Effects of increasing non-paretic step length on paretic leg movement during hemiparetic gait: a pilot study

[Purpose] Gait training that increases non-paretic step length in stroke patients increases the propulsive force of the paretic leg. However, it limits knee flexion during the swing phase of gait, and this may cause gait disturbances such as worsening of gait pattern and increased risk of falling. Therefore, this study aimed to investigate the effects of increasing non-paretic step length on the joint movement and muscle activity of a paretic lower limb during hemiparetic gait. [Participants and Methods] A total of 15 hemiparetic patients with chronic stroke were enrolled in this study. Spatiotemporal parameters, along with kinematic and electromyography data of their paretic lower limbs, were measured during a 10-m distance overground walking. Two walking conditions were assessed: normal (comfortable gait) and non-paretic-long (gait with increased non-paretic step length) conditions. [Results] Under the non-paretic-long condition, the trailing limb angle was larger than under the normal condition. However, no significant difference was observed in the knee flexion angle during the swing phase. [Conclusion] Increasing non-paretic step length during gait is unlikely to limit knee flexion during the swing phase and can safely improve the propulsive force of a paretic leg.     

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.     

The characteristics of multi-directional step distance and the association between stepping laterality and walking ability of patients with stroke

[Purpose] The purpose of this study was to determine the effect of stepping limb and step direction on step distance and the association of step distance and stepping laterality in step difference with walking ability and motor dysfunction. [Subjects and Methods] The subjects were thirty-nine patients with chronic hemiparesis as a result of stroke, who performed the MSL (Maximum Step Length) test along with tests of motor impairment, gait speed and Functional Ambulation Category. The MSL test is a clinical test of stepping distance in which participants step to the front, side, and back. The subjects were classified into three groups according to the stepping laterality in front step distance. [Results] Step distance did not differ across stepping limbs but did differ across step directions. Front step distance was significantly longer than side and back step distance. Participants with forward paretic step length shorter than forward non-paretic step length had significantly higher walking ability than participants with symmetric forward step length or forward paretic step length longer than forward non-paretic step length [Conclusion] Patients with stroke have characteristic step distances in each direction. Adequate weight shift toward the paretic limb when stepping with the non-paretic limb is associated with walking ability.Key words: Maximum step length, Stepping laterality, Stroke     

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     

Effect of the use of a body weight-supported walker on gait parameters in hemiplegic stroke patients

[Purpose] This study investigated gait parameter changes in hemiplegic stroke patients who walked with a body weight-supported (BWS) walker and evaluated the usefulness of using the BWS walker in a walking exercise. [Participants and Methods] Nineteen hemiplegic stroke patients hospitalized in a convalescent rehabilitation ward were enrolled in the study. Trunk acceleration was used to evaluate walking with and without a BWS walker. Gait speed, cadence, stride length, step time symmetry, stride time variability, and stride time regularity were calculated from the accelerometer waveform. [Results] Hemiplegic stroke patients had a faster gait speed, walked more symmetrically, and had less variation in their gait cycle when using the BWS walker than when not using it. [Conclusion] Using a BWS walker may help hemiplegic stroke patients learn to walk more efficiently in terms of their gait speed.Key words: Stroke, Hemiplegia, Body weight-supported walker     

Differences in gastrocnemius muscle architecture between the paretic and non-paretic legs in children with hemiplegic cerebral palsy

BACKGROUND: The aim of this study was to investigate the architectural alterations of skeletal muscle following hemiplegic cerebral palsy. If associated with functional and clinical measures of disability, information on muscle architecture could then be used as an objective tool in the assessment of motor disability in these patients. METHODS: Ultrasonography was used to assess in vivo the gastrocnemius muscle architecture in the paretic and non-paretic legs of eight children with cerebral palsy. FINDINGS: Fascicle length and muscle thickness at the resting ankle position were reduced in the paretic compared to the non-paretic legs by up to 18% and 20%, respectively (P<0.05), indicating a loss of both in-series and in-parallel sarcomeres in the affected muscles. However, pennation angle was similar (P>0.05) in the two legs. INTERPRETATION: The present results indicate that paresis in hemiplegic cerebral palsy may affect the geometry of skeletal muscle. Further studies are required to examine the relation between muscle architecture, severity of motor disability, and treatment.     

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.     

全身振动刺激对脑卒中偏瘫患者步行效率的影响

目的：观察全身振动训练对脑卒中偏瘫患者步行效率的影响。方法：脑卒中患者11例,均进行全身振动刺激,频率10Hz,振幅4mm,时间10min。振动刺激前后进行步态分析。结果：振动刺激10min后,11例患者步频、步速及患侧步长、患侧单支撑相时间、健腿摆动相时间、健侧髋关节最大屈曲角度、健患侧髋关节及膝关节最大屈曲角度、患侧踝关节最大背伸角度均较刺激前明显增加（P〈0.05）;步行周期、双支撑相时间显著缩短（P〈0.05）;健侧步长、健侧单支撑相时间、患腿摆动相时间刺激前后比较差异无统计学意义。结论：全身振动刺激可以显著改善脑卒中偏瘫患者步行时空参数,提高患者的步行能力。     

Gait training using a hybrid assistive limb after botulinum toxin treatment for cerebral palsy: a case report

[Purpose] Hybrid Assistive Limb^® (HAL; Cyberdyne, Tsukuba, Japan) is a wearable robot that assists patients based on their voluntary movements. We report gait training with HAL after botulinum toxin treatment for spasticity of the lower limb in cerebral palsy (CP). [Participant and Methods] The participant was a 36 year-old male with spastic diplegia due to periventricular leukomalacia, with Gross Motor Function Classification System (GMFCS) level II. HAL training was performed in 20-minute sessions (3 sessions/week for 4 weeks). The outcome measures were range of motion, spasticity, walking ability, muscle strength, gross motor function measure (GMFM), Canadian Occupational Performance Measure (COPM), and Pediatric Evaluation of Disability Inventory measured before, immediately after, and one, two, and three months after HAL training. [Results] No adverse events were observed during training. After the HAL intervention, gait speed, step length, cadence, 6-min walking distance (6MD), knee extension strength, GMFM, and COPM increased, and Physiological Cost Index declined. Three months post-intervention, gait speed, step length, cadence, 6MD, and GMFM remained higher than those observed within the first two months. [Conclusion] Gait training with HAL can be a safe and feasible method for patients with CP who undergo botulinum toxin treatment to improve walking ability and motor function.     

Immediate effect of video viewing with an illusion of walking at a faster speed using virtual reality on actual walking of stroke patients

[Purpose] The objective of this study was to provide cerebral stroke patients with virtual reality videos of gait occurring at a faster speed than their actual measured gait speed and ascertain the effect on generating errors of gait. [Participants and Methods] The participants were 12 stroke patients. They were given a 2-minute virtual reality presentation of gait occurring at a speed faster than their actual measured comfortable walking speed. Immediately following the presentation, their 10-m walking speed was measured again to observe the immediate effect of the intervention, after which the time required to walk at maximum gait speed was measured. Stride length, cadence, and walking speed before and after the intervention were compared. In addition, heard an immersive feeling. [Results] At a comfortable walking speed, the cadence improved significantly post-intervention. Walking speed and stride length also tended to increase. At the maximum walking speed, there were no significant differences in any parameter. There was no problem with the immersive feeling. [Conclusion] After watching virtual reality videos of gait at a speed faster than the patients’ actual gait speed, their walking speed tended to increase in comfortable walking. It was speculated that this technique could be applied to walking training, depending on the device.     

运用三维步态分析评价下肢机器人训练对偏瘫患者步行能力的影响

目的应用三维步态分析评价下肢机器人训练对脑卒中偏瘫患者步行功能的影响。 方法采用随机数字表法将60例脑卒中偏瘫患者分为观察组及对照组,两组30例。2组患者均给予常规药物治疗及康复干预,对照组同时辅以传统下肢步行训练,观察组则辅以下肢机器人训练。2组患者下肢训练时长均为每次30min,每周训练5d。于治疗前、治疗8周后分别采用三维步态分析系统检测2组患者步态时间参数、时相参数、关节活动角度及地面反作用力大小等指标。 结果观察组患者经下肢机器人辅助训练后,其步速［(59.34±12.20)cm/s］、步频［(89.39±13.80)次/分钟］、跨步长［(74.17±15.54)cm］提高,步宽［(18.69±3.16)cm］缩小;患侧支撑期百分比［（69.72±10.06）%］、健侧与患侧支撑期比值（1.07±0.11）、双支撑期百分比［（16.85±8.23）%］、髋关节最大活动度［（35.39±9.31）°］、膝关节最大活动度［（50.21±15.34）°］、垂直地面反作用力峰值占体重百分比［（109.36±13.28）%］、患侧向前地面反作用力峰值占体重百分比［（6.95±1.98）%］均明显改善,与治疗前及对照组间差异均具有统计学意义（均P<0.05）。 结论与传统步行训练比较,下肢机器人训练能更有效改善脑卒中偏瘫患者步行功能,该疗法值得临床推广、应用。     

The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy

Purpose.?To assess the effectiveness of a hinged ankle-foot orthoses on gait impairments and energy expenditure in children with hemiplegic cerebral palsy (CP) whom orthoses were indicated to control equines.

Method.?Eleven children (seven males, four females) who had a diagnosis of hemiplegic cerebral palsy were included in the study. Each child underwent gait analysis and energy consumption studies with and without ankle-foot orthosis (AFO). The AFOs were all custom-made for the individual child and had plantarflexion stop at 0° with no dorsoflexion stop. The Vicon 512 Motion analysis system was used for gait analysis. Walking energy expenditure measurements were done with breath by breath method using an open-circuit indirect calorimeter (Vmax 29c, Sensormedics, USA). All tests were carried out on the same day with enough resting period.

Results.?AFO application, as compared with the barefoot condition improved walking speed, stride length and single support time. Double support time was decreased significantly with AFOs and no change in cadance. Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase. Knee flexion at initial contact was decreased and no significant change in maximum knee extension at stance and maximum knee flexion at swing was obtained. The oxygen consumption was significantly reduced during AFO walking.

Conclusion.?The hinged AFO is useful in controlling dynamic equinus deformity and reducing the energy expenditure of gait in children with hemiplegic spastic cerebral palsy.     

虚拟现实同步减重训练脑梗死患者可改善下肢运动功能

背景：脑卒中患者多有步行功能障碍,虚拟现实同步减重训练开始运用于脑梗死患者的步态训练。 目的：评估虚拟现实同步减重训练对亚急性期脑梗死患者下肢运动功能的影响。 方法：20例起病3个月内的脑梗死患者随机分配至实验组（虚拟现实同步减重训练）和常规组（常规物理治疗）。在3周步态训练前后各做一次三维步态并进行下肢运动功能评估。对以下参数进行训练前后组内和组间对比：步行速度、步调、步行时间、单腿支撑时间（%）、双腿支撑时间（%）、摆动时间、步长、步幅、下肢各关节活动度、功能性步行分类、下肢Fugl-Meyer评分和Brunel平衡评分。 结果与结论：训练前两组患者的性别、年龄、病程、偏瘫侧、步行速度、功能性步行分类、下肢Fugl-Meyer评分和Brunel平衡评分差异无显著性（P〉0.05）。训练后两组患者的下肢Fugl-Meyer评分和功能性步行分类均有改善（P〈0.05）。实验组在步行速度、步调、患侧步行时间、健侧步行时间、患侧单腿支撑时间、患侧摆动时间、健侧摆动时间、步幅、患侧步长和健侧步长的改善方面较常规组有优势。     

The effect of hinged ankle-foot orthosis on gait and energy expenditure in spastic hemiplegic cerebral palsy

Purpose. To assess the effectiveness of a hinged ankle-foot orthoses on gait impairments and energy expenditure in children with hemiplegic cerebral palsy (CP) whom orthoses were indicated to control equines.

Method. Eleven children (seven males, four females) who had a diagnosis of hemiplegic cerebral palsy were included in the study. Each child underwent gait analysis and energy consumption studies with and without ankle-foot orthosis (AFO). The AFOs were all custom-made for the individual child and had plantarflexion stop at 0° with no dorsoflexion stop. The Vicon 512 Motion analysis system was used for gait analysis. Walking energy expenditure measurements were done with breath by breath method using an open-circuit indirect calorimeter (Vmax 29c, Sensormedics, USA). All tests were carried out on the same day with enough resting period.

Results. AFO application, as compared with the barefoot condition improved walking speed, stride length and single support time. Double support time was decreased significantly with AFOs and no change in cadance. Ankle dorsiflexion at initial contact, midstance and midswing showed significiant increase. Knee flexion at initial contact was decreased and no significant change in maximum knee extension at stance and maximum knee flexion at swing was obtained. The oxygen consumption was significantly reduced during AFO walking.

Conclusion. The hinged AFO is useful in controlling dynamic equinus deformity and reducing the energy expenditure of gait in children with hemiplegic spastic cerebral palsy.     

核心稳定性训练对脑卒中偏瘫患者步态时空参数和对称性参数的影响

摘要 目的：应用步态分析,观察核心稳定性训练对脑卒中偏瘫患者步态时空参数和对称性参数的影响。 方法：选取脑卒中偏瘫患者60例,按随机数字表法将其分为观察组及对照组,每组30例。两组均进行常规治疗,观察组在此基础上给予核心稳定性训练。分别于治疗前和治疗6周后使用三维步态分析仪器检测并获得两组患者的步态参数。 结果：治疗6周后,两组患者步频、步幅、步速、患侧摆动相和健侧摆动相均较治疗前明显提高（P<0.01）,步宽、步态周期、双支撑相、患侧支撑相、健侧支撑相、步长偏差、健侧患侧支撑相比值和患侧健侧摆动相比值均较治疗前显著减小（P<0.01）。组间比较显示,观察组患者的步频、步幅、步速、步宽、步态周期、双支撑相、健侧支撑相、健侧摆动相、步长偏差、健侧患侧支撑相比值和患侧健侧摆动相比值改善均明显优于对照组（P<0.05或0.01）。 结论：核心稳定性训练能有效改善脑卒中偏瘫患者步态时空参数和对称性参数,提高脑卒中偏瘫患者的步行功能和步态的对称性。     

Effect of ankle-foot orthoses on gait in typically developing children: Developmental trend in segmental coordination

Objective: As orthoses, and particularly ankle-foot orthoses, are widely used in the management of children with motor disorders, including cerebral palsy, we aimed to study their effect in normal children in order to add to normative gait data, which are essential for diagnosing, understanding and treating abnormal gait patterns. Design: We analyzed the effect of ankle-foot orthoses on classical gait parameters and lower limb segments coordination patterns in typically developing children in two age groups reflecting different neuromaturational/developmental situations. We recorded 3D kinematic gait patterns in 9 children (4-5 years) and 11 children (9-10 years) walking barefoot or wearing bilateral solid ankle-foot orthoses maintaining the ankle joint angle at a neutral position. Results: Ankle-foot orthoses induced little change in cadence, step length, step width or walking velocity in younger children, though they altered intralimb coordination through the gait cycle. In older children, walking velocity was reduced, shank elevation amplitude increased, while lower limb coordination changed less significantly. In this age group, ankle-foot orthoses significantly reduced the variability of coordinative strategies. Conclusion: Ankle-foot orthoses affect the gait pattern in children with a typical development at different levels in younger and older subjects, but the resulting changes are minimal.     

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.     

Immediate effects of an elastic arm sling on walking patterns of chronic stroke patients

[Purpose] We developed a new arm sling with an elastic bandage which we hearafter refer to as “the elastic arm sling”. This study investigated the immediate effects of the elastic arm sling on the gait patterns of stroke patients. [Subjects and Methods] Thirteen stroke patients were enrolled in this study after providing their informed consent. They walked on a GAITRite mat twice, with a 5-min rest between the trials. [Results] Significant improvements were seen in cadence and walking velocity during walking while wearing the elastic arm sling. Furthermore, patients who used the elastic arm sling showed significant increases in step lengths of the affected and unaffected limbs. The stride lengths of the affected and unaffected sides while wearing the elastic arm sling and those without the elastic arm sling also significantly differed. [Conclusion] These results demonstrate that the elastic arm sling is a useful tool for the gait training of stroke patients, especially cadence, walking velocity, and the step and stride lengths of both limbs. Therefore, therapists should use the elastic arm sling as a gait-training assistive device for stroke patients.Key words: Elastic arm sling, Hemiplegic gait, Orthotic devices     

Immediate Effect of Postural Insoles on Gait Performance of Children with Cerebral Palsy: Preliminary Randomized Controlled Double-blind Clinical Trial

[Purpose] Improved gait efficiency is one of the goals of therapy for children with cerebral palsy (CP). Postural insoles can allow more efficient gait by improving biomechanical alignment. The aim of the present study was to assess the effect of postural insoles on gait performance of children with CP classified as levels I or II of the Gross Motor Function Classification System (GMFCS). [Subjects and Methods] the study was a randomized controlled double-blind clinical trial. After meeting the legal aspects and the eligibility criteria, 10 children between four and 12 years old were randomly divided into a two groups: a control group (n=5), and an experimental group (n=5). Children in the control group used a placebo insoles, and children in the experimental group used postural insoles. Evaluation consisted of three-dimensional gait analysis under three conditions: barefoot, shoes without insoles and shoes with postural insoles or shoes with placebo insoles. [Results] Regarding the immediate effects of insole use, significant improvements in gait velocity and cadence were observed in the experimental group in comparison to the control group. [Conclusion] The use of postural insoles led to improvements in gait velocity and cadence of the children with cerebral palsy classified as levels I or II of the GMFCS.Key words: Cerebral palsy, Orthoses, Postural insole     

Effects of walking with loads above the ankle on gait parameters of persons with hemiparesis after stroke

Background

Walking with a load at the ankle during gait training is a simple way to resist lower limb movements to induce functional muscle strengthening. This study investigated the effects of walking with different loads attached above the paretic ankle on biomechanical gait parameters during over ground walking in post-stroke participants.

Methods

Ten participants with moderate chronic hemiparesis were evaluated while walking over ground with three different loads (0.5, 1.0, and 1.5 kg) attached above the paretic ankle. Gait speed, cadence, step lengths as well as hip and knee angular displacements, joint moments and power of the paretic limb were compared while walking with and without loads.

Findings

Walking with a load led to an increased in gait speed (+ 0.03–0.05 m/s), and in step length of the paretic leg (+ 5.6 to 9.4% step length, effect size = 0.49–0.63), but not of the non-paretic leg. The proportion of the stance and swing phases did not change. Maximal joint moments (+ 20 to 48%, effect size = 0.26–0.55) and power (+ 20 to 114%, effect size = 0.30–0.57) increases varied across participants but were mostly affected in early stance at the hip and during the late swing phase at the knee. Mean angular displacement changes were less than 4°.

Interpretation

Post-stroke participants are able to increase hip and knee power bursts to meet the increased mechanical demand of added loads attached to the paretic ankle, while preserving the basic pattern of walking. Further study is needed before using loading to functionally strengthen paretic muscles.