Effect of forced use of the lower extremity on gait performance and mobility of post-acute stroke patients

PEMOCS: theory derivation of a concept for PErsonalized MOtor-Cognitive exergame training in chronic Stroke-a methodological paper with an application example

Background

Coping with residual cognitive and gait impairments is a prominent unmet need in community-dwelling chronic stroke survivors. Motor-cognitive exergames may be promising to address this unmet need. However, many studies have so far implemented motor-cognitive exergame interventions in an unstructured manner and suitable application protocols remain yet unclear. We, therefore, aimed to summarize existing literature on this topic, and developed a training concept for motor-cognitive exergame interventions in chronic stroke.

Methods

The development of the training concept for personalized motor-cognitive exergame training for stroke (PEMOCS) followed Theory Derivation procedures. This comprised (1.1) a thorough (narrative) literature search on long-term stroke rehabilitation; (1.2) a wider literature search beyond the topic of interest to identify analogies, and to induce creativity; (2) the identification of parent theories; (3) the adoption of suitable content or structure of the main parent theory; and (4) the induction of modifications to adapt it to the new field of interest. We also considered several aspects of the "Framework for Developing and Evaluating Complex Interventions" by the Medical Research Council. Specifically, a feasibility study was conducted, and refining actions based on the findings were performed.

Results

A training concept for improving cognitive functions and gait in community-dwelling chronic stroke survivors should consider the principles for neuroplasticity, (motor) skill learning, and training. We suggest using a step-based exergame training for at least 12 weeks, 2-3 times a week for approximately 45 min. Gentile's Taxonomy for Motor Learning was identified as suitable fundament for the personalized progression and variability rules, and extended by a third cognitive dimension. Concepts and models from related fields inspired further additions and modifications to the concept.

Conclusion

We propose the PEMOCS concept for improving cognitive functioning and gait in community-dwelling chronic stroke survivors, which serves as a guide for structuring and implementing motor-cognitive exergame interventions. Future research should focus on developing objective performance parameters that enable personalized progression independent of the chosen exergame type.

Variation in the rate of recovery in motor function between the upper and lower limbs in patients with stroke: some proposed hypotheses and their implications for research and practice

Background

Stroke results in impairment of motor function of both the upper and lower limbs. However, although it is debatable, motor function of the lower limb is believed to recover faster than that of the upper limb. The aim of this paper is to propose some hypotheses to explain the reasons for that, and discuss their implications for research and practice.

Method

We searched PubMED, Web of Science, Scopus, Embase and CENTRAL using the key words, stroke, cerebrovascular accident, upper extremity, lower extremity, and motor recovery for relevant literature.

Result

The search generated a total of 2,551 hits. However, out of this number, 51 duplicates were removed. Following review of the relevant literature, we proposed four hypotheses: natural instinct for walking hypothesis, bipedal locomotion hypothesis, central pattern generators (CPGs) hypothesis and role of spasticity hypothesis on the subject matter.

Conclusion

We opine that, what may eventually account for the difference, is the frequency of use of the affected limb or intensity of the rehabilitation intervention. This is because, from the above hypotheses, the lower limb seems to be used more frequently. When limbs are used frequently, this will result in use-dependent plasticity and eventual recovery. Thus, rehabilitation techniques that involve high repetitive tasks practice such as robotic rehabilitation, Wii gaming and constraint induced movement therapy should be used during upper limb rehabilitation.

Effect of constraint-induced movement therapy on lower extremity motor dysfunction in post-stroke patients: A systematic review and meta-analysis

Objective

Constraint-induced movement therapy (CIMT) is a common treatment for upper extremity motor dysfunction after a stroke. However, whether it can effectively improve lower extremity motor function in stroke patients remains controversial. This systematic review comprehensively studies the current evidence and evaluates the effectiveness of CIMT in the treatment of post-stroke lower extremity motor dysfunction.

Methods

We comprehensively searched randomized controlled trials related to this study in eight electronic databases (PubMed, Embase, The Cochrane Library, Web of Science, CBM, CNKI, WAN FANG, and VIP). We evaluated CIMT effectiveness against post-stroke lower extremity motor dysfunction based on the mean difference and corresponding 95% confidence interval (95% CI). We assessed methodological quality based on the Cochrane Bias Risk Assessment Tool. After extracting the general information, mean, and standard deviation of the included studies, we conducted a meta-analysis using RevMan 5.3 and Stata 16.0. The primary indicator was the Fugl-Meyer Assessment scale on lower limbs (FMA-L). The secondary indicators were the Berg balance scale (BBS), 10-meter walk test (10MWT), gait speed (GS), 6-min walk test (6MWT), functional ambulation category scale (FAC), timed up and go test (TUGT), Brunnstrom stage of lower limb function, weight-bearing, modified Barthel index (MBI), functional independence measure (FIM), stroke-specific quality of life questionnaire (SSQOL), World Health Organization quality of life assessment (WHOQOL), and National Institute of Health stroke scale (NIHSS).

Results

We initially identified 343 relevant studies. Among them, 34 (totaling 2,008 patients) met the inclusion criteria. We found that patients treated with CIMT had significantly better primary indicator (FMA-L) scores than those not treated with CIMT. The mean differences were 3.46 (95% CI 2.74–4.17, P < 0.01, I2 = 40%) between CIMT-treated and conventional physiotherapy-treated patients, 3.83 (95% CI 2.89–4.77, P < 0.01, I2 = 54%) between patients treated with CIMT plus conventional physiotherapy and patients treated only with conventional physiotherapy, and 3.50 (95% CI 1.08–5.92, P < 0.01) between patients treated with CIMT plus western medicine therapy and those treated only with western medicine therapy. The secondary indicators followed the same trend. The subgroup analysis showed that lower extremity CIMT with device seemed to yield a higher mean difference in FMA-L scores than lower extremity CIMT without device (4.52, 95% CI = 3.65–5.38, P < 0.01 and 3.37, 95% CI = 2.95–3.79, P < 0.01, respectively).

Conclusion

CIMT effectively improves lower extremity motor dysfunction in post-stroke patients; however, the eligible studies were highly heterogeneous.

Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277466.

P, Misri Z, Pai S. Effect of Compelled Body Weight Shift (CBWS) Therapy in Comparison to ProprioceptiveTraining on Functional Balance, Gait, andMuscle Strength Among Acute Stroke Subjects

Background:

The majority of poststroke individuals tend to exhibit reduced loading over the paretic lower extremity, leading to increased postural sway, and gait asymmetry predisposing to a higher number of falls. Compelled body weight shift (CBWS) therapy is an innovative method aimed to force body weight shift toward the paretic extremity. Proprioceptive training (PT) is another method that improves balance ability contributing to the increase in muscle activity. Both the CBWS and PT have been shown to improve the quality of life in stroke subjects.

Aims and Objectives:

The aim of this study is to compare the effects of CBWS therapy and PT in improving balance, kinematic gait parameters, and muscle strength among acute stroke patients.

Methods:

Thirty subjects were nonrandomly divided into two groups where both groups received routine physiotherapy for two weeks in addition to which the CBWS group incorporated a 15 mm platform placed under the unaffected extremity while the PT group included incorporated proprioceptive exercises on the ground and foam mat. Functional balance, functional mobility, videographic analysis of degrees of hip flexion, knee hyperextension, and ankle dorsiflexion along with gait speed and spatiotemporal gait parameters were obtained.

Results:

The pre-post analysis within both groups revealed statistically significant improvement in all parameters except for the kinematic parameters of gait. However, no statistically significant difference was observed between the CBWS and PT groups.

Conclusion:

CBWS can be used as an alternative to PT in the rehabilitation of stroke patients concerning balance and gait. CBWS provided during active treatment sessions results as effective as those seen as a result of all-day therapy.

Gait symmetry - A valid parameter for pre and post planning for total knee arthroplasty

OBJECTIVES

We aimed to determine whether GS can help to plan and rearrange the treated side by using IMUs to measure the joint angle of the hip, knee, and ankle. We hypothesized that the kinematics in healthy individuals for both sides are approximately equal during walking.

METHODS

IMUs were used to measure the joint angles of 25 healthy participants during walking. The participants performed the 10-meter walk test. The normalized symmetry index (SI_norm) was used to calculate the symmetry of joint angles for the hip, knee, and ankle throughout the gait cycle.

RESULTS

The SI_norm demonstrated high symmetry between both legs; and the ranges were -1.5% and 1.1% for the hip, -3.0% and 3.1% for the knee, and -12% and 9.2% for the ankle joint angle throughout the gait cycle.

CONCLUSION

The SI_norm provides strong information that can be helpful in the planning process for the surgeries. Further, the IMUs system gives the possibility to measure the patients before their surgeries and use their data to plan and rearrange for the operated side.

Effect of additional load on angular parameters during gait and balance in children with hemiparesis – Cross sectional study

Study aim: To study the effect of additional load over ankle and knee joints on angular parameters during gait and balance in children with hemiparesis.

Material and methods: 10 children with hemiparesis were recruited and stratified into 2 chronological age groups: group A (4–8 years) and group B (9–12 years). Additional loads of 0.7 kg and 1.1 kg were placed on the affected and non-affected lower limb at the ankle and knee joint for group A and group B respectively. Angular parameters during gait were assessed using Kinovea software (version 0.8.15) and balance using the Pediatric Balance Scale.

Results: Application of additional load of 0.7 kg over the non-affected leg knee joint is able to produce significant changes in ankle joint angles (p < 0.05) at initial contact and knee joint angles at heel-off (p < 0.05), toe-off (p < 0.001), acceleration (p < 0.05) and deceleration (p < 0.05) phases of gait and balance in group A, whereas on application of additional load of 1.1 kg over the affected leg at the ankle joint significant improvement in knee joint angles at initial contact (p < 0.001) and the deceleration (p < 0.05) phase of gait in group B was observed. There was significant improvement in the Pediatric Balance Scale score in both groups (p < 0.05).

Conclusions: Additional load over knee and ankle joints of the affected and non-affected leg showed more improvement in angular parameters during gait and balance in younger children with hemiparesis than older children, as they present an immature form of gait that can be modified, corrected and brought back to a normal angle.

Effects of Lower Limb Constraint Induced Movement Therapy in People With Stroke: A Systematic Review and Meta-Analysis

Background: Constraint induced movement therapy (CIMT) is effective at improving upper limb outcomes after stroke.

Aim: The aim of this study was to carry out a systematic review and meta-analysis of the effects of lower limb CIMT studies of any design in people with stroke.

Materials/ Method: PubMED, PEDro, OTSeeker, CENTRAL, and Web of Science were searched from their earliest dates to February 2021. Lower limbs CIMT studies that measured outcomes at baseline and post-intervention were selected. Sample size, mean, and standard deviation on the outcomes of interest and the protocols of both the experimental and control groups were extracted. McMaster Critical Review Form was used to assess the methodological quality of the studies.

Result: Sixteen studies with different designs were included in this review. The result showed that lower limb CIMT improves functional, physiological and person's reported outcomes including motor function, balance, mobility, gait speed, oxygen uptake, exertion before and after commencement of activities, knee extensor spasticity, weight bearing, lower limb kinematics and quality of life in people with stroke post intervention. However, there were only significant differences in quality of life in favor of CIMT post-intervention [mean difference (MD) = 16.20, 95% CI = 3.30–29.10, p = 0.01]; and at follow-up [mean difference (MD) = 14.10, 95% CI = 2.07–26.13, p = 0.02] between CIMT and the control group. Even for the quality of life, there was significant heterogeneity in the studies post intervention (I² = 84%, p = 0.01).

Conclusion: Lower limb CIMT improves motor function, balance, functional mobility, gait speed, oxygen uptake, weigh bearing, lower limb kinematics, and quality of life. However, it is only superior to the control at improving quality of life after stroke based on the current literature.

Effect of constraint-induced movement therapy on persons-reported outcomes of health status after stroke: a systematic review and meta-analysis

Constraint-induced movement therapy (CIMT) is used for the rehabilitation of motor function after stroke. The aim of this review was to investigate its effect on persons-reported outcomes of health status (PROsHS) compared with conventional therapy. The study was a systematic review and meta-analysis registered in PROSPERO (CRD42019142279). Five databases PubMED, PEDro, OTSeeker, CENTRAL and Web of Science were searched. Randomized controlled trials were included if they assessed PROsHS. Mean scores of PROsHS, sample size and dose of CIMT and control groups interventions were extracted. The result was analyzed using qualitative and quantitative syntheses. Nine studies (n = 558) were included in the review. From the result, CIMT significantly improved PROsHS postintervention. However, postintervention, there was no statistically significant difference between groups for the upper limb [Mean difference (MD) = 6.67, 95% confidence interval (CI) = -2.09 to 15.44, P = 0.14] and the lower limb (MD = -1.86, 95% CI = -16.29 to 12.57, P = 0.80). Similarly, there was no statistically significant percentage of variation across studies, upper limb (I2 = 0%, P = 0.92) and lower limb (I2 = 0%, P = 0.86). For the lower limb at follow-up, there was no statistically significant difference between groups (MD = 0.97, 95% CI = -13.59 to 15.53, P = 0.90). When upper and lower limbs studies were pooled, there was no statistically significant difference between groups postintervention (MD = 0.22, 95% CI = -0.15 to 0.58, P = 0.24) and at follow-up (MD = 0.03, 95% CI = -0.43 to 0.49, P = 0.90). CIMT improves PROsHS after stroke. However, it is not superior to conventional therapy based on the current literature.

Reliability and validity of the modified functional ambulation category scale in patients with hemiparalysis

[Purpose] This study aimed to examine the inter- and intra-rater reliability and validity of the modified functional ambulation category (mFAC) scale. [Subjects and Methods] The participants were 66 stroke patients with hemiparalysis. The inter- and intra-rater validity of the mFAC was calculated using the Spearman correlation coefficient. A score comparison of the stable or maximum gait speed with regard to mFAC and modified Rivermead Mobility Index (mRMI) performances was performed as a univariate linear regression analysis to determine how the Kruskal-Wallis test affects the mRMI and stable/maximum gait speed with regard to mFAC. [Results] The inter-rater reliability of the mFAC (intraclass coefficient [ICC]) was 0.982 (0.971–0.989), with a kappa coefficient of 0.923 and a consistency ratio of 94%. In contrast, the intra-rater reliability of the mFAC (ICC) was 0.991 (0.986–0.995), with a kappa coefficient of 0.961 and a consistency ratio of 96%, showing higher reliability. Moreover, there was a significant difference in stable/maximum gait speed between the mFAC and the mRMI. [Conclusion] Since the mFAC has sufficient inter- and intra-reliability and high validity, it can be used as an assessment tool that reflects the gait performance and mobility of stroke patients.