The Influence of Treadmill Inclination on the Gait of Ambulatory Hemiparetic Subjects

Effects of ankle exoskeleton assistance and plantar pressure biofeedback on incline walking mechanics and muscle activity in cerebral palsy

Ankle dysfunction affects more than 50 % of people with cerebral palsy, resulting in atypical gait patterns that impede lifelong mobility. Incline walking requires increased lower limb effort and is a promising intervention that targets lower-limb extensor muscles. A concern when prescribing incline walking to people with gait deficits is that this exercise may be too challenging or reinforce unfavorable gait patterns. This study aims to investigate how ankle exoskeleton assistance and plantar pressure biofeedback would affect gait mechanics and muscle activity during incline walking in CP. We recruited twelve children and young adults with CP. Participants walked with ankle assistance alone, biofeedback alone, and the combination while we assessed ankle, knee, and hip mechanics, and plantar flexor and knee extensor activity. Compared to incline walking without assistance or biofeedback, ankle assistance alone reduced the peak biological ankle moment by 12 % (p < 0.001) and peak soleus activity by 8 % (p = 0.013); biofeedback alone increased the biological ankle moment (4 %, p = 0.037) and power (19 %, p = 0.012), and plantar flexor activities by 9 - 27 % (p ≤ 0.026); assistance-plus-biofeedback increased biological ankle and knee power by 34 % and 17 %, respectively (p ≤ 0.05). The results indicate that both ankle exoskeleton assistance and plantar pressure biofeedback can effectively modify lower limb mechanics and muscular effort during incline walking in CP. These techniques may help in establishing personalized gait training interventions by providing the ability to adjust intensity and biomechanical focus over time.

Energy expenditure and perceived effort during uphill and downhill walking in people with multiple sclerosis

BACKGROUND

Walking on different slopes is a common daily activity for many ambulatory people with multiple sclerosis (pwMS) AIM: Investigate energy expenditure measures of walking on level, uphill and downhill slopes in pwMS.

DESIGN

Observational case-control study.

SETTING

Sheba Multiple Sclerosis Center, Tel-Hashomer, Israel.

POPULATION

Eighteen pwMS; 10 women and 8 men, aged 39.7 (SD=6.8), mean EDSS was 2.9 (SD=1.2) and 23 healthy adults; 8 women and 15 men, aged 37.1 (S.D.=5.3).

METHODS

Energy expenditure values were obtained via a metabolic device during four conditions: sitting, comfortable walking, uphill and downhill walking. Each walking trial, obtained on a treadmill, lasted 6-min and were separated by10-min recovery intervals.

RESULTS

For both pwMS and healthy controls, the O2 rate and O2 cost was higher during uphill walking compared to level walking and lower during downhill walking compared with level walking. O2 rate and net O2 cost during uphill walking was lower in pwMS compared with the healthy controls. The most demanding effort was during uphill walking, with pwMS rating it more demanding compared with the healthy controls.

CONCLUSIONS

Perceived effort of walking on different slopes is not consistent with changes in the energy expenditure values in pwMS.

CLINICAL REHABILITATION IMPACT

pwMS describe the effort of walking on different slopes higher than normal, regardless of the energy expenditure values.

Effects of Transcranial Direct Current Stimulation Combined with Treadmill Training on Kinematics and Spatiotemporal Gait Variables in Stroke Survivors: A Randomized, Triple-Blind, Sham-Controlled Study

The present study assessed the effects of anodal transcranial direct current stimulation (tDCS) combined with treadmill training on spatiotemporal and kinematic variables in stroke survivors using gait speed as the primary outcome. A randomized, sham-controlled, triple-blind, study was conducted involving 28 patients with hemiparesis allocated to two groups. The experimental group was submitted to treadmill training combined with anodal tDCS over the primary motor cortex (M1) of the damaged hemisphere. The control group was submitted to treadmill training combined with sham tDCS. Stimulation was administered (2 mA, 20 min) five times a week for two weeks during treadmill training. No significant differences (p > 0.05) in spatiotemporal variables were found in the intra-group and inter-group analyses. However, the experimental group demonstrated improvements in kinematic variables of the knee and ankle (p < 0.05) and these results were maintained one month after the end of the intervention. The inter-group analysis revealed significant differences (p < 0.05) with regard to the pelvis, hip and knee. Anodal tDCS over M1 of the damaged hemisphere combined with treadmill training did not affect spatiotemporal variables, but promoted improvements in kinematic variables of the pelvis, hip, knee and ankle and results were maintained one month after treatment.

Effects of inclined treadmill training on inadequate ankle control during walking in individuals after stroke: A pilot randomized controlled trial

BACKGROUND: Inadequate ankle control influences walking ability in people after stroke. Walking on inclined surface activates ankle muscles and movements. However, the effect of inclined treadmill training on ankle control is not clear. OBJECTIVE: To investigate the effects of inclined treadmill training on ankle control in individuals with inadequate ankle control after chronic stroke. METHODS: This was a randomized single-blinded study. Eighteen participants were randomly assigned to receive 12 sessions of 30 min inclined (n = 9) or regular (n = 9) treadmill training and 5 min over-ground walking training. The outcomes included ankle control during walking, muscle strength of affected leg, walking performance, and stair climbing performance. RESULTS: Inclined treadmill training significantly improved ankle dorsiflexion at initial contact (p = 0.002), increased tibialis anterior activities (p = 0.003 at initial contact, p = 0.006 in swing phase), and decreased dynamic plantarflexors spasticity (p = 0.027) as compared with regular treadmill training. Greater improvements were also shown in stair climbing with affected leg leading (p = 0.006) and affected knee extensors strength (p = 0.002) after inclined treadmill training. CONCLUSIONS: Inclined treadmill training was proposed to improve inadequate ankle control after chronic stroke. Inclined treadmill training also improved the stair climbing ability accompanied with increased muscle strength of the affected lower extremity.

The Effect of Inclines on Joint Angles in Stroke Survivors During Treadmill Walking

Stroke severely affects the quality of life, specifically in walking independently. Thus, it is crucial to understand the impaired gait pattern. This gait pattern has been widely investigated when walking on a level treadmill. However, knowledge about the gait pattern when walking on inclines is scarce. Therefore, this study attempted to fulfill this knowledge gap. In this study, 15 stroke survivors and 15 age/height/weight healthy controls were recruited. The participants were instructed to walk on three different inclines: 0°, 3°, and 6°. The participants were required to walk on each incline for 2 min and needed to complete each incline two times. The dependent variables were the peak values for ankle/knee/hip joint angles and the respective variability of these peak values. The results showed that an increment of the incline significantly increased the peak of the hip flexion and the peak of the knee flexion but did not affect the peak values of the ankle joints in the paretic leg in these stroke survivors. In comparison with the healthy controls, lower hip extension, lower hip flexion, lower knee flexion, and lower ankle plantar flexion were observed in stroke survivors. A clinical application of this work might assist the physical therapists in building an effective treadmill training protocol.

Dynamic Asymmetries Do Not Match Spatiotemporal Step Asymmetries during Split-Belt Walking

While walking on split-belt treadmills (two belts running at different speeds), the slower limb shows longer anterior steps than the limb dragged by the faster belt. After returning to basal conditions, the step length asymmetry is transiently reversed (after-effect). The lower limb joint dynamics, however, were not thoroughly investigated. In this study, 12 healthy adults walked on a force-sensorised split-belt treadmill for 15 min. Belts rotated at 0.4 m s−1 on both sides, or 0.4 and 1.2 m s−1 under the non-dominant and dominant legs, respectively. Spatiotemporal step parameters, ankle power and work, and the actual mean velocity of the body’s centre of mass (CoM) were computed. On the faster side, ankle power and work increased, while step length and stance time decreased. The mean velocity of the CoM slightly decreased. As an after-effect, modest converse asymmetries developed, fading within 2–5 min. These results may help to decide which belt should be assigned to the paretic and the unaffected lower limb when split-belt walking is applied for rehabilitation research in hemiparesis.

Single-session training on an ascending treadmill slope: effects on gait parameters in persons with stroke. A pilot study

OBJECTIVE

Treadmill training with an upward incline could improve gait parameters altered in persons with stroke, especially lower limb flexion. This study aimed to determine the effects of a treadmill single-session training with a 10% upward incline on biomechanical gait parameters in persons with stroke.

METHODS

Fifteen persons with stroke-related hemiparesis performed a 20-min treadmill training session with a 10% ascending incline in this interventional pilot study. Spatiotemporal, kinematic and kinetic parameters were evaluated, overground, with a tridimensional optoelectronic system, before the session, immediately after and after a 20-min rest period.

RESULTS

The single-session training on a treadmill with a 10% incline has significantly increased hip flexion peak on the paretic side (39.8°± 8.1 in baseline to 42.7°± 8.6 after the session, P < 0.001, large effect size) and knee flexion peak on the paretic side (39.9°± 11.6 in baseline to 43.1°± 11.7 after the session, P = 0.004, large effect size). Gait speed, other spatiotemporal gait parameters and propulsion on the paretic side were also significantly increased (P < 0.05, all large effects size). These short-term changes were maintained after the break.

CONCLUSIONS

A treadmill single-session training with a 10% upward incline induces biomechanical changes in people with stroke. The environmental constraints of this training could explain these biomechanical adaptations, concerning especially paretic hip and knee flexion.

DNN-Based FES Control for Gait Rehabilitation of Hemiplegic Patients

In this study, we proposed a novel machine-learning-based functional electrical stimulation (FES) control algorithm to enhance gait rehabilitation in post-stroke hemiplegic patients. The electrical stimulation of the muscles on the paretic side was controlled via deep neural networks, which were trained using muscle activity data from healthy people during gait. The performance of the developed system in comparison with that of a conventional FES control method was tested with healthy human subjects.

High Intensity Exercise for Walking Competency in Individuals with Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

To assess the effects of high intensity exercise on walking competency in individuals with stroke.

DATA SOURCES

A systematic electronic searching of the PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCOhost), and SPORTSDiscus (EBSCOhost) was initially performed up to June 25, 2019.

STUDY SELECTION

Randomized controlled trials or clinical controlled trials comparing any walking or gait parameters of the high intensity exercise to lower intensity exercise or usual physical activities were included. The risk of bias of included studies was assessed by the Cochrane risk of bias tool. The quality of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.

DATA EXTRACTION

Data were extracted by 2 independent coders. The mean and standard deviation of the baseline and endpoint scores after training for walking distance, comfortable gait speed, gait analysis (cadence, stride length, and the gait symmetry), cost of walking, Berg Balance Scale , Time Up&Go (TUG) Test and adverse events were extracted.

DATA SYNTHESIS

A total of 22 (n = 952) studies were included. Standardized mean difference (SMD), weighted mean difference (WMD), and odds ratios (ORs) were used to compute effect size and subgroup analysis was conducted to test the consistency of results with different characteristics of exercise and time since stroke. Sensitivity analysis was used to assess the robustness of the results, which revealed significant differences on walking distance (SMD = .32, 95% CI, .17-.46, P < .01, I² = 39%; WMD = 21.76 m), comfortable gait speed (SMD = .28, 95% CI, .06-.49, P = .01, I² = 47%; WMD = .04 m/s), stride length (SMD = .51, 95% CI, .13-.88, P < .01, I² = 0%; WMD = .12 m) and TUG (SMD = -.36, 95% CI, -.72 to .01, P = .05, I² = 9%; WMD = -1.89 s) in favor of high intensity exercise versus control group. No significant differences were found between the high intensity exercise and control group in adverse events, including falls (OR = 1.40, 95% CI, .69-2.85, P = .35, I² = 11%), pain (OR = 3.34, 95% CI, .82-13.51, P = .09, I² = 0%), and skin injuries (OR = 1.08, 95% CI, .30-3.90, P = .90, I² = 0%).

CONCLUSIONS

This systematic review suggests that high intensity exercise could be safe and more potent stimulus in enhancing walking competency in stroke survivors, with a capacity to improve walking distance, comfortable gait speed, stride length, and TUG compared with low to moderate intensity exercise or usual physical activities.

The Motion of Body Center of Mass During Walking: A Review Oriented to Clinical Applications

Human walking is usually conceived as the cyclic rotation of the limbs. The goal of lower-limb movements, however, is the forward translation of the body system, which can be mechanically represented by its center of mass (CoM). Lower limbs act as struts of an inverted pendulum, allowing minimization of muscle work, from infancy to old age. The plantar flexors of the trailing limbs have been identified as the main engines of CoM propulsion. Motion of the CoM can be investigated through refined techniques, but research has been focused on the fields of human and animal physiology rather than clinical medicine. Alterations in CoM motion could reveal motor impairments that are not detectable by clinical observation. The study of the three-dimensional trajectory of the CoM motion represents a clinical frontier. After adjusting for displacement due to the average forward speed, the trajectory assumes a figure-eight shape (dubbed the “bow-tie”) with a perimeter about 18 cm long. Its lateral size decreases with walking velocity, thus ensuring dynamic stability. Lateral redirection appears as a critical phase of the step, requiring precise muscle sequencing. The shape and size of the “bow-tie” as functions of dynamically equivalent velocities do not change from child to adulthood, despite anatomical growth. The trajectory of the CoM thus appears to be a promising summary index of both balance and the neural maturation of walking. In asymmetric gaits, the affected lower limb avoids muscle work by pivoting almost passively, but extra work is required from the unaffected side during the next step, in order to keep the body system in motion. Generally, the average work to transport the CoM across a stride remains normal. In more demanding conditions, such as walking faster or uphill, the affected limb can actually provide more work; however, the unaffected limb also provides more work and asymmetry between the steps persists. This learned or acquired asymmetry is a formerly unsuspected challenge to rehabilitation attempts to restore symmetry. Techniques of selective loading of the affected side, which include constraining the motion of the unaffected limb or forcing the use of the affected limb on split-belt treadmills which impose a different velocity and power to either limb, are now under scrutiny.

Effects of inclined treadmill training on functional and cardiovascular parameters of stroke patients: study protocol for a randomized controlled trial

Background

Treadmill training has been widely used for gait recovery after stroke. Gait re-establishment is one of the main objectives of rehabilitation programs after stroke, aiming to acquire more functional patterns and increase walking speed, along with improvement in cardiovascular function. The aim of this study is to evaluate the effects of a treadmill gait training protocol on functional and cardiovascular variables in patients with chronic stroke.

Methods

A single-blind randomized clinical trial will be conducted. The sample will consist of 36 patients, who will be allocated in three groups: control group (n = 12), experimental group 1 (n = 12), and experimental group 2 (n = 12). The intervention will occur for 6 consecutive weeks, three times a week, 30 min each session, in all groups. The control group will perform a treadmill gait training without inclination, experimental group 1 will perform a treadmill gait training with anterior inclination of 5%, and experimental group 2 will perform a treadmill gait training with anterior inclination of 10%. All participants will be assessed for sample characterization measures, gait speed, functional capacity, systemic arterial blood pressure, heart rate, peripheral oxygen saturation, exercise capacity, neuromuscular torque, and quality of life. Evaluations of outcome measures will occur at the end of the interventions (post-training) and after 1 month and 1 year after the end of the interventions (short- and long-term follow-up). Statistical analysis will be performed descriptively and inferentially. Alpha equals 5% will be considered for inferential analysis. Mixed analysis of variance with repeated measures will be used to compare outcome measures between groups and between baseline, post-training, and follow-up. Normality test (Shapiro–Wilk) and subsequently t test (or Mann–Whitney) will be used to compare groups during the same training session.

Discussion

It is believed that treadmill training, especially treadmill training with anterior inclination, may result in improved exercise capacity in patients with stroke, reduced blood pressure and heart rate values, and an improvement in functional parameters with increased gait speed, functional capacity, quadriceps muscle torque, and quality of life.

Trial registration

Registration in Brazilian Registry of Clinical Trials (ReBEC) identifier RBR-5ffbxz, date of registration October 25 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3298-3) contains supplementary material, which is available to authorized users.

Crouch gait can be an effective form of forced-use/no constraint exercise for the paretic lower limb in stroke

In hemiplegic gait the paretic lower limb provides less muscle power and shows a briefer stance compared with the unaffected limb. Yet, a longer stance and a higher power can be obtained from the paretic lower limb if gait speed is increased. This supports the existence of a ‘learned non-use’ phenomenon, similar to that underlying some asymmetric impairments of the motion of the eyes and of the upper limbs. Crouch gait (CG) (bent-hip bent-knee, about 30° minimum knee flexion) might be an effective form of ‘forced-use’ treatment of the paretic lower limb. It is not known whether it also stimulates a more symmetric muscle power output. Gait analysis on a force treadmill was carried out in 12 healthy adults and seven hemiplegic patients (1–127 months after stroke, median: 1.6). Speed was imposed at 0.3 m/s. Step length and single and double stance times, sagittal joint rotations, peak positive power, and work in extension of the hip, knee, and ankle (plantar flexion), and surface electromyography (sEMG) area from extensor muscles during the generation of power were measured on either side during both erect and crouch walking. Significance was set at P less than 0.05; corrections for multiplicity were applied. Patients, compared with healthy controls, adopted in both gait modalities and on both sides a shorter step length (61–84%) as well as a shorter stance (76–90%) and swing (63–83%) time. As a rule, they also provided a higher muscular work (median: 137%, range: 77–250%) paralleled by a greater sEMG area (median: 174%, range: 75–185%). In erect gait, the generation of peak extensor power across hip, knee, and ankle joints was in general lower (83–90%) from the paretic limb and higher (98–165%) from the unaffected limb compared with control values. In CG, peak power generation across the three lower limb joints was invariably higher in hemiparetic patients: 107–177% from the paretic limb and 114–231% from the unaffected limb. When gait shifted from erect to crouch, only for hemiplegic patients, at the hip, the paretic/unaffected ratio increased significantly. For peak power, work, sEMG area, and joint rotation, the paretic/unaffected ratio increased from 55 to 85%, 56 to 72%, 68 to 91%, and 67 to 93%, respectively. CG appears to be an effective form of forced-use exercise eliciting more power and work from the paretic lower limb muscles sustained by a greater neural drive. It also seems effective in forcing a more symmetric power and work from the hip extensor muscles, but neither from the knee nor the ankle.

Optimizing a Treadmill Ramp Protocol to Evaluate Aerobic Capacity of Hemiparetic Poststroke Patients

Bernardes, WL, Montenegro, RA, Monteiro, WD, de Almeida Freire, R, Massaferri, R, and Farinatti, P. Optimizing a treadmill ramp protocol to evaluate aerobic capacity of hemiparetic poststroke patients. J Strength Cond Res 32(3): 876-884, 2018-A correct assessment of cardiopulmonary capacity is important for aerobic training within motor rehabilitation of poststroke hemiparetic patients (PSHPs). However, specific cardiopulmonary exercise testing (CPET) for these patients are scarce. We proposed adaptations in a protocol originally developed for PSHPs by Ovando et al. (CPET1). We hypothesized that our adapted protocol (CPET2) would improve the original test, by preventing early fatigue and increasing patients' peak performance. Eleven PSHPs (52 ± 14 years, 10 men) performed both protocols. CPET2 integrated changes in final speed (100-120% vs. 140% maximal speed in 10-m walking test), treadmill inclination (final inclination of 5 vs. 10%), and estimated test duration (10 vs. 8 minutes) to smooth the rate of workload increment of CPET1. Peak oxygen uptake (V[Combining Dot Above]O2peak) (20.3 ± 6.1 vs. 18.6 ± 5.0 ml·kg·min; p = 0.04), V[Combining Dot Above]O2 at gas exchange transition (V[Combining Dot Above]O2-GET) (11.5 ± 2.9 vs. 9.8 ± 2.0 ml·kg·min; p = 0.04), and time to exhaustion (10 ± 3 vs. 6 ± 2 minutes; p < 0.001) were higher in CPET2 than in CPET1. Slopes and intercepts of regressions describing relationships between V[Combining Dot Above]O2 vs. workload, heart rate vs. workload, and V[Combining Dot Above]O2 vs. heart rate were similar between CPETs. However, standard errors of estimates obtained for regressions between heart rate vs. workload (3.0 ± 1.3 vs. 3.8 ± 1.0 b·min; p = 0.004) and V[Combining Dot Above]O2 vs. heart rate (6.0 ± 2.1 vs. 4.8 ± 2.4 ml·kg·min; p = 0.05) were lower in CPET2 than in CPET1. In conclusion, the present adaptations in Ovando's CPET protocol increased exercise tolerance of PSHPs, eliciting higher V[Combining Dot Above]O2peak and V[Combining Dot Above]O2-GET, preventing earlier fatigue, and providing better physiological relationships along submaximal workloads.

Exploration of Two Training Paradigms Using Forced Induced Weight Shifting With the Tethered Pelvic Assist Device to Reduce Asymmetry in Individuals After Stroke: Case Reports

Many robotic devices in rehabilitation incorporate an assist-as-needed haptic guidance paradigm to promote training. This error reduction model, while beneficial for skill acquisition, could be detrimental for long-term retention. Error augmentation (EA) models have been explored as alternatives. A robotic Tethered Pelvic Assist Device has been developed to study force application to the pelvis on gait and was used here to induce weight shift onto the paretic (error reduction) or nonparetic (error augmentation) limb during treadmill training. The purpose of these case reports is to examine effects of training with these two paradigms to reduce load force asymmetry during gait in two individuals after stroke (>6 mos). Participants presented with baseline gait asymmetry, although independent community ambulators. Participants underwent 1-hr trainings for 3 days using either the error reduction or error augmentation model. Outcomes included the Borg rating of perceived exertion scale for treatment tolerance and measures of force and stance symmetry. Both participants tolerated training. Force symmetry (measured on treadmill) improved from pretraining to posttraining (36.58% and 14.64% gains), however, with limited transfer to overground gait measures (stance symmetry gains of 9.74% and 16.21%). Training with the Tethered Pelvic Assist Device device proved feasible to improve force symmetry on the treadmill irrespective of training model. Future work should consider methods to increase transfer to overground gait.

The effect of uphill and downhill walking on gait parameters: A self-paced treadmill study

It has been shown that gait parameters vary systematically with the slope of the surface when walking uphill (UH) or downhill (DH) (Andriacchi et al., 1977; Crowe et al., 1996; Kawamura et al., 1991; Kirtley et al., 1985; McIntosh et al., 2006; Sun et al., 1996). However, gait trials performed on inclined surfaces have been subject to certain technical limitations including using fixed speed treadmills (TMs) or, alternatively, sampling only a few gait cycles on inclined ramps. Further, prior work has not analyzed upper body kinematics. This study aims to investigate effects of slope on gait parameters using a self-paced TM (SPTM) which facilitates more natural walking, including measuring upper body kinematics and gait coordination parameters. Gait of 11 young healthy participants was sampled during walking in steady state speed. Measurements were made at slopes of +10°, 0° and -10°. Force plates and a motion capture system were used to reconstruct twenty spatiotemporal gait parameters. For validation, previously described parameters were compared with the literature, and novel parameters measuring upper body kinematics and bilateral gait coordination were also analyzed. Results showed that most lower and upper body gait parameters were affected by walking slope angle. Specifically, UH walking had a higher impact on gait kinematics than DH walking. However, gait coordination parameters were not affected by walking slope, suggesting that gait asymmetry, left-right coordination and gait variability are robust characteristics of walking. The findings of the study are discussed in reference to a potential combined effect of slope and gait speed. Follow-up studies are needed to explore the relative effects of each of these factors.

Effects of treadmill incline and speed on peroneus longus muscle activity in persons with chronic stroke and healthy subjects

OBJECTIVE

To examine the effects of walking at different inclines and speeds on Peroneus Longus (PL) muscle activation and medial gastrocnemius (MG) coactivation with PL in healthy controls and subjects with stroke.

DESIGN

Nineteen persons post-stroke (13M/6F) and fifteen healthy controls (10M/5F) walked on a treadmill at different inclines (0°, 3°, and 6°) and speeds (self-selected, self-selected+20%, self-selected+40%). The electromyographic activity of the PL and MG muscles in the stance phase of gait cycle was measured.

RESULTS

The paretic PL muscle activity did not change with incline, but increased at +40% speed only (p<0.05). The nonparetic PL increased at 6° incline and at faster speeds (p<0.05). In the healthy group, PL muscle activity increased only on the right side at 6° incline, but increased bilaterally at +40% faster speed (p<0.05). The timing of PL muscle activity did not change with incline (p>0.05), but was significantly delayed at +40% faster speed on the paretic side only (p<0.05). In healthy controls, PL muscle activation timing was unchanged with incline (p>0.05), but was significantly delayed at +40% speed only on the left side (p<0.05). The MG/PL amplitude and timing ratios were not significantly different between various walking conditions (p>0.05).

CONCLUSION

An increase in PL activity occurs to provide ankle stability at walking speeds up to 40% faster than the self-selected speed. Important interlimb differences which may be related to leg dominance and motor control were observed in both stroke and healthy control groups in both PL muscle timing and their clinical impact should be investigated in future studies.

How Arch Support Insoles Help Persons with Flatfoot on Uphill and Downhill Walking

The main purpose of this study was to investigate the effect of arch support insoles on uphill and downhill walking of persons with flatfoot. Sixteen healthy college students with flatfoot were recruited in this study. Their heart rate, peak oxygen uptake (VO₂), and median frequency (MDF) of surface electromyogram were recorded and analyzed. Nonparametric Wilcoxon signed-rank test was used for statistical analysis. The main results were as follows: (a) peak VO₂ significantly decreased with arch support insoles compared with flat insoles during uphill and downhill walking (arch support insole versus flat insole: uphill walking, 20.7 ± 3.6 versus 31.6 ± 5.5; downhill walking, 10.9 ± 2.3 versus 16.9 ± 4.2); (b) arch support insoles could reduce the fatigue of the rectus femoris muscle during downhill walking (MDF slope of arch support insole: 0.03 ± 1.17, flat insole: −6.56 ± 23.07); (c) insole hardness would increase not only the physical sensory input but also the fatigue of lower-limb muscles particularly for the rectus femoris muscle (MDF slope of arch support insole: −1.90 ± 1.60, flat insole: −0.83 ± 1.10) in persons with flatfoot during uphill walking. The research results show that arch support insoles could effectively be applied to persons with flatfoot to aid them during uphill and downhill walking.

Wearable tubing assistive walking device immediately enhances gait parameters in subjects with stroke: A randomized controlled study

BACKGROUND

Stroke patients develop compensatory movements due to limitations of ankle dorsiflexion and knee flexion. To solve the limitations, there are many adjustable walking assistive devices such as robotic devices, ankle-foot orthoses, and functional electric stimulation in rehabilitation session. However, these assistive devices have some disadvantages, including expense and discomforts. Therefore, the development of a new assistive device for stroke patients is needed to assist ankle dorsiflexion and knee flexion.

OBJECTIVE

This study investigated the effects of a wearable tubing assistive walking device (WTAWD) on gait parameters (gait speed, cadence, and step length and stride length on affected and less affected sides) in patients with stroke.

METHODS

Gait parameters were measured using the GAITRite system. One-way repeated measures analysis of variance was used to determine gait differences under three conditions (WTAWD, barefoot, and conventional elastic band orthosis).

RESULTS

Gait speed, cadence, and step length and stride length on both affected and less affected sides were significantly greater with WTAWD, compared to barefoot and conventional elastic band orthosis conditions.

CONCLUSION

WTAWD could be effective for patients with stroke.

Effects of treadmill inclination on hemiparetic gait: controlled and randomized clinical trial

OBJECTIVE

The aim of this study was to analyze the effects of inclined treadmill training on the kinematic characteristics of gait in subjects with hemiparesis.

DESIGN

A blind, randomized, controlled study was conducted with 28 subjects divided into two groups: the control group, submitted to partial body weight-support treadmill gait training with no inclination, and the experimental group, which underwent partial body weight-support treadmill training at 10% of inclination. All volunteers were assessed for functional independence, motor function, balance, and gait before and after the 12 training sessions.

RESULTS

Both groups showed posttraining alterations in balance (P < 0.001), motor function (P < 0.001), and functional independence (P = 0.002). Intergroup differences in spatiotemporal differences were observed, where only the experimental group showed posttraining alterations in velocity (P = 0.02) and paretic step length (P = 0.03). Angular variables showed no significant differences in either group.

CONCLUSIONS

In subjects with hemiparesis, the addition of inclination is a stimulus capable of enhancing the effects of partial body weight-support treadmill gait training.

Does altering inclination alter effectiveness of treadmill training for gait impairment after stroke? A randomized controlled trial

OBJECTIVE

To assess whether a downhill walking training programme is more effective than the same amount of training applied uphill in chronic stroke survivors.

DESIGN

Randomized, single-blind study.

SETTING

Outpatient rehabilitation service.

METHODS

Thirty-eight adults with hemiplegia from stroke lasting more than three months were randomly allocated to one of the two groups: 'UP' - 45 minutes of physical therapy + 30 minutes of treadmill with 5% ascending slope; and 'DOWN' - 45 minutes of physical therapy + 30 minutes of treadmill with 5% descending slope. Both groups were treated 5 times a week for six weeks. Patients were evaluated before treatment, at the end of treatment and after three months.

OUTCOME MEASURES

Primary outcome measure was the number of patients showing an improvement in 6-minute walking test (6MWT) greater than 50 m. Secondary outcome measures were: (1) number of patients showing a clinically relevant improvement of gait speed during 10-m walking test (10mWT); (2) number of patients showing an improvement in timed up and go (TUG) greater than minimal detectable change.

RESULTS

Both groups had a significant improvement after treatment and at follow-up. At the end of treatment, compared to UP group, more patients in the DOWN group showed clinically significant improvements in primary and secondary outcomes (16/19 patients for 6MWT, 11/19 patients for 10mWT and 9/19 patients for TUG compared with 3/19, 4/19 and 2/19 patients, respectively, P < 0.01). At follow-up, results were similar except for 10mWT.

CONCLUSIONS

In chronic stroke patients, downhill treadmill training produces a bigger effect than uphill training.

Chronic Stroke Survivors Benefit From High-Intensity Aerobic Treadmill Exercise

Background and objective. Ambulatory subjects after stroke may benefit from gait-oriented cardiovascular fitness training, but trials to date have not primarily assessed older persons. Methods. Thirty-eight subjects (age >60 years) with residual hemiparetic gait were enrolled >6 months after stroke. Participants were randomized to receive 3 months (3×/week) progressive graded, high-intensity aerobic treadmill exercise (TAEX) or conventional care physiotherapy. Primary outcome measures were peak exercise capacity (Vo2peak) and sustained walking capacity in 6-minute walks (6MW). Secondary measures were gait velocity in 10-m walks, Berg Balance Scale, functional leg strength (5 chair-rise), self-rated mobility (Rivermead Mobility Index), and quality of life (SF-12). Results. Thirty-six participants completed the study (18 TAEX, 18 controls). TAEX but not conventional care improved Vo2peak (difference 6.4 mL/kg/min, P < .001) and 6MW (53 m, P < .001). Likewise, maximum walking speed (0.13 m/s, P = .01), balance ( P < .05), and the mental subscore of the SF-12 ( P < .01) improved more after TAEX. Gains in Vo2peak correlated with the degree at which training intensity could be progressed in the individual participant ( P < .01). Better walking was related to progression in treadmill velocity and training duration ( P < .001). Vo2peak and 6MW performances were still higher 1 year after the end of training when compared with the baseline, although endurance walking (6MW) at 1 year was lower than immediately after training ( P < .01). Conclusion. This trial demonstrates that TAEX effectively improves cardiovascular fitness and gait in persons with chronic stroke.

Evaluation of gait symmetry after stroke: a comparison of current methods and recommendations for standardization

Symmetry is a gait characteristic that is increasingly measured and reported, particularly in the stroke patient population. However, there is no accepted standard for assessing symmetry making it difficult to compare across studies and establish criteria to guide clinical decision making. This study compares the most common expressions of spatiotemporal gait symmetry to describe post-stroke gait and makes recommendations regarding the most suitable measure for standardization. The following symmetry equations were compared: symmetry ratio, symmetry index, gait asymmetry and symmetry angle using step length, swing time, stance time, double support time and an intra-limb ratio of swing: stance time. Comparisons were made within a group of 161 community-dwelling, ambulatory individuals with stroke and 81 healthy adults as a reference group. Our analysis supports the recommendations of the symmetry ratio as the equation for standardization and step length, swing time and stance time as the gait parameters to be used in the equation. Future work should focus on establishing the intra-individual variability of these measures and linking them to mechanisms of gait dysfunction.

Overground physical therapy gait training for chronic stroke patients with mobility deficits

BACKGROUND

Overground gait training forms a major part of physical therapy services for chronic stroke patients in almost every setting. Overground gait training refers to physical therapists' observation and cueing of the patient's walking pattern along with related exercises, but does not include high-technology aids such as functional electrical stimulation or body weight support.

OBJECTIVES

To assess the effects of overground physical therapy gait training on walking ability for chronic stroke patients with mobility deficits.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched March 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), CINAHL (1982 to May 2008), AMED (1985 to March 2008), Science Citation Index Expanded (1981 to May 2008), ISI Proceedings (Web of Science, 1982 to May 2006), Physiotherapy Evidence Database (http://www.pedro.org.au/) (May 2008), REHABDATA (http://www.naric.com/research/rehab/) (1956 to May 2008), http://www.clinicaltrials.gov (May 2008), http://www.controlled-trials.com/ (May 2008), and http://www.strokecenter.org/ (May 2008). We also searched reference lists of relevant articles, and contacted authors and trial investigators.

SELECTION CRITERIA

Randomised controlled trials comparing overground physical therapy gait training with a placebo intervention or no treatment for chronic stroke patients with mobility deficits.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently selected trials. Three authors independently extracted data and assessed quality. We contacted study authors for additional information.

MAIN RESULTS

We included nine studies involving 499 participants. We found no evidence for a benefit on the primary variable, post-test gait function, based on three studies with 269 participants. Uni-dimensional performance variables did show significant effects post-test. Gait speed increased by 0.07 metres per second (95% confidence interval (CI) 0.05 to 0.10) based on seven studies with 396 participants, timed up-and-go (TUG) test improved by 1.81 seconds (95% CI -2.29 to -1.33), and six-minute-walk test (6MWT) increased by 26.06 metres (95% CI 7.14 to 44.97) based on four studies with 181 participants. We found no significant differences in deaths/disabilities or in adverse effects, based on published reports or personal communication from all of the included studies.

AUTHORS' CONCLUSIONS

We found insufficient evidence to determine if overground physical therapy gait training benefits gait function in patients with chronic stroke, though limited evidence suggests small benefits for uni-dimensional variables such as gait speed or 6MWT. These findings must be replicated by large, high quality studies using varied outcome measures.

Progressive Staging of Pilot Studies to Improve Phase III Trials for Motor Interventions

Based on the suboptimal research pathways that finally led to multicenter randomized clinical trials (MRCTs) of treadmill training with partial body weight support and of robotic assistive devices, strategically planned successive stages are proposed for pilot studies of novel rehabilitation interventions. Stage 1, consideration-of-concept studies, drawn from animal experiments, theories, and observations, delineate the experimental intervention in a small convenience sample of participants, so the results must be interpreted with caution. Stage 2, development-of-concept pilots, should optimize the components of the intervention, settle on most appropriate outcome measures, and examine dose-response effects. A well-designed study that reveals no efficacy should be published to counterweight the confirmation bias of positive trials. Stage 3, demonstration-of-concept pilots, can build out from what has been learned to test at least 15 participants in each arm, using random assignment and blinded outcome measures. A control group should receive an active practice intervention aimed at the same primary outcome. A third arm could receive a substantially larger dose of the experimental therapy or a combinational intervention. If only 1 site performed this trial, a different investigative group should aim to reproduce positive outcomes based on the optimal dose of motor training. Stage 3 studies ought to suggest an effect size of 0.4 or higher, so that approximately 50 participants in each arm will be the number required to test for efficacy in a stage 4, proof-of-concept MRCT. By developing a consensus around acceptable and necessary practices for each stage, similar to CONSORT recommendations for the publication of phase III clinical trials, better quality pilot studies may move quickly into better designed and more successful MRCTs of experimental interventions.

Resistance-based, reciprocal upper and lower limb locomotor training in chronic stroke: a randomized, controlled crossover study

Objective: To determine efficacy of a bilateral reciprocal training regimen on affected leg impairment and dynamic balance.

Design: Randomized, controlled, single-blinded crossover study.

Setting: Outpatient rehabilitation hospital.

Participants: Seven patients who experienced stroke >1 year prior to study entry exhibiting affected leg weakness.

Intervention: Subjects were randomly assigned to receive both of the following in a randomized, sequential order: (a) a resistance-based, reciprocal, affected leg locomotor training protocol using the NuStep apparatus ( n = 4) and (b) a home exercise programme (HEP) consisting of self-supervised practice with fractionated joint movements of the lower limb. Each phase of the intervention was performed for 30 minutes each session, three days a week, and conducted over an eight-week period.

Main outcome measures: Outcomes were evaluated by a blinded rater using the lower extremity scale of the Fugl-Meyer and the Berg Balance Scale.

Results: After HEP participation, subjects showed nominal or no changes on any of the outcome measures. After NuStep participation, patients in both treatment groups showed impairment reductions as shown by the Fugl-Meyer (+4.3; +2.2), and increased balance as shown by the Berg Balance Scale (+4.0; +4.0). These trends were exhibited regardless of group assignment.

Conclusion: Impairment reductions and balance gains may be achieved using a resistance-based, reciprocal upper and lower limb locomotor training protocol.