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.

     

The impact of robot-mediated adaptive I-TRAVLE training on impaired upper limb function in chronic stroke and multiple sclerosis

Purpose: The current study aimed to investigate proof-of-concept efficacy of an individualized, robot-mediated training regime for people with MS (pwMS) and stroke patients.

Method: Thirteen pwMS and 14 chronic stroke patients performed 36 (stroke) or 40 (pwMS) training sessions with the I-TRAVLE system. Evaluation of upper limb function was performed at baseline, after training and at 3 months follow-up. Clinical outcome measures consisted of active range of motion (ROM), Motricity Index, Jamar handgrip strength, perceived fatigue and strength, Wolf Motor Function Test (WFMT) and ABILHAND. Robot-generated outcome measures consisted of movement velocity, ROM and actual covered distance compared to straight-line distance.

Results: In pwMS, significant improvements were found after training in active shoulder ROM, handgrip strength, perceived strength and WMFT activities. No significant change in clinical outcome was found in stroke patients, except for perceived strength. Significant improvement in speed and movement duration was found after training in both groups. At follow-up, clinical outcome deteriorated in pwMS and was maintained in stroke patients.

Conclusions: Robot-mediated training resulted in improved movement coordination in both groups, as well as clinical improvement in pwMS. Absence of functional improvements in stroke patients may relate to severe upper limb dysfunction at baseline.

• Implications for Rehabilitation

• Robot-mediated training improved strength, active range of motion and upper limb capacity in pwMS.

• Robot-mediated therapy allows for adapted training difficulty.

     

The impact of walking speed on the effects of functional electrical stimulation for foot drop in people with multiple sclerosis

Purpose: Functional electrical stimulation (FES) is effective in assisting people with multiple sclerosis (pwMS) with gait. Previous studies have investigated the effects of FES in pwMS with slow self-selected walking speeds (SSWS). This study reports on the effect of the Odstock Dropped Foot Stimulator (ODFS) on the speed and oxygen (O₂) cost of gait in pwMS walking at a range of SSWS. Methods: Twenty pwMS (mean age 50.4?±?7.3 years) currently using FES walked at their SSWS for 5?min with and without FES. O₂ cost of gait was measured using a gas analysis system, and gait speed was calculated. Data were analysed for all participants, and comparisons were made between those with a SSWS < and >0.8?m/s (walking speed required for community ambulation). Results: Significant improvements in the speed and O₂ cost of gait were seen using FES in the group with SSWS <0.8?m/s (n?=?11, p?=?0.005). When participants’ SSWS >0.8?m/s, no difference in gait speed was noted, and a significant increase in O₂ cost of gait using FES (n?=?9, p?=?0.004) was noted. Conclusion: FES has a different effect on the speed and O₂ cost of gait dependent on the SSWS of pwMS. This requires further investigation.

• Implications for Rehabilitation

• Functional electrical stimulation (FES) used for foot drop is effective in improving the speed and oxygen cost of walking in pwMS walking at SSWS <0.8?m/s.

• FES does not seem to have a beneficial effect on the speed and oxygen cost of walking in pwMS walking at SSWS >0.8?m/s.

• Further research is needed to understand the possible mechanisms involved so that FES for foot drop can be efficiently prescribed.

     

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.

     

An innovative training program based on virtual reality and treadmill: effects on gait of persons with multiple sclerosis

Aim: In this single blind randomized controlled trial, we examined the effect of a virtual reality-based training on gait of people with multiple sclerosis.

Methods: Twenty-five individuals with multiple sclerosis with mild to moderate disability were randomly assigned to either the control group (n?=?11) or the experimental group (n?=?14). The subjects in the control group received treadmill training. Subjects in the experimental group received virtual reality based treadmill training. Clinical measures and gait parameters were evaluated.

Result: Subjects in both the groups significantly improved the walking endurance and speed, cadence and stride length, lower limb joint ranges of motion and powers, during single and dual task gait. Moreover, subjects in the experimental group also improved balance, as indicated by the results of the clinical motor tests (p?Conclusion: Our results support the perceived benefits of training programs that incorporate virtual reality to improve gait measures in individuals with multiple sclerosis.

• Implication of rehabilitation

• Gait deficits are common in multiple sclerosis (85%) and worsen during dual task activities.

• Intensive and progressive treadmill training, with and without virtual reality, is effective on dual task gait in persons with multiple sclerosis.

• Virtual reality-based treadmill training requiring obstacle negotiation increases the range of motion and the power generated at the hip, consequently allowing longer stride length and, consequently, higher gait speed.

     

The experience of transitioning from relapsing remitting to secondary progressive multiple sclerosis: views of patients and health professionals

Purpose:The majority of people with multiple sclerosis (pwMS) initially present with discreet periods of relapses followed by partial remission of symptoms (RRMS). Over time, most pwMS transition to secondary progressive MS (SPMS), characterized by a gradual accumulation of disability. This study aimed to explore the experiences, coping and needs associated with transitioning from RRMS to SPMS.

Method: Data were collected via semi-structured interviews with nine pwMS and seven specialist MS health professionals (HPs). Thematic analysis was used to analyze the data.

Results:Four major themes were identified: “Is this really happening?”; “Becoming a reality”; “A life of struggle”; and “Brushing oneself off and moving on.” Findings suggested a process of moving from uncertainty towards confirmation of one’s diagnostic label. Being reclassified with SPMS served as a turning point for many, and was accompanied by a range of cognitive, emotional and behavioral responses. The value of adequate information and support surrounding the transition, and the potential benefit of education and support for health professionals in relation to the transition were indicated.

Conclusions: Understanding pwMS’ experiences of the transition is essential if clinicians are to provide pwMS with appropriate support during the transition.

• Implications for Rehabilitation

• The timing and delivery of preparatory education for patients about the transition to SPMS should be carefully considered.

• Sufficient information and follow-up support following the reclassification of SPMS is crucial but sometimes lacking.

• The importance of sensitive communication of the reclassification of SPMS was highlighted. MS Specialist health professionals may potentially benefit from training and support around communication of the reclassification of SPMS.

• Given the potential negative psychological impact of the transition, the psychological wellbeing of the patients during the transition to SPMS should be monitored and responded to appropriately.

     

Gait training of subacute stroke patients using a hybrid assistive limb: a pilot study

Purpose To determine whether gait training with a hybrid assistive limb (HAL) as an exoskeleton robotic device was safe and could increase functional mobility and gait ability in subacute stroke patients. Methods The participants were eight patients with post-stroke hemiparesis whose walking impairment and gait recovery curves had plateaued. The intervention program was gait training using HAL and a walker for 20?min daily 5 days a week for 5 weeks. The 10-m maximum walking speed (MWS), self-selected walking speed (SWS) and 2-min-walk test (2MT) without HAL were used as primary outcome measures to determine the effects of training. The Berg Balance Scale (BBS), Fugl-Meyer Assessment of Motor Recovery after Stroke (FMA) and functional ambulation category (FAC) were assessed as secondary outcomes. These measures were assessed before and after the 5-week intervention program and were analyzed statistically using a paired t-test. Results All eight participants completed the intervention program with no adverse events. There were significant increases in MWS, SWS and 2MT. BBS, FMA and FAC also increased, but not significantly. Conclusion The new HAL exoskeleton robotic device was efficient and safe for improving motor function and gait in patients in the subacute stage after stroke.

• Implications for Rehabilitation

• Gait training using HAL will improve gait ability of individuals with post stroke.

• The HAL achieve intensive gait training without increase spasticity and abnormal gait pattern.

     

Enhanced life-role participation in response to comprehensive gait training in chronic stroke survivors*

Purpose: Intensive gait training can produce improvements in gait and function (> 6 months after stroke); findings are mixed for enhanced life role participation. Therefore, it is unclear if improved gait and function translate into life role participation gain. Our objective was to evaluate whether intensive gait therapy can produce significant improvements in life role participation for chronic stroke survivors. Methods: In conjunction with a clinical gait training trial, we conducted a secondary analysis for a 44-member cohort with stroke (>6 months). Gait training interventions included exercise, body weight supported treadmill training (BWSTT), over-ground gait training, and functional electrical stimulation (FES) for 1.5 h/day, 4 days/wk for 12 weeks. Study measures included Tinetti Gait (TG) (gait impairment), Functional Independence Measure (FIM, function), Stroke Impact Scale Subscale of Life Role Participation (SISpart), and Craig Handicap Assessment & Reporting Technique (CHART, life-role participation). Analyses included Wilcoxon Signed Rank Test and PLUM Regression Model. Results: Gait interventions produced significant improvement in CHART (p = 0.020), SISpart (p = 0.011), FIM (p < 0.0001), and Tinetti Gait (p < 0.0001). Age, gender and time since stroke did not predict response to treatment. Conclusions: Intensive, multi-modal, long-duration gait therapy resulted in significant gain in life-role participation, according to a relatively comprehensive, homogeneous measure.

Implications for Rehabilitation

• It is important to measure life role participation in rehabilitation intervention studies, and using a homogenous measure of life role participation provides clear results.

• Intensive gait training produced a significant improvement in life role participation in the chronic phase after stroke.

• Functional electrical stimulation (FES) had no significant additive effect on life role participation during the treatment phase, but FES did have an additive effect during the follow-up period, in enhancing life role participation beyond that obtained using an identical comprehensive gait training intervention without FES.

     

Treadmill training with an incline reduces ankle joint stiffness and improves active range of movement during gait in adults with cerebral palsy

Purpose: We investigated if 30?min of daily treadmill training with an incline for 6 weeks would reduce ankle joint stiffness and improve active range of movement in adults with cerebral palsy (CP).

Methods: The study was designed as a randomized controlled clinical trial including 32 adults with CP (GMFCS 1–3) aged 38.1 SD 12 years. The training group (n?=?16) performed uphill treadmill training at home daily for 30?min for 6 weeks in addition to their usual activities. Passive and reflex mediated stiffness and range of motion (ROM) of the ankle joint, kinematic and functional measures of gait were obtained before and after the intervention/control period. Intervention subjects trained 31.4 SD 10.1 days for 29.0 SD 2.3?min (total) 15.2?h.

Results: Passive ankle joint stiffness was reduced (F?=?5.1; p?=?0.031), maximal gait speed increased (F?=?42.8, p?F?=?5.3, p?F?=?12.5; p?Conclusion: Daily treadmill training with an incline for 6 weeks reduces ankle joint stiffness and increases active ROM during gait in adults with CP. Intensive gait training may thus be beneficial in preventing and reducing contractures and help to maintain functional gait ability in adults with CP.

• Implications for rehabilitation

• Uphill gait training is an effective way to reduce ankle joint stiffness in adult with contractures.

• 6 weeks of daily uphill gait training improves functional gait parameters such as gait speed and dorsal flexion during gait in adults with cerebral palsy.

     

Comparative biomechanical analysis of gait in patients with central cord and Brown-Séquard syndrome

Abstract

Purpose: This is a pilot study with the aim to highlight the use of kinematic and kinetic analyses as an adjunct to the assessment of individual patients with central cord syndrome (CCS) and hemisection or Brown-Séquard syndrome (BSS) and to discuss their possible consequences for clinical management. Methods: The sample studied consisted of 17 patients with CCS, 13 with BSS and 20 control subjects (control group (CG)). Data were obtained using a three-dimensional motion analysis system and two force plates. Gait differences were compared between CCS, BSS walking at a self-selected speed and CG at both a self-selected and a similar speed to that of the patient groups. Results: The most relevant findings involved the knee and ankle, especially in the sagittal plane. In patients with CCS, knee flexion at initial contact was increased with respect to those in the BSS group (p?<?0.01). The ankle in the BSS group made initial contact with a small degree of plantar flexion. Conclusion: The use of gait biomechanical analysis to detect underlying impairments can help the physician to set a specific rehabilitation program in each CCS and BSS walking patient. In this group of patients, rehabilitation treatment should aim to improve gait control and optimise ankle positioning at initial contact.

• Implications for Rehabilitation

• In this study, gait differences between patients with CSS and BSS were evaluated with biomechanical equipment.

• The most remarkable differences were found in the knee and ankle sagittal plane due to ankle position at initial contact.

• In this group of patients, rehabilitation treatment should aim to improve gait control and to get a better ankle positioning at initial contact.

     

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.

     

Enhanced life-role participation in response to comprehensive gait training in chronic-stroke survivors

Purpose: Intensive gait training can produce improvements in gait and function (>6 months after stroke); however, findings are mixed for enhanced life-role participation. Therefore, it is unclear if improved gait and function translate into life-role participation gain. Our objective was to evaluate whether intensive gait therapy can produce improvements in life-role participation for chronic-stroke survivors, according to a comprehensive measure dedicated to life-role participation. Methods: In conjunction with a clinical gait-training trial, we conducted a secondary analysis for a 44-member cohort with stroke (>6 months). Gait-training interventions included functional neuromuscular stimulation, body-weight supported treadmill training, over-ground gait training and exercise for 1.5 hours/day, 4 days/week for 12 weeks. Study measures included Tinetti Gait (gait impairment), Functional Independence Measure (FIM, function), Stroke Impact Scale subscale of life-role participation (SIS part) and Craig Handicap Assessment and Reporting Technique (CHART, life-role participation). Analysis included Wilcoxon signed rank test and polytomous universal regression model. Results: Gait interventions produced significant improvement in CHART (p = 0.020), SIS part (p = 0.011), FIM (p < 0.0001), and Tinetti Gait (p < 0.0001). Age, gender and time since stroke did not predict response to treatment. Conclusions: Intensive gait therapy resulted in significant gain in life-role participation, according to a comprehensive measure, so dedicated.

Implications for Rehabilitation

• It is important to measure life-role participation in rehabilitation intervention studies, and using a homogeneous measure of life-role participation provides clear results.

• Intensive gait training produced a significant improvement in life-role participation in the chronic phase after stroke.

• Functional electrical stimulation (FES) had no significant additive effect on life-role participation during the treatment phase, but FES did have an additive effect during the follow-up period in enhancing life-role participation beyond that obtained using an identical comprehensive gait-training intervention without FES.

     

Real-time feedback of dynamic foot pressure index for gait training of toe-walking children with spastic diplegia

Purpose: The aim of this study was to determine whether and how real-time feedback of dynamic foot pressure index (DFPI) could be used to correct toe-walking gait in spastic diplegic children with dynamic equinus.

Methods: Thirteen spastic diplegic children with dynamic equinus were asked to wear a monitoring device to record their ambulation during daily gait, conventional training gait, and feedback training gait. Parameters based on their DFPI and stride duration were compared among the three test conditions.

Results: The results with feedback training were significantly better for all DFPI parameters in comparison to patients’ daily gait and showed significant improvements in DFPI for toe-walking gait and percentage of normal gait in comparison to conventional training methods. Moreover, stride duration under two training gaits was longer than patient’s daily gait, but there was no significant difference between the two training gaits.

Conclusions: Although the stride duration for the two training gaits was similar, gait training with real-time feedback of DFPI did produce noticeably superior results by increasing heel-loading impulse of toe-walking gait and percentage of normal gait in comparison to convention training methods. However, its effectiveness was still impacted by the motion limitations of diplegic children.

• Implications for Rehabilitation

• The DFPI-based gait training feedback system introduced in this study was shown to be more effective at toe-walking gait rehabilitation training over conventional training methods.

• The feedback system accomplished superior improvement in correcting toe-walking gait, but its effectiveness in an increasing heel-loading impulse in normal gait was still limited by the motion limitations of diplegic children.

• Stride duration of normal gait and toe-walking gait was similar under conventional and feedback gait training.

     

The effect of symptom-controlling medication on gait outcomes in people with multiple sclerosis: a systematic review

Purpose: To synthesise and critically appraise randomised controlled trials examining the effect of symptom-controlling medication on gait outcomes in people with multiple sclerosis (MS).

Method: The literature search examined five databases (Medline, Embase, AMED, Cochrane (CENTRAL), and CINAHL until the end of November 2016. Eligible studies included medication to address symptoms associated with MS and an objective gait outcome measure. Two reviewers independently extracted data and assessed study quality using structured data extraction forms and the PEDro scale.

Results: From 249 papers identified, 13 papers met inclusion criteria, examining three medications. Fampridine was found to significantly increase gait speed, but only in those people who responded to medication, which was less than half (pooled mean: 39%). Ten milligrams of fampridine twice daily significantly improves gait endurance. No definitive conclusions can be made about the efficacy of cannabinoid medication due to conflicting results across three studies. A single study of baclofen did not provide evidence to support the use of this medication to improve gait.

Conclusions: Limited evidence is available to guide gait symptom control for people with MS. Further research that includes three-dimensional gait analysis, patient perceived measures of gait dysfunction and explores combined efficacy of other modalities on gait is needed.

• Implications for Rehabilitation

• Gait disturbance is a common and disabling symptom of multiple sclerosis.

• Fampridine and cannabis medication may increase gait speed, baclofen does not.

• Fampridine can be used to improve gait endurance.

• Future research should include both quantitative and qualitative outcome measures of gait and investigate the combined efficacy of pharmacological and non-pharmacological interventions to assist clinicians to maximise gait improvements.

     

Influence of trunk control and lower extremity impairments on gait capacity in children with cerebral palsy

Abstract

Purpose: We investigated the combined impact of trunk control and lower extremities impairments on predicting gait capacity in children with cerebral palsy (CP) and evaluated relationships between trunk control and lower extremities impairments.

Methods: Data of 52 children with CP [29 boys, mean age 11 years 9 months (±4 years 6 months)] were included in this observational study. Gait capacity was measured by the “modified Time Up and Go test”. Experienced therapists performed the “Modified Ashworth Scale”, “Manual Muscle Test”, the “Selective Control Assessment of the Lower Extremity”, and the “Trunk Control Measurement Scale”. We calculated Spearman correlations coefficients (ρ) and performed regression analyses.

Results: Trunk control was the strongest predictor (β?=?–0.624, p?<?0.001) when explaining the variance of gait capacity and remained in the model together with spasticity (R²?=?0.67). Muscle strength and selectivity correlated moderately to strongly with the trunk control and gait capacity (–0.68?≤?ρ?≤?–0.78), but correlations for the spasticity were low (ρ<–0.3).

Conclusions: The interconnection between trunk control, leg muscle strength and selectivity for gait capacity in children with CP was shown. It indicates the significance of these impairments in gait assessment and, potentially, rehabilitation.

• Implications for Rehabilitation

• Trunk control was the strongest predictor for gait capacity in a regression model with lower extremity spasticity, muscle strength and selectivity and age as independent variables.

• Lower extremity muscle strength, selectivity, and trunk control explained a similar amount of gait capacity variance which is higher than that explained by lower extremity spasticity.

• Lower extremity muscle strength and selectivity correlated strongly with trunk control.

• Therefore, we cautiously suggest that a combined trunk control and lower extremity training might be promising for improving gait capacity in children with CP (Gross Motor Function Classification System level I–III), which needed to be tested in future intervention-studies.

     

Using mixed methods case-series evaluation in the development of a guided self-management hybrid CBT and ACT intervention for multiple sclerosis pain

Purpose: Two-thirds of the people with multiple sclerosis (pwMS) experience pain. Medications provide minimal relief, and current non-pharmacological interventions lack a clear conceptualization of MS pain. This study explored the potential efficacy of a telephone-supported hybrid cognitive behavior therapy and acceptance and commitment therapy self-management intervention for pwMS based on an empirically supported model of MS pain using a replicated single-case series design.

Methods: Seven pwMS with varied demographic and disease characteristics completed the 8-week home-based program alongside 3 hours of telephone support. Online questionnaires were completed every four days for 16 weeks (4-weeks baseline, 8-weeks treatment, 4-weeks follow-up). The primary outcomes were pain severity and pain interference. Psychological process variables drawn from the MS pain model were also completed, and post-treatment qualitative interviews conducted.

Results: Simulation modeling analysis (SMA) showed three patients had large improvements in pain outcomes, two showed no change and two worsened. Five participants showed significant change on various psychological process variables. Change in pain catastrophizing was the most consistent finding.

Conclusions: The findings suggest a self-management program for MS pain with minimal therapy support may be effective for some pwMS, but not those with more complex comorbidities. The participants suggested web-based delivery may simplify the approach, and therapist telephone contact was highly valued.

• Implications for Rehabilitation

• This case series suggests a hybrid CBT/ACT self-management workbook program for MS pain improves severity and impact of pain in some pwMS.

• Pain-related catastrophizing reduced in most pwMS, whilst change in other ACT and CBT process variables varied across the individuals.

• PwMS feedback suggests a tailored web-based delivery of the program with therapist telephone support may be optimal.

• PwMS with serious co-morbid depression and very advanced disease may not respond well to this self-management approach.

     

Effects of supervised slackline training on postural instability,freezing of gait,and falls efficacy in people with Parkinson’s disease

Purpose: The aim of this study was to assess whether supervised slackline training reduces the risk of falls in people with Parkinson’s disease (PD).

Methods: Twenty-two patients with idiopathic PD were randomized into experimental (EG, N?=?11) and control (CG, N?=?11) groups. Center of Pressure (CoP), Freezing of Gait (FOG), and Falls Efficacy Scale (FES) were assessed at pre-test, post-test and re-test. Rate perceived exertion (RPE, Borg’s 6–20 scale) and local muscle perceived exertion (LRPE) were also assessed at the end of the training sessions.

Results: The EG group showed significant improvements in FOG and FES scores from pre-test to post-test. Both decreased at re-test, though they did not return to pre-test levels. No significant differences were detected in CoP parameters. Analysis of RPE and LRPE scores revealed that slackline was associated with minimal fatigue and involved the major lower limb and lumbar muscles.

Conclusions: These findings suggest that slacklining is a simple, safe, and challenging training and rehabilitation tool for PD patients. It could be introduced into their physical activity routine to reduce the risk of falls and improve confidence related to fear of falling.

• Implications for Rehabilitation

• Individuals with Parkinson’s disease (PD) are twice as likely to have falls compared to patients with other neurological conditions.

• This study support slackline as a simple, safe, and challenging training and rehabilitation tool for people with PD, which reduce their risk of falls and improve confidence related to fear of falling.

• Slackline in people with PD yields a low tiredness or fatigue impact and involves the major lower limb and lumbar muscles.

     

Therapists’ cues influence lower limb muscle activation and kinematics during gait training in subacute stroke

Abstract

Purpose: Symmetrical gait is a key goal of rehabilitation post-stroke. Therapists employ techniques such as verbal instruction and haptic cues to increase activation of paretic muscles. We examined whether verbal or tactile cueing altered spatiotemporal gait parameters, kinematics and electromyography (EMG) of lower limb muscles on the more-affected side within a training session.

Materials and methods: Patients (n?=?10) were recruited from rehabilitation services (<9?months post-stroke). Tactile (to the hip muscles) or verbal cues were provided on two testing days, 7–10?days apart (randomized order). Gait and angular kinematics were recorded using a Vicon motion capture system and muscle activation using EMG; at baseline (PRE), during the cue, directly afterwards without a cue (POST) and 20?min later without a cue (RETEST).

Results: Both verbal and tactile cueing significantly increased muscle activity in paretic muscles but with no immediate effect on step length asymmetry. Tactile cues, more than verbal, temporarily altered gait speed, cadence and time in double support. Verbal cues caused more robust increases in muscle activation of vastus lateralis at weight acceptance and medial gastrocnemius activity from toe off to midswing.

Conclusions: Within a treatment session, tactile cues more effectively altered cadence and double support time while verbal cues more consistently increased vastus lateralis and medial gastrocnemius activity. The effectiveness of these methods in fostering motor relearning in the longer term is an important area for future research.

• Implications for Rehabilitation

• Therapist cueing alters muscle activity on hemiparetic side with no effects on symmetry.

• Tactile cues, more so than verbal cues, increase cadence and reduce time in double support.

• Verbal cues are more effective at increasing vastus lateralis and plantarflexor muscle activity.

     

Effects of 12-week supervised treadmill training on spatio-temporal gait parameters in patients with claudication

The purpose of the study was to evaluate selected temporal and spatial gait parameters in patients with intermittent claudication after completion of 12-week supervised treadmill walking training. The study included 36 patients (26 males and 10 females) aged: mean 64 (SD 7.7) with intermittent claudication. All patients were tested on treadmill (Gait Trainer, Biodex). Before the programme and after its completion, the following gait biomechanical parameters were tested: step length (cm), step cycle (cycle/s), leg support time (%), coefficient of step variation (%) as well as pain-free walking time (PFWT) and maximal walking time (MWT) were measured. Training was conducted in accordance with the current TASC II guidelines. After 12 weeks of training, patients showed significant change in gait biomechanics consisting in decreased frequency of step cycle (p?p?p?p?p?p?>?0.05).

• Implications for Rehabilitation

• Twelve-week treadmill walking training programme may lead to significant improvement of temporal and spatial gait parameters in patients with intermittent claudication.

• Twelve-week treadmill walking training programme may lead to significant improvement of pain-free walking time and maximum walking time in patients with intermittent claudication.

     

Post-operative delayed ambulation after thymectomy is associated withpre-operative six-minute walk distance

Objective: Delayed post-operative ambulation is a risk of post-operative complications and increases overall healthcare costs. We investigated pre-operative and intraoperative variables associated with delayed ambulation in patients who underwent thymectomy.

Methods: A total of 57 consecutive patients undergoing thymectomy were included in this study. Pre-operative functional exercise capacity was evaluated by six-minute walk distance. Ambulation was considered to be delayed if the patient could not walk the ward on post-operative day 1. Binary logistic regression analysis was performed to clarify the factors associated with delayed ambulation.

Results: Pre-operative six-minute walk distance was the only significant variable that was associated with delayed ambulation. The area under the receiver operating characteristic curve for predicting delayed ambulation was 0.684 (95% confidential interval: 0.546–0.823, p?=?0.017), and the optimal discriminatory pre-operative six-minute walk distance value was 498 m. Post-operative hospital stay was significantly longer in patients with low six-minute walk distance (<498 m) than those with high six-minute walk distance (≥498 m). In contrast, the presence of myasthenia gravis or adjuvant chemoradiotherapy was not associated with delayed ambulation.

Conclusions: Our results suggest that low pre-operative six-minute walk distance is associated with delayed post-operative ambulation and longer post-operative hospital stay in patients who underwent thymectomy.

• Implications for rehabilitation

• The predictors for delayed ambulation after thymectomy are not fully investigated.

• The presence of myasthenia gravis was not associated with delayed ambulation.

• Low pre-operative six-minute walk distance was associated with delayed ambulation.