Perceived barriers and facilitators for gait-related participation in people after stroke: From a patients' perspective

Development of an interprofessional diagnostic toolkit to enhance outside walking gait-related participation of people after stroke in Germany: study protocol of an ongoing multi-methods study

INTRODUCTION

Persons after stroke experience limitations in activities of daily living even in the chronic phase. Many patients who had a stroke report mobility limitations with loss of social roles such as reduced gait-related participation. International best-practice recommendations for patients who had a stroke include interprofessional diagnostics as a core element for goal setting and intervention planning to improve social participation. Interprofessional diagnostics has not yet been implemented in Germany.

METHODS AND ANALYSIS

The aim is to develop an interprofessional diagnostic toolkit. This will be done in a multi-step process: first, an integrative review is conducted to synthesise the literature. Second, the experiences regarding diagnostics and walking outside is captured in focus groups with persons after stroke, relatives and health professionals. Third, a toolkit for the interprofessional diagnostic process of gait-related-participation will be developed based on the results of the previous steps in a future workshop. Fourth, the results of each work package will be integrated into the iterative development process for evaluation and implementation. All steps will be performed in accordance with the respective reporting guidelines.

ETHICS AND DISSEMINATION

This study has been approved by the ethics committee at the Ludwig Maximilians University (LMU), Germany and is overseen by LMU-Medical Institutional Review Board. Written informed consent will be obtained from all participants. Results will be disseminated through knowledge exchange with stakeholders and in peer-reviewed journal publications, scientific conferences, formal and informal reports. Stakeholders, patients and providers will be involved in most steps of the development from the beginning, which will facilitate later implementation at a larger scale.

TRIAL REGISTRATION NUMBER

German Register Clinical Trials/Deutsches Register Klinischer Studien DRKS00032389.

Recent Advances in Self-Powered Wearable Flexible Sensors for Human Gaits Analysis

The rapid progress of flexible electronics has met the growing need for detecting human movement information in exoskeleton auxiliary equipment. This study provides a review of recent advancements in the design and fabrication of flexible electronics used for human motion detection. Firstly, a comprehensive introduction is provided on various self-powered wearable flexible sensors employed in detecting human movement information. Subsequently, the algorithms utilized to provide feedback on human movement are presented, followed by a thorough discussion of their methods and effectiveness. Finally, the review concludes with perspectives on the current challenges and opportunities in implementing self-powered wearable flexible sensors in exoskeleton technology.

How, and to what end, is the WHO-ICF framework represented in physiotherapy? Insights from a qualitative research synthesis

BACKGROUND

It has been two decades since the World Health Organization's endorsement of the International Classification of Functioning, Disability and Health (ICF). It is timely to undertake a rigorous search that analyzes the discourses around the ICF's conceptual framework within physiotherapy, the kinds of enquiry to date and the professional areas where this is happening and how.

PURPOSE

The aim of this research is to synthesize the literature related to how the physiotherapy profession (practice, research and education) thinks about and puts to use the WHO ICF.

RESULTS

A final sample of 37 papers was agreed. Five overarching third-order interpretations were derived: (i) A way of thinking and practicing, (ii) Endorsed but not embedded, (iii) Striking a balance, (iv) Power of participation and (v) Moving forward. Together, these themes illustrate the evolving role of the ICF in physiotherapy over the previous two decades. They highlight the ICF's potential for shaping the future of physiotherapy practice, education and research.

CONCLUSIONS

Work is needed to connect existing literature about the ICF and related models and embed the ICF, its language and philosophy across physiotherapy education and practice. Re-representation of the model might help address misinterpretation of the ICF, but fundamentally, embedding the ICF in entry-level curriculum is likely to be the most significant driver of change in practice.

Accuracy, concurrent validity, and test-retest reliability of pressure-based insoles for gait measurement in chronic stroke patients

Introduction

Wearables are potentially valuable tools for understanding mobility behavior in individuals with neurological disorders and how it changes depending on health status, such as after rehabilitation. However, the accurate detection of gait events, which are crucial for the evaluation of gait performance and quality, is challenging due to highly individual-specific patterns that also vary greatly in movement and speed, especially after stroke. Therefore, the purpose of this study was to assess the accuracy, concurrent validity, and test-retest reliability of a commercially available insole system in the detection of gait events and the calculation of stance duration in individuals with chronic stroke.

Methods

Pressure insole data were collected from 17 individuals with chronic stroke during two measurement blocks, each comprising three 10-min walking tests conducted in a clinical setting. The gait assessments were recorded with a video camera that served as a ground truth, and pressure insoles as an experimental system. We compared the number of gait events and stance durations between systems.

Results and discussion

Over all 3,820 gait events, 90.86% were correctly identified by the insole system. Recall values ranged from 0.994 to 1, with a precision of 1 for all measurements. The F1 score ranged from 0.997 to 1. Excellent absolute agreement (Intraclass correlation coefficient, ICC = 0.874) was observed for the calculation of the stance duration, with a slightly longer stance duration recorded by the insole system (difference of -0.01 s). Bland-Altmann analysis indicated limits of agreement of 0.33 s that were robust to changes in walking speed. This consistency makes the system well-suited for individuals post-stroke. The test-retest reliability between measurement timepoints T1 and T2 was excellent (ICC = 0.928). The mean difference in stance duration between T1 and T2 was 0.03 s. We conclude that the insole system is valid for use in a clinical setting to quantitatively assess continuous walking in individuals with stroke.

Effects of robotic-assisted gait training on physical capacity, and quality of life among chronic stroke patients: A randomized controlled study

BACKGROUND

Even though robotic therapy is becoming more commonly used in research protocols for lower limb stroke rehabilitation, there still is a significant gap between research evidence and its use in clinical practice. Therefore, the present study was designed assuming that the wearable mobile gait device training for chronic stroke patients might have different effects on functional independence when compared to training with a stationary gait device. The present study aims to examine the effects of gait training with ExoAthlet exoskeleton and Lokomat Free-D on functional independence, functional capacity, and quality of life in chronic stroke patients.

METHODS

The present study included 32 chronic stroke patients. Participants were randomly divided into two groups. Functional independence of patients was evaluated by using Functional Independence Measure (FIM), physical function was assessed by using the 30-second chair stand test (30-CST), functional capacity was measured by using the 6-Minute Walk Test (6MWT), and quality of life was assessed by using Short Form 36 (SF36). All participants underwent a conventional physiotherapy program for eight weeks, three sessions per week, and each session lasted 60 min. After the physiotherapy program, one group received gait training by using ExoAthlet exoskeleton (ExoAtlet 1 model/2019, Russia), while the other group received training by using Lokomat Free-D (Hocoma, Lokomat Pro Free-D model/2015, Switzerland). Participants were assessed at baseline and post-intervention.

RESULTS

Results achieved in this study revealed that there was a statistically significant difference between FIM, 30-CST, 6MWT, and SF36 scores before and after the treatment in both groups (p < 0.05).There was no difference in FIM, 30-CST, and 6MWT results between Exoskeleton ExoAthlet and Lokomat Free-D groups (p > 0.05). However, there was a statistically significant difference between Exoskeleton ExoAthlet and Lokomat Free-D groups in terms of SF-36 sub-parameters "vitality", "mental health", "bodily pain", and "general health perception" (p < 0.05).

CONCLUSIONS

This study demonstrated that the use of ExoAthlet exoskeleton and Lokomat Free-D in addition to conventional physiotherapy, was effective in improving functional independence, physical function, functional capacity, and quality of life among chronic stroke patients. Incorporation of robotic gait aids into rehabilitation for chronic stroke patients might offer significant advantages.

Sympathetic nervous system responses during complex walking tasks and community ambulation post-stroke

Stroke survivors frequently report increased perceived challenge of walking (PCW) in complex environments, restricting their daily ambulation. PCW is conventionally measured through subjective questionnaires or, more recently, through objective quantification of sympathetic nervous system activity during walking tasks. However, how these measurements of PCW reflect daily walking activity post-stroke is unknown. We aimed to compare the subjective and objective assessments of PCW in predicting home and community ambulation. In 29 participants post-stroke, we measured PCW subjectively with the Activities-specific Balance Confidence (ABC) Scale and objectively through electrodermal activity, quantified by change in skin conductance levels (SCL) and skin conductance responses (SCR) between outdoor-complex and indoor-steady-state walking. High-PCW participants were categorized into high-change SCL (ΔSCL ≥ 1.7 μs), high-change SCR (ΔSCR ≥ 0.2 μs) and low ABC (ABC < 72%) groups, while low-PCW participants were categorized into low-change SCL (ΔSCL < 1.7 μs), low-change SCR (ΔSCR < 0.2 μs) and high-ABC (ABC ≥ 72%) groups. Number and location of daily steps were quantified with accelerometry and Global Positioning System devices. Compared to low-change SCL group, the high-change SCL group took fewer steps in home and community (p = 0.04). Neither ABC nor SCR groups differed in home or community steps/day. Objective measurement of PCW via electrodermal sensing more accurately represents home and community ambulation compared to the subjective questionnaire.

The Immediate Effects of Different Types of Augmented Feedback on Fast Walking Speed Performance and Intrinsic Motivation After Stroke

Objective

To examine the immediate effects of different types of augmented feedback on walking speed and intrinsic motivation post-stroke.

Design

A within-subjects repeated-measures design.

Setting

A university rehabilitation center.

Participants

Eighteen individuals with chronic stroke hemiparesis with a mean age of 55.67±13.63 years and median stroke onset of 36 (24, 81) months (N=18).

Interventions

Not applicable.

Primary outcome

Fast walking speed measured on a robotic treadmill for 13 meters without feedback and 13 meters with augmented feedback on each of the 3 experimental conditions: (1) without virtual reality (VR), (2) with a simple VR interface, and (3) with VR-exergame. Intrinsic motivation was measured using the Intrinsic Motivation Inventory (IMI).

Results

Although the differences were not statistically significant, fast-walking speed was higher in the augmented feedback without VR (0.86±0.44 m/s); simple VR interface (0.87±0.41 m/s); VR-exergame (0.87±0.44 m/s) conditions than in the fast-walking speed without feedback (0.81±0.40 m/s) condition. The type of feedback had a significant effect on intrinsic motivation (P=.04). The post hoc analysis revealed borderline significance on IMI-interest and enjoyment between the VR-exergame condition and the without-VR condition (P=.091).

Conclusion

Augmenting feedback affected the intrinsic motivation and enjoyment of adults with stroke asked to walk fast on a robotic treadmill. Additional studies with larger samples are warranted to examine the relations among these aspects of motivation and ambulation training outcomes.

Case report: A novel approach of closed-loop brain stimulation combined with robot gait training in post-stroke gait disturbance

Most post-stroke patients have long-lasting gait disturbances that reduce their daily activities. They often show impaired hip and knee joint flexion and ankle dorsiflexion of the lower limbs during the swing phase of gait, which is controlled by the corticospinal tract from the primary motor cortex (M1). Recently, we reported that gait-synchronized closed-loop brain stimulation targeting swing phase-related activity in the affected M1 can improve gait function in post-stroke patients. Subsequently, a gait-training robot (Orthobot^®) was developed that could assist lower-limb joint movements during the swing phase of gait. Therefore, we investigated whether gait-synchronized closed-loop brain stimulation combined with robot-assisted training targeting the swing phase could enhance the recovery of post-stroke gait disturbance. A 57-year-old female patient with chronic post-stroke hemiparesis underwent closed-loop brain stimulation combined with robot-assisted training for 10 min 2 years after left pons infarction. For closed-loop brain stimulation, we used transcranial oscillatory electrical current stimulation over the lesioned M1 foot area with 1.5 mA of DC offset and 0-3 mA of sine-wave formed currents triggered by the paretic heel contact to set the maximum current just before the swing phase (intervention A; two times repeated, A1 and A2). According to the N-of-1 study design, we also performed sham stimulation (intervention B) and control stimulation not targeting the swing phase (intervention C) combined with robot-assisted training in the order of A1-B-A2-C interventions. As a result, we found larger improvements in gait speed, the Timed Up and Go test result, and muscle strength after the A1 and A2 interventions than after the B and C interventions. After confirming the short-term effects, we performed an additional long-term intervention twice a week for 5 weeks, for a total of 10 sessions. Gait parameters also largely improved after long-term intervention. Gait-synchronized closed-loop brain stimulation combined with robot-assisted training targeting the swing phase of gait may promote the recovery of gait function in post-stroke patients. Further studies with a larger number of patients are necessary.

Post-Stroke Experiences and Rehabilitation Needs of Community-Dwelling Chinese Stroke Survivors: A Qualitative Study

Stroke survivors encounter significant limitations in daily life activities and face increased risk of health complications such as stroke recurrence. Considering the escalating demand for personalised community rehabilitation services, this qualitative study was conducted to understand the current recovery experiences, needs, and expectations of community-dwelling stroke survivors. Fifty stroke survivors were recruited from two tertiary teaching hospitals and community centres in two provinces in mainland China. Semi-structured interviews were carried out, and participants were asked to describe their experiences of stroke, current lifestyles, exercise habits, and rehabilitation needs and expectations. Resulting data were thematically analysed. The majority of participants were first-time stroke survivors (80%) and lived with their family or caregivers (92%). Four main themes and twelve sub-themes emerged from the data: (1) shifts in social life, (2) shaken sense of self and perceived helplessness, (3) complex rehabilitation needs, and (4) perceptions and patterns of physical activity. Findings suggest that though survivors recognised their need for further rehabilitation, their demands remained unmet due to a combination of personal and external factors such as limited mobility and the absence of supportive companions and accessible facilities. The enhancement and diversification of home rehabilitation strategies are therefore necessary to make community rehabilitation more accessible and equitable.

Benefits of an interdisciplinary stroke clinic: addressing a gap in physical therapy at post-stroke neurology follow-up

BACKGROUND AND PURPOSE

An interdisciplinary stroke clinic (ISC) can improve communication and identify people post-stroke who have not reached their full recovery potential. We describe the characteristics of participants who underwent physical therapy (PT) evaluation in addition to their outpatient neurology evaluation and identify the association of assessment scales that predicted referral for additional rehabilitation.

METHODS

Participants' post-stroke seen in the ISC were included in the study. The PT evaluation included the Berg Balance Scale (BBS), Ten-Meter Walk Test (10MWT), Six-Minute Walk Test (6MWT), and Short Form-Stroke Impact Scale (SF-SIS). Multivariable logistic regression analysis was performed to identify factors associated with referral for additional rehabilitation.

RESULTS

The study consisted of 148 participants with a mean age of 63 (SD ± 15) years; 58% were women and 76% were Whites. Additional rehabilitation was recommended for 59% of participants. In multivariate analysis, reduced speed on comfortable 10MWT (OR = 0.06; 95%CI = 0.01-0.51) and lower SF-SIS score (OR = 0.76; 95%CI = 0.66-0.87) were significantly associated with referral for additional PT or occupational therapy.

CONCLUSION

A significant number of post-acute stroke survivors were found to be appropriate for additional rehabilitation when assessed clinically by a neurologic physical therapist in an ISC. The measures that most closely correlated with this in-person clinical evaluation were 10MWT and SF-SIS.IMPLICATIONS FOR REHABILITATIONAn interdisciplinary stroke clinic can improve communication and identify people post-stroke who have not reached their full recovery potential.In a pilot study, a significant number of post-acute stroke survivors were found to be appropriate for additional rehabilitation when assessed clinically by a neurologic physical therapist in an interdisciplinary stroke clinic.Reduced speed on comfortable Ten-Meter Walk Test and lower Short Form-Stroke Impact Scale scores were associated with referral for additional rehabilitation.

Barriers to Gait Training among Stroke Survivors: An Integrative Review

Gait recovery is vital for stroke survivors' ability to perform their activities associated with daily living. Consequently, a gait impairment is a significant target for stroke survivors' physical rehabilitation. This review aims to identify barriers to gait training among stroke survivors. An integrative review was conducted following Whittemore and Knafl's methodology. The research was carried out on the electronic databases Scopus, PubMed, and B-on, applying a time span of 2006 to 2022. A total of 4189 articles were initially identified. After selecting and analyzing the articles, twelve studies were included in the sample. This review allowed for the identification of several barriers to gait training among stroke survivors, which can be grouped into three categories: individual, environmental, and rehabilitation workforce-related barriers. These findings highlight that participation in gait training is not solely dependent on the stroke survivor. Instead, the uptake of rehabilitation programs may also depend on environmental and rehabilitation workforce-related factors.

[Functional and activity limitations in patients after a stroke]

One of the main characteristics of the goal of rehabilitation after a stroke is the focus on restoring a certain level of functioning. The formation of the goal of rehabilitation and the implementation of effective rehabilitation are possible when taking into account not only the clinical diagnosis, but also the problems and possibilities of the patient in the categories of the International Classification of Functioning, Disabilities and Health (ICF).

PURPOSE OF THE STUDY

To assess the types and degree of functional limitations and activity limitations in patients after ischemic and hemorrhagic strokes in the early recovery period, taking into account the type of stroke and the affected vascular pool.

MATERIAL AND METHODS

528 patients after a stroke were examined. Functional limitations and activity limitations were assessed in ICF categories, taking into account the type of stroke (hemorrhagic, ischemic) and the affected vascular system (carotid, vertebrobasilar), including dysfunctions (motor, global and specific mental functions, balance function, functions of the cardiovascular system), activity restrictions (limitations of paretic limbs mobility, functional independence from others). To quantify the degree of limitation, generally accepted rating scales were used (Medical Research Council Scale, Modified Ashworth Scale of muscle spasticity, Frenchay arm test, Hauser ambulation index, Rivermead mobility index, Functional Independence Measure, «Memory for images», «Learning 10 words», «Red-black Schulte-Platonov tables», Luscher color test, The hospital Anxiety and Depression Scale, Recovery Locus of Control), stabilography method, registration of office and outpatient blood pressure.

RESULTS

Limitations of the functions of paretic limbs and activity associated with maintaining body position, walking, movement, transfer, manipulation of objects and self-care, dependence on others in everyday life were found in most patients after hemorrhagic stroke (in 94-95%) and ischemic (in 88-93%) stroke in the carotid pool, while more severe disorders were recorded in cases of hemorrhagic type of stroke. Violation of global mental functions was recorded in ¼ of patients, specific mental functions - in 60-75% of patients after hemorrhagic stroke and ischemic stroke in the carotid pool. In ischemic stroke happens in the vertebrobasilar basin, the limitations of the daily activity of patients were determined by the violation of static and dynamic balance; a mild degree of impairment of specific mental functions and limitation of activity (self-service) were also recorded.

CONCLUSION

After a stroke, motor function disorders, mobility limitations of paretic limbs and self-service, postural disorders are recorded. After an ischemic stroke in the vertebrobasilar basin, the restrictions on the activity of patients are determined by postural disorders. Taking into account the identified features of functional limitations and activity limitations in patients after a stroke will allow developing a differentiated approach not only to the formation of goals and objectives of rehabilitation, but also to the choice of rehabilitation methods.

To What Extent is Walking Ability Associated with Participation in People after Stroke?

OBJECTIVES

This study aims to 1) identify the relation between walking ability and participation after stroke and 2) explore whether change in walking ability is associated with change in participation over time in community living-people after stroke.

MATERIALS AND METHODS

Fifty-two people after stroke were assessed at baseline and after a 6-week gait training intervention. People were included between two weeks and six months after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation was used to measure participation. Assessment of walking ability included the six-minute walking test for walking endurance, Timed-up & Go test for functional mobility, Mini Balance Evaluation Systems Test for dynamic balance, and total duration of walking activity per day to measure walking activity.

RESULTS

At baseline, six-minute walking test, Timed-up & Go test, and Mini Balance Evaluation Systems Test were univariately associated with participation (P < 0.001). Backward multiple regression analysis showed that the Mini Balance Evaluation Systems Test independently explained 55.7% of the variance in participation at baseline. Over time, only change in the six-minute walking test was positively associated with change in participation (R² = 0.087, P = 0.040).

CONCLUSIONS

Cross-sectional associations showed that walking ability, and especially dynamic balance, contributes to participation after stroke. Dynamic balance, as underlying variable for walking, was an important independently related factor to participation after stroke which needs attention during rehabilitation. Longitudinally, improvement in walking endurance was significantly associated with improvement in participation, which indicates the relevance of training walking endurance to improve participation after stroke.

Effect of Virtual Reality Gait Training on Participation in Survivors of Subacute Stroke: A Randomized Controlled Trial

OBJECTIVE

After stroke, people experience difficulties with walking that lead to restrictions in participation in daily life. The purpose of this study was to examine the effect of virtual reality gait training (VRT) compared to non-virtual reality gait training (non-VRT) on participation in community-living people after stroke.

METHODS

In this assessor-blinded, randomized controlled trial with 2 parallel groups, people were included between 2 weeks and 6 months after stroke and randomly assigned to the VRT group or non-VRT group. Participants assigned to the VRT group received training on the Gait Real-time Analysis Interactive Lab (GRAIL), and participants assigned to the non-VRT group received treadmill training and functional gait exercises without virtual reality. Both training interventions consisted of 12 30-minute sessions during 6 weeks. The primary outcome was participation measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) 3 months postintervention. Secondary outcomes included subjective physical functioning, functional mobility, walking ability, dynamic balance, walking activity, fatigue, anxiety and depression, falls efficacy, and quality of life.

RESULTS

Twenty-eight participants were randomly assigned to the VRT group and 27 to the non-VRT group, of whom 25 and 22 attended 75% or more of the training sessions, respectively. No significant differences between the groups were found over time for the USER-P restrictions subscale (1.23; 95% CI = -0.76 to 3.23) or secondary outcome measures. Patients' experiences with VRT were positive, and no serious adverse events were related to the interventions.

CONCLUSIONS

The effect of VRT was not statistically different from non-VRT in improving participation in community-living people after stroke.

IMPACT

Although outcomes were not statistically different, treadmill-based VRT was a safe and well-tolerated intervention that was positively rated by people after stroke. VR training might, therefore, be a valuable addition to stroke rehabilitation.

LAY SUMMARY

VRT is feasible and was positively experienced by people after stroke. However, VRT was not more effective than non-VRT for improving walking ability and participation after stroke.