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The role of movement errors in modifying spatiotemporal gait asymmetry post stroke: a randomized controlled trial.

ABSTRACT: OBJECTIVE:Current rehabilitation to improve gait symmetry following stroke is based on one of two competing motor learning strategies: minimizing or augmenting symmetry errors. We sought to determine which of those motor learning strategies best improves overground spatiotemporal gait symmetry. DESIGN:Randomized controlled trial. SETTING:Rehabilitation research lab. SUBJECTS:In all, 47 participants (59?±?12?years old) with chronic hemiparesis post stroke and spatiotemporal gait asymmetry were randomized to error augmentation, error minimization, or conventional treadmill training (control) groups. INTERVENTIONS:To augment or minimize asymmetry on a step-by-step basis, we developed a responsive, "closed-loop" control system, using a split-belt instrumented treadmill that continuously adjusted the difference in belt speeds to be proportional to the patient's current asymmetry. MAIN MEASURES:Overground spatiotemporal asymmetries and gait speeds were collected prior to and following 18 training sessions. RESULTS:Step length asymmetry reduced after training, but stance time did not. There was no group?×?time interaction. Gait speed improved after training, but was not affected by type of asymmetry, or group. Of those who trained to modify step length asymmetry, there was a moderately strong linear relationship between the change in step length asymmetry and the change in gait speed. CONCLUSION:Augmenting errors was not superior to minimizing errors or providing only verbal feedback during conventional treadmill walking. Therefore, the use of verbal feedback to target spatiotemporal asymmetry, which was common to all participants, appears to be sufficient to reduce step length asymmetry. Alterations in stance time asymmetry were not elicited in any group.

SUBMITTER: Lewek MD

PROVIDER: S-EPMC5748372 | biostudies-literature | 2018 Feb

REPOSITORIES: biostudies-literature

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The role of movement errors in modifying spatiotemporal gait asymmetry post stroke: a randomized controlled trial.

Lewek Michael D MD Braun Carty H CH Wutzke Clint C Giuliani Carol C

Clinical rehabilitation 20170727 2

<h4>Objective</h4>Current rehabilitation to improve gait symmetry following stroke is based on one of two competing motor learning strategies: minimizing or augmenting symmetry errors. We sought to determine which of those motor learning strategies best improves overground spatiotemporal gait symmetry.<h4>Design</h4>Randomized controlled trial.<h4>Setting</h4>Rehabilitation research lab.<h4>Subjects</h4>In all, 47 participants (59 ± 12 years old) with chronic hemiparesis post stroke and spatiote ...[more]

PMID: 28750549

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Project description:BackgroundRegaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AANmDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AANmDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation.MethodsThirty-four participants with unilateral, supratentorial stroke were enrolled (< 10 weeks post onset, Functional Ambulation Categories 3-5) and randomly assigned to six weeks of AANmDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3-5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (WEXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2).ResultsTwo participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AANmDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, WEXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0-T1) and paretic step length (T0-T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AANmDOF robotic group compared to the conventional group (T0-T2).ConclusionsGenerally, AANmDOF robotic training was not superior to conventional training for improving gait pattern in subacute stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AANmDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing. Trial registration Registry number Netherlands Trial Register ( www.trialregister.nl ): NTR5060. Registered 13 February 2015.

Project description:BackgroundRobots offer an alternative, potentially advantageous method of providing repetitive, high-dosage, and high-intensity training to address the gait impairments caused by stroke. In this study, we compared the effects of the Stride Management Assist (SMA®) System, a new wearable robotic device developed by Honda R&D Corporation, Japan, with functional task specific training (FTST) on spatiotemporal gait parameters in stroke survivors.MethodsA single blinded randomized control trial was performed to assess the effect of FTST and task-specific walking training with the SMA® device on spatiotemporal gait parameters. Participants (n=50) were randomly assigned to FTST or SMA. Subjects in both groups received training 3 times per week for 6-8 weeks for a maximum of 18 training sessions. The GAITRite® system was used to collect data on subjects' spatiotemporal gait characteristics before training (baseline), at mid-training, post-training, and at a 3-month follow-up.ResultsAfter training, significant improvements in gait parameters were observed in both training groups compared to baseline, including an increase in velocity and cadence, a decrease in swing time on the impaired side, a decrease in double support time, an increase in stride length on impaired and non-impaired sides, and an increase in step length on impaired and non-impaired sides. No significant differences were observed between training groups; except for SMA group, step length on the impaired side increased significantly during self-selected walking speed trials and spatial asymmetry decreased significantly during fast-velocity walking trials.ConclusionsSMA and FTST interventions provided similar, significant improvements in spatiotemporal gait parameters; however, the SMA group showed additional improvements across more parameters at various time points. These results indicate that the SMA® device could be a useful therapeutic tool to improve spatiotemporal parameters and contribute to improved functional mobility in stroke survivors. Further research is needed to determine the feasibility of using this device in a home setting vs a clinic setting, and whether such home use provides continued benefits.Trial registrationThis study is registered under the title "Development of walk assist device to improve community ambulation" and can be located in clinicaltrials.gov with the study identifier: NCT01994395 .

Project description:Understanding the reorganization of the central nervous system after stroke is an important endeavor in order to design new therapies in gait training for stroke patients. Current clinical evaluation scores and gait velocity are insufficient to describe the state of the nervous system, and one aspect where this is lacking is in the quantification of gait symmetry. Previous studies have pointed out that spatiotemporal gait asymmetries are commonly observed in stroke patients with hemiparesis. Such asymmetries are known to cause long-term complications like joint pain and deformation. Recent studies also indicate that spatiotemporal measures showed that gait symmetry worsens after discharge from therapy. This study shows that muscle synergy analysis can be used to quantify gait symmetry and compliment clinical measures. Surface EMG was collected from lower limb muscles of subacute post-stroke patients (with an onset of around 14 days) from two groups, one undergoing robotic-assisted therapy (known as HAL group) and the other undergoing conventional therapy (known as Control group). Muscle synergies from the paretic and non-paretic limb were extracted with Non-Negative Matrix Factorization (NNMF) and compared with each other to obtain a gait symmetry index over therapy sessions. Gait events were tracked with motion tracking (for the HAL group) or foot pressure sensors (for the conventional therapy group). Patients from both groups were assessed over a 3-weeks long gait training program. Results indicated that there were no differences in muscle synergy symmetry for both groups of patients. However, the timing of muscle synergies were observed to be symmetrical in the HAL group, but not for the Control group. Intergroup comparisons of symmetry in muscle synergies and their timings were not significantly different. This could be due to a large variability in recovery in the Control group. Finally, stance time ratio was not observed to improve in both groups after their respective therapies. Interestingly, FIM and FMA scores of both groups were observed to improve after their respective therapies. Analysis of muscle coordination could reveal mechanisms of gait symmetry which could otherwise be difficult to observe with clinical scores.

Project description:Gait deficit is a major complaint in patients after stroke, restricting certain activities of daily living. Photobiomodulation therapy combined with a static magnetic field (PBMT-SMF) has been studied for several diseases, and the two therapies are beneficia. However, their combination has not yet been evaluated in stroke. Therefore, for PBMT-SMF to be used more often and become an adjunctive tool in the rehabilitation of stroke survivors at physical therapy rehabilitation centers and clinics, some important aspects need to be clarified. This study aimed to test different doses of PBMT-SMF, to identify the ideal dose to cause immediate effects on the spatiotemporal and kinematic variables of gait in post-stroke patients. A randomized, triple-blinded, placebo-controlled crossover pilot study was performed. A total of 10 individuals with hemiparesis within 6 months to 5 years since the occurrence of stroke, aged 45-60 years, were included in the study. Participants were randomly assigned and treated with a single PBMT-SMF dose (sham, 10 J, 30 J, or 50 J) on a single application, with one dose per stage at 7-day intervals between stages. PBMT-SMF was applied with a cluster of 12 diodes (4 of 905 nm laser, 4 of 875 nm LEDs, and 4 of 640 nm LEDs, SMF of 35 mT) at 17 sites on both lower limbs after baseline evaluation: plantar flexors (2), knee extensors (9), and flexors (6). The primary outcome was self-selected walking speed, and the secondary outcomes were kinematic parameters. Gait analysis was performed using SMART-D 140® and SMART-D INTEGRATED WORKSTATION®. The outcomes were measured at the end of each stage after the single application of each PBMT-SMF dose tested. No significant differences (p > 0.05) in spatiotemporal variables were observed between the different doses, compared with the baseline evaluation. However, differences (p < 0.05) were observed in the kinematic variable of the hip in the paretic and non-paretic limbs, specifically in the minimum flexion/extension angulation during the support phase (HMST-MIN) in doses 10 J, 30 J, and 50 J. A single application of PBMT-SMF at doses of 10 J, 30 J, and 50 J per site of the lower limbs did not demonstrate positive effects on the spatiotemporal variables, but it promoted immediate effects in the kinematic variables of the hip (maximum and minimum flexion/extension angulation during the support phase) in the paretic and non-paretic limbs in post-stroke people.

Project description:BackgroundOccupational therapy (OT) is an effective evidence-based intervention that positively influences stroke patients'independence recovery, leading to new opportunities for better quality of life outcomes.ObjectivesTo explore the effectiveness of an early OT intervention program (EOTIPS) in the process of hospital to home discharge after stroke in Spain.Material and methodsWe conducted a prospective, randomized controlled clinical trial that included 60 adults who suffered a stroke and were discharged home. Participants assigned to the experimental group (n = 30) were included in EOTIPS and compared with a control group (n = 30). Evaluations assessed quality of life (Stroke and Aphasia Quality of Life Scale [SAQOL-39]), functional independence (Modified Rankin Scale [mRS], Barthel Index [BI] and Stroke Impact Scale-16 [SIS-16]), perceptual-cognitive skills (Montreal Cognitive Assessment [MoCA]), upper limb function (Fugl Meyer Assessment [FMA]), mobility (Berg Balance Scale [BBS] and Timed Up & Go [TUG]), communication skills (Communicative Activity Log [CAL]) and mood disorders (Beck Depression Inventory-II [BDI-II] and Hamilton Anxiety Scale [HAM-A]); they were completed within two weeks post-stroke and after three months follow-up. Statistical analysis included intent-to-treat analysis, considering all participants (dropouts as failures), and efficacy analysis, considering only end-of-treatment participants.ResultsParticipants in the intervention group showed a significant better evolution in the main outcome measure of quality of life (SAQOL-39 p = .029), as well as for independence (mRSp = .004), perceptual-cognitive skills (MoCA p = .012)and symptoms of depression (BDI-II p = .011) compared to the control group.ConclusionsEOTIPS was effective in improving quality of life, as well as enhancing perceptual-cognitive skills, independence and reducing levels of depression for patients who suffered a stroke in a Spanish cohort and could be considered as an applicable non-pharmacologic therapeutic tool that can lead to patients' positive outcomes after stroke. This study was registered on ClinicalTrials.gov with the identifier NCT04835363.

Project description:BackgroundTelerehabilitation allows rehabilitative training to continue remotely after discharge from acute care and can include complex tasks known to create rich conditions for neural change.ObjectivesThe purposes of this study were: (1) to explore the feasibility of using telerehabilitation to improve ankle dorsiflexion during the swing phase of gait in people with stroke and (2) to compare complex versus simple movements of the ankle in promoting behavioral change and brain reorganization.DesignThis study was a pilot randomized controlled trial.SettingTraining was done in the participant's home. Testing was done in separate research labs involving functional magnetic resonance imaging (fMRI) and multi-camera gait analysis.PatientsSixteen participants with chronic stroke and impaired ankle dorsiflexion were assigned randomly to receive 4 weeks of telerehabilitation of the paretic ankle.InterventionParticipants received either computerized complex movement training (track group) or simple movement training (move group).MeasurementsBehavioral changes were measured with the 10-m walk test and gait analysis using a motion capture system. Brain reorganization was measured with ankle tracking during fMRI.ResultsDorsiflexion during gait was significantly larger in the track group compared with the move group. For fMRI, although the volume, percent volume, and intensity of cortical activation failed to show significant changes, the frequency count of the number of participants showing an increase versus a decrease in these values from pretest to posttest measurements was significantly different between the 2 groups, with the track group decreasing and the move group increasing.LimitationsLimitations of this study were that no follow-up test was conducted and that a small sample size was used.ConclusionsThe results suggest that telerehabilitation, emphasizing complex task training with the paretic limb, is feasible and can be effective in promoting further dorsiflexion in people with chronic stroke.

Project description:BackgroundFalls are the leading cause of injury in stroke patients. However, the cause of a fall is complicated, and several types of risk factors are involved. Therefore, a comprehensive model to predict falls with high sensitivity and specificity is needed.MethodsThis study was a prospective study of 112 inpatients in a rehabilitation ward with follow-up interviews in patients' homes. Evaluations were performed 1 month after stroke and included the following factors: (1) status of cognition, depression, fear of fall and limb spasticity; (2) functional assessments [walking velocity and the Functional Independence Measure (FIM)]; and (3) objective, computerized gait and balance analyses. The outcome variable was the number of accidental falls during the 6-month follow-up period after baseline measurements.ResultsThe non-faller group exhibited significantly better walking velocity and FIM scale compared to the faller group (P < .001). The faller group exhibited higher levels of spasticity in the affected limbs, asymmetry of gait parameters in single support (P < .001), double support (P = .027), and step time (P = .003), and lower stability of center of gravity in the medial-lateral direction (P = .008). Psychological assessments revealed that the faller group exhibited more severe depression and lower confidence without falling. A multivariate logistic regression model identified three independent predictors of falls with high sensitivity (82.6%) and specificity (86.5%): the asymmetry ratio of single support [adjusted odds ratio, aOR = 2.2, 95% CI (1.2-3.8)], the level of spasticity in the gastrocnemius [aOR = 3.2 (1.4-7.3)], and the degree of depression [aOR = 1.4 (1.2-1.8)].ConclusionsThis study revealed depression, in additional to gait asymmetry and spasticity, as another independent factor for predicting falls. These results suggest that appropriate gait training, reduction of ankle spasticity, and aggressive management of depression may be critical to prevent falls in stroke patients.

Dataset Information

The role of movement errors in modifying spatiotemporal gait asymmetry post stroke: a randomized controlled trial.

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The role of movement errors in modifying spatiotemporal gait asymmetry post stroke: a randomized controlled trial.

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