Effect of bilateral lower limb strengthening exercise on balance and walking in hemiparetic patients after stroke: a randomized controlled trial

Efficacy of a Four-Week Diagonal Pattern Exercise Program on Trunk and Lower Limb Function in Patients With Stroke-Induced Hemiplegia

Objective The intended effect of this investigation is to quantify the efficacy of a four-week program of diagonal pattern exercises in managing trunk impairments and improving gait difficulties in hemiplegic stroke subjects. The study aims to measure changes in trunk stability and gait parameters post-intervention, providing insights into the potential therapeutic benefits of these exercises for stroke rehabilitation. Methodology This experimentation approach encompassing before and the follow-up test evaluations was implemented in this investigation. It was conducted at Madha College of Physiotherapy, Chennai, using convenience sampling to recruit 20 stroke subjects meeting specific inclusion criteria. Participants underwent pre-test evaluations for trunk control and gait. They were then divided equally into two groups for a four-week intervention comprising diagonal pattern exercises or single-plane training. Treatment sessions were administered five days per week for 45 minutes each. Posttest evaluations assessed changes in trunk control using the Trunk Impairment Scale (TIS) and gait parameters via the Timed Up and Go (TUG) test. Results Pretest analysis indicated no substantial baseline variations among the experimental and control groups, affirming their suitability for comparison. Posttest analysis of intervention at a 5% significance level revealed that the experimental group demonstrated a statistically significant improvement in trunk control, as measured by the TIS and TUG test, compared to the control group. The paired t-test results showed significant differences in pre- and posttest values within each group, while the unpaired t-test confirmed the superiority of the experimental group's outcomes, with a P-value < 0.05. This improvement is likely due to the effectiveness of the diagonal pattern exercise in enhancing trunk muscle activity and coordination. Conclusions This study concludes that diagonal pattern training is more beneficial for improving trunk musculature control and locomotory ability in chronic cerebrovascular accident subjects. The exercise program's simplicity, minimal risks, and ease of home application after initial therapist supervision make it a promising therapeutic approach.

Effects of Lower Limb Proprioceptive Training on Balance and Trunk Control Among the Adult Stroke Population

Background and objective Balance and trunk control are major concerns among older adults during stroke rehabilitation. Loss of proprioception in the affected limb has a greater influence on motor learning and reeducation during balance training. Available studies stress the relevance of strength and functional training in regaining balance and trunk control. Proprioception training, in addition to available rehabilitation, can optimize the balance among this population. Our study aimed to find out the effects of proprioceptive training on balance and trunk control among the chronic stroke population. Methodology Out of 45 subjects enrolled at the Indian Head Injury Foundation, New Delhi, India, 30 subjects were selected based on selection criteria and randomized into two groups using the chit method, with 15 subjects in each group. The control group received conventional training, which included a range of motion, stretching, and strengthening exercises, while the intervention group received additional proprioceptive training five days per week for four consecutive weeks. Subjects were assessed on the Berg Balance Scale and Trunk Control Test for balance and trunk control on day one and after four weeks. A paired t-test was used to analyze the difference within the groups, and unpaired t-tests were used between the groups, keeping p < 0.05 as a significance level. Results After four weeks of intervention, statistically significant improvements were seen in the balance and trunk control groups, with p < 0.05 in both groups. However, a significant improvement in balance was observed in the experimental group when compared across groups (p = 0.001), whereas no statistically significant improvement in trunk control was found (p = 0.061). Conclusion We conclude that proprioceptive training and conventional physiotherapy both help to improve balance. Proprioceptive training is better for improving balance, but it has no significant effects on trunk control. It is likely that an extended intervention time or a different form of intervention may be required to achieve substantial gains in these areas. Future research might look at other outcome measures or the impacts of other types of therapies to see which ones are most helpful at increasing trunk control.

Relationship between hamstrings-quadriceps strength ratio and the performance of tasks in Berg's Balance Scale among stroke survivors in Abakaliki, Nigeria

Aim

The study was designed to establish the relationship between hamstrings-quadriceps (H-Q) strength ratio and the performance of tasks in Berg's Balance Scale among stroke survivors.

Method

Twenty-five stroke survivors participated in the study. The hamstrings and quadriceps muscle strengths of both the paretic and non-paretic sides were determined at 60° knee flexion with an electronic tensiometer. The participants undertook the tasks in Berg's Balance Scale.

Results

The moment of correlation between the paretic H-Q strength ratio and the total score of the Berg's Balance Scale was 0.630, while the non-paretic was -0.144. Tasks such as standing unsupported (0.360), sitting unsupported (0.348) and standing with eyes closed (0.262) showed a weak correlation with the paretic H-Q strength ratio. Sitting to standing (0.469), standing to sitting (0.405), transfers (0.470), standing with feet together (0.565), retrieving an object from the floor (0.544), turning to look behind (0.400), turning 360° (0.589) and one leg stance (0.649) showed moderate correlation with the paretic H-Q strength ratio; while reaching forward (0.768), placing alternate foot on stool (0.710) and tandem standing (0.744) showed strong correlation with the paretic H-Q strength ratio.

Conclusion

The study concluded that the H-Q strength ratios of the paretic limbs of stroke survivors showed significant relationships with the performance of tasks in Berg's Balance Scale. It is recommended that the H-Q strength ratio is considered as a clinical measurement tool in the balance rehabilitation of stroke survivors.

Investigating the Effect of Novel Gamified Stepper on Lower Limb Biomechanics in Seated Healthy Subjects

The present study introduces a new gamified stepper device designed for bilateral lower limb rehabilitation, which is combined with a 3-D exergame. To the best of our knowledge, this is the initial study to utilize the stepping exercise for seated lower limb rehabilitation. The device comprises a stepping mechanism and a magnetic encoder. The modified stepper facilitates the bilateral training in the lower limb within its workspace. The magnetic encoder provides real-time rotational angle data during the exercise. A task-specific exergame platform was created and integrated with the device to enhance user compliance and engagement with the exercise. Experiments were conducted with ten healthy individuals with no history of lower limb injury to evaluate the system's feasibility for providing bilateral training and the effectiveness of the exergame platform. Participants were asked to perform bilateral lower limb exercise with a metronome and gamified stepper device in a seated position. Lower limb range of motion (ROM) and EMG activations were recorded during the exercises. The results indicate that the device was capable of providing cyclical ROM training with reduced muscle activation of the lower limb, and the exergame platform increased motivation to continue the exercises. This study can serve as the foundation for developing a robotic version of the proposed stepper device.

Strength Training of the Nonhemiplegic Side Promotes Motor Function Recovery in Patients With Stroke: A Randomized Controlled Trial

OBJECTIVE

To observe the effect of strength training of the nonhemiplegic side (NHS) on balance function, mobility, and muscle strength of patients with stroke.

DESIGN

A single-blinded (evaluator) randomized controlled trial.

SETTING

A tertiary hospital rehabilitation center.

PARTICIPANTS

139 patients with first stroke (N=139) were recruited and randomly separated into a trial (n=69) or control group (n=70).

INTERVENTIONS

The control group underwent usual rehabilitation training, including step training and trunk control training in standing position. The trial group underwent strength training of NHS on the basis of usual rehabilitation training. The strength training of NHS included lower limb stepping training with resisting elastic belt and upper limb pulling elastic belt training in standing position. The training for both groups was 45 min, once a day, 5 days a week for 6 weeks.

MAIN OUTCOME MEASURES

Balance evaluation was done with the Berg Balance Scale (BBS); mobility assessment with the 6-minute walk test (6-MWT); activities of daily life was examined via the modified Barthel Index (MBI); muscle strengths of the biceps brachii, iliopsoas, and quadriceps were measured via the isokinetic muscle strength testing system. All assessments were performed at baseline (T0) and after intervention (T1).

RESULTS

The trial group performed better than control group in BBS scores (adjusted mean difference: 6.83; 95% confidence interval [CI]: 4.71-8.94) and 6-MWT (adjusted mean difference: 50.32; 95% CI: 40.58-60.05) after intervention. In terms of muscle strength of the hemiplegic side, the trial group displayed greater gains in biceps brachii, iliopsoas, and quadriceps than control group after intervention.

CONCLUSION

Strength training of the NHS can promote recovery of balance, mobility, and muscle strength of the paretic side of patients with stroke.

Bilateral Lower Limb Training for Post-stroke Survivors: A Bibliometric Analysis

Stroke is one of the most disabling conditions affecting the middle-aged population all around the world. This study aims to explore the rehabilitation of stroke patients using bibliometric analysis, which includes statistical analysis of recent articles, books, and other kinds of publications, to assess scientific output and determine the significance of scientific investigations in terms of both quality and quantity. In this study, an analysis of global trends in research in bilateral lower limb training for training balance and walking for patients in the subacute stage post-stroke between 1988 and 2021 was done. All the articles were obtained from PubMed databases. CiteSpace software was used to analyze the relationship between publications and country, journals, institutions, authors, references, and the keywords used. A total of 160 publications were included in the analysis. There was a tremendous increase in the research of physiotherapy intervention in patients who had residual disability post-stroke with a publication rate of 7.1 articles per year of publications. The use of the sophisticated PubMed database to extract articles allowed for a thorough and powerful bibliometric analysis of stroke rehabilitation research published between 1988 and 2020. In general, the number of studies on bilateral training has increased in recent decades. This historical overview of rehabilitation for post-stroke survivors will serve as a valuable starting point for future study into possible collaborators, focus issues, and trends. This bibliometric analysis highlights the potential value of exercise therapy for stroke survivors in creating more effective hemiplegia rehabilitation programs. This research may encourage the use of strengthening in the therapeutic therapy of hemiplegia balance. The groundwork will be laid for future research on strengthening stroke to be organized and given top priority.

Effects of Creatine Supplementation and Progressive Resistance Training in Stroke Survivors

The purpose was to investigate the effects of progressive resistance training (PRT) and creatine supplementation in stroke survivors. Participants were randomized to one of two groups: creatine (n = 5; 51 ± 16y) or placebo (n = 3; 73 ± 8y) during 10 weeks of supervised PRT. Prior to and following PRT and supplementation, assessments were made for body composition (lean tissue and fat mass), muscle thickness, muscle strength (1-repetition maximum), functional exercise capacity (6-minute walk test, Berg Balance Scale; BBS), cognition (Montreal Cognitive Assessment; MoCA), and symptoms of anxiety (Generalized Anxiety Disorder Assessment-7; GAD-7) and depression (Center for Epidemiological Studies Depression Scale; CES-D). There were time main effects for leg press strength (increased; p = 0.001), chest press strength (increased; p = 0.003), elbow flexor muscle thickness (increased; p = 0.007), BBS (increased; p = 0.002), MoCA (increased; p = 0.031) and CES-D (decreased; p = 0.045). There was a group x time interaction for the 6 minute walk test (p = 0.039). The creatine group significantly increased walking distance over time (p = 0.002) with no change in the placebo group (p = 0.120). Ten weeks of PRT had some positive effects on measures of muscle strength and size, balance, cognition and depression. The addition of creatine to PRT significantly improved walking performance in stroke survivors.

A Robot-Assisted Therapy to Increase Muscle Strength in Hemiplegic Gait Rehabilitation

This study examines the feasibility of using a robot-assisted therapy methodology based on the Bobath concept to perform exercises applied in conventional therapy for gait rehabilitation in stroke patients. The aim of the therapy is to improve postural control and movement through exercises based on repetitive active-assisted joint mobilization, which is expected to produce strength changes in the lower limbs. As therapy progresses, robotic assistance is gradually reduced and the patient's burden increases with the goal of achieving a certain degree of independence. The relationship between force and range of motion led to the analysis of both parameters of interest. The study included 23 volunteers who performed 24 sessions, 2 sessions per week for 12 weeks, each lasting about 1 h. The results showed a significant increase in hip abduction and knee flexion strength on both sides, although there was a general trend of increased strength in all joints. However, the range of motion at the hip and ankle joints was reduced. The usefulness of this platform for transferring exercises from conventional to robot-assisted therapies was demonstrated, as well as the benefits that can be obtained in muscle strength training. However, it is suggested to complement the applied therapy with exercises for the maintenance and improvement of the range of motion.

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

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

Effects of Self RehAbilitation Video Exercises (SAVE) on Functional Restorations in Patients with Subacute Stroke

Background: Additional exercise therapy has been shown to positively affect acute stroke rehabilitation, which requires an effective method to deliver increased exercise. In this study, we designed a 4-week caregiver-supervised self-exercise program with videos, named “Self rehAbilitation Video Exercises (SAVE)”, to improve the functional outcomes and facilitate early recovery by increasing the continuity of rehabilitation therapy after acute stroke. Methods: This study is a non-randomized trial. Eighty-eight patients were included in an intervention group (SAVE group), who received conventional rehabilitation therapies and an additional self-rehabilitation session by watching bedside exercise videos and continued their own exercises in their rooms for 60 min every day for 4 weeks. Ninety-six patients were included in a control group, who received only conventional rehabilitation therapies. After 4 weeks of hospitalization, both groups assessed several outcome measurements, including the Berg Balance Scale (BBS), Modified Barthel Index (MBI), physical component summary (PCS) and the mental component summary of the Short-Form Survey 36 (SF-36), Mini-Mental State Examination, and Beck Depression Inventory. Results: Differences in BBS, MBI, and PCS components in SF-36 were more statistically significant in the SAVE group than that in the control group (p < 0.05). Patients in the SAVE group showed more significant improvement in BBS, MBI, and PCS components in SF-36 as compared to that in the control group. Conclusions: This evidence-based SAVE intervention can optimize patient recovery after a subacute stroke while keeping the available resources in mind.

The effects of lower extremity cross-training on gait and balance in stroke patients: a double-blinded randomized controlled trial

BACKGROUND

Cross-training is an indirect intervention to promote muscle activity on the affected side by applying resistance exercise to stronger parts of the body. Indirect interventions are useful for treating patients who have difficulty with direct interventions. Previous studies have focused on measuring increased muscle strength and muscle activity in healthy individuals.

AIM

This study aimed to investigate the effects of cross-training on gait and balance in hemiplegic patients when applied to the affected and unaffected lower extremities.

DESIGN

Double-blinded randomised controlled trial.

SETTING

In-patients attending the rehabilitation treatment room of a single center.

POPULATION

Fifty-two stroke patients were randomly allocated to a control group (N.=19), affected side cross-training group (N.=15), and unaffected side cross-training group (N.=18).

METHODS

Patients were administered general neurological physiotherapy for 30 mins, twice daily, 5 days/week for 4 weeks. The two intervention groups underwent 30 mins of cross-training instead of general neurological physiotherapy once daily, 3 days/week for 4 weeks (postintervention). For data analysis, one-way ANOVA for between-group comparisons and paired t-tests were performed for within-group comparisons between pre- and postintervention groups (significance level of 0.05).

RESULTS

In the Timed Up and Go Test (TUG), comparing pre- and postintervention, the control group showed no significant change (P>0.05), while the affected side and unaffected side cross-training groups showed significant improvements in function (P<0.05). In the 10-meter Walk Test, the control group showed no significant change (P>0.05), while the affected side and unaffected side cross-training groups showed significant increases in speed (P<0.05). In balance testing, the limits of stability showed a significantly increase in all three groups (P<0.05). There were no pre- or postintervention differences in gait or balance between the groups (P>0.05).

CONCLUSIONS

Gait and balance improved in hemiplegic stroke patients who participated in cross-training, regardless of the intervention applied to the affected or unaffected side.

CLINICAL REHABILITATION IMPACT

In clinical settings, for patients who experience difficulties with direct interventions on the affected side, we propose indirect interventions to improve gait and balance.

Sensorized Assessment of Dynamic Locomotor Imagery in People with Stroke and Healthy Subjects

Dynamic motor imagery (dMI) is a motor imagery task associated with movements partially mimicking those mentally represented. As well as conventional motor imagery, dMI has been typically assessed by mental chronometry tasks. In this paper, an instrumented approach was proposed for quantifying the correspondence between upper and lower limb oscillatory movements performed on the spot during the dMI of walking vs. during actual walking. Magneto-inertial measurement units were used to measure limb swinging in three different groups: young adults, older adults and stroke patients. Participants were tested in four experimental conditions: (i) simple limb swinging; (ii) limb swinging while imagining to walk (dMI-task); (iii) mental chronometry task, without any movement (pure MI); (iv) actual level walking at comfortable speed. Limb swinging was characterized in terms of the angular velocity, frequency of oscillations and sinusoidal waveform. The dMI was effective at reproducing upper limb oscillations more similar to those occurring during walking for all the three groups, but some exceptions occurred for lower limbs. This finding could be related to the sensory feedback, stretch reflexes and ground reaction forces occurring for lower limbs and not for upper limbs during walking. In conclusion, the instrumented approach through wearable motion devices adds significant information to the current dMI approach, further supporting their applications in neurorehabilitation for monitoring imagery training protocols in patients with stroke.

Effects of trunk rehabilitation with kinesio and placebo taping on static and dynamic sitting postural control in individuals with chronic stroke: A randomized controlled trial

Background: Impaired trunk postural control is common after stroke. Combining kinesio taping with trunk rehabilitation has been shown to enhance the recovery of postural control ability in patients with stroke.Objective: We investigated whether the combination of kinesio taping with trunk rehabilitation would improve dynamic and static sitting stability after stroke.Methods: Twenty-eight patients with stroke were recruited and randomly assigned to one of the two 8-week trunk rehabilitation programs with kinesio (experimental group) or placebo taping (control group). Outcome measures were dynamic forward, dynamic backward, affected-side, and unaffected-side sway areas, static sway area and length, and the total limit of stability (LOS) area. The variables were measured using the BioRescue analysis system. All outcome measures were assessed at baseline and after 8 weeks of trunk rehabilitation.Results: Significant increases were observed in the dynamic forward, dynamic backward, affected-side, and unaffected-side sway areas, and the total LOS area, in the experimental and control groups, whereas decreases were observed in the static sway area and length. The dynamic forward sway area was significantly higher in the experimental group than in the control group, but there were no significant differences between the groups in the other variables.Conclusions: Trunk rehabilitation is effective for improving dynamic and static sitting stability after stroke. The addition of kinesio taping to the back muscles further increases forward mobility.

Cross-sectional study of quadriceps properties and postural stability in patients with chronic stroke and limited vs. non-limited community ambulation

Background: Changes in the paretic-side metabolism post-stroke and quadriceps muscle mechanical properties favour muscle wasting, affecting postural instability and walking impairment. Further clarification is needed in subjects post-stroke who show limited or non-limited community ambulation. Objectives: To analyze between-limb differences in quadriceps muscle thickness, strength and thigh cutaneous temperature, as well as investigate postural stability in subjects with chronic stroke and limited vs. non-limited community ambulation and compared against healthy controls. Methods: In this controlled cross-sectional study, 26 participants with chronic hemiparesis post-stroke (divided in a slow gait group (SG<0.8 m/s) (n = 13) and a fast gait group with full community ambulation speed (FG≥0.8 m/s)) and 18 healthy people were recruited. Thigh surface temperature, rectus femoris (RF) and vastus intermedius (VI) muscles thickness, quadriceps' isometric maximal voluntary contraction and postural stability were measured. Results: The SG presented significantly lower RF (P = .019) and VI (P = .006) muscle thickness, less peak force (P < .001) and lower temperature (P = .002) in the paretic vs the non-paretic limb. The FG showed significantly lower VI thickness (P = .036) and peak force (P < .001) in the paretic vs the non-paretic limb. Regarding balance, all indices were worse in the SG versus the FG and CG. Conclusions: Subjects of the FG, despite showing full community ambulation speed, had less quadriceps strength and VI muscle thickness but not RF muscle wasting in the paretic limb. The paretic VI muscle wasting may be an important factor to reach normal walking. The SG showed between-limb differences in all the studied variables and the worst postural stability.

Coordinative Motion-Based Bilateral Rehabilitation Training System with Exoskeleton and Haptic Devices for Biomedical Application

According to the neuro-rehabilitation theory, compared with unilateral training, bilateral training is proven to be an effective method for hemiparesis, which affects the most part of stroke patients. In this study, a novel bilateral rehabilitation training system, which incorporates a lightweight exoskeleton device worn on the affected limb; a haptic device (Phantom Premium), which is used for generating a desired tactile feedback for the affected limb; and a VR (virtual reality) graphic interface, has been developed. The use of VR technology during rehabilitation can provide goal directed tasks with rewards and motivate the patient to undertake extended rehabilitation. This paper is mainly focused on elbow joint training, and other independent joints can be trained by easily changing the VR training interface. The haptic device is adopted to enable patients to use their own decision making abilities with a tactical feedback. Integrated with a VR-based graphic interface, the goal-oriented task can help to gradually recovery their motor function with a coordinative motion between two limbs. In particular, the proposed system can accelerate neural plasticity and motor recovery in those patients with little muscle strength by using the exoskeleton device. The exoskeleton device can provide from relatively high joint impedance to near-zero impedance, and can provide a partial assist as the patient requires.

Immediate effects of rest periods on balance control in patients after stroke. A randomized controlled pilot trial

Objectives

This randomized controlled trial evaluates the effects of two different rest periods between as set of balance exercises after stroke during inpatient rehabilitation.

Results

Twenty patients after stroke [11 males; mean (SD) age 65.4 (11.5) years; duration of illness 5.3 (3.4) weeks; 16 (80%) left-sided strokes] were randomly allocated into two groups of either a full rest (FR) of 4 min (n = 10) or a short rest (SR) of 1 min between exercise sets (n = 10). Patients improved from baseline until immediately after exercises in one-leg standing time on the affected leg [SR: mean difference 5.1 s (SD 10.3) and FR: 2.0 s (2.4)] and tandem standing time (TST). [SR: 14.9 s (SD 24.6) and FR: 5.7 s (12.0)], but OLST and TST did not differ significantly between groups (p = 0.35 and p = 0.52, respectively).

Trial registration The study was registered retrospectively in the German Register of Clinical Trials with the ID: DRKS00013979

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3450-2) contains supplementary material, which is available to authorized users.