The effects of balance training on gait late after stroke: a randomized controlled trial

Ankle stiffness asymmetry is associated with balance function in individuals with chronic stroke

Ankle joint is one of important contributors on balance in stroke survivors. This study aimed to investigate the relationships of ankle stiffness symmetry ratios along the talocrural and subtalar axes with clinical balance measures and weight distribution during quiet standing in ambulatory chronic post-stroke survivors. The clinical trials involved 15 ambulatory elderly with chronic post-stroke hemiparesis and 15 healthy controls. Ankle stiffness was evaluated during non-weight-bearing isokinetic passive biaxial ankle movements, and ankle stiffness symmetry ratios between paretic and non-paretic ankle stiffness (SR: Inversion/Eversion SRIE & Dorsi-/Plantarflexion SRDP) were measured. A certified physiotherapist evaluated the Berg Balance Scale (BBS) and weight-distribution ratio (WDR) on bilateral force plates during quiet standing. Correlation coefficients, the factor analysis, and Pearson linear multiple regression were assessed with measured parameters. Correlation coefficients showed significances in-betweens; BBS and SRDP (r = -0.543, p = 0.022), WDR and SRIE (r = -0.667, p = 0.004), SRIE and SRDP (r = -0.604, p = 0.011). The exploratory factor analysis suggested four extracted factors; (1) Balance & Gait, (2) Stroke, (3) Symmetry and (4) Dimension. The first and second factors include general and pathological characteristics in stoke participants respectively. The third factor is associated with symmetrical characteristics explaining up to 99.9% of the variance. Multiple regression analysis showed ankle stiffness ratios predict BBS up to 60% of variance. The biaxial ankle stiffness ratio is a useful clinical variable that assesses balance function, in ambulatory chronic stroke survivors.

Trunk training following stroke

BACKGROUND

Previous systematic reviews and randomised controlled trials have investigated the effect of post-stroke trunk training. Findings suggest that trunk training improves trunk function and activity or the execution of a task or action by an individual. But it is unclear what effect trunk training has on daily life activities, quality of life, and other outcomes.

OBJECTIVES

To assess the effectiveness of trunk training after stroke on activities of daily living (ADL), trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life when comparing with both dose-matched as non-dose-matched control groups.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, and five other databases to 25 October 2021. We searched trial registries to identify additional relevant published, unpublished, and ongoing trials. We hand searched the bibliographies of included studies.

SELECTION CRITERIA

We selected randomised controlled trials comparing trunk training versus non-dose-matched or dose-matched control therapy including adults (18 years or older) with either ischaemic or haemorrhagic stroke. Outcome measures of trials included ADL, trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two main analyses were carried out. The first analysis included trials where the therapy duration of control intervention was non-dose-matched with the therapy duration of the experimental group and the second analysis where there was comparison with a dose-matched control intervention (equal therapy duration in both the control as in the experimental group).  MAIN RESULTS: We included 68 trials with a total of 2585 participants. In the analysis of the non-dose-matched groups (pooling of all trials with different training duration in the experimental as in the control intervention), we could see that trunk training had a positive effect on ADL (standardised mean difference (SMD) 0.96; 95% confidence interval (CI) 0.69 to 1.24; P < 0.001; 5 trials; 283 participants; very low-certainty evidence), trunk function (SMD 1.49, 95% CI 1.26 to 1.71; P < 0.001; 14 trials, 466 participants; very low-certainty evidence), arm-hand function (SMD 0.67, 95% CI 0.19 to 1.15; P = 0.006; 2 trials, 74 participants; low-certainty evidence), arm-hand activity (SMD 0.84, 95% CI 0.009 to 1.59; P = 0.03; 1 trial, 30 participants; very low-certainty evidence), standing balance (SMD 0.57, 95% CI 0.35 to 0.79; P < 0.001; 11 trials, 410 participants; very low-certainty evidence), leg function (SMD 1.10, 95% CI 0.57 to 1.63; P < 0.001; 1 trial, 64 participants; very low-certainty evidence), walking ability (SMD 0.73, 95% CI 0.52 to 0.94; P < 0.001; 11 trials, 383 participants; low-certainty evidence) and quality of life (SMD 0.50, 95% CI 0.11 to 0.89; P = 0.01; 2 trials, 108 participants; low-certainty evidence). Non-dose-matched trunk training led to no difference for the outcome serious adverse events (odds ratio: 7.94, 95% CI 0.16 to 400.89; 6 trials, 201 participants; very low-certainty evidence). In the analysis of the dose-matched groups (pooling of all trials with equal training duration in the experimental as in the control intervention), we saw that trunk training had a positive effect on trunk function (SMD 1.03, 95% CI 0.91 to 1.16; P < 0.001; 36 trials, 1217 participants; very low-certainty evidence), standing balance (SMD 1.00, 95% CI 0.86 to 1.15; P < 0.001; 22 trials, 917 participants; very low-certainty evidence), leg function (SMD 1.57, 95% CI 1.28 to 1.87; P < 0.001; 4 trials, 254 participants; very low-certainty evidence), walking ability (SMD 0.69, 95% CI 0.51 to 0.87; P < 0.001; 19 trials, 535 participants; low-certainty evidence) and quality of life (SMD 0.70, 95% CI 0.29 to 1.11; P < 0.001; 2 trials, 111 participants; low-certainty evidence), but not for ADL (SMD 0.10; 95% confidence interval (CI) -0.17 to 0.37; P = 0.48; 9 trials; 229 participants; very low-certainty evidence), arm-hand function (SMD 0.76, 95% CI -0.18 to 1.70; P = 0.11; 1 trial, 19 participants; low-certainty evidence), arm-hand activity (SMD 0.17, 95% CI -0.21 to 0.56; P = 0.38; 3 trials, 112 participants; very low-certainty evidence). Trunk training also led to no difference for the outcome serious adverse events (odds ratio (OR): 7.39, 95% CI 0.15 to 372.38; 10 trials, 381 participants; very low-certainty evidence). Time post stroke led to a significant subgroup difference for standing balance (P < 0.001) in non-dose-matched therapy. In non-dose-matched therapy, different trunk therapy approaches had a significant effect on ADL (< 0.001), trunk function (P < 0.001) and standing balance (< 0.001). When participants received dose-matched therapy, analysis of subgroup differences showed that the trunk therapy approach had a significant effect on ADL (P = 0.001), trunk function (P < 0.001), arm-hand activity (P < 0.001), standing balance (P = 0.002), and leg function (P = 0.002). Also for dose-matched therapy, subgroup analysis for time post stroke resulted in a significant difference for the outcomes standing balance (P < 0.001), walking ability (P = 0.003) and leg function (P < 0.001), time post stroke significantly modified the effect of intervention.  Core-stability trunk (15 trials), selective-trunk (14 trials) and unstable-trunk (16 trials) training approaches were mostly applied in the included trials.

AUTHORS' CONCLUSIONS

There is evidence to suggest that trunk training as part of rehabilitation improves ADL, trunk function, standing balance, walking ability, upper and lower limb function, and quality of life in people after stroke. Core-stability, selective-, and unstable-trunk training were the trunk training approaches mostly applied in the included trials. When considering only trials with a low risk of bias, results were mostly confirmed, with very low to moderate certainty, depending on the outcome.

The Application of Biological Feedback in the Rehabilitation of Patients after Ischemic Stroke

Balance disorders are the main concern for patients after an ischemic stroke. They are caused by an abnormal force on the affected side or paresis, which causes uneven loading and visuospatial disorders. Minimizing the effects of stroke is possible through properly conducted rehabilitation. One of the known ways to achieve this objective is biological feedback. The lack of proper muscle tone on one side of the body is manifested by the uneven pressure of the lower extremities on the ground. The study and control groups were composed of two equal groups of 92 people each, in which the same set of kinesiotherapeutic exercises were applied. Patients in the study group, in addition to standard medical procedures, exercised five days a week on a Balance Trainer for four weeks. The examination and training with the device were recorded on the first day of rehabilitation, as well as after two and four weeks of training. The assessment was performed using the following functional tests and scales: Brunnström, Rankin, Barthel, Ashworth, and VAS. Patients in the control group started exercising on the Balance Trainer two weeks after the first day of rehabilitation using traditional methods. The study results reveal statistically significant reductions in the time the body’s center of gravity (COG) spent in the tacks, outside the tracks and in the COG distance, lower COG excursions in all directions. Post-stroke patients that received biofeedback training presented significantly better results than patients that did not receive such training.

The effects of sling exercise program on balance and body activities in children with spastic cerebral palsy

The purpose of this study was to investigate the static and dynamic balance and body activities after administering a trunk stability exercise program using a sling for children with spastic cerebral palsy of Gross Motor Function Classification System (GMFCS) levels III–IV. This study was conducted based on a quasi-experimental study design. Six of the study participants were assigned to the control group and six were assigned to the experimental group using simple random sampling. Both groups underwent a double-blind clinical trial study in which exercise therapy was performed for 40 min twice a week for 8 weeks. The experimental group underwent the sling exercise program and the control group underwent neuro-developmental treatment. The results showed that static and dynamic balance were significantly different before and after intervention in both the experimental and control groups (P<0.05), and there was also a statistically significant difference between the two groups (P<0.05). Gross motor function and activities of daily life showed significant improvement before and after intervention in the experimental group (P<0.05), but there was no statistically significant difference in the control group (P<0.05). There was a statistically significant difference between the two groups (P<0.05). Therefore, the sling exercise program can be used as an effective treatment for improving balance and physical activity in children with cerebral palsy of GMFCS levels III–IV who have difficulty walking. In addition, such exercise will have a positive impact on the independence of such children and help them to participate in social activities.

Effectiveness of Radial Extracorporeal Shock Wave Therapy and Visual Feedback Balance Training on Lower Limb Post-Stroke Spasticity, Trunk Performance, and Balance: A Randomized Controlled Trial

Stroke remains one of the leading causes of disability in adults, and lower limb spasticity, affected stance, and balance impact everyday life and activities of such patients. Robotic therapy and assessment are becoming important tools to clinical evaluation for post-stroke rehabilitation. The aim of this study was to determine in a more objective manner the effects of visual feedback balance training through a balance trainer system and radial extracorporeal shock wave therapy (rESWT), along with conventional physiotherapy, on lower limb post-stroke spasticity, trunk control, and static and dynamic balance through clinical and stabilometric assessment. The study was designed as a randomized controlled trial. The experimental group underwent conventional physiotherapy, visual feedback balance training, and rESWT. The control group underwent conventional physiotherapy, visual feedback training and sham rESWT. The statistical analysis was performed using GraphPad Software and MATLAB. Primary clinical outcome measures were The Modified Ashworth Scale (MAS), passive range of motion (PROM), Visual Analogue Scale (VAS), and Clonus score. Secondary outcome measures were trunk performance, sensorimotor, and lower limb function. Stabilometric outcome measures were trunk control, static balance, and dynamic balance. Visual feedback training using the Prokin system and rESWT intervention, along with conventional physiotherapy, yielded statistically significant improvement both on clinical and stabilometric outcome measures, enhancing static and dynamic balance, trunk performance, sensorimotor outcome, and limb function and considerably diminishing lower limb spasticity, pain intensity, and clonus score in the experimental group.

Effects of Mirror Therapy Combined with EMG-Triggered Functional Electrical Stimulation to Improve on Standing Balance and Gait Ability in Patient with Chronic Stroke

This study was performed to evaluate the effects of EMG-triggered functional electrical stimulation on balance and gait ability on patient with Chronic Stroke. A total of 60 chronic stroke patients were divided into mirror treatment and functional electrical (MT-EF) Group, MT group, CON group. Each group performed 60 min a day five times a week for eight weeks. MT-FE group was performed 30 min five times a week for eight weeks in mirror therapy process with EMG-FES. MT group performed 30 min five times a week for eight weeks in mirror therapy process. CON group was performed 30 min five times a week for eight weeks in conservative treatment. To measure the balance ability, Biorescue (COP, LOS), Berg balance scale (BBS) and FRT, and the gait ability test was performed by 10 m walk test. MT-FE group revealed significant differences in COP, LOS, BBS, FRT and 10 m walk test as compared to the MT and CON groups (p < 0.05). Our results showed that MT-FE was more effective on COP, LOS, BBS, FRT and 10 m walk test in patients with chronic stroke. Our results also showed that MT-EF group was more effective on balance and gait ability in patients with chronic stroke. We suggest that this study can be used for intervention data for recovering balance and gait ability in chronic stroke patients.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

Effects of visual feedback balance training with the Pro-kin system on walking and self-care abilities in stroke patients

Some scholars' studies have demonstrated that Pro-kin balance system training is able to promote the recovery of the balance function in stroke patients. The present study has expanded on those studies, and was not merely limited to studying balance, but also encompassed walking and self-care abilities of the patients; furthermore, the association among balance and walking and self-care abilities was also explored.A total of 40 stroke patients were randomly and equally divided into 2 groups: the control group (n = 20) and the treatment group (n = 20). Both groups underwent conventional balance training, although the treatment group also underwent visual feedback balance training with the Pro-kin system. The balance function was assessed using the Berg Balance Scale (BBS), the Timed "Up & Go" (TUG) test, and Pro-kin system parameters. The Pro-kin system parameters included the perimeter and ellipse area, which were both tested once with eyes open (EO) and eyes closed (EC). Walking ability was assessed using the Holden Walking Ability Scale, according to the Functional Ambulation Classification (FAC). The self-care abilities were assessed with the Barthel Index (BI). The tests were conducted prior to training, and 3 weeks after the end of the training programme.No significant differences were noted among the groups before the training. After 3 weeks of training, for both the groups, significant improvements in balance and the walking and self-care abilities were noted: The BBS value was significantly increased (P < .05), whereas the TUG, perimeter, and ellipse area with EO and EC measurements were significantly decreased after treatment (P < .05). The FAC and BI readings were significantly increased after treatment (P < 0.05), and the treatment group outperformed the control group (P < .05). Furthermore, the balance function was shown to be strongly correlated with the walking and self-care abilities (P < .01).The present study has demonstrated that the use of the Pro-kin visual feedback balance training system in combination with conventional training is a viable method for improving walking and self-care abilities of stroke patients.

Differences in Muscle Synergy Symmetry Between Subacute Post-stroke Patients With Bioelectrically-Controlled Exoskeleton Gait Training and Conventional Gait Training

Understanding the reorganization of the central nervous system after stroke is an important endeavor in order to design new therapies in gait training for stroke patients. Current clinical evaluation scores and gait velocity are insufficient to describe the state of the nervous system, and one aspect where this is lacking is in the quantification of gait symmetry. Previous studies have pointed out that spatiotemporal gait asymmetries are commonly observed in stroke patients with hemiparesis. Such asymmetries are known to cause long-term complications like joint pain and deformation. Recent studies also indicate that spatiotemporal measures showed that gait symmetry worsens after discharge from therapy. This study shows that muscle synergy analysis can be used to quantify gait symmetry and compliment clinical measures. Surface EMG was collected from lower limb muscles of subacute post-stroke patients (with an onset of around 14 days) from two groups, one undergoing robotic-assisted therapy (known as HAL group) and the other undergoing conventional therapy (known as Control group). Muscle synergies from the paretic and non-paretic limb were extracted with Non-Negative Matrix Factorization (NNMF) and compared with each other to obtain a gait symmetry index over therapy sessions. Gait events were tracked with motion tracking (for the HAL group) or foot pressure sensors (for the conventional therapy group). Patients from both groups were assessed over a 3-weeks long gait training program. Results indicated that there were no differences in muscle synergy symmetry for both groups of patients. However, the timing of muscle synergies were observed to be symmetrical in the HAL group, but not for the Control group. Intergroup comparisons of symmetry in muscle synergies and their timings were not significantly different. This could be due to a large variability in recovery in the Control group. Finally, stance time ratio was not observed to improve in both groups after their respective therapies. Interestingly, FIM and FMA scores of both groups were observed to improve after their respective therapies. Analysis of muscle coordination could reveal mechanisms of gait symmetry which could otherwise be difficult to observe with clinical scores.

Rehabilitation from meningioma

This chapter discusses the complex process of acute rehabilitation of patients after meningioma. Acute inpatient rehabilitation after meningioma utilizes an interdisciplinary approach to provide comprehensive rehabilitation through a team of physical, occupational, and speech therapists, nurses, doctors, recreational therapists, neuropsychologists, case managers and social workers, all of whom specialize in providing rehabilitation care. The prognosis of rehabilitation outcomes in this population is similar to that of the stroke population, and patients benefit from rehabilitation to maximize function in the setting of ongoing treatment. Common functional deficits include speech, cognitive, motor, and visual deficits. Medical complications include heterotopic ossification, venous thromboembolism, bowel and bladder complications, and pain. Patients must also be managed for behavioral complications such as agitation and maintenance of the sleep-wake cycle. The wide variety of functional outcomes following meningioma diagnosis and treatment necessitates a flexible rehabilitation course including testing for deficits, monitoring of outcomes, and ongoing therapy support.

Use of real-time visual feedback during overground walking training on gait symmetry and velocity in patients with post-stroke hemiparesis: randomized controlled, single-blind study

This study aimed to determine the efficacy of using real-time visual feedback during overground walking training to improve walking function in patients with post-stroke hemiparesis. Twenty-four patients with post-stroke hemiparesis who were able to walk independently under less impact of synergy pattern on the affected lower limbs (Brunnstrom stage IV or V) were randomly assigned to either the experimental group or the control group. All subjects performed overground walking for 30 min, three times a week for 6 weeks, with real-time visual feedback (weight load to the affected lower limb) provided during training for subjects in the experimental group. Outcome measures comprised the timed up-and-go test and gait parameters (step length, stride length, single and double support times, step and stride length ratios, and single support time ratio). In between-group comparison, the changes between pre-test and post-test scores in all parameters were significantly greater in the experimental group than in the control group (P < 0.05), except for double support time and step length ratio. Furthermore, post-test values of all parameters were significantly more improved in the experimental group than in the control group (P < 0.05). Our findings suggest that real-time visual feedback may be an advantageous therapeutic adjunct to reinforce the effects of overground walking training in patients with post-stroke hemiparesis.

Effects of Fresnel prism glasses on balance and gait in stroke patients with hemiplegia: A randomized controlled trial pilot study

BACKGROUND

Fresnel prism shifts the field of view and converts object position in space, but its effect on stroke patients without unilateral neglect has not been examined.

OBJECTIVE

We aimed to investigate the effect of Fresnel prism glasses on balance and gait in stroke patients with hemiplegia.

METHODS

This study included 17 stroke patients with hemiplegia without unilateral neglect. Balance and gait training were applied in the control group (n= 9), and Fresnel prism glasses were applied with balance and gait training in the experimental group (n= 8). In all groups, interventions were done for 30 min/day for 5 times/week for 4 weeks. Motor-free visual perception test for visual perception (MVPT), Berg Balance Scale (BBS), and functional reach test (FRT) for dynamic balance ability, and gait were performed. Measurements were done before and after interventions.

RESULTS

MVPT showed no significant difference between the groups (p> 0.05). A significant increase in BBS and FRT results was found before and after interventions in the experimental group (p< 0.05). Gait variables showed significant difference in the experimental group (p< 0.05).

CONCLUSION

Fresnel prism glasses may effectively improve dynamic balance and gait functions by shifting body weight to the affected side of stroke patients with hemiplegia without vision loss.

Effect of Underwater Treadmill Gait Training With Water-Jet Resistance on Balance and Gait Ability in Patients With Chronic Stroke: A Randomized Controlled Pilot Trial

Objective: The purpose of this study was to determine the effects of underwater treadmill gait training with water-jet resistance and underwater treadmill gait training with ankle weights on balance and gait abilities in chronic stroke patients.

Methods: Twenty-two inpatients and outpatients with stroke-induced impairments were randomly assigned into two groups: an underwater treadmill gait training with water-jet resistance group (n = 11) and an underwater treadmill gait training with ankle weights group (n = 11). Participants received conventional physical therapy for 30 min and underwater treadmill gait training with water-jet resistance or ankle weights for 30 min. Intervention was performed 5 days a week for 4 weeks. The Balance System SD was used to assess static and dynamic balance. The GAITRite system was used to assess gait velocity, cadence, step length, stride length, and swing phase. All measurements were performed at the beginning of the study and 4 weeks after the intervention.

Results: The water-jet resistance group and ankle weights group showed significant improvement in static balance (P < 0.00 vs. P = 0.01), dynamic balance (P < 0.00 vs. P = 0.57), gait velocity (P < 0.00 vs. P = 0.037), cadence (P < 0.00 vs. P = 0.001), step length (P < 0.00 vs. P = 0.003), stride length (P < 0.00 vs. P = 0.023), and swing phase (P < 0.00 vs. P < 0.00). However, the static and dynamic balance ability score (P < 0.00), gait velocity (P < 0.00), cadence (P < 0.00), step length (P < 0.00), stride length (P < 0.00), and swing phase (P = 0.023) in the group that received underwater treadmill gait training with water-jet resistance improved more than in the group that received underwater treadmill gait training with ankle weights.

Conclusions: Our results demonstrated that underwater treadmill gait training with water-jet resistance is effective in improving static and dynamic balance as well as gait abilities in chronic stroke patients. Thus, training using underwater treadmill gait training with water-jet resistance may be useful in facilitating active rehabilitation in chronic stroke patients.

Effectiveness of rehabilitation interventions to improve paretic propulsion in individuals with stroke - A systematic review

BACKGROUND

Stroke survivors often show reduced walking velocity and gait asymmetry. These gait abnormalities are associated with reduced propulsion of the paretic leg. This review aimed to provide an overview of the potential effectiveness of post-stroke rehabilitation interventions to improve paretic propulsion, ankle kinetics and walking velocity.

METHODS

A systematic search was performed in Pubmed, Web of Science, Embase, and Pedro. Studies were eligible if they reported changes in propulsion measures (impulse, peak value and symmetry ratios) or ankle kinetics (moment and power) following intervention in stroke survivors (group size ≥10). Study selection, data extraction and quality assessment were performed independently by two authors.

FINDINGS

A total of 28 studies were included, of which 25 studies applied exercise interventions, two studies focused on surgical interventions, and one on non-invasive brain stimulation. The number of high-quality trials was limited (N = 6; score Downs and Black scale ≥19). Propulsion measures were the primary outcome in eight studies. In general, mixed results were reported with 14 interventions yielding improvements in propulsion and ankle kinetics. In contrast, gains in walking velocity were observed in the vast majority of studies (N = 20 out of 23).

INTERPRETATION

Interventions that yielded gains in propulsion appeared to have in common that they challenged and/or enabled the utilization of latent propulsive capacity of the paretic leg during walking. Walking speed generally increased, regardless of the observed change in propulsion, suggesting the use of compensatory mechanisms. Findings should, however, be interpreted with some caution, as the evidence base for this emerging focus of rehabilitation is limited.

Effects of visual feedback training using transient Fresnel prism glasses on balance ability in stroke patients without hemispatial neglect

The center of mass of the body in patients with stroke was oriented toward the nonparetic side. Abnormal weight shift increases the risk of falls. Therefore, many therapists make an effort to help their functional recovery through balance training. Our aim was to investigate the effect of visual feedback intervention using a Fresnel prism on static and dynamic balance in stroke patients without hemispatial neglect. Participants were assigned to control group (n=10) and experimental group (n=9). In the control group, neurodevelopmental therapy was performance for 30 min. In the experimental group, Fresnel prism glasses were applied with neurodevelopmental therapy for 30 min. We executed motor-free visual perception test for visual perception, balancia for static balance ability, and functional reach test and Berg balance test for dynamic balance ability, respectively. All tests were measured immediately after intervention. The visual perception function showed significant difference between unaffected side performance behaviors and visual perceptual processing time (P<0.05). In the static balance, there was a significant difference in sway velocity and sway distances (P<0.05). Dynamic balance was also significant different between groups (P<0.05). Visual feedback using Fresnel prism helps to control the static and dynamic balance ability by inducing weight shift toward the affected side in stroke patients. Therefore, a Fresnel prism may be suggested as an intervention tool to assist weight training for patients with stroke.

Effects of balance evaluation comparison of dynamic balance and Y balance

This study measured balance ability using both an existing clinical test tool, the Y-balance test (YBT), and an automated version of the YBT named the dynamic balance test (DBT) developed in this study. Correlations between the two methods were examined to determine whether the DBT can be used as an objective tool for balance ability evaluation. The subjects included in the study were 32 healthy male adults in their 20s, who were randomized into two groups, YBT and DBT, to compare the balance ability between the two groups. The maximum stretching distances of both legs in the anterior (AT), posteromedial (PM), and posterolateral (PL) directions were measured. Furthermore, to compensate for the difference in length between left and right legs, the mean and standard deviations were determined using the standardization formula, and the standardized values were represented as percentages. For the statistical analysis of the data, an independent t-test was performed using SPSS ver. 18.0. The test results showed no significant differences between the two groups in both left and right legs in the AT, PM, and PL directions (P>0.05). Therefore, measuring balance ability with the DBT, which uses digital sensor measurement technology (an automated data recording, wireless data transmission, storage, and management system; measurement is possible even by one subject of balance ability test), was found to be advantageous in respect to the YBT in terms of time, efficiency, and convenience.

Gait Training with Bilateral Rhythmic Auditory Stimulation in Stroke Patients: A Randomized Controlled Trial

The aim of this study was to investigate the effect of gait training with bilateral rhythmic auditory stimulation (RAS) on lower extremity rehabilitation in stroke patients. Forty-four participants (<6 months after stroke) were randomly allocated to the gait training with bilateral rhythmic auditory stimulation (GTBR) group (n = 23) and the control group (n = 21). The GTBR group had gait training with bilateral RAS for 30 min a day, 5 days a week, in a 6-week period, in addition to conventional therapy. The control group had gait training without RAS, and conventional therapy. Outcome measures included gait symmetry, gait ability, balance ability, and lower extremity function. Gait symmetry on step time showed significant improvements compared to baseline (p < 0.05) in the GTBR group, but not in the control group. Gait ability was significantly improved in both groups relative to baseline values (p < 0.05), and the GTBR group showed significantly greater improvement in comparison to the control group (p < 0.05). Both groups showed significant improvements in the Timed Up and Go test (TUG), Berg Balance Scale (BBS), and Fugl–Meyer Assessment (FMA) compared to baseline (p < 0.05). GTBR is an effective therapeutic method of improving symmetric gait in stroke rehabilitation. Moreover, we found that GTBR beat frequency matching fast step time might be even more beneficial in improving gait symmetry. Future studies may develop a method of applying RAS on step time and length for improvement of gait symmetry in stroke patients.

Slackline Training (Balancing Over Narrow Nylon Ribbons) and Balance Performance: A Meta-Analytical Review

BACKGROUND

Adequate static and dynamic balance performance is an important prerequisite during daily and sporting life. Various traditional and innovative balance training concepts have been suggested to improve postural control or neuromuscular fall risk profiles over recent years. Whether slackline training (balancing over narrow nylon ribbons) serves as an appropriate training strategy to improve static and dynamic balance performance is as yet unclear.

OBJECTIVE

The aim was to examine the occurrence and magnitude of effects of slackline training compared with an inactive control condition on static and dynamic balance performance parameters in children, adults and seniors.

DATA SOURCES

Five biomedical and psychological databases (CINAHL, EMBASE, ISI Web of Knowledge, PubMed, SPORTDiscus) were screened using the following search terms with Boolean conjunctions: (slacklin* OR slack-lin* OR tight rop* OR tightrop* OR Slackline-based OR line-based OR slackrop* OR slack-rop* OR floppy wir* OR rop* balanc* OR ropedanc* OR rope-danc*) STUDY SELECTION: Randomized and non-randomized controlled trials that applied slackline training as an exercise intervention compared with an inactive control condition focusing on static and dynamic balance performance (perturbed and non-perturbed single leg stance) in healthy children, adults and seniors were screened for eligibility.

DATA EXTRACTION

Eligibility and study quality [Physiotherapy Evidence Database (PEDro) scale] were independently assessed by two researchers. Standardized mean differences (SMDs) calculated as weighted Hedges' g served as main outcomes in order to compare slackline training versus inactive control on slackline standing as well as dynamic and static balance performance parameters. Statistical analyses were conducted using a random-effects, inverse-variance model.

RESULTS

Eight trials (mean PEDro score 6.5 ± 0.9) with 204 healthy participants were included. Of the included subjects, 35 % were children or adolescents, 39 % were adults and 26 % were seniors. Slackline training varied from 4 to 6 weeks with 16 ± 7 training sessions on average, ranging from 8 to 28 sessions. Mean overall slackline training covered 380 ± 128 min. Very large task-specific effects in favor of slackline training compared with the inactive control condition were found for slackline standing time {SMD 4.63 [95 % confidence interval (CI) 3.67-5.59], p < 0.001}. Small and moderate pooled transfer effects were observed for dynamic [SMD 0.52 (95 % CI 0.08-0.96), p = 0.02] and static [SMD 0.30 (95 % CI -0.03 to 0.64), p = 0.07] standing balance performance, respectively.

CONCLUSIONS

Slackline training mainly revealed meaningful task-specific training effects in balance performance tasks that are closely related to the training content, such as slackline standing time and dynamic standing balance. Transfer effects to static and dynamic standing balance performance tasks are limited. As a consequence, slackline devices should be embedded into a challenging and multimodal balance training program and not used as the sole form of training.

Immediate effect of scalp acupuncture on the gait of patients with subacute intracerebral haemorrhage analysed by three-dimensional motion: secondary analysis of a randomised controlled trial

OBJECTIVE

To investigate the immediate effect of scalp acupuncture on walking pattern, using three-dimensional gait analysis (3D-GA), among patients in the subacute stage of intracerebral haemorrhage (ICH).

METHODS

A subset of 30 patients with subacute ICH participating in a recently published randomised controlled trial who were able to walk independently were assessed by 3D-GA before and immediately after scalp acupuncture treatment (treatment group) or no intervention (control group) and the results presented here as a secondary analysis. The acupuncture manipulation was repeated three times with an interval of 5 min. Spatiotemporal and kinematic parameters during walking were collected and analysed using a 3D motion analysis system.

RESULTS

After treatment, there were significant differences between the treatment and control groups in the spatiotemporal parameters of step length, velocity and cadence (p<0.05) and double-limb support. No significant difference was found in step width. When kinematic parameters were evaluated, the treatment group showed a significantly decreased peak pelvic anterior tilt angle and an increased hip extension angle after scalp acupuncture treatment, whereas the control group demonstrated no temporal changes. There were no significant changes in any other kinematic parameters in either group.

CONCLUSIONS

As the first exploratory study to investigate the effect of the scalp acupuncture on gait performance in patients with subacute ICH, this secondary analysis of a recent randomised trial suggested an immediate effect of treatment on spatiotemporal parameters. Improvement in gait pattern may be associated with a decreased anterior tilt of the pelvis and augmented hip joint motion during walking.

TRIAL REGISTRATION NUMBER

ChiCTR-TRC-08000225; Post-results.

The effect of ball exercise on the balance ability of young adults

[Purpose] The aim of this study was to investigate the effects of static and dynamic balance by using Medicine-ball and Swiss-ball exercises. [Subjects and Methods] Thirty-six normal adults who agreed to participate were included in the study. Subjects were randomly assigned to the Medicine-ball (n=18) and Swiss-ball groups (n=18). The participants performed the exercise for 6 weeks. Balance error scoring system and one leg standing test were performed to determine static balance, and functional reach test and timed up and go test were performed to determine dynamic balance. [Results] A significant improvement was observed from the Medicine-ball and Swiss-ball exercises, but no difference was found between the groups. In addition, a significant difference was found between balance error scoring system, one leg standing test and functional reach test after pre- and post-exercise of the Medicine-ball and Swiss-ball. [Conclusion] The findings of this study showed that the Medicine-ball and Swiss-balls were effective in improving static and dynamic balance.

Effect of balance training with Pro-kin System on balance in patients with white matter lesions

Patients with white matter lesions (WMLs) often present with problems of balance. The aim of this study was to verify the effects of combined Pro-kin system and conventional balance training to improve balance ability in WMLs patients.This is a randomized controlled study, and 40 participants were divided into 2 groups: the intervention group (n=18) received Pro-kin system with additional conventional balance training for 20 minutes per session, 5 times a week, for 2 weeks. The control group (n = 19) received only conventional balance training. Outcome measures were examined before and after the 2 weeks intervention using the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Pro-kin system.After completion of the 2 weeks intervention, BBS, TUG, and Pro-kin system results significantly improved in the intervention group (P < .05). In the control group, BBS and Pro-kin system results significantly improved (P < .05). Changes in all outcomes but the ellipse area with eye closed (P < .05) were significantly higher in the intervention group than in the control group.The combination of Pro-kin system and conventional balance training is a potentially valuable treatment for patients with WMLs.

The Role of Posturography in Assessing the Process of Rehabilitation in Poststroke Patients-A Case Study

Stroke is one of the most common causes of death and disability both in Poland and around the world. Each year, 250 out of 100,000 people in Europe are diagnosed with a disruption of cerebral perfusion in the form of stroke. In Poland, approximately 65,000-70,000 people are affected each year, with the incidence steadily increasing. Stroke survivors suffer from impaired cognitive and motor functions. Moreover, they exhibit severe gait pattern abnormalities, which together with balance disorders, constitute the main factors increasing the risk of falls in this patient group. Therefore, postural stability and gait assessments in these patients should be an important part of every examination instead of being conducted only for the purposes of physical rehabilitation. Currently, the most common method of postural stability assessment both in the healthy and those affected with a disorder is posturography. The aim of the study was to evaluate selected posturographic parameters in poststroke patients before and after rehabilitation treatment.

The effects of visual control whole body vibration exercise on balance and gait function of stroke patients

[Purpose] This study aims to verify the effects of visual control whole body vibration exercise on balance and gait function of stroke patients. [Subjects and Methods] A total of 22 stroke patients were randomly assigned to two groups; 11 to the experimental group and 11 to the control group. Both groups received 30 minutes of Neuro-developmental treatment 5 times per week for 4 weeks. The experimental group additionally performed 10 minutes of visual control whole body vibration exercise 5 times per week during the 4 weeks. Balance was measured using the Functional Reach Test. Gait was measured using the Timed Up and Go Test. [Results] An in-group comparison in the experimental group showed significant differences in the Functional Reach Test and Timed Up and Go Test. In comparing the groups, the Functional Reach Test and Timed Up and Go Test of the experimental group were more significantly different compared to the control group. [Conclusion] These results suggest that visual control whole body vibration exercise has a positive effect on the balance and gait function of stroke patients.

Balance evaluation techniques and physical therapy in post-stroke patients: A literature review

A stroke (cerebrovascular accident - CVA) is a significant social-economic issue. Approximately 15-30% of all patients develop life-long disability, 20% require over 3 months of specialized care in healthcare institutions, and the majority of the patients never recover the ability to maintain a proper vertical position. Such CVA sequelae as balance disturbances not only negatively affect patients' daily physical activity, but also result in social isolation. A number of standardized clinical scales, tests, and instrumental examination techniques have been proposed for evaluating not only post-CVA balance function, but also any changes in this function following various interventions. Even though scientific literature lists numerous methods and instruments for the improvement of balance after a CVA, not all of them are equally effective, and there have been rather controversial evaluations of some techniques. Nevertheless, the application of the majority of the techniques as complementary or alternative measures to traditional physical therapy (PT) frequently yields better results.

Effects of ankle biofeedback training on strength, balance, and gait in patients with stroke

[Purpose] This study aimed to investigate the effects of ankle biofeedback training on muscle strength of the ankle joint, balance, and gait in stroke patients. [Subjects and Methods] Twenty-seven subjects who had had a stroke were randomly allocated to either the ankle biofeedback training group (n=14) or control group (n=13). Conventional therapy, which adhered to the neurodevelopmental treatment approach, was administered to both groups for 30 minutes. Furthermore, ankle strengthening exercises were performed by the control group and ankle biofeedback training by the experimental group, each for 30 minutes, 5 days a week for 8 weeks. To test muscle strength, balance, and gait, the Biodex isokinetic dynamometer, functional reach test, and 10 m walk test, respectively, were used. [Results] After the intervention, both groups showed a significant increase in muscle strength on the affected side and improved balance and gait. Significantly greater improvements were observed in the balance and gait of the ankle biofeedback training group compared with the control group, but not in the strength of the dorsiflexor and plantar flexor muscles of the affected side. [Conclusion] This study showed that ankle biofeedback training significantly improves muscle strength of the ankle joint, balance, and gait in patients with stroke.

Effect of Sling Exercise Training on Balance in Patients with Stroke: A Meta-Analysis

Objective

This study aims to evaluate the effect of sling exercise training (SET) on balance in patients with stroke.

Methods

PubMed, Cochrane Library, Ovid LWW, CBM, CNKI, WanFang, and VIP databases were searched for randomized controlled trials of the effect of SET on balance in patients with stroke. The study design and participants were subjected to metrological analysis. Berg balance Scale (BBS), Barthel index score (BI), and Fugl-Meyer Assessment (FMA) were used as independent parameters for evaluating balance function, activities of daily living(ADL) and motor function after stroke respectively, and were subjected to meta-analysis by RevMan5.3 software.

Results

Nine studies with 460 participants were analyzed. Results of meta-analysis showed that the SET treatment combined with conventional rehabilitation was superior to conventional rehabilitation treatments, with increased degrees of BBS (WMD = 3.81, 95% CI [0.15, 7.48], P = 0.04), BI (WMD = 12.98, 95% CI [8.39, 17.56], P < 0.00001), and FMA (SMD = 0.76, 95% CI [0.41, 1.11], P < 0.0001).

Conclusion

Based on limited evidence from 9 trials, the SET treatment combined with conventional rehabilitation was superior to conventional rehabilitation treatments, with increased degrees of BBS, BI and FMA, So the SET treatment can improvement of balance function after stroke, but the interpretation of our findings is required to be made with caution due to limitations in included trials such as small sample sizes and the risk of bias. Therefore, more multi-center and large-sampled randomized controlled trials are needed to confirm its clinical applications.

Effects of 8 weeks of mat-based Pilates exercise on gait in chronic stroke patients

[Purpose] The purpose of this study was to investigate the effects of an 8-week program of Pilates exercise on gait in chronic hemiplegia patients and to determine whether or not it can be used for rehabilitation in postsrtoke patients. [Subjects and Methods] Twenty individuals with unilateral chronic hemiparetic stroke (age, 66.1 ± 4.4 yrs; height, 162.3 ± 8.3 cm; weight, 67.4 ± 12.3 kg) participated in this study and were randomly allocated equally to either a Pilates exercise group or a control group. To identify the effects of Pilates exercise, a 3-D motion analysis with 8 infrared cameras was performed. [Results] For the gait parameters, improvements were found in the Pilates exercise group for all variables, and statistical significance was observed for stride length, gait velocity, knee range of motion and hip range of motion. For the asymmetry indexes, insignificant improvements were found for all variables in the Pilates exercise group. [Conclusion] In conclusion, an 8-week program of Pilates exercise had a positive influence on improving the gait ability of poststroke patients, and the intervention could be applied to poststroke patients with various levels of physical disability by adjusting the intensity of training.

Slacklining and stroke: A rehabilitation case study considering balance and lower limb weakness

To ascertain the effectiveness of slacklining as a supplementary therapy for elderly stroke patients who are functionally non-progressing. This case study involved an 18-mo prospective observation of the management of an 87-year-old female stroke-patient of the left hemisphere with reduced balance, reduced lower limb muscular activation, hypertonia, and concurrent postural deficits. This entailed the initial acute care phase through to discharge to home and 18-mo final status in her original independent living setting. The introduction of slacklining as an adjunct therapy was made 12 mo post incident. Slacklining involves balance retention on a tightened band where external environmental changes cause a whole-body dynamic response to retain equilibrium. It is a complex neuromechanical task enabling individualized self-developed response strategies to be learned and adapted. This facilitates the innate process of balance retention, lower-limb and core muscle activation, and stable posture through a combination of learned motor skills and neurological system down regulation. Individuals adopt and follow established sequential motor learning stages where the acquired balance skills are achieved in a challenging composite-chain activity. Slacklining could be considered an adjunct therapy for lower limb stroke rehabilitation where function is compromised due to decreased muscle recruitment, decreased postural control and compromised balance. Initial inpatient rehabilitation involved one-month acute-care, one-month rehabilitation, and one-month transitional care prior to home discharge. A further six months of intensive outpatient rehabilitation was provided with five hourly sessions per week including:supervised and self-managed hydrotherapy, plus one individual and two group falls’ prevention sessions. These were supported by daily home exercises. At 12 mo post incident, recovery plateaued, then regressed following three falls. Rehabilitation was subsequently modified with the hydrotherapy retained and the group sessions replaced with an additional individual session supplemented with slacklining. The slacklining followed stages one and two of a standardized five-stage protocol. Self-reported functional progression resumed with improvement by 14 mo which further increased and was sustained 18 mo (Students’t test P < 0.05). Slacklining’s external stimulations activate global-body responses through innate balance, optimal postural and potentially down-regulated reflex control. Incorporated into stroke rehabilitation programs, slacklining can provide measurable functional gains.

A computer vision based candidate for functional balance test

Balance in humans is a motor skill based on complex multimodal sensing, processing and control. Ability to maintain balance in activities of daily living (ADL) is compromised due to aging, diseases, injuries and environmental factors. Center for Disease Control and Prevention (CDC) estimate of the costs of falls among older adults was $34 billion in 2013 and is expected to reach $54.9 billion in 2020. In this paper, we present a brief review of balance impairments followed by subjective and objective tools currently used in clinical settings for human balance assessment. We propose a novel computer vision (CV) based approach as a candidate for functional balance test. The test will take less than a minute to administer and expected to be objective, repeatable and highly discriminative in quantifying ability to maintain posture and balance. We present an informal study with preliminary data from 10 healthy volunteers, and compare performance with a balance assessment system called BTrackS Balance Assessment Board. Our results show high degree of correlation with BTrackS. The proposed system promises to be a good candidate for objective functional balance tests and warrants further investigations to assess validity in clinical settings, including acute care, long term care and assisted living care facilities. Our long term goals include non-intrusive approaches to assess balance competence during ADL in independent living environments.

An efficacy study on improving balance and gait in subacute stroke patients by balance training with additional motor imagery: a pilot study

[Purpose] The few studies conducted on subacute stroke patients have focused only on gait function improvement. This study therefore aimed to confirm the effect of balance training with additional motor imagery on balance and gait improvement in subacute stroke patients. [Subjects and Methods] Participants were divided into an experimental or control group. The experimental group received balance training for 20 minutes/day with mental imagery for 10 minutes/day, three days/week, for four weeks. The control group received only balance training for 30 minutes. Before and after the 12 sessions, balance and gait ability were assessed by the researcher and a physical therapist. [Results] After completion of the 4-week intervention, Berg Balance Scale, Timed Up and Go test, Functional Reach Test, and Four Square Step test scores significantly increased in the experimental group. In the control group, Berg Balance Scale and Functional Reach Test scores significantly improved. Changes in the Timed Up and Go test, Functional Reach Test, and Four Square Step Test scores after intervention were significantly higher in the experimental than in the control group. [Conclusion] Specific balance training with additional motor imagery may result in better rehabilitation outcomes of gait and balance ability than balance training alone.

Effect of dual tasks on balance ability in stroke patients

[Purpose] The purpose of this study was to determine the effects of training using dual tasks on balance ability in stroke patients. [Subjects] Forty stroke patients were divided into a dual-task training group (N = 20) and a single task training group (N = 20) randomly. [Methods] The subjects in the single-task traing group stood in a comfortable position, faced a therapist, then threw a Swiss ball back and forth. They then performed balance training in which they raised and lowered their ankles while facing forward or moved objects from one table to another. The DTG performed dual tasks, which involved performing a task on an unstable surface using a balance pad. Both groups received training 30 min per day, five times per week, for eight weeks. [Results] The DTG showed significant increases in weight distribution rate, anterior limit of stability, posterior limit of stability, and BBS scores compared with the STG. [Conclusion] According to the results of this study, dual-task training and single-task training were effective in improving balance in stroke patients, dual task training is more effective for increasing balance ability.

Task-specificity of balance training

Despite much research on balance training, it is still unclear whether balance training leads to highly task-specific adaptations or rather non-specific adaptations. Hence, in this study we examined whether balance training increased performance only in the balance task that was trained or also in non-trained tasks. Forty healthy participants (28 m 12 f, 25 ± 4 years, 177 ± 10 cm, 73 ± 14 kg) were assigned to one of two training groups (TGs) or a control group. Both TGs completed six sessions over 2 weeks, only the training device differed. Before and after the training, performance in the trained task as well as in additional untrained tasks was recorded. ANOVAs showed that each TG outperformed the other groups only in the task they had trained (e.g., task trained by TG1: +225% in TG1, only +41% and +30% in TG2 and control, group*time interaction, p<0.001; Untrained task 1: TG1 +48%, TG2 +48%, and control +30%, no significant interaction, p=0.72). In summary, 2 weeks of balance training resulted in highly task-specific effects, no transfer even to very similar tasks was observed. Therefore, we recommend identifying and training exactly those tasks that need improvement, and test the efficacy of training programs using specific tests instead of general tests with limited functional relevance.

Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review

QUESTION

In people after stroke, does virtual reality based rehabilitation (VRBR) improve walking speed, balance and mobility more than the same duration of standard rehabilitation? In people after stroke, does adding extra VRBR to standard rehabilitation improve the effects on gait, balance and mobility?

DESIGN

Systematic review with meta-analysis of randomised trials.

PARTICIPANTS

Adults with a clinical diagnosis of stroke.

INTERVENTION

Eligible trials had to include one these comparisons: VRBR replacing some or all of standard rehabilitation or VRBR used as extra rehabilitation time added to a standard rehabilitation regimen.

OUTCOME MEASURES

Walking speed, balance, mobility and adverse events.

RESULTS

In total, 15 trials involving 341 participants were included. When VRBR replaced some or all of the standard rehabilitation, there were statistically significant benefits in walking speed (MD 0.15 m/s, 95% CI 0.10 to 0.19), balance (MD 2.1 points on the Berg Balance Scale, 95% CI 1.8 to 2.5) and mobility (MD 2.3 seconds on the Timed Up and Go test, 95% CI 1.2 to 3.4). When VRBR was added to standard rehabilitation, mobility showed a significant benefit (0.7 seconds on the Timed Up and Go test, 95% CI 0.4 to 1.1), but insufficient evidence was found to comment about walking speed (one trial) and balance (high heterogeneity).

CONCLUSION

Substituting some or all of a standard rehabilitation regimen with VRBR elicits greater benefits in walking speed, balance and mobility in people with stroke. Although the benefits are small, the extra cost of applying virtual reality to standard rehabilitation is also small, especially when spread over many patients in a clinic. Adding extra VRBR time to standard rehabilitation also has some benefits; further research is needed to determine if these benefits are clinically worthwhile.

Use of the Microsoft Kinect system to characterize balance ability during balance training

The risk of falling increases significantly in the elderly because of deterioration of the neural musculature regulatory mechanisms. Several studies have investigated methods of preventing falling using real-time systems to evaluate balance; however, it is difficult to monitor the results of such characterizations in real time. Herein, we describe the use of Microsoft's Kinect depth sensor system to evaluate balance in real time. Six healthy male adults (25.5±1.8 years, 173.9±6.4 cm, 71.4±6.5 kg, and 23.6±2.4 kg/m(2)), with normal balance abilities and with no musculoskeletal disorders, were selected to participate in the experiment. Movements of the participants were induced by controlling the base plane of the balance training equipment in various directions. The dynamic motion of the subjects was measured using two Kinect depth sensor systems and a three-dimensional motion capture system with eight infrared cameras. The two systems yielded similar results for changes in the center of body mass (P>0.05) with a large Pearson's correlation coefficient of γ>0.60. The results for the two systems showed similarity in the mean lower-limb joint angle with flexion-extension movements, and these values were highly correlated (hip joint: within approximately 4.6°; knee joint: within approximately 8.4°) (0.40<γ<0.74) (P>0.05). Large differences with a low correlation were, however, observed for the lower-limb joint angle in relation to abduction-adduction and internal-external rotation motion (γ<0.40) (P<0.05). These findings show that clinical and dynamic accuracy can be achieved using the Kinect system in balance training by measuring changes in the center of body mass and flexion-extension movements of the lower limbs, but not abduction-adduction and internal-external rotation.

Effects of virtual reality-based training and task-oriented training on balance performance in stroke patients

[Purpose] This study aimed to investigate the clinical effects of virtual reality-based training and task-oriented training on balance performance in stroke patients. [Subjects and Methods] The subjects were randomly allocated to 2 groups: virtual reality-based training group (n = 12) and task-oriented training group (n = 12). The patients in the virtual reality-based training group used the Nintendo Wii Fit Plus, which provided visual and auditory feedback as well as the movements that enabled shifting of weight to the right and left sides, for 30 min/day, 3 times/week for 6 weeks. The patients in the task-oriented training group practiced additional task-oriented programs for 30 min/day, 3 times/week for 6 weeks. Patients in both groups also underwent conventional physical therapy for 60 min/day, 5 times/week for 6 weeks. [Results] Balance and functional reach test outcomes were examined in both groups. The results showed that the static balance and functional reach test outcomes were significantly higher in the virtual reality-based training group than in the task-oriented training group. [Conclusion] This study suggested that virtual reality-based training might be a more feasible and suitable therapeutic intervention for dynamic balance in stroke patients compared to task-oriented training.

Comparison of kinematic variables obtained by inertial sensors among stroke survivors and healthy older adults in the Functional Reach Test: cross-sectional study

BACKGROUND

Balance dysfunction is one of the most common problems in people who suffer stroke. To parameterize functional tests standardized by inertial sensors have been promoted in applied medicine. The aim of this study was to compare the kinematic variables of the Functional Reach Test (FRT) obtained by two inertial sensors placed on the trunk and lumbar region between stroke survivors (SS) and healthy older adults (HOA) and to analyze the reliability of the kinematic measurements obtained.

METHODS

Cross-sectional study. Five SS and five HOA over 65. A descriptive analysis of the average range as well as all kinematic variables recorded was developed. The intrasubject and intersubject reliability of the measured variables was directly calculated.

RESULTS

In the same intervals, the angular displacement was greater in the HOA group; however, they were completed at similar times for both groups, and HOA conducted the test at a higher speed and greater acceleration in each of the intervals. The SS values were higher than HOA values in the maximum and minimum acceleration in the trunk and in the lumbar region.

CONCLUSIONS

The SS show less functional reach, a narrower, slower and less accelerated movement during the FRT execution, but with higher peaks of acceleration and speed when they are compared with HOA.

Effect of space balance 3D training using visual feedback on balance and mobility in acute stroke patients

[Purpose] The purpose of the study was to determine the effects of balance training with Space Balance 3D, which is a computerized measurement and visual feedback balance assessment system, on balance and mobility in acute stroke patients. [Subjects and Methods] This was a randomized controlled trial in which 52 subjects were assigned randomly into either an experimental group or a control group. The experimental group, which contained 26 subjects, received balance training with a Space Balance 3D exercise program and conventional physical therapy interventions 5 times per week during 3 weeks. Outcome measures were examined before and after the 3-week interventions using the Berg Balance Scale (BBS), Timed Up and Go (TUG) test, and Postural Assessment Scale for Stroke Patients (PASS). The data were analyzed by a two-way repeated measures ANOVA using SPSS 19.0. [Results] The results revealed a nonsignificant interaction effect between group and time period for both groups before and after the interventions in the BBS score, TUG score, and PASS score. In addition, the experimental group showed more improvement than the control group in the BBS, TUG and PASS scores, but the differences were not significant. In the comparisons within the groups by time, both groups showed significant improvement in BBS, TUG, and PASS scores. [Conclusion] The Space Balance 3D training with conventional physical therapy intervention is recommended for improvement of balance and mobility in acute stroke patients.

The effects of symmetric center of pressure displacement training with feedback on the gait of stroke patients

[Purpose] This study investigated the effects of COP displacement training using visual feedback had on the gait of patients with hemiplegia due to stroke. [Subjects and Methods] This study was conducted with 20 patients with hemiplegia due to stroke. The training consisted of five training sets repeated 10 times and the activity was conducted for 15 minutes each session, three times per week for six weeks immediately after completion of central nervous system developmental treatment. [Results] A comparison of the results of before and after the experiment found that the COP displacement training group showed significant improvements in step length, stride length, gait velocity, and the functional reach test, while the control group showed significant improvement only in the functional reach test. In the intergroup comparison, the COP displacement training group showed significant improvements in paretic side step length, paretic side stride length, gait velocity, and the functional reach test compared to the control group. [Conclusion] In conclusion, according to the results of this study, visual feedback training for COP displacement is more effective at enhancing the gait and balance of hemiplegic patients due to stroke than only performing feedback training for even weight distribution.

Effects of auditory feedback during gait training on hemiplegic patients' weight bearing and dynamic balance ability

[Purpose] This study examined the effects of auditory feedback during gait on the weight bearing of patients with hemiplegia resulting from a stroke. [Subjects] Thirty hemiplegic patients participated in this experiment and they were randomly allocated to an experimental group and a control group. [Methods] Both groups received neuro-developmental treatment for four weeks and the experimental group additionally received auditory feedback during gait training. In order to examine auditory feedback effects on weight bearing during gait, a motion analysis system GAITRite was used to measure the duration of the stance phase and single limb stance phase of the subjects. [Results] The experimental group showed statistically significant improvements in the duration of the stance phase and single limb stance phase of the paretic side and the results of the Timed Up and Go Test after the training. [Conclusion] Auditory feedback during gait training significantly improved the duration of the stance phase and single limb stance phase of hemiplegic stroke patients.

Gait mechanics in patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is characterized by the frequent association of disease outside the lung. The objective of this study was to determine the presence of biomechanical gait abnormalities in COPD patients compared to healthy controls while well rested and without rest.

METHODS

Patients with COPD (N = 17) and aged-matched, healthy controls (N = 21) walked at their self-selected pace down a 10-meter walkway while biomechanical gait variables were collected. A one-minute rest was given between each of the five collected trials to prevent tiredness (REST condition). Patients with COPD then walked at a self-selected pace on a treadmill until the onset of self-reported breathlessness or leg tiredness. Subjects immediately underwent gait analysis with no rest between each of the five collected trials (NO REST condition). Statistical models with and without covariates age, gender, and smoking history were used.

RESULTS

After adjusting for covariates, COPD patients demonstrated more ankle power absorption in mid-stance (P = 0.006) than controls during both conditions. Both groups during NO REST demonstrated increased gait speed (P = 0.04), stride length (P = 0.03), and peak hip flexion (P = 0.04) with decreased plantarflexion moment (P = 0.04) and increased knee power absorption (P = 0.04) as compared to REST. A significant interaction revealed that peak ankle dorsiflexion moment was maintained from REST to NO REST for COPD but increased for controls (P < 0.01). Stratifying by disease severity did not alter these findings, except that step width decreased in NO REST as compared to REST (P = 0.01). Standardized effect sizes of significant effects varied from 0.5 to 0.98.

CONCLUSIONS

Patients with COPD appear to demonstrate biomechanical gait changes at the ankle as compared to healthy controls. This was seen not only in increased peak ankle power absorption during no rest but was also demonstrated by a lack of increase in peak ankle dorsiflexion moment from the REST to the NO REST condition as compared to the healthy controls. Furthermore, a wider step width has been associated with fall risk and this could account for the increased incidence of falls in patients with COPD.

Virtual reality training improves balance function

Virtual reality is a new technology that simulates a three-dimensional virtual world on a computer and enables the generation of visual, audio, and haptic feedback for the full immersion of users. Users can interact with and observe objects in three-dimensional visual space without limitation. At present, virtual reality training has been widely used in rehabilitation therapy for balance dysfunction. This paper summarizes related articles and other articles suggesting that virtual reality training can improve balance dysfunction in patients after neurological diseases. When patients perform virtual reality training, the prefrontal, parietal cortical areas and other motor cortical networks are activated. These activations may be involved in the reconstruction of neurons in the cerebral cortex. Growing evidence from clinical studies reveals that virtual reality training improves the neurological function of patients with spinal cord injury, cerebral palsy and other neurological impairments. These findings suggest that virtual reality training can activate the cerebral cortex and improve the spatial orientation capacity of patients, thus facilitating the cortex to control balance and increase motion function.

Comparison between the Effects of Horseback Riding Exercise and Trunk Stability Exercise on the Balance of Normal Adults

[Purpose] The aim of this study was to compare the effects of horseback riding exercise and trunk stability exercise on static and dynamic balance in normal adults. [Subjects and Methods] Twenty-two normal adults residing in communities were randomly divided into a horseback riding exercise group and a trunk stability exercise group, and they conducted exercise for eight weeks. [Results] Sway times of the COG (center of gravity) decreased significantly, and the A-P (anterior-posterior) and M-L (medial-lateral) velocities significantly decreased in both groups. A comparison of sway times of the COG after the intervention between the two groups revealed that the horseback riding exercise group showed larger decreases than the trunk stability exercise group. [Conclusion] In terms of the musculoskeletal factor, horseback riding may result in functional improvement and increased stability, and it may stimulate proprioceptive sense input in neurological terms. It is therefore considered a composite exercise method that may strengthen the two factors simultaneously.

The effects of horse riding simulation training on stroke patients' balance ability and abdominal muscle thickness changes

[Purpose] The purpose of this study was to assess the effects of horse riding simulation training on changes in balance ability and abdominal muscle thicknesses of stroke patients. [Subjects] Thirty stroke patients with hemiplegia were recruited, and they were randomly assigned to a control or experimental group. [Methods] The experimental group performed horse riding simulation training, whereas the control group performed trunk exercises for 8 weeks. Balance ability was measured using a BioRescue system. The thicknesses of subjects' external oblique, internal oblique, and transversus abdominis muscles were measured by ultrasonic imaging. [Results] In the experimental group, balance ability was significantly improved after training. Similarly, the thickness of the abdominal muscles on the affected side changed after training in the experimental group, whereas the control group showed no statistically significant changes. [Conclusion] We suggest that horse riding simulation training is more effective than trunk exercises at reducing the center of pressure path length and travel speed and improving the asymmetry of the abdominal muscles of stroke patients.

Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke

OBJECTIVE

To study the clinical effectiveness and the usability of a virtual reality-based intervention compared with conventional physical therapy in the balance recovery of individuals with chronic stroke.

DESIGN

Randomized controlled trial.

SETTING

Outpatient neurorehabilitation unit.

PARTICIPANTS

A total of 20 individuals with chronic stroke.

INTERVENTIONS

The intervention consisted of 20 one-hour sessions, five sessions per week. The experimental group combined 30 minutes with the virtual reality-based intervention with 30 minutes of conventional training. The control group underwent one hour conventional therapy.

MAIN MEASURES

Balance performance was assessed at the beginning and at the end of the trial using the Berg Balance Scale, the balance and gait subscales of the Tinetti Performance-Oriented Mobility Assessment, the Brunel Balance Assessment, and the 10-m Walking Test. Subjective data of the virtual reality-based intervention were collected from the experimental group, with a feedback questionnaire at the end of the trial.

RESULTS

The results revealed a significant group-by-time interaction in the scores of the Berg Balance Scale (p < 0.05) and in the 10-m Walking Test (p < 0.05). Post-hoc analyses showed greater improvement in the experimental group: 3.8 ±2.6 vs. 1.8 ±1.4 in the Berg Balance Scale, -1.9 ±1.6 seconds vs. 0.0 ±2.3 seconds in the 10-m Walking Test, and also in the number of participants who increased level in the Brunel Balance Assessment (χ(2) = 2.5, p < 0.01).

CONCLUSIONS

Virtual reality interventions can be an effective resource to enhance the improvement of balance in individuals with chronic stroke.