Correlations between ankle–foot impairments and dropped foot gait deviations among stroke survivors

BackgroundThe purpose of this paper is to 1) evaluate the relationship between ankle kinematics during gait and standardized measures of ankle impairments among sub-acute stroke survivors, and 2) compare the degree of stroke-related ankle impairment between individuals with and without dropped foot gait deviations.MethodsFifty-five independently ambulating stroke survivors participated in this study. Dropped foot was defined as decreased peak dorsiflexion during the swing phase and reduced ankle joint motion in stance. Standardized outcome measures included the Chedoke–McMaster Stroke Assessment (motor impairment), Modified Ashworth Scale (spasticity), Medical Research Council (muscle strength), passive and active range of motion, and isometric muscle force.FindingsFoot impairment was not related to peak dorsiflexion during swing (r = ? 0.17, P = 0.247) and joint motion during stance (r = 0.05, P = 0.735). Active (r = 0.45, P < 0.001) and passive (r = 0.48, P < 0.001) range of motion was associated with stance phase joint motion. Peak dorsiflexion during swing was related to isometric dorsiflexor muscle force (r = ? 0.32, P = 0.039). Individuals with dropped foot demonstrated greater motor impairment, plantarflexor spasticity and ankle muscle weakness compared to those without dropped foot.InterpretationOur investigation suggests that ankle–foot impairments are related to ankle deviations during gait, as indicated by greater impairment among individuals with dropped foot. These findings contribute to a better understanding of gait-specific ankle deviations, and may lead to the development of a more effective clinical assessment of dropped foot impairment.     

The effect of ankle–foot orthosis plantarflexion stiffness on ankle and knee joint kinematics and kinetics during first and second rockers of gait in individuals with stroke

BackgroundStiffness of an ankle–foot orthosis plays an important role in improving gait in patients with a history of stroke. To address this, the aim of this case series study was to determine the effect of increasing plantarflexion stiffness of an ankle–foot orthosis on the sagittal ankle and knee joint angle and moment during the first and second rockers of gait.MethodsGait data were collected in 5 subjects with stroke at a self-selected walking speed under two plantarflexion stiffness conditions (0.4 Nm/° and 1.3 Nm/°) using a stiffness-adjustable experimental ankle–foot orthosis on a Bertec split-belt fully instrumented treadmill in a 3-dimensional motion analysis laboratory.FindingsBy increasing the plantarflexion stiffness of the ankle–foot orthosis, peak plantarflexion angle of the ankle was reduced and peak dorsiflexion moment was generally increased in the first rocker as hypothesized. Two subjects demonstrated increases in both peak knee flexion angle and peak knee extension moment in the second rocker as hypothesized. The two subjects exhibited minimum contractility during active plantarflexion, while the other three subjects could actively plantarflex their ankle joint.InterpretationIt was suggested that those with the decreased ability to actively plantarflex their ankle could not overcome excessive plantarflexion stiffness at initial contact of gait, and as a result exhibited compensation strategies at the knee joint. Providing excessively stiff ankle–foot orthoses might put added stress on the extensor muscles of the knee joint, potentially creating fatigue and future pathologies in some patients with stroke.     

The impact of rollator loading on gait and fall risk in neurorehabilitation – a pilot study

Purpose: Rollator loading is an application used clinically sometimes to improve functional integrity and security of the patients’ gait. As empirical evidence supporting this intervention is equivocal, the purpose of this study was to examine the effects of rollator loading on several gait parameters and fall risk. Methods: An explicatory experiment with a follow-up cohort study of falls was conducted. In the experimental part of the study, participants (n?=?25) were evaluated three times by means of different gait and fall risk assessments, whereby each trial was carried out with different rollator loading (0, 4.5 and 9?kg, respectively). Participants were blinded towards the applied load. In addition, the odds ratio of falls with respect to rollator loading in all-day rehabilitation life was determined. Results: No changes in spatio-temporal gait parameters and fall risk in relation to a particular load could be identified by clinical measures in the tested sample. A separate sub-group analysis (Parkinson’s disease, hemiparesis and ataxia) showed only little impact of the load in each case. Rollator loading had no impact on the odds ratio of inpatient fall risk. Conclusion: On the basis of our findings, weighting of rollators can neither be discouraged nor recommended.

• Implications for Rehabilitation

• Unless more research is has been conducted on this topic, rollator loading can neither be recommended nor discouraged in individuals suffering from neurologic diseases.

• There is more research needed to examine the impact on ambulation in distinct conditions such as severe ataxia and fear of falling.

     

Effects of a knee–ankle–foot orthosis on gait biomechanical characteristics of paretic and non-paretic limbs in hemiplegic patients with genu recurvatum

Background

A knee–ankle–foot orthosis may be prescribed for the prevention of genu recurvatum during the stance phase of gait. It allows also to limit abnormal plantarflexion during swing phase. The aim is to improve gait in hemiplegic patients and to prevent articular degeneration of the knee. However, the effects of knee–ankle–foot orthosis on both the paretic and non-paretic limbs during gait have not been evaluated. The aim of this study was to quantify biomechanical adaptations induced by wearing a knee–ankle–foot orthosis, on the paretic and non-paretic limbs of hemiplegic patients during gait.

Methods

Eleven hemiplegic patients with genu recurvatum performed two gait analyses (without and with the knee–ankle–foot orthosis). Spatio-temporal, kinematic and kinetic gait parameters of both lower limbs were quantified using an instrumented gait analysis system during the stance and swing phases of the gait cycle.

Findings

The knee–ankle–foot orthosis improved spatio-temporal gait parameters. During stance phase on the paretic side, knee hyperextension was reduced and ankle plantarflexion and hip flexion were increased. During swing phase, ankle dorsiflexion increased in the paretic limb and knee extension increased in the non-paretic limb. The paretic limb knee flexion moment also decreased.

Interpretation

Wearing a knee–ankle–foot orthosis improved gait parameters in hemiplegic patients with genu recurvatum. It increased gait velocity, by improving cadence, stride length and non-paretic step length. These spatiotemporal adaptations seem mainly due to the decrease in knee hyperextension during stance phase and to the increase in paretic limb ankle dorsiflexion during both phases of the gait cycle.     

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.

     

Fast gait speed and self-perceived balance as valid predictors and discriminators of independent community walking at 6 months post-stroke – a preliminary study

Abstract

Purpose: To determine the validity of walking speed, muscle strength, function of the hemiparetic lower limb and self-perceived balance to predict and discriminate independent community walkers (ICW) within the first 6 months post-stroke. Methods: Inpatients with a first ischemic stroke (<3 months), able to walk, were evaluated (T₀) and re-evaluated after 6 months post-stroke (T₁). Comfortable, fast speed and the difference between fast and comfortable speed, muscle strength of knee flexors and extensors, sensory-motor function of the hemiparetic lower limb and self-perceived balance were assessed at T₀ and T₁. At T₁, a self-reported question was used to discriminate ICW versus Dependent Community Walkers (DCW). ROC curve analysis was used to determine valid predictive (T₀) and discriminative (T₁) cut-offs of ICW. Results: Only 25.7% of the 35 participants were ICW at T₁. Valid predictive cut-offs at T₀ were found for fast speed (≥0.42?m/s) and Falls Efficacy Scale (<57). Valid discriminators were found at T1 for fast speed (>0.84?m/s) and FES (<18.50). Conclusion: Fast speed and self-perceived balance appear to be important characteristics of ICW at 6 months and may be useful early predictors of the potential for patients to achieve this. Further research is needed to ensure the precision of these functional cut-offs.

• Implications for Rehabilitation

• Prognostic information is important for people with stroke and health services. The ability to walk faster than 0.42?m/s and a fear of falling on the Falls Efficacy Scale of less than 57 in the first 3 months after stroke predict who will be an independent community walker at 6 months.

• At 6 months after stroke, people who cannot walk faster than 0.84?m/s or who have a have Falls Efficacy Scale score <18.5 are unlikely to be walking independently in the community.

• Rehabilitation to promote independent walking should focus on walking speed, balance re-education and strategies to reduce fear of falling.

     

Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon – A pilot study

Musculoskeletal impairments affect one-third of the adult population, are one of the major contributors to lost time from work, and account for one-third of a general practitioner's caseload. These injuries respond well to physiotherapy, but access can be limited in a publicly funded health care system. Improved access to physiotherapy occurs in a collaborative model of care in orthopedic clinics however the extent to which the patient receives similar diagnoses and treatment recommendations has not been reported. The purpose of this study was to determine diagnostic concordance and accuracy, and treatment concordance between a physiotherapist and orthopedic surgeons. Twenty-five subjects in an orthopedic clinic were assessed by a physiotherapist and an orthopedic surgeon. Diagnosis and treatment recommendations were made by each separately. These were compared for concordance between professionals and diagnostic accuracy. The physiotherapist and the orthopedic surgeon had 90% concordance in diagnoses of knee and shoulder impairments, and 75% accuracy when compared to definitive diagnostic methods. They had 87% agreement in treatment recommendations, however, the physiotherapist gave three treatment recommendations per patient where the surgeon gave two. In a collaborative care context therefore, this study suggests, that physiotherapists have similar diagnostic capabilities to orthopedic surgeons, and they will enhance the conservative treatment options offered to orthopedic patients.     

The influence of a rocker sole adaptation on gait parameters in spinal cord injury patients ambulating with the advanced reciprocating gait orthosis – a pilot study

Objective: When walking with an advanced reciprocating gait orthosis (ARGO), ankle and knee joint motion is restricted which causes an un-cosmetic gait compared to normal walking. The purpose of this study was to develop and evaluate a rocker modification for use with the ARGO in order to improve hip joint kinematics, walking speed, step length and cadence. Method: Spinal cord injury patients (n?=?4) with thoracic-level injury participated in this study, and walked with a standard ARGO and one which was also adapted with a rocker sole in a randomized order. Results: Mean walking speed and step length were both significantly increased by volunteer SCI subjects when ambulating using the ARGO adapted with a rocker sole compared to the standard ARGO. Cadence was not significantly affected, but swing time was significantly reduced and mean hip flexion and extension were both significantly increased when walking with the adapted ARGO. Conclusion: The rocker sole modification produced an increase in walking speed and step length, and improved sagittal plane hip joint kinematics when ambulating using an ARGO. Using this type of shoe modification has the potential to improve gait parameters in SCI patients compared to the standard unmodified version.

• Implications for Rehabilitation

• The ARGO adapted with a rocker sole could be used by spinal cord injury patients.

• A major advantage of the walking with the ARGO adapted with a rocker sole was increased of walking speed and step length, and improvement of the sagittal plane hip joint kinematics.

• The findings of this study would appear to provide useful data for rehabilitation teams who utilize orthoses to walk and rehabilitate SCI subjects. Using this type of shoe modification has the potential to improve gait parameters in SCI patients compared to the standard un-modified version.

     

Influence of foot orthoses on plantar pressures,foot pain and walking ability of rheumatoid arthritis patients–a randomised controlled study

Purpose. To compare the effectiveness of functional foot orthoses and unshaped (flat) orthotic material on plantar pressure redistribution, forefoot pain reduction and walking ability in rheumatoid arthritis (RA) patients.

Methods. Forty patients with RA were randomised to receive unshaped material (UM) (n = 20) or functional foot orthoses (n = 20). Plantar pressure measurement was performed with an F-scan system. Foot pain was assessed by the pain subscale of the Foot Function Index. Walking ability was assessed by the 6-min walking test. Investigations were performed at baseline, 1 week after the patient received shoes with orthoses and 6 months later.

Results. Plantar pressures were significantly higher at painful than at non-painful foot areas. No differences in plantar pressure redistribution were found between the groups. Notable reduction of pain and improvement of activity (walking ability) was observed in both groups. Foot pain has moderate impact on the walking ability of RA patients.

Conclusions. The study showed no clear advantage of functional foot orthoses over UM.     

Upper body movements in children with hemiplegic cerebral palsy walking with and without an ankle–foot orthosis

Background

It has previously been discussed that treatment of the hemiplegic arm in patients with cerebral palsy can improve gait parameters in the lower body. Our question was whether improving the ankle rocker with an orthosis has an effect on the upper body during walking. The main aim was to investigate, which trunk and arm kinematics of toe walking children with hemiplegic cerebral palsy are changed by wearing a hinged ankle–foot orthosis, restoring an initial heel contact.

Methods

Specific parameters of the pelvis, thorax, and arm kinematics were investigated. Differences in the hemiplegic side between the barefoot and the orthotic condition were calculated by Students t-tests. Additionally, the 95% confidence intervals were used to explore clinically relevant differences between the controls and the patients and asymmetries within the patients' affected and unaffected sides.

Findings

Pelvic tilt range of motion (barefoot: 7.5° (6.1–9.0°), orthosis: 6.6° (5.1–8.1) P = 0.040) and mean shoulder abduction (barefoot: 14.3° (10.2–18.4°), orthosis: 12.1° (8.4–15.8) P = 0.027) were the only two parameters with statistically significant differences, although not clinically relevant, between the barefoot and orthotic conditions. Abnormalities in all three planes were explored between the patients and controls. The entire trunk was more externally rotated, the pelvis stood lower, and the elbow was more flexed on the hemiplegic side compared to the unaffected side.

Interpretation

A hinged ankle–foot orthosis, restoring the first ankle rocker, had no clinically relevant effects on trunk kinematics. None of the observed upper body gait deviations seemed to be secondary to or caused by toe walking.     

Experiences of individuals with chronic low back pain during and after their participation in a spinal stabilisation exercise programme – A pilot qualitative study

Spinal stabilisation exercises are commonly used in the management of low back pain (LBP). There is limited evidence relating to patients' experiences of their involvement in such programmes. The aim of this study was to explore the experiences of a sample of individuals with chronic LBP who participated in a randomised controlled trial (RCT) investigating the most efficacious dosage and frequency of spinal stabilisation exercises. The qualitative study involved nine participants who took part in focus group discussions. The data were analysed using thematic content analysis and provided insights into the experiences of the participants. Four themes emerged: Physical dimensions of the LBP experience, emotional and psychological dimensions of the LBP experience and perceived effects of the programme and lastly, the impact of the treatment programme on participants' knowledge, understanding and adherence. In conclusion participants' experiences were not limited to the positive effects of stabilisation exercises on pain, functional disability and quality of life, but also reflected increases in confidence, the formulation of self help strategies and the ability to exert better control over their LBP. The findings highlight the importance of well planned associated educational support packages in the treatment of LBP paving the way for future qualitative research.     

Replacing canes with an elasticated orthotic-garment in chronic stroke patients – The influence on gait and balance. A series of N-of-1 trials

ObjectiveTo investigate the effect of replacing canes with an elasticated orthotic-garment on balance and gait-function in chronic stroke survivors.DesignExperimental, N-of-1 series with a replicated, ABC design with randomised phase duration in a home setting.ParticipantsFour cane using chronic stroke survivors (P1-4).InterventionsPhase A (9–12 weeks) cane-walking “as usual” to establish baseline values; Phase B (9–16 weeks) intervention: orthotic-garment worn throughout the day with maximal cane-use reduction; Phase C (9–10 weeks) participant-determined follow-up: either no walking-aid, orthotic-garment or cane.Outcome measuresPrimary: Functional-Gait-Assessment (FGA), Secondary: Trunk-sway during walking measured as Total-Angle-Area (TAA°²) in frontal and sagittal-planes, both measured weekly.ResultsVisual and statistical analysis of results showed significant improvements in FGA from phase A to B in all participants. Improvement continued in phase C in P2, stabilized in P1 and P4 and deteriorated in P3. A Minimal-Clinical-Important-Difference of 6 points-change was achieved in P2 & P4. Trunk-sway reduced during walking, indicating increased stability, in two participants from phase A to B and in three participants from A to C but no TAA changes were statistically significant. In phase C participant-selected walking-aids were: P1 cane-usage reduced by 25%, P2 independent-walking with no assistive-device, S3 usual cane-usage, P4 orthotic-garment with reduced cane-usage 2-3 days-a-week, usual cane-usage 4–5 days.ConclusionsAlthough walking ability is multifactorial these results indicate that the choice of walking-aids can have a specific and clinically relevant impact on gait following stroke.“Hands-free” assistive-devices may be more effective than canes in improving gait-function in some patients.Clinicaltrials.gov idNCT03642444.     

A novel mechanotronic orthosis enables symmetrical gait kinematics in a patient with a femoral nerve palsy – a case study

The usage of stance- and swing-phase control orthoses (SSCOs) is a good option in patients with neuromuscular insufficiency of the quadriceps muscle in a broad range of musculo-skeletal disorders. The subjective sensation of improved mobility in daily life and walking comfort could be objectively confirmed by the ability to walk without crutches and by harmonization of the gait patterns in hip and knee. They could also be a considered mobility device after limb salvage surgery, which may even have an impact on preoperative decision making.

• IMPLICATIONS FOR REHABILITATION

• Symmetric gate in spite of femoral nerve palsy.

• Early gate improvements even after hours.

• High patient?s motivation to use the device.

     

Experiences of using mobile phones in everyday life among persons with stroke and their families in Uganda – a qualitative study

Aim The aim of this study was to describe the experiences and meaning of using mobile phones in everyday life after stroke, among persons with stroke and their family members. Methods Qualitative semi-structured interviews were conducted among 11 persons with stroke and 9 family members 2 months to 2 years after the stroke. The interviews were analysed by using constant comparative grounded theory (GT) approach. Results Seven categories were identified from the analysis of the participants’ experiences. The mobile phone: (1) as an enabler of communication and connections with other people, (2) a source of inspiration for agency, (3) structuring routine and activities in daily life, (4) as a facilitator of social and economic wellbeing of an individual or family, (5) promoter of belonging and participation in social relationships, (6) facilitator of reintegration to community living and (7) enabler of family members to feel secure. From these categories, a core category emerged: The mobile phone as a “life line” and an extension of the body enabling connection, belonging and agency to act in a complex everyday life situation. Conclusion The study gives support for the possibility of using mobile phones to facilitate change and community integration in the rehabilitation process after stroke.

• Implications for Rehabilitation

• Stroke leads to decreased functioning in everyday life due to impairments, activity limitations and participation restrictions as well caregiver burden.

• Mobile phones seem to be an accessible and affordable technology used in daily life of persons with stroke and family members and connects them to the needed services and social relationships.

• The mobile phone technology reduces resource and infrastructural challenges and increases accessibility to rehabilitation interventions.

• The mobile phone was an important instrument that facilitated the quality of life of persons with stroke and their family members and could increase their participation in rehabilitation interventions.

     

Safety and feasibility of transcranial direct current stimulation in amyotrophic lateral sclerosis – a pilot study with a single subject experimental design

Introduction: Transcranial direct current stimulation (tDCS) has been explored as a neuromodulatory tool to prime motor function in several neurological disorders. Studies using tDCS in amyotrophic lateral sclerosis (ALS) are limited. We investigated the safety, feasibility and effects of long-term tDCS in an individual with ALS. Methods: A 36-year-old male diagnosed with clinically definite ALS received 12 sessions each of anodal, sham, and cathodal tDCS. Outcome measures included disease progression (revised ALS functional rating scale (ALSFRS-R)), clinical measures of endurance and mobility, and corticomotor excitability. Results: No adverse events or change in disease progression were noticed during the study. Small improvement in gait speed (15% increase) was noticed with anodal tDCS only. Conclusions: This case study demonstrates the safety and feasibility of long-term facilitatory and inhibitory tDCS on a single participant with ALS. This study serves as a guideline for implementing tDCS in future ALS trials.     

Is there a relationship between fatigue questionnaires and gait mechanics in persons with multiple sclerosis?

Huisinga JM, Filipi ML, Schmid KK, Stergiou N. Is there a relationship between fatigue questionnaires and gait mechanics in persons with multiple sclerosis?

Objective

To evaluate reported fatigue levels and gait deficits in patients with multiple sclerosis (MS) to determine the relationships that may exist between fatigue in patients with MS and alterations in gait mechanics.

Design

Cross-sectional.

Setting

Biomechanics laboratory.

Participants

Subjects with MS (n=32) and age- and sex-matched controls (n=30).

Interventions

None.

Main Outcome Measures

Fatigue Severity Scale (FSS), Modified Fatigue Index Scale (MFIS), and 36-Item Short Form Health Survey (SF-36) to assess fatigue and general health. Biomechanical gait analysis was performed to measure peak joint torques and powers in the sagittal plane at the ankle, knee, and hip. Correlations were performed between fatigue measures and degree of deficit within each patient with MS for each joint torque and power measure.

Results

FSS score significantly correlated with deficits in ankle power generation at late stance and walking velocity. MFIS score significantly correlated with deficits in peak knee extensor torque and knee power absorption at early stance. SF-36 subscale scores correlated with several joint torque and power variables.

Conclusions

Subjective fatigue rating scale scores alone should not be used as an indicator of motor disability or disease progression as it affects walking performance of patients with MS.