Article

The Application Study of Specific Ankle-Foot Orthoses for Stroke Patients by 3D Printing Somos NeXt

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Objective : To investigate the effects of specific ankle-foot orthoses (AFOs) fabricated by 3D printing Somos NeXt on patients with stroke. Method: The ankle and foot were scanned by Artec 3D scanner. The model was performed with finite element analysis (FEA) using the software Abaqus to optimize the structure. Based on the structural optimization, AFOs were fabricated by 3D printing technique of Somos NeXt. Gait parameters were measured using the Gait Watch system. Seven sensors were bound to the sacrum, anterior side in the middle segment of the bilateral femoral femur, the median side at the proximal end of the bilateral tibia, and dorsal part of the bilateral foot. Results: The AFOs fabricated by 3D printing Somos NeXt significantly improved the temporalspatial parameters including velocity (20.75 vs. 17.38 cm/s) and stride length (47.88 vs. 43.63 cm), as well as increased cadence (52.5 vs. 48.75 times/min), while slightly decreased gait cycle (2.57 vs. 2.80 cm) and double limb support phase (34.00 vs. 37.13%). The AFOs also improved symmetry parameters such as the step length difference (9.75 vs. 15.25 cm), step length ratio (1.87 vs. 3.98), and swing phase ratio (0.99 vs. 0.75). Conclusion: The AFOs fabricated by 3D printing Somos NeXt have a significant effect on the improvement of velocity and stride length in patients with stroke.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Studies to determine the stress distribution occurring in AFOs started to be carried out in more detail with the development of the FE method [13,14]. Today, the FE method continues to be used frequently in the development of new AFO designs, along with new technologies such as 3D scanning [15,16] and 3D printing [16,17] Stresses in AFOs are usually concentrated in the lateral and medial parts of the ankle [15,18,19]. In our previous study, we proposed a novel circular trimline design such that we moved the trimline from the lateral and medial sides to the dorsal region [15]. ...
... Studies to determine the stress distribution occurring in AFOs started to be carried out in more detail with the development of the FE method [13,14]. Today, the FE method continues to be used frequently in the development of new AFO designs, along with new technologies such as 3D scanning [15,16] and 3D printing [16,17] Stresses in AFOs are usually concentrated in the lateral and medial parts of the ankle [15,18,19]. In our previous study, we proposed a novel circular trimline design such that we moved the trimline from the lateral and medial sides to the dorsal region [15]. ...
Article
Full-text available
Ankle-foot orthoses (AFOs) are typically prescribed to improve the gait function of ambulatory children with neurological conditions such as cerebral palsy or spina bifida. Due to the excessive and repetitive loading conditions, plastic material deformation can be observed in AFOs, especially over the lateral and medial parts of the ankle, which limits the effect of AFOs in the stabilization of the ankle joint. Trimline design and severity influence the rotational stiffness of an AFO considerably. In this study, we proposed novel trimming approaches for AFOs such that the trimlines were performed on the dorsal side rather than lateral and medial sides to reduce the magnitude of peak stresses and provide a homogenous stress distribution over AFOs. We analyzed eight dorsal trimline designs having different basic geome-tries by using the finite element method. To objectively evaluate the stress levels, the same boundary and loading conditions were considered for all design alternatives. We found that low peak stress values were observed in the AFO models with trimline geometries of the circle, ellipse, and slot variations. The vertical elliptic trimline on the dorsal side of the AFO was the most effective to decrease the magnitude of the peak stresses. The findings of our study are expected to contribute a complementary solution to orthotists in the fabrication of AFOs with high durability. Ó 2021 Karabuk University. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Article
Full-text available
Background One of the most significant challenges for patients who survive a stroke is relearning basic motor tasks such as walking. The goal of this study was to evaluate whether training on a treadmill with visual biofeedback improves gait symmetry, as well as spatiotemporal and kinematic gait parameters, in stroke patients. Material/Methods Thirty patients in the chronic phase after a stroke were randomly allocated into groups with a rehabilitation program of treadmill training with or without visual biofeedback. The training program lasted 10 days. Spatiotemporal and kinematic gait parameters were evaluated. For all parameters analyzed, a symmetrical index was calculated. Follow-up studies were performed 6 months after completion of the program. Results The symmetrical index had significantly normalized in terms of the step length (p=0.006), stance phase time, and inter-limb ratio in the intervention group. After 6 months, the improvement in the symmetry of the step length had been maintained. In the control group, no statistically significant change was observed in any of the parameters tested. There was no significant difference between the intervention group and the control group on completion of the program or at 6 months following the completion of the program. Conclusions Training on a treadmill has a significant effect on the improvement of spatiotemporal parameters and symmetry of gait in patients with chronic stroke. In the group with the treadmill training using visual biofeedback, no significantly greater improvement was observed.
Article
Full-text available
Background Three-dimensional (3D) printing has numerous applications and has gained much interest in the medical world. The constantly improving quality of 3D-printing applications has contributed to their increased use on patients. This paper summarizes the literature on surgical 3D-printing applications used on patients, with a focus on reported clinical and economic outcomes. Methods Three major literature databases were screened for case series (more than three cases described in the same study) and trials of surgical applications of 3D printing in humans. Results227 surgical papers were analyzed and summarized using an evidence table. The papers described the use of 3D printing for surgical guides, anatomical models, and custom implants. 3D printing is used in multiple surgical domains, such as orthopedics, maxillofacial surgery, cranial surgery, and spinal surgery. In general, the advantages of 3D-printed parts are said to include reduced surgical time, improved medical outcome, and decreased radiation exposure. The costs of printing and additional scans generally increase the overall cost of the procedure. Conclusion3D printing is well integrated in surgical practice and research. Applications vary from anatomical models mainly intended for surgical planning to surgical guides and implants. Our research suggests that there are several advantages to 3D-printed applications, but that further research is needed to determine whether the increased intervention costs can be balanced with the observable advantages of this new technology. There is a need for a formal cost–effectiveness analysis.
Article
Full-text available
Objective: To compare the effects on walking of functional electrical stimulation (FES) and ankle foot orthoses for foot-drop of central neurological origin, assessed in terms of unassisted walking behaviours compared with assisted walking following a period of use (combined-orthotic effects). Data sources: MEDLINE, AMED, CINAHL, Cochrane Central Register of Controlled Trials, Scopus, REHABDATA, PEDro, NIHR Centre for Reviews and Dissemination and clinicaltrials.gov, plus reference list, journal, author and citation searches. Study selection: English language comparative randomized controlled trials (RCTs). Data synthesis: Seven RCTs were eligible for inclusion. Two of these reported different results from the same trial and another 2 reported results from different follow-up periods and were therefore combined, resulting in 5 synthesized trials with 815 stroke participants. Meta-analyses of data from the final assessment in each study and 3 overlapping time-points showed comparable improvements in walking speed over 10 m (p = 0.04-0.79), functional exercise capacity (p = 0.10-0.31), timed up-and-go (p = 0.812 and p = 0.539) and perceived mobility (p = 0.80) for both interventions. Conclusion: Data suggest that, in contrast to assumptions that predict FES superiority, ankle foot orthoses have equally positive combined-orthotic effects as FES on key walking measures for foot-drop caused by stroke. However, further long-term, high-quality RCTs are required. These should focus on measuring the mechanisms-of-action; whether there is translation of improvements in impairment to function, plus detailed reporting of the devices used across diagnoses. Only then can robust clinical recommendations be made.
Article
Full-text available
The advent of three-dimensional printing (3DP) technology has enabled the creation of a tangible and complex 3D object that goes beyond a simple 3D-shaded visualization on a flat monitor. Since the early 2000s, 3DP machines have been used only in hard tissue applications. Recently developed multi-materials for 3DP have been used extensively for a variety of medical applications, such as personalized surgical planning and guidance, customized implants, biomedical research, and preclinical education. In this review article, we discuss the 3D reconstruction process, touching on medical imaging, and various 3DP systems applicable to medicine. In addition, the 3DP medical applications using multi-materials are introduced, as well as our recent results.
Article
Full-text available
[Purpose] The aim of the present study was to analyze the effect of an ankle-foot orthosis on gait variables (velocity and cadence) of stroke patients. To do this, a systematic review was conducted of four databases. [Subjects and Methods] The papers identified were evaluated based on the following inclusion criteria: 1) design: controlled, clinical trial; 2) population: stroke patients; 3) intervention: analysis of spatiotemporal variables of gait with an ankle-foot orthosis; 4) control group with different intervention or no intervention; and 5) outcome: improvement in gait velocity or cadence. [Results] Thirteen controlled trials addressing the effect of an ankle-foot orthosis on gait variables of stroke patients were found. They exhibited methodological quality of 3 or more points on the PEDro scale. [Conclusion] While the findings suggest the benefits of an AFO regarding gait velocity, the impact of this type of orthosis on cadence remains inconclusive. Thus, there is a need for further well-designed randomized, controlled, clinical trials to establish better scientific evidence for the effects of AFO usage on gait variables of stroke patients.
Article
Full-text available
This investigation utilized a single case design to evaluate the effects of a dynamic AFO on ambulation in post stroke hemiplegia. A single patient with stroke related hemiplegia using a dynamic AFO underwent gait analysis while walking on level ground. Outcome measures included temporal-spatial gait parameters and bilateral kinematic joint angles at the ankle, knee, and hip with and without AFO. Walking speed, stride length, step length and cadence increased with the dynamic AFO. Step width and double support decreased, while single support remained unchanged on the affected limb with the dynamic AFO. With the dynamic AFO there was increased hip flexion at foot strike and toe-off, increased hip sagittal plane angular velocity during swing, and decreased abduction. The dynamic AFO had a positive effect on the participant's overall gait which included improved temporal-spatial parameters and gait velocity which is likely due to a decrease in the overall energy cost of walking. Kinematic angles at the hip were most notably affected by brace utilization and this effect should be more fully explored. Further research with a larger sample utilizing dynamic AFOs is indicated to explore the generalizability of these findings and to determine the potential utility of these braces as an alternative to the traditionally prescribed solid AFO.
Article
Full-text available
Physiotherapy is usually provided only in the first few months after stroke, while its effectiveness and appropriateness in the chronic phase are uncertain. The authors conducted a systematic review and meta-analysis of randomised clinical trials (RCT) to evaluate the efficacy of physiotherapy interventions on motor and functional outcomes late after stroke. The authors searched published studies where participants were randomised to an active physiotherapy intervention, compared with placebo or no intervention, at least 6 months after stroke. The outcome was a change in mobility and activities of daily living (ADL) independence. The quality of the trials was evaluated using the PEDro scale. Findings were summarised across studies as effect size (ES) or, whenever possible, weighted mean difference (WMD) with 95% CI in random effects models. Fifteen RCT were included, enrolling 700 participants with follow-up data. The meta-analysis of primary outcomes from the original studies showed a significant effect of the intervention (ES 0.29, 95% CI 0.14 to 0.45). The efficacy of the intervention was particularly evident when short- and long-distance walking were considered as separate outcomes, with WMD of 0.05 m/s (95% CI 0.008 to 0.088) and 20 m (95% CI 3.6 to 36.0), respectively. Also, ADL improvement was greater, though non-significantly, in the intervention group. No significant heterogeneity was found. A variety of physiotherapy interventions improve functional outcomes, even when applied late after stroke. These findings challenge the concept of a plateau in functional recovery of patients who had experienced stroke and should be valued in planning community rehabilitation services.
Article
Background: Ankle foot orthoses (AFOs) are frequently prescribed to improve gait deviation and normalize walking pattern in patients with drop foot hemiplegia disorder. This study was to review the efficacy of different techniques of AFO construction and biomechanics parameters of AFOs. Furthermore, this study aimed to provide a guideline for researchers in detail and help them choose a sufficient measurement instrument. Methods: Information sources included MEDLINE, CINAHL, Scopus, PubMed, and the Full Cochrane Library up to December 25, 2015. The inclusion criteria include: (1) type and method of controlled clinical trial studies; (2) age of hemiplegia groups (3); AFOs as an intervention; and (4) kinetic and kinematic parameters, and energy expenditure as an intervention of gait performance. Results: Considering eligibility criteria such as study design, setting, time frame and Language 9 papers with Pedro scores of 5 to 8 for methodological quality were included in the review. Conclusion: The findings of this review can help to develop guidelines for the best AFO reporting as an intervention and to prevent vagueness of results in the different types of AFOs.
Article
Background: This study aimed to evaluate the effect of rocker bar ankle foot orthosis (RAFO) on the spatiotemporal characteristics of gait in chronic hemiplegic patients compared with the effect of solid ankle foot orthosis (SAFO). Methods: Following ethical approval, 18 patients with chronic hemiplegia, at least 6 months post stroke, were investigated in barefoot condition, with SAFO and RAFO in random sequences. Their spatiotemporal characteristics were examined by 2 force platforms and a Vicon motion analysis system. Results: There were significant changes in spatiotemporal outcome measures between barefoot condition and using SAFO and RAFO (P < .05). Compared with SAFO, RAFO resulted in significantly more step length, faster gait velocity, and less preswing time (P < .05), although no significant differences were seen regarding step width and cadence (P > .05). Furthermore, RAFO led to significant increases in hip extension and knee flexion at toe-off, whereas SAFO did not change these parameters (P < .05). Conclusion: Findings of the present study showed that RAFO further improves gait abilities in chronic hemiplegic patients compared with SAFO, which could be due to the positive effect of added rocker bar on push-off function during the late stance phase of gait.
Article
Background: Non-invasive brain stimulation (NIBS) facilitates motor improvements post stroke. Transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS) are representative NIBS techniques frequently used in stroke motor rehabilitation. Our primary question is: Do these two techniques improve force production capability in paretic limbs? Objective: The current systematic review and meta-analysis investigated the effects of tDCS and rTMS on paretic limb force production in stroke survivors. Methods: Our comprehensive search identified 23 studies that reported changes in force production following tDCS or rTMS interventions. Each used random assignment and a sham control group. The 23 qualified studies in our meta-analysis generated 29 comparisons: 14 tDCS and 15 rTMS comparisons. Results: Random effects models indicated improvements in paretic limb force after tDCS and rTMS rehabilitation. We found positive effects on force production in the two sets of stimulation protocols: (a) increasing cortical activity in the ipsilesional hemisphere and (b) decreasing cortical activity in the contralesional hemisphere. Moreover, across acute, subacute, and chronic phases, tDCS and rTMS improved force production. Conclusion: Cumulative meta-analytic results revealed that tDCS and rTMS rehabilitation protocols successfully improved paretic limb force production capabilities.
Article
This Viewpoint discusses the potential uses for 3D printing technologies in patient care. 3D printing—a manufacturing technique by which objects are built from digital data in a way analogous to how computer text is printed on a page—has captured the imagination of many with its potential to offer flexible, inexpensive manufacturing for widespread use. 3D printers have been used to build everything from rockets to houses to guns to other 3D printers, their capabilities limited only by access to a low-cost 3D printer, a set of digital blueprints, and some ingenuity.
Article
3D printing is expected to revolutionize health care through uses in tissue and organ fabrication; creation of customized prosthetics, implants, and anatomical models; and pharmaceutical research regarding drug dosage forms, delivery, and discovery.
Article
The aim of this systematic review was to summarize the improvements in balance after robot-assisted gait training (RAGT) in stroke patients. Two databases were searched: PubMed and Web of Knowledge. The most important key words are "stroke," "RAGT," "balance," "Lokomat," and "gait trainer." Studies were included if stroke patients were involved in RAGT protocols, and balance was determined as an outcome measurement. The articles were checked for methodological quality by 2 reviewers (Cohen's κ = 0.72). Nine studies were included (7 true experimental and 2 pre-experimental studies; methodological quality score, 56%-81%). In total, 229 subacute or chronic stroke patients (70.5% male) were involved in RAGT (3 to 5 times per week, 3 to 10 weeks, 12 to 25 sessions). In 5 studies, the gait trainer was used; in 2, the Lokomat was used; in 1 study, a single-joint wearable knee orthosis was used; and in 1 study, the AutoAmbulator was used. Eight studies compared RAGT with other gait rehabilitation methods. Significant improvements (no to large effect sizes, Cohen's d = 0.01 to 3.01) in balance scores measured with the Berg Balance Scale, the Tinetti test, postural sway tests, and the Timed Up and Go test were found after RAGT. No significant differences in balance between the intervention and control groups were reported. RAGT can lead to improvements in balance in stroke patients; however, it is not clear whether the improvements are greater compared with those associated with other gait rehabilitation methods. Because a limited number of studies are available, more specific research (eg, randomized controlled trials with larger, specific populations) is necessary to draw stronger conclusions.
Article
We investigated the effectiveness of an AFO-shaped band as an assistive walking device in patients with neurological lesions. The participants included 11 patients with a recent history of a CVA and one multiple sclerosis patient. In each patient, the order of conditions (AFO, AFO-shaped band, barefoot) was randomized. Participants were required to walk on the GAITRite mat twice during each condition. The average gait velocity among patients using the AFO-shaped elastic band was significantly higher than those under barefoot conditions (p = 0.015). Participants using the AFO-shaped elastic band also showed a significantly higher average number of steps per minute (cadence) as compared with the barefoot and AFO conditions (p = 0.007). Significant differences in stride length on the unaffected side were found between the AFO-shaped band and barefoot conditions (p = 0.029). Our results indicated that the AFO-shaped elastic band could be useful for patients with central neurological lesions with respect to gait, especially walking velocity, cadence, and stride length on the affected side. Thus, the AFO-shaped elastic band could be a practical tool for clinicians to train patients with central neurological lesions to walk.
Article
Purpose: In healthy subjects, the self-selected walking speed (SSWS) corresponds to the lowest cost of transport (CT). This study tested the hypothesis that SSWS could be determined by the work of breathing instead of the CT in patients with chronic heart failure (CHF). Methods: Seventeen patients with CHF due to left ventricular systolic dysfunction and 17 healthy controls were compared. Both groups were submitted to a walking cost protocol on the treadmill at the SSWS, at two speeds below (-0.5 and -1.0 km·h), and two speeds above (+0.5 and +1.0 km·h). The CT and ventilatory efficiency, as determined by the ventilatory equivalent for carbon dioxide (V˙E/V˙CO2), were compared. Results: CHF patients had a lower SSWS than healthy controls (0.75 ± 0.14 vs 0.98 ± 0.30 m·s, P < 0.01). Among the five speeds, the controls' SSWS was the most economical. For CHF patients, the SSWS was less economical than the higher speeds. However, V˙E/V˙CO2 at the SSWS was lower when compared with other speeds in both groups. Conclusions: In contrast to what happens with healthy subjects, where the SSWS has the lowest CT, CHF patients choose an SSWS with higher CT, but with lower ventilatory cost. These findings are compatible with the concept that interventions that enhance ventilatory efficiency may increase SSWS in CHF.
Article
Background: Recently, additive fabrication has been proposed as a feasible engineering method for manufacturing of customized ankle foot orthoses (AFOs). Consequently, studies on safety, comfort and effectiveness are now carried out to assess the performance of such devices. Objective: Evaluate the clinical performance of customized (selective laser sintering) SLS-AFOs on eight subjects with unilateral drop foot gait and compare to clinically accepted (polypropylene) PP-AFOs. Study design: Active control trial. Methods: For each subject two customized AFOs were fabricated: one SLS-AFO manufactured following an additive fabrication framework and one thermoplastic PP-AFO manufactured according to the traditional handcraft method. Clinical performance of both AFOs was evaluated during gait analysis. Results: A significant beneficial effect of both custom-moulded PP-AFO and customized SLS-AFO in terms of spatial temporal gait parameters and ankle kinematic parameters compared to barefoot gait of adults with drop foot gait are observed. No statistically significant difference between the effect of PP-AFO and of SLS-AFO was found in terms of spatial temporal gait parameters and ankle kinematic parameters. Conclusion: AFOs manufactured through the SLS technique show performances that are at least equivalent to the handcrafted PP-AFOs commonly prescribed in current clinical practice. Clinical relevance Manufacturing personalized AFOs with selective laser sintering (SLS) in an automated production process results in decreased production time and guarantees the consistency of shape and functional characteristics over different production time points compared to the traditional manufacturing process. Moreover, it reduces the dependency of the appliance on the experience and craftsmanship of the orthopaedic technician.
Article
Passive-dynamic ankle-foot orthoses (PD-AFOs) constitute a class of ankle braces that rely on material properties and physical features to establish functional characteristics such as bending or rotational stiffness. We have developed a novel framework that combines a fully parameterized PD-AFO computer-aided design (CAD) model and free-form fabrication to rapidly manufacture customized PD-AFOs. The three-dimensional locations of select anatomic landmarks serve to fit customize the PD-AFO CAD model. A virtual orthopedic alignment process and selection of discrete design parameter values further customize the orthosis, which is fabricated via selective laser sintering. CAD models were customized and full-scale orthoses were manufactured for two nondisabled subjects. The surface of one half-scale CAD model was marked with 3 mm hemispherical dimples, and four orthoses were manufactured in different build orientations and positions. Dimensional accuracy was determined by calculating discrepancies between corresponding CAD and fabricated orthoses interdimple distances. Subjective evaluations of the full-scale PD-AFOs following use in gait were positive. Dimension discrepancies were well under a 2 mm tolerance for the four half-scale orthoses. Mean foot plate, strut, and cuff component discrepancies were 0.31 +/- 0.28, 0.34 +/- 0.08, 0.52 +/- 0.39 mm, respectively, and 0.29 +/- 0.23 mm for the overall orthosis. Dimensional accuracy of the rapid customization and manufacturing framework was well within tolerances suggested in the literature.
Article
Symmetry is a gait characteristic that is increasingly measured and reported, particularly in the stroke patient population. However, there is no accepted standard for assessing symmetry making it difficult to compare across studies and establish criteria to guide clinical decision making. This study compares the most common expressions of spatiotemporal gait symmetry to describe post-stroke gait and makes recommendations regarding the most suitable measure for standardization. The following symmetry equations were compared: symmetry ratio, symmetry index, gait asymmetry and symmetry angle using step length, swing time, stance time, double support time and an intra-limb ratio of swing: stance time. Comparisons were made within a group of 161 community-dwelling, ambulatory individuals with stroke and 81 healthy adults as a reference group. Our analysis supports the recommendations of the symmetry ratio as the equation for standardization and step length, swing time and stance time as the gait parameters to be used in the equation. Future work should focus on establishing the intra-individual variability of these measures and linking them to mechanisms of gait dysfunction.
Article
This study investigates if fabrication techniques employed at different orthotic centres affect the characteristics of the manufactured plastic orthoses. Plaster models were formed from the same master mould. The thickness and bending stiffness of the supplied polypropylene sheets were measured prior to fabrication. An orthotic technician at each of the 3 orthotic centres manufactured 4 homopolymer and 4 copolymer polypropylene ankle-foot orthoses (AFOs), following each centre's fabrication practice. Another technician at one of the orthotic centres manufactured an additional 4 homopolymer and 4 copolymer AFOs. The thickness, the dorsiflexion stiffness and plantar-flexion stiffness of the 32 fabricated AFOs were monitored and compared. Analysis of the results suggests: Copolymer polypropylene sheets are supplied marginally thicker than homopolymer polypropylene sheets The difference between the thickness of the 16 copolymer and 16 homopolymer AFOs was not significant. The thickness of the AFOs manufactured in copolymer was less consistent than homopolymer. Dorsiflexion stiffness of the copolymer AFOs was less consistent than homopolymer AFOs. Although the bending stiffness of the copolymer and homopolymer sheets differed significantly, there was no significant difference between the dorsiflexion stiffness of the copolymer and homopolymer AFOs. Plantarflexion stiffness was consistent for both the copolymer and the homopolymer AFOs and there was no significant difference between the plantarflexion stiffness of the copolymer and homopolymer AFOs. The thickness and flexural stiffness of the AFOs manufactured by 2 technicians at the same centre did not differ. These results are useful benchmarks for the flexural stiffness of AFOs.
Article
To assess whether EMG-triggered neuromuscular electrical stimulation (EMG-NMES) applied to the extensor muscles of the forearm improves hand function after stroke. Systematic review of randomized controlled trials. A computer-aided literature search up to June 2006 identified articles comparing EMG-NMES of the upper extremity with usual care. Methodological quality was rated on the Physiotherapy Evidence Database scale (PEDro), and the Hedges' g model was used to calculate the summary effect sizes (SES) using fixed or random models depending on heterogeneity. Eight studies, selected out of 192 hits and presenting 157 patients, were included in quantitative and qualitative analyses. The methodological quality ranged from 2 to 6 points. The meta-analysis revealed non-significant effect sizes in favour of EMG-NMES for reaction time, sustained contraction, dexterity measured with the Box and Block manipulation test, synergism measured with the Fugl-Meyer Motor Assessment Scale and manual dexterity measured with the Action Research Arm test. No statistically significant differences in effects were found between EMG-NMES and usual care. Most studies had poor methodological quality, low statistical power and insufficient treatment contrast between experimental and control groups. In addition, all studies except two investigated the effects of EMG-NMES in the chronic phase after stroke, whereas the literature suggests that an early start, within the time window in which functional outcome of the upper limb is not fully defined, is more appropriate.
Gait analysis: Normal and pathological function
  • M Burnfield
M. Burnfield, Gait analysis: Normal and pathological function. Journal of Sports Science and Medicine 9, 353 (2010).