Gait training with auditory feedback improves trunk control, muscle activation and dynamic balance in patients with hemiparetic stroke: A randomized controlled pilot study

Feedback Interventions in Motor Recovery of Lateropulsion after Stroke: A Literature Review and Case Series

Lateropulsion is a post-stroke phenomenon marked by an active push of the body across the midline towards the more affected side and/or a resistance of the weight shift towards the less affected side. Within the mechanisms of treatment, feedback systems have been shown to be effective. The aim of the present study was to create a body of knowledge by performing a literature review on the use of feedback mechanisms in the treatment of lateropulsion and to report two cases of lateropulsion patients who had undergone feedback-based treatment.

METHODS

The review was performed across five different databases (Embase, Medline/PubMed, Scopus, Web of Science, and PEDro) up to February 2024, and haptic feedback intervention was incorporated into the case series (with lateropulsion and ambulation capacity as the main variables).

RESULTS

In total, 211 records were identified and 6 studies were included after the review of the literature. The most used feedback modality was visual feedback. In the case series, positive results were observed from the intervention, particularly in the recovery of lateropulsion and balance, as well as in the improvement of gait for one patient. Patients demonstrated good adherence to the intervention protocol without adverse effects.

CONCLUSIONS

Visual feedback is the most commonly used feedback modality in lateropulsion patients but other mechanisms such as haptic feedback also are feasible and should be taken into account. Larger sample sizes, extended follow-up periods, and the isolation of feedback mechanisms must be established to clarify evidence.

Effect of insole on postural control and gait of stroke patients: a systematic review and meta-analysis

This systematic review aims to examine the evidence of adding postural insole to traditional physical therapy to improve weight distribution, gait, mobility, balance, and postural control in stroke survivors. Five databases were searched to retrieve all related randomized controlled trials examining the effect of insole on stroke patients. Two independent authors checked the potential articles against eligibility criteria according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A meta-analysis was conducted for available outcomes and the statistical heterogeneity was examined using the I2 test. Of 762 articles, only 15 with 448 patients were included after they met the inclusion criteria with most of them including participants exceeding 6 months of stroke incidence. When insole was used as compelled body weight shifting method, pooled statistical analysis revealed significant improvement in gait velocity [standardized mean difference (SMD) = 0.67; 95% confidence interval (CI): 0.31, 1.02; P = 0.0003], cadence (SMD = 0.67; 95% CI: 0.16, 1.18; P = 0.01] and stride length (SMD = 1.11; 95% CI: 0.57, 1.65; P < 0.0001), while no significant effect on step length (SMD = 0.48; 95% CI: -0.37, 1.33; P = 0.27). Pooled statistical analysis of balance outcomes revealed significant improvement in weight-bearing symmetry balance (SMD = 0.82; 95% CI: 0.25, 1.39; P = 0.005) and long-term improvement in Berg Balance Scale (SMD = 1.19; 95% CI: 0.19, 2.20; P = 0.02), while no difference was observed in balance confidence (SMD = 0.44; 95% CI: -0.15, 1.04; P = 0.14) and sensorimotor functions (SMD = 0.36; 95% CI -0.39, 1.11; P = 0.35). Insoles significantly improved spatiotemporal gait parameters, gait symmetry, and static balance compared with traditional physical therapy alone.

Developmental Study on "Smart Silver Care": A Mobile Application to Alleviate Loneliness in Older Adults within the Community

BACKGROUND

Loneliness poses a significant threat to the quality of life of older adults. Therefore, it is essential to implement non-face-to-face services to solve the loneliness of older adults in the community.

OBJECTIVES

This study used the ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model to develop mobile applications as a loneliness intervention for older adults living in the community.

METHODS

A mobile application was developed using the ADDIE model to alleviate loneliness in older adults living in the community. The development process included a systematic review, a face-to-face preference survey, and an experts' evaluation. From 11 to 15 June 2021, the following six databases were used to search for related articles: Ovid-Medline, Ovid-EMBASE, Cochrane Library, KISS, Korea Med, RISS. A preference analysis was conducted on 100 adults aged 65 or older living in the community from 15 July to 31 August 2021.

RESULTS

A mobile application for community-dwelling older adults was developed. Its contents included emotional support, cognition, physical activity, health data, nutrition, and motivation. They were organized through a systematic review and preference survey in the analysis stage. They were also designed as main menus and sub-content at the design stage. They also designed the structure, functionality, and interface layout. The application was developed by integrating the designed content and determining the operating system, language, access method, privacy, and server history. Then, experts evaluated the validity of the application.

CONCLUSIONS

The prototype mobile application incorporates emotional support, cognition, physical activity, health data, nutrition, and motivation. It is expected to help older adults achieve their goals by promoting participation. By incorporating expert validity into the content development process of early prototypes, we have improved the usability and acceptability of our products. Future pilot trials are needed to evaluate the effectiveness of this mobile application among older adults.

Robotic Biofeedback for Post-Stroke Gait Rehabilitation: A Scoping Review

This review aims to recommend directions for future research on robotic biofeedback towards prompt post-stroke gait rehabilitation by investigating the technical and clinical specifications of biofeedback systems (BSs), including the complementary use with assistive devices and/or physiotherapist-oriented cues. A literature search was conducted from January 2019 to September 2022 on Cochrane, Embase, PubMed, PEDro, Scopus, and Web of Science databases. Data regarding technical (sensors, biofeedback parameters, actuators, control strategies, assistive devices, physiotherapist-oriented cues) and clinical (participants' characteristics, protocols, outcome measures, BSs' effects) specifications of BSs were extracted from the relevant studies. A total of 31 studies were reviewed, which included 660 stroke survivors. Most studies reported visual biofeedback driven according to the comparison between real-time kinetic or spatiotemporal data from wearable sensors and a threshold. Most studies achieved statistically significant improvements on sensor-based and clinical outcomes between at least two evaluation time points. Future research should study the effectiveness of using multiple wearable sensors and actuators to provide personalized biofeedback to users with multiple sensorimotor deficits. There is space to explore BSs complementing different assistive devices and physiotherapist-oriented cues according to their needs. There is a lack of randomized-controlled studies to explore post-stroke stage, mental and sensory effects of BSs.

Investigation of Flow Changes in Intracranial Vascular Disease Models Constructed with MRA Images

This study aimed to develop a magnetic resonance imaging (MRI)-compatible flow delivery system and individualized models of circle of Willis (CoW), which include 50% and 100% blockage in internal carotid artery (ICA50 and ICA100), and 100% blockage in vertebral artery (VA100). Images were obtained using 3D time-of-flight and phase-contrast magnetic resonance angiography (MRA) sequences, and changes in velocity and flow direction at CoW models were analyzed. For the ICA50 and VA100 models, the flow was similar to that of the normal model. For the ICA 50 model, it was found that 50% blockage did not affect cerebral blood flow. For the VA100 model, decreased flow in the posterior cerebral artery and a change to the flow direction in the posterior communicating artery were found. For the ICA100 model, particularly, decreased flow in the ipsilateral middle and anterior cerebral arteries and a change to the flow direction in the ipsilateral anterior cerebral artery of the CoW were found. These results demonstrated that the flow system with various CoW disease models tailored to individual characteristics could be used to predict stroke onset more quickly. For the ICA50 and VA100 models, the possibility of cerebral infarction was significantly lower. On the other hand, for the ICA100 model, there was a high possibility of decreased flow, which could lead to cerebral infarction.

The effect of backward walking observational training on gait parameters and balance in chronic stroke: randomized controlled study

BACKGROUND

Backward walking (BW) and action observation training may potentially help people at risk of falls. Moreover, action observation training could be a potential intervention to improve gait after a stroke.

AIM

We aimed to identify the effects of BW action observational training (BWOT) on gait parameters and balance in chronic stroke patients.

DESIGN

Randomized, controlled study.

SETTING

Rehabilitation center.

POPULATION

Twenty-four chronic stroke patients were randomly assigned to BWOT (N.=12) and landscape observational training (LOT) (N.=12) groups.

METHODS

The BWOT group performed BW after watching a video of a BW, while the LOT group performed BW training after watching a video of a landscape. Both groups received traditional therapy for 5 days per week and BWOT for 3 days a week for 4 weeks. The primary and secondary outcomes were gait and balance, respectively. Static balance was measured using the 5 Times Sit-To-Stand Test (5TSTS), the center of pressure (COP) displacement, and weight distribution (WD) of the affected side. Dynamic balance was measured using the activity-specific balance confidence (ABC) scale.

RESULTS

The BWOT group showed significant improvements in gait velocity (p=0.001, η²=0.470), step length (P=0.007, η²=0.313), stride lengths (P<0.002, η²=0.431), 5TSTS (P=0.021, η²=0.231), COP velocity (P=0.022, η²=0.226), length (P=0.001, η²=0.504), WD of the affected side (P=0.033, η²=0.193), and ABC score (P=0.023, η²=0.226) than the LOT group.

CONCLUSIONS

The 4-week BWOT training program significantly improved the gait parameters and static and dynamic balance in stroke patients.

CLINICAL REHABILITATION IMPACT

BWOT is an accessible and effective method of rehabilitation training that can also be applied to conventional therapy as a useful method for improving the gait and balance after stroke.

[The impact of a comprehensive support response biofeedback program on patient recovery and quality of life after stroke]

OBJECTIVE

To assess the impact of a comprehensive support response biofeedback program on patient recovery and quality of life after a stroke during a six-month follow-up.

MATERIAL AND METHODS

One hundred poststroke patients were followed-up during six months after a course of treatment using a comprehensive program based on biofeedback on the support reaction, including stabilometric training «standing on the platform»; training using a power joystick for a hand on a static stabilometric platform; therapeutic gymnastic exercises for the upper shoulder girdle.

RESULTS

Within six months after the course of treatment, there were no statistically significant changes in the motor function of the paretic hand according to the Fugle-Meyer and Ashworth scale. In neuropsychological testing after 3 months, the indicators on MoCA, Stroop, Symbols and Numbers, Schulte, Speech Fluency, and Kohs block design tests did not show negative dynamics. There was a decrease in indicators, which did not reach the values before treatment, after 3 months according to the Digit Span test, delayed recall according to the «memorizing 10 words» test by A.R. Luria After 6 month, there were no changes on MoCA, Symbols and Numbers, Schulte and Kohs block design tests. The decline after 6 months was observed on Speech Fluency, Stroop, Digit Span tests and Delayed Recall on the 10-Word Memory Test. At the same time, there was a positive dynamic of indicators of emotional status, activity of daily life and functional activity after 3 and 6 months of follow-up, the indicator of the quality of life of patients improved after 6 months.

CONCLUSION

Persistent therapeutic effect of the complex program carried out for 6 months was noted in relation to motor disorders in the paretic hand. There is an improvement in the emotional state, functional status, quality of life. When assessing cognitive functions, the therapeutic effect is stable for 3 months according to most scales. At the same time, the decrease in cognitive testing indicators on individual scales, in our opinion, determines the feasibility of repeated courses of treatment in three to six months in order to prevent the progression of disorders.

Effectiveness of the Mobility Rehab System for Mobility Training in Older Adults: A Pragmatic Clinical Trial

Introduction: Mobility impairments are among the main causes of falls in older adults and patients with neurological diseases, leading to functional dependence and substantial health care costs. Feedback-based interventions applied in controlled, laboratory environments have shown promising results for mobility rehabilitation, enhancing the benefits of standard therapy. However, the effectiveness of sensor-based feedback to improve gait in actual outpatient physical therapy settings is unknown. The proposed trial examines the effectiveness of a physical therapist-assisted, visual feedback system using wearable inertial sensors, Mobility Rehab, for mobility training in older adults with gait disturbances in an outpatient clinic. Methods: The study is a single site, pragmatic clinical trial in older adults with gait disturbances. Two hundred patients undergoing their outpatient rehabilitation program are assigned, by an independent assistant, for screening by one of four therapists, and assigned to either a standard physical therapy or therapist-assisted feedback therapy. Both groups train twice a week for 6 weeks. Four physical therapists were randomized and stratified by years of experience to deliver standard therapy or therapist-assisted feedback rehabilitation. Each session is 45 min long. Gait is trained for 30 min. The additional 15 min include exercises for endurance, strength, and static and dynamic balance in functional tasks. Mobility Rehab uses unobtrusive, inertial sensors on the feet and belt with real-time algorithms to provide real-time feedback on gait metrics (i.e., gait speed, double support time, foot clearance, angle at foot strike, and arm swing), which are displayed on a hand-held monitor. Blinded assessments are carried out before and after the intervention. The primary outcome measure is subjects' perception of balance as measured by the Activities-specific Balance Confidence scale. Gait speed, as measured with wearable inertial sensors during walking, is the secondary outcome measure. Discussion: We hypothesize that therapist-assisted feedback rehabilitation will be more effective than standard rehabilitation for gait. Feedback of motor performance plays a crucial role in rehabilitation and objective characterization of gait impairments by Mobility Rehab has the potential to improve the accuracy of patient-specific gait feedback. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT03869879.

Electromyographic Analyses of Trunk Musculature after Stroke: An Integrative Review

Background: Observational and intervention studies examining trunk electromyographic (EMG) activity following stroke are underpowered and fail criteria for systematic reviews of randomized control trials. Objective: To systematically evaluate and summarize evidence about trunk muscle activation after stroke during ADL and with diagnostic and therapeutic interventions.Methods: Search databases were Medline Complete, CINAHL and Health Sources: Nursing Academic Edition. Studies written in English after 1989 included these search terms: stroke, muscle activity, and trunk including abdominal or back muscles. Systematic reviews, single case studies, dissertations, or letters to the editor were excluded. Reviewers used Covidence to screen relevant research and extract information after title, abstract, and full-text screening. Information extracted related to stroke severity, time since onset, specific muscles and EMG analysis technique, and study limitations. Articles were classified as observational, intervention or device-related.Results: The electronic search yielded 188 articles and a hand search found 3. Title and abstract screening yielded 102 articles for full text screening. Ultimately, 45 articles were extracted. Trunk muscle recruitment during function and movement demonstrated significant differences in trunk EMG recruitment timing, magnitude, and symmetry after stroke when compared with healthy participants. Individuals with stroke demonstrated significant differences when comparing paretic to non-paretic side trunk EMG measures. Intervention studies showed some effect on improving trunk muscle activation but they had small sample sizes and methodological issues.Conclusions: Trunk muscle activation after stroke can be monitored with EMG during rehabilitation programs which challenge functional recovery.

Winter School on sEMG Signal Processing: An Initiative to Reduce Educational Gaps and to Promote the Engagement of Physiotherapists and Movement Scientists With Science

The application of surface electromyography (sEMG) in neurology is sometimes limited by a scientific background in the use of sEMG. Students frequently use sEMG only when developing their graduate studies. To reduce these barriers, we promoted a free Winter School on sEMG to Latin American students. The school was a 3-day event with theoretical classes and computer programming in Matlab. Lectures were delivered in Portuguese and Spanish to 50 participants. All lectures were recorded and made available on YouTube®. After the School, participants completed a written exam to receive a certificate. The written exam revealed the average effectiveness of 71 ± 20% in the comprehension of topics addressed during the school. Participants rated the School as “excellent” and considered the event as having changed their thoughts about the use of sEMG. Limited mathematical skills or background were the main barriers identified to follow the lectures and to make use of sEMG. We conclude that the Winter School had a positive impact on participant's formation, especially by showing them the importance of continuous involvement with the concepts related to sEMG to become proficient in its use. From the participant's point of view, the activity was excellent and the follow up of the school on YouTube® suggests that combining face-to-face activities followed by the online availability of lectures is a valid strategy to reinforce the learning process and to reduce barriers in the use of sEMG. Whether similar results would be achieved for a paid registration event in an economically developing region, still requires further investigation.

Surface Electromyographic Biofeedback and the Effortful Swallow Exercise for Stroke-Related Dysphagia and in Healthy Ageing

Dysphagia is common after stroke, leading to adverse outcome. The Effortful Swallow (ES) is recommended to improve swallowing but it is not known if dysphagic patients can increase muscle activity during the exercise or if age affects performance. Providing surface electromyographic (sEMG) biofeedback during dysphagia therapy may enhance exercise completion, but this has not been investigated and the technique’s acceptability to patients is not known. Aims: To determine if age or post-stroke dysphagia affect the ability to increase submental muscle activity during the ES, if sEMG biofeedback improves ES performance and if sEMG is an acceptable addition to therapy. In a Phase I study submental sEMG amplitudes were measured from 15 people with dysphagia < 3 months post-stroke and 85 healthy participants aged 18–89 years during swallowing (NS) and when they performed the ES with and without sEMG biofeedback. Participant feedback was collected via questionnaire. Measurements were compared with repeated measures ANOVA and age effects were examined with linear regression. Both groups produced significantly greater muscle activity for the ES than NS (p < 0.001) and significantly increased activity with biofeedback (p < 0.001) with no effect of age. Participant feedback about sEMG was very positive; over 98% would be happy to use it regularly. The ES is a physiologically beneficial dysphagia exercise, increasing muscle activity during swallowing. sEMG biofeedback further enhances performance and is considered an acceptable technique by patients. These findings support the potential application of sEMG biofeedback and the ES in dysphagia therapy in stroke, justifying further investigation of patient outcome.