capacity and patient-reported outcomes. Objective information about daily life performance is usually not available, but it may improve therapy personalization.

Objective

To show that sensor-derived information about daily life performance is clinically valuable for counseling and the planning of rehabilitation programs for individual stroke patients who live at home. Performance information is clinically valuable if it can be used as a decision aid for the therapeutic management or counseling of individual patients.

Methods

This was an observational, cross-sectional case series including 15 ambulatory stroke patients. Motor performance in daily life was assessed with body-worn inertial sensors attached to the wrists, shanks and trunk that estimated basic physical activity and various measures of walking and arm activity in daily life. Stroke severity, motor function and activity, and degree of independence were quantified clinically by standard assessments and patient-reported outcomes. Motor performance was recorded for an average of 5.03 ± 1.1 h on the same day as the clinical assessment. The clinical value of performance information is explored in a narrative style by considering individual patient performance and capacity information.

Results

The patients were aged 59.9 ± 9.8 years (mean ± SD), were 6.5 ± 7.2 years post stroke, and had a National Institutes of Health Stroke Score of 4.0 ± 2.6. Capacity and performance measures showed high variability. There were substantial discrepancies between performance and capacity measures in some patients.

Conclusions

This case series shows that information about motor performance in daily life can be valuable for tailoring rehabilitative therapy plans and counseling according to the needs of individual stroke patients. Although the short recording time (average of 5.03 h) limited the scope of the conclusions, this study highlights the usefulness of objective measures of daily life performance for the planning of rehabilitative therapies. Further research is required to investigate whether information about performance in daily life leads to improved rehabilitative therapy results.

Using a cane for one month does not improve walking or social participation in chronic stroke: An attention-controlled randomized trial

OBJECTIVE

To examine the effects of the provision of a cane, delivered to ambulatory people with chronic stroke, for improving walking and social participation.

DESIGN

Two-arm, randomized trial.

SETTING

Community-based.

PARTICIPANTS

Ambulatory individuals with chronic stroke.

INTERVENTIONS

The experimental intervention was the provision of a single-point cane during one month. The control group received a placebo intervention.

OUTCOME MEASURES

Walking speed, step length, cadence, walking capacity, and walking confidence were measured without the cane to examine its rehabilitative effect. Walking speed was also measured with the cane for inclusiveness, and social participation was measured for examining carry over effects. Outcomes were measured at baseline, and after one and two months.

RESULTS

Fifty individuals were included. In the experimental group, mean age was 69 years (SD 14), and walking speed was 0.58 m/s (SD 0.17). In the control group, mean age was 68 years (SD 13), and walking speed was 0.63 m/s (SD 0.15). When walking without the cane, after one and after two months, there were no between-group differences in any measures. When walking with the cane, after one month, the experimental group walked 0.14 m/s (95% CI 0.05-0.23) faster than the control group and after two months, they were still walking 0.18 m/s (95% CI 0.06-0.30) faster.

CONCLUSION

Use of a cane improved walking speed, only when participants walked with the cane. Use of cane for one month did not improve walking outcomes, when walking without the cane. People with stroke would need to continue to use the cane to maintain any benefits in walking speed.

Gait speed and adverse outcomes following hospitalised exacerbation of COPD

Four-metre gait speed (4MGS) is a simple physical performance measure and surrogate marker of frailty that is associated with adverse outcomes in older adults. We aimed to assess the ability of 4MGS to predict prognosis in patients hospitalised with acute exacerbations of COPD (AECOPD).213 participants hospitalised with AECOPD (52% male, mean age and FEV₁, 72 years and 35% predicted) were enrolled. 4MGS and baseline demographics were recorded at hospital discharge. All-cause readmission and mortality were collected for 1 y after discharge, and multivariable Cox-proportional hazards regression were performed. Kaplan-Meier and Competing risk analysis was conducted comparing time to all-cause readmission and mortality between 4MGS quartiles.111 participants (52%) were readmitted, and 35 (16%) died during the follow-up period. 4MGS was associated with all-cause readmission, with an adjusted subdistribution hazard ratio of 0.868 (95% CI 0.797-0.945; p=0.001) per 0.1 m·s^-1 increase in gait speed, and with all-cause mortality with an adjusted subdistribution hazard ratio of 0.747 (95% CI: 0.622-0.898; p=0.002) per 0.1 m·s^-1 increase in gait speed. Readmission and mortality models incorporating 4MGS had higher discrimination than age or FEV₁% predicted alone, with areas under the receiver operator characteristic curves of 0.73 and 0.80 respectively. Kaplan-Meier and Competing Risk curves demonstrated that those in slower gait speed quartiles had reduced time to readmission and mortality (log rank both p<0.001).4MGS provides a simple means of identifying at-risk patients with COPD at hospital discharge. This provides valuable information to plan post-discharge care and support.

Feasibility of training using full immersion virtual reality video game in young stroke survivor: A case report

BACKGROUND

With the recent developments in science, full-immersion virtual reality devices have been developed, which may have feasibility for stroke rehabilitation.

OBJECTIVE

This case report investigated the feasibility of training using a full-immersion virtual reality video game for improving motor function, balance, and gait in a young stroke survivor.

METHOD

The case was a 27-year-old woman with stroke. A training using full-immersion virtual reality video game (Sony PlayStation®VR) was performed for 30 minutes per session, 3 sessions per week, for 6 weeks, with a total of 18 sessions. Before training and at each training for 6 weeks, with a total of 19 times, the motor function, balance, and gait were assessed using the Motor Assessment Scale (MAS), Berg Balance Scale (BBS), Timed Up and Go (TUG) Test, and Tinetti Balance Assessment, 10 Meter Walk Test (10MWT), Tinetti Gait Assessment, and Dynamic Gait Index (DGI).

RESULTS

During the training, there were no adverse events reported. The case achieved 14 points higher than the pre-assessment with 34 points on the MAS, 16 points higher than the pre-assessment with 48 points on BBS, 6.85 sec lower than the pre-assessment, with 13.58 sec on TUG, 5 points higher than the pre-assessment with 13 points on the Tinetti Balance Assessment, 5.36 sec lower than the pre-assessment, with 8.15 sec on the 10MWT, 4 points higher than the pre-assessment with 10 points on the Tinetti Gait Assessment, and 10 points higher than the pre-assessment with 21 points on the DGI.

CONCLUSION

This case report suggests that training using a full-immersion virtual reality video game may be a safe and effective method to improve motor function, balance, and gait in a young stroke survivor.

Responsiveness and interpretability of commonly used outcome assessments of mobility capacity in older hospital patients with cognitive spectrum disorders

Background

In older hospital patients with cognitive spectrum disorders (CSD), mobility should be monitored frequently with standardised and psychometrically sound measurement instruments. This study aimed to examine the responsiveness, minimal important change (MIC), floor effects and ceiling effects of commonly used outcome assessments of mobility capacity in older patients with dementia, delirium or other cognitive impairment.

Methods

In a cross-sectional study that included acute older hospital patients with CSD (study period: 02/2015–12/2015), the following mobility assessments were applied: de Morton Mobility Index (DEMMI), Hierarchical Assessment of Balance and Mobility (HABAM), Performance Oriented Mobility Assessment, Short Physical Performance Battery, 4-m gait speed test, 5-times chair rise test, 2-min walk test, Timed Up and Go test, Barthel Index mobility subscale, and Functional Ambulation Categories. These assessments were administered shorty after hospital admission (baseline) and repeated prior to discharge (follow-up). Global rating of mobility change scales and a clinical anchor of functional ambulation were used as external criteria to determine the area under the curve (AUC). Construct- and anchor-based approaches determined responsiveness. MIC values for each instrument were established from different anchor- and distribution-based approaches.

Results

Of the 63 participants (age range: 69–94 years) completing follow-up assessments with mild (Mini Mental State Examination: 19–24 points; 67%) and moderate (10–18 points; 33%) cognitive impairment, 25% were diagnosed with dementia alone, 13% with delirium alone, 11% with delirium superimposed on dementia and 51% with another cognitive impairment. The follow-up assessment was performed 10.8 ± 2.5 (range: 7–17) days on average after the baseline assessment. The DEMMI was the most responsive mobility assessment (all AUC > 0.7). For the other instruments, the data provided conflicting evidence of responsiveness, or evidence of no responsiveness. MIC values for each instrument varied depending on the method used for calculation. The DEMMI and HABAM were the only instruments without floor or ceiling effects.

Conclusions

Most outcome assessments of mobility capacity seem insufficiently responsive to change in older hospital patients with CSD. The significant floor effects of most instruments further limit the monitoring of mobility alterations over time in this population. The DEMMI was the only instrument that was able to distinguish clinically important changes from measurement error.

Trial registration

German Clinical Trials Register (DRKS00005591). Registered February 2, 2015.

Concurrent validity and reliability of an activity monitoring for rehabilitation (AMoR) platform for step counting and sitting/lying time in post-stroke individuals

BACKGROUND

Objective and reliable measurements to investigate daily behavior patterns in people with stroke could help therapeutic interventions after a stroke.

OBJECTIVE

To evaluate whether the Activity Monitoring for Rehabilitation (AMoR) platform has adequate concurrent validity and reliability for step counting and time spent sitting/lying in people post-stroke and to investigate its percentage accuracy for step counting at different walking speeds.

METHODS

Cross-sectional observational study. Fifty chronic post-stroke subjects used the AMoR platform and SAM simultaneously while a Video camera recorded the same activities during clinical trials. Spearman's correlation coefficient, the mean absolute percentage error, the intraclass correlation coefficient and Bland-Altman plot analyses were used to estimate the validity and reliability of the AMoR platform and StepWatch^TM Activity Monitor (SAM). The accuracy percentage was calculated for each device and plotted as a function of the walking speed during the 10-meter walk test (10MWT).

RESULTS

There was a very high correlation for step counting in all tests and a high correlation for time spent sitting/lying. The mean absolute percentage error values remained below 4% for step counting and time sitting/lying. The AMoR platform also showed excellent reliability for step counting and sitting/lying time, with values within the limit of agreement in the Bland-Altman plots. A high percentage of accuracy for step counting in the AMoR platform was observed during the 10MWT.

CONCLUSION

The AMoR platform is valid and reliable for step counting and time spent sitting/lying, with a high percentage of accuracy at different walking speeds in the post-stroke population.