Stepping to the Beat: Feasibility and Potential Efficacy of a Home-Based Auditory-Cued Step Training Program in Chronic Stroke

Effects of rhythmic auditory stimulation on motor function and balance ability in stroke: A systematic review and meta-analysis of clinical randomized controlled studies

OBJECTIVE

Rhythmic auditory stimulation (RAS) belongs to neurologic music therapy, which has attracted clinical attention because of its efficacy in motor function after stroke. This study aimed to summarize the effectiveness of rhythmic auditory stimulation (RAS) for the treatment of motor function and balance ability in stroke through a systematic review and meta-analysis.

METHODS

All studies were retrieved from six databases. The effects of RAS on stroke were determined using the following indicators: motor function including step length, step cadence, velocity, Fugl-Meyer assessment (FMA); and balance ability including overall balance index (OBI) and Berg Balance Scale (BBS). The risk map of bias of the quality of the studies and the meta-analysis results of the indicators was prepared using RevMan 5.2 software.

RESULTS

A total of 1,363 abstracts were retrieved. Among them, 325 duplicate studies were eliminated, and 971 studies were excluded after reading the titles and abstracts. In addition, by downloading the full text for further reading and screening, 47 studies were excluded. A total of 22 studies were included in the systematic review, and 18 studies were included in the meta-analysis. Assessment of quality, based on the PEDro scale, two studies had low quality, three studies had excellent quality, and the other studies had good quality; based on the Cochrane Collaborative Network Bias Risk Assessment Scale. A total of 15 studies specifically explained the random methods used. Meanwhile, seven studies did not report random sequence generation. A total of 10 studies reported that the evaluation of experimental results was blinded. In the meta-analysis, the results of motor function [namely, velocity (SMD = 0.99, 95% CI (0.43, 1.55)), step length (SMD = 0.97, 95% CI (0.74, 1.20)), and step cadence (MD = 5.16, 95% CI (4.17, 6.14)), FMA (MD = 2.93, 95% CI (2.04, 3.83))], were statistically significant (P < 0.01). The results of balance ability [OBI (MD = -0.51, 95% CI (-0.86, -0.16)) and BBS (MD = 2.93, 95% CI (1.67, 4.20))], were also statistically significant (P < 0.01). Among all the outcome indicators, three indicators were included in more than 10 studies: these are step length, step cadence, and velocity. The results showed that the two sides of the funnel chart were asymmetrical, thus these results all showed heterogeneity. The GRADEpro GDT online tool was used to evaluate the quality of evidence for the outcome indicators in the included studies. Five outcome indicators were included, of which three were low-quality indicators and two were moderate-quality indicators.

CONCLUSIONS

RAS could improve gait parameters, walking function, and balance ability of individuals with stroke. However, studies or samples of outcome indicators for balance ability of stroke patients is relatively insufficient, which also requires further research in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, identifier: CRD42021225102.

Auditory rhythmical cueing to improve gait in community-dwelling stroke survivors (ACTIVATE): a pilot randomised controlled trial

Background

Gait impairment limiting mobility and restricting activities is common after stroke. Auditory rhythmical cueing (ARC) uses a metronome beat delivered during exercise to train stepping and early work reports gait improvements. This study aimed to establish the feasibility of a full scale multicentre randomised controlled trial to evaluate an ARC gait and balance training programme for use by stroke survivors in the home and outdoors.

Methods

A parallel-group observer-blind pilot randomised controlled trial was conducted. Adults within 2 years of stroke with a gait-related mobility impairment were recruited from four NHS stroke services and randomised to an ARC gait and balance training programme (intervention) or the training programme without ARC (control). Both programmes consisted of 3x30 min sessions per week for 6 weeks undertaken at home/nearby outdoor community. One session per week was supervised and the remainder self-managed. Gait and balance performance assessments were undertaken at baseline, 6 and 10 weeks. Key trial outcomes included recruitment and retention rates, programme adherence, assessment data completeness and safety.

Results

Between November 2018 and February 2020, 59 participants were randomised (intervention n=30, control n=29), mean recruitment rate 4/month. At baseline, 6 weeks and 10 weeks, research assessments were conducted for 59/59 (100%), 47/59 (80%) and 42/59 (71%) participants, respectively. Missing assessments were largely due to discontinuation of data collection from mid-March 2020 because of the UK COVID-19 pandemic lockdown. The proportion of participants with complete data for each individual performance assessment ranged from 100% at baseline to 68% at 10 weeks. In the intervention group, 433/540 (80%) total programme exercise sessions were undertaken, in the control group, 390/522 (75%). Falls were reported by five participants in the intervention group, six in the control group. Three serious adverse events occurred, all unrelated to the study.

Conclusion

We believe that a definitive multicentre RCT to evaluate the ARC gait and balance training programme is feasible. Recruitment, programme adherence and safety were all acceptable. Although we consider that the retention rate and assessment data completeness were not sufficient for a future trial, this was largely due to the UK COVID-19 pandemic lockdown.

Trial registration

ISRCTN, ISRCTN10874601, Registered on 05/03/2018,

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01193-y.

The efficacy of a task model approach to ADL rehabilitation in stroke apraxia and action disorganisation syndrome: A randomised controlled trial

BACKGROUND

Apraxia and action disorganization syndrome (AADS) after stroke can disrupt activities of daily living (ADL). Occupational therapy has been effective in improving ADL performance, however, inclusion of multiple tasks means it is unclear which therapy elements contribute to improvement. We evaluated the efficacy of a task model approach to ADL rehabilitation, comparing training in making a cup of tea with a stepping training control condition.

METHODS

Of the 29 stroke survivors with AADS who participated in this cross-over randomized controlled feasibility trial, 25 were included in analysis [44% females; mean(SD) age = 71.1(7.8) years; years post-stroke = 4.6(3.3)]. Participants attended five 1-hour weekly tea making training sessions in which progress was monitored and feedback given using a computer-based system which implemented a Markov Decision Process (MDP) task model. In a control condition, participants received five 1-hour weekly stepping sessions.

RESULTS

Compared to stepping training, tea making training reduced errors across 4 different tea types. The time taken to make a cup of tea was reduced so the improvement in accuracy was not due to a speed-accuracy trade-off. No improvement linked to tea making training was evident in a complex tea preparation task (making two different cups of tea simultaneously), indicating a lack of generalisation in the training.

CONCLUSIONS

The clearly specified but flexible training protocol, together with information on the distribution of errors, provide pointers for further refinement of task model approaches to ADL rehabilitation. It is recommended that the approach be tested under errorless learning conditions with more impaired patients in future research.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrials.gov on 5th August 2019 [NCT04044911] https://clinicaltrials.gov/ct2/show/NCT04044911?term=Cogwatch&rank=1.

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.

Adapting Footfall Rhythmicity to Auditory Perturbations Affects Resilience of Locomotor Behavior: A Proof-of-Concept Study

For humans, the ability to effectively adapt footfall rhythm to perturbations is critical for stable locomotion. However, only limited information exists regarding how dynamic stability changes when individuals modify their footfall rhythm. In this study, we recorded 3D kinematic activity from 20 participants (13 males, 18–30 years old) during walking on a treadmill while synchronizing with an auditory metronome sequence individualized to their baseline walking characteristics. The sequence then included unexpected temporal perturbations in the beat intervals with the subjects required to adapt their footfall rhythm accordingly. Building on a novel approach to quantify resilience of locomotor behavior, this study found that, in response to auditory perturbation, the mean center of mass (COM) recovery time across all participants who showed deviation from steady state (N = 15) was 7.4 (8.9) s. Importantly, recovery of footfall synchronization with the metronome beats after perturbation was achieved prior (+3.4 [95.0% CI +0.1, +9.5] s) to the recovery of COM kinematics. These results highlight the scale of temporal adaptation to perturbations and provide implications for understanding regulation of rhythm and balance. Thus, our study extends the sensorimotor synchronization paradigm to include analysis of COM recovery time toward improving our understanding of an individual’s resilience to perturbations and potentially also their fall risk.

A general procedure to measure the pacing of body movements timed to music and metronome in younger and older adults

Finger-tapping tasks are classically used to investigate sensorimotor synchronization in relation to neutral auditory cues, such as metronomes. However, music is more commonly associated with an entrained bodily response, such as toe tapping, or dancing. Here we report an experimental procedure that was designed to bridge the gap between timing and intervention studies by directly comparing the effects of metronome and musical cue types on motor timing abilities across the three naturalistic voluntary actions of finger tapping, toe tapping, and stepping on the spot as a simplified case of whole body movement. Both pacing cues were presented at slow, medium, and fast tempi. The findings suggested that the task of stepping on the spot enabled better timing performances than tapping both in younger and older adults (75+). Timing performances followed an inverse U shape with best performances observed in the medium tempi that were set close to the spontaneous motor tempo in each movement type. Finally, music provided an entrainment effect in addition to pace setting that enabled better motor timing and greater stability than classically reported using a metronome. By applying time-stamp analyses to kinetic data, we demonstrate that tapping and stepping engage different timing modes. This work details the importance of translational research for a better understanding of motor timing. It offers a simple procedure that strengthens the validity of applying academic work and contributes in knowledge towards a wide range of therapeutic interventions.

A Music-Based Digital Therapeutic: Proof-of-Concept Automation of a Progressive and Individualized Rhythm-Based Walking Training Program After Stroke

BACKGROUND

The rhythm of music can entrain neurons in motor cortex by way of direct connections between auditory and motor brain regions.

OBJECTIVE

We sought to automate an individualized and progressive music-based, walking rehabilitation program using real-time sensor data in combination with decision algorithms.

METHODS

A music-based digital therapeutic was developed to maintain high sound quality while modulating, in real-time, the tempo (ie, beats per minute, or bpm) of music based on a user's ability to entrain to the tempo and progress to faster walking cadences in-sync with the progression of the tempo. Eleven individuals with chronic hemiparesis completed one automated 30-minute training visit. Seven returned for 2 additional visits. Safety, feasibility, and rehabilitative potential (ie, changes in walking speed relative to clinically meaningful change scores) were evaluated.

RESULTS

A single, fully automated training visit resulted in increased usual (∆ 0.085 ± 0.027 m/s, P = .011) and fast (∆ 0.093 ± 0.032 m/s, P = .016) walking speeds. The 7 participants who completed additional training visits increased their usual walking speed by 0.12 ± 0.03 m/s after only 3 days of training. Changes in walking speed were highly related to changes in walking cadence (R² > 0.70). No trips or falls were noted during training, all users reported that the device helped them walk faster, and 70% indicated that they would use it most or all of the time at home.

CONCLUSIONS

In this proof-of-concept study, we show that a sensor-automated, progressive, and individualized rhythmic locomotor training program can be implemented safely and effectively to train walking speed after stroke. Music-based digital therapeutics have the potential to facilitate salient, community-based rehabilitation.

Auditory rhythmical cueing to improve gait and physical activity in community-dwelling stroke survivors (ACTIVATE): study protocol for a pilot randomised controlled trial

Background

Mobility problems are present in 70–80% of stroke survivors and can result in impaired gait and reduced physical activity limiting independent living. Auditory rhythmic cueing (ARC) has been used to provide auditory feedback and shows promise in improving a variety of walking parameters following stroke. The aim of this pilot study is to assess the feasibility of conducting a multi-centre, observer blind, randomised controlled trial of auditory rhythmical cueing (ARC) intervention in home and community settings in North East England.

Methods

This pilot observer blind randomised controlled feasibility trial aims to recruit 60 participants over 15 months from community stroke services in the North East of England. Participants will be within 24 months of stroke onset causing new problems with mobility. Each participant will be randomised to the study intervention or control group. Intervention treatment participants will undertake 18 auditory rhythmical cueing (ARC) treatment sessions over 6 weeks (3 × 30 min per week, 6 supervised (physiotherapist/research associate)/12 self-managed) in a home/community setting. A metronome will be used to provide ARC during a series of balance and gait exercises, which will be gradually progressed. The control treatment participants will undertake the same duration balance and gait exercise training programme as the intervention group but without the ARC. Feasibility will be determined in terms of recruitment, retention, adverse events, adherence, collection of descriptive clinical and accelerometer motor performance data at baseline, 6 weeks and 10 weeks and description of participant, provider and clinical therapists’ experiences. As well as using questionnaires to collate participant views, qualitative interviews will be undertaken to further understand how the intervention is delivered in practice in a community setting and to identify aspects perceived important by participants.

Discussion

The ACTIVATE study will address an important gap in the evidence base by reporting whether it is feasible to deliver auditory rhythmical cueing in the home and community to improve gait and balance parameters following stroke. The feasibility of the study protocol will be established and results will inform the design of a future multi-centre randomised controlled trial.

Trial registration

Trial register: ISRCTN, Trial identifier: ISRCTN10874601: Date of registration: 12/03/2018.

A Novel Square-Stepping Exercise Program for Older Adults (StepIt): Rationale and Implications for Falls Prevention

The ability to effectively execute compensatory steps is critical for preventing accidental falls, and consequently stepping training is an essential ingredient of fall prevention programs. In this paper, we propose a concept for stepping training that aims to maximize training effects by taking into account recent research evidence and a precise dosing of training ingredients. The concept addresses motor as well as cognitive falls-related aspects, it is suitable for individual as well as group based training, and it does not require costly equipment. Theory and evidence behind all of the training principles is reviewed, and an example of an exercise protocol is described in detail. Participants are presented with stepping patterns which they have to memorize and implement on a mat. In order to enable investigation of dose-response effects, the difficulty level systematically and gradually increases session by session based on four principles: execution speed, pattern complexity, pattern length and execution in dual-/multi-tasking conditions. The presented concept can be used as a framework for the development of further prevention and/or rehabilitation stepping exercise programs. Further studies using this exercise regimen or modified versions of it are encouraged.

Gait Asymmetry Post-Stroke: Determining Valid and Reliable Methods Using a Single Accelerometer Located on the Trunk

Asymmetry is a cardinal symptom of gait post-stroke that is targeted during rehabilitation. Technological developments have allowed accelerometers to be a feasible tool to provide digital gait variables. Many acceleration-derived variables are proposed to measure gait asymmetry. Despite a need for accurate calculation, no consensus exists for what is the most valid and reliable variable. Using an instrumented walkway (GaitRite) as the reference standard, this study compared the validity and reliability of multiple acceleration-derived asymmetry variables. Twenty-five post-stroke participants performed repeated walks over GaitRite whilst wearing a tri-axial accelerometer (Axivity AX3) on their lower back, on two occasions, one week apart. Harmonic ratio, autocorrelation, gait symmetry index, phase plots, acceleration, and jerk root mean square were calculated from the acceleration signals. Test-retest reliability was calculated, and concurrent validity was estimated by comparison with GaitRite. The strongest concurrent validity was obtained from step regularity from the vertical signal, which also recorded excellent test-retest reliability (Spearman's rank correlation coefficients (rho) = 0.87 and Intraclass correlation coefficient (ICC21) = 0.98, respectively). Future research should test the responsiveness of this and other step asymmetry variables to quantify change during recovery and the effect of rehabilitative interventions for consideration as digital biomarkers to quantify gait asymmetry.

Effects of rhythmic auditory cueing on stepping in place in patients with Parkinson's disease

BACKGROUND

Stepping in place (SIP) is a useful locomotor training intervention. The purpose of this study was to investigate the effects of single auditory-cued SIP training on cortical excitability, rhythmic movements and walking ability in patients with Parkinson's disease(PD).

METHODS

Cross-over randomized control trial. Each participant completed two interventions with at least one-week washout period in between: (1) SIP with concurrent auditory cues (AC condition) and (2) SIP without auditory cues (NC condition).

RESULTS

In the primary outcome, the cortical silent period (CSP) duration increased (P = .005), whereas short intracortical inhibition (SICI) decreased after training (P = .001). Freezers demonstrated enhanced inhibition in the resting motor threshold and CSP duration. SICI and intracortical facilitation were modulated in both groups under the AC condition. In the secondary outcomes, the stepping variability decreased significantly (AC: P = .033; NC: P = .009), whereas walking cadence increased after training (AC: P = .019; NC: P = .0023).

CONCLUSIONS

Auditory-cued SIP training improved the lower-limb movement variability and modulated the cortical excitability in patients with PD. Freezers may benefit more from this training than nonfreezers.

A Review on the Relationship Between Sound and Movement in Sports and Rehabilitation

The role of auditory information on perceptual-motor processes has gained increased interest in sports and psychology research in recent years. Numerous neurobiological and behavioral studies have demonstrated the close interaction between auditory and motor areas of the brain, and the importance of auditory information for movement execution, control, and learning. In applied research, artificially produced acoustic information and real-time auditory information have been implemented in sports and rehabilitation to improve motor performance in athletes, healthy individuals, and patients affected by neurological or movement disorders. However, this research is scattered both across time and scientific disciplines. The aim of this paper is to provide an overview about the interaction between movement and sound and review the current literature regarding the effect of natural movement sounds, movement sonification, and rhythmic auditory information in sports and motor rehabilitation. The focus here is threefold: firstly, we provide an overview of empirical studies using natural movement sounds and movement sonification in sports. Secondly, we review recent clinical and applied studies using rhythmic auditory information and sonification in rehabilitation, addressing in particular studies on Parkinson's disease and stroke. Thirdly, we summarize current evidence regarding the cognitive mechanisms and neural correlates underlying the processing of auditory information during movement execution and its mental representation. The current state of knowledge here reviewed provides evidence of the feasibility and effectiveness of the application of auditory information to improve movement execution, control, and (re)learning in sports and motor rehabilitation. Findings also corroborate the critical role of auditory information in auditory-motor coupling during motor (re)learning and performance, suggesting that this area of clinical and applied research has a large potential that is yet to be fully explored.

Stepping to an Auditory Metronome Improves Weight-Bearing Symmetry in Poststroke Hemiparesis

Asymmetry in weight-bearing is a common feature in poststroke hemiparesis and is related to temporal asymmetry during walking. The aim of this study was to investigate the effect of an auditory cue for stepping in place on measures of temporal and weight-bearing asymmetry. A total of 10 community-dwelling adults (6 males and 4 females) with chronic poststroke hemiparesis performed 5 un-cued stepping trials and 5 stepping trials cued by an auditory metronome cue. A Vicon system was used to collect full body kinematic trajectories. Two force platforms were used to measure ground reaction forces. Step, swing, and stance times were used to calculate temporal symmetry ratios. Weight-bearing was assessed using the vertical component of the ground reaction force and center of mass-center of pressure separation at mid-stance. Weight-bearing asymmetry was significantly reduced during stepping with an auditory cue. Asymmetry values for step, swing, and stance times were also significantly reduced with auditory cueing. These findings show that auditory cueing when stepping in place produces immediate reductions in measures of temporal asymmetry and dynamic weight-bearing asymmetry.