Measurement of Community Ambulation After Stroke

How robot-assisted gait training affects gait ability, balance and kinematic parameters after stroke: a systematic review and meta-analysis

INTRODUCTION

Gait ability is often cited by stroke survivors. Robot-assisted gait training (RAGT) can help stroke patients with lower limb motor impairment regain motor coordination.

EVIDENCE ACQUISITION

PubMed, Cochrane Library, Embase were systematically searched until September 2023, to identify randomized controlled trials presenting: stroke survivors as participants; RAGT as intervention; conventional rehabilitation as a comparator; gait assessment, through scales or quantitative parameters, as outcome measures.

EVIDENCE SYNTHESIS

Twenty-seven publications involving 1167 patients met the inclusion criteria. Meta-analysis showed no significant differences in speed, cadence, spatial symmetry, and changes in joint mobility angles between the RAGT group and the control group. In addition, RAGT was associated with changes in affected side step length (SMD=0.02, 95% CI: 0.01, 0.03; P<0.0001), temporal symmetry (SMD=-0.38, 95% CI: -0.6, -0.16; P=0.0006], Six-Minute Walk Test (SMD=25.14, 95% CI: 10.19, 40.09; P=0.0010] and Functional Ambulation Categories (SMD=0.32, 95% CI: 0.01, 0.63; P=0.04). According to the PEDro scale, 19 (70.4%) studies were of high quality and eight were of moderate quality (29.6%).

CONCLUSIONS

Taken together, the review synthesis showed that RAGT might have a potential role in the recovery of walking dysfunction after stroke. However, its superiority over conventional rehabilitation requires further research. Additionally, it may provide unexpected benefits that the effects of RAGT with different types or treatment protocols were further compared.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Effects of gait adaptation training on augmented reality treadmill for patients with stroke in community ambulation

Gait adaptability is essential for stroke survivors to achieve efficient and safe community ambulation. However, conventional treadmill rehabilitation is only a repetitive practice of leg movement. This study compared the effects of augmented reality treadmill-based gait adaptation training with regular treadmill programs for patients with stroke. Forty patients with stroke (n = 40) were randomly assigned to the gait adaptation training {n = 20, age: 49.85 [standard deviation (SD) 8.44] years; onset of stroke: 107.80 (SD 48.31) days} and regular training [n = 20, age: 50.75 (SD 8.05) years, onset of stroke: 111.60 (SD 49.62) days] groups. Both groups completed three sessions of training per week for 5 weeks (15 sessions). The primary outcomes were the 10-m walk test and success rate of obstacle avoidance, while secondary outcomes included the Berg balance scale, component timed-up-and-go, and fall rate in a 6-month follow-up period. Assessments were performed before and after the intervention. The paired t-test was applied to compare the differences within groups and independent sample t-test was performed to compare the differences between groups. The 10-m walk test, success rate of obstacle avoidance, Berg balance scale, and component timed-up-and-go all significantly improved in the both groups (P < .001). The success rate of obstacle avoidance [P = .02, 95% confidence interval (CI): -21.07, -1.64], Berg Balance Scale (P = .02, 95% CI: -8.03, -0.67), 'turning around time' (P = .04, 95% CI: 0.08, 2.81), 'stand-to-sit' (P = .03, 95% CI: 0.16, 2.41) and 'total time' (P = .048, 95% CI: 0.04, 10.32) improved significantly in gait adaptation training group after intervention, while the 10-m walk test (P = .09, 95% CI: -0.17, 0.01), timed 'sit-to-stand' (P = .09, 95% CI: -0.14, 2.04), and 'linear walking' (P = .09, 95% CI: -0.27, 3.25) in gait adaptation training group did not show statistical difference compared to the regular training group. Total fall rate during the follow-up period was statistically decreased in the gait adaptation training group (P = .045). Both interventions improved mobility outcomes, with augmented reality treadmill-based gait adaptation indicating greater improvement in obstacle avoidance, balance, turning, and stand-to-sit. Augmented reality treadmill-based gait adaptation training emerges as an effective and promising intervention for patients with stroke in early rehabilitation.

Community mobility and participation assessment of manual wheelchair users: a review of current techniques and challenges

According to the World Health Organization, hundreds of individuals commence wheelchair use daily, often due to an injury such as spinal cord injury or through a condition such as a stroke. However, manual wheelchair users typically experience reductions in individual community mobility and participation. In this review, articles from 2017 to 2023 were reviewed to identify means of measuring community mobility and participation of manual wheelchair users, factors that can impact these aspects, and current rehabilitation techniques for improving them. The selected articles document current best practices utilizing self-surveys, in-clinic assessments, and remote tracking through GPS and accelerometer data, which rehabilitation specialists can apply to track their patients' community mobility and participation accurately. Furthermore, rehabilitation methods such as wheelchair training programs, brain-computer interface triggered functional electric stimulation therapy, and community-based rehabilitation programs show potential to improve the community mobility and participation of manual wheelchair users. Recommendations were made to highlight potential avenues for future research.

The effect of body awareness on trunk control, affected upper extremity function, balance, fear of falling, functional level, and level of independence in patients with stroke

OBJECTIVES

This study was conducted to examine the effects of body awareness on trunk control, affected upper extremity function, balance, fear of falling, functional level, and level of independence in patients with stroke.

METHODS

35 individuals between the ages of 21 and 78 who were diagnosed with stroke were included in the study. The body awareness of the individuals participating in the study was determined with the Body Awareness Questionnaire (BAQ), trunk control with Trunk Impairment Scale (TIS), the affected upper extremity functions with Motor Activity Log-28 (MAL,-28), and Fugl-Meyer Upper Extremity Assessment (FMUEA), balance with Berg Balance Scale (BBS), fear of falling with Tinetti Falls Efficacy Scale (TFES), functional level with Barthel Activities of Daily Living Index (BI) and level of independence with Functional Independence Measures (FIM).

RESULTS

For patients participating in the study, 26% were female, 74% were male and 43% showed left, 57% showed right hemisphere involvement. In simple linear regression analysis, BAQ measurement had a statistically significant effect on TIS (F = 25.439 p = 0.001), MAL-28 (F = 7.852 p = 0.008), FMUEA (F = 12.155 p = 0.001), BBS (F = 13.506 p = 0.001), TFES (F = 13.119 p = 0.001), BI (F = 19.977 p = 0.001) and FIM (F = 22.014 p = 0.001) in patients with stroke.

CONCLUSIONS

In conclusion, body awareness was found to be one of the factors affecting trunk control, affected upper extremity function, balance, fear of falling, functional level, and level of independence in patients with stroke. It was thought that there was a need for assessment of body awareness and include bodyawareness in rehabilitation programs in patients with stroke.

Impact of a dual task on the energy cost of walking in individuals with subacute phase stroke

OBJECTIVE

To assess the impact of cognitive Dual Task (DT) during walking on the energy cost of walking (Cw) in individuals with subacute stroke. The secondary objective was to determine whether there is an association between the Cw and cortical activity of the prefrontal area.

METHODS

Any individual with stroke localized in the temporal-parietal regions and able to walk without human assistance was included. Cw and prefrontal cortical activity, recorded by fNIRS, were measured during simple task walking activity and cognitive dual task during walking.

RESULTS

Nineteen individuals with stroke (age = 67.7 ± 9.6 yrs) were included. The cognitive DT during walking resulted in an increase in Cw of 23.1%; 95%CI [13.1%; 34.5%]. The increase in Cw in cognitive DT was correlated with the Cw for the single task walking activity (r = 0.48, p < 0.01) as well as the predominance of cortical activity of the prefrontal area in the contralesional hemisphere (r = -0.33, p < 0.01).

CONCLUSION

There is an increase in Cw during the cognitive DT. This increase is even more significant, as the Cw of the single task walking activity is high, and the cortical activity of the prefrontal areas predominates in the contralesional hemisphere.

The 5-STS is a prognostic factor of sub-acute stroke patients who will not become community walkers at discharge from rehabilitation

BACKGROUND

The recovery of community ambulation is a common concern among individuals after stroke.

OBJECTIVES

(1) To develop a potential readily applicable prognostic model able to correctly discriminate stroke patients who will not become independent community walkers at discharge; (2) To investigate the effects of early reassessment during the first month of treatment on the prediction accuracy of this model.

METHODS

This was a prospective cohort study. A consecutive sample of 80 patients at ≤60 days poststroke were assessed at baseline of outpatient physical rehabilitation and reassessed one month later. Non-functional community ambulation was measured.

RESULTS

Seventy-four patients were followed until discharge. Of these, 47 patients were non-functional community walkers at discharge. A prediction model based on baseline performance in the five repetition sit-to-stand [5-STS] test was able to discriminate those patients of the sample (Area-under-curve = 0.956), and again with data from reassessment (AUC = 0.952). A time of 21 s at baseline was a highly prognostic cut-off point for discrimination (sensitivity = 87.2% and 85.1%). The combined use of baseline and reassessment data improved sensitivity (98.1%)CONCLUSION:Early findings of the 5-STS among stroke patients is an independent prognostic factor associated with independent community walking at discharge. It could discriminate individuals who will not become community walkers at discharge.

Informing the development of an outcome set and banks of items to measure mobility among individuals with acquired brain injury using natural language processing

BACKGROUND

The sheer number of measures evaluating mobility and inconsistencies in terminology make it challenging to extract potential core domains and items. Automating a portion of the data synthesis would allow us to cover a much larger volume of studies and databases in a smaller fraction of the time compared to the usual process. Thus, the objective of this study was to identify a comprehensive outcome set and develop preliminary banks of items of mobility among individuals with acquired brain injury (ABI) using Natural Language Processing (NLP).

METHODS

An umbrella review of 47 reviews evaluating the content of mobility measures among individuals with ABI was conducted. A search was performed on 5 databases between 2000 and 2020. Two independent reviewers retrieved copies of the measures and extracted mobility domains and items. A pre-trained BERT model (state-of-the-art model for NLP) provided vector representations for each sentence. Using the International Classification of Functioning, Disability, and Health Framework (ICF) ontology as a guide for clustering, a k-means algorithm was used to retrieve clusters of similar sentences from their embeddings. The resulting embedding clusters were evaluated using the Silhouette score and fine-tuned according to expert input.

RESULTS

The study identified 246 mobility measures, including 474 domains and 2109 items. Encoding the clusters using the ICF ontology and expert knowledge helped in regrouping the items in a way that is more closely related to mobility terminology. Our best results identified banks of items that were used to create a 24 comprehensive outcome sets of mobility, including Upper Extremity Mobility, Emotional Function, Balance, Motor Control, Self-care, Social Life and Relationships, Cognition, Walking, Postural Transition, Recreation, and Leisure Activities, Activities of Daily Living, Physical Functioning, Communication, Work/Study, Climbing, Sensory Functions, General Health, Fatigue, Functional Independence, Pain, Alcohol and Drugs Use, Transportation, Sleeping, and Finances.

CONCLUSION

The banks of items of mobility domains represent a first step toward establishing a comprehensive outcome set and a common language of mobility to develop the ontology. It enables researchers and healthcare professionals to begin exposing the content of mobility measures as a way to assess mobility comprehensively.

The impact of the energy cost of walking on the quality of life of post-stroke individuals: A one-year longitudinal study

BACKGROUND

The increased energy cost of walking (Cw) for stroke patients affects the walking function and walking independence of stroke patients. However, its impact on quality of life (QoL) has never been studied.

OBJECTIVE

Assess the association between Cw and QoL for post-stroke individuals in the year following hospital discharge.

METHOD

Thirty-seven individuals with stroke were included. QoL was assessed by the EuroQol-5 Dimensions on the day after hospital discharge (T0), at six months (T1) and at one year after hospital discharge (T2). Concomitant an evaluation of Cw, mood disorders (HADS), fatigue, independence in activities of daily living and the presence of a family caregiver was performed. The association between QoL and the different covariates was analyzed using multiple regression analysis.

RESULTS

At T2, data from 29 individuals were analyzable. Multiple regression analyses showed Cw had a significant influence on the QoL at T1 (coeff -0.42 (-0.71 to -0.12), P = .008) and T2 (coeff -0.49 (-0.71 to -0.26), P < .001). HADS score was the only other variable to significantly impact variances of QoL at T0, T1 and T2. Moreover, we showed that Cw at T0 explained 29% of variances of QoL at T1 and 42% at T2.

CONCLUSION

Cw appears to be an independent factor in the QoL of individuals with stroke at six months and one year after hospital discharge. In addition, the initial Cw and HADS are predictive of QoL at one year highlighting the importance of early interventions in these two dimensions to improve QoL over the long term.

Quality of mobility measures among individuals with acquired brain injury: an umbrella review

Background and objective

While several mobility measures exist, there is large variability across measures in how mobility is conceptualized, the source of information and the measurement properties making it challenging to select relevant mobility measures for individuals with acquired brain injury (ABI). Therefore, the objective was to conduct a comprehensive synthesis of existing evidence on the measurement properties, the interpretability and the feasibility of mobility measures from various sources of information (patients, clinicians, technology) using an umbrella review of published systematic reviews among individuals with ABI.

Methods

Ovid MEDLINE, CINHAL, Cochrane Library and EMBASE electronic databases were searched from 2000 to March 2020. Two independent reviewers appraised the methodological quality of the systematic reviews using the Joanna Briggs Institute critical appraisal checklist. Measurement properties and quality of evidence were applied according to COnsensus-based Standards for the Selection of Health Measurement Instrument (COSMIN) guidelines. Mobility measures were categorized using international standards with the international classification of functioning, disability and health (ICF).

Results

Thirty-five systematic reviews were included covering 147 mobility measures, of which 85% were mapped to the ICF Activity and Participation component. Results showed an acceptable overall "sufficient" rating for reliability, construct validity and responsiveness for 132 (90%), 127 (86%) and 76 (52%) of the measures, respectively; however, among these measures, ≤ 25% of the methods for evaluating these properties were rated as ‘high’ quality of evidence. Also, there was limited information that supports measure feasibility and scoring interpretability.

Conclusions

Future systematic reviews should report measures’ content validity to support the use of the measure in clinical care and research. More evaluations of the minimal important difference and floor and ceiling effects are needed to help guide clinical interpretation.

Registration information

International Prospective Register of Systematic Reviews (PROSPERO); ID: CRD42018100068.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03103-4.

Dance-based exergaming on postural stability and kinematics in people with chronic stroke - A preliminary study

INTRODUCTION

The study evaluated the feasibility, and compliance of a dance-based exergaming (DBExG) on postural stability (PS) and lower extremity (LE) kinematics, along with post-intervention changes in gait function and falls self-efficacy in people with chronic stroke (PwCS).

METHODS

Fifteen PwCS underwent DBExG for six weeks using Kinect "Just Dance 3." Pre- to post- changes were recorded during DBExG assessment on a fast-paced song (130 bpm) using an 8-camera motion capture system to assess PS (center of mass [CoM] excursions [EXs] in the anterior-posterior [AP] and mediolateral [ML] directions) and LE kinematics (hip, knee, and ankle joint angle EXs). Gait function was also assessed with gait parameters, such as gait speed, cadence, and gait symmetry on an electronic walkway. Falls self-efficacy was recorded with Falls Efficacy Scale (FES).

RESULTS

The AP and ML CoM EXs and paretic joint angle EXs significantly increased pre- to post- DBExG assessment (p < .05). Gait parameters, and falls self-efficacy measures significantly changed pre- to post- DBExG (p < .05).

CONCLUSIONS

Results exhibited the feasibility of the proposed DBExG for positively impacting postural stability, and kinematics, along with increasing gait function and falls self-efficacy among PwCS.

Comparative Study on Overground Gait of Stroke Survivors With a Conventional Cane and a Haptic Cane

The conventional cane (single cane) is widely used to promote gait ability of stroke survivors as it provides postural stability by extending the base of support. However, its use can reduce muscle activity in the user's paretic side and cause upper limb neuropathies due to the intermittent and excessive loading of the upper limb. The provision of low magnitude support and speed regulation may result in collective improvement of gait parameters such as symmetry, balance and muscle activation. In this paper, we developed a robotic Haptic Cane (HC) that is composed of a tilted structure with motorized wheels and sensors to allow continuous haptic contact with the ground while moving at a regulated speed, and carried out gait experiments to compare the HC with an Instrumented conventional Cane (IC). The results show that use of the HC involved more continuous ground support force of a comparatively lesser magnitude than the IC, and resulted in greater improvements in the swing symmetry ratio and significant improvements in the step length symmetry ratio. Percentage of Non-Paretic Activity (%NPA) of paretic muscles (vastus medialis obliquus (VMO), semitendinosus (SMT), tibialis anterior (TBA) and gastrocnemius medialis (GCM)) in swing phase was significantly improved by the use of either device at fast speed. However, the use of HC improved %NPA of paretic VMO and SMT more than the use of IC at both preferred and fast speeds. It also significantly improved %NPA of paretic GCM in stance phase. Furthermore, comfortable speed with the HC was higher than with the IC and exhibited better RMS of anteroposterior (AP) tilt. Thus, the developed device with a simple and intuitive mechanism can provide efficient assistance for overground gait of stroke patients with a high possibility of widespread use.

Efficacy of a novel walking assist device with auxiliary laser illuminator in stroke Patients~ a randomized control trial

BACKGROUND/PURPOSE

Task-oriented functional walking is important in stroke patients. We aimed to investigate effects of a quad-cane with auxiliary laser illuminator (laser-cane) among stroke patients.

METHODS

This was a randomized-prospective study. Patients in the experimental group (EG) received 15-min of walking training with laser-cane and 15-min of traditional physical therapy. Patients in the control group (CG) received the same rehabilitation without laser-cane. The rehabilitation lasted for 4 weeks, twice per week. Primary outcome were gait parameters. Secondary outcomes were Berg Balance Scale (BBS), Timed Up and Go Test (TUG), and Barthel index (BI). Outcomes were measured at baseline, at the end of the rehabilitation (visit-1), and 4 weeks later (visit-2).

RESULTS

Both the groups (both n = 15) showed improvement of cadence, relative stance and swing phase duration of non-paretic side, BBS, and TUG at both visits. In the intragroup comparison, the EG additionally improved at stride length, relative stance and swing phase duration of paretic side, and gait speed at both visits; temporal swing symmetry, and toe-off angle of non-paretic side at the visit-2. Intergroup comparing for changing of outcomes with the CG, stride length and gait speed increased, relative stance phase duration of the non-paretic site decreased, and the temporal swing symmetry improved at the visit-1; relative stance phase duration of the paretic side decreased and the temporal stance symmetry improved at the visit-2 in the EG.

CONCLUSION

Rehabilitation with laser-cane improved the balance, activity of daily living, gait symmetry and gait parameters of stroke patients.

The Functional Independence of Patients With Stroke Sequelae: How Important Is the Speed, Oxygen Consumption, and Energy Cost of Walking?

OBJECTIVE

To evaluate the association between self-selected walking speed (S_free), oxygen consumption at S_free (Vo_2free), the oxygen cost of walking (Cw) at S_free, and mobility independence and independence for activities of daily living in individuals poststroke.

DESIGN

Cross-sectional study.

SETTING

Hospital.

PARTICIPANTS

Individuals with stroke who were able to walk without human assistance were included. We included 90 individuals (N=90; mean age, 63.5±14.0y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Cw was captured during walking from measurements of S_free and Vo_2free. We assessed mobility independence based on the modified Functional Ambulation Classification (mFAC) and independence in activities of daily living by the Barthel Index (BI). Multiple linear regression analyses were performed to evaluate the independence of Cw, Vo_2free, and S_free from the determination of BI and mFAC among the various characteristics of the population (age, stroke delay, body mass index, motor function, spasticity).

RESULTS

We reported Cw=0.36 mL/kg/m (interquartile range [IQR]=0.28 mL/kg/m), S_free=0.60±0.32 m/s, Vo_2free=11.2 mL/kg/min (IQR=1.8 mL/kg/min). The multiple linear regression analyses showed that Cw and S_free were independently associated with the BI (P<.01) and the mFAC (P<.01) scores. Vo_2free was not found to be an explanatory variable of functional independence (P>.05).

CONCLUSIONS

Cw was independently associated with functional independence. This association appears to be primarily determined by S_free and not Vo_2free, underscoring the importance of evaluating and acting on S_free to improve the functional independence of individuals with stroke.

Community ambulation in people with lower limb amputation: An observational cohort study

ABSTRACT

Lower limb amputation (LLA) is still a health issue requiring rehabilitation and long-term care even in industrial societies. Several studies on subjects with LLA have been focused on the efficacy of rehabilitation and factors influencing the use of prosthesis. However, literature data on the recovery of ability to walk outdoors, and thus to participate in social life in this population is limited.To investigate potential correlations between socio-demographic and clinical factors, and the use of the prosthesis for indoor and/or outdoor walking referred to as community ambulation (CA) in subjects with LLA.An observational cohort study on 687 LLA subjects was conducted. Socio-demographic and clinical characteristics of 302 subjects who received similar rehabilitative treatment with respect to the standard protocol were collected by a telephone survey with a structured questionnaire. The CA recovery, in terms of patient's autonomy and participation, assessed by Walking Handicap Scale, was considered as the main outcome.The univariate analysis demonstrated statistical significant positive correlation between CA and gender (χ2 = 3.901, P = .048); amputation level (χ2 = 24.657, P < .001); pre-LLA (χ2 = 6.338, P = .012) and current work activity (χ2 = 25.192, P < .001); prosthesis use (χ2 = 187.037, P < .01); and time from LLA (r = 0.183, P < .001); increasing age was negatively correlated with the outcome (r = -0.329, P < .001), while pain intensity was not significant. Being male (75.4%); trans-tibial (TT) amputation level (9.79%); working before (3.81%) and after LLA (7.68%); and the prosthesis use (24.63%) increased the probability of CA recovery. Multivariate binary logistic regression analysis confirmed that the prosthesis use (P < .001) and TT amputation level (P = .042) are predictors of a positive outcome (Walking Handicap Scale 4-6).These findings highlight the importance of the use of prosthesis in people with LLA for the restoration of a good capacity of participation (CA), especially in subjects with TT amputation level. The identification of predictive factors may help tailor-made rehabilitation approaches addressing an earlier reintegration to social life.

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

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Associations between functional fitness and walking speed in older adults

This cross-sectional study aimed to explore 1) the overall associations between functional fitness and walking speed in older adults and 2) the key functional fitness parameters affecting older adults' walking speeds. A total of 242 apparently healthy older adults finished a 6-m walking speed test at both usual walking speed (UWS) and maximum walking speed (MWS). Functional fitness was assessed using the Senior Fitness Test battery. The results revealed significantly moderate correlations of functional fitness with UWS (r = 0.380) and MWS (r = 0.436). Both age (UWS = -0.332, MWS = -0.324) and dynamic balance and agility (UWS = 0.329, MWS = 0.411) were key indicators of both UWS and MWS. In addition, gender (r = 0.090), aerobic endurance (r = 0.326), and lower body flexibility (r = 0.183) were key fitness indicators of MWS in older adults.

Evaluation of the Feasibility of a Two-Week Course of Aquatic Therapy and Thalassotherapy in a Mild Post-Stroke Population

Strokes are a leading cause of disability in developed countries. Patients with disabilities need rehabilitation to improve their physical functioning, mental status, and quality of life. Currently, no high-quality evidence can be found attesting the benefits of any of the interventions that are nowadays used. Water-based exercise may improve the physical conditions and quality of life of people in the post-stroke phase. The objective of this study is to test whether aquatic therapy in an enriched environment at the seaside (a thalassotherapy center) could play a role in this condition. A quasi-experimental prospective study consisting of a specific program assessed 62 patients with a mild–moderate disability pre- and post-2 weeks of intensive treatment. They followed a thalassotherapy regimen including aquatic therapy in a sea water pool at 32–34 °C for 45 min daily five times a week. The outcomes measured were the Berg Balance scale, the Timed Up and Go test, the 10-meter walking test, the 6-min walking test, the Pain Visual Analogue Scale, the WHO Well-being index, EuroQoL VAS and EuroQoL 5D. We observed a significant improvement in all outcomes measured (p < 0.001, except mobility EuroQoL p < 0.05), except in the other four dimensions of the EuroQoL 5D and 10-metre walking test (NS). Conclusion: A two-week intensive course of aquatic therapy and thalassotherapy may be beneficial in the short term by reducing pain and improving the functional status and overall well-being of post-stroke patients.

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

Persistent Effect of Gait Exercise Assist Robot Training on Gait Ability and Lower Limb Function of Patients With Subacute Stroke: A Matched Case-Control Study With Three-Dimensional Gait Analysis

Introduction

Gait exercise assist robot (GEAR), a gait rehabilitation robot developed for poststroke gait disorder, has been shown to improve walking speed and to improve the poststroke gait pattern. However, the persistence of its beneficial effect has not been clarified. In this matched case–control study, we assessed the durability of the effectiveness of GEAR training in patients with subacute stroke on the basis of clinical evaluation and three-dimensional (3D) gait analysis.

Methods

Gait data of 10 patients who underwent GEAR intervention program and 10 patients matched for age, height, sex, affected side, type of stroke, and initial gait ability who underwent conventional therapy were extracted from database. The outcome measures were walk score of Functional Independence Measure (FIM-walk), Stroke Impairment Assessment Set total lower limb motor function score (SIAS-L/E), and 3D gait analysis data (spatiotemporal factors and abnormal gait patter indices) at three time points: baseline, at the end of intervention, and within 1 week before discharge.

Results

In the GEAR group, the FIM-walk score, SIAS-L/E score, cadence, and single stance time of paretic side at discharge were significantly higher than those at post-training (p < 0.05), whereas the stance time and double support time of the unaffected side, knee extensor thrust, insufficient knee flexion, and external rotated hip of the affected side were significantly lower (p < 005). However, no significant differences in these respects were observed in the control group between the corresponding evaluation time points.

Conclusion

The results indicated significant improvement in the GEAR group after the training period, with respect to both clinical parameters and the gait pattern indices. This improvement was not evident in the control group after the training period. The results possibly support the effectiveness of GEAR training in conferring persistently efficient gait patterns in patients with poststroke gait disorder. Further studies should investigate the long-term effects of GEAR training in a larger sample.

Life-Space Mobility and Relevant Factors in Community-dwelling Individuals with Stroke in Japan: A Cross-sectional Study

Objective

Individuals with stroke frequently experience mobility deficits and limited community reintegration. This study aimed to investigate life-space mobility and relevant factors in community-living individuals with stroke.

Methods

This was a cross-sectional study of 46 community-dwelling individuals with chronic stroke in Japan (mean age 72.7 ± 7.4 years; mean time post-stroke 63.6 ± 43.3 months; 26 men/20 women). We measured life-space mobility using a Japanese translation of the Life-Space Assessment. The following factors that might affect life-space mobility were assessed: the ability to perform activities of daily living, physical performance, fear of falling, and cognitive function.

Results

A total of 41 participants (89.1%) had restricted life-space mobility (Life-Space Assessment score <60 points). A multiple linear regression analysis showed that limitations in activities of daily living, walking speed, and Falls Efficacy Scale-International scores were independently related to Life-Space Assessment scores. This model explained 51.3% of the variance in Life-Space Assessment scores.

Conclusions

Most individuals with stroke had restricted life-space mobility. Life-space mobility was associated with the ability to perform activities of daily living, walking speed, and fear of falling. These findings could contribute to the development of rehabilitation interventions for regaining life-space mobility in individuals with stroke.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Using an Accelerometer-Based Step Counter in Post-Stroke Patients: Validation of a Low-Cost Tool

Monitoring the real-life mobility of stroke patients could be extremely useful for clinicians. Step counters are a widely accessible, portable, and cheap technology that can be used to monitor patients in different environments. The aim of this study was to validate a low-cost commercial tri-axial accelerometer-based step counter for stroke patients and to determine the best positioning of the step counter (wrists, ankles, and waist). Ten healthy subjects and 43 post-stroke patients were enrolled and performed four validated clinical tests (10 m, 50 m, and 6 min walking tests and timed up and go tests) while wearing five step counters in different positions while a trained operator counted the number of steps executed in each test manually. Data from step counters and those collected manually were compared using the intraclass coefficient correlation and mean average percentage error. The Bland–Altman plot was also used to describe agreement between the two quantitative measurements (step counter vs. manual counting). During walking tests in healthy subjects, the best reliability was found for lower limbs and waist placement (intraclass coefficient correlations (ICCs) from 0.46 to 0.99), and weak reliability was observed for upper limb placement in every test (ICCs from 0.06 to 0.38). On the contrary, in post-stroke patients, moderate reliability was found only for the lower limbs in the 6 min walking test (healthy ankle ICC: 0.69; pathological ankle ICC: 0.70). Furthermore, the Bland–Altman plot highlighted large average discrepancies between methods for the pathological group. However, while the step counter was not able to reliably determine steps for slow patients, when applied to the healthy ankle of patients who walked faster than 0.8 m/s, it counted steps with excellent precision, similar to that seen in the healthy subjects (ICCs from 0.36 to 0.99). These findings show that a low-cost accelerometer-based step counter could be useful for measuring mobility in select high-performance patients and could be used in clinical and real-world settings.

Oxygen Cost During Walking in Individuals With Stroke: Hemiparesis Versus Cerebellar Ataxia

Background. Understanding the factors that limit mobility in stroke patients is fundamental for proposing appropriate rehabilitation strategies. A high oxygen cost during walking (Cw) has a strong impact on the community ambulation of hemiparetic patients. The Cw in poststroke cerebellar ataxia is poorly evaluated, unlike hemiparetic gait. Objective. To compare the oxygen cost/self-selected walking speed (S) relationship in stroke individuals with cerebellar ataxia or hemiparetic gait. Methods. Thirty-three subjects were included (14 cerebellar stroke, 19 hemispheric stroke), with stroke confirmed by brain imaging and able to walk without human assistance. We measured Cw using the Metamax3B. The relationship between Cw and self-selected walking speed was modelled by logistic regression and then compared between the cerebellar and hemispheric groups. Results. No significant difference was found between the 2 groups for all characteristics of the population, except motor impairments, spasticity, and ataxia (P < .01). We identified 2 separate Cw/S relationships with different logistic regression equations for the 2 groups. Faster than 0.4 m s⁻¹, Cw was 30.6% to 39.9% higher in patients with cerebellar stroke in comparison with hemispheric stroke individuals. The Cw was correlated with ataxia (r = 0.88; P < .001) in the cerebellar group, whereas there was a correlation with motor impairments (r = −0.61; P < .01), spasticity (r = 0.59; P < .01), and ataxia (r = 0.81; P < .01) in hemispheric stroke individuals. Conclusion. The Cw in poststroke cerebellar ataxia is significantly higher compared with hemiparetic patients at an equivalent walking speed. The impact on community walking needs to be explored in stroke survivors with cerebellar stroke.

Utility of Dynamic Balance Measurements in Discriminating Community Ambulation Levels Among Individuals with Stroke: A Cross-sectional Study

OBJECTIVE

To examine the association between dynamic balance measurements and community ambulation levels among individuals with chronic stroke.

METHODS

This cross-sectional study was performed in 2-day care facilities for older adults located in urban areas. Forty-seven community-dwelling poststroke adults who could walk independently were participated. Community ambulation performance was assessed using the Functional Ambulation Classification of the Hospital at Sagunto (FACHS). Dynamic balance and mobility were measured with the Mini-Balance Evaluation Systems Test (Mini-BESTest), the Timed Up and Go (TUG) test, and 10 m maximum walking speed.

RESULTS

Participants were classified into 3 groups according to FACHS scores: household (n = 15), neighborhood (n = 19), and community walkers (n = 13). Neighborhood and community walkers scored significantly higher on the Mini-BESTest and had a shorter TUG test time than household walkers. Community walkers had a significantly faster walking speed than household walkers, whereas neighborhood walkers did not have a faster walking speed than household walkers. Ordinal logistic regression analyses revealed the Mini-BESTest score (odds ratio [OR] 1.24; 95% confidence interval [CI]: 1.07-1.44) and the TUG test time (OR .91; 95% CI: .85-.98) were significantly associated with ambulation levels after adjusting for confounders.

CONCLUSIONS

Dynamic balance measurement tools may have better responsiveness in detecting community ambulation levels among individuals with chronic stroke than walking speed.

Low gait speed is associated with low physical activity and high sedentary time following stroke

PURPOSE

This study describes physical activity levels and factors associated with physical activity at the end of stroke rehabilitation.

METHODS

Primary stroke survivors were assessed at completion of physical rehabilitation. Outcomes included physical activity (e.g. step count, moderate-vigorous physical activity duration) and sedentary time measured with the Sensewear Armband, gait speed, and cognition. The number of participants meeting physical activity recommendations was calculated. Differences in physical activity were examined between household ambulators (gait speed <0.4 m/s), limited community ambulators (0.4-0.8 m/s), and unlimited community ambulators (>0.8 m/s). The influence of age, cognition, and gait speed on physical activity was determined by multiple regression.

RESULTS

Seventy-nine stroke survivors participated. Twenty-one participants achieved 30 min/day of moderate-vigorous physical activity accumulated in 10 min bouts. Unlimited community ambulators took more steps/day (median 4975 vs. 469 limited, 355 household, p < 0.001), had higher moderate-vigorous physical activity (median 74 min/day vs. 22 limited, 31 household, p < 0.001) and lower sedentary time (mean 1105 vs. 1239 limited, 1232 household minutes/day, p < 0.001). Age, gait speed, and cognition predicted 21.3% of the variance in moderate-vigorous physical activity (p = 0.001); adding employment status to the model predicted 57.3% of the variance in step count (p < 0.001).

CONCLUSIONS

Physical activity is low following stroke and should be a target for treatment, particularly in those with gait speeds ≤0.8 m/s.Implications for rehabilitationSeventy-three percent of stroke survivors performed ≥30 minutes of moderate to vigorous physical activity throughout the day.Twenty-seven percent of stroke survivors accumulated ≥30 minutes of moderate to vigorous physical activity in 10 minute bouts.Despite relatively good physical ability, daily step count was low in this sample.Those with gait speeds ≤0.8 m/s had lower physical activity levels and higher sedentary time.

Evaluation of Predictive Factors Influencing Community Reintegration in Adult Patients with Stroke

Objectives

Patients with stroke are faced with gait, balance, and fall difficulties which could impact on their community reintegration. In Nigeria, community reintegration after stroke has been understudied. The objective of this study was to evaluate the predictors of community reintegration in adult patients with stroke.

Materials and Methods

Participants were 91 adult patients with stroke. Gait variables, balance self-efficacy, community balance/mobility, and fall self-efficacy were assessed using Rivermead Mobility Index, Activities-specific Balance Confidence Scale, Community Balance and Mobility Scale, and Falls Efficacy Scale-International respectively. Reintegration to Normal Living Index was used to assess satisfaction with community reintegration. Pearson Product-Moment Correlation Coefficient was used to determine the relationship between community reintegration and gait spatiotemporal variables, balance performance, and risk of fall. Multiple regression analysis was used to determine predictors of community reintegration (P ≤ 0.05).

Results

There was significant positive relationship between community reintegration and cadence (r = 0.250, P = 0.017), functional mobility (r = 0.503, P = 0.001), balance self-efficacy (r = 0.608, P = 0.001), community balance/mobility (r = 0.586, P = 0.001), and duration of stroke (r = 0.220, P = 0.036). Stride time (r = -0.282, P = 0.073) and fall self-efficacy (r = 0.566, P = 0.001) were negatively correlated with community reintegration. Duration of stroke, balance self-efficacy, community balance/mobility, and fall self-efficacy (52.7% of the variance) were the significant predictors of community reintegration.

Conclusion

Community reintegration is influenced by cadence, functional mobility, balance self-efficacy, community balance/mobility, and duration of stroke. Hence, improving balance and mobility during rehabilitation is important in enhancing community reintegration in patients with stroke.

Duke Activity Status Index cut-off scores for assessing functional capacity after stroke

PURPOSE

To determine the Duke Activity Status Index (DASI) cut-off scores and verify if they would be able to discriminate between chronic stroke individuals, who had poor, from those who had good functional capacity (FC).

MATERIALS AND METHODS

Cross-sectional study, where 92 individuals with chronic stroke had their FC measured by DASI scores and were classified into community and non-community walkers. Both the receiver operating characteristic and the area under the curve were used to determine the best DASI cut-off values that could discriminate between individuals, who had poor, from those who had good FC. Binary logistic regression analysis is used to investigate the ability of DASI scores in predicting community walkers.

RESULTS

DASI cut-off value of 31.95 showed to be sensitive and specific to differentiate between individuals, who had poor from good FC. The regression analysis revealed that the chance of individuals, who had better FC (≥ 31.95) be community walkers was 10.69 (95%CI:4-32.75) times higher than that of those who had poor FC (< 31.95). The model demonstrated good predictive ability.

CONCLUSIONS

The DASI cut-off value of 31.95 showed to be sensitive and specific to distinguish between chronic stroke individuals, who had poor, from those who had good FC.IMPLICATIONS FOR REHABILITATIONThe identification of individuals, who have good and poor functional capacity, is important for clinical reasoning and decision-making in stroke rehabilitation.The Duke Activity Status Index (DASI) is a clinically useful tool for the assessment of functional capacity, based upon the performance of common daily living activities.The DASI cut-off of 31.95 points was able to discriminate between individuals with stroke, who had poor, from those who had good functional capacity.The chance of individuals, who had good functional capacity (DASI ≥ 31.95) be community walkers was 10.69 times higher than that of those who had poor functional capacity (DASI < 31.95).The findings support the use of the DASI as a simple tool for the assessment of functional capacity, especially in low-resource settings.

Effects of Vibrotactile Biofeedback Coding Schemes on Gait Symmetry Training of Individuals With Stroke

Variations in biofeedback coding schemes for postural control, in recent research, have shown significant differences in performance outcomes due to variations in coding schemes. However, the application of vibrotactile biofeedback coding schemes to gait symmetry training is not well explored. In this paper, we devised various vibrotactile biofeedback modes and identified their efficacy during gait symmetry training of individuals suffering from hemiparesis due to stroke. These modes are composed of variations in vibration type (on-time or intensity), and relation type (proportional or inversely-proportional) with the error in symmetry ratio. Eight individuals with stroke participated in walking trials. From dependent t-tests on the collected data, we found improved achievement of temporal gait symmetry while utilizing all the provided biofeedback modes compared to no biofeedback (P < 0.001). Furthermore, two-way repeated measures ANOVA revealed statistically significant difference in symmetry ratio for main effect of vibration type (P-value = 0.016, partial eta squared = 0.585). The participants performed better with modes of biofeedback with varying vibration on-times. Furthermore, participants showed better performance when the biofeedback varied proportionally with the error. These findings suggest that biofeedback coding schemes may have a significant effect on the performance of gait training.

Measuring Community Mobility in Survivors of Stroke Using Global Positioning System Technology: A Prospective Observational Study

BACKGROUND AND PURPOSE

Returning to community mobility is important for people recovering from a stroke, yet few studies have directly measured this construct following inpatient rehabilitation. Using global positioning system (GPS) technology, we examined community mobility of survivors of stroke (SS) over the first year after discharge and compared them to an age-matched comparison group without neurological impairment.

METHODS

We conducted a prospective observational study that included SS (n = 14) and age- and location-matched comparison subjects (CS; n = 6). All participants identified target locations important to their community mobility goals and wore a GPS unit during the first, fifth and ninth weeks after discharge, or from baseline for CS, and at 26 and 52 weeks' follow up. The 6-minute walk test (SMWT), Berg balance test (BBT), Reintegration to Normal Living (RNLI), and Short Form-36 Quality of Life Survey Physical Functioning domain (SF-36-PF) were collected. Number of trips and percentage of targets visited were extracted from GPS data.

RESULTS

Twelve of 14 SS completed 9 weeks, 7 completed the full year, and no CS withdrew. The SS took fewer trips and attained fewer targets compared with CS at weeks 1 and 9, but not at weeks 5, 26, and 52. All 4 clinical outcome measures were significantly correlated to trips (Spearman r for SMWT = 0.5067, BBT = 0.3841, RNLI = 0.4119, and SF-36-PF = 0.4192).

DISCUSSION AND CONCLUSIONS

Directly measured community mobility in SS was decreased through 9 weeks following discharge from inpatient rehabilitation. The limited strength of bivariate correlations between clinical measures and number of trips supported the uniqueness of the community mobility construct.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A277).

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

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

Relationships between gait variability and ambulatory activity post stroke

BACKGROUND

Fall risk and balance confidence are related to gait variability and ambulatory activity post stroke, yet whether a relationship exists between gait variability and ambulatory activity is unknown. Knowing if gait variability measured under naturalistic conditions is related to ambulatory activity could explain more about the relationship between falls and walking activity post-stroke.

OBJECTIVES

To examine relationships between spontaneous, daily ambulatory activity and gait variability during single- and dual-task walking, in low- and high-distraction settings in adults post stroke.

METHODS

Sixteen community-dwelling adults post stroke participated in a cross-sectional study. Spatiotemporal gait parameters were recorded during single- and cognitive-motor dual-task walking in low- and high-distraction settings. Coefficient of variation was calculated for stride length and stride duration. Average walking bout duration, maximum walking bout duration, and total number of steps per day were captured using an activity monitor. Correlations between ambulatory activity measures and gait variability were examined.

RESULTS

In the high-distraction setting, single-task stride duration variability was negatively related to all three ambulatory activity measures, but the strongest relationship was a negative correlation between dual-task stride duration variability and average walking duration. In the low-distraction setting, single-task stride duration variability was negatively related to maximum walking duration. None of the other variability measures were related to ambulatory activity.

CONCLUSIONS

The finding that stride duration variability in a high-distraction environment, with or without an additional cognitive task, is related to ambulatory activity in community-dwelling stroke survivors suggests that assessments incorporating attentional demands of real-world walking may be useful additions to clinical practice.

Ergometer cycling improves the ambulatory function and cardiovascular fitness of stroke patients-a randomized controlled trial

[Purpose] The aim of this study was to assess the effects of ergometer cycling on the ambulatory function and cardiovascular fitness of patients with stroke in the sub-acute phase. [Participants and Methods] Twenty (20) patients with stroke in the sub-acute phase were randomly allocated to either an ergometer cycling group (n=10) or a control group (n=10). The experimental (ergometer cycling) group performed cycling exercises in addition to conventional physiotherapy for 60 minutes per session, three times per week for 8 weeks. The control group only received conventional physiotherapy for the same duration as the experimental group. Assessments of participants' functional ambulatory category, ambulatory velocity, 6-minute walk test, heart rate and blood pressure were conducted at baseline and at the end of the 8-week intervention. [Results] The means of the ambulatory velocity and distance walked in 6 minutes were significantly higher in the ergometer cycling group than those of the control group at week 8. However, the increase in the FAC score was not significant. The means of heart rate, systolic and diastolic blood pressures significantly decreased in the ergometer cycling group compared to the control group at the end of the 8-week of intervention. [Conclusion] This study demonstrated that ergometer cycling improved the ambulatory function and cardiovascular fitness of patients with stroke in the sub-acute phase.

The effects of a community-based walking program on walking ability and fall-related self-efficacy of chronic stroke patients

The objectives of this study were to evaluate the effects of community-based walking training (CWT) on the walking ability and fall-related self-efficacy of chronic stroke patients and compare the effects of CWT to the conventional walking programs in stroke patients. Previous studies focused on walking speed, walking endurance, and balance. However, no studies have examined the changes in fall-related self-efficacy after CWT. In order to achieve purpose of this study, 45 chronic stroke patients, who were hospitalized at National Rehabilitation Center, were randomly divided into the CWT group (CWTG, n=15), the treadmill walking training group (TWTG, n=15), and the control group (CG, n=15). The treatment was conducted 3 times per week (30 min each) for 4 weeks. CWT was carried out by gradually increasing the difficulty level in various environments outside the hospital room. The results revealed that the CWTG was more effective in enhancing the walking ability and fall-related self-efficacy than the TWTG and the CG. These findings demonstrated that the CWTG increased the walking ability and fall-related self-efficacy of chronic stroke patients. Therefore, we suggest that adding CWT to standard rehabilitation might be an effective method for improving walking ability and fall-related self-efficacy in chronic stroke patients.

Factors Affecting Walking Speed in Schizophrenia Patients

Objective

This study investigated the factors affecting walking speed in schizophrenia patients who were inpatients at a psychiatric hospital.

Methods

The study subjects were 37 patients with schizophrenia who were hospitalized in a psychiatric hospital. The measured assessment items included age, duration of hospitalization, duration of disease, muscle strength (30-s chair stand test), balance ability (one-leg standing time with eyes open/closed, Functional Reach Test, and Timed Up & Go Test), flexibility (long sitting position toe-touching distance), walking speed (10-m maximum walking speed), and the antipsychotic drug intake.

Results

The walking speed was found to be correlated with the results of the 30-s chair stand test, the one-leg standing time with eyes open, the one-leg standing time with eyes closed, and the Timed Up & Go Test. Stepwise multiple regression analysis revealed that only the Timed Up & Go Test results affected walking speed.

Conclusion

In schizophrenia patients, walking speed is influenced by balance and lower-limb muscle force, just as it is for patients without mental diseases. In schizophrenia patients, the dynamic balance ability has a strong influence on the walking speed.

Community ambulation of stroke survivors at 6 months follow-up: an observational study on sociodemographic and sub-acute clinical indicators

BACKGROUND

Despite the importance of walking recovery in real life contexts, only 7% of stroke survivors at discharge from neuro-rehabilitation units recover independent walking in the community. However, studies on outcome indicators of walking ability restoration following stroke rarely regard the community ambulation.

AIM

The aim of the study is to investigate how sociodemographic and sub-acute clinical characteristics of stroke survivors at admission and at discharge may predict a good participation in community walking activity 6 months post-stroke.

DESIGN

Retrospective observational study.

SETTING

Inpatient neuro-rehabilitation centers.

POPULATION

Three-hundred-ten stroke survivors.

METHODS

A secondary analysis were performed on collected sociodemographic and clinical data of subjects after first-ever stroke within 72 hours of admission to acute care facilities (T1), at discharge (T2), and subsequently after 6-months post-stroke (T3). The regression analysis between every independent variable at T1 and T2 and Walking Handicap Scale-WHS (negative: 1-3; positive: 4-6) assessed at T3 were performed to identify the most important early predictors.

RESULTS

At T1, being younger, having a good ability to walk, early mobilization out of bed, not having TACI, and being female are significant positive indicators while, clinical complications are significantly negative for a WHS:4-6 at T3. No correlation was found between WHS and gender, etiology, the side of lesion, the presence of aphasia, and the presence of risk factors. The combination of risk factors indicates a negative WHS at T3.

CONCLUSIONS

The presence of risk factors and clinical complications delay significantly the walking ability restoration and return to social life. Such status consistently with the patient's compliance must not postpone the rehabilitation relatively, rehabilitation must be facilitated with targeted programs taking care particularly of people with negative indicators for recovery of community ambulation 6 months post-stroke.

CLINICAL REHABILITATION IMPACT

Early indicators are considerable in order to predict a targeted prognosis and better provide a tailored rehabilitation program.

Brain imaging of locomotion in neurological conditions

Impaired locomotion is a frequent and major source of disability in patients with neurological conditions. Different neuroimaging methods have been used to understand the brain substrates of locomotion in various neurological diseases (mainly in Parkinson's disease) during actual walking, and while resting (using mental imagery of gait, or brain-behavior correlation analyses). These studies, using structural (i.e., MRI) or functional (i.e., functional MRI or functional near infra-red spectroscopy) brain imaging, electrophysiology (i.e., EEG), non-invasive brain stimulation (i.e., transcranial magnetic stimulation, or transcranial direct current stimulation) or molecular imaging methods (i.e., PET, or SPECT) reveal extended brain networks involving both grey and white matters in key cortical (i.e., prefrontal cortex) and subcortical (basal ganglia and cerebellum) regions associated with locomotion. However, the specific roles of the various pathophysiological mechanisms encountered in each neurological condition on the phenotype of gait disorders still remains unclear. After reviewing the results of individual brain imaging techniques across the common neurological conditions, such as Parkinson's disease, dementia, stroke, or multiple sclerosis, we will discuss how the development of new imaging techniques and computational analyses that integrate multivariate correlations in "large enough datasets" might help to understand how individual pathophysiological mechanisms express clinically as an abnormal gait. Finally, we will explore how these new analytic methods could drive our rehabilitative strategies.

Effect of Stride Management Assist Gait Training for Poststroke Hemiplegia: A Single Center, Open-Label, Randomized Controlled Trial

BACKGROUND

Poststroke gait disorders negatively impact activities of daily living. Rehabilitation for stroke patients is aimed at improving their walking ability, balance, and quality of life. Robot-assisted gait training (RAGT) is associated with an increased number of task-specific exercises, which may benefit poststroke motor learning. We investigated the effects of RAGT using Stride Management Assist (SMA, which increases walk ratio by inducing hip-joint flexion and extension) in subacute stroke patients with hemiplegia.

METHODS

We conducted a single center, open-label randomized controlled trial in hemiplegia patients who experienced a first ever stroke and were admitted to the convalescent rehabilitation ward. A total of 41 were divided into the control (20 patients) and experimental group (21 patients). A 10-day, conventional gait training program was carried out for the control group; and RAGT with SMA was used for the experimental group. The maximum walking speed and other gait parameters were compared preintervention and postintervention. The intergroup differences in the improvement ratio were compared using an intention-to-treat analysis.

RESULTS

Ten-day intervention was completed by 36 patients. There was no difference between the 2 groups regarding gait parameters at intervention initiation. The improvement ratio of the maximum walking speed was significantly higher for the experimental group. Significant improvements were observed postintervention for maximum walking speed, paralysis-side step length, symmetry, and cadence in the experimental group. No adverse events attributable to the SMA were observed.

CONCLUSIONS

Ten days of RAGT with the SMA was effective for improving gait disorders of subacute stroke patients.

Adaptation and post-adaptation effects of haptic forces on locomotion in healthy young adults

BACKGROUND

Developing rehabilitation strategies to improve functional walking and postural control in patients is a priority for rehabilitation clinicians and researchers alike. One possible strategy is the use of sensory modalities to elicit adaptive locomotor gait patterns. This study aimed to explore to what extent haptic inputs, in the form of forward-leading tensile forces delivered to the hand, compared to no force, may lead to adaptation and post-adaptation effects on gait parameters, during and after the haptic exposure, respectively.

METHODS

Thirteen healthy young individuals were recruited for this study. We developed an innovative system combining virtual reality and haptic tensile forces in the direction of locomotion to simulate walking with a dog. A robotic arm generated forces via an adapted leash to the participant's hand while they walked on a self-paced treadmill immersed in a virtual environment with scene progression synchronized to the treadmill.

RESULTS

All participants showed significant increases in instantaneous gait velocity and stride length, with accompanying decreases in double-limb support time (p < 0.05) when walking with a haptic tensile force of either 10 or 20 N, relative to pre-force epoch levels, indicating an adaptation effect. When the 10 or 20 N force was removed, gait measures generally remained changed relative to baseline pre-force levels (p < 0.05), providing evidence of a post-adaptation effect.

CONCLUSIONS

Changes in spatiotemporal outcomes provide evidence that both adaptation and post-adaptation effects were present in response to the application and removal of a haptic force. Future studies will investigate whether similar changes in elderly and post-stroke populations can be actualized during steady-state walking.

A novel one arm motorized walker for hemiplegic stroke survivors: a feasibility study

BACKGROUND

A hemiplegic stroke survivor with a moderate to severe gait disturbance may have difficulty walking using a one-arm walker. This study aimed to test the safety and feasibility of a prototype one-arm motorized walker that uses a power-driven device to provide gait assistance to hemiplegic stroke survivors with moderate to severe gait disturbances.

METHODS

A one-arm motorized walker with a power-driven device was developed and tested with respect to 10 distinct variables, including weight, degrees of freedom, handle, handle substitution function, two-sided use function, variable handle height, redirecting function, electric moving parts through the handle control, brake function using the handle control, folding chairs, and design stability. Its safety and feasibility were tested in 19 hemiplegic stroke individuals using the Likert scale and a simple interview.

RESULTS

The walker consists of a frame platform including a handle, electric motor for driving, one wheel for driving, two wheels for turning, unlocking sensor, driving button, and turning buttons. The walker is programmed so that a touch sensor in the handle can unlock the locking system. Furthermore, it is programmed so that a user can propel it by pushing the handle downward or pressing a button and can control directions for turning right or left by pressing buttons. Safety and performance testing was achieved for 10 separate variables, and a Likert scale score of 3.5 of 5 was recorded.

CONCLUSION

This walker's novel design was developed for hemiplegic stroke survivors with moderate to severe gait disturbances. Our findings indicate that the walker is both safe and feasible for providing walking assistance to hemiplegic stroke survivors and establish the potential advantages of the one-arm motorized walker.

Smartphone App-Based Assessment of Gait During Normal and Dual-Task Walking: Demonstration of Validity and Reliability

BACKGROUND

Walking is a complex cognitive motor task that is commonly completed while performing another task such as talking or making decisions. Gait assessments performed under normal and "dual-task" walking conditions thus provide important insights into health. Such assessments, however, are limited primarily to laboratory-based settings.

OBJECTIVE

The objective of our study was to create and test a smartphone-based assessment of normal and dual-task walking for use in nonlaboratory settings.

METHODS

We created an iPhone app that used the phone's motion sensors to record movements during walking under normal conditions and while performing a serial-subtraction dual task, with the phone placed in the user's pants pocket. The app provided the user with multimedia instructions before and during the assessment. Acquired data were automatically uploaded to a cloud-based server for offline analyses. A total of 14 healthy adults completed 2 laboratory visits separated by 1 week. On each visit, they used the app to complete three 45-second trials each of normal and dual-task walking. Kinematic data were collected with the app and a gold-standard-instrumented GAITRite mat. Participants also used the app to complete normal and dual-task walking trials within their homes on 3 separate days. Within laboratory-based trials, GAITRite-derived heel strikes and toe-offs of the phone-side leg aligned with smartphone acceleration extrema, following filtering and rotation to the earth coordinate system. We derived stride times-a clinically meaningful metric of locomotor control-from GAITRite and app data, for all strides occurring over the GAITRite mat. We calculated stride times and the dual-task cost to the average stride time (ie, percentage change from normal to dual-task conditions) from both measurement devices. We calculated similar metrics from home-based app data. For these trials, periods of potential turning were identified via custom-developed algorithms and omitted from stride-time analyses.

RESULTS

Across all detected strides in the laboratory, stride times derived from the app and GAITRite mat were highly correlated (P<.001, r²=.98). These correlations were independent of walking condition and pocket tightness. App- and GAITRite-derived stride-time dual-task costs were also highly correlated (P<.001, r²=.95). The error of app-derived stride times (mean 16.9, SD 9.0 ms) was unaffected by the magnitude of stride time, walking condition, or pocket tightness. For both normal and dual-task trials, average stride times derived from app walking trials demonstrated excellent test-retest reliability within and between both laboratory and home-based assessments (intraclass correlation coefficient range .82-.94).

CONCLUSIONS

The iPhone app we created enabled valid and reliable assessment of stride timing-with the smartphone in the pocket-during both normal and dual-task walking and within both laboratory and nonlaboratory environments. Additional work is warranted to expand the functionality of this tool to older adults and other patient populations.

Effects of gait training on sand on improving the walking ability of patients with chronic stroke:a randomized controlled trial

[Purpose] This study examines how difference in sandy ground between firm ground influences the effects of gait training in patients with chronic stroke. [Subjects and Methods] A total of 28 patients with chronic stroke were evenly divided into experimental and control groups. Initial evaluation of the subjects was conducted by Timed Up & Go (TUG) and 6-Minute Walking Test (6MWT). Each patient in both groups received daily, 30-minute gait training on sandy ground and firm ground, five times each week, for a total of six weeks, after which reevaluation was conducted. [Results] In TUG, both groups showed significant improvement after the intervention. In 6MWT, only the experimental group achieved significantly increased distance after the intervention. However, there was no between-group difference. Improvement in dynamic balancing ability depends on repeated gait training rather than differences in the ground environment. However, gait endurance showed a difference depending on the types of ground, regardless of repeated gait training. [Conclusion] This can be attributed to the fact that gait training on sand requires use of more diverse muscles. Hence, we can confirm the potential of sand as a new material for training ground when attempting to improve walking ability, particularly gait endurance, among patients with chronic stroke.