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To assess the effects of pedaling exercise on the muscle activities in hemiparetic lower limbs in patients with stroke. In this before-and-after trial, 17 nonambulatory patients with chronic hemiparetic stroke were recruited. Using a servo-dynamically controlled ergometer with a trunk support, the patients pedaled at a resistance of 5 N-m at their comfortable speeds. Muscle activities were recorded with surface electrodes from bilateral quadriceps femoris, medial hamstrings, tibialis anterior, and medial gastrocnemius, and integrated electromyograms were used for analysis of muscle activity patterns during the pedaling cycle. Muscle activities during pedaling were compared with those during voluntary knee extension of the affected limb before, immediately after, and 30 min after the pedaling. We found phasic muscle activities in the affected limb during pedaling that were antiphasic to the contralateral side. The muscle activities of quadriceps femoris and tibialis anterior increased significantly during pedaling compared with those during voluntary knee extension effort, whereas the muscle activity of medial hamstrings did not change. The postpedaling facilitation of quadriceps and tibialis anterior and the inhibition of gastrocnemius during voluntary knee extension effort lasted at least for 30 min. Pedaling could facilitate phasic and coordinated muscle activities even in patients with severe hemiparesis, and it is potentially an effective mode of muscle reeducation.
Content may be subject to copyright.
Toshiyuki Fujiwara, MD, DMSc
Meigen Liu, MD, DMSc
Naoichi Chino, MD, DMSc
From the Department of
Rehabilitation Medicine, Keio
University School of Medicine, Tokyo,
All correspondence and requests for
reprints should be addressed to
Toshiyuki Fujiwara, MD, DMSc,
Department of Rehabilitation
Medicine, Keio University School of
Medicine, Shinanomachi 35,
Shinjyuku, Tokyo 160-8582, Japan.
American Journal of Physical
Medicine & Rehabilitation
Copyright © 2003 by Lippincott
Williams & Wilkins
DOI: 10.1097/01.PHM.0000064722.01940.E4
Effect of Pedaling Exercise on the
Hemiplegic Lower Limb
Fujiwara T, Liu M, Chino N: Effect of pedaling exercise on the hemi-
plegic lower limb. Am J Phys Med Rehabil 2003;82:357–363.
Objective: To assess the effects of pedaling exercise on the muscle
activities in hemiparetic lower limbs in patients with stroke.
Design: In this before-and-after trial, 17 nonambulatory patients with
chronic hemiparetic stroke were recruited. Using a servo-dynamically
controlled ergometer with a trunk support, the patients pedaled at a
resistance of 5 N-m at their comfortable speeds. Muscle activities were
recorded with surface electrodes from bilateral quadriceps femoris,
medial hamstrings, tibialis anterior, and medial gastrocnemius, and
integrated electromyograms were used for analysis of muscle activity
patterns during the pedaling cycle. Muscle activities during pedaling
were compared with those during voluntary knee extension of the af-
fected limb before, immediately after, and 30 min after the pedaling.
Results: We found phasic muscle activities in the affected limb dur-
ing pedaling that were antiphasic to the contralateral side. The muscle
activities of quadriceps femoris and tibialis anterior increased signifi-
cantly during pedaling compared with those during voluntary knee ex-
tension effort, whereas the muscle activity of medial hamstrings did not
change. The postpedaling facilitation of quadriceps and tibialis anterior
and the inhibition of gastrocnemius during voluntary knee extension
effort lasted at least for 30 min.
Conclusion: Pedaling could facilitate phasic and coordinated muscle
activities even in patients with severe hemiparesis, and it is potentially
an effective mode of muscle reeducation.
Key Words: Ergometer, Reciprocal Inhibition, Central Pattern Gen-
erator, Locomotion
May 2003 Pedaling Exercise and Hemiparesis 357
Research Article
In patients with hemiparetic stroke,
the ability to ambulate is often lim-
ited by muscle weakness, the inability
to achieve single-limb support during
the stance phase, or by strong syner-
gies and spasticity that inhibit selec-
tive phasic activation of muscles dur-
ing the gait cycle.
To restore motor
control in these paretic limbs, the
facilitation of weak muscles and se-
lective phasic muscle activation are
required to avoid exacerbation of syn-
ergies and spasticity. Conventional
methods of rehabilitation attempt to
retrain weak muscles through reedu-
cation and actual gait exercise, but
when the patient’s abilities for volun-
tary control of the affected limb and
for ambulation are limited, these
modes of training are often difficult
to apply.
The muscle activity pattern dur-
ing pedaling is known to be very sim-
ilar to other forms of locomotion,
including gait, and is assumed to be
generated by a similar central net-
Features of muscle coordina-
tion during pedaling include rela-
tively low coactivation of one-joint
and two-joint antagonists.
is a functional, safe, and accessible
mode of exercise for patients with a
wide range of ambulatory capability.
Recent studies suggest that pedaling
is a potentially effective training mo-
dality for reversing muscular weak-
ness and possibly improving motor
performance in patients with hemi-
However, there are pa-
tients with severe hemiparesis who
cannot pedal conventional cycle er-
gometers because of their weakness,
spasticity, or poor sitting balance. In
this study, we used a newly intro-
duced servo-dynamically controlled
cycle ergometer that can achieve a
highly precise load control even at
lower pedaling resistance and that is
equipped with a trunk-stabilizing
unit so that it can be applied even to
patients with severe hemiparesis and
poor sitting ability. The aim of the
study was to investigate the effects of
pedaling exercise on the muscle ac-
tivities of the affected lower limbs in
nonambulatory patients with hemi-
paretic stroke in whom conventional
methods of muscle reeducation are
difficult to apply.
Subjects. The subjects were 17 pa-
tients (12 men and five women) with
chronic (3 mo) poststroke hemipa-
resis. They were recruited from the
inpatients of a 120-bed, nonacute set-
ting, regional, general rehabilitation
center from September 2000 to May
2001. We selected patients (1) whose
onset of stroke was 3 mo before the
study; (2) who had sustained a single,
unilateral cerebrovascular accident;
(3) who were not able to walk, even
with assistive devices; (4) whose knee
extension test scores of the Stroke
Impairment Assessment Set
3, indicating that they could not
fully extend and flex their affected
knees in the sitting position; (5) who
had no history of osteoarthritis, se-
vere cardiopulmonary disease, or vas-
cular disease in the lower limbs; (6)
and without a fixed contracture in
the paretic lower limb. Their mean
age was 55.1 yr (SD 10.9), and an
average duration after the onset of
stroke was 158.8 days (SD 57.9).
Five suffered from cerebral infarction
and 12 from cerebral hemorrhage as
judged by either computed tomo-
graphic scanning or magnetic reso-
nance imaging, and nine patients had
left and eight patients had right
hemisphere lesion. The details of
their characteristics are shown in Ta-
ble 1. The protocol was approved by
the institutional review committee.
All participants were fully explained
the purposes and procedures of this
study, and informed consent was ob-
tained from the patients and their
family members. Daily rehabilitation
therapies consisting of a range of mo-
tion exercise, muscle reeducation,
basic activities training, and activities
of daily living training were given to
all patients five times a week by phys-
ical therapists, occupational thera-
pists, and nursing staffs. Speech and
cognitive therapies were provided
when indicated (nine patients).
Study Protocol. The patients were
seated comfortably on a servo-dy-
namically controlled ergometer
(StrrengthErgo, Mitsubishi Electric
Company, Tokyo, Japan) that can
achieve a highly precise load control
(coefficient of variation, 5%) over a
wide range of pedaling resistance (0
240 N-m), even at the lower end of
resistance. It also has a specially de-
signed, adjustable seat with a back-
rest and a seat belt for trunk stabili-
zation and can therefore be applied
even to patients with severe motor
impairment and poor sitting ability.
The seat height was 51 cm, and the
crank length was 17 cm. The distance
from the seat edge to the crank axis
and the height of the pedal axis were
adjusted so that the knee extension
angle was 10 degrees from full ex-
tension when the patients extended
their knees maximally. The subject’s
feet were firmly strapped to sandals
that were attached to pedals. The
trunk was also strapped to the back-
rest, whose tilt angle was set at 80
degrees, with a seat belt.
First, the patients were asked to
extend their affected knees five times
(knee extension test), and muscle ac-
tivities were recorded from the af-
fected lower limb as described below.
After a 5-min rest, they were asked to
pedal the ergometer at their comfort-
able speeds for 5 min (mean, 16.2
rpm; SD 5.9), and muscle activities
of the affected and unaffected lower
limbs were examined during pedal-
ing. The pedal resistance was set at 5
N-m with an isotonic mode that
maintains a constant pedal resistance
throughout the pedal cycle, regard-
less of the pedal speed. The knee ex-
tension test was repeated again im-
mediately after pedaling and then 30
min later, with recordings of muscle
358 Fujiwara et al. Am. J. Phys. Med. Rehabil. Vol. 82, No. 5
Assessment. For the analysis of mus-
cle activities, we dened the 0-degree
crank angle as the point at which
maximal hip exion was attained dur-
ing pedaling. Based on the crank an-
gle, one pedaling cycle was divided
into four phases, 90 degrees for each
(Fig. 1).
Phase 1 is when the knee is
extending and the crank is moving
away from the body, and phase 2 is
when the knee is extending and the
crank is moving toward the body.
Phase 3 is when the knee is exing
and the crank is moving toward the
body, and phase 4 is when the knee is
exing and the crank is moving away
from the body. Phases 1 and 2 are
considered as extension phases, and
phases 3 and 4 are regarded as exion
Muscle activities of bilateral
quadriceps femoris (Quad), medial
hamstrings (MH), tibialis anterior
(TA), and medial gastrocnemius (MG)
were recorded with Ag/AgCl surface
electrodes with diameters of 9 mm
(Nihon Koden, Tokyo, Japan). The
electrodes were applied with a center-
to-center spacing of 20 mm and
placed parallel to the muscle bers
and distal from the motor points of
individual muscles. Before attaching
the electrodes, the skin areas were
rubbed with alcohol, and the skin re-
sistance was kept below 5 k. A Neu-
ropack 8 electromyography (EMG)
machine (Nihon Kohden) was used to
record and analyze the EMG data.
The bandpass lter was set at 30 Hz
to 2 kHz. Pedal angles and EMG data
were transmitted after the end of the
measurement to a personal computer
and further processed by wave-analy-
sis software AcqKnowledge III
(BIOPAC systems, Santa Barbara,
CA). All EMG signals were rectied,
and then integrated EMG values
(IEMG) were calculated over each of
the four phases dened above. The
EMG data were quantied for each
muscle by expressing the IEMG of
each phase as a percentage of the
total IEMG over the entire cycle and
averaged over at least ten cycles
(%IEMG). The mean affected-side
IEMGs during phase 1 and those dur-
Clinical characteristics of patients
Patient Age Sex
Time from Onset
1 62 M L H 92 0 1 0 1 b
2 55 M L H 220 2 1 0 0
3 64 M L H 130 2 1 0 1 b
4 54 M R H 180 1 0 0 0
5 57 M L H 150 1 1 0 1 a
6 66 M R I 305 2 1 0 0
7 64 M R H 210 1 1 0 0
8 48 M R H 124 2 1 0 0
9 45 M L I 180 2 2 0 1 a
10 44 F R H 240 1 1 0 1 a
11 58 F L I 153 1 1 0 1 b
12 55 F L I 180 0 0 0 1 b
13 63 M L H 150 1 1 0 0
14 66 M R H 93 2 1 0 1 b
15 56 F R I 120 2 1 0 1 b
16 22 M R H 95 1 1 0 1 a
17 59 F L H 120 1 1 0 1 b
Lesion L; left, R; right hemisphere, SIAS; Stroke Impairment Assessment Set, Hip Flx; hip exion test, Knee Ext; knee
extension test, 0 no voluntary movement is noted; 1 minimal movement is noted, but the foot is not lifted off the oor;
2the foot is barely lifted off the oor; Foot Pat; foot pat test 0; no contraction of tibialis anterior. Tone L/E; muscle tone of
lower extremity; 0 remarkably increased; 1 a moderately increased; 1 b diminished.
Figure 1: The denition of pedaling
phases. The 0-degree crank angle
was dened as the point at which
maximal hip exion was attained dur-
ing pedaling. Based on the crank an-
gle, one pedaling cycle was divided
into four phases, 90 degrees for
each. Phase 1 is when the knee is
extending and the crank is moving
away from the body, and phase 2 is
when the knee is extending and the
crank is moving toward the body.
Phase 3 is when the knee is exing
and the crank is moving toward the
body, and phase 4 is when the knee
is exing and the crank is moving
away from the body.
May 2003 Pedaling Exercise and Hemiparesis 359
ing the knee extension test before,
immediately after, and 30 min after
pedaling were compared.
Statistical Analysis. A repeated mea-
sure analysis of variance
was used
to compare the inter-side and inter-
phase differences of muscle activities
during pedaling. A one-factor analy-
sis of variance model and post hoc
test with Fishers protected least sig-
nicant difference
were used to
identify the difference of voluntary
knee extension muscle activities be-
fore pedaling, immediately after, and
30 min after the pedaling. A Pvalue
of 5% was considered to indicate
statistical signicance; all tests were
two-tailed. All statistical analyses
were performed on a personal com-
puter with a statistical package Stat-
cel for Macintosh (OMS Company,
Tokyo, Japan).
Muscle Activities During Pedaling.
All participants completed the 5 min
of pedaling without any manual as-
sistance. Even among patients with
severe hemiparesis who could not
voluntarily extend their affected
knees, muscle activities antiphasic to
the contralateral limbs were observed
during pedaling (Fig. 2). Relative
IEMGs of each of the four phases are
shown for each muscle in Table 2.
The repeated analysis of variance
showed no signicant inter-side dif-
ference (unaffected vs. affected) but
signicant interphase difference in
all muscles (Table 3).
Comparison of Muscle Activities Dur-
ing Voluntary Knee Extension and
Pedaling. The mean IEMGs during
phase 1 of pedaling cycle of affected
Quad, MH, TA, and MG were 79.7
52.2, 57.8 31.2, 85.0 59.6, and
31.9 23.7
V/sec. The Quad to MH
and TA to MG IEMG ratios were 1.43
0.72 and 3.61 2.88. When the
muscle activities of the affected limb
during voluntary knee extension and
during the knee extension phase
(phase 1) of the pedaling cycle were
compared with paired ttest,
and TA activities were signicantly
greater during pedaling (P0.05),
whereas the MH activity was not sig-
nicantly different between the two
conditions. The Quad to MH and TA
to MG IEMG ratios increased signi-
cantly during pedaling (P0.05).
Short-Term Effects of Pedaling.
When the muscle activities of the
affected leg during voluntary knee
extension were compared before,
immediately after, and 30 min after
the pedaling, Quad and TA muscle
activities were signicantly in-
creased after the pedaling, and
these increments lasted for at least
30 min (analysis of variance, P
0.05) (Table 4). The MH and MG
muscle activities were reduced after
the pedaling, and these decrements
also continued for 30 min after ex-
ercise, although statistically signif-
icant only for the MG (analysis of
variance, P0.05).
In this study, we used a servo-
dynamically controlled ergometer
that could keep the predetermined
pedal load (5 N-m) during the whole
pedaling cycle and was equipped with
a trunk-stabilizing unit. It was easy
for the patients to pedal with their
unaffected lower limbs at a load of 5
N-m. Furthermore, the trunk-stabili-
zation unit helped patients with poor
sitting ability to pedal without dif-
culty. Therefore, all participants
could complete the pedaling proto-
col, despite their severe hemiparesis.
During pedaling, we observed
phasic and coordinated muscle activ-
ities not only in the unaffected but
also in the affected lower limbs
among patients with severe hemipa-
resis. Muscle activities on the unaf-
fected side showed similar EMG pro-
les as previously reported in healthy
Compared with the unaf-
fected side, the pattern of affected-
side muscle activities showed no sig-
nicant difference during each
Figure 2: A typical muscle activity pattern during pedaling. The integrated
electromyographic data of bilateral leg muscles of patient 11, whose Stroke
Impairment Assessment Set knee extension score was 1 (minimal movement is
noted, but the foot is not lifted off the oor), is illustrated. The reciprocating
pattern of agonists and antagonists is observed not only on the unaffected side
but also on the affected side, which was antiphasic to the contralateral limb.
Quad, quadriceps femoris; MH, medial hamstrings; TA, tibialis anterior; MG,
medial gastrocnemius.
360 Fujiwara et al. Am. J. Phys. Med. Rehabil. Vol. 82, No. 5
pedaling phase, although the value of
IEMGs of affected-side muscles
were smaller than the unaffected
side. After pedaling, facilitation of
agonists and inhibition of antago-
nists were found during voluntary
knee extension, and they lasted at
least for 30 min thereafter. These
results suggested that the pedaling
exercise might be a useful method
of muscle reeducation for paretic
In patients with hemiparesis,
the impairment of reciprocal inhi-
bition and the weakness of the af-
fected limb can exacerbate the mo-
tor irradiation to the synergistic
muscle groups and the co-contrac-
tion of the antagonists. The patho-
logic synergies, described by
as the extensor and
the exor synergies, are two of the
major problems in stroke rehabili-
tation. Because pedaling facilitates
selective muscle activation with less
co-contraction of antagonists, it
can potentially be an effective mode
of muscle reeducation.
Treadmill walking with partial
body weight support is also re-
ported to be an effective method of
muscle reeducation for the restora-
tion of gait.
The partial body
support inhibits the overactivities
of antigravity muscles. However, it
is reported that the facilitation of
knee extensors is not so strong in
partial body weight support, and
their muscle activities during body
weightsupported walking are less
than during ground-level walk-
One of the main functions of
the knee extensors is the support of
the body weight. For patients with
severe hemiparesis, the paresis of
the knee extensors, especially of the
Quad, has a critical role for the abil-
ity to stand, stand up, and transfer.
The major difference in muscle ac-
tivities during pedaling and walking
was the four to ve times greater
activity in the vastus medialis and
vastus lateralis muscles obtained
during pedaling.
In our study, we
demonstrated that pedaling could
facilitate the quadriceps muscle
without exacerbating the antago-
nistscoactivation and the extensor
synergy. Because pedaling can be
performed in the sitting position,
patients who are still nonambula-
tory can feel more secure, and the
burden on therapists is less than
during assistive gait training.
Collins et al.
showed that
contralateral passive pedaling re-
duces the amplitude of the H reex
in the soleus. It is suggested that
contralateral sensory activity con-
tributes to the movement-elicited
afferent discharge that tunes the
spinal somatosensory-motor mech-
anism for human locomotion. Fuji-
wara et al.
demonstrated that ex-
ercising the unaffected lower limb
could facilitate a selective muscular
contraction on the affected limb
and may be a benecial technique
for reeducation of selective muscle
activation in patients with severe
hemiparesis. These reciprocal ef-
fects from the contralateral limb
might contribute to facilitate the
selective and phasic muscle activi-
ties during pedaling. It is proposed
that phase-dependent and inter-
limb modulation at the central pat-
tern generator play an important
role for this mechanism.
The positron emission tomogra-
phy study during cycling movement
showed that active cycling signi-
cantly activated areas bilaterally in
Muscle activities (%IEMG) during each pedaling phase
Muscle Phase 1 Phase 2 Phase 3 Phase 4
Unaffected Quad 49.0 17.3 16.7 10.9 12.9 6.8 25.1 16.3
Affected Quad 43.3 9.8 26.6 8.0 18.6 9.0 14.2 6.4
Unaffected MH 16.0 12.3 17.6 12.3 39.8 13.4 27.5 11.6
Affected MH 32.5 8.2 25.8 7.1 25.7 11.6 20.1 7.3
Unaffected TA 28.6 17.1 19.8 12.2 22.8 7.1 32.4 18.9
Affected TA 37.7 13.1 21.9 8.6 20.4 9.4 21.2 7.6
Unaffected MG 10.5 8.5 31.4 18.7 37.5 23.2 12.2 18.4
Affected MG 29.6 14.1 28.6 12.9 25.4 19.9 18.1 9.5
Mean SD (%).
Repeated analysis of variance results: Muscle activities
(%IEMG) during each pedaling phase
Interside difference P0.84 P0.37 P0.60 P0.10
Interphase difference P0.001 P0.04 P0.001 P0.03
May 2003 Pedaling Exercise and Hemiparesis 361
the primary sensory cortex, primary
motor cortex, and supplementary
motor cortex and in the anterior part
of the cerebellum.
The primary mo-
tor cortex activation was positively
correlated with the rate of the active
cycling movements. It is suggested
that higher motor centers, including
the primary and supplementary mo-
tor cortices and the cerebellum, take
an active part in the generation and
control of rhythmic motor tasks such
as cycling. These spinal and supraspi-
nal motor control mechanisms might
be activated by pedaling and help to
restore well coordinated selective
muscle activities in the affected lower
In addition, the affected limb was
moved not only by itself but also pas-
sively with the assistance of the un-
affected limb pedaling. Pedaling by
the unaffected limb has some stretch-
ing effect on the affected limb, and
our results might possibly be inter-
preted on the basis of this passive
stretching effect.
In this preliminary study, we did
not assess the long-term effects of
pedaling on muscular coordination
and on functional activities such as
standing and locomotion. To clarify
the clinical usefulness of pedaling,
further research should be done, in-
cluding randomized, control trials, to
compare pedaling exercise with con-
ventional training modalities for the
affected limb. Furthermore, electro-
physiologic studies such as H reexes
and exor reexes are needed to elu-
cidate the mechanisms of the pedal-
ing effect.
Pedaling could facilitate phasic
and coordinated muscle activities
even in patients with severe hemipa-
resis, and it is potentially an effective
mode of muscle reeducation.
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Knee Extension
Before Pedaling
Knee Extension Immediately
After Pedaling
Knee Extension 30 Min
After Pedaling ANOVA P
Affected Quad 40.4 27.1 77.6 40.6
86.8 43.5
Affected MH 81.1 114.9 50.5 27.4 51.4 28.2 0.38
Quad/MH 0.84 0.47 1.70 0.78
1.81 0.64
Affected TA 42.8 33.1 96.0 51.2
97.0 68.9
Affected MG 47.1 37.8 22.6 16.3
27.1 18.6
TA/MG 1.11 0.55 5.02 2.86
3.95 2.24
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Book Review
Traumatic Brain Injury Rehabilitation: Children and Adolescents, Second Edition, by Mark Ylvisaker, PhD,
Published by Butterworth-Heinemann, Boston, MA, 1998, 479 pages, $64.99. ISBN 0-7506-9972-8.
This is a revised edition of Head Injury Rehabilitation: Children and Adolescents, which has been an essential
reference for both clinicians and family members. The publication of the second edition was prompted by the
interim advances in the understanding of pediatric cognitive development, the evolution of theories in special
education that focus on contextual learning, and years of practical experience in the rehabilitation of children
and adolescents by the author and 29 contributors. The strengths and weaknesses of the book are the result of
an effort to appeal to a wide audience, including medical rehabilitation professionals, educators, and family
members. Thus, the book offers chapters on subjects ranging from medical management, nursing perspectives,
and assistive technology to cognitive assessment, cognitive rehabilitation of executive functions, educational
interventions, and career development, with extensive bibliographies at the end of each chapter.
Although the chapters on medical management and pharmacologic intervention are somewhat supercial, those
dealing with swallowing and feeding, school re-entry, and cognitive rehabilitation are detailed and useful both
in theoretical frameworks and practical suggestions. Each chapter is written as a stand-alone reference,
although this results in some repetition of information. The most important contributions of this book are the
solid commitment to collaboration of rehabilitation professionals with the client, the family, and the other
institutions providing services and the nuanced approach to cognitive rehabilitation, focusing on executive
function throughout the developmental spectrum and the goal of shifting the childs strategies from external to
internal loci of control. Practical suggestions, checklists, and examples translate theory into useful knowledge.
This book will be valuable for all members of the rehabilitation team, including physicians, nurses, therapists,
and psychologists, as well as educators and family members.
Book Rating: 多多多多
Janice Cockrell, MD
Portland, Oregon
May 2003 Pedaling Exercise and Hemiparesis 363
... Normal gait exercises are difficult to apply when the patients cannot voluntary control the affected limb [32]. Pedaling is an effective training method for reversing muscular weakness, in which the muscle activity pattern is similar to other forms of locomotion, including gait, and multiple muscle groups can be trained efficiently. ...
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Passive path tracking training is usually used for robot assisted lower limb rehabilitation. The movement of robot will cause the fluctuation of joint force. This paper presents an optimal training path planning algorithm to reduce the patient's joint force caused by a moveable multifunction rehabilitation robot during passive pedaling training. The dynamics model of the human-robot system is established, and the joint forces of the patient are analysed. The planning process is divided into a series of motion steps based on the original training path, at which the optimal algorithm is applied to search the best path. Then, the optimal path is fitted by Bezier curve to get a closed training trajectory. Finally, a Bionic Experiment Platform (BEP) and Human-robot Interaction Platform (HIP) are established to verify the effectiveness of the optimal algorithm. The (BEP) experimental results show that the knee joint force drops by an average of 12.71%, and the maximum drops by 15.41%.The HIP experiment results show that the interaction force drops by an average of 8.5%.
... Individuals with post-stroke hemiparesis, who exhibit asymmetrical muscle activation, reduced motor control, combined with metabolic and structural changes within the skeletal muscle, also tend to have a decline in balance and ambulation capacity [2]. Pedalling-based therapy, which generates cyclic and symmetric power output without the requirement of balance maintenance, has been shown to improve patient aerobic capacity [3,4], ambulatory balance, and motor performance in stroke patients [5,6]. It can be performed in the home while seated and without lower limb weight bearing, and is considered a safe alternative to walking in subjects with postural instability and fall risk [3,7]. ...
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Video and music as a dissociative attention stimulus during exercise is known to distract from the discomfort of physical exertion and improve exercise adherence; however, the influence of video-based feedback and engagement during pedalling on the performance and motivation of pedalling in stroke patients is poorly understood. The aim of this study was to employ a novel video-based engagement paradigm for pedalling in stroke patients and evaluate its capacity to influence the cadence control, physiological output, and perceived motivation and enjoyment. Thirteen stroke patients were recruited with low-to-moderate lower-limb disability (mean age: 64.0 yrs.). A reference group of 18 healthy young adult subjects (mean age: 27.7 yrs.) was also recruited to assess the broad applicability of the techniques to a contrasting non-pathological cohort. The participants pedalled at a slow (60 RPM) and fast (100 RPM) target speed with constant resistance in 15 min pedalling bouts that included (i) baseline pedalling with real-time visual feedback of cadence deviation from the target provided only in the first 20 s (ii) real-time visual feedback of cadence data over the entire pedalling session, and (iii) real-time engagement to maintain the playback rate of a prerecorded video by pedalling at the target speed. During low speed pedalling, stroke patients demonstrated significantly smaller absolute cadence deviation during pedalling with feedback (mean difference: 1.8 RPM, p = 0.014) and video-based engagement (mean difference: 2.4 RPM, p = 0.006) compared to the baseline pedalling. For the healthy adults, feedback and video-based engagement reduced cadence deviation significantly at all speeds (p < 0.05). All but one stroke patient either enjoyed or really enjoyed the video engagement during pedalling and felt motivated to undertake this form of exercise in therapy in the future. This proof-of-concept study showed that feedback and video-based engagement may improve the targeted pedalling performance in stroke patients, and by helping dissociate subjects from physical cues associated with fatigue, may ultimately improve exercise motivation and compliance.
... LMS was evaluated using a Strength Ergo 240 (SE240; Mitsubishi, Tokyo, Japan), in terms of the moment of maximum strength or peak torque (PT) of the extensor muscles of the lower limbs. The SE240 is a safe and simple tool for measuring the LMS, even in patients with severe motor impairment, because its seat has a backrest and fixed trunk with a seat belt (22,23). The muscle strength of the bilateral lower limbs was measured in the sitting position with the hips flexed at 110°. ...
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Objective Leg muscle strength (LMS) is decreased in early-stage Parkinson disease (PD) patients and is associated with slower walking and falls. However, LMS in advanced PD has not been well investigated. The purpose of this study was to evaluate LMS in advanced PD patients and its effects on gait performance, activities of daily living (ADL), and the cognitive function. Methods The medical records of 132 patients with idiopathic advanced PD (Hoehn and Yahr [H&Y] stages 3 and 4) with a mean disease duration of 9.6 years were retrospectively reviewed. Leg extensor muscle strength of the patients was measured using a Strength Ergo 240. The associations between the LMS and gait performance, Barthel index, H&Y stage, and Mini-Mental State Examination (MMSE) score were analyzed. Results A Spearman's correlation analysis showed that LMS was correlated with the sex, age, age of disease onset, H&Y stage, Barthel index, MMSE score, and gait parameters. A multivariable linear regression analysis for identifying predictors of LMS showed that the gait velocity (β=0.377), Barthel index (β=0.281), sex (β=-0.187), and disease duration (β=-0.155) were significant. A receiver operating characteristic curve analysis for discriminating between H&Y stage 3 and 4 was performed for LMS; the area under the curve was 0.774 (95% confidence interval=0.696-0.851). Conclusions LMS was strongly associated with multiple domains of clinical characteristics, especially gait velocity and the Barthel index. Our study also suggested that LMS can be a predictor of PD progression.
... The warm-up phase was a 5 min passive constant speed cycling, at 25 rpm. Active pedaling was performed for 15 min, followed by a 5 min cool-down phase of passive cycling, with a constant speed of 25 rpm too [31,32]. -15 min of graduated LE isotonic exercises for hip, knee, and ankle joints in various positions. ...
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Recovery of lower extremity (LE) function in chronic stroke patients is considered a barrier to community reintegration. An adequate training program is required to improve neural and functional performance of the affected LE in chronic stroke patients. The current study aimed to evaluate the effect of somatosensory rehabilitation on neural and functional recovery of LE in stroke patients. Thirty male and female patients were recruited and randomized to equal groups: control group (GI) and intervention group (GII). All patients were matched for age, duration of stroke, and degree of motor impairment of the affected LE. Both groups received standard program of physical therapy in addition to somatosensory rehabilitation for GII. The duration of treatment for both groups was eight consecutive weeks. Outcome measures used were Functional Independent Measure (FIM) and Quantitative Electroencephalography (QEEG), obtained pre- and post-treatment. A significant improvement was found in the FIM scores of the intervention group (GII), as compared to the control group (GI) (p < 0.001). Additionally, QEEG scores improved within the intervention group post-treatment. QEEG scores did not improve within the control group post-treatment, except for “Cz-AR”, compared to pretreatment, with no significant difference between groups. Adding somatosensory training to standard physical therapy program results in better improvement of neuromuscular control of LE function in chronic stroke patients.
... Cependant, il semble que le pédalage puisse améliorer l'activité et la coordination des muscles phasiques des patients hémiparétiques, et pourrait ainsi améliorer la marche (42) . Toutefois, il est possible que les patients en phase chronique augmentent la vitesse et la résistance (50) de pédalage en utilisant toujours les mêmes schémas moteurs altérés, ce qui ne permettrait pas d'améliorer la coordination locomotrice (51) . La différence de ces résultats reste difficile à expliquer en raison du petit nombre d'études sur le sujet et des modalités variables de réentraînement. ...
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ABSTRACT Introduction : Following a stroke, the maximal strength capacity, walking ability, and lower limb strength are considerably diminished. Only a few studies have investigated the outcome of aerobic training on muscular strength and its long-term impact. The aim of this study is to evaluate the short- and long-term effects of aerobic interval training on muscular strength after a stroke. Method : Ten subjects in the post-stroke chronic phase participated in three training sessions per week on an ergocycle over a period of 8 weeks. The main criterion of assessment was based on the isokinetic and isometric strength of knee flexors and extensors. Secondary criteria included cardiovascular parameters, walking pace parameters, and maximal power output. Results : For both knees and both muscular groups, the isokinetic strength was observed to have significantly increased (between 21.21 % and 63.87 % amelioration ; p< 0.05) 6 months after the end of the training period. The walking pace parameters had also improved. Discussion and conclusion : The present study highlights not only the positive impact of interval training on muscular isokinetic strength and walking parameters during the poststroke chronic phase but also the fact that the improvements persist for 6 months after the end of training.
... However, few studies have been conducted thus far on ergometric pedaling exercise in elderly persons from the viewpoint of an isokinetic exercise. Ergometric pedaling exercise is a functional, safe, and accessible mode of exercise for patients with a wide range of ambulatory capability (Fujiwara et al., 2003). ...
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This study examined the characteristics of lower limb muscle activity in elderly persons after ergometric pedaling exercise for 1 month. To determine the effect of the exercise, surface electromyography (SEMG) of lower limb muscles was subjected to Daubechies-4 wavelet transformation, and mean wavelet coefficients were compared with the pre-exercise coefficients and the post-exercise coefficients in each wavelet level. The characteristics of muscle activity after pedaling exercise were also compared between the elderly subjects and young subjects. For the elderly subjects, the mean wavelet coefficients were significantly decreased in the tibialis anterior and the gastrocnemius medialis at wavelet levels of 3, 4, and 5 (125–62.5, 62.5–31.25, and 31.25–15.625 Hz, respectively), by pedaling exercise. However, the mean power of wavelet levels of 2 and 3 (250–125 and 125–62.5 Hz) within the rectus femoris and the biceps femoris were significantly increased in the young subjects. The effect of pedaling exercise is different from the effects of heavy-resistance training. It was suggested that the muscle coordination, motor unit (MU) firing frequency, and firing fiber type of lower limb muscles are changed with the different characteristics between elderly and young persons by pedaling exercise for 1 month.
Introduction: The effect of early initiation of gait training using hybrid assistive limb (HAL) remains unclear. This observational study aimed to investigate whether early initiation of gait training using HAL improves functional outcomes in patients with stroke. Methods: We retrospectively analyzed patients with acute stroke admitted to our facility. HAL was used for exoskeletal robotic gait training. Study participants were median split into an early group and a late group based on the days from stroke onset to initiation of gait training using HAL. The functional outcomes, defined by the Brunnstrom recovery stage (BRS), modified Rankin Scale (mRS), and Functional Independence Measure (FIM) at discharge, were compared using propensity score-matched analysis. Results: We performed a propensity score-matched analysis in 63 patients with stroke (31 from the early group and 32 from the late group), and 17 pairs were matched. There were no significant differences in discharge in the BRS of the upper limb and finger in the post-matched cohort. On the other hand, the BRS of the lower limb in the early group was significantly higher than that in the late group. In addition, the mRS, but not FIM scores, was significantly better in the early group than that in the late group. Conclusions: In conclusion, early initiation of gait training using HAL might improve the motor function of the paralyzed lower limb and disability in patients with stroke.
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Background and Aims Stroke is a major cause of neurologic disability worldwide. Most cases of stroke have a sedentary lifestyle and diminished aerobic capacity. The present study aimed to systematically investigate the effect of aerobic exercise training on motor function improvement of patients following stroke. Methods This research is a systematic review. Keyword studies of aerobics, exercise, mobility, rehabilitation, stroke, walking, and treadmill were conducted in the Embase, Science Direct, PubMed, Medline, and Google Scholar databases from 2000 to 2019. Studies in two categories of aerobic exercise and motor ability, including adults with a history of stroke more than six months with the ability to move independently, have exercise intervention and assessment of motor abilities. Of 87 articles in the initial search, 31 were included in this study. Results Among 31 studies reviewed, 10 studies focused on the effect of continuous passive exercise and 12 studies on the effect of aerobic exercise on the motor abilities of stroke patients. Meanwhile, although six studies showed a positive impact of using the treadmill on functional capacity, five studies did not show an improvement in the balance of these patients under the treadmill. Conclusion A review of the research findings showed that the specific type, intensity, and duration of various types of motor interventions could improve parts of the physical fitness of stroke patients during the rehabilitation programs; therefore, the risk of re-stroke and cardiovascular disorders is reduced.
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Very recent studies show that a cognitive-motor interference can expose people not only to a motor danger but also weaken their cognitive capabilities. This effect is called the dual-task cost. One of the most popular examples of it nowadays is the smartphone use while walking, which is well examined. Yet, there are no studies that would analyse to what extent the other high-popular dual-task situation – shopping at the supermarket, weakens cognitive processes. To shed some light on this issue, we investigated a behavioral experiment on everyday mental calculations. Methods: Twenty mathematical-ly-educated adults took part in this study. We used stimuli in the form of shop labels. The participant’s task was to add two prices or state the price after a discount. They carried out the tasks by turns, either by standing (single-task) or walking with a shopping basket (dual-task). EEG controlled level of their attention. Results: We found that a cognitive-motor interference do not affected the everyday mental calculations. But, such familiar mental arithmetic as calculating prices after discounts was frighteningly difficultfor the participants. Conclusions: While our findingdoes not confirmthe occurrence of dual-task costs in everyday mental calculations, it has profound consequences for a mathematical education, which effects turn out to be useless in real life.
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The purpose of this descriptive study was to examine bicycle pedaling as a model for studying motor control dysfunction in persons with hemiplegia. Results of a kinematic analysis of the involved lower extremity of 10 hemiplegic patients were compared with the lower-extremity kinematic data of 10 "normal" (nonhemiplegic) subjects. Subjects pedaled at a constant work load at two pedaling rates. Hip, knee, and ankle angular-displacement variables were studied. Statistical comparisons for variables at the hip and knee were not significantly different between groups or between pedaling speeds. Ankle dorsiflexion and total ankle excursion were significantly different across pedaling speeds, but not between groups. Phase-plane analyses of angular-displacement and angular-velocity variables revealed that the most striking difference between the hemiplegic and the normal subjects was the control of ankle displacement and velocity of the lower extremity during pedaling.
With hemiplegia following stroke, a person's movement response to anti-gravity posture often appears rigid and inflexible, exacerbating the motor dysfunction. A major determinant of pathological movement in anti-gravity postures is the failure to adapt muscle-activity patterns automatically to changes in posture. The aim of the present study was to determine whether the impaired motor performance observed when persons with hemiplegia pedal in a horizontal position is exacerbated at more vertical anti-gravity body orientations. Twelve healthy elderly subjects and 17 subjects with chronic (> 6 months) post-stroke hemiplegia participated in the study. Subjects pedalled a modified ergometer at different body orientations (from horizontal to vertical), maintaining the same workload, cadence, and hip and knee kinematics. Pedal reaction forces, and crank and pedal kinematics, were measured and then used to calculate the work done by each leg and their net positive and negative components. The EMG was recorded from four leg muscles (tibialis anterior, medial gastrocnemius, rectus femoris and biceps femoris). The main result from this study was that impaired plegic leg performance, as measured by net negative work done by the plegic leg and abnormal early rectus femoris activity, was exacerbated at the most vertical body orientations. However, contrary to the belief that muscle activity cannot adapt to anti-gravity postures, net positive work increased appropriately and EMG activity in all muscles showed modulated levels of activity similar to those in elderly control subjects. These results support the hypothesis that increased verticality exacerbates the already impaired movement performance. Yet, much of the motor response to verticality was flexible and appropriate, given the mechanics of the task.
This article will review those electrophysiological investigations which have addressed the neuronal mechanisms underlying impaired gait. The aims of the review are to provide further insights to the underlying pathophysiology of impaired gait and also towards the selection of an appropriate treatment. From the patients' point of view the first indication of a central motor system lesion is an impairment of movement, most notably locomotion. These symptoms are characteristic in cases of spasticity, cerebellar lesion or Parkinson's disease. Clinical examination reveals typical changes in tendon tap reflexes and muscle tone which were believed to account for the movement disorder presented. However, we now know that there is only a weak relationship between the physical symptoms observed during clinical examination under passive motor conditions and the altered neuronal mechanisms underlying the impairment during active motion. By recording and analysing electrophysiological and biomechanical parameters during functional movements such as locomotion, the significance of impaired reflex behaviour or the pathophysiology of muscle tone and its contribution to the movement disorder can be reliably assessed. Consequently, the treatment should not be cosmetic, i.e. the correction of an isolated clinical parameter, but should be based on the pathophysiology and significance of those mechanisms underlying the impairment of the patients' movements. Data from electrophysiological and biomechanical investigations of locomotion of patients with spasticity, cerebellar disorder or Parkinson's disease are discussed in this review. The neuronal mechanisms, which are essentially central programs and afferent input, involved in disorders of gait are evaluated on the basis of their function in healthy subjects. The impact of this analysis in deciding an appropriate treatment are discussed with respect to the pathophysiology underlying the gait disorder (spasticity, cerebellar disorder or Parkinson's disease). At the present time we have only a basic understanding of the essential receptor systems, such as leg extensor load receptors, and their interaction with other systems involved in postural control. In the future, the knowledge gained from gait analysis may help in the selection of the appropriate pharmacological and physical treatment required even though the patient may only be at an early stage of motor impairment.
A principle of poststroke rehabilitation is that effort should be avoided since it leads to increased spasticity and produces widespread associated abnormal reactions. Although weakness also contributes to movement dysfunction after a stroke, it has been feared that heightened activity levels during strength training will further exacerbate the abnormal tone imbalance present in spastic hemiplegia. The purpose of this study was to test this hypothesis by quantifying the effects of increased workload on motor performance during different speeds of pedaling exercise in persons with poststroke hemiplegia. Twelve healthy elderly subjects and 15 subjects with poststroke hemiplegia of greater than 6 months since onset were tested. The experimental protocol consisted of having subjects pedal at 12 randomly ordered workload and cadence combinations (45-J, 90-J, 135-J, and 180-J workloads at 25, 40, and 55 rpm). Pedal reaction forces were measured and used to calculate work done by each leg, including net positive and negative components. An electromyogram was recorded from seven leg muscles. The main finding was that net mechanical work done by the plegic leg increased as workload increased in 75 of 81 instances without increasing the percentage of inappropriate muscle activity. This study provides evidence that persons with hemiplegia increase force output by their plegic limb when pedaling against higher workloads without exacerbation of impaired motor control. Therefore, exertional pedaling exercise is a beneficial intervention for achieving gains in muscular force output without worsening motor control impairments.
To investigate whether phase-dependent reversals in reflex responses on electromyography (EMG) are accompanied by movement reversals, a series of human volunteers were studied for their behavioural responses to sural nerve stimulation during running or walking on a treadmill. Low-intensity stimulation (< 2.5 x perception threshold, T) of the sural nerve yielded facilitatory responses in the tibialis anterior muscle (TA), correlated with an induced ankle dorsiflexion (mean maximum 4°) in early swing. The same stimuli yielded primarily TA suppression and weak ankle plantar flexion (mean maximum 1°) at end swing. The correlated induced knee angle changes did not precede the ankle changes, and they were relatively small. Mean maximum flexion in early swing was 6.2°, while mean maximum extension was 3.7°. High-intensity stimulation of the sural nerve (> 2.5 x T) always gave rise to suppression of the ongoing activity. This resulted in a second type of movement reversal. During late stance and early swing the responses in TA were suppressive (i.e. below background activity) and related to ankle plantar flexion. In contrast, the responses during early and middle stance consisted of suppression in extensor activity (gastrocnemius medialis and soleus) and ankle dorsiflexion. The data are discussed in terms of a new hypothesis, which states that the responses to electrical stimulation of cutaneous nerves during locomotion do not correspond directly to corrections for stumbling following mechanical perturbations during the step cycle. Instead, the data invite a reinterpretation in terms of the opening and closing of reflex pathways, presumably by a central pattern generator for locomotion.
The aim of the study was to quantify the activity as recorded by electromyography during ergometer cycling in eleven different muscles of the lower extremity. Eleven healthy subjects rode in twelve different ways at different work-load, pedalling rate, saddle height and pedal foot position. Vastus medialis and lateralis, gastrocnemius medialis and lateralis and the soleus muscle were the most activated muscles. Changes in muscle activity during different calibrations were studied in eight of the eleven muscles. An increase in work-load significantly increased the mean maximum activity in all the eight muscles investigated. An increase of the pedalling rate increased the activity in the gluteus maximus, gluteus medius, vastus medialis, medial hamstring, gastrocnemius medialis and soleus muscles. An increase of the saddle height increased the muscle activity in the gluteus medius, medial hamstring and gastrocnemius medialis muscles. Use of a posterior pedal foot position increased the activity in the gluteus medius and rectus femoris muscles, and decreased the activity in the soleus muscle.
The effect of a treadmill training with partial body-weight support was investigated in nine nonambulatory hemiparetic patients with a mean poststroke interval of 129 days. They had received regular physiotherapy within a comprehensive stroke rehabilitation program at least 3 weeks before the treadmill training without marked improvement of their gait ability. After 25 additional treadmill training sessions scoring of functional performance and conventional gait analysis showed a definite improvement: gait ability, assessed by the Functional Ambulation Category (0 to 5) improved with a mean of 2.2 points, other motor functions, assessed by the Rivermead Motor Assessment Score with a mean of +3.9 points for gross function (range 0 to 13) and of +3.2 points for leg and trunk section (range 0 to 10)] and gait cycle parameters (p < .01). Muscle tone and strength of the paretic lower limb remained stable. We suggest that treadmill training with partial body-weight support could augment restoration of ambulation and other motor functions in hemiparetic patients by active and repetitive training.
The research question was, do events arising from rhythmic passive movement of the human leg lead to inhibition of the H reflex pathway in the stationary leg contralateral to that movement? Further, as the angular velocity of the passive movement increases, does the contralateral reflex inhibition also increase? Stable stimulation of the tibial nerve elicited H reflexes in the EMG of soleus. Trials involved the stimulated or the contralateral leg being rotated passively in a pedalling motion, at various velocities. The controls were made with the subjects seated and relaxed. The results showed that reflex magnitudes were significantly depressed when the test limb was passively rotated at 60 rpm. in comparison to the seated control trials. Rotation of the opposite limb depressed reflex magnitudes in the test limb, which was stationary. This contralateral inhibition increased, (mean reflex magnitudes of 62.68%, 41.04%, 16.65% and 9.58% of peak-to-peak Mmax), as the velocity of rotation of the opposite limb increased (10, 30, 60, 90 rpm, respectively) (P < 0.01). The effect of movement velocity was interpreted as the result of altered sensory receptor discharge arising from the passive movement. It is concluded that contralateral sensory activity contributes to the movement-elicited afferent discharge which tunes the spinal somatosensory-motor mechanisms for human locomotion.