Over-ground and robotic-assisted locomotor training in adults with chronic stroke: a blinded randomized clinical trial

Purpose: The purpose was to compare the effectiveness of robotic-assisted body weight supported treadmill training using the Lokomat^® to over-ground gait training (OGT) in adults with chronic stroke. Methods: Participants were randomly assigned to the Lokomat^® or OGT interventions. Both protocols included 40 sessions over 8 weeks. Primary outcome measures were the 10-meter walk test and 6-minute walk distance. Secondary measures included the Functional Independence Measure^TM locomotion score, Fugl-Meyer Lower Extremity Motor Score (FM-LE), Barthel Index, and Stroke Impact Scale. Blinded assessors tested the participants at baseline, post-intervention, and 3-month follow-up. Results: Eleven Lokomat^® and nine OGT participants completed the study. Within group differences in the FM-LE score and Barthel Index occurred over time from baseline to post-intervention and baseline to 3-month follow-up. No other within group differences and no between group differences were observed. Conclusions: Although walking measures did not show significant changes between groups, LE motor function and physical functional levels improved over time within both groups. The Lokomat^® may allow aggressive locomotor training, particularly for the lower functioning patients who wish to improve walking ability due to apparent eased therapist physical burden, when compared to OGT, although an increased risk of skin breakdown is present.

Implications for Rehabilitation

• Survivors of chronic stroke can continue to improve in motor recovery and functional ability after intensive over-ground or robotic-assisted locomotor training.

• Over-ground and robotic-assisted locomotor training appear to equivalently enhance motor recovery and functional ability in low functioning survivors of chronic stroke.

• Risk of skin breakdown is significant with roboticassisted locomotor training.

     

A comparison of treadmill walking and overground walking in independently ambulant stroke patients: A pilot study

Purpose. The purpose of the study was to compare the spatio-temporal and joint kinematic gait parameters of stroke patients walking on a treadmill and overground, to examine the assumption that patients walking on a treadmill will approximate the requirements of walking overground.

Methods. Ten independently ambulant chronic stroke patients were included in the study. Vicon? was used to collect spatio-temporal and joint kinematic data during overground walking at comfortable speed and at matched speed on the treadmill.

Results. Walking on the treadmill demonstrated statistically significantly lower cadence, and longer step times of the non-hemiplegic and hemiplegic limbs. Absolute stance times of both limbs, absolute double support time, relative stance time and relative double support time were significantly longer during treadmill walking. Compared to overground walking, the inter-limb symmetries of step time, stance time, and stance/swing time ratio were significantly greater on the treadmill. During treadmill walking, joint kinematic data showed statistically significant changes with greater flexion of the nonhemiplegic knee and hip at initial contact, and less hip extension of the hemiplegic limb. Maximal ankle plantarflexion and knee extension of the hemiplegic limb occurred later in the gait cycle on the treadmill.

Conclusion. These differences suggest it may be useful to use treadmill in conjunction with overground walking to focus on improving specific walking deficits in patients with stroke.     

Test-retest reliability of the GAITRite system in people with stroke undergoing rehabilitation

Purpose.?To determine the test-retest reliability of the GAITRite system in measuring spatio-temporal gait parameters in people with stroke undergoing inpatient rehabilitation and to investigate whether walking ability influences test-retest reliability.

Method.?A within-subject repeated measures study was conducted. Twenty-one individuals with first stroke undergoing inpatient rehabilitation participated. The Motor Assessment Scale Item 5 score was used to categorise participants into poorer (score 3 or 4) or better walkers (score 5 or 6). Participants made two passes at a self-selected gait speed over the GAITRite mat on two separate occasions. Intra-class correlation coefficients (ICC_(2,1)) and 95%% limits of agreement for spatio-temporal gait parameters between the two occasions and groups were determined.

Results.?No differences in gait parameters between the two sessions (p > 0.15) were found. Test-retest reliability for the whole group was good to excellent, ICC_(2,1) ranging from 0.72 to 0.94. Walking ability did influence these findings with fair to good reliability demonstrated for both poorer (ICC_(2,1) > 0.57) and better walkers (ICC_(2,1) > 0.41).

Conclusions.?It appears that the GAITRite has good test-retest reliability in this group of people with first stroke undergoing rehabilitation. Test reliability seems to be slightly higher for poorer walkers than better walkers.     

A comparison of gait biomechanics and metabolic requirements of overground and treadmill walking in people with stroke

Background

Comparisons of treadmill and overground walking following stroke indicate that symmetry in temporal-distance measures is better on the treadmill suggestive of better gait economy. We examined this issue by examining the kinematic, kinetic and metabolic demands associated with overground and treadmill walking at matched speeds and also explored the effect of increasing treadmill speed.

Methods

Ten people with hemiparesis walked overground at their preferred speed which was matched on the treadmill. Belt speed was then increased 10% and 20% above preferred speed. Temporal-distance outcomes, angular kinematics and vertical ground reaction forces were recorded during steady state (stable heart rate and oxygen uptake).

Findings

Step and stance times were longer when walking overground but the degree of symmetry was comparable for both surfaces. In contrast kinematic data revealed significant interlimb asymmetry with respect to all lower limb joint excursions during overground walking accompanied by higher vertical ground reaction forces at push-off. The metabolic demands, however, were lower when walking overground than on the treadmill. Increasing the belt speed increased angular displacements and the vertical forces associated with both limbs such that symmetry remained unchanged. Metabolic demands increased significantly.

Interpretation

People with stroke adopt a more symmetrical kinematic walking pattern on the treadmill which is maintained at faster belt speeds. Surprisingly, at matched speed the metabolic cost was significantly higher with treadmill walking. We suggest further research to explore whether an increased reliance on the hip musculature to compensate lower push-off forces could explain the higher the energy cost.     

Increased power generation in impaired lower extremities correlated with changes in walking speeds in sub-acute stroke patients

Background

Establishing changes in net joint power in the lower extremity of patients during recovery of walking might direct gait training in early stroke rehabilitation. It is hypothesized that (1) net joint power in the lower extremity joints would increase in sub-acute stroke patients following gait rehabilitation, and (2) the improvements in net joint power would be significantly correlated with changes in walking speed.

Methods

Thirteen sub-acute patients (<3 months from stroke onset) participated in the study. All patients completed 6 weeks of gait training (3 weeks of robotic gait training and 3 weeks of physiotherapy). The gait patterns were analyzed using 3D motion analysis before and after training. The assessed variables were; gait speed and the net peak joint power of the ankle plantar flexors, hip extensors, hip flexors, hip abductors, and knee extensors.

Findings

Ankle plantar flexor power in the impaired limb and hip extensor power in the unimpaired limb increased significantly following training (133% and 77%, respectively; P < 0.002). Improvements (from 20% to 133%) in net joint power of the ankle plantar flexors, hip extensors, hip flexors, and hip abductors of the impaired limb and ankle plantar flexors and hip abductors of the unimpaired limb significantly correlated with the recovery of walking speed following training (0.24 m/s to 0.51 m/s) (r = 0.71–0.86).

Interpretation

The findings suggested investigations for strengthening the plantar flexors, hip flexors, hip extensors, and hip abductors concentrically, and knee extensors eccentrically in the impaired limb to determine the effectiveness in improving gait performance.     

Effects of shoe characteristics on dynamic stability when walking on even and uneven surfaces in young and older people

Menant JC, Perry SD, Steele JR, Menz HB, Munro BJ, Lord SR. Effects of shoe characteristics on dynamic stability when walking on even and uneven surfaces in young and older people.

Objective

To systematically investigate the effects of various shoe features (sole hardness, heel height, heel collar height, tread pattern) on dynamic balance control and perceptions of comfort and stability in young and older people walking over even and uneven surfaces.

Design

A mixed-design 3-way repeated measures with age as a between-subjects factor and surface and shoe conditions as within-subjects factors.

Setting

Gait laboratory.

Participants

Young adults (n=11) and community-dwelling older adults (n=15).

Interventions

Not applicable.

Main Outcome Measures

Center of mass (COM)−base of support (BOS) margins, vertical and braking loading rates, and subjective ratings of perceived shoe comfort and stability.

Results

Overall, compared with the standard shoes, the soft sole shoes led to greater lateral COM-BOS margin (P<.001), whereas the elevated heel shoes caused reductions in posterior COM-BOS margin (P=.001) and in vertical and braking loading rates (both, P<.001). Subjects rated the elevated heel shoes as significantly less comfortable (P<.001) and less stable (P<.001) than the standard shoes. Only the young subjects perceived the soft-sole shoes to be less stable than the standard shoes (P=.003).

Conclusions

Both young and older subjects adopted a conservative walking pattern in the elevated heel shoes and exhibited impaired mediolateral balance control in the soft-sole shoes. In contrast, increased sole hardness (above that found in a standard shoe), a tread sole, and a raised collar height did not improve walking stability in either group. It is concluded that shoes with elevated heels or soft soles should not be recommended for older people and that a standard laced shoe with a low collar and a sole of standard hardness with or without a tread provides optimal dynamic stability when walking on even and uneven surfaces.     

How people with stroke and healthy older people experience the eating process

The aim of this study was to describe the process of eating, experiences of eating and oral functions. Participants consisted of 30 people with first stroke and localization of the damage verified by computer topography (CT), and 15 healthy older people. All were observed during test-meals, interviewed about eating, and oral functions were tested. The results demonstrated that most (21) people with stroke had some difficulties in eating and expressed feelings of fear and shame about eating and changed physical and social appearance, mainly related to difficulties in preparing and transporting food to the mouth as well as swallowing deficits.     

Kinematic, kinetic and metabolic parameters of treadmill versus overground walking in healthy older adults

Background

Although treadmill and overground walking appear to be biomechanically similar in healthy, young adults it is not known whether this can be generalized to older subjects or if the metabolic demands are correspondingly comparable.

Methods

Ten healthy adults between 50 and 73 years of age walked at the same speed overground and on a treadmill. Temporal parameters, angular kinematics and vertical ground reaction forces were recorded during walking once subjects were in steady state as determined from their heart rate and oxygen uptake.

Findings

Step, stride and joint angular kinematics were similar for both modes of walking with the exception of the maximum hip flexion and knee extension which were more pronounced with treadmill or overground walking, respectively but in both instances differed by less than 3°. Vertical ground reaction force profiles were similar although the peak associated with push-off was 5.5% smaller with treadmill walking. The metabolic requirements of treadmill walking were about 23% higher than that associated with overground walking.

Interpretation

While treadmill and overground walking are biomechanically similar, the metabolic cost of treadmill walking is higher. Clinically this may be important when using a treadmill for gait retraining in patient populations as it may lead to premature fatigue or undesirable physiologic challenge.     

Assessing advanced walking ability in people with stroke using the Groningen Meander Walking Test

Abstract

Objectives: (1) To investigate the intrarater, interrater and test–retest reliabilities of the Groningen Meander Walking Test in people with stroke; (2) to compare the performance of the Groningen Meander Walking Test between people with stroke and healthy older adults; (3) to quantify any correlations between the Groningen Meander Walking Test and other stroke-specific impairment measurements; and (4) to determine the cut off time that best discriminates between 30 people with stroke and 30 age-matched healthy elderly.

Method: Using a cross-sectional design, the Groningen Meander Walking Test was administered along with the Fugl-Meyer Motor Assessment for the lower extremities, measurement of lower limb muscle strength, Berg’s Balance Scale, comfortable walking speed, Timed up and Go test and Community Integration Measure-Cantonese version.

Results: The Groningen Meander Walking Test completion times showed excellent intrarater, interrater and test–retest reliabilities (ICC = 0.984–1.00). Our study also showed that stroke subjects took three times longer (28.8?s) than the healthy subjects (9.0?s) in completion times. Both Groningen Meander Walking Test completion times and overstep scores significantly correlated with comfortable walking speed and Timed up and Go test. The cut off time for people with stroke was 11.98 seconds (sensitivity = 0.967; specificity = 1.0) to discriminate against healthy elderly.

Conclusion: The Groningen Meander Walking Test is a highly reliable and valid tool for quantifying the advanced walking abilities of people with stroke.

• Implications for Rehabilitation

• The Groningen Meander Walking Test completion times demonstrated excellent intrarater, interrater and test–retest reliabilities.

• The Groningen Meander Walking Test completion times correlates well with Berg Balance Scale scores, comfortable walking and Timed Up and Go test times.

• The Groningen Meander Walking Test overstep scores correlates significantly to its completion times, Fugl-Myer Assessment-Lower Extremity scores, comfortable walking speed and Timed Up and Go test times.

• A cut off time of 11.98s best for Groningen Meander Walking Test completion times discriminates people with stroke from healthy elderly with sensitivity of 97% and specificity of 100%.

• The Groningen Meander Walking Test is highly reliable and easy to administer in assessing advanced walking abilities in people with stroke.

     

Using crutches during walking possibly reduces gait imagery accuracy among healthy young and older adults

[Purpose] Although crutches are widely used in the field of rehabilitation to improve gait performance, patients usually have difficulties using them, and this may increase their risks for falls. This study aimed to define the accuracy of gait imagery during walking with and without crutches, in healthy young and older adults, using the mental chronometry method. [Participants and Methods] Overall, 99 healthy young (mean age, 20.2 ± 1.0 years) and 39 healthy older adults (mean age, 71.3 ± 2.9 years) performed the imagery and execution tasks, which involved walking through a distance of 10 meters both with and without crutches. Using the mental chronometry method, the accuracy of the motor imagery was defined as the difference between the imagery time and the actual execution time. Two-way analysis of variance and one-sample t-tests were performed to evaluate the accuracy of the gait imagery. [Results] Both the young and older adults significantly overestimated their gait speeds when using crutches; the overestimation was larger among the older adults. [Conclusion] The overestimations indicate that participants estimated their gait speeds with crutches to be faster than their actual speeds. Therefore, using crutches decreased the accuracy of gait imagery and might therefore increase an individual’s risk of falling during walking.     

Test position and hip strength in healthy adults and people with chronic stroke

Barbic S, Brouwer B. Test position and hip strength in healthy adults and people with chronic stroke.

Objective

To determine if peak torques generated by the hip flexors and extensors are dependent on test position in healthy adults and in people with chronic stroke.

Design

Cross-sectional study.

Setting

Motor performance laboratory.

Participants

Volunteers were 10 young (20.7±1.5y), 10 older adults (62.1±7y), and 10 stroke survivors (60.6±10y) who were an average of 5 years poststroke.

Interventions

Not applicable.

Main Outcome Measures

Isokinetic (60°/s) peak concentric hip flexor and extensor torques (in Nm/kg) generated in supine and standing positions.

Results

Peak flexor torques measured in standing were generally higher than in supine (P=.018); a pattern evident in all groups, but significant only in stroke. An interaction between test position and group for hip extensor strength (P=.016) reflected 2 distinct patterns in which torques were highest in standing among the young subjects and highest in supine after stroke.

Conclusions

Isokinetic hip flexor and extensor strength measured in standing and supine are comparable in young and older healthy people. In chronic stroke, the test position may over or underestimate maximum peak torque depending on the muscle group tested, particularly on the side ipsilateral to the lesion. These findings may have implications for predicting functional ability from strength measurements.     

A comparison of the effects of visual deprivation and regular body weight support treadmill training on improving over-ground walking of stroke patients: a multiple baseline single subject design

Abstract

The body-weight-support treadmill (BWST) is commonly used for gait rehabilitation, but other forms of BWST are in development, such as visual-deprivation BWST (VDBWST). In this study, we compare the effect of VDBWST training and conventional BWST training on spatiotemporal gait parameters for three individuals who had hemiparetic strokes. We used a single-subject experimental design, alternating multiple baselines across the individuals. We recruited three individuals with hemiparesis from stroke; two on the left side and one on the right. For the main outcome measures we assessed spatiotemporal gait parameters using GAITRite, including: gait velocity; cadence; step time of the affected side (STA); step time of the non-affected side (STN); step length of the affected side (SLA); step length of the non-affected side (SLN); step-time asymmetry (ST-asymmetry); and step-length asymmetry (SL-asymmetry). Gait velocity, cadence, SLA, and SLN increased from baseline after both interventions, but STA, ST-asymmetry, and SL-asymmetry decreased from the baseline after the interventions. The VDBWST was significantly more effective than the BWST for increasing gait velocity and cadence and for decreasing ST-asymmetry. VDBWST is more effective than BWST for improving gait performance during the rehabilitation for ground walking.     

Relationship between oxygen cost of walking and level of walking disability after stroke: An experimental study

Background and Purpose

Since physical inactivity is the major risk factor for recurrent stroke, it is important to understand how level of disability impacts oxygen uptake by people after stroke. This study investigated the nature of the relationship between level of disability and oxygen cost in people with chronic stroke.

Methods

Level of walking disability was measured as comfortable walking speed using the 10‐m Walk Test reported in m/s with 55 ambulatory people 2 years after stroke. Oxygen cost was measured during 3 walking tasks: overground walking at comfortable speed, overground walking at fast speed, and stair walking at comfortable speed. Oxygen cost was calculated from oxygen uptake divided by distance covered during walking and reported in ml?kg^?1?m^?1.

Results

The relationship between level of walking disability and oxygen cost was curvilinear for all 3 walking tasks. One quadratic model accounted for 81% (95% CI [74, 88]) of the variance in oxygen cost during the 3 walking tasks:

Discussion

The oxygen cost of walking was related the level of walking disability in people with chronic stroke, such that the more disabled the individual, the higher the oxygen cost of walking; with oxygen cost rising sharply as disability became severe. An equation that relates oxygen cost during different walking tasks according to the level of walking disability allows clinicians to determine oxygen cost indirectly without the difficulty of measuring oxygen uptake directly.     

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.

     

Gait velocity and walking distance to predict community walking after stroke

Gait speed and walking distance were evaluated as predictors for levels of community walking after stroke. In this study, 103 stroke survivors were identified as limited (n = 67) or independent community walkers (n = 36). Ten meter and six min walk tests were used to measure gait speed and walking distance, respectively. The discriminative properties of gait speed and walking distance for community walking were investigated using receiver operating characteristic curves. Cut‐off values of 0.87 m/s for community walking gait speed for walking distance had positive predictive values of 65% and 55%, respectively. The negative predictive value ranged from 89% for gait speed to 79% for walking distance. Gait speed and walking distance showed significant differences between limited and independent community walking. Gait speed was more significantly related to community walking than walking distance. The results of this study suggest that gait speed is a better predictor for community walking than walking distance in moderately affected post‐stroke survivors.