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Training Conditions Influence Walking Kinematics and Self-Selected Walking Speed in Patients with Neurological Impairments
Abstract
Gait training is a major focus of rehabilitation for many people with neurological disorders, yet systematic reviews have failed to identify the most effective form of gait training. The main objective of this study was to compare conditions for gait training for people with acquired brain injury (ABI). Seventeen people who had sustained an ABI and were unable to walk without assistance were recruited as a sample. Each participant was exposed to seven alternative gait training conditions in a randomized order. These were: (1) therapist manual facilitation; (2) the use of a gait-assistive device; (3) unsupported treadmill walking; and (4) four variations of body weight support treadmill training (BWSTT). Quantitative gait analysis was performed and Gait Profile Scores (GPS) were generated for each participant to determine which condition most closely resembled normal walking. BWSTT without additional therapist or self-support of the upper limbs was associated with more severe gait abnormality [Wilks' lambda = 0.20, F(6, 6) = 3.99, p = 0.047]. With the exception of therapist facilitation, the gait training conditions that achieved the closest approximation of normal walking required self-support of the upper limbs. When participants held on to a stable handrail, self-selected gait speeds were up to three times higher than the speeds obtained for over-ground walking [Wilks' lambda = 0.17, F(6, 7) = 5.85, p < 0.05]. The provision of stable upper-limb support was associated with high self-selected gait speeds that were not sustained when walking over ground. BWSTT protocols may need to prioritize reduction in self-support of the upper limbs, instead of increasing treadmill speed and reducing body weight support, in order to improve training outcomes.
... Zur Verbesserung der Gehleistungen können mittlerweile eine ganze Reihe verschiedener Ansätze genutzt werden [2,4,5,26,27]. Es lassen sich aktuell zwei grundlegende Prinzipien in der neurologisch-motorischen Rehabilitation des Gehens aus wissenschaftlichen Studien ableiten: ▪ Zur Wiederherstellung und zur Verbesserung der Gehfunktion wird aktuell international in der Physiotherapie ein aufgabenspezifisch repetitiver Ansatz favorisiert [6,15,23,26]. ...
... Zur Verbesserung der Gehleistungen können mittlerweile eine ganze Reihe verschiedener Ansätze genutzt werden [2,4,5,26,27]. Es lassen sich aktuell zwei grundlegende Prinzipien in der neurologisch-motorischen Rehabilitation des Gehens aus wissenschaftlichen Studien ableiten: ▪ Zur Wiederherstellung und zur Verbesserung der Gehfunktion wird aktuell international in der Physiotherapie ein aufgabenspezifisch repetitiver Ansatz favorisiert [6,15,23,26]. ▪ Die zurzeit wichtigsten Unterscheidungen des Gehtrainings für Patienten nach Hirnschädigung betreffen den Schweregrad der Erkrankung des Patienten. Auf der einen Seite steht der bereits gehfähige Patient, bei dem die Physiotherapie vor allem auf die Sicherheit und die Verbesserung bestimmter Gangparameter wie Schrittlänge und Gehgeschwindigkeit abzielt, oder, z. ...
Ein wichtiges Ziel der stationären Rehabilitation von Patienten mit Schädel-Hirn-Traumata (SHT) ist die Verbesserung der Mobilität, insbesondere die Verbesserung der posturalen Kontrolle und der selbstständigen Gehleistung. Darauf ist die Physiotherapie spezialisiert.
Durch Einschränkungen der Balance und der Gehfähigkeit sind zahlreiche Alltagsleistungen wie selbstständige Toilettengänge, die Essenszubereitung sowie das Aufstehen und Hinsetzen nur mit viel Unterstützung von Hilfspersonen möglich. Dem Wiederherstellen der Mobilität kommt innerhalb der neurologischen Rehabilitation somit eine erhebliche Bedeutung zu.
... The length of time postinjury or diagnosis varied considerably from acute (1mo) to chronic (10y) with a median time of 9 months. 14 Normative data were collected on a population of 25 participants (16 men; mean age Ϯ SD, 27.8Ϯ7.4y; mean height Ϯ SD, 74.3Ϯ7.0cm; ...
... The results of this study suggest that treadmill training (ϮBWS) with handrail support appears to provide a suitable method for task-specific training of dynamic balance because it replicates ML COM amplitudes found in nonpathologic gait. Although it remains unclear whether rehabilitation programs that include treadmill training (ϮBWS) improve functional mobility more than other methods of gait retraining, 14 the evidence suggests that BWSTT allows for a greater distance to be walked, at an increased gait velocity, and with a higher intensity of activity. For example, in the subacute stroke setting, patients walked distances approximately 5 times greater per 30-minute session when performing BWSTT compared with overground walking in the first week of an intervention. ...
To investigate movement of the center of mass (COM) during different gait training methods in people with neurologic conditions.
Coordination of the gait cycle, represented by mediolateral COM displacement amplitude, timing, and stability, was assessed during a variety of gait training methods performed in a single session.
Gait laboratory.
People who were unable to walk unassisted due to an acquired brain injury (n=17) and healthy control subjects (n=25).
The participants performed 7 alternative gait training methods in a randomized order. These were therapist manual facilitation, the use of a gait assistive device, treadmill walking with handrail support, and 4 variations of body weight-support treadmill training with combinations of handrail and/or therapist support.
Mediolateral COM movement was analyzed in terms of displacement amplitude (overall range of motion), timing (relative to stride time), and stability (steadiness of the movement). Normative values for these measures were acquired from 25 healthy participants walking at a self-selected comfortable pace.
Body weight-support treadmill training without any additional support resulted in significantly (P<.05) greater amplitude, altered timing, and reduced movement stability compared with nonpathologic gait. Allowing handrail support or therapist facilitation reduced this effect and resulted in treadmill training (± body weight support) having lower movement amplitudes when compared with the other training methods. Therapist manual facilitation most closely matched nonpathologic gait for timing and stability.
In the context of overall dynamic gait coordination, no single method of training provides the optimal stimulus. A training program that uses a variety of techniques may provide a beneficial rehabilitation response.
... A recent study by Peters et al. 7) found that gait speed and mobility significantly improved in 10 subjects with brain injury after 20 sessions of BWSTT. Williams et al. 8) found that the manual assistance provided during BWSTT improved gait kinematics and the timing of muscle activation but was physically taxing on therapists. To replicate a normal gait pattern, historically 1-3 therapists are needed during BSWTT to control trunk and limb kinematics. ...
Purpose People with polytrauma injuries along with diffuse axonal brain injury (TBI+DAI) present unique challenges to the physical therapist during comprehensive inpatient rehabilitation. The literature available to rehabilitation professionals regarding exoskeleton gait training (EGT) in the traumatic brain injury (TBI) population is limited. The purpose of this case report is to describe the use of EGT and traditional physical therapy management of an adult with polytrauma injuries and TBI+DAI during an inpatient rehabilitation stay. Methods The subject was a 31 year old veteran male diagnosed with polytrauma injuries and TBI+DAI, resulting from a high speed motor vehicle collision. He began to emerge from comatose state 8 days post-injury, was admitted to an inpatient rehabilitation facility and began physical therapy 23 days post-injury. He participated in physical therapy one to two times daily for 60 minute sessions with five additional EGT sessions and two community re-integration outings, for an average of 7 sessions per week throughout episode of care. Results Measures were taken at admission and were reassessed weekly. Functional Independence Measure total score increased from 62 to 117 and the motor subscale increased from 37 to 89. Berg Balance Scale score increased from 0 to 54. Gait distance increased from 20 feet with quad cane and moderate assistance from physical therapist to 5,755 feet with single point cane and modified independence. Conclusion This case reports describes the use of off-label EGT in addition to traditional physical therapy management that was successful in increasing the quality and efficiency of gait in an individual with polytrauma injuries and TBI+DAI.
... Despite the volume of research into walking after ABI, understanding of the differences in walking biomechanics is limited (Williams, Galna, Morris and Olver, 2010). Biomechanical deviations vary when walking conditions are changed in people who require assistance to walk after ABI (Williams et al., 2011); this high variability suggests a case series analysis could be informative for understanding patterns of recovery. ...
Purpose:
Determine how mobility changes over 6 months in people unable to walk at 8-weeks post-Acquired Brain Injury (ABI); if there is an association over time between postural alignment and mobility post-ABI; and if alignment after ABI becomes closer to healthy alignment over time.
Methods:
Fourteen adults with ABI, evaluated over 6 months, and a reference sample of 30 healthy adults were studied. The primary measure for changes in mobility was the Clinical Outcome Variables Scale (COVS). Secondary measures were sit-to-stand, timed standing holding rails, independent walking speed and number of testing conditions achieved. The Functional Independence Measure (FIM) was scored at rehabilitation admission and discharge. To analyze postural alignment, participants were recorded in sitting and standing, each repeated holding rails, and walking if able. Three-dimensional kinematic data were used to quantify whole-body postural alignment, equal to mean segment displacements from the base of support in the transverse plane. Associations between three-dimensional kinematic alignment scores and COVS scores were calculated using Linear Mixed-Effects Models.
Results:
Participants made significant improvements in COVS scores, most secondary mobility scores, and FIM scores over time (p ≤ .001). Relationships between increasing COVS scores and decreasing sitting and standing mal-alignment scores were statistically significant. Visual analysis of graphed segment positions indicated that sitting and standing alignment became more similar to healthy alignment over time; this was not clear for walking.
Conclusion:
Improvement in postural alignment may be a factor for improving mobility in people with severe impairments after ABI.
... To replicate a normal gait pattern during manually facilitated locomotor training, 1-3 therapists are needed to control or assist with trunk and limb kinematics. Provision of manual assistance during partial-body weightÀ supported treadmill training (PBWSTT) has demonstrated improved gait kinematics and muscle activation patterns but can be physically taxing on therapists and patients [16]. Consequently, robotic gait devices such as the Lokomat (Hocoma, Volketswil, Switzerland) and GE-O (Reha Technology, Olten, Switzerland) have been developed to assist in this task. ...
... Brain & NeuroRehabilitation intervention and manual assistance that have been challenging for therapists and patients will be reduced [23]. The complaints of the participants and the difficulties identified in this study will contribute to the development and customization of safe and comfortable end-effector type robots and to the design of future clinical trials. ...
Unlabelled:
Robots are being used to assist the recovery of walking ability for patients with neurologic disorders. This study aimed to evaluate the feasibility and functional improvement of training with robot-assisted gait training (RAGT) using the Morning Walk®, an end-effector type robot using footplates and saddle seat support. A total of 189 individuals (65.1% men, 34.9% women; mean age, 53.2 years; age range: 5-87 years) with brain lesions, spinal cord injuries, Parkinson's disease, peripheral neuropathies, and pediatric patients were involved in this retrospectively registered clinical trial. Each participant performed 30 minutes of RAGT, five times a week, for a total of 24 sessions. Failure was defined as an inability to complete all 24 sessions, and the reasons for discontinuation were analyzed. Parameters of Medical Research Council scales and Functional Ambulation Categories were analyzed before and after RAGT training. Among the 189 patients, 22 (11.6%) failed to complete the RAGT. The reasons included decreased cooperation, musculoskeletal pain, saddle seat discomfort, excessive body-weight support, joint spasticity or restricted joint motion, urinary incontinence from an indwelling urinary catheter, and fatigue. Comparison between the pre- and post-training motor and ambulatory functions showed significant improvement. The result of the study indicates that the Morning Walk® is feasible and safe and useful for functional improvement in patients with various neurologic disorders.
Trial registration:
Clinical Research Information Service Identifier: KCT0003627.
... To replicate a normal gait pattern during manually facilitated locomotor training, 1-3 therapists are needed to control or assist with trunk and limb kinematics. Provision of manual assistance during partial-body weightÀ supported treadmill training (PBWSTT) has demonstrated improved gait kinematics and muscle activation patterns but can be physically taxing on therapists and patients [16]. Consequently, robotic gait devices such as the Lokomat (Hocoma, Volketswil, Switzerland) and GE-O (Reha Technology, Olten, Switzerland) have been developed to assist in this task. ...
Background:
Literature in the application of gait training techniques in persons with traumatic brain injury (TBI) is limited. Current techniques require multiple staff and are physically demanding. The use of a robotic locomotor training may provide improved training capacity for this population.
Objective:
To examine the impact of 3 different modes of locomotor therapy on gait velocity and spatiotemporal symmetry using an end effector robot (G-EO); a robotic exoskeleton (Lokomat), and manual assisted partial-body weight-supported treadmill training (PBWSTT) in participants with traumatic brain injury.
Design:
Randomized, prospective study.
Setting:
Tertiary rehabilitation hospital.
Participants:
A total of 22 individuals with ≥12 months chronic TBI with hemiparetic pattern able to walk overground without assistance at velocities between 0.2 and 0.6 m/s.
Intervention:
Eighteen sessions of 45 minutes of assigned locomotor training.
Outcome measures:
Overground walking self-selected velocity (SSV), maximal velocity (MV), spatiotemporal asymmetry ratio, 6-Minute Walk Test (6MWT), and mobility domain of Stroke Impact Scale (MSIS).
Results:
Severity in walking dysfunction was similar across groups as determined by walking velocity data. At baseline, participants in the Lokomat group had a baseline velocity that was slightly slower compared with the other groups. Training elicited a statistically significant median increase in SSV for all groups compared with pretraining (Lokomat, P = .04; G-EO, P = .03; and PBWSTT, P = .02) and MV excluding the G-EO group (Lokomat, P = .04; PBWSTT, P = .03 and G-EO, P = .15). There were no pre-post significant differences in swing time, stance time, and step length asymmetry ratios at SSV or MV for any of the interventions. Mean rank in the change of SSV and MV was not statistically significantly different between groups. Participants in the G-EO and PBWSTT groups significantly improved their 6MWT posttraining (P = .04 and .03, respectively). The MSIS significantly improved only for the Lokomat group (P = .04 and .03). The data did not elicit between-groups significant differences for 6MWT and MSIS. There was less use of staff for Lokomat than G-EO.
Conclusions:
Locomotor therapy using G-EO, Lokomat, or PBWSTT in individuals with chronic TBI increased SSV and MV without significant changes in gait symmetry. Staffing needed for therapy provision was the least for the Lokomat. A larger study may further elucidate changes in gait symmetry and other training parameters.
Level of evidence:
II.
Primary objective: To examine the relationship between postural alignment and mobility skills for adults after acquired brain injury (ABI).
Methods: Systematic review of the literature. Seven electronic databases, grey literature and reference lists of the shortlisted publications were searched. Studies were included if participants were adults with ABI, both postural alignment and mobility were measured and analysis included a relationship between alignment and mobility. Those that met the inclusion criteria were assessed with a critical appraisal tool. The review was registered with PROSPERO, registration number CRD42015019867.
Results: Seven observational studies were included that had examined a relationship between postural alignment and mobility after ABI. Critical appraisal scores were moderate to strong. While some studies reported that improved postural alignment was related to improved mobility after ABI, results varied and there was insufficient evidence to answer the primary question. Heterogeneous study designs did not allow meta-regression.
Conclusions: A small amount of observational evidence exists for a relationship between postural alignment and mobility after ABI. Results vary, with some studies reporting that a more stable, upright trunk correlates with better mobility, and others providing conflicting or ambiguous results. Further research is needed to establish the relationship between postural alignment and mobility skills after ABI.
Gait retraining programs are prescribed to assist in the rehabilitation process of many clinical conditions. Using lateral trunk lean modification as the model, the aim of this study was to assess the concurrent validity of kinematic data recorded using a marker-based 3D motion analysis (3DMA) system and a low-cost alternative, the Microsoft Kinect™ (Kinect), during a gait retraining session. Twenty healthy adults were trained to modify their gait to obtain a lateral trunk lean angle of 10°. Real-time biofeedback of the lateral trunk lean angle was provided on a computer screen in front of the subject using data extracted from the Kinect skeletal tracking algorithm. Marker coordinate data were concurrently recorded using the 3DMA system, and the similarity and equivalency of the trunk lean angle data from each system were compared. The lateral trunk lean angle data obtained from the Kinect system without any form of calibration resulted in errors of a high (>2°) magnitude (mean error=3.2±2.2°). Performing global and individualized calibration significantly (P<0.001) improved this error to 1.7±1.5° and 0.8±0.8° respectively. With the addition of a simple calibration the anatomical position coordinates of the Kinect can be used to create a real-time biofeedback system for gait retraining. Given that this system is low-cost, portable and does not require any sensors to be attached to the body, it could provide numerous advantages when compared to laboratory-based gait retraining systems.
Objective:
To identify factors that predict running ability following traumatic brain injury (TBI), and to quantify performance thresholds for these predictors.
Design:
Cross-sectional cohort study.
Participants:
One hundred fourteen people with TBI.
Outcome measures:
Self-selected walking speed, the high-level mobility assessment tool, postural stability (lateral center of mass displacement), ankle power generation at push-off and quality of gait performance (Gait Profile Score).
Results:
All predictor variables were all strongly associated with the ability to run. However, only self-selected walking speed contributed significantly to the final result. Investigation of performance thresholds for self-selected walking speed indicated that following TBI, people who walk at speeds of 1.0 m/s or higher are 16.9 times more likely of being able to run than for those who walk at speeds of less than 1.0 m/s.
Conclusions:
Self-selected walking speeds higher than 1.0 m/s greatly increase the likelihood of running following brain injury. The 1.0 m/s threshold, although slower than able-bodied self-selected walking speeds, may be an important indicator of the ability to run in this population.
Sixty male and fifty-eight female subjects ranging in age from 20 to 79 years performed walking at a controlled pace barefoot, wearing standard shoes, and wearing their personal shoes. Additionally these subjects performed walking in the standard shoe at a freely selected speed. Selected kinematic variables for the knee and ankle joint complexes and ground reaction forces were measured in three dimensions to determine differences with respect to age and gender. Additionally a comparison of the path of motion during ground contact and the active range of motion measured in a range of motion fixture were made. A multivariate analysis revealed a number of the kinematic and kinetic variables which were significantly different although the absolute differences were generally small. The comparison of path of motion and range of motion revealed a high correlation for abduction and adduction and plantarflexion and dorsiflexion. It is speculated that changes in gait pattern with increasing age are associated with decreasing muscle strength and a need for increased stability during locomotion with increasing age. The high correlation between path of motion and range of motion is associated with the decrease in muscle strength with increasing age, which is assumed to influence both path of motion and range of motion.
The purpose of this study was to identify goal priorities in a sample of individuals with chronic stroke.
Method
In this descriptive study involving 19 community-dwelling individuals with stroke, participants were interviewed on the Canadian Occupational Performance Measure (COPM) to ascertain problem areas experienced after hospital discharge. Once problems were identified, they were classified under the three dimensions of the COPM: self-care, productivity, and leisure.
Results
The mean time since stroke was 6.8 (± 2.9) years. Eighty-four problems were identified within the three dimensions of the COPM. The most frequently cited problems in each dimension were bathing (self-care) by 42% of participants, household maintenance (productivity) by 32% of participants, and walking outdoors (leisure) by 32% of participants. Overall, participants rated their performance of identified problems and satisfaction with their abilities as low and rated each dimension as equally important for problem priority.
Conclusion
Long after hospital discharge, individuals with chronic stroke were able to identify issues of concern that could benefit from involvement of rehabilitation professionals. Clinicians should be aware that issues of bathing, walking, household maintenance, and recreational activities are of particular importance to people with chronic stroke living in the community. A client-centred approach to problem generation (ie, use of the COPM) may assist in enhancing client involvement and motivation towards rehabilitation.
To assess the quality of current evidence as to the effectiveness of robot-assisted gait training in spinal cord injured patients, focusing on walking ability and performance.
A search was conducted in MEDLINE, Web of Knowledge, Cochrane Library, Physiotherapy Evidence Database (PEDro) and Digital Academic Repositories (DAREnet) (1990-2009). Key words included "spinal cord injury", "(robot-assisted) gait rehabilitation" and "driven gait orthosis". Articles were included when complete and incomplete adult spinal cord injured patients participated in robot-assisted gait training intervention studies. The methodological quality was rated independently by 2 researchers using "van Tulder criteria list" and "evaluation of quality of an intervention study". Descriptive analyses were performed using the Population Intervention Comparison Outcome (PICO) method.
Two randomized controlled trials (mean quality score: 11.5/19) and 4 pre-experimental trials (mean quality score: 24.25 (standard deviation; SD 0.28)/48) involving 43 patients with incomplete, acute or chronic lesions between C3 and L1 were analysed. Five studies used the Lokomat and one used the LokoHelp. Although some improvements were reported related to body functions and activities, there is insufficient evidence to draw firm conclusions, due to small samples sizes, methodological flaws and heterogeneity of training procedures.
There is currently no evidence that robot-assisted gait training improves walking function more than other locomotor training strategies. Well-designed randomized controlled trials are needed.
To evaluate the effect of body weight-supported gait training on restoration of walking, activities of daily living, and quality of life in persons with an incomplete spinal cord injury by a systematic review of the literature.
Cochrane, MEDLINE, EMBASE, CINAHL, PEDro, DocOnline were searched and identified studies were assessed for eligibility and methodological quality and described regarding population, training protocol, and effects on walking ability, activities of daily living and quality of life. A descriptive and quantitative synthesis was conducted.
Eighteen articles (17 studies) were included. Two randomized controlled trials showed that subjects with injuries of less than one year duration reached higher scores on the locomotor item of the Functional Independence Measure (range 1-7) in the over-ground training group compared with the body weight-supported treadmill training group. Only for persons with an American Spinal Injury Association Impairment Scale C or D was the mean difference significant, with 0.80 (95% confidence interval 0.04-1.56). No differences were found regarding walking velocity, activities of daily living or quality of life.
Subjects with subacute motor incomplete spinal cord injury reached a higher level of independent walking after over-ground training, compared with body weight-supported treadmill training. More randomized controlled trials are needed to clarify the effectiveness of body weight-supported gait training on walking, activities of daily living, and quality of life for subgroups of persons with an incomplete spinal cord injury.
: Overground gait training-observation and cueing of patient's walking pattern along with related exercises-forms a major part of rehabilitation services for individuals with chronic stroke in almost every setting. This report of a Cochrane systematic review assessed the effects of overground gait training on walking ability for individuals with mobility deficits subsequent to chronic stroke.
: We searched the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Science Citation Index Expanded, http://www.clinicaltrials.gov, among other databases through spring 2008. We also searched reference lists and contacted authors and trial investigators.
: Only randomized controlled trials comparing overground physical therapy gait training with a placebo or no treatment condition were included.
: Nine studies involving 499 participants were included. We found no evidence of a benefit on walking function, the primary variable, based on three studies (n = 269). Some performance variables did show significant effects. Walking speed increased by 0.07 m/sec [95% confidence interval (CI), 0.05-0.10] based on seven studies (n = 396), Timed Up and Go test improved by 1.81 seconds (95% CI, -2.29 to -1.33) based on three studies (n = 118), and six-minute walk test increased by 26.06 m (95% CI, 7.14-44.97) based on four studies (n = 181).
: We found insufficient evidence to determine whether overground physical therapy gait training benefits walking function in individuals with chronic stroke, although limited evidence suggests potential benefits for some performance variables. High-quality randomized controlled trials are needed to replicate and extend these findings.
Task-specific training programs after stroke improve walking function, but it is not clear which biomechanical parameters of gait are most associated with improved walking speed.
The purpose of this study was to identify gait parameters associated with improved walking speed after a locomotor training program that included body-weight-supported treadmill training (BWSTT).
A prospective, between-subjects design was used.
Fifteen people, ranging from approximately 9 months to 5 years after stroke, completed 1 of 3 different 6-week training regimens. These regimens consisted of 12 sessions of BWSTT alternated with 12 sessions of: lower-extremity resistive cycling; lower-extremity progressive, resistive strengthening; or a sham condition of arm ergometry. Gait analysis was conducted before and after the 6-week intervention program. Kinematics, kinetics, and electromyographic (EMG) activity were recorded from the hemiparetic lower extremity while participants walked at a self-selected pace. Changes in gait parameters were compared in participants who showed an increase in self-selected walking speed of greater than 0.08 m/s (high-response group) and in those with less improvement (low-response group).
Compared with participants in the low-response group, those in the high-response group displayed greater increases in terminal stance hip extension angle and hip flexion power (product of net joint moment and angular velocity) after the intervention. The intensity of soleus muscle EMG activity during walking also was significantly higher in participants in the high-response group after the intervention.
Only sagittal-plane parameters were assessed, and the sample size was small.
Task-specific locomotor training alternated with strength training resulted in kinematic, kinetic, and muscle activation adaptations that were strongly associated with improved walking speed. Changes in both hip and ankle biomechanics during late stance were associated with greater increases in gait speed.
Body weight support (BWS) systems on treadmill have been proposed as a strategy for gait training of subjects with stroke. Considering that ground level is the most common locomotion surface and that there is little information about individuals with stroke walking with BWS on ground level, it is important to investigate the use of BWS on ground level in these individuals as a possible alternative strategy for gait training.
Thirteen individuals with chronic stroke (four women and nine men; mean age 54.46 years) were videotaped walking on ground level in three experimental conditions: with no harness, with harness bearing full body weight, and with harness bearing 30% of full body weight. Measurements were recorded for mean walking speed, cadence, stride length, stride speed, durations of initial and terminal double stance, single limb support, swing period, and range of motion of ankle, knee, and hip joints; and foot, shank, thigh, and trunk segments.
The use of BWS system leads to changes in stride length and speed, but not in stance and swing period duration. Only the hip joint was influenced by the BWS system in the 30% BWS condition. Shank and thigh segments presented less range of motion in the 30% BWS condition than in the other conditions, and the trunk was held straighter in the 30% BWS condition than in the other conditions.
Individuals with stroke using BWS system on ground level walked slower and with shorter stride length than with no harness. BWS also led to reduction of hip, shank, and thigh range of motion. However, this system did not change walking temporal organization and body side asymmetry of individuals with stroke. On the other hand, the BWS system enabled individuals with chronic stroke to walk safely and without physical assistance. In interventions, the physical therapist can watch and correct gait pattern in patients' performance without the need to provide physical assistance.
Objective: To confirm previous findings that hip abductor activity measured by electromyography (EMG) on the side contralateral to cane use is reduced during walking in stroke patients. To assess whether an orthosis (TheraTogs) or hip abductor taping increase hemiplegic hip abductor activity compared with activity during cane walking or while walking without aids. To investigate the effect of each condition on temporo-spatial gait parameters.
Design: Randomized, within-participant experimental study.
Setting: Gait laboratory.
Subjects: Thirteen patients following first unilateral stroke.
Intervention: Data collection over six gait cycles as subjects walked at self-selected speed during: baseline (without aids) and in randomized order with (1) hip abductor taping, (2) TheraTogs, (3) cane in non-hemiplegic hand.
Main measures: Peak EMG of gluteus medius and tensor fascia lata and temporo-spatial gait parameters.
Results: Cane use reduced EMG activity in gluteus medius from baseline by 21.86%. TheraTogs increased it by 16.47% (change cane use—TheraTogs P=0.001, effect size = -0.5) and tape by 5.8% (change cane use—tape P=0.001, effect size = -0.46). In tensor fascia lata cane use reduced EMG activity from baseline by 19.14%. TheraTogs also reduced EMG activity from baseline by 1.10% (change cane use—TheraTogs P=0.009, effect size -0.37) and tape by 3% (not significant). Gait speed (m/s) at: baseline 0.44, cane use 0.45, tape 0.48, TheraTogs 0.49.
Conclusion: Hip abductor taping and TheraTogs increase hemiplegic hip abductor activity and gait speed during walking compared with baseline and cane use.
This study aimed to assess the effectiveness of gait training using body weight support on a treadmill compared with conventional gait training for people with subacute stroke who were unable to walk.
This was a single-blind, randomized, controlled trial with a 6-month follow-up. Ninety-seven subjects were recruited within 6 weeks of stroke onset and were randomly assigned to conventional rehabilitative treatment plus gait training with body weight support on a treadmill (experimental group; n=52) and conventional treatment with overground gait training only (control group; n=45). All subjects were treated in 60-minute sessions every weekday for 4 weeks. Outcome measures were Motricity Index, Trunk Control test, Barthel Index, Functional Ambulation Categories, 10-meter and 6-minute Walk Tests, and Walking Handicap Scale. Assessments were made at baseline, after 20 sessions of treatment, 2 weeks after treatment, and 6 months after stroke.
After treatment, all patients were able to walk. Both groups showed improvement in all outcome measures (P<0.0063) at the end of the treatment and at follow-up. No differences were seen between the 2 groups before, during, and after treatment and at follow-up.
In subacute patients with stroke, gait training on a treadmill with body weight support is feasible and as effective as conventional gait training. However, the need for more personnel for treadmill training makes the use of robotically assisted systems more compelling.
To analyse the effects of gait therapy for patients after acute stroke in a randomized controlled trial.
Fifty-six patients with a mean of 8 days post-stroke participated in: (i) gait trainer exercise; (ii) walking training over ground; or (iii) conventional treatment. Patients in the gait trainer exercise and walking groups practiced gait for 15 sessions over 3 weeks and received additional physiotherapy. Functional Ambulatory Category and several secondary outcome measures assessing gait and mobility were administered before and after rehabilitation and at 6-month follow-up. Patients also evaluated their own effort.
Walking ability improved more with intensive walk training compared with conventional treatment; median Functional Ambulatory Category was zero in all patients at the start of the study, but it was 3 in both walk-training groups and 0.5 in the conventional treatment group at the end of the therapy. Median Functional Ambulatory Category was 4 in both walk-training groups and 2.5 in conventional treatment group at 6-month follow-up. Mean accomplished walking distance was not different between the gait trainer exercise and over ground walking groups. Borg scale indicated more effort in over ground walking. Secondary outcomes also indicated improvements.
Exercise therapy with walking training improved gait function irrespective of the method used, but the time and effort required to achieve the results favour the gait trainer exercise. Early intensive gait training resulted in better walking ability than did conventional treatment.
An operational definition of post-traumatic amnesia is presented and a standardized procedure for the measurement of post-traumatic amnesia, which has been clinically tested in over 100 patients with severe, closed head injury is described. Twenty patients with severe head injuries who were still experiencing post-traumatic amnesia (as defined in this study), were assessed on an independent test of learning ability, as were 20 other patients with severe head injury who were no longer suffering post-traumatic amnesia. The performance of the two groups differed significantly; those in a state of post-traumatic amnesia performed more poorly. Both these groups showed significant impairment when compared with a control group of 20 patients who were in hospital because of orthopaedic injuries that were suffered during a motor vehicle accident. These preliminary results are sufficiently encouraging to recommend this simple procedure for routine use in hospitals, to enhance the accuracy of measuring the severity of head injury. The medicolegal use of this measure is also discussed.
The limited walking ability that follows a stroke restricts the patient's independent mobility about the home and community, a significant social handicap. To improve the in-hospital prediction of functional outcome, the relationships between impairment, disability, and handicap were assessed with clinical measures in 147 stroke patients.
The patients' level of functional walking ability at home and in the community was assigned by expert clinicians to one of the six categories of a modified Hoffer Functional Ambulation scale at least 3 months after discharge. A 19-item questionnaire was further used to assess current customary mobility of the subjects. Functional muscle strength and proprioception were tested, and walking velocity was measured.
The significant indicators of impairment, upright motor control knee flexion and extension strength, differentiated household from community ambulators. The addition of velocity improved the functional prediction. Proprioception was clinically normal in all walkers. The validity of the criteria for the six levels of walking handicap was confirmed statistically. Stepwise discriminant analysis reduced the ambulation activities on the questionnaire from 19 to 7. Redefinition of the criteria for patient classification using the coefficients and constants of the seven critical functions improved the prediction of patient walking ability to 84%.
The results of this study offer a quantitative method of relating the social disadvantage of stroke patients to the impairment and disability sustained. The measurement of therapeutic outcome in relation to the social advantage for the patient would allow more efficient standardization of treatment and services.
Objective: To establish baseline measurements of trunk movements during hemiplegic gait, to assess the relationship between trunk movements and walking ability, and to investigate the effect of walking aids on the trunk movements.
Method: Twenty subjects with a chronic hemiplegia from a stroke, who could walk independently, were recruited. Lateral and vertical movements of the pelvis, and symmetry of these movements were measured using CODA (a three-dimensional movement analysis system) as the subjects walked at their own pace without an aid. They were also tested as they walked with a stick and a tripod to assess the effect of different walking aids. Mean values for the trunk movements and symmetry were calculated, Pearson's correlations assessed the relationship between each trunk movement and gait velocity (a measure of overall walking ability), and the influence of the different aids was assessed using a one-way repeated measures ANOVA.
Results: Lateral displacement was large (mean = 9.9 cm, SD 3.9) and orientated to the sound side, vertical displacement was small (mean = 2.45 cm, SD 1.4). The movements showed marked asymmetry which favoured the hemiplegic side in that there was less movement of, or towards this side. There was a significant relationship (at 5% level) between walking ability and lateral movements (r= 0.6), but not vertical movements (r= 0.41). No significant differences were found with the different aids.
Conclusion: These results give baseline values for trunk movements during hemiplegic gait and the relationship between the movements and walking ability. The use of walking aid and the type of walking aid did not affect the subjects' trunk movements or walking ability.
Objective: To examine the effects of one-point and four-point canes on postural sway and on the distribution of weight between the lower extremities and the walking aids in hemiparetic patients.
Setting: Flieman Geriatric Rehabilitation Hospital, Haifa, Israel.
Subjects: Thirty hemiparetic patients following a unilateral stroke, with moderate functional impairment, and 20 age-matched healthy subjects.
Intervention: Subjects were tested on two forceplates, which were placed at a 30° angle from each other with the heel end of the plates separated by 3 cm. Each subject was tested under three conditions: with no cane, with a one-point cane, and with a four-point cane. Testing time was 30 seconds, and order of testing was randomized.
Outcome measures: Weight borne by the lower extremities and by the walking aids expressed as a percentage of overall body weight, and Sway Index indicating vertical pressure ‘uctuations over both feet.
Results: In both subject groups, the one-point cane did not reduce sway signi”cantly in comparison with no cane, while the four-point cane reduced sway signi”cantly in comparison with both no cane and one-point cane. Neither cane type affected weight-bearing on the paretic leg, while signi”cantly reducing weight-bearing on the uninvolved extremity. Mean percentage of body weight on the four-point cane was signi”cantly higher than on the one-point cane
Conclusions: A four-point cane increases stability of moderately involved hemiparetic patients during stance more than a one-point cane. The noted shift of weight toward the walking aid does not adversely affect weight-bearing on the paretic limb.
To assess the sensations of instability that many patients report after traumatic brain injury (TBI).
A controlled study.
A motion analysis and vestibular and balance laboratory.
Twenty subjects, 10 with TBI and complaints of instability, and 10 without TBI.
Balance and gait analysis.
Dizziness Handicap Inventory (DHI), caloric irrigation, optokinetic testing, Dix-Hallpike Test, posturography, and center of mass (COM) movement.
Subjects were well matched in terms of age, height, weight, and gender. DHI scores of those with and without TBI differed significantly (32.2+/-23.0 vs 0.2+/-0.63, P<.001). Caloric and optokinetic circularvection testing were abnormal only in subjects with TBI (8/10 and 4/10, respectively). Benign paroxysmal positioning vertigo was present in only 3 subjects with TBI, and this either resolved spontaneously (n=1) or was successfully treated (n=2). Composite posturography scores of those with and without TBI differed significantly (69.6+/-35.8 vs 79.5+/-40.5, P=.02). Gait parameters also differed significantly between the groups (P=.05), with the subjects with TBI having lower anterior and posterior and higher medial and lateral COM displacements and velocities.
Patients' complaints of instability after TBI may have objective correlates and may be rectifiable. Balance and gait testing in these patients is warranted.
Rehabilitation after hemiplegic stroke has typically relied on the training of patients in compensatory strategies. The translation of neuroscientific research into care has led to new approaches and renewed promise for better outcomes. Improved motor control can progress with task-specific training incorporating increased use of proximal and distal movements during intensive practice of real-world activities. Functional gains are incorrectly said to plateau by 3-6 months. Many patients retain latent sensorimotor function that can be realised any time after stroke with a pulse of goal-directed therapy. The amount of practice probably best determines gains for a given level of residual movement ability. Clinicians should encourage patients to build greater strength, speed, endurance, and precision of multijoint movements on tasks that increase independence and enrich daily activity. Imaging tools may help clinicians determine the capacity of residual networks to respond to a therapeutic approach and help establish optimal dose-response curves for training. Promising adjunct approaches include practice with robotic devices or in a virtual environment, electrical stimulation to increase cortical excitability during training, and drugs to optimise molecular mechanisms for learning. Biological strategies for neural repair may augment rehabilitation in the next decade.
Objective: To evaluate the effect of repetitive locomotor training on an electromechanical gait trainer plus physiotherapy in subacute stroke patients.
Design: Randomized controlled trial.
Setting: Four German neurological rehabilitation centres. Subjects: One hundred and fifty-five non-ambulatory patients (first-time stroke <60 days).
Intervention: Group A received 20 min locomotor training and 25 min physiotherapy; group B had 45 min physiotherapy every week day for four weeks.
Main outcome measures: Primary variables were gait ability (Functional Ambulation Category, 0-5) and the Barthel Index (0-100), blindly assessed at study onset, end, and six months later for follow-up. Responders to the therapy had to become ambulatory (Functional Ambulation Category 4 or 5) or reach a Barthel Index of ≥ 75. Secondary variables were walking velocity, endurance, mobility and leg power.
Results: The intention-to-treat analysis revealed that significantly greater number of patients in group A could walk independently: 41 of 77 versus 17 of 78 in group B (P B < 0.0001) at treatment end. Also, significantly more group A patients had reached a Barthel Index ≥ 75: 44 of 77 versus 21 of 78 (P B < 0.0001). At six-month follow-up, the superior gait ability in group A persisted (54 of 77 versus 28 of 78, P B < 0.0001), while the Barthel Index responder rate did not differ. For all secondary variables, group A patients had improved significantly more (P B < 0.0001) during the treatment period, but not during follow-up.
Conclusions: Intensive locomotor training plus physiotherapy resulted in a significantly better gait ability and daily living competence in subacute stroke patients compared with physiotherapy alone.
Restoration and improvement of gait after stroke are major aspects of neurorehabilitation. Mobilization out of the bed into the wheelchair and verticalisation with the help of a standing frame are first steps. With the patient cardiovascular stable, gait restoration is put on the agenda. Instead of tone-inhibiting and gait preparatory maneuvers, patients should practice complex gait cycles repetitively. Treadmill training with partial body weight support enables the harness-secured patients to practice numerous steps assisted by two or three therapists. In controlled studies, it proved equally effective as walking on the floor. Gait machines, as the Lokomat or the Gait Trainer GTI, intend to relieve the strenuous effort for the therapists. For the GTI, several controlled trials showed a superior effect in acute stroke patients with respect to walking ability and velocity. For the ambulatory patient, aerobic treadmill training is effective to improve speed and endurance without worsening gait quality. Belt velocity and inclination are gradually increased so that the patients reach a predefined target heart rate. On the belt, patients walk more symmetrically, and higher velocities result in a facilitation of paretic muscles and render gait more efficient. In summary, gait rehabilitation has seen dramatic changes over the last years. More is to be expected.
Purpose. Walking speed is a cardinal indicator of poststroke gait performance; however, no consensus exists regarding the optimal treatment method(s) for its enhancement. The most widely accepted criterion for establishing the contribution of treatment to walking speed is the gain in speed. The actual speed, however, at the end of the intervention (final speed) may be more important for functional community ambulation. This review examines the contribution of the prevailing methods for gait rehabilitation to final walking speed. Method. Walking speed information was derived from studies included in meta-analyses, systematic reviews, and clinical practice guidelines. Recent references, not included in the mentioned sources, were incorporated in cases when gait speed was an outcome variable. Final speed was assessed by the reported speed values and by inferring the capacity for functional community walking at the end of the intervention period. Results. Similar outcomes for final walking speed were found for the different prevailing treatment methods. Treatment gains were likewise comparable and generally insufficient for upgrading patients' functional community walking capacity. Conclusions. Different treatment methods exist for poststroke gait rehabilitation. Their availability, mode of application, and costs vary, yet outcomes are largely similar. Therefore, choosing an appropriate method may be guided by a pragmatic approach. Simple "low technology" and conventional exercise to date is at least as efficacious as more complex strategies such as treadmill and robotic-based interventions.
Does mechanically assisted walking with body weight support result in more independent walking and is it detrimental to walking speed or capacity in non-ambulatory patients early after stroke?
Systematic review with meta-analysis of randomised trials.
Non-ambulatory adult patients undergoing inpatient rehabilitation up to 3 months after stroke.
Mechanically assisted walking (eg, treadmill, electromechanical gait trainer, robotic device, servo-motor) with body weight support (eg, harness with or without handrail, but not handrail alone) versus assisted overground walking of longer than 15 min duration.
The primary outcome was the proportion of participants achieving independent walking. Secondary outcomes were walking speed measured as m/s during the 10-m Walk Test and walking capacity measured as distance in m during the 6-min Walk Test.
Six studies comprising 549 participants were identified and included in meta-analyses. Mechanically assisted walking with body weight support resulted in more people walking independently at 4 weeks (RD 0.23, 95% CI 0.15 to 0.30) and at 6 months (RD 0.23, 95% CI 0.07 to 0.39), faster walking at 6 months (MD 0.12 m/s, 95% CI 0.02 to 0.21), and further walking at 6 months (MD 55 m, 95% CI 15 to 96) than assisted overground walking.
Mechanically assisted walking with body weight support is more effective than overground walking at increasing independent walking in non-ambulatory patients early after stroke. Furthermore, it is not detrimental to walking speed or capacity and clinicians should therefore be confident about implementing this intervention.
The main objective of this randomized trial was to determine whether treadmill walking with body weight support was effective at establishing independent walking more often and earlier than current physiotherapy intervention for nonambulatory stroke patients.
A randomized trial with concealed allocation, blinded assessment, and intention-to-treat analysis was conducted. One hundred twenty-six stroke patients who were unable to walk were recruited and randomly allocated to an experimental or a control group within 4 weeks of stroke. The experimental group undertook up to 30 minutes per day of treadmill walking with body weight support via an overhead harness whereas the control group undertook up to 30 minutes of overground walking. The primary outcome was the proportion of participants achieving independent walking within 6 months.
Kaplan-Meier estimates of the proportion of experimental participants who achieved independent walking were 37% compared with 26% of the control group at 1 month, 66% compared with 55% at 2 months, and 71% compared with 60% at 6 months (P=0.13). The experimental group walked 2 weeks earlier, with a median time to independent walking of 5 weeks compared to 7 weeks for the control group. In addition, 14% (95% CI, -1-28) more of the experimental group were discharged home.
Treadmill walking with body weight support is feasible, safe, and tends to result in more people walking independently and earlier after stroke. Trial Registration- ClinicalTrial.gov (NCT00167531).
The aim of this study was to assess the influence of different types of walking aid on the temporal-distance (T-D) parameters of hemiplegic gait. Twenty hemiplegic subjects who were able to walk independently took part in the study. The subjects’gait was measured as they walked with no aid, a stick of normal height, a high stick and a tripod. The response to different walking conditions was varied, but the subjects could be divided into three groups based on their response. Eleven (55%) subjects tended to walk best without an aid, 5 (25%) subjects showed no difference between the conditions, and 4 (20%) subjects tended to perform better with an aid than without one. None of the aids emerged as the aid of choice but the tripod tended to produce a worse gait than the other two aids.
Severity of hemiplegia, overall gait performance and type of aid normally used were compared in each response group. It was concluded that the severity of hemiplegia was an important determinant of the subjects’response to different walking aids. For people with a relatively mild hemiplegia and who were ‘good walkers’, the use of an aid was either detrimental or had no effect on gait, whereas for those with a more severe hemiplegia and who were ‘poor walkers’, the use of an aid had a beneficial effect on gait.
Reduced gait speed is common following traumatic brain injury (TBI). Several studies have found that people with TBI display increased lateral movement in their center of mass while walking. It has been hypothesized that reduced gait speed following TBI is a consequence of increased caution and postural instability, but reduced ankle power generation at push-off may also play a contributing role.
To determine whether postural instability or reduced muscle power were associated with reduced gait speed following TBI.
A convenience sample of 55 people with TBI receiving physiotherapy for gait disorders were assessed using 3D gait analysis at self-selected and fast walking speeds. A comparison group of 10 healthy controls performed walking trials at a speed matched to the mean TBI self-selected speed and at a fast walking speed.
When matched for speed, people with TBI walked with similar cadence and step length but with reduced ankle power generation at push-off and increased hip power generation both in early stance and in preswing compared with healthy controls. Width of base of support and postural instability were also significantly increased for people with TBI. The differences between the 2 groups at the matched speed remained for the fast speed condition. Postural stability did not deteriorate with increasing gait speed in either group.
Reduced gait speed following TBI appears to be attributable to biomechanical deficiencies such as reduced ankle power generation rather than reduced postural stability and increased caution.
To examine the effects of 3 different walking aids on walking capacity, temporo-spatial gait parameters, and patient satisfaction.
Observational study.
University Hospital of Geneva.
Hemiparetic inpatients (N=25) with impaired gait, at an early stage of rehabilitation, unfamiliar with any of the walking aids tested.
On 3 consecutive days subjects used, in random order, 1 of 3 walking aids: 4-point cane, simple cane with ergonomic handgrip, and Nordic stick.
Maximal walking distance in 6 minutes, temporo-spatial gait parameters determined with a commercial electronic gait analysis system, and patients' preference on a subjective ranking scale.
Walking distance was greatest with the simple cane with an ergonomic handgrip, followed by the 4-point cane and the Nordic walking stick. Walking velocity was highest with the simple cane, which was also indicated as the preferred walking aid by the patients. There was no significant difference in step length symmetry.
The simple cane with the ergonomic handgrip was not only preferred by patients, but was also the most efficient among 3 commonly used walking aids. It appears justified to take patients' subjective preference into account when prescribing a walking aid.
The Gait Deviation Index (GDI) has been proposed as an index of overall gait pathology. This study proposes an interpretation of the difference measure upon which the GDI is based, which naturally leads to the definition of a similar index, the Gait Profile Score (GPS). The GPS can be calculated independently of the feature analysis upon which the GDI is based. Understanding what the underlying difference measure represents also suggests that reporting a raw score, as the GPS does, may have advantages over the logarithmic transformation and z-scaling incorporated in the GDI. It also leads to the concept of a Movement Analysis Profile (MAP) to summarise much of the information contained within kinematic data. A validation study on all children attending a paediatric gait analysis service over 3 years (407 children) provides evidence to support the use of the GPS through analysis of its frequency distribution across different Gross Motor Function Classification System (GMFCS) and Gillette Functional Assessment Questionnaire (FAQ) categories, investigation of intra-session variability, and correlation with the square root of GGI. Correlation with GDI confirms the strong relationship between the two measures. The study concludes that GDI and GPS are alternative and closely related measures. The GDI has prior art and is particularly useful in applications arising out of feature analysis such as cluster analysis or subject matching. The GPS will be easier to calculate for new models where a large reference dataset is not available and in association with applications using the MAP.
To assess the immediate effects of assistive walking devices on functional mobility, walking impairments, and patients' opinions in nonambulant patients after stroke.
Randomized crossover trial.
Inpatient rehabilitation units of 3 United Kingdom hospitals.
Twenty nonambulant patients with stroke undergoing rehabilitation to restore walking.
Five walking conditions: (1) Walking with no device (the control condition), (2) walking with a walking cane, (3) ankle foot orthosis, (4) slider shoe, and (5) a combination of all 3 devices.
Functional mobility (functional ambulation categories), walking impairments (speed, step length of the weak leg), and patients' opinions.
Functional mobility improved with all assistive devices (P<.0001-.005; effect sizes 1.68-0.52; number needed to treat=2-5). Walking impairments were unchanged (P<.800-.988). Participants were generally positive about the devices. They felt their walking, confidence, and safety improved and found the appearance and comfort of the devices acceptable. They would rather walk with the devices than delay walking until a normative gait pattern was achieved without them.
Assistive walking devices improved functional mobility in nonambulant rehabilitation patients with stroke. No changes in walking impairments were found. Participants were generally positive about using the devices. The results support the use of assistive walking devices to enable early mobilization after stroke; 2 patients would need to be treated with a cane or combined devices for 1 to improve functional mobility.
Walking speed is a cardinal indicator of poststroke gait performance; however, no consensus exists regarding the optimal treatment method(s) for its enhancement. The most widely accepted criterion for establishing the contribution of treatment to walking speed is the gain in speed. The actual speed, however, at the end of the intervention (final speed) may be more important for functional community ambulation. This review examines the contribution of the prevailing methods for gait rehabilitation to final walking speed.
Walking speed information was derived from studies included in meta-analyses, systematic reviews, and clinical practice guidelines. Recent references, not included in the mentioned sources, were incorporated in cases when gait speed was an outcome variable. Final speed was assessed by the reported speed values and by inferring the capacity for functional community walking at the end of the intervention period.
Similar outcomes for final walking speed were found for the different prevailing treatment methods. Treatment gains were likewise comparable and generally insufficient for upgrading patients' functional community walking capacity.
Different treatment methods exist for poststroke gait rehabilitation. Their availability, mode of application, and costs vary, yet outcomes are largely similar. Therefore, choosing an appropriate method may be guided by a pragmatic approach. Simple "low technology" and conventional exercise to date is at least as efficacious as more complex strategies such as treadmill and robotic-based interventions.
Treadmill training with partial body weight support is a new and promising therapy in gait rehabilitation of stroke patients. The study intended to investigate its efficiency compared with gait training within regular physiotherapy in nonambulatory patients with chronic hemiparesis.
An A-B-A single-case study design compared treadmill training plus partial body weight support (A) with physiotherapy based on the Bobath concept (B) in seven nonambulatory hemiparetic patients. The minimum poststroke interval was 3 months, and each treatment phase lasted 3 weeks. Variables were gait ability assessed by the Functional Ambulation Category, other motor functions tested by the Rivermead Motor Assessment, muscle strength assessed by the Motricity Index, muscle tone rated by the Modified Ashworth Spasticity Scale, and gait cycle parameters.
Treadmill training was more effective with regard to restoration of gait ability (P < .05) and walking velocity (P < .05). Other motor functions improved steadily during the study. Muscle strength did not change, and muscle tone varied in an unsystematic way. The ratio of cadence to stride length did not alter significantly.
Treadmill training offers the advantages of task-oriented training with numerous repetitions of a supervised gait pattern. It proved powerful in gait restoration of nonambulatory patients with chronic hemiparesis. Treadmill training could therefore become an adjunctive tool to regain walking ability in a shorter period of time.
Although gait training is prominent in the rehabilitation of hemiparetic stroke patients, little is known about its outcome and prognostic factors in mildly affected patients. We therefore intended to assess gait in ambulatory stroke patients before and after a 4-week inpatient rehabilitation program based on the neurodevelopmental technique.
We measured vertical ground reaction forces by force plates in 148 stroke patients. Variables were stance durations, peak vertical ground reaction forces at heel strike (Fz1) and toe-off (Fz2), loading and deloading rates, time to Fz1, and time to Fz2. The absolute changes for both legs and symmetry outcome were calculated. In addition, we assessed maximal walking speed, walking endurance, stair climbing ability, and the Motricity Index.
Stance duration, weight acceptance, push-off of both legs, and the stance duration symmetry improved independent of changes of gait velocity. The symmetry of the ground reaction forces did not improve. Results were even worse for Fz1 and the loading rate at the end of treatment. Sex, age, side of hemiparesis, motor strength, stroke interval, and sensory impairment had no influence on the outcome of symmetry. Functional performance did not improve considerably.
The absolute changes of the ground reaction forces indicated better weight acceptance and push-off of both legs and thus confirmed the efficacy of the neurodevelopmental technique. The symmetry outcome and the functional performance at the end of treatment, however, challenge the efficacy of intensive rehabilitation therapy for 4 weeks in its attempts to restore physiological gait in these mildly affected patients.
A new gait training strategy for patients with stroke proposes to support a percentage of the patient's body weight while retraining gait on a treadmill. This research project intended to compare the effects of gait training with body weight support (BWS) and with no body weight support (no-BWS) on clinical outcome measures for patients with stroke.
One hundred subjects with stroke were randomized to receive one of two treatments while walking on a treadmill: 50 subjects were trained to walk with up to 40% of their body weight supported by a BWS system with overhead harness (BWS group), and the other 50 subjects were trained to walk bearing full weight on their lower extremities (no-BWS group). Treatment outcomes were assessed on the basis of functional balance, motor recovery, overground walking speed, and overground walking endurance.
After a 6-week training period, the BWS group scored significantly higher than the no-BWS group for functional balance (P = 0.001), motor recovery (P = 0.001), overground walking speed (P = 0.029), and overground w alking endurance (P = 0.018). The follow-up evaluation, 3 months after training, revealed that the BWS group continues to have significantly higher scores for overground walking speed (P = 0.006) and motor recovery (P = 0.039).
Retraining gait in patients with stroke while a percentage of their body weight was supported resulted in better walking abilities than gait training while the patients were bearing their full weight. This novel gait training strategy provides a dynamic and integrative approach for the treatment of gait dysfunction after stroke.
Although the neurodevelopmental technique (Bobath) is the most widely used approach in the gait rehabilitation of hemiparetic subjects in Europe, there is little neurophysiological evidence for its presumed effects on gait symmetry and facilitation of paretic muscles during the therapeutic intervention. The study, therefore, investigated the immediate effects of gait entrainment by a physical therapist on the gait of hemiparetic subjects.
Cycle parameters, gait symmetry, hip joint movement and the electromyographic activity of several lower limb muscles were assessed in 22 patients during a classic intervention by five Bobath therapists and while walking with and without a cane.
Multivariate statistics revealed that, while being assisted by the therapist, patients walked faster (P = 0.022), with a longer relative stance period of the affected leg (P = 0.005), a higher symmetry (P = 0.002), larger hip extension (P = 0.001) and more activation (P = 0.026) of the Mm. triceps surae, vastus lateralis, biceps femoris and gluteus medius as compared to walking with and without a cane. Extensor spasticity of the plantar-flexor tended to increase (n.s.). In five subjects, no after-effect could be documented 1 h after a gait training of 30 min.
The study confirmed a more balanced walking pattern in conjunction with facilitation of various weight bearing muscles during the therapeutic intervention. A prolonged single stance period of the affected leg, an unobstructed hip movement, enhanced weight acceptance and a faster gait seemed to be responsible for the observed immediate effects of the therapeutic intervention.
To assess the effects of cane use on the hemiplegic gait of stroke patients, focusing on the temporal, spatial, and kinematic variables.
Case-control study comparing the effect of walking with and without a cane using a six-camera computerized motion analysis system.
Stroke clinic of a tertiary care hospital.
Fifteen ambulatory stroke patients were analyzed, including 10 men and 5 women (mean age, 56.9 years; mean time since stroke, 9.8 weeks). Nine age-matched healthy elderly subjects were recruited as a control group.
Stroke patients walking with a cane showed significantly increased stride period, stride length, and affected side step length, as well as decreased cadence and step width (p < .05) in comparison with those who walked without a cane. There were no significant differences in the gait phases and the five gait events of hemiplegic gait walking with or without a cane. Cane use thus may have more effect on spatial variables than on temporal variables. The affected-side kinematics of hemiplegic gait with a cane showed increased pelvic obliquity, hip abduction, and ankle eversion during terminal stance phase; increased hip extension, knee extension, and ankle plantar-flexion during preswing phase; and increased hip adduction, knee flexion, and ankle dorsiflexion during swing phase as compared with hemiplegic gait without a cane. A cane thus improved the hemiplegic gait by assisting the affected limb to smoothly shift the center of body mass toward the sound limb and to enhance push off during preswing phase. It also improved circumduction gait during swing phase.
Stroke patients walking with a cane demonstrated more normal spatial variables and joint motion than did those without a cane.
This case report describes the use of gait re-education based on the Bobath concept to measure the changes that occurred in the gait of 2 patients with hemiplegia who were undergoing outpatient physical therapy.
One patient ("NM"), a 65-year-old woman, was referred for physical therapy 6 weeks following a right cerebrovascular accident. She attended 30 therapy sessions over a 15-week period. The other patient ("SA"), a 71-year-old woman, was referred for physical therapy 7 weeks following a left cerebrovascular accident. She attended 28 therapy sessions over a 19-week period. Clinical indexes of impairment and disability and 3-dimensional gait data were obtained at the start of treatment and at discharge. Therapy was based on the Bobath concept.
At discharge, NM demonstrated improvements in her hip and knee movements, reduced tone, and improved mobility. At discharge, SA demonstrated improved mobility. During gait, both patients demonstrated more normal movement patterns at the level of the pelvis, the knee, and the ankle in the sagittal plane. SA also demonstrated an improvement in hip extension.
These cases demonstrate that recovery of more normal movement patterns and functional ability can be achieved following a cardiovascular accident and provide insight into the clinical decision making of experienced practitioners using Bobath's concept.
To investigate gait outcomes with supported treadmill ambulation training (STAT) associated with regular rehabilitation in acute stroke survivors.
Randomized controlled trial, pilot study.
Rehabilitation medicine service at a Veterans Affairs medical center.
Seven acute stroke survivors assigned to regular intervention group and 6 patients assigned to STAT intervention.
Regular intervention consisted of 3 hours daily of physical therapy, kinesiotherapy, and occupational therapy. STAT group received regular rehabilitation with STAT substituted for usual gait training. Participants were tested at baseline, treated for an average of 3 weeks, and retested on discharge. The analysis of covariance procedure was used to test for differences between the 2 approaches.
Functional Ambulation Category Scale, gait speed, walking distance, gait energy expenditure, and gait energy cost.
The small sample size did not generate enough power to detect significant differences in any variable. However, medium to large effect sizes of 0.7 and 1.16 standard deviation units were observed for gait energy cost and walk distance, respectively.
This pilot study indicated that STAT is a safe, feasible, and promising intervention for acute stroke survivors. A larger trial is warranted for statistical relevance.
Patients with traumatic brain injury (TBI) complain of "imbalance" or "unsteadiness" while walking, despite a normal gait on clinical examination. Thus, the purpose of this study was to determine if it was possible to quantitatively assess dynamic stability that did not have an obvious neuromuscular origin in individuals following TBI. Ten patients with documented TBI and 10 age, gender, and stature-matched healthy individuals participated in the study. All subjects were instructed to perform unobstructed level walking and to step over obstacles corresponding to 2.5%, 5%, 10%, and 15% of their height. A 13-link biomechanical model of the human body was used to compute the kinematics of the whole body center of mass (COM). Subjects with TBI walked with a significantly slower gait speed and shorter stride length than their matched controls. Furthermore, subjects with TBI displayed a significantly greater and faster medio-lateral (M-L) COM motion and maintained a significantly greater M-L separation distance between their COM and center of pressure (COP) than their matched control subjects. These measurements indicate that subjects with TBI have difficulty maintaining dynamic stability in the frontal plane and have a reduced ability to successfully arrest their sagittal momentum. These findings provide an objective measurement that reflects the complaints of instability not observable on clinical examination for individuals who have suffered a TBI. This ability to identify any functional impairment after a traumatic brain injury that may affect patient safety is critical for prevention of re-injury during the recovery period.
Patients with mild traumatic brain injury (TBI) often complain of dizziness. However, these problems may be undetected by a clinical exam. Therefore, the purpose of this study was to evaluate the relationships between the subjective and objective measures of balance impairment. Ten patients with TBI (6 men and 4 women) and 10 matched controls participated in this study. Average duration since the TBI was 2.8 years (range 0.4-14.4). Six of the 10 subjects with TBI had abnormal imaging studies. All subjects and controls had a normal neuromuscular exam. Tinetti Balance Assessments were obtained and the TBI group was not significantly different from the control group. The Dizziness Handicap Inventory (DHI) score supported their complaints of "unsteadiness" and "imbalance" from the subjects with TBI. The DHI score was 32 +/- 23 (range 4-68) out of a maximum possible score of 100. Balance was tested using computerized dynamic posturography. The Sensory Organization Test score was significantly lower for subjects who had a TBI (70 +/- 12) compared to the control subjects (80 +/- 8), which indicated that the subjects with TBI had poorer balance than the control subjects. A 13-link biomechanical model of the human body was used to compute the kinematics of the whole body center of mass (COM) while walking on a level surface. The subjects with TBI had significantly less displacement in the anterior/posterior direction, walked significantly slower, had significantly greater medial/lateral sway and velocity than the normal controls, and had significantly greater medial/lateral imbalance. There was a significant relationship between the physical aspects of the DHI and posturography. There was also significant relationship between the physical, functional, and total DHI and the motion of the COM. Overall, the motion of the COM predicted between 42 and 69% of the DHI score. The present study has demonstrated that objective measurements can quantify the patient's functional deficits. Therefore, these objective measurement techniques should be used to assess the clinical complaints of imbalance from patients with TBI.
Question
After recent stroke, does six weeks of aerobic treadmill training increase maximum walking speed and capacity more than Bobath walking training?
Design
Randomised, controlled trial with concealed allocation.
Setting
Rehabilitation unit.
Patients
Fifty patients were recruited within six weeks of their first supratentorial stroke. Eligibility criteria included ability to walk 12 m with intermittent help or stand-by, 50 to 75 years of age, a Barthel Index of 50 to 80, and participation in a 12-week rehabilitation program. Twenty-five patients were randomised to the treatment group and 25 to the control group.
Interventions
Each patient received 60 min of individual physiotherapy time per week day for six weeks. For patients in the treatment group, therapy consisted of 30 min of treadmill training and 30 min of Bobath walking training. During treadmill training, patients wore a harness to prevent falls and exercised at 60% of their heart rate reserve. Patients in the control group received 60 min of Bobath walking training. Other aspects of the rehabilitation programme were maintained in both groups according to individual needs.
Outcomes
The primary outcomes were walking speed and capacity, measured at the end of the six week program and 12 weeks later. Speed was taken as the average of two trials of walking 10 m at maximum speed. Capacity was assessed using the six minute walk test. Secondary outcomes included gross motor functions and walking quality.
Results
From baseline to six weeks, speed increased 0.15 m/sec (95% CI 0.12 to 0.18) and capacity increased 34.9 m (95% CI 14.8 to 55) more in the treatment group than in the control group. From baseline to 12 weeks post-program, speed increased 0.22 m/sec (95% CI 0.12 to 0.32) and capacity increased 54.3 m (95% CI 29.8 to 78.2) more in the treatment group than in the control group. Secondary outcomes did not differ significantly at any time between groups.
Conclusion
Treadmill training induces greater improvements in walking speed and distance than Bobath walking training in patients with moderate physical disability due to recent first stroke.
Background:
Treadmill training, with some body weight supported using a harness, is a method of treating walking after stroke. Systematic review is required to assess the cost, effectiveness and acceptance of this treatment.
Objectives:
To assess the effectiveness of treadmill training and/or body weight support in the treatment of walking after stroke. The primary outcomes investigated were walking speed and walking dependency.
Search strategy:
We searched the Cochrane Stroke Group Trials Register (last searched 21 March 2003), the Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 1 2003), MEDLINE (1966-March 2003), EMBASE (1980-March 2003), CINAHL (1982-February 2003) and PEDro (last searched 21 March 2003). In addition, we handsearched relevant conference proceedings, screened reference lists and contacted trialists to identify further published and unpublished trials.
Selection criteria:
Randomised, or quasi-randomised, controlled and cross-over trials of treadmill training and/or body weight support for the treatment of walking after stroke were eligible.
Data collection and analysis:
Two reviewers independently selected trials and extracted data. Trialists were contacted for additional information. A fixed effects model was used for analysis, but if heterogeneity existed (Chi squared statistic) a random effects model was used. Results were analysed as weighted mean differences (WMD) for continuous variables and relative risk (RR) for dichotomous variables. The main outcome variables were walking speed and dependency.
Main results:
Eleven trials (458 participants) were included. There were no statistically significant differences between treadmill training, with or without body weight support, and other interventions for walking speed or dependence. There was a small trend toward the effectiveness of treadmill training with body weight support for participants who could walk independently (WMD: 0.24 m/sec, 95% CI: -0.19 to 0.66 for speed; random effects). The one trial which compared treadmill training with and without body weight support showed benefit at the end of follow-up (mean difference: 0.22 m/sec, 95% CI: 0.05 to 0.39). Adverse events occurred slightly more frequently in participants receiving treadmill training, although statistically there were no differences.
Reviewer's conclusions:
Overall, no statistically significant effect of treadmill training and body weight support was detected. However, among people who could walk independently, treadmill training with body weight support appeared to be more effective than other interventions at improving walking speed, but this conclusion was not robust.
The location of the hip joint centre (HJC) is required for calculations of hip moments, the location and orientation of the femur, and muscle lengths and lever arms. In clinical gait analysis, the HJC is normally estimated using regression equations based on normative data obtained from adult populations. There is limited relevant anthropometric data available for children, despite the fact that clinical gait analysis is predominantly used for the assessment of children with cerebral palsy. In this study, pelvic MRI scans were taken of eight adults (ages 23-40), 14 healthy children (ages 5-13) and 10 children with spastic diplegic cerebral palsy (ages 6-13). Relevant anatomical landmarks were located in the scans, and the HJC location in pelvic coordinates was found by fitting a sphere to points identified on the femoral head. The predictions of three common regression equations for HJC location were compared to those found directly from MRI. Maximum absolute errors of 31 mm were found in adults, 26 mm in children, and 31 mm in the cerebral palsy group. Results from regression analysis and leave-one-out cross-validation techniques on the MRI data suggested that the best predictors of HJC location were: pelvic depth for the antero-posterior direction; pelvic width and leg length for the supero-inferior direction; and pelvic depth and pelvic width for the medio-lateral direction. For single-variable regression, the exclusion of leg length and pelvic depth from the latter two regression equations is proposed. Regression equations could be generalised across adults, children and the cerebral palsy group.
The objective of this study was to attempt the analysis of the ground-foot reaction forces in hemiplegic patients in routine gait re-education conditions, with and without supporting this process with typical orthopaedic aids. Ninety people with hemiparesis participated. The subjects were divided into three groups, according to their locomotion type (no walking aids, stick and elbow crutch). The ground-foot reaction forces during level gait trial were measured for each subject. Analysis was carried out by means of Kistler lane. The ANOVA results showed a considerable effect on almost all ground-foot reaction force parameters, brought about both by the paralysis itself and any walking stick or elbow crutch supporting locomotion. The use of the orthopaedic provisions, especially the elbow crutch, prolongs the time of the single-stance phase duration considerably. In conclusion, the distinct asymmetry of hemiplegic gait manifests itself in the distribution of the ground-foot reaction force. In the sagittal plane, the values of the force impulse indicate that people with a walking stick accelerated using the healthy limb and slowed down using the paralysed limb. In elbow crutch patients the acceleration function seems to be taken over by the crutch.
The purpose of the current study was to examine the effect of different reference frames on lower limb joint moments during gait with a view to identifying a recommended convention for clinical purposes. Data were collected from 10 subjects (nine able-bodied adults and one child with diplegic cerebral palsy) whilst walking at a self-selected speed. Calculations utilised a three-dimensional inverse dynamics model. For each joint, moments were expressed in four different reference frames. Three of the frames were orthogonal: laboratory frame; anatomical frame of proximal segment; anatomical frame of distal segment. The fourth reference frame was a non-orthogonal joint coordinate system (JCS). Significant differences in the joint moment profiles during gait were found with alternative references frames. This was apparent primarily for the transverse plane joint moments for able-bodied adult gait. For the pathological gait pattern presented, there were also marked differences in the frontal plane joint moments and more subtle ones in the sagittal plane. Whilst it is recognised that all possible reference frames for the expression of the net moment vector are mathematically valid, a decision needs to be made as to which one is more clinically useful. It is proposed that the non-orthogonal JCS is most logical on the basis of what, biomechanically, the joint moment actually represents.
To compare the therapeutic effects of conventional gait training (CGT), gait training using an electromechanical gait trainer (EGT), and gait training using an electromechanical gait trainer with functional electric stimulation (EGT-FES) in people with subacute stroke.
Nonblinded randomized controlled trial.
Rehabilitation hospital for adults.
Fifty patients were recruited within 6 weeks after stroke onset; 46 of these completed the 4-week training period.
Participants were randomly assigned to 1 of 3 gait intervention groups: CGT, EGT, or EGT-FES. The experimental intervention was a 20-minute session per day, 5 days a week (weekdays) for 4 weeks. In addition, all participants received their 40-minute sessions of regular physical therapy every weekday as part of their treatment by the hospital.
Five-meter walking speed test, Elderly Mobility Scale (EMS), Berg Balance Scale, Functional Ambulatory Category (FAC), Motricity Index leg subscale, FIM instrument score, and Barthel Index.
The EGT and EGT-FES groups had statistically significantly more improvement than the CGT group in the 5-m walking speed test (CGT vs EGT, P=.011; CGT vs EGT-FES, P=.001), Motricity Index (CGT vs EGT-FES, P=.011), EMS (CGT vs EGT, P=.006; CGT vs EGT-FES, P=.009), and FAC (CGT vs EGT, P=.005; CGT vs EGT-FES, P=.002) after the 4 weeks of training. No statistically significant differences were found between the EGT and EGT-FES groups in all outcome measures.
In this sample with subacute stroke, participants who trained on the electromechanical gait trainer with body-weight support, with or without FES, had a faster gait, better mobility, and improvement in functional ambulation than participants who underwent conventional gait training. Future studies with assessor blinding and larger sample sizes are warranted.
We sought to investigate the efficacy of treatment strategies used to manage motor impairments following acquired brain injury (ABI) in order to provide guidance for clinical practice based on the best available evidence. METHODS AND MAIN OUTCOMES: A systematic review of the literature from 1980-2005 was conducted focusing on pharmacological, non-pharmacological, and exercise interventions available for motor impairments post ABI. The efficacy of a given intervention was classified as strong (supported by two or more randomized controlled trials (RCTs)), moderate (supported by a single RCT), or limited (supported by other types of studies in the absence of RCTs).
Thirty-six studies examining a variety of treatment approaches for motor impairments and activity limitations following ABI were evaluated. The majority of interventions are only supported by limited evidence. However, there is strong evidence that serial casting does reduce ankle plantar contractures due to spasticity of cerebral origin, and strong evidence also suggests that partial body weight supported gait training does not provide any added benefit over conventional gait training. There is also moderate evidence to support the use of functional fine motor control retraining to improve motor coordination, tizanidine for upper and lower extremity spasticity, and specific sit-to-stand training to improve functional ability. There is also moderate evidence that casting alone is as effective as casting and Botulinum toxin injections for plantar contractures.
Although there are a variety of treatment strategies to manage motor impairments and activity limitations following ABI, most are only supported by limited evidence pointing to the need for studies of improved methodological quality in this area.
Gait velocity is a powerful indicator of function and prognosis after stroke. Gait velocity can be stratified into clinically meaningful functional ambulation classes, such as household ambulation (<0.4 m/s), limited community ambulation (0.4 to 0.8 m/s), and full community ambulation (>0.8 m/s). The purpose of the current study was to determine whether changes in velocity-based community ambulation classification were related to clinically meaningful changes in stroke-related function and quality of life.
In subacute stroke survivors with mild to moderate deficits who participated in a randomized clinical trial of stroke rehabilitation and had a baseline gait velocity of 0.8 m/s or less, we assessed the effect of success versus failure to achieve a transition to the next class on function and quality of life according to domains of the Stroke Impact Scale (SIS).
Of 64 eligible participants, 19 were initially household ambulators, and 12 of them (68%) transitioned to limited community ambulation, whereas of 45 initially limited community ambulators, 17 (38%) became full community ambulators. Function and quality-of-life SIS scores after treatment were significantly higher among survivors who achieved a favorable transition compared with those who did not. Among household ambulators, those who transitioned to limited or full community ambulation had significantly better SIS scores in mobility (P=0.0299) and participation (P=0.0277). Among limited community ambulators, those who achieved the transition to full community ambulatory status had significantly better scores in SIS participation (P=0.0085).
A gait velocity gain that results in a transition to a higher class of ambulation results in better function and quality of life, especially for household ambulators. Household ambulators possibly had more severe stroke deficits, reducing the risk of "ceiling" effects in SIS-measured activities of daily living and instrumental activities of daily living. Outcome assessment based on transitions within a mobility classification scheme that is rooted in gait velocity yields potentially meaningful indicators of clinical benefit. Outcomes should be selected that are clinically meaningful for all levels of severity.
To estimate the extent to which clinical and functional features of stroke were related to the use of mobility assistive technology devices.
Longitudinal study of quality of life after stroke.
Hospitals, rehabilitation centers, and universities in Ontario and Quebec.
Subjects (N=316) with confirmed initial stroke were included in this analysis. Fifty-eight percent of the overall sample were men (n=184). The mean age of this sample at the time of the stroke +/- standard deviation was 65.3+/-15.3 years (range, 19-96y). One hundred thirty-five patients received a mobility assistive device poststroke, and 181 did not.
Assistive devices for mobility (canes, walkers, wheelchairs).
Assistive device use and mobility capacity.
Mobility device nonusers were less physically disabled than device users on a variety of measures. Poor physical functioning but good cognition were reliably associated with mobility device use. Use of multiple mobility assistive devices was more often associated with poorer physical functioning than was single device use. For single device users, wheelchair use was predicted by cognition, functional independence, and stroke recovery. Cane users, compared with walker users, had better mobility and were less physically impaired by stroke.
Patients were well matched to device type based on their mobility capacity. The findings of this study suggest that assistive device prescription-outcome relationships in stroke can be effectively and meaningfully modeled.
Background:
Electromechanical and robotic-assisted gait training devices are used in rehabilitation and might help to improve walking after stroke.
Objectives:
To investigate the effect of automated electromechanical and robotic-assisted gait training devices for improving walking after stroke.
Search strategy:
We searched the Cochrane Stroke Group Trials Register (last searched September 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 3, 2006), MEDLINE (1966 to September 2006), EMBASE (1980 to September 2006), CINAHL (1982 to October 2006), AMED (1985 to October 2006), SPORTDiscus (1949 to August 2006), the Physiotherapy Evidence Database (PEDro, searched September 2006) and the engineering databases COMPENDEX (1972 to October 2006) and INSPEC (1969 to October 2006). We handsearched relevant conference proceedings, searched trials and research registers, checked reference lists and contacted authors in an effort to identify further published, unpublished and ongoing trials.
Selection criteria:
We included studies using random assignment.
Data collection and analysis:
Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. The primary outcome was the proportion of patients walking independently (without assistance or help of a person) at follow up.
Main results:
Eight trials (414 participants) were included in this review. Electromechanical-assisted gait training in combination with physiotherapy increased the odds of becoming independent in walking (odds ratio (OR) 3.06, 95% confidence interval (CI) 1.85 to 5.06; P < 0.001), and increased walking capacity (mean difference (MD) = 34 metres walked in six minutes, 95% CI 8 to 60; P = 0.010), but did not increase walking velocity significantly (MD = 0.08 m/sec, 95% CI -0.01 to 0.17; P = 0.08). However, the results must be interpreted with caution because (1) variations between the trials were found with respect to duration and frequency of treatment and differences in ambulatory status of patients, and (2) some trials tested electromechanical devices in combination with functional electrical stimulation.
Authors' conclusions:
Patients who receive electromechanical-assisted gait training in combination with physiotherapy after stroke are more likely to achieve independent walking than patients receiving gait training without these devices. However, further research should address specific questions, for example, which frequency or duration of electromechanical-assisted gait training might be most effective and at what time after stroke, and follow-up studies are needed to find out how long the benefit lasts. Future research should include estimates of the costs (or savings) due to electromechanical gait training.
Stroke is a major source of disability in Canada and other developed countries, which carries with it a high toll in terms of personal suffering for the stroke survivor and their family in addition to the associated economic costs. Despite the impressive body of evidence describing effective and feasible stroke rehabilitation practices, stroke survivors, their families, and health professionals currently do not benefit from a rehabilitation system that is well organized and evidence based. Using the principles of best evidence, we make the case for needed changes to the current system based on 5 processes of care known to be important in the pursuit of optimal outcomes: (1) admission to specialized stroke rehabilitation units, (2) early admission to stroke rehabilitation units, (3) intensive stroke rehabilitation therapies, (4) task-specific rehabilitation therapies, and (5) well-resourced outpatient programs. Implementation of these strategies will be expected to result in improved functional gain, fewer complications, decreased mortality, and reduced need for institutionalization. In addition to providing improved care for both the stroke survivor and their family, evidence-based stroke rehabilitation care is more efficient and may reduce costs. Our experience in Canada suggests that instituting these 5 measures alone will result in significant improvements to the health care system.
To investigate the impact of locomotor treadmill training with partial body-weight support (BWS) before the initiation of overground gait for adults less than 6 weeks poststroke.
Parallel group, posttest only.
Inpatient rehabilitation center.
Adults after first stroke admitted to an inpatient rehabilitation unit: treadmill group (n=7) and comparison group (n=7).
Locomotor treadmill training with partial BWS or traditional gait training methods.
Gait kinematics, symmetry, velocity, and endurance at least 6 months postinsult.
Data from 3-dimensional gait analysis and 6-minute walk test (6MWT) supported improved gait for adults postacute stroke who practiced gait on a treadmill before walking over ground. Gait analysis showed increased knee flexion during swing and absence of knee hyperextension in stance for the treadmill group. In addition, more normal ankle kinematics at initial contact and terminal stance were observed in the treadmill group. Improved gait symmetry in the treadmill group was confirmed by measures of single support time, hip flexion at initial contact, maximum knee flexion, and maximum knee extension during stance. The treadmill group also walked further and faster in the 6MWT than the comparison group.
Application of locomotor treadmill training with partial BWS before overground gait training may be more effective in establishing symmetric and efficient gait in adults postacute stroke than traditional gait training methods in acute rehabilitation.