Impact of locomotion training with a neurologic controlled hybrid assistive limb (HAL) exoskeleton on neuropathic pain and health related quality of life (HRQoL) in chronic SCI: a case study*

Chronic neuropathic pain (CNP) is a common condition associated with spinal cord injury (SCI) and has been reported to be severe, disabling and often treatment-resistant and therefore remains a clinical challenge for the attending physicians. The treatment usually includes pharmacological and/or nonpharmacological approaches. Body weight supported treadmill training (BWSTT) and locomotion training with driven gait orthosis (DGO) have evolved over the last decades and are now considered to be an established part in the rehabilitation of SCI patients. Conventional locomotion training goes along with improvements of the patients' walking abilities in particular speed and gait pattern. The neurologic controlled hybrid assistive limb (HAL®, Cyberdyne Inc., Ibraki, Japan) exoskeleton, however, is a new tailored approach to support motor functions synchronously to the patient's voluntary drive. This report presents two cases of severe chronic and therapy resistant neuropathic pain due to chronic SCI and demonstrates the beneficial effects of neurologic controlled exoskeletal intervention on pain severity and health-related quality of life (HRQoL). Both of these patients were engaged in a 12 weeks period of daily HAL®-supported locomotion training. In addition to improvements in motor functions and walking abilities, both show significant reduction in pain severity and improvements in all HRQoL domains. Although various causal factors likely contribute to abatement of CNP, the reported results occurred due to a new approach in the rehabilitation of chronic spinal cord injury patients. These findings suggest not only the feasibility of this new approach but in conclusion, demonstrate the effectiveness of neurologic controlled locomotion training in the long-term management of refractory neuropathic pain.

• Implications for Rehabilitation

• CNP remains a challenge in the rehabilitation of chronic SCI patients.

• Locomotion training with the HAL exoskeleton seems to improve CNP in chronic SCI.

• HAL locomotion training is feasible and safe in the rehabilitation of chronic SCI patients.

     

Balance impairment limits ability to increase walking speed in individuals with chronic stroke

Purpose Determine the relationship between balance impairments and the ability to increase walking speed (WS) on demand in individuals with chronic stroke. Methods WS and Berg Balance Scale (BBS) data were collected on 124 individuals with chronic stroke (>6 months). The ability to increase WS on demand (walking speed reserve, WSR) was quantified as the difference between participants’ self-selected (SSWS) and maximal (MWS) walking speeds. Correlation, regression and receiver operating characteristic (ROC) analyses were performed to investigate the relationship between balance and the ability to increase WS. Results Of sample, 58.9% were unable to increase WS on demand (WSR?r_s=0.74, 0.65–0.81) and were predictive of ‘able/unable’ to increase WS [odds ratio (OR)?=?0.75, 0.67–0.84]. The AUC for the ROC curve constructed to assess the accuracy of BBS to discriminate between able/unable to increase WS was 0.85 (0.78–0.92). A BBS cutscore of 47 points was identified [sensitivity: 72.6%, specificity: 90.2%,?+likelihood ratio (LR): 7.41, ?LR: 0.30]. Conclusions The inability to increase WS on demand is common in individuals with chronic stroke, and balance appears to be a significant contributor to this difficulty. A BBS cutscore of 47 points can identify individuals who may benefit from balance interventions to improve the ability to increase their WS.

• Implications for Rehabilitation

• A majority of individuals with chronic stroke may be unable to increase their walking speed beyond their self-selected speed on demand.

• This may limit functional ambulation, as these individuals are walking “at capacity”.

• Balance impairments contribute to the inability to increase walking speed.

• A Berg Balance Scale score <47 points can be used to identify individuals with chronic stroke walking “at capacity” due to balance impairments.

     

Body weight supported treadmill training versus traditional training in patients dependent on walking assistance after stroke: a randomized controlled trial

Purpose: Treadmill training with body weight support (TTBWS) for relearning walking ability after brain damage is an approach under current investigation. Efficiency of this method beyond traditional training is lacking evidence, especially in patients needing walking assistance after stroke. The objective of this study was to investigate change in walking and transfer abilities, comparing TTBWS with traditional walking training. Methods: A single-blinded, randomized controlled trial was conducted. Sixty patients referred for multi-disciplinary primary rehabilitation were assigned into one of two intervention groups, one received 30 sessions of TTBWS plus traditional training, the other traditional training alone. Daily training was 1?hr. Outcome measures were Functional Ambulation Categories (FAC), Walking, Functional Independence Measure (FIM); shorter transfer and stairs, 10 m and 6-min walk tests. Results: Substantial improvements in walking and transfer were shown within both groups after 5 and 11 weeks of intervention. Overall no statistical significant differences were found between the groups, but 12 of 17 physical measures tended to show improvements in favour of the treadmill approach. Conclusions: Both training strategies provided significant improvements in the tested activities, suggesting that similar outcomes can be obtained in the two modalities by systematic, intensive and goal directed training.

Implications for Rehabilitation

• Treadmill training with body weight support (TTBWS) and traditional gait training were found to be equally effective in improving walking and transfer in patients dependent on walking assistance after stroke.

• However, most outcome measures showed a tendency of improvement in favour of the treadmill group.

• Both training modalities were systematic, goal-directed and intensive, and the time used for training was the same.

• The choice between the two equally effective training alternatives should be based on the patients’ preference, and availability of equipment and resources.

     

Locomotion Improvement Using a Hybrid Assistive Limb in Recovery Phase Stroke Patients: A Randomized Controlled Pilot Study

Objective

To compare the efficacy of gait training using a single-leg version of the Hybrid Assistive Limb (HAL) on the paretic side with conventional gait training in individuals with subacute stroke.

Design

Randomized open controlled pilot trial.

Setting

Hospitalized care.

Participants

Convenience sample of 44 patients who met the criteria; 12 patients refused. After randomization (N=32), 10 patients withdrew and a total of 22 poststroke participants (HAL group: n=11; conventional group: n=11) completed the randomized controlled trial.

Interventions

All participants received twelve 20-minute sessions in 4 weeks of either HAL (wearing the single-leg version of the HAL on their paretic side) or conventional (performed by skilled and experienced physical therapists) gait training.

Main Outcome Measures

Outcome measures were evaluated prior to training and after 12 sessions. Functional Ambulation Category (FAC) was the primary outcome measure, whereas secondary outcome measures included maximum walking speed, timed Up and Go test, 6-minute walk distance, Short Physical Performance Battery, Fugl-Meyer Assessment of Lower Extremity, and isometric muscle strength (hip flexion and extension, knee flexion and extension).

Results

No participants withdrew because of adverse effects. Participants who received gait training with the HAL showed significantly more improvement in the FAC than those who received conventional gait training (95% confidence interval, .02–.88; P=.04). Secondary measures did not differ between the 2 groups.

Conclusions

The results obtained in this randomized controlled trial suggest that a gait training program with the HAL could improve independent walking more efficiently than conventional gait training.     

Training to walk amid uncertainty with Re-Step: measurements and changes with perturbation training for hemiparesis and cerebral palsy

Abstract

Purpose: To describe Re-Step?, a novel mechatronic shoe system that measures center of pressure (COP) gait parameters and complexity of COP dispersion while walking, and to demonstrate these measurements in healthy controls and individuals with hemiparesis and cerebral palsy (CP) before and after perturbation training. Method: The Re-Step? was used to induce programmed chaotic perturbations to the feet while walking for 30?min for 36 sessions over 12-weeks of training in two subjects with hemiparesis and two with CP. Results: Baseline measurements of complexity indices (fractal dimension and approximate entropy) tended to be higher in controls than in those with disabilities, while COP variability, mean and variability of step time and COP dispersion were lower. After training the disabled subjects these measurement values tended toward those of the controls, along with a decrease in step time, 10?m walk time, average step time, percentage of double support and increased Berg balance score. Conclusions: This pilot trial reveals the feasibility and applicability of this unique measurement and perturbation system for evaluating functional disabilities and changes with interventions to improve walking.

• Implication for Rehabilitation

• Walking, of individuals with cerebral palsy and hemiparesis following stroke, can be viewed in terms of a rigid motor behavior that prevents adaptation to changing environmental conditions.

• Re-Step system (a) measures and records linear and non-linear gait parameters during free walking to provide a detailed evaluation of walking disabilities, (b) is an intervention training modality that applies unexpected perturbations during walking.

• This perturbation intervention may improve gait and motor functions of individuals with hemiparesis and cerebral plasy.

     

The effect of a task-specific locomotor training strategy on gait stability in patients with cerebellar disease: a feasibility study

Purpose: There is a lack of evidence-based recommendations for the physiotherapeutic intervention specifically for locomotor training in patients with cerebellar ataxia. The purpose of this study is to determine the feasibility and effect of a more specific rehabilitation strategy that aims to improve gait quality in patients with cerebellar ataxia.

Methods: Nineteen patients with degenerative cerebellar ataxia were recruited to participate in the study. The patients participated in a 12-week locomotor training program, two times per week for 1.5?h per session (a total of 24 training sessions). The treatment approach emphasized the relearning of proper gait movement strategies through intensive practice that enhances the patient's perception and control of the essential components of normal gait movement.

Results: A quantitative analysis of step-by-step gait performance indicated that postural sway during locomotion was reduced, and the gait movement pattern became more consistent after the 12-week locomotor training program. These improvements in gait stability persisted over the 3-month period following intervention.

Conclusion: This study provides preliminary evidence that learning-based rehabilitation strategies targeting disease-specific locomotion symptoms may be helpful for reducing ataxic gait and improving motor control during walking in patients with cerebellar dysfunction.

• Implications for rehabilitation

• Physiotherapeutic interventions that aim to promote gait stability in cerebellar patients need to create a specific learning context that improve disease-related gait deficits.

• It is desirable to use explicit instructions to facilitate the conscious awareness and control of body center and posture.

• As patients reacquire the fundamental gait ability, providing training experience with various locomotor tasks that facilitate the transfer of learning may be helpful to increase generalizability of locomotor intervention.

     

The immediate effects of robot-assistance on energy consumption and cardiorespiratory load during walking compared to walking without robot-assistance: a systematic review

Purpose: The integration of sufficient cardiovascular stress into robot-assisted gait (RAG) training could combine the benefits of both RAG and aerobic training. The aim was to summarize literature data on the immediate effects of RAG compared to walking without robot-assistance on metabolic-, cardiorespiratory- and fatigue-related parameters.

Methods: PubMed and Web of Science were searched for eligible articles till February 2016. Means, SDs and significance values were extracted. Effect sizes were calculated.

Results: Fourteen studies were included, concerning 155 participants (85 healthy subjects, 39 stroke and 31 spinal cord injury patients), 9 robots (2 end-effectors, 1 treadmill-based and 6 wearable exoskeletons), and 7 outcome parameters (mostly oxygen consumption and heart rate). Overall, metabolic and cardiorespiratory parameters were lower during RAG compared to walking without robot-assistance (moderate to large effect sizes). In healthy subjects, when no body-weight support (BWS) was provided, RAG with an end-effector device was more energy demanding than walking overground (p?>?.05, large effect sizes).

Conclusions: Generally, results suggest that RAG is less energy-consuming and cardiorespiratory stressful than walking without robot-assistance, but results depend on factors such as robot type, walking speed, BWS and effort. Additional research is needed to draw firm conclusions.

• Implications for Rehabilitation

• Awareness of the energy consumption and cardiorespiratory load of robot-assisted gait (RAG) training is important in the rehabilitation of (neurological) patients with impaired cardiorespiratory fitness and patients who are at risk of cardiovascular diseases. On the other hand, the integration of sufficient cardiometabolic stress in RAG training could combine the effects of both RAG and aerobic training.

• Energy consumption and cardiorespiratory load during walking with robot-assistance seems to depend on factors such as robot type, walking speed, body-weight support or amount of effort. These parameters could be adjusted in RAG rehabilitation to make RAG more or less energy-consuming and cardiorespiratory stressful.

• Overall, short duration exoskeleton walking seems less energy-consuming and cardiorespiratory stressful than walking without robot-assistance. This might implicate that the exercise intensity is safe for (neurological) patients at risk of cardiovascular diseases. How this changes in extended walking time is unclear.

     

Recovery of walking ability using a robotic device in subacute stroke patients: a randomized controlled study

Purpose: This study investigates the effectiveness of Lokomat + conventional therapy in recovering walking ability in non-ambulatory subacute stroke subjects involved in inpatient rehabilitation. Method: Thirty first-ever stroke patients completed 8 weeks of intervention. One group (n?=?16) received Lokomat therapy twice a week, combined with three times 30?min a week of conventional overground therapy. The second group (n?=?14) received conventional assisted overground therapy only, during a similar amount of time (3.5?h a week). The intervention was part of the normal rehabilitation program. Primary outcome measure was walking speed. Secondary outcome measures assessed other walking- and mobility-related tests, lower-limb strength and quality of life measures. All outcome measures were assessed before and after the intervention and at wk 24 and wk 36 after start of the intervention. Results: Patients showed significant (p?Conclusion: These results indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as conventional therapy alone.

• Implications for Rehabilitation

• Recovery of walking after stroke is important.

• Robot-assisted therapy is currently receiving much attention in research and rehabilitation practice as devices such as the Lokomat seem to be promising assistive devices.

• Technical developments, sub-optimal study designs in literature and new therapy insights warrant new effectiveness studies.

• Results of a financially and practically feasible study indicate that substituting Lokomat therapy for some of conventional therapy is as effective in recovering walking ability in non-ambulatory stroke patients as compared to conventional overground therapy alone.

     

2nd International Symposium on Gait and Balance in Multiple Sclerosis: interventions for gait and balance in MS

Abstract

Purpose: To provide a review of the 2nd International Symposium on Gait and Balance in Multiple Sclerosis (MS), emphasizing interventions in gait and balance for people with MS. Method: Review of current research on interventions used with people having MS and with people having other disorders that may provide novel insights into improving gait and balance and preventing falls in people with MS (pwMS). Results: Nine speakers provided evidence-based recommendations for interventions aimed at improving gait and balance dysfunction. Speaker recommendations covered the following areas: balance rehabilitation, self-management, medications, functional electrical stimulation, robotics, sensory augmentation, gait training with error feedback and fall prevention. Conclusions: The causes of gait and balance dysfunction in pwMS are multifactorial and therefore may benefit from a wide range of interventions. The symposium provides avenues for exchange of evidence and clinical experience that is critical in furthering physical rehabilitation including gait and balance dysfunction in MS.

• Implications for Rehabilitation

• Approaches to improve Gait and Balance dysfunction in Multiple Sclerosis.

• Balance exercises that include training of sensory strategies.

• Self-management and self-management support.

• Pharmacologic intervention, such as Dalfampradine.

• Functional electrical stimulation that may provide the extra stimulation to influence coordinated leg movements needed for walking.

     

What is it like to walk with the help of a robot? Children’s perspectives on robotic gait training technology

Abstract

Purpose: Robotic gait training is an emerging intervention that holds great therapeutic promise in the rehabilitation of children with neuromotor disorders such as cerebral palsy (CP). Little is known about children and parents’ views on this new technology. The purpose of this qualitative study was to investigate the expectations and experiences of children with CP in relation to robotic gait training using the Lokomat®Pro. Method: An interpretivist qualitative design was employed in which perspectives of children and parents were elicited through separate semi-structured interviews to examine expectations of and experiences with the Lokomat. Results: Four themes related to children’s expectations and experiences using the Lokomat were identified: (1) Not sure what to expect, but okay, I will do it; (2) It’s more than just the Lokomat, it’s the people that make the difference; (3) Having mixed impressions about the Lokomat; and (4) It’s probably helping me, but I don’t really know. Conclusions: Rehabilitation professionals, researchers and parents are encouraged to reflect on why and how one might engage children in gait-related rehabilitation in ways that appeal to children’s desires and expectations. This may shape how interventions are presented to children and how goals and outcomes are framed.

• Implications for Rehabilitation

• Children in this study did not consistently feel excited about, have a wish to use, or have a sustained interest in the use of a robotic technology, and at times experienced some anxiety in relation to their participation in the intervention.

• Contrary to assumptions that disabled children value walking “normally”, children in this study did not express a desire to walk in typical (non-disabled) gait patterns, and equated so-called “normal” walking with their usual walking styles.

• Thus, we encourage clinicians, researchers and parents to reflect on why, when and how best to engage children in gait-related rehabilitation in ways that appeal to and align with children’s desires and expectations.

     

Bilateral step length estimation using a single inertial measurement unit attached to the pelvis

Background

The use of automated electromechanical devices for gait training in neurological patients is increasing, yet the functional outcomes of well-defined training programs using these devices and the characteristics of patients that would most benefit are seldom reported in the literature. In an observational study of functional outcomes, we aimed to provide a benchmark for expected change in gait function in early stroke patients, from an intensive inpatient rehabilitation program including both robotic and manual gait training.

Methods

We followed 103 sub-acute stroke patients who met the clinical inclusion criteria for Body Weight Supported Robotic Gait Training (BWSRGT). Patients completed an intensive 8-week gait-training program comprising robotic gait training (weeks 0-4) followed by manual gait training (weeks 4-8). A change in clinical function was determined by the following assessments taken at 0, 4 and 8 weeks (baseline, mid-point and end-point respectively): Functional Ambulatory Categories (FAC), 10 m Walking Test (10 MWT), and Tinetti Gait and Balance Scales.

Results

Over half of the patients made a clinically meaningful improvement on the Tinetti Gait Scale (> 3 points) and Tinetti Balance Scale (> 5 points), while over 80% of the patients increased at least 1 point on the FAC scale (0-5) and improved walking speed by more than 0.2 m/s. Patients responded positively in gait function regardless of variables gender, age, aetiology (hemorrhagic/ischemic), and affected hemisphere. The most robust and significant change was observed for patients in the FAC categories two and three. The therapy was well tolerated and no patients withdrew for factors related to the type or intensity of training.

Conclusions

Eight-weeks of intensive rehabilitation including robotic and manual gait training was well tolerated by early stroke patients, and was associated with significant gains in function. Patients with mid-level gait dysfunction showed the most robust improvement following robotic training.     

Balance and walking performance are improved after resistance and aerobic training in persons with chronic stroke

Purpose: To investigate the effect of different types of physical training on balance performance and whether improved balance correlates with improved walking performance.

Methods: Forty eight participants with chronic stroke were randomly assigned to aerobic training on cycle ergometer (AT-group), resistance training of the lower extremities (RT-group), or sham training of upper extremities (ST-group). Participants exercised 3 d/week for 12 weeks. Balance (Berg Balance Scale), peak oxygen uptake rate, isometric knee extensor strength, maximal gait speed, and 6?minute walk test were measured at baseline and after 12 weeks.

Results: Training specific effects were observed; the AT-group improved peak oxygen uptake rate by 15.5 (6.0–25.0)%, the RT-group improved non-paretic knee extensor strength by 35.1 (18.3–51.9)% and the ST-group improved non-paretic knee extensor strength by 8.9 (0.7–17.1)%. All groups improved balance (6.0 (95% CI: 3.2–8.8)%), maximal gait speed (10.2 (6.5–14.0)%), and 6?minute walk distance (12.4 (8.8–15.9)%) but balance improvements did not correlate with improvements in muscle strength, peak oxygen uptake rate, or walking.

Conclusions: Physical exercise improves balance and walking performance, but improved balance is not a prerequisite for functional improvements in chronic stroke.

• Implications for Rehabilitation

• Aerobic training and progressive resistance training show small significant improvements in balance and walking, indicating a possible clinical relevance of these training modalities.

• Improvements in balance may not be a prerequisite for improvements in walking distance when assistive devices are allowed during walking tests.

     

A randomised controlled trial of integrated electrical stimulation and physiotherapy to improve mobility for people less than 6 months post stroke

Purpose: To investigate the feasibility of combining physiotherapy and functional electrical stimulation to improve gait post stroke. Methods: A parallel group partially single-blinded randomised clinical trial. Adults living at home, less than 6 months post stroke, were randomised to Group A (physiotherapy, n?=?10) or Group B (physiotherapy and common peroneal nerve stimulation, n?=?10). Assessments were conducted before randomisation (Week 1), after intervention (Week 8) and after 12 weeks follow-up (Week 20). Results: No between group differences were observed. There were statistically significant within group differences after the intervention period in both groups for walking speed and distance walked (without stimulation), Rivermead Mobility Index and Canadian Occupational Performance Measure, maintained at Week 20. There was statistically significant improvement in 10-m walking speed (Group B) when the stimulator was used at Week 8 (p?=?0.03, median 0.04?m/s (8%)). Only Group B had statistically significant within group change in Rivermead Visual Gait Analysis (Week 8), maintained at Week 20. Conclusions: Integrating electrical stimulation and physiotherapy was feasible and improved walking speed. There was no evidence of a training effect compared with physiotherapy alone. One-hundred forty-four participants per group would produce an adequately powered study based on this protocol.

• Implications for Rehabilitation

• At the end of the intervention period participants using electrical stimulation to correct dropped foot walked faster.

• It was feasible for electrical stimulation to be combined with physiotherapy for people less than 6 months post stroke.

• A larger adequately powered study is required to establish whether there are training effects associated with use of stimulation in this population.

     

A textured insole improves gait symmetry in individuals with stroke

Abstract

Purpose: Gait asymmetry is a common consequence of stroke and improving gait symmetry is an important goal of rehabilitation. We investigated the effect of a single textured insole in improving gait symmetry in individuals with stroke.

Method: Seventeen individuals with stroke who had asymmetrical gait were recruited and required to walk with a textured insole positioned in the shoe on the unaffected side or without the insole. Gait parameters were evaluated using the instrumented walkway. Gait velocity, cadence, and symmetry indices for the spatial and temporal parameters of gait and center of pressure displacements were obtained.

Results: When walking with a textured insole, symmetry indexes for stance, single support phases of gait, as well as center of pressure displacements improved significantly. While using a textured insole, the duration of the stance phase and a single support phase decreased on the unaffected side and increased on the affected side significantly. Gait velocity and cadence were not affected by the use of the insole.

Conclusions: Individuals with stroke walking with a textured insole placed in the shoe on the unaffected side improved the symmetry of their gait. The outcome provides a foundation for future investigations of the efficacy of using a single textured insole in gait rehabilitation of individuals with unilateral impairment.

• Implications for Rehabilitation

• A single textured insole positioned in the shoe on the unaffected side improved gait symmetry in individuals with stroke.

• Gait velocity and cadence were not affected by the use of the insole.

     

A single robotic session that guides or increases movement error in survivors post-chronic stroke: which intervention is best to boost the learning of a timing task?

Purpose: Timing deficits can have a negative impact on the lives of survivors post-chronic stroke. Studies evaluating ways to improve timing post stroke are scarce. The goal of the study was to evaluate the impact of a single session of haptic guidance (HG) and error amplification (EA) robotic training interventions on the improvement of post-stroke timing accuracy.

Materials and methods: Thirty-four survivors post-chronic stroke were randomly assigned to HG or EA. Participants played a computerized pinball-like game with their affected hand positioned in a robot that either helped them perform better (HG) or worse (EA) during the task. A baseline and retention phase preceded and followed HG and EA, respectively, in order to assess their efficiency at improving absolute timing errors. The impact of the side of the stroke lesion on the participants’ performance during the timing task was also explored for each training group.

Results: An improvement in timing performance was only noted following HG (8.9?±?4.9?ms versus 7.8?±?5.3?ms, p?=?0.032). Moreover, for the EA group only, participants with a left-sided stroke lesion showed a worsening in performance as compared to those with a right-sided stroke lesion (p?=?0.001).

Conclusion: Helping survivors post-chronic stroke perform a timing-based task is beneficial to learning. Future studies should explore longer and more frequent HG training sessions in order to further promote post stroke motor recovery.

• Implications for Rehabilitation

• Timing is crucial for the accomplishment of daily tasks.

• The number of studies dedicated to improving timing is scarce in the literature, even though timing deficits are common post stroke.

• This innovative study evaluated the impact of a single session of haptic guidance-HG and error amplification-EA robotic training interventions on improvements in timing accuracy among survivors post chronic stroke.

• HG robotic training improves timing accuracy more than EA among survivors post chronic stroke.

     

Effects of modified constraint-induced movement therapy on the lower extremities in patients with stroke: a pilot study

Purpose: This study aimed to qualify the improvements of modified constraint-induced movement therapy (m-CIMT) on the lower limb of stroke patients via assessing the centre of mass (COM) displacement and the basic gait parameters.

Methods: A total of 22 hemiplegic patients after stroke with first-time clinical cerebral infarction or haemorrhagic cerebrovascular accident were included in this study from May to December, 2014. The patients were randomly divided into m-CIMT group and the conventional therapy group (control group), and received corresponding training for five days/week for four weeks. The COM displacement and gait parameters were assessed by three-dimensional segmental kinematics method in pre-intervention and post- intervention therapy.

Results: After four weeks of m-CIMT, the COM displacement on sagittal plane of paretic leg during stance phase was increased (pre: 91.04?±?4.39?cm, post: 92.38?±?4.58?cm, p?p?p?Conclusion: The m-CIMT intervention improves the COM displacement in sagittal and frontal plane, as well as gait parameters. These suggest that m-CIMT intervention may be feasible and effective for the rehabilitation of hemiplegic gait.

• Implications for Rehabilitation

• Segmental kinematics method was used to estimate the displacement of the COM.

• m-CIMT interventions improved the COM displacement of patients after stroke.

• m-CIMT interventions improved the hemiplegic gait parameters.

     

Orthotic and therapeutic effect of functional electrical stimulation on fatigue induced gait patterns in people with multiple sclerosis

Purpose: To assess the orthotic and therapeutic effects of prolonged use of functional electrical stimulation (FES) on fatigue induced gait patterns in people with Multiple Sclerosis (MS). Method: Thirteen people with MS completed 3D gait analysis with FES off and on, before and after a fatiguing 6-minute walk, at baseline and after 8 weeks of use of FES. Results: Eleven participants completed all testing. An orthotic effect on gait was not evident on first use of FES. However, therapeutic effects on gait after 8 weeks use were generally positive, including increases in walking speed due to improved neuromuscular control and power generated at the hip and ankle of the more affected limb. The action of FES alone was not sufficient to overcome all fatigue related deficits in gait but there was evidence 8 weeks use of FES can ameliorate some fatigue effects on lower limb kinetics, including benefits to ankle mechanics involved in generating power around push-off during stance. Conclusions: Eight-weeks of FES can benefit the gait pattern of people with MS under non-fatigued and fatigued conditions.

• Implications for rehabilitation

• In some people with MS prolonged use of FES may be necessary before observing positive orthotic effects.

• Improvements in the neuromuscular control of the more affected lower limb may develop with prolonged use of FES in people with MS.

• Only some therapeutic benefits of FES are maintained during fatigued walking in people with MS.

• FES may be considered as a gait retraining device as well as an orthotic intervention for people with MS.

     

Efficacy of corrective spinal orthoses on gait and energy consumption in scoliosis subjects: a literature review

Background: Adolescent idiopathic scoliosis (AIS) is a progressive growth disease that affects spinal anatomy, mobility, and left-right trunk symmetry. As a consequence, AIS can modify human gait. Spinal orthoses are a commonly used conservative method for the treatment of AIS.

Objective: This review evaluated the AIS spinal orthosis literature that involved gait and energy consumption evaluations.

Study design: Literature review.

Method: According to the population intervention comparison outcome measure methods and based on selected keywords, 10 studies met the inclusion criteria.

Results: People with AIS who wore a spinal orthosis, compared with able-bodied participants, walked slower with decreased hip and pelvic movements, decreased hip mediolateral forces, ground reaction force asymmetry, and excessive energy cost. Pelvis and hip frontal plane motion decreased when wearing an orthosis. Hip and pelvis movement symmetry improved when using an orthosis. Ankle and foot kinematics did not change with orthotic intervention. People with AIS continued to have excessive energy expenditure with an orthosis.

Conclusion: Spinal orthoses may be considered for improving the walking style, although energy cost does not decline following the orthotic intervention.

• Implications for Rehabilitations

• Problems related to scoliosis include reduced quality of life, disability, pain, postural alterations, sensory perturbations, standing instability and gait modifications.

• Wearing corrective spinal orthoses in AIS subjects produce a reduction in walking speed and cadence, increase in stride length and reduction of gait load asymmetry compared to without brace condition.

• Spinal orthoses do not decline excessive energy expenditure to walk versus without it.