偏瘫患者站姿平衡和负重与鞋坡度及高度的相关性

目的确定鞋的坡度和高度对偏瘫患者站姿平衡和负重的影响。方法测量偏瘫患者在安静站立状态下及被迫体位转换时的重力支撑的关系。参加者:为康复医院的9例急性期一侧脑卒中后偏瘫的住院患者,要求在无协助或休息的情况下能够独自站立3～5min,同时符合其他包括的标准。干预:在调整鞋的不同坡度(5°,7.5°,2.5°)和不同高度(0.6,0.9,1.2cm)的情况下,要求患者做体位转动,其重力支撑对称得分用来表示站姿平衡的特征。主要结果测量:重力支撑对称得分。结果在不提高鞋的高坡度时,偏瘫一侧肢体对称负重能力低犤负载体重的(39.9±0.80)%犦。如在患侧肢升高鞋底的高度和坡度,当人体位转动时,可以促进站姿平衡和负重的改善。倘若鞋的坡度为5°时,体质量的分配最平衡犤人体质量的(51.4±1.1)%犦。结论要改善双脚站立时的平衡水平,建议应用调整患侧肢体鞋的高坡度,帮助患者克服患肢失用后的锻炼困难,从而保持运动时的身体平衡。     

The effect of shoe lifts on static and dynamic postural control in individuals with hemiparesis

OBJECTIVE: To determine the effect of lifts to the shoe of the nonaffected leg on weight symmetry and dynamic posturography in individuals with hemiparesis. DESIGN: Quantitative posturography was performed to determine subjects' response to sudden perturbations. Subjects received graded forward and backward perturbations while standing on a movable force platform. Compelled shift of the body weight was induced with sized lifts to the shoe of the nonaffected leg. Balance responses were analyzed in terms of latency and strength of neuromuscular response. Symmetry scores were used to characterize the symmetry of stance. SETTING: Free-standing acute inpatient rehabilitation hospital. PARTICIPANTS: Ten individuals with hemiparesis as a result of unilateral stroke. MAIN OUTCOME MEASURES: Weight symmetry scores, latencies of each leg's active response to the support surface translations, and response strength scores of each leg to the platform translations. RESULTS: When no lift was used, weight symmetry was characterized by underloading of the affected limb, as well as by longer onset latencies for the affected limb compared with the stronger one (158.5 +/- 3.9 vs 151.1 +/- 3.5 ms; p < .01 for large backward translations; 165.7 +/- 7.2 vs 158.0 +/- 5.1 ms; p < .01 for large forward translations). Response strength of the nonparetic limb was 2 times greater than the response strength of the weaker extremity (p < .05). Compelled weight shift induced by lifts applied to the shoe of the nonparetic limb promoted improved weight symmetry, shortened latencies, and increased magnitudes of the response strength. CONCLUSION: Lifts applied to the shoe of the stronger limb induced a body weight shift toward the paretic limb and resulted in improved symmetry of stance and postural control of individuals with hemiparesis. We suggest that compelled weight distribution induced by lifts to the shoe of the stronger limb could help treat ambulatory individuals with asymmetric stance and hemiparesis caused by unilateral stroke.     

The effect of immediate decreasing of weight bearing asymmetry on quiet standing postural control in individuals with chronic stroke

The main patterns characterizing standing posture of hemiparetic patients include: weight-bearing asymmetry (WBA), larger postural sway, asymmetrical contribution of lower limbs to balance control, and increased visual dependency to balance control. The aim of this study was to evaluate the effect of decreasing WBA with the use of a shoe lift, on quiet standing postural control in patients with chronic stroke. Twenty-seven patients participated in this study. Patients completed two tests: 1) quiet standing; and 2) quiet standing while a lift was placed under the non-paretic limb. The following tests were completed on force plates for evaluation: asymmetry of the balance measures (weight bearing, root mean square (RMS) of anterior-posterior (AP) and medial-lateral (ML) center of pressure (COP) velocity), RMS of total AP and ML COP velocity, and AP and ML Romberg quotients. Paired t-tests were used to analyze the data. The mean value of WBA index decreased significantly after using a lift (p < 0.05). However, the changes of the mean value of other postural control parameters were not significant (p > 0.05). The results indicate that there may not be an association between decreased WBA and improved postural control during quiet standing in patients with stroke.     

The effects of dynamic ankle-foot orthoses on functional ambulation activities,weight bearing and spatio-temporal characteristics of hemiparetic gait

Purpose. To investigate the effects of dynamic ankle-foot orthoses (DAFOs) on functional ambulation activities, weight bearing and spatio-temporal characteristics of hemiparetic gait and to inquire whether wearing a DAFO for 3 months has a carryover effect.

Method.?Fourteen chronic hemiparetic patients who could walk independently with or without a cane were the subjects of the study. Patients were assessed initially with tennis shoes and were given custom fabricated DAFOs which they wore for three months and were retested under two conditions: with tennis shoes only and with DAFOs worn in these shoes. All patients were assessed for weight bearing percentage of the affected side, cadence, step length of the involved and uninvolved sides, step width, functional reach, timed up and go, timed down stairs, timed up stairs, physiologic cost index and velocity.

Results.?Comparison of initial and third month assessments with shoes only condition showed that there was no significant improvement for the measured parameters. When comparison was made at the third month while patients were wearing tennis shoes only and when they were wearing DAFO's in their shoes there was a significant difference in favour of the condition where patients were wearing DAFOs.

Conclusion.?The benefits of using DAFOs in chronic hemiparetic patients are lost when the patients are not wearing their orthoses.     

Immediate effects of an individually designed functional ankle-foot orthosis on stance and gait in hemiparetic patients

OBJECTIVE: To evaluate the immediate effects of individually designed functional in-shoe ankle-foot orthoses (AFO) made of soft and hard cast on balance, standing, and gait parameters in hemiparetic patients. DESIGN: Crossover design with randomized order of the intervention. SETTING: A rehabilitation centre for adults with neurological disorders. SUBJECTS: Twenty-eight patients with hemiparesis due to stroke or traumatic brain injury. MEASURES: Postural sway, standing and gait parameters based on ground reaction forces in two conditions: Patients were randomly assigned to varying sequences of wearing AFO in footwear or wearing footwear alone. RESULTS: AFO significantly improved weight-bearing on the affected leg (affected/ unaffected side symmetry: 2.25 +/- 1.5 with AFO versus 3.4 +/- 2.5 without AFO, P<0.05) and postural sway in stance (12.5 mm +/- 5.2 with AFO versus 15.7 mm +/- 6.7 without AFO, P < 0.05), double stance duration (21.1 +/-14.4% of gait cycle with AFO versus 25.9 +/- 21.6% of gait cycle without AFO, P < 0.05), and symmetry ratios of gait parameters such as stance duration (2.0 +/- 1.5 s with AFO versus 3.3 +/- 3.6 s without AFO, P < 0.05) and deceleration forces (1.6 +/- 0.5 with AFO versus 1.9 +/- 0.6 without AFO, P < 0.05) during gait. No significant differences were observed in all other symmetry ratios of gait parameters. CONCLUSION: An individually designed functional in-shoe AFO can improve stance and gait parameters, even in a single use, in patients with hemiparesis.     

Influence of weight bearing visual feedback on movement symmetry during sit to stand task

BackgroundWeight-bearing asymmetry is common in individuals with hip osteoarthritis and after total hip arthroplasty. Including symmetry training to the rehabilitation programs may normalize movement strategies during dynamic tasks. The purpose of this study was to evaluate the immediate influences of real-time visual feedback of weight distribution on the interlimb movement symmetry during the sit-to-stand task, before and after total hip arthroplasty, and to determine whether physical impairments affect the response to visual feedback.MethodsSubjects before and after total hip arthroplasty participated in three- dimensional motion analysis. Subjects completed 3 trials of sit-to-stand task in two conditions; “without visual feedback” and “with visual feedback”. Outcome measures were the interlimb symmetry of vertical ground reaction force, and joint kinematics and kinetics. Pain and strength of lower limbs were assessed.FindingsCompared to “without visual feedback” condition, subjects moved with greater symmetry of vertical ground reaction force and joint kinetics when visual feedback was received. However, subjects continued to demonstrate interlimb difference for joint kinetics and vertical ground reaction force in the visual feedback condition. The increase in symmetry was not strongly influenced by physical impairments and subjects before and after total hip arthroplasty responded similarly to the feedback.InterpretationsWe concluded that in a single session, the visual feedback of weight bearing distribution had a positive immediate effect on movement symmetry during the sit-to-stand task. Future studies that assess long-term retention and functional benefits are warranted before visual feedback is incorporated in rehabilitation for this patient population.     

康复护理对提高偏瘫患者手功能障碍的影响

目的探讨康复护理对偏瘫患者手运动功能及日常生活活动能力的影响。方法采用运动疗法、ADL训练、作业疗法等对94例接受偏瘫康复的患者手的功能障碍进行1～6个月的康复护理,并用运动功能Fugl-Meyer评价法中腕关节与手的主动运动功能积分及Barther指数积分于治疗前、后对偏瘫侧手的运动功能、日常生活活动能力进行评估,比较治疗效果。结果治疗后94例患者手的运动功能、日常生活活动能力均有明显改善(P<0.005)。结论康复护理能显著提高偏瘫患者手运动功能及日常生活活动能力。     

Effect of heel lifts in elderly individuals with spinal kyphosis

BackgroundThe present study aimed to elucidate the effects of heel lifts on spinal alignment, walking, and foot pressure pattern in elderly individuals with spinal kyphosis.MethodsThe spinal alignment, walking speed, step length and foot pressure of 33 community-dwelling elderly individuals with spinal kyphosis (3 men, 30 women; mean age 77.3 years) were examined before and after the application of 10-mm moderately elastic heel lifts.FindingsSpinal alignment of total inclination (mean value 6.9°vs 4.5°) and thoracic angle (43.6°vs 36.2°) were significantly lower after the application of heel lifts than before the application. The lumbar angle (7.3°vs 10.0°) was significantly higher after the application than before the application. Walking speed (0.78 vs 0.88 m/s) and step length (0.42 m vs 0.45 m) were significantly higher after the application. The partial foot pressure as a percentage of body weight of the hallux (6.7% vs 9.0%) and lateral toes (6.5% vs 9.0%) was significantly higher after the application of heel lifts than before the application. The partial foot pressure as a percentage of body weight of the heel (68.9% vs 57.5%) was significantly lower after the application than before the application.InterpretationIn conclusion, heel lifts influenced the sagittal spinal alignment of elderly individuals. Walking speed and step length increased after the application of these devices. Increase in foot pressure in the hallux and lateral toe areas was probably related to these improvements in walking parameters.     

Comparison of strength measurements under single-joint and multi-joint conditions in hemiparetic individuals

OBJECTIVE: It has been suggested that the measurement of strength is inappropriate in patients with stroke, in large part because of the presence of abnormal synergy patterns. The aim of the present study was to characterize force production during multi-joint maximal exertion involving different combinations of activation between shoulder and elbow flexors and extensors. DESIGN: Cross-sectional study. SETTING: Rehabilitation centre. SUBJECTS: A convenience sample of 16 chronic hemiparetic stroke subjects. MAIN OUTCOME MEASURES: Maximal torques in flexion and extension at the shoulder and the elbow were measured using static dynamometers (single-joint condition). In addition, the maximal forces produced at the wrist were measured in four directions in the sagittal plane requiring different torque combinations between shoulder and elbow flexors and extensors (multi-joint condition). RESULTS: No difference was found across directions for the ratios of maximal forces (paretic/nonparetic) in the multi-joint condition (p = 0.227; mean ratios (+/- SD) for each direction ranging from 0.59+/-0.23 to 0.68+/-0.27), suggesting that the ability to produce force did not change as a function of the required torque combination. In addition, relative torques (% of the maximal torque in the single-joint condition) exerted during the multi-joint exertions were similar on the paretic and the nonparetic side. CONCLUSIONS: These results do not support the assumption that force production is limited by abnormal synergy patterns between flexors and extensors at the shoulder and the elbow in hemiparetic patients.     

Standing balance training: effect on balance and locomotion in hemiparetic adults

The effects of balance retraining on standing balance and locomotor performance were examined in postacute hemiparetic adults. Balance during habitual and instructed-even standing, as well as locomotor performance, were measured before and after a three- to four-week treatment period. Two groups of 21 matched subjects participated in physical therapy. One group received standing balance training with a specially designed feedback device that provided dynamic visual information about relative weight distribution over the paretic and nonparetic limb. Subjects trained with the feedback device showed significantly better static standing symmetry than did subjects who did not receive augmented feedback, p less than .05. Although both groups improved significantly in gait velocity, cadence, stride length, and cycle time, p less than .01, the initially identified asymmetrical locomotor pattern appeared to be only minimally affected by the standing balance training. Results indicated that although standing balance and locomotor control mechanisms may be highly interrelated, a reduction in standing balance asymmetry does not necessarily lead to a concomitant reduction in the asymmetrical limb movement patterns associated with hemiparetic locomotion.     

Single blind randomized controlled trial of visual feedback after stroke: Effects on stance symmetry and function

A number of before and after and single case design studies of visual feedback have shown improvements in stance symmetry after stroke, an associated improvement in function has been demonstrated. This study examines this promising technique further using a single-blind controlled trial. Twenty-six patients were recruited from a register of consecutive admissions and randomized into treatment and control groups. Both groups received additional therapy, only the treatment group received visual feedback. Assessments were carried out independently. Significant improvements were seen in the treatment group in measures of stance symmetry and sway and motor and ADL function. Between group differences had disappeared at three months. The results indicate that feedback training incorporated into functional physiotherapy treatment can improve stance symmetry and sway. Transfer of training was indicated by improvements in ADL and gross motor function. Three months later the improvement was maintained, but did not automatically continue without treatment.     

The effect of a balance training programme on centre of pressure excursion in one-leg stance

Background. Balance training is widely used in the rehabilitation after an ankle sprain and is thought to have a decreasing effect on postural sway. The present study investigated whether a 5.5-week balance training programme leads to a decreased postural sway showing in a reduced range of centre of pressure excursion.

Methods. Thirty university students participated in this study. Twenty-two untrained subjects were randomly assigned to either an intervention group (n = 11) or a control group (n = 11). The remaining eight subjects were participants in an organized volleyball competition and were assigned to an additional volleyball group (n = 8). All subjects of the intervention group and the volleyball group received a 5.5-week balance training programme, while subjects of the control group received no training. Centre of pressure of the ground reaction force was measured as a proxy measure of postural sway, using a force platform. Measurements took place before and after the 5.5-week training programme for standing on one leg (both for right and for left leg) of single leg stance, both for the eyes-open and eyes-closed situation. From these measurements centre of pressure excursion in the anterior–posterior and the medial–lateral direction was calculated. A linear regression analysis was performed to check for differences in centre of pressure excursion between any of the groups over the training period.

Findings. No differences in changes of centre of pressure excursion were found between any of the groups over the 5.5-week training period.

Interpretation. Balance training does not lead to a reduction in centre of pressure excursion in a general population consisting of non-injured and previously injured subjects.     

The effect of good and poor walking shoe characteristics on plantar pressure and gait in people with gout

BackgroundPrevious research has shown that good footwear characteristics may reduce foot pain and foot-related disability in people with gout. The aim of this study was to determine the effect of good and poor footwear characteristics on plantar pressure and spatiotemporal parameters of gait in people with gout.MethodsThirty-six people with gout participated in a cross-sectional repeated measures study. Plantar pressure and spatiotemporal parameters were recorded in two shoe conditions: (1) the participants own footwear, and (2) either a new pair of walking shoes with good footwear characteristics (n = 21) or poor characteristics (n = 15). Differences between good and poor shoe groups compared to participants own shoes were also determined.FindingsCompared to participant’s own shoes, footwear with good characteristics significantly reduced peak pressure at metatarsal 3 and 5, reduced pressure time integrals beneath the heel and metatarsals 3 and 5 and increased pressure time integrals beneath the midfoot. The footwear with poor characteristics significantly increased peak pressure beneath the heel and lesser toes, reduced peak pressure at metatarsal 3 and reduced pressure time integrals in the midfoot compared to participants own shoes. Both good and poor footwear significantly increased walking velocity, step length, and stride length compared to participants own shoes.InterpretationWalking shoes with good footwear characteristics can influence plantar pressure values and encourage a more efficient heel to toe gait pattern in people with gout. These changes may contribute to the reduction in foot pain and foot-related problems in this population.