The effect of a foot gymnastic exercise programme on gait performance in older adults: A randomised controlled trial

Abstract

Background. Aged-related loss of ankle dorsiflexion range of motion (ROM) and toe plantarflexor strength play an important role in gait performance. Further, conventional strength, balance and gait training can significantly improve the lower extremity muscle power and functional abilities of older individuals. It remains unclear, however, whether training effects can be enhanced by augmenting ankle ROM and toe plantarflexor strength complementary to training. Objective. This study investigated the effect of physical exercise combined with foot gymnastics on the gait performance in older adults.

Methods. Fifty-six independent living, older adults aged 66-91 years were randomly assigned to either foot gymnastics group (FG;n - 28) or training group (TG;n = 28). Further, 14 subjects were integrated as a control group (CG;n = 14) (no exercise). The FG and TG completed the same training program consisting of aerobic exercises, progressive resistance strength training and stretching exercises twice per week for 12 weeks, whereas the FG performed additional foot gymnastic exercises at the end of the training session and a 10-min foot gymnastics home-program daily. Assessments included the Falls Efficacy Scale - International (FES-I), Expanded Timed Get-up-and-Go test (ETGUG), gait analysis and muscle power measurements of the knee and ankle joint at pre- and post-training.

Results. No significant change in FES-I score occurred in either group. The FG showed a significant improvement of ankle ROM. There were significant time x group interactions in walking speed, step length, in several muscle power measurements and in ETGUG. The positive effects of gait parameters ranged between 1 and 11% and between 2 and 12%, of muscle power between 14 and 34% and 14 and 46% and of ETGUG were 10 and 8% for the FG and TG, respectively. The FG and TG did not differ significantly in their improvements. The CG showed a trend to deteriorations between 0 and -6% for gait parameters, between -4 and - 14% for muscle power and 0% for ETGUG.

Conclusions. The results of this study provide evidence of significant improvements in gait performance, muscle power and ETGUG after a conventional training program in independent living, older adults. However, there is no additional effect on physical performance after foot gymnastic exercises.     

The effect of a training program combined with augmented afferent feedback from the feet using shoe insoles on gait performance and muscle power in older adults: a randomised controlled trial

Background.?Aged-related loss of afferent feedback of the feet plays an important role in gait performance. Although strength, balance and gait training can significantly improve the muscle power and functional abilities of older individuals, it remains unclear whether training effects can be enhanced by augmenting afferent feedback from the feet adding shoe insoles complementary to conventional training.

Objective.?The current study investigated the effect of physical exercise combined with wearing MedReflex® shoe insoles on the gait performance and muscle power in older adults.

Methods.?Twenty-eight independent living, older adults aged 65–91 years were randomly assigned to either an insole group (IG; n?=?14) or a training group (TG; n?=?14). Further 14 subjects matched to the IG and TG were recruited as a control group (CG; n?=?14) (no exercise). The IG and TG completed the same training program consisting of aerobic exercises, progressive resistance strength training and stretching exercises twice per week for 12 weeks, whereas, the IG wore the insoles during everyday life and during training sessions. Assessments included the Falls Efficacy Scale – International (FES-I), gait analysis and muscle power measurements of the knee and ankle joint at pre- and post-training.

Results.?There were significant time?×?group interactions in walking speed, step length and in several muscle power measurements. The positive effects of gait parameters ranged between 1% and 12% and between 1% and 8% and the trend to improvements of muscle power ranged between 15–79% and 20–79% for the IG and TG, respectively. The IG and TG did not differ significantly in their improvements. The CG showed a trend to deteriorations between 0% and??5% for gait parameters and between??4% and??14% for muscle power. No significant change in FES-I score occurred in neither groups.

Conclusions.?The results of this study provide evidence of significant improvements in gait performance and muscle power after a conventional training program in independent living, older adults. However, there is no additional effect of long-term adaptation of gait caused by wearing insoles concurrent to physical training.     

Effect of Strength Training of Ankle Plantarflexors on Selective Voluntary Motor Control,Gait Parameters,and Gross Motor Function of Children with Cerebral Palsy

[Purpose] The purpose of this study was to investigate the effect of ankle plantarflexor strength training on selective voluntary motor control, gait parameters, and gross motor function of children with cerebral palsy (CP), focusing on changes in the strength and muscle activity of the ankle plantarflexors. [Methods] Six children aged between 4 and 10 years with CP participated in a 6 week strengthening program. The subjects were evaluated before and after the intervention in terms of ankle plantarflexor strength, muscle activity, gait velocity, cadence, step length, and D (standing) and E (walking, running, and jumping) dimensions of the Gross Motor Function Measure (GMFM). The data were analyzed using the non-parametric Wilcoxon signed-rank test. [Results] The strength of the plantarflexors increased in the majority of subjects. Significant and clinically meaningful post-intervention improvements in subject''s gait velocity, cadence, and step length were found. [Conclusion] The controlled ankle plantarflexor strengthening program may lead to improvements in strength and spatiotemporal gait parameters of children with CP.Key words: Ankle plantarflexor, Strengthening exercise, Gait parameter     

Muscle strengthening and physical conditioning to reduce impairment and disability in chronic stroke survivors.

OBJECTIVE: To evaluate the impact of a program of muscle strengthening and physical conditioning on impairment and disability in chronic stroke subjects. DESIGN: A randomized pretest and posttest control group, followed by a single-group pretest and posttest design. SUBJECTS: Thirteen community-dwelling stroke survivors of at least 9 months. INTERVENTION: A 10-week (3 days/week) program consisting of a warm-up, aerobic exercises, lower extremity muscle strengthening, and a cool-down. MAIN OUTCOME MEASURES: Peak isokinetic torque of the major muscle groups of the affected lower limb, quadriceps and ankle plantarflexor spasticity, gait speed, rate of stair climbing, the Human Activity Profile (HAP), and the Nottingham Health Profile (NHP) were recorded twice for the treatment group and three times for the control group. RESULTS: Significant improvements were found for all the selected outcome measures (HAP, NHP, and gait speed) for the treatment group (p < .001). In terms of overall training effects, the 13 subjects demonstrated increases in strength of the affected major muscle groups, in HAP and NHP profiles, and in gait speed and rate of stair climbing without concomitant increases in either quadriceps or ankle plantarflexor spasticity. CONCLUSIONS: The 10-week combined program of muscle strengthening and physical conditioning resulted in gains in all measures of impairment and disability. These gains were not associated with measurable changes of spasticity in either quadriceps or ankle plantarflexors.     

Quantifying established clinical assessment measures using 3D-movement analysis in individuals with Down syndrome

Purpose.?A movement protocol for quantifying functional limitation in people with Down syndrome (DS) during the execution of a series of range of motion (ROM) tasks has been developed as a new assessment approach, combining quantitative measures of movement analysis and functional mobility with clinically established qualitative motor skill assessments.

Methods.?Fifteen subjects with DS and 11 subjects with typical development were evaluated using this movement protocol.

Results.?The results revealed longer durations in execution across all tasks in the DS group and were most likely due to low muscular tone and poor coordination. A significant difference in ankle ROM was found in the DS group during leg-lifting, with a wide plantar-flexion demonstrated during the entire movement. This result may be associated with the typical strategy for foot contact that generally favours the toe. Significant differences were also found in the trunk ROM and in the knee ROM and may likely reflect an increase of agonist–antagonist co-contraction, a strategy that may modify stability and dynamic equilibrium.

Conclusion.?The combined quantitative/qualitative protocol is an important advancement in evaluating individuals with DS and should be integrated into a more comprehensive evaluation of dynamic gait and lower limb analysis.     

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.

     

Quantitative assessment of the effects of 6 months of adapted physical activity on gait in people with multiple sclerosis: a randomized controlled trial

Purpose: The purpose of this study is to quantitatively assess the effect of 6 months of supervised adapted physical activity (APA i.e. physical activity designed for people with special needs) on spatio-temporal and kinematic parameters of gait in persons with Multiple Sclerosis (pwMS).

Methods: Twenty-two pwMS with Expanded Disability Status Scale scores ranging from 1.5 to 5.5 were randomly assigned either to the intervention group (APA, n?=?11) or the control group (CG, n?=?11). The former underwent 6 months of APA consisting of 3 weekly 60-min sessions of aerobic and strength training, while CG participants were engaged in no structured PA program. Gait patterns were analyzed before and after the training using three-dimensional gait analysis by calculating spatio-temporal parameters and concise indexes of gait kinematics (Gait Profile Score – GPS and Gait Variable Score – GVS) as well as dynamic Range of Motion (ROM) of hip, knee, and ankle joints.

Results: The training originated significant improvements in stride length, gait speed and cadence in the APA group, while GPS and GVS scores remained practically unchanged. A trend of improvement was also observed as regard the dynamic ROM of hip, knee, and ankle joints. No significant changes were observed in the CG for any of the parameters considered.

Conclusions: The quantitative analysis of gait supplied mixed evidence about the actual impact of 6 months of APA on pwMS. Although some improvements have been observed, the substantial constancy of kinematic patterns of gait suggests that the full transferability of the administered training on the ambulation function may require more specific exercises.

• Implications for rehabilitation

• Adapted Physical Activity (APA) is effective in improving spatio-temporal parameters of gait, but not kinematics, in people with multiple sclerosis.

• Dynamic range of motion during gait is increased after APA.

• The full transferability of APA on the ambulation function may require specific exercises rather than generic lower limbs strength/flexibility training.

     

The Effect of an Inclined Ankle on the Activation of the Abductor Hallucis Muscle during Short Foot Exercise

[Purpose] The purpose of this study was to identify the effects of an inclined ankle on the activation of the abductor hallucis muscle during short foot exercises. [Subjects] We recruited 14 healthy volunteers who were free of pain, and did not suffer from arthritis or osteomuscular problems related to the foot or ankle. [Methods] The subjects performed short foot exercises and short inclined foot exercises with 30° passive ankle dorsiflexion. [Results] The exercise with an inclined foot showed a significantly larger activation of the abductor hallucis than that shown during the neutral short foot exercises. [Conclusion] These results suggest that passive ankle dorsiflexion during short foot exercise for strengthening the abductor hallucis is a more effective clinical treatment exercise.Key words: Abductor hallucis, Inclined ankle, Short foot exercise     

Effects of Progressive Resistance Training Integrated with Foot and Ankle Compression on Spatiotemporal Gait Parameters of Individuals with Stroke

[Purpose] The purpose of this study was to investigate the effect of progressive resistance training (PRT) integrated with foot and ankle compression on the gait ability of post-stroke patients. [Subjects and Methods] Participants were randomly allocated to two groups: the PRT group (n=14) and the control group (n=14). Subjects in the PRT group received training for 30 minutes, five days per week, for a period of six weeks. Gait ability was evaluated using the RsScan system. [Results] Use of PRT integrated with foot and ankle compression resulted in significant improvements in temporal parameters (gait velocity, step time, and double limb support) and spatial parameters (step length, stride length, and heel-to- heel base of support). [Conclusion] Progressive resistance training integrated with foot and ankle compression improved the gait ability of stroke patients. These results suggest the feasibility and suitability of integration of PRT with foot and ankle compression for individuals with stroke.Key words: Progressive resistance training, Stroke, Gait     

Effects of physical exercise on the functional recovery of rat hindlimbs with impairments of the sciatic nerve as assessed by 2D video analysis

[Purpose] The purpose of this study was to investigate the effects of treadmill training on functional recovery by analyzing the ankle joint as well as the knee and hip joints with 2D video analysis during gait by rats with sciatic nerve injury. [Subjects and Methods] Twenty-four male Sprague-Dawley rats were used in this study. The sham group (SG) received only a sham operation without any sciatic injury; the training group (TG) performed treadmill training for 4 weeks after sciatic injury; and the control group (CG) wasn’t provided with any therapeutic intervention after sciatic injury. [Results] The ankle, knee, and hip ROM of TG and CG during the initial, mid stance, and toe-off phases of gait at post-test were significantly different from SG. [Conclusion] Physical exercise, like treadmill training, is beneficial for the improvement of the ankle, knee and hip joints of rats with crushed sciatic nerve injury.Key words: Sciatic nerve injury, Physical exercise, 2D video analysis     

Effects of Combining Electric Stimulation With Active Ankle Dorsiflexion While Standing on a Rocker Board: A Pilot Study for Subjects With Spastic Foot After Stroke

Cheng J-S, Yang Y-R, Cheng S-J, Lin P-Y, Wang R-Y. Effects of combining electric stimulation with active ankle dorsiflexion while standing on a rocker board: a pilot study for subjects with spastic foot after stroke.

Objective

To investigate the therapeutic effects of combining electric stimulation (ES) with active ankle dorsiflexion while standing on a rocker board in subjects with plantarflexor spasticity after stroke.

Design

Randomized controlled trial.

Setting

A rehabilitation medical center.

Participants

Subjects (N=15) with spastic foot after stroke.

Interventions

Subjects were randomly assigned to an experimental or a control group. The experimental group received ES of ankle dorsiflexors in concert with a motor training paradigm that required the subject to dorsiflex the ankles in response to a cue while standing on a rocker board. After 30 minutes of this exercise, subjects received ambulation training focusing on ankle control for 15 minutes. The control group received general range of motion and strength exercises for 30 minutes, followed by 15 minutes of ambulation training focusing on ankle control. Sessions occurred 3 times a week for 4 weeks.

Main Outcome Measures

Dynamic spasticity of plantarflexors, dorsiflexor muscle strength, balance performance, gait kinematics, and functional gait performance as assessed by the Emory Functional Ambulation Profile (EFAP) were used as outcome measurements.

Results

The experimental group demonstrated a greater decrease in dynamic ankle spasticity at a comfortable gait speed (P=.049), a greater improvement in spatial gait symmetry (P=.015), and a greater improvement in functional gait ability as indicated by the EFAP (P=.015) than the control group.

Conclusions

Our results suggest that repeated ES with volitional ankle movements can decrease dynamic ankle spasticity in subjects with stroke. Furthermore, such improvement parallels better gait symmetry and functional gait performance.     

Effect of robotic locomotor training in an individual with Parkinson's disease: a case report

Purpose.?The purpose was to test the effect of robot-assisted gait therapy with the Lokomat system in one representative individual with Parkinson's disease (PD).

Methods.?The patient was a 67-year-old female with more than an 8-year history of PD. The manifestations of the disease included depressive mood with lack of motivation, moderate bradykinesia, rigidity and resting tremor, both involving more the right side of the body, slow and shuffling gait with episodes of freezing and risk of falling. The patient underwent six sessions of robot-assisted gait training. The practice included treadmill walking at variable speed for 25–40?min with a partial body weight support and assistance from the Lokomat orthosis.

Results.?After the therapy, the patient increased the gait speed, stride length and foot clearance during over ground walking. She reduced the time required to complete a 180° turn and the latency of gait initiation. Improvements were observed in some items of the Unified Parkinson's Disease Rating Scale including motivation, bradykinesia, rigidity, freezing, leg agility, gait and posture.

Conclusions.?Although the results supported the feasibility of using robot-assisted gait therapy in the rehabilitation an individual with PD, further studies are needed to assess a potential advantage of the Lokomat system over conventional locomotor training for this population.     

Comparison of foot pressure in stretching exercises according to the type of ankle ramp

[Purpose] This study compared and analyzed use of an existing ankle ramp and a newly developed ankle ramp for stretching exercises. [Subjects] Fourteen subjects were included; they were stroke patients more than 6 months after onset, with no orthopedic or biological problems in the legs, so independent gait was possible. [Methods] The subjects performed stretching exercises for 5 min with an existing ankle ramp and a newly developed ankle ramp; foot pressure was then measured. [Results] The averaged percentage and kilopascal data for weight bearing and foot pressure on the affected side with the newly developed ankle ramp for stretching exercises were significantly higher than those with the existing ankle ramp. [Conclusion] Our results suggest that stretching exercises using the newly developed ankle ramp more effectively increase foot pressure than the existing ankle ramp.Key words: Ankle ramp, Foot pressure, Stroke     

Effects of biofeedback treatment on gait in children with cerebral palsy

Purpose:?We evaluated the effectiveness of biofeedback treatment on gait function in children with cerebral palsy.

Method:?Thirty-six children with spastic cerebral palsy and dynamic equinus deformity were included in the study. The biofeedback group consisted of 21 children who each received EMG biofeedback training plus conventional exercise programme. The control group consisted of 15 children who each received conventional exercise programme only. Active range of motion of the ankle joints, muscle tone of plantar flexors, and gait function of the children were evaluated and compared.

Results:?The biofeedback group displayed statistically significant improvements regarding tonus of plantar flexor muscles and active ROM of ankle joints (p?<?0.000 for all parameters). Gait function showed statistically significant progress in both of the groups, but the biofeedback group was superior to controls.

Conclusions:?Children with cerebral palsy and dynamic equinus deformities may benefit from biofeedback treatment for ambulation.     

Improvement of gait in a stroke patient. A 7-year longitudinal study

Purpose.?To report on the gait improvement obtained in a stroke patient after applying three treatments for spastic equinus varus foot: botulinum toxin injection (BTI), tibial nerve neurotomy (TNN), and orthopaedic surgery (triple arthrodesis), during a 7-year longitudinal follow-up period.

Method.?A quantified analysis of a stroke patient's gait was performed on a Gaitrite® walking mat before and after applying BTI 3 years, TNN 4 years and orthopaedic surgery 7 years after the stroke.

Results.?After the three treatments, the spasticity disappeared, the range of ankle motion improved and voluntary command of the tibialis anterior became possible. Upon comparing the gait parameters before treatment and after the three treatments, it was observed that the comfortable gait velocity had increased (from 0.42?m/s to 0.70?m/s), the step length had become more symmetrical (from left 19?cm, right 57?cm to left 50?cm, right 51?cm), the step width had decreased (from 23?cm to 12?cm). In terms of participation, walking barefoot had become possible without a cane, as well as going up and down stairs and walking outdoors on uneven ground without any help.

Conclusions.?Stroke patients during the chronic phase with a spastic equinovarus deformity can benefit from various commonly used therapeutic interventions. BTI and TNN were found to be efficient but only for a short time. Orthopaedic surgery gave the most long-lasting results. Further studies should be performed on a larger number of patients to determine the most suitable options for treating stroke patients with an equinus varus foot.     

Optimising the effects of rigid ankle foot orthoses on the gait of children with cerebral palsy (CP) – an exploratory trial

Purpose: This exploratory trial investigated the effects of rigid ankle foot orthoses (AFO) with an optimally cast Angle of the Ankle in the AFO (AAAFO) on the gait of children with Cerebral Palsy (CP), and whether tuning of the AFO – Footwear Combination (AFO-FC) further affected gait. Methods: Eight children with CP underwent gait analysis and tuning of their AFO-FCs using a 3-D motion analysis system. Comparisons were carried out for selected gait parameters between three conditions – barefoot, non-tuned AFO-FC and tuned AFO-FC. Results: In comparison to barefoot gait, walking with a non-tuned AFO-FC produced significant (p?Conclusions: The findings of the current study indicate the potential benefits of using rigid AFO-FC with optimal AAAFO and tuning of AFO-FCs. This study emphasises the need for categorising children with CP based on their gait patterns when investigating the effects of interventions such as AFOs.

• Implications for Rehabilitation

• Rigid ankle foot orthoses (AFO) cast at an optimal angle to accommodate the length of gastrocnemius muscle may positively influence walking in children with Cerebral Palsy (CP).

• Tuning of the AFO-Footwear Combination (AFO-FC) has potential benefits to the walking of children with CP, depending on their gait abnormalities.

• When investigating the effects of interventions such as AFOs, it is important to categorise children with CP based on their gait abnormalities.

     

Effects of one session radial extracorporeal shockwave therapy on post-stroke plantarflexor spasticity: a single-blind clinical trial

Purpose To examine the effects of radial extracorporeal shockwave therapy (rESWT) on plantarflexor spasticity after stroke. Method Twelve patients with stroke were randomly included for this prospective, single-blind clinical trial. Patients received one rESWT session (0.340?mJ/mm², 2000 shots) on plantarflexor muscle. The Modified Modified Ashworth Scale (MMAS), H-reflex tests, ankle range of motion (ROM), passive plantarflexor torque (PPFT) and timed up and go test (TUG) were measured at baseline (T₀), immediately after treatment (T₁) and one hour after the end of the treatment (T₂). Results Patients had improved the MMAS scores for both the gastrocnemius and the soleus muscles, active and passive ROM, PPFT and TUG over time after rESWT. For the PPFT, it was greater at high velocity than at low velocity, and there was a significant three-way interaction between time, knee position (extended/flexed) and velocity (low/high). The H-reflex latency had decreased at T₁, but there was no significant effect on H_max/M_max ratio. Conclusions The rESWT improved plantarflexor spasticity, and the effects sustained for one hour, whereas it was not effective in improving spinal excitability.

• Implications for Rehabilitation

• One session radial extracorporeal shock wave therapy (rESWT) is safe and effective in improving post stroke plantarflexor spasticity, ankle active and passive range of motion, passive torque, and walking capability.

• The spasticity scores improved for both the gastrocnemius and the soleus muscles and persisted one hour after rESWT.

• The magnitude of resistive plantarflexor passive torque in the knee extended position and high velocity was larger over time suggesting greater gastrocnemius spasticity than soleus.

• The rESWT had no significant effects on alpha motorneuron excitability.