Gait training strategies utilized in poststroke rehabilitation: are we really making a difference?

Performing Enriched Environment Studies to Improve Functional Recovery

Physical therapy and social interactions between the stroke patient and healthcare professionals or relatives facilitate the process of recovery and promote improvement of lost neurological function after stroke. These observations can be mimicked in an experimental setting by multimodal stimulation provided in the concept of enriched environment. The enriched environment is a housing condition combining social interactions and sensorimotor stimulation that improves lost neurological function without affecting the extent of brain damage after experimental stroke. This chapter provides a detailed protocol on how to perform enriched housing experiments including conceptual and technical considerations as a tool to investigate mechanisms of recovery after brain injury.

A Comparison of Three Common Rehabilitation Interventions Used to Improve Cardiovascular Fitness after Stroke: An Overview of the Literature

Background

One of the most frequent consequences of stroke is a reduction in heart function. After a stroke, one of the main aims of physiotherapy practice is to improve cardiovascular fitness (CVF). This paper is aimed at identifying the best effective intervention of improving the cardiovascular fitness (CVF) after stroke while focusing on body weight-supported treadmill training (BWSTT), over gait training (OGT), and therapeutic exercise.

Methods

Different electronic databases were searched until July 2022. Controlled randomized trials examining the effects of BWSTT, OGT, and therapeutic exercise to improve CVF on an ambulatory person with stroke, written in English and reporting cardiovascular fitness or at least one of its indicators, such as peak oxygen consumption (VO₂), gait speed, gait energy expenditure, and functional independence measure for locomotion (FIM-L), were included. The quality of the methodology was evaluated using the Physiotherapy Evidence Database (PEDro) scale.

Results

The research yielded 3854 relevant studies, of which 22 met the eligibility criteria. The primary indicators of the CVF, VO₂ and energy expenditure, were used to examine the CVF in only three studies, while the rest used other indicators of the CVF. There was a lack of sufficient evidence to establish the superiority of one intervention over another. However, it appears that utilizing BWSTT to improve the CVF after stroke is effective.

Conclusion

Physiotherapy has the potential to enhance the CVF of stroke patients. However, effective interventions and long-term effects remain debatable.

Foundational ingredients of robotic gait training for people with incomplete spinal cord injury during inpatient rehabilitation (FIRST): A randomized controlled trial protocol

Introduction

As technological advances allow the use of robotic exoskeleton devices with gait training, there is a critical need to establish a robotic gait training (RGT) program to meet the needs of people with spinal cord injury (SCI) during inpatient rehabilitation. The purposes of this study are to prospectively examine the efficacy of a stakeholder informed RGT program compared to usual care gait training (UC) during inpatient rehabilitation in people with incomplete SCI and compare the intensity of RGT and UC gait training during inpatient rehabilitation.

Study design

128 patients with incomplete SCI admitted to our inpatient rehabilitation facility will be screened for eligibility and randomized to either the RGT or UC group. RGT sessions will use the Ekso robotic exoskeleton [class II medical device (United States FDA)]. UC sessions will use traditional gait training approaches such as manually assisted overground gait training with walkers and orthotics and body weight–supported treadmill training (BWSTT). Our primary outcome is gait function as characterized by the Walking Index for Spinal Cord Injury–II (WISCI-II). Secondary outcomes are gait speed, Spinal Cord Independence Measure (SCIM), Numeric Pain Rating Scale (NPRS), Fatigue Severity Scale (FSS), Penn Spasm Frequency Scale (PSFS), Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder– 7 (GAD-7), International Spinal Cord Injury Quality of Life Basic Data Set, and a Qualitative Questionnaire. Assessments of primary and secondary outcomes will occur at admission and discharge from inpatient rehabilitation. General or generalized linear models will be used to analyze differences between groups for all measures.

Clinical impact

Successful completion of this study will provide a usable, replicable, stakeholder informed RGT intervention for use with individuals with incomplete SCI during inpatient rehabilitation.

Acceptability and deliverability of an auditory rhythmical cueing (ARC) training programme for use at home and outdoors to improve gait and physical activity post-stroke

BACKGROUND

Although laboratory studies demonstrate that training programmes using auditory rhythmical cueing (ARC) may improve gait post-stroke, few studies have evaluated this intervention in the home and outdoors where deployment may be more appropriate. This manuscript reports stakeholder refinement of an ARC gait and balance training programme for use at home and outdoors, and a study which assessed acceptability and deliverability of this programme.

METHODS

Programme design and content were refined during stakeholder workshops involving physiotherapists and stroke survivors. A two-group acceptability and deliverability study was then undertaken. Twelve patients post-stroke with a gait related mobility impairment received either the ARC gait and balance training programme or the gait and balance training programme without ARC. Programme provider written notes, participant exercise and fall diaries, adverse event monitoring and feedback questionnaires captured data about deliverability, safety and acceptability of the programmes.

RESULTS

The training programme consisted of 18 sessions (six supervised, 12 self-managed) of exercises and ARC delivered by a low-cost commercially available metronome. All 12 participants completed the six supervised sessions and 10/12 completed the 12 self-managed sessions. Provider and participant session written records and feedback questionnaires confirmed programme deliverability and acceptability.

CONCLUSION

An ARC gait and balance training programme refined by key stakeholders was feasible to deliver and acceptable to participants and providers.

TRIAL REGISTRATION

ISCTRN 12/03/2018.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Post-stroke gait training practices in a low resource setting: a cross-sectional survey among Indian physiotherapists

BACKGROUND

Independent mobility is the most important determinant of quality of life after stroke and it is vital that training aimed at restoration of gait is based on contemporary evidence. Despite several practice guidelines for gait rehabilitation after stroke existing globally, their feasibility of application in low-resource settings is often questionable.

OBJECTIVE

To investigate the current practices in gait training among Indian physiotherapists involved in the rehabilitation of stroke survivors.

METHODS

A questionnaire on the various aspects of gait training was developed and the content was validated by experts. The survey was made available online and distributed among Indian physiotherapists working in the field of stroke rehabilitation, using snowball sampling. Frequency distribution was used to summarize responses to each component of the questionnaire.

RESULTS

Responses were obtained from 250 practicing physiotherapists. The majority of the respondents (55%) reported that they initiate gait training within seven days after stroke. Gait training sessions ranged from 15-30 minutes (55%), once every day (44%), and the majority (89%) reported use of subjective outcome measures to evaluate gait. Although most respondents agreed on the use of assistive aids, 24% indicated that their use may deter gait, rather than improve it. Nearly 86% of the respondents reported that they do not follow standard guidelines pertaining to gait rehabilitation for stroke survivors.

CONCLUSION

The findings of the study point toward a lack of evidence-based practice among Indian physiotherapists while training gait after stroke. This implied the urgent need for development and implementation of country specific guidelines for stroke rehabilitation.

Exploiting telerobotics for sensorimotor rehabilitation: a locomotor embodiment

Background

Manual treadmill training is used for rehabilitating locomotor impairments but can be physically demanding for trainers. This has been addressed by enlisting robots, but in doing so, the ability of trainers to use their experience and judgment to modulate locomotor assistance on the fly has been lost. This paper explores the feasibility of a telerobotics approach for locomotor training that allows patients to receive remote physical assistance from trainers.

Methods

In the approach, a trainer holds a small robotic manipulandum that shadows the motion of a large robotic arm magnetically attached to a locomoting patient's leg. When the trainer deflects the manipulandum, the robotic arm applies a proportional force to the patient. An initial evaluation of the telerobotic system’s transparency (ability to follow the leg during unassisted locomotion) was performed with two unimpaired participants. Transparency was quantified by the magnitude of unwanted robot interaction forces. In a small six-session feasibility study, six individuals who had prior strokes telerobotically interacted with two trainers (separately), who assisted in altering a targeted gait feature: an increase in the affected leg’s swing length.

Results

During unassisted walking, unwanted robot interaction forces averaged 3−4 N (swing–stance) for unimpaired individuals and 2−3 N for the patients who survived strokes. Transients averaging about 10 N were sometimes present at heel-strike/toe-off. For five of six patients, these forces increased with treadmill speed during stance (R² = .99; p < 0.001) and increased with patient height during swing (R² = .71; p = 0.073). During assisted walking, the trainers applied 3.0 ± 2.8 N (mean ± standard deviation across patients) and 14.1 ± 3.4 N of force anteriorly and upwards, respectively. The patients exhibited a 20 ± 21% increase in unassisted swing length between Days 1−6 (p = 0.058).

Conclusions

The results support the feasibility of locomotor assistance with a telerobotics approach. Simultaneous measurement of trainer manipulative actions, patient motor responses, and the forces associated with these interactions may prove useful for testing sensorimotor rehabilitation hypotheses. Further research with clinicians as operators and randomized controlled trials are needed before conclusions regarding efficacy can be made.

Early mobilization of a patient with acquired brain injury using a new standing aid, the Innowalk Pro. A single subject experimental design

BACKGROUND

Early mobilization is regarded as important in patients with severe acquired brain injury.

OBJECTIVE

To explore the feasibility, physical and physiological responses of using a new assistive, electric standing device, Innowalk Pro (IP), that passively moves the legs in an upright position.

DESIGN

A single-subject experimental design.

METHODS

A three-phase model (A₁-B-A₂) was chosen; A₁: baseline using a standing frame, B: an intervention using IP and A₂: withdrawal using a standing frame. Outcome measures: Patient's and assistive personnel's experiences with Likert scales, Modified Trunk Impairment Scale, Modified Ashworth Scale (MAS), Lidcombe Template (passive ankle dorsiflexion), duration of the training, blood pressure and heart rate.

RESULTS

A 40-year-old female, with subarachnoid haemorrhage, perceived training in the IP as more physically exhausting than training in a standing frame, influencing the training time. However, she preferred the IP over the standing frame. Trunk control did not improve, until the withdrawal phase. A small MAS reduction in ankle plantar flexors was maintained in the A₂-phase. The heart rate showed an ascending trend in A₁, and a non-significant descending trend in B- and A₂-phases. Blood pressure showed a flat trend line in A₁ and B-phases, and a descending trend in A₂.

CONCLUSION

The new IP was considered a feasible and motivating intervention. Heart rate tended to decrease during IP training, while the blood pressure remained stable. Further research is needed to evaluate whether the IP should be a preferable or a supplementary assistive device for early mobilization.Implications for rehabilitationA new electrical standing device, Innowalk Pro, which moves the legs in upright position, was found to be feasible in early mobilisation of a patient with severe brain injury.Trained physiotherapist and assistive personnel are recommended for safe training.Physiological responses like heart rate and blood pressure remained relatively stable when training in Innowalk Pro.We question whether the leg movements when standing in Innowalk Pro, may contribute to improvement in trunk control.

Physiotherapy students' perspectives on the use and implementation of exoskeletons as a rehabilitative technology in clinical settings

PURPOSE

Wearable lower body robotic exoskeletons are an emerging technology used in gait rehabilitation to facilitate task-specific overground walking. Despite their proposed utility as a rehabilitation intervention, exoskeletons have not been widely implemented into clinical practice by physiotherapists. This study aims to inform future development of exoskeleton technology through the exploration of physiotherapy student perspectives on the use of the H2 robotic exoskeleton and the implementation of exoskeletons as a therapeutic technology in neurological gait rehabilitation.

METHODS

A qualitative descriptive study, including fifteen physiotherapy students, was conducted using three equally sized focus groups. A collaborative data analysis process was employed using the DEPICT model.

RESULTS

Five themes were identified during data analysis: developing evidence-informed practice, clinical considerations for exoskeleton use, resource demands, device-specific challenges for implementation, and future development. The results suggest there are several barriers limiting novel clinicians' future use of exoskeletons.

CONCLUSION

This study highlights current challenges surrounding exoskeleton implementation into clinical practice and provides direction for future exoskeleton development.Implications for rehabilitationPhysiotherapy students view exoskeletons as a potentially valuable rehabilitation tool once perceived limitations are addressed.This study encourages collaboration between physiotherapists and biomedical engineers for future exoskeleton development.More research is needed to inform treatment parameters and appropriate client criteria to guide exoskeleton use for gait rehabilitation.

Computational Design of FastFES Treatment to Improve Propulsive Force Symmetry During Post-stroke Gait: A Feasibility Study

Stroke is a leading cause of long-term disability worldwide and often impairs walking ability. To improve recovery of walking function post-stroke, researchers have investigated the use of treatments such as fast functional electrical stimulation (FastFES). During FastFES treatments, individuals post-stroke walk on a treadmill at their fastest comfortable speed while electrical stimulation is delivered to two muscles of the paretic ankle, ideally to improve paretic leg propulsion and toe clearance. However, muscle selection and stimulation timing are currently standardized based on clinical intuition and a one-size-fits-all approach, which may explain in part why some patients respond to FastFES training while others do not. This study explores how personalized neuromusculoskeletal models could potentially be used to enable individual-specific selection of target muscles and stimulation timing to address unique functional limitations of individual patients post-stroke. Treadmill gait data, including EMG, surface marker positions, and ground reactions, were collected from an individual post-stroke who was a non-responder to FastFES treatment. The patient's gait data were used to personalize key aspects of a full-body neuromusculoskeletal walking model, including lower-body joint functional axes, lower-body muscle force generating properties, deformable foot-ground contact properties, and paretic and non-paretic leg neural control properties. The personalized model was utilized within a direct collocation optimal control framework to reproduce the patient's unstimulated treadmill gait data (verification problem) and to generate three stimulated walking predictions that sought to minimize inter-limb propulsive force asymmetry (prediction problems). The three predictions used: (1) Standard muscle selection (gastrocnemius and tibialis anterior) with standard stimulation timing, (2) Standard muscle selection with optimized stimulation timing, and (3) Optimized muscle selection (soleus and semimembranosus) with optimized stimulation timing. Relative to unstimulated walking, the optimal control problems predicted a 41% reduction in propulsive force asymmetry for scenario (1), a 45% reduction for scenario (2), and a 64% reduction for scenario (3), suggesting that non-standard muscle selection may be superior for this patient. Despite these predicted improvements, kinematic symmetry was not noticeably improved for any of the walking predictions. These results suggest that personalized neuromusculoskeletal models may be able to predict personalized FastFES training prescriptions that could improve propulsive force symmetry, though inclusion of kinematic requirements would be necessary to improve kinematic symmetry as well.

Feasibility of integrating robotic exoskeleton gait training in inpatient rehabilitation

Objective: Learning to walk is a major goal of inpatient rehabilitation and robotic exoskeletons may provide a new gait training approach. Our purpose was to determine the feasibility of integrating the Ekso Gait Training device into inpatient rehabilitation in a neurologic population.Design: Longitudinal cohort design and convenience sample including physical therapists trained to use the Ekso Bionics Ekso GT™ robotic exoskeleton or inpatients with stroke or SCI. Therapists completed a focus group and survey at baseline and 6 months after initial Ekso training. Patients completed a survey indicating their satisfaction with using the Ekso.Results: Twenty-five patients used the Ekso an average of 4.5 sessions during their 38.5-day rehabilitation stay. Survey and focus group feedback revealed that therapists encountered measurement difficulties with the Ekso and limited treatment time influencing effectiveness of usage. After 6 months, therapists reported an improvement in feasibility. Patients tolerated Ekso sessions well, without any complications or adverse incidents, and reported improved mobility post session.Conclusion: Integrating Ekso gait training into clinical practice was not seamless but appears feasible. Barriers were addressed within the rehabilitation team and received administrative support in a process lasting several months. Patients enjoyed walking in Ekso and felt secure within the device.Implications for rehabilitationIntegrating Ekso gait training into clinical practice during inpatient rehabilitation is feasible.Overcoming barriers to implementation required administrative support and clinician persistence over several months.Patients tolerated Ekso sessions well, without any complications or adverse incidents.

Walking With a Robotic Exoskeleton Does Not Mimic Natural Gait: A Within-Subjects Study

Background

Robotic exoskeleton devices enable individuals with lower extremity weakness to stand up and walk over ground with full weight-bearing and reciprocal gait. Limited information is available on how a robotic exoskeleton affects gait characteristics.

Objective

The purpose of this study was to examine whether wearing a robotic exoskeleton affects temporospatial parameters, kinematics, and muscle activity during gait.

Methods

The study was completed by 15 healthy adults (mean age 26.2 [SD 8.3] years; 6 males, 9 females). Each participant performed walking under 2 conditions: with and without wearing a robotic exoskeleton (EKSO). A 10-camera motion analysis system synchronized with 6 force plates and a surface electromyography (EMG) system captured temporospatial and kinematic gait parameters and lower extremity muscle activity. For each condition, data for 5 walking trials were collected and included for analysis.

Results

Differences were observed between the 2 conditions in temporospatial gait parameters of speed, stride length, and double-limb support time. When wearing EKSO, hip and ankle range of motion (ROM) were reduced and knee ROM increased during the stance phase. However, during the swing phase, knee and ankle ROM were reduced when wearing the exoskeleton bionic suit. When wearing EKSO, EMG activity decreased bilaterally in the stance phase for all muscle groups of the lower extremities and in the swing phase for the distal muscle groups (tibialis anterior and soleus) as well as the left medial hamstrings.

Conclusions

Wearing EKSO altered temporospatial gait parameters, lower extremity kinematics, and muscle activity during gait in healthy adults. EKSO appears to promote a type of gait that is disparate from normal gait in first-time users. More research is needed to determine the impact on gait training with EKSO in people with gait impairments.

A Challenge-Based Approach to Body Weight-Supported Treadmill Training Poststroke: Protocol for a Randomized Controlled Trial

Background

Body weight support treadmill training protocols in conjunction with other modalities are commonly used to improve poststroke balance and walking function. However, typical body weight support paradigms tend to use consistently stable balance conditions, often with handrail support and or manual assistance.

Objective

In this paper, we describe our study protocol, which involved 2 unique body weight support treadmill training paradigms of similar training intensity that integrated dynamic balance challenges to help improve ambulatory function post stroke. The first paradigm emphasized walking without any handrails or manual assistance, that is, hands-free walking, and served as the control group, whereas the second paradigm incorporated practicing 9 essential challenging mobility skills, akin to environmental barriers encountered during community ambulation along with hands-free walking (ie hands-free + challenge walking).

Methods

We recruited individuals with chronic poststroke hemiparesis and randomized them to either group. Participants trained for 6 weeks on a self-driven, robotic treadmill interface that provided body weight support and a safe gait-training environment. We assessed participants at pre-, mid- and post 6 weeks of intervention-training, with a 6-month follow-up. We hypothesized greater walking improvements in the hands-free + challenge walking group following training because of increased practice opportunity of essential mobility skills along with hands-free walking.

Results

We assessed 77 individuals with chronic hemiparesis, and enrolled and randomized 30 individuals poststroke for our study (hands-free group=19 and hands-free + challenge walking group=20) from June 2012 to January 2015. Data collection along with 6-month follow-up continued until January 2016. Our primary outcome measure is change in comfortable walking speed from pre to post intervention for each group. We will also assess feasibility, adherence, postintervention efficacy, and changes in various exploratory secondary outcome measures. Additionally, we will also assess participant responses to a study survey, conducted at the end of training week, to gauge each group's training experiences.

Conclusions

Our treadmill training paradigms, and study protocol represent advances in standardized approaches to selecting body weight support levels without the necessity for using handrails or manual assistance, while progressively providing dynamic challenges for improving poststroke ambulatory function during rehabilitation.

Trial Registration

ClinicalTrials.gov NCT02787759; https://clinicaltrials.gov/ct2/show/NCT02787759 (Archived by Webcite at http://www.webcitation.org/6yJZCrIea)

A narrative review of gait training after stroke and a proposal for developing a novel gait training device that provides minimal assistance

BACKGROUND

Gait impairment is common in stroke survivors. Recovery of walking ability is one of the most pressing objectives in stroke rehabilitation.

OBJECTIVES

Of this report are to briefly review recent progress in gait training after stroke including the use of partial body weight-supported treadmill training (PBWSTT) and robot-assisted step training (RAST), and propose a minimal assistance strategy that may overcome some of limitations of current RAST.

METHODS

The literature review emphasizes a dilemma that recent randomized clinical trials did not support the use of RAST. The unsatisfactory results of current RAST clinical trials may be partially due to a lack of careful analysis of movement deficiencies and their relevance to gait training task specificity after stroke. Normal movement pattern is implied to be part of task specificity in the current RAST. Limitations of such task specificity are analyzed.

RESULTS

Based on the review, we redefine an alternative set of gait training task specificity that represents a minimal assistance strategy in terms of assisted body movements and amount of assistance. Specifically, assistances are applied only to hip flexion and ankle dorsiflexion of the affected lower limb during swing phase. Furthermore, we propose a conceptual design of a novel device that may overcome limitations of current RAST in gait training after stroke. The novel device uses a pulling cable, either manually operated by a therapist or automated by a servomotor, to provide assistive forces to help hip flexion and ankle dorsiflexion of the affected lower limb during gait training.

CONCLUSION

The proposed minimal assistance strategy may help to design better devices for gait or other motor training.

Influence of skill and exercise training parameters on locomotor recovery during stroke rehabilitation

PURPOSE OF REVIEW

Research findings from the fields of motor learning and exercise physiology suggest specific training parameters that can be manipulated during physical rehabilitation profoundly influence skilled task performance. This review details the rationale for some of these training variables and their application in selected intervention studies focused on improving walking function in patients poststroke.

RECENT FINDINGS

Basic and applied studies have shown that the amount, intensity, and variability of specific task practice applied during rehabilitation interventions can affect recovery of walking poststroke. Many studies detailing the effects of conventional, therapist, and mechanically assisted interventions may incorporate some of these training parameters but minimize others, and their relative contributions may influence walking outcomes. Specific patient factors, such as the stroke acuity and degree of impairments, appear to influence the relative contributions of these training variables, and different patient subgroups may benefit from greater emphasis on specific parameters.

SUMMARY

The present findings suggest these training parameters should be considered when evaluating or implementing physical interventions directed toward improving locomotor function poststroke. More work is needed to understand their optimal combinations to maximize walking outcomes in patients with different levels of impairment poststroke.

Therapists' cues influence lower limb muscle activation and kinematics during gait training in subacute stroke

PURPOSE

Symmetrical gait is a key goal of rehabilitation post-stroke. Therapists employ techniques such as verbal instruction and haptic cues to increase activation of paretic muscles. We examined whether verbal or tactile cueing altered spatiotemporal gait parameters, kinematics and electromyography (EMG) of lower limb muscles on the more-affected side within a training session.

MATERIALS AND METHODS

Patients (n = 10) were recruited from rehabilitation services (<9 months post-stroke). Tactile (to the hip muscles) or verbal cues were provided on two testing days, 7-10 days apart (randomized order). Gait and angular kinematics were recorded using a Vicon motion capture system and muscle activation using EMG; at baseline (PRE), during the cue, directly afterwards without a cue (POST) and 20 min later without a cue (RETEST).

RESULTS

Both verbal and tactile cueing significantly increased muscle activity in paretic muscles but with no immediate effect on step length asymmetry. Tactile cues, more than verbal, temporarily altered gait speed, cadence and time in double support. Verbal cues caused more robust increases in muscle activation of vastus lateralis at weight acceptance and medial gastrocnemius activity from toe off to midswing.

CONCLUSIONS

Within a treatment session, tactile cues more effectively altered cadence and double support time while verbal cues more consistently increased vastus lateralis and medial gastrocnemius activity. The effectiveness of these methods in fostering motor relearning in the longer term is an important area for future research. Implications for Rehabilitation Therapist cueing alters muscle activity on hemiparetic side with no effects on symmetry. Tactile cues, more so than verbal cues, increase cadence and reduce time in double support. Verbal cues are more effective at increasing vastus lateralis and plantarflexor muscle activity.

A Rehabilitation-Internet-of-Things in the Home to Augment Motor Skills and Exercise Training

Although motor learning theory has led to evidence-based practices, few trials have revealed the superiority of one theory-based therapy over another after stroke. Nor have improvements in skills been as clinically robust as one might hope. We review some possible explanations, then potential technology-enabled solutions. Over the Internet, the type, quantity, and quality of practice and exercise in the home and community can be monitored remotely and feedback provided to optimize training frequency, intensity, and progression at home. A theory-driven foundation of synergistic interventions for walking, reaching and grasping, strengthening, and fitness could be provided by a bundle of home-based Rehabilitation Internet-of-Things (RIoT) devices. A RIoT might include wearable, activity-recognition sensors and instrumented rehabilitation devices with radio transmission to a smartphone or tablet to continuously measure repetitions, speed, accuracy, forces, and temporal spatial features of movement. Using telerehabilitation resources, a therapist would interpret the data and provide behavioral training for self-management via goal setting and instruction to increase compliance and long-term carryover. On top of this user-friendly, safe, and conceptually sound foundation to support more opportunity for practice, experimental interventions could be tested or additions and replacements made, perhaps drawing from virtual reality and gaming programs or robots. RIoT devices continuously measure the actual amount of quality practice; improvements and plateaus over time in strength, fitness, and skills; and activity and participation in home and community settings. Investigators may gain more control over some of the confounders of their trials and patients will have access to inexpensive therapies.

Gait Training in Chronic Stroke Using Walk-Even Feedback Device: A Pilot Study

Asymmetrical gait and a reduction in weight bearing on the affected side are a common finding in chronic stroke survivors. The purpose of this pilot study was to determine the effectiveness of a shoe insole device that we developed, called Walk-Even, in correcting asymmetric gait in chronic stroke survivors. Six individuals with chronic (>6 months) stroke underwent 8 weeks of intervention with 2 sessions/week, each consisting of 20 minutes of gait training and 20 minutes of lower-extremity strength training. The 2 control participants underwent conventional gait training, while 4 participants underwent gait training using the Walk-Even. Following intervention, all the participants improved on most of the gait measures: peak pressure of the foot, time of transfer of weight from heel-to-forefoot, center of pressure (COP) trajectory, COP velocity, asymmetry ratio of stance, mean-force-heel, mean-force-metatarsals, Timed “Up and Go,” and Activities-specific Balance Scale. The improvement was more pronounced in the 4 participants that underwent training with Walk-Even compared to the control participants. This pilot study suggests that a combination of strength and gait training with real-time feedback may reduce temporal asymmetry and enhance weight-bearing on the affected side in chronic stroke survivors. A large randomized controlled study is needed to confirm its efficacy.

Muscle Synergies Facilitate Computational Prediction of Subject-Specific Walking Motions

Researchers have explored a variety of neurorehabilitation approaches to restore normal walking function following a stroke. However, there is currently no objective means for prescribing and implementing treatments that are likely to maximize recovery of walking function for any particular patient. As a first step toward optimizing neurorehabilitation effectiveness, this study develops and evaluates a patient-specific synergy-controlled neuromusculoskeletal simulation framework that can predict walking motions for an individual post-stroke. The main question we addressed was whether driving a subject-specific neuromusculoskeletal model with muscle synergy controls (5 per leg) facilitates generation of accurate walking predictions compared to a model driven by muscle activation controls (35 per leg) or joint torque controls (5 per leg). To explore this question, we developed a subject-specific neuromusculoskeletal model of a single high-functioning hemiparetic subject using instrumented treadmill walking data collected at the subject's self-selected speed of 0.5 m/s. The model included subject-specific representations of lower-body kinematic structure, foot-ground contact behavior, electromyography-driven muscle force generation, and neural control limitations and remaining capabilities. Using direct collocation optimal control and the subject-specific model, we evaluated the ability of the three control approaches to predict the subject's walking kinematics and kinetics at two speeds (0.5 and 0.8 m/s) for which experimental data were available from the subject. We also evaluated whether synergy controls could predict a physically realistic gait period at one speed (1.1 m/s) for which no experimental data were available. All three control approaches predicted the subject's walking kinematics and kinetics (including ground reaction forces) well for the model calibration speed of 0.5 m/s. However, only activation and synergy controls could predict the subject's walking kinematics and kinetics well for the faster non-calibration speed of 0.8 m/s, with synergy controls predicting the new gait period the most accurately. When used to predict how the subject would walk at 1.1 m/s, synergy controls predicted a gait period close to that estimated from the linear relationship between gait speed and stride length. These findings suggest that our neuromusculoskeletal simulation framework may be able to bridge the gap between patient-specific muscle synergy information and resulting functional capabilities and limitations.

Emergent properties of neural repair: elemental biology to therapeutic concepts

Stroke is the leading cause of adult disability. The past decade has seen advances in basic science research of neural repair in stroke. The brain forms new connections after stroke, which have a causal role in recovery of function. Brain progenitors, including neuronal and glial progenitors, respond to stroke and initiate a partial formation of new neurons and glial cells. The molecular systems that underlie axonal sprouting, neurogenesis, and gliogenesis after stroke have recently been identified. Importantly, tractable drug targets exist within these molecular systems that might stimulate tissue repair. These basic science advances have taken the field to its first scientific milestone; the elemental principles of neural repair in stroke have been identified. The next stages in this field involve understanding how these elemental principles of recovery interact in the dynamic cellular systems of the repairing brain. Emergent principles arise out of the interaction of the fundamental or elemental principles in a system. In neural repair, the elemental principles of brain reorganization after stroke interact to generate higher order and distinct concepts of regenerative brain niches in cellular repair, neuronal networks in synaptic plasticity, and the distinction of molecular systems of neuroregeneration. Many of these emergent principles directly guide the development of new therapies, such as the necessity for spatial and temporal control in neural repair therapy delivery and the overlap of cancer and neural repair mechanisms. This review discusses the emergent principles of neural repair in stroke as they relate to scientific and therapeutic concepts in this field. Ann Neurol 2016;79:895–906

Gait post-stroke: Pathophysiology and rehabilitation strategies

We reviewed neural control and biomechanical description of gait in both non-disabled and post-stroke subjects. In addition, we reviewed most of the gait rehabilitation strategies currently in use or in development and observed their principles in relation to recent pathophysiology of post-stroke gait. In both non-disabled and post-stroke subjects, motor control is organized on a task-oriented basis using a common set of a few muscle modules to simultaneously achieve body support, balance control, and forward progression during gait. Hemiparesis following stroke is due to disruption of descending neural pathways, usually with no direct lesion of the brainstem and cerebellar structures involved in motor automatic processes. Post-stroke, improvements of motor activities including standing and locomotion are variable but are typically characterized by a common postural behaviour which involves the unaffected side more for body support and balance control, likely in response to initial muscle weakness of the affected side. Various rehabilitation strategies are regularly used or in development, targeting muscle activity, postural and gait tasks, using more or less high-technology equipment. Reduced walking speed often improves with time and with various rehabilitation strategies, but asymmetric postural behaviour during standing and walking is often reinforced, maintained, or only transitorily decreased. This asymmetric compensatory postural behaviour appears to be robust, driven by support and balance tasks maintaining the predominant use of the unaffected side over the initially impaired affected side. Based on these elements, stroke rehabilitation including affected muscle strengthening and often stretching would first need to correct the postural asymmetric pattern by exploiting postural automatic processes in various particular motor tasks secondarily beneficial to gait.

Residual Elimination Algorithm Enhancements to Improve Foot Motion Tracking During Forward Dynamic Simulations of Gait

Patient-specific gait optimizations capable of predicting post-treatment changes in joint motions and loads could improve treatment design for gait-related disorders. To maximize potential clinical utility, such optimizations should utilize full-body three-dimensional patient-specific musculoskeletal models, generate dynamically consistent gait motions that reproduce pretreatment marker measurements closely, and achieve accurate foot motion tracking to permit deformable foot-ground contact modeling. This study enhances an existing residual elimination algorithm (REA) Remy, C. D., and Thelen, D. G., 2009, “Optimal Estimation of Dynamically Consistent Kinematics and Kinetics for Forward Dynamic Simulation of Gait,” ASME J. Biomech. Eng., 131(3), p. 031005) to achieve all three requirements within a single gait optimization framework. We investigated four primary enhancements to the original REA: (1) manual modification of tracked marker weights, (2) automatic modification of tracked joint acceleration curves, (3) automatic modification of algorithm feedback gains, and (4) automatic calibration of model joint and inertial parameter values. We evaluated the enhanced REA using a full-body three-dimensional dynamic skeletal model and movement data collected from a subject who performed four distinct gait patterns: walking, marching, running, and bounding. When all four enhancements were implemented together, the enhanced REA achieved dynamic consistency with lower marker tracking errors for all segments, especially the feet (mean root-mean-square (RMS) errors of 3.1 versus 18.4 mm), compared to the original REA. When the enhancements were implemented separately and in combinations, the most important one was automatic modification of tracked joint acceleration curves, while the least important enhancement was automatic modification of algorithm feedback gains. The enhanced REA provides a framework for future gait optimization studies that seek to predict subject-specific post-treatment gait patterns involving large changes in foot-ground contact patterns made possible through deformable foot-ground contact models.

Effect of task-oriented training for people with stroke: a meta-analysis focused on repetitive or circuit training

PURPOSE

The current meta-analysis reviewed evidence for effective task-oriented training focused on repetitive or circuit training after stroke.

METHOD

Searches were conducted of randomized, controlled trials using task-oriented training. The quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) scale. Eleven studies were analyzed regarding the magnitude of effect sizes (ESs) and categorized according to extremities focused upon for training, outcome measures, and study variables. This included duration and frequency of training and stroke stage.

RESULTS

The PEDro scores ranged from 4 to 8 (median = 7). The overall ES of the 11 studies was large. The effects for lower extremities and both acute/sub-acute and chronic stage stroke were large and significant. Significant effects were also found for gait velocity, gait endurance, balance, timed up and go test, and strength of the lower extremities. There was no significant effect of training focused on upper extremities. Training with a duration of 2 weeks and frequency of 7 days a week had the greatest effects.

CONCLUSIONS

Task-oriented training interventions are useful for improving muscle strength and gait related activities in both acute/sub-acute and chronic stroke patients. Although this meta-analysis provides evidence of task-oriented training for improving functioning after stroke, further studies are necessary to investigate the effects of training on upper extremities and the overall cost-effectiveness of such training.

A pilot study of partial unweighted treadmill training in mobility-impaired older adults

Background. Partial unweighted treadmill training is a potentially effective modality for improving fitness and function in frail elders. We tested the feasibility of partial unweighted treadmill training in older, mobility-impaired veterans. Methods. Eight mobility-impaired elders participated in partial unweighted treadmill training three times/week for twelve weeks. Outcome measures included gait speed, performance-oriented mobility assessment (POMA), eight foot up and go, and the SF-36 physical functioning short form. Results. There was significant improvement in treadmill walking time (+8.5 minutes; P < 0.001), treadmill walking speed (+0.14 meters/second; P = 0.02), and percent of body weight support (−2.2%; P = 0.02). Changes in physical performance included usual gait speed (+0.12 meters/second; P = 0.001), rapid gait speed (+0.13 meters/second; P = 0.01), POMA (+2.4 summary score; P < 0.001), and eight foot up and go (−1.2 seconds; P = 0.05). Conclusions. Partial unweighted treadmill training is feasible in mobility-impaired elders. Improvements in treadmill training capacity resulted in clinically meaningful improvements in fitness levels and improved mobility.

Experiences of participation in rhythm and movement therapy after stroke

PURPOSE

The aim of this study was to investigate how persons with stroke experience participation in rhythm and music therapy.

METHODS

To gain knowledge of the qualitatively different ways persons with stroke experience participation in Ronnie Gardiner Rhythm and Music (RGRM) therapy, a phenomenographic approach was chosen. Interviews with 17 persons with stroke were done. Selection criteria were set to capture the variations in how the phenomenon appeared to the informants.

RESULTS

Two qualitatively different ways of experiencing the RGRM therapy were identified: (A) challenge leading to connection with the body and (B) being able. A feeling of being connected to the body was achieved as a result of the challenging tasks. By gaining a feeling of body awareness joy, energy and desire to do things increased. Learning new skills was promoted by having to be concentrated during therapy sessions and a sense of being able to carry out difficult tasks was achieved.

CONCLUSIONS

Participation in RGRM seems to have helped the persons come to terms with their changed bodies, leading to feelings of being connected with their bodies. A feeling of change in competence occurred when an ability to carry out the tasks was simultaneously achieved.

IMPLICATIONS FOR REHABILITATION

Stroke may cause considerable functional limitations with needs of rehabilitation services as a consequence. Participation in rhythm and movement activities may help persons who have had a stroke come to terms with their "new" bodies. The rhythm and movement activities were considered demanding and helped return to a meaningful life.

Technological advances in interventions to enhance poststroke gait

Neurologic rehabilitation interventions may be either therapeutic or compensatory. Included in this article are lower extremity functional electrical stimulation, body weight-supported treadmill training, and lower extremity robotic-assisted gait training. These poststroke gait training therapies are predicated on activity-dependent neuroplasticity. All three interventions have been trialed extensively in research and clinical settings to show a positive effect on various gait parameters and measures of walking performance. This article provides an overview of evidence-based research that supports the efficacy of these three interventions to improve gait, as well as providing perspective on future developments to enhance poststroke gait in neurologic rehabilitation.

Task-Oriented Physical Exercise Using Postural Re-Alignment with Body Weight Support in Chronic Stroke

The recovery of functional gait is the main target for subjects who have suffered a stroke. The methods designed to improve balance and gait appear to be essential for skills and autonomy and to reduce the costs of assistance. The aim of our study was to evaluate the improvement of stroke victims in the chronic phase through the rehabilitation of gait, balance and posture using postural re-alignment with specific body weight support. The study includes 20 subjects with residual hemiparetic gait after stroke. Evaluation with international rating scales, gait analysis and stabilometric test was carried out at the beginning and after the 1st and the 3rd month of therapy; a follow-up control was made 3 months after the end of the rehabilitation program. All subjects underwent the rehabilitation protocol with Dynamic Antigravity Postural System 2 times a week for 3 months and were also treated with high efficiency focused acoustic waves (ViSS) to increase strength and muscular endurance (300Hz) or to reduce spastic hypertonia (200–120 Hz). The study shows a significant improvement in gait and balance with the persistence of results at the follow-up 3 months after the end of treatment. The subjects showed an increase in walking speed, greater stability and a consequent reduction of sedentary lifestyle with less risk of complications or recurrence. In conclusion this rehabilitation program is efficient for posture and walking quality.

Improving gait and balance in patients with leukoaraiosis using transcranial direct current stimulation and physical training: an exploratory study

BACKGROUND

Leukoaraiosis describes ischemic white matter lesions, a leading cause of gait disturbance in the elderly.

OBJECTIVE

Our aim was to improve gait and balance in patients with leukoaraiosis by combining a single session of transcranial direct current stimulation (tDCS) and physical training (PT).

METHODS

We delivered anodal tDCS over midline motor and premotor areas in 9 patients with leukoaraiosis. Patients underwent gait and balance training during tDCS stimulation (real/sham). This was repeated 1 week later with the stimulation crossed-over (sham/real) in a double-blind design. Assessments included gait velocity, stride length, stride length variability (primary gait outcomes), and a quantitative retropulsion test (primary balance outcome).

RESULTS

. Combining tDCS and PT improved gait velocity, stride length, stride length variability, and balance (all at P ≤ .05). Overall, training without tDCS showed no significant effects.

CONCLUSIONS

Combined anodal tDCS and PT improves gait and balance in this patient group, suggesting that tDCS could be an effective adjunct to PT in patients with leukoaraiosis, for whom no treatment is currently available.

Control Architecture of a 10 DOF Lower Limbs Exoskeleton for Gait Rehabilitation

This paper describes the control architecture of a 10 DOF (Degrees of Freedom) lower limbs exoskeleton for the gait rehabilitation of patients with gait dysfunction. The system has 4 double-acting rod pneumatic actuators (two for each leg) that control the hip and knee joints. The motion of each cylinder's piston is controlled by two proportional pressure valves, connected to both cylinder chambers.

The control strategy has been specifically designed in order to ensure a proper trajectory control for guiding patient's legs along a fixed reference gait pattern.

An adaptive fuzzy controller which is capable of compensating for the influence of the dry friction was successfully designed, implemented and tested on an embedded real-time PC/104.

In order to verify the proposed control architecture, laboratory experiments without a patient were carried out and the results are reported here and discussed.

A system to integrate electrical stimulation with robotically controlled treadmill training to rehabilitate stepping after spinal cord injury

A functional electrical stimulation (FES) system was engineered to integrate information from a robotically controlled position during stepping in order to time stimulation to continuous gait information in a rodent model of spinal cord injury (SCI). In contrast to conventional FES systems which have a fixed timing pattern relative to gait cycle onset (i.e., toe off/heel off or paw contact/heel strike), this system allows adaptation of stimulation to a robotically controlled position. Rationale for the system design is presented along with bench-test results verifying the timing of the stimulation with respect to hindlimb position. This robotically timed FES system will enable studies investigating the capability of this FES therapy to encourage rehabilitation by way of spinal plasticity.

Compelled Body Weight Shift Technique to Facilitate Rehabilitation of Individuals with Acute Stroke

BACKGROUND

The study evaluates the effectiveness of Compelled Body Weight Shift (CBWS) approach in the rehabilitation of individuals with stroke. CBWS involves a forced shift of body weight towards a person's affected side by means of a shoe insert that establishes a lift of the nonaffected lower extremity.

METHODS

Eleven patients with acute stroke were randomly assigned to experimental and control groups. The experimental group received a two-week conventional physical therapy combined with CBWS and the control group received only a two-week conventional therapy. Weight bearing, Gait velocity, Berg's Balance, and Fugl-Meyer's Scores were recorded before and after the intervention.

RESULTS

Weight bearing on the affected side increased in the experimental group and decreased in the control group. The increase in gait velocity with treatment was significant in both the groups (P < 0.05). However, experimental group (P = 0.01) demonstrated larger improvements in gait velocity compared to the control group (P = 0.002). Berg Balance and Fugl-Meyer scores increased for both the groups.

CONCLUSION

The implementation of a two-week intervention with CBWS resulted in the improvement in weight bearing and gait velocity of individuals with acute stroke. The present preliminary study suggests that CBWS technique could be implemented as an adjunct to conventional rehabilitation program for individuals with acute stroke.

Augmented dynamics and motor exploration as training for stroke

With chronic stroke survivors (n = 30), we investigated how upper extremity training with negative viscosity affects coordination under unperturbed conditions. Subjects trained with a planar robotic interface simulating 1) negative viscosity augmented to elbow and shoulder joints; 2) negative viscosity combined with inertia; or 3) a null-field condition. Two treatment groups practiced with both force conditions (cross-over design), while a control group practiced with a null-field condition. Training (exploratory movement) and evaluations (prescribed circular movement) alternated in several phases to facilitate transfer from forces to the null field. Negative viscosity expanded exploration especially in the sagittal axis, and resulted in significant within-day improvements. Both treatment groups exhibited next day retention unobserved in the control. Our results suggest enhanced learning from forces that induce a broader range of kinematics. This study supports the use of robot-assisted training that encourages active patient involvement by preserving efferent commands for driving movement.

Feed forward and feedback control for over-ground locomotion in anaesthetized cats

The biological central pattern generator (CPG) integrates open and closed loop control to produce over-ground walking. The goal of this study was to develop a physiologically based algorithm capable of mimicking the biological system to control multiple joints in the lower extremities for producing over-ground walking. The algorithm used state-based models of the step cycle each of which produced different stimulation patterns. Two configurations were implemented to restore over-ground walking in five adult anaesthetized cats using intramuscular stimulation (IMS) of the main hip, knee and ankle flexor and extensor muscles in the hind limbs. An open loop controller relied only on intrinsic timing while a hybrid-CPG controller added sensory feedback from force plates (representing limb loading), and accelerometers and gyroscopes (representing limb position). Stimulation applied to hind limb muscles caused extension or flexion in the hips, knees and ankles. A total of 113 walking trials were obtained across all experiments. Of these, 74 were successful in which the cats traversed 75% of the 3.5 m over-ground walkway. In these trials, the average peak step length decreased from 24.9 ± 8.4 to 21.8 ± 7.5 (normalized units) and the median number of steps per trial increased from 7 (Q1 = 6, Q3 = 9) to 9 (8, 11) with the hybrid-CPG controller. Moreover, within these trials, the hybrid-CPG controller produced more successful steps (step length ≤ 20 cm; ground reaction force ≥ 12.5% body weight) than the open loop controller: 372 of 544 steps (68%) versus 65 of 134 steps (49%), respectively. This supports our previous preliminary findings, and affirms that physiologically based hybrid-CPG approaches produce more successful stepping than open loop controllers. The algorithm provides the foundation for a neural prosthetic controller and a framework to implement more detailed control of locomotion in the future.

An observational report of intensive robotic and manual gait training in sub-acute stroke

Background

The use of automated electromechanical devices for gait training in neurological patients is increasing, yet the functional outcomes of well-defined training programs using these devices and the characteristics of patients that would most benefit are seldom reported in the literature. In an observational study of functional outcomes, we aimed to provide a benchmark for expected change in gait function in early stroke patients, from an intensive inpatient rehabilitation program including both robotic and manual gait training.

Methods

We followed 103 sub-acute stroke patients who met the clinical inclusion criteria for Body Weight Supported Robotic Gait Training (BWSRGT). Patients completed an intensive 8-week gait-training program comprising robotic gait training (weeks 0-4) followed by manual gait training (weeks 4-8). A change in clinical function was determined by the following assessments taken at 0, 4 and 8 weeks (baseline, mid-point and end-point respectively): Functional Ambulatory Categories (FAC), 10 m Walking Test (10 MWT), and Tinetti Gait and Balance Scales.

Results

Over half of the patients made a clinically meaningful improvement on the Tinetti Gait Scale (> 3 points) and Tinetti Balance Scale (> 5 points), while over 80% of the patients increased at least 1 point on the FAC scale (0-5) and improved walking speed by more than 0.2 m/s. Patients responded positively in gait function regardless of variables gender, age, aetiology (hemorrhagic/ischemic), and affected hemisphere. The most robust and significant change was observed for patients in the FAC categories two and three. The therapy was well tolerated and no patients withdrew for factors related to the type or intensity of training.

Conclusions

Eight-weeks of intensive rehabilitation including robotic and manual gait training was well tolerated by early stroke patients, and was associated with significant gains in function. Patients with mid-level gait dysfunction showed the most robust improvement following robotic training.

Rehabilitation of gait after stroke: a review towards a top-down approach

This document provides a review of the techniques and therapies used in gait rehabilitation after stroke. It also examines the possible benefits of including assistive robotic devices and brain-computer interfaces in this field, according to a top-down approach, in which rehabilitation is driven by neural plasticity.The methods reviewed comprise classical gait rehabilitation techniques (neurophysiological and motor learning approaches), functional electrical stimulation (FES), robotic devices, and brain-computer interfaces (BCI).From the analysis of these approaches, we can draw the following conclusions. Regarding classical rehabilitation techniques, there is insufficient evidence to state that a particular approach is more effective in promoting gait recovery than other. Combination of different rehabilitation strategies seems to be more effective than over-ground gait training alone. Robotic devices need further research to show their suitability for walking training and their effects on over-ground gait. The use of FES combined with different walking retraining strategies has shown to result in improvements in hemiplegic gait. Reports on non-invasive BCIs for stroke recovery are limited to the rehabilitation of upper limbs; however, some works suggest that there might be a common mechanism which influences upper and lower limb recovery simultaneously, independently of the limb chosen for the rehabilitation therapy. Functional near infrared spectroscopy (fNIRS) enables researchers to detect signals from specific regions of the cortex during performance of motor activities for the development of future BCIs. Future research would make possible to analyze the impact of rehabilitation on brain plasticity, in order to adapt treatment resources to meet the needs of each patient and to optimize the recovery process.

Abnormal leg muscle latencies and relationship to dyscoordination and walking disability after stroke

The purpose was to determine timing characteristics of leg muscle latencies for patients following stroke (>12 months) who had persistent coordination and gait deficits, and to determine the relationships among abnormal latencies, dyscoordination, and gait deficits. We compared nine healthy controls and 27 stroke survivors. Surface electromyography measured activation and deactivation latencies of knee flexor and extensor muscles during a ballistic knee flexion task, consistency of latencies across repetitions, and close coupling between agonist and antagonist muscle latencies. We measured Fugl-Meyer (FM) coordination and the functional gait measure, six minute walk test (6MWT). For stroke subjects, there were significant delays of muscle activation and deactivation, abnormal inconsistency, and abnormal decoupled agonist and antagonist activations. There was good correlation between activation latencies and FM and 6MWT. Results suggest abnormal timing characteristics underlie coordination impairment and dysfunctional gait. These abnormal muscle activation and deactivation timing characteristics are important targets for rehabilitation.

Varied overground walking-task practice versus body-weight-supported treadmill training in ambulatory adults within one year of stroke: a randomized controlled trial protocol

BACKGROUND

Although task-oriented training has been shown to improve walking outcomes after stroke, it is not yet clear whether one task-oriented approach is superior to another. The purpose of this study is to compare the effectiveness of the Motor Learning Walking Program (MLWP), a varied overground walking task program consistent with key motor learning principles, to body-weight-supported treadmill training (BWSTT) in community-dwelling, ambulatory, adults within 1 year of stroke.

METHODS/DESIGN

A parallel, randomized controlled trial with stratification by baseline gait speed will be conducted. Allocation will be controlled by a central randomization service and participants will be allocated to the two active intervention groups (1:1) using a permuted block randomization process. Seventy participants will be assigned to one of two 15-session training programs. In MLWP, one physiotherapist will supervise practice of various overground walking tasks. Instructions, feedback, and guidance will be provided in a manner that facilitates self-evaluation and problem solving. In BWSTT, training will emphasize repetition of the normal gait cycle while supported over a treadmill, assisted by up to three physiotherapists. Outcomes will be assessed by a blinded assessor at baseline, post-intervention and at 2-month follow-up. The primary outcome will be post-intervention comfortable gait speed. Secondary outcomes include fast gait speed, walking endurance, balance self-efficacy, participation in community mobility, health-related quality of life, and goal attainment. Groups will be compared using analysis of covariance with baseline gait speed strata as the single covariate. Intention-to-treat analysis will be used.

DISCUSSION

In order to direct clinicians, patients, and other health decision-makers, there is a need for a head-to-head comparison of different approaches to active, task-related walking training after stroke. We hypothesize that outcomes will be optimized through the application of a task-related training program that is consistent with key motor learning principles related to practice, guidance and feedback.

TRIAL REGISTRATION

ClinicalTrials.gov # NCT00561405.

Using virtual reality to improve walking post-stroke: translation to individuals with diabetes

Use of virtual reality (VR) technology to improve walking for people post-stroke has been studied for its clinical application since 2004. The hardware and software used to create these systems has varied but has predominantly been constituted by projected environments with users walking on treadmills. Transfer of training from the virtual environment to real-world walking has modest but positive research support. Translation of the research findings to clinical practice has been hampered by commercial availability and costs of the VR systems. Suggestions for how the work for individuals post-stroke might be applied and adapted for individuals with diabetes and other impaired ambulatory conditions include involvement of the target user groups (both practitioners and clients) early in the design and integration of activity and education into the systems.