Description of a multifaceted rehabilitation program including overground gait training for a child with cerebral palsy: A case report

ABSTRACT

This case describes the outcomes of a multifaceted rehabilitation program including body weight-supported overground gait training (BWSOGT) in a nonambulatory child with cerebral palsy (CP) and the impact of this treatment on the child's functional mobility. The patient is a nonambulatory 10-year-old female with CP who during an inpatient rehabilitation stay participated in direct, physical therapy 6 days per week for 5 weeks. Physical therapy interventions included stretching of her bilateral lower extremities, transfer training, bed mobility training, balance training, kinesiotaping, supported standing in a prone stander, two trials of partial weight-supported treadmill training, and for 4 weeks, three to five times per week, engaged in 30 minutes of BWSOGT using the Up n' go® gait trainer, Lite Gait Walkable^TM, and Rifton Pacer gait trainer. Following the multifaceted rehabilitation program, the patient demonstrated increased step initiation, increased weight bearing through bilateral lower extremities, improved bed mobility, and increased participation in transfers. The child's Gross Motor Functional Measure (GMFM) scores increased across four dimensions and her Physical Abilities and Mobility Scale (PAMS) increased significantly. This case report illustrates that a multifaceted rehabilitation program including BWSOGT was an effective intervention strategy to improve functional mobility in this nonambulatory child with CP.     

Human-centered robotics applied to gait training and assessment

Robot-aided gait training can increase the duration and number of training sessions while reducing the number of therapists required for each patient. However, current automated gait trainers do not adapt their movement to the patient's muscular efforts and passive musculoskeletal properties. Furthermore, robot-aided training without therapists lacks the feedback required for patient assessment. In this article, we present results from the literature and our research to provide an overview of novel human-centered strategies for robot behaviors that are patient-cooperative and support motor-function assessment. Combining robot-aided training with robot-aided assessment will likely make future gait therapy easier, more comfortable, and more efficient. Broad clinical testing is still required for proving this assumption.     

Kinematic and kinetic asymmetries in hemiplegic patients' gait initiation patterns.

OBJECTIVE: To assess the kinetic and kinematic characteristics of hemiplegic stroke patients' gait initiation patterns during the various gait initiation phases. DESIGN AND SUBJECTS: Gait initiation was studied in 3 hemiplegic subjects with a spastic equinus varus foot and 3 control subjects. METHODS: Temporal and kinetic analysis of gait initiation was performed with 2 AMTI force plates, and kinematic analysis of gait initiation with an ELITE optoelectronic system. A one-way ANOVA was performed directly on the phase durations, forces, centre of pressure displacements, stride length, and ankle motion range. RESULTS: Duration of the monopodal phase was shorter in hemiplegic patients when the affected leg rather than the sound one was used as the supporting leg. Propulsion forces were exerted by the hemiplegic patients' sound leg during the postural phase. Hemiplegic patients' body weight was supported more by the sound leg than by the affected leg. Knee was lifted higher on the affected side during the swing phase to compensate for the equinus. Initial contact was performed with a flat foot on the affected side. CONCLUSION: Quantitative data obtained on the gait initiation phase suggest that hemiplegic patients develop asymmetrical adaptive posturo-motor strategies to compensate for their impairments.     

The influence of accuracy constraints on EMG and kinetic variables during gait initiation

[Purpose] This study investigated the effects of accuracy constraints (targets) placed on the stepping-limb heel-strike (HS) on the electromyogram (EMG) and ground reaction forces (GRFs) during gait initiation. [Subjects and Methods] Twenty healthy subjects (29.2 ± 2.9 years) were asked to begin walking or stepping over a 10-cm-high obstacle at a fast speed. A 3-cm-diameter target was placed on the ground to dictate the position and accuracy of the stepping-limb HS. [Results] The results showed that the initiation velocity increase in the no-target conditions was due to modulation of the stance- and stepping-limb GRFs and a corresponding increase in the tibialis anterior (TA) activities of both limbs before stepping-limb toe-off. This was achieved by significantly increasing the stepping- and stance-limb TAEMG1 (determined between the onset of movement and time to peak anteroposterior (A-P) GRF of the stepping- and stance- limb) for the no-target conditions. It seems, therefore, that TAEMG1 and the slope to stepping-limb peak A-P GRF contributed to the intended velocity of initiation. [Conclusion] These data indicate that gait initiation and/or stepping over an obstacle may prove to be tasks by which motor control can be measured. The present study provides insight into the working mechanisms of the stepping and stance limbs and shows a clear need to further investigate whether the intact or affected limb should be used to initiate gait during rehabilitation and prosthetic training.Key words: Electromyogram, Gait initiation, Ground reaction forces     

Asymétries chronométriques, cinétiques et cinématiques de l''initiation de la marche chez un sujet hémiplégique

OBJECTIVE: To investigate the temporal, kinetic and kinematic asymmetry of gait initiation in one subject with hemiplegia with an equinus varus foot. MATERIAL AND METHODS: A kinetic analysis with two AMTI force plates and a kinematic analysis with an ELITE optoelectronic system of gait initiation were performed in one subject with hemiplegia. RESULTS: The duration of the gait initiation phases was asymmetrical. The monopodal phase was shorter when the affected lower limb was supporting than when the healthy one was supporting. The propulsion resulted from the force exerted on the healthy lower limb. The distribution of body weight on the lower limbs was asymmetrical. Body weight support was more important on the healthy side than on the affected side. Maximal extension of the ankle on the hemiplegic side occurred during the swing phase. Ground clearance was increased by elevating the knee higher on the affected side than on the healthy side during the swing phase. Initial contact with the floor was performed with the foot flat on the affected side. CONCLUSION: This preliminary study has shown that gait initiation in one subject with hemiplegia was asymmetrical in kinetics and kinematics. The results concerning kinematics have not been reported previously for gait initiation in subjects with hemiplegia. The study of gait initiation should allow for better understanding postural and movement control strategies developed by patients with hemiplegia.     

Kinematic effects of different gait speeds during gait initiation movement

[Purpose] We investigated the influence of gait speed on the movement strategy during gait initiation. [Participants and Methods] This study included 21 young healthy individuals (11 males and 10 females; mean age, 21.7 ± 0.5 years; mean height, 166.1 ± 9.8 cm; and mean weight, 57.3 ± 11.2 kg). A three-dimensional motion analyzer and strain gauge force platform were used in this study. The measurement task consisted of gait initiation from the quiet stance; the two measurement conditions were normal gait and the highest speed. The analysis interval was from the start of the center of pressure migration to the heel contact at the first step of the swing limb. The center of gravity, center of pressure, joint movements, step length, and step time during the anticipatory postural control (from the start of center of pressure migration to swing leg-heel off) and swing (swing leg-heel off to swing leg-heel contact) phases were analyzed. [Results] Significant differences were observed in the center of gravity, center of pressure, hip flexion, abduction movement, stance-limb ankle dorsiflexion movement during the anticipatory postural control phase, and step time during the anticipatory postural control and swing phases. The stance-limb ankle plantar flexion movement and step length did not differ significantly in the swing phase. [Conclusion] When the gait speed increases, fluctuations in the joint movements increase as the center of pressure displacement increases, thus requiring complex control.     

Lower limb ice application alters ground reaction force during gait initiation

BACKGROUND:

Cryotherapy is a widely used technique in physical therapy clinics and sports. However, the effects of cryotherapy on dynamic neuromuscular control are incompletely explained.

OBJECTIVES:

To evaluate the effects of cryotherapy applied to the calf, ankle and sole of the foot in healthy young adults on ground reaction forces during gait initiation.

METHOD:

This study evaluated the gait initiation forces, maximum propulsion, braking forces and impulses of 21 women volunteers through a force platform, which provided maximum and minimum ground reaction force values. To assess the effects of cooling, the task - gait initiation - was performed before ice application, immediately after and 30 minutes after removal of the ice pack. Ice was randomly applied on separate days to the calf, ankle and sole of the foot of the participants.

RESULTS:

It was demonstrated that ice application for 30 minutes to the sole of the foot and calf resulted in significant changes in the vertical force variables, which returned to their pre-application values 30 minutes after the removal of the ice pack. Ice application to the ankle only reduced propulsion impulse.

CONCLUSIONS:

These results suggest that although caution is necessary when performing activities that require good gait control, the application of ice to the ankle, sole of the foot or calf in 30-minute intervals may be safe even preceding such activities.     

Asymmetry of gait initiation in patients with unilateral knee arthritis

OBJECTIVE: To identify how patients with knee arthritis modify their equilibrium and movement control strategies during gait initiation. DESIGN: Observational study. SETTING: University hospital movement analysis laboratory. PARTICIPANTS: Twelve patients with unilateral knee arthritis and 12 healthy control subjects. MAIN OUTCOME MEASURES: Durations of the phases of gait initiation (ie, postural, monopodal, and double-support phases), center-of-pressure displacements, ground reaction forces, pelvic velocity, step length, and knee range of motion were measured using a movement analysis system and force plates. RESULTS: Gait initiation was slower in patients than in controls no matter which leg was the supporting one. In patients, the durations of the postural and the monopodal phases were modified in an asymmetrical way according to the leg used as the supporting one. The postural phase was lengthened and the monopodal phase was shortened when the affected leg was the supporting one. Opposite effects were observed when the sound leg was supporting. Step length, knee range of motion, and maximal pelvic velocity were reduced in patients whatever the side of the supporting leg. CONCLUSION: Gait initiation is an asymmetrical process in unilateral knee arthritis patients, who develop adaptive posturomotor strategies that shorten the monopodal phase on the affected leg.     

Frequency domain characteristics of ground reaction forces during walking of young and elderly females

OBJECTIVE: To examine the frequency domain characteristics of the ground reaction forces of young and elderly females during free walking. DESIGN: Independent t-tests were used to examine the frequency content of all three components of the ground reaction force. BACKGROUND: Frequency domain analysis has the potential to assist in identifying changes in gait that may be masked in the time domain. No research has been done to identify changes in gait due to age-related impairments in the frequency domain. METHODS: Ten young and ten elderly females walked at a prescribed speed while ground reaction forces were collected via a force platform. The highest frequency required to reconstruct the 99% of the signal's power in each direction was calculated from the ground reaction forces. RESULTS: The frequency content significantly decreased in the anterior-posterior direction for the young group. No significant differences were found for the other two directions (vertical and mediolateral) between the two groups. The elderly had a significantly higher frequency content compared with the young in the anterior-posterior direction. CONCLUSIONS: Ageing differences were detected using the frequency domain analysis for the anterior-posterior direction. It is possible that these differences were the result of the decrease in walking speed associated with the elderly group. RELEVANCE: Frequency domain analysis of the ground reaction forces is a useful addition to the gait analyst's armamentarium especially when such changes are not obvious in the time domain.     

Gait initiation in older adults with postural instability

BACKGROUND: This study examined changes in the translation of the center of pressure during forward and lateral (90 degrees to the side) gait initiation in two populations of older adults with postural instability. METHODS: Twenty-eight older adults transitioning to frailty and 16 persons with Parkinson's disease in the "on medication state" were evaluated during initiation trials. Displacements, velocities, and smoothness of the center of pressure trace were calculated and compared. FINDINGS: Both groups produced movements of the center of pressure that on average were reduced compared to healthy populations. Adults transitioning to frailty were able to scale the output of the motor program so forces that propel the body in the intended direction of movement were maximized as evidenced by movements of the center of pressure. The adults transitioning to frailty produced patterns of center of pressure trajectories that were more similar to healthy adults where as individuals with Parkinson's disease produced trajectories that were counterproductive to producing efficient gait initiation in both the forward and lateral direction. INTERPRETATION: These findings suggest that persons with Parkinson's disease even when in the medicated state exhibit inefficient postural adjustments during both forward and lateral gait initiation and that these postural adjustments are more susceptible to deterioration from the complex interaction of central and peripheral changes associated with Parkinson's disease than to aging alone.     

Balance and gait improved in patients with MS after physiotherapy based on the Bobath concept

Background and Purpose . Patients with multiple sclerosis (MS) tend to have movement difficulties, and the effect of physiotherapy for this group of patients has been subjected to limited systematic research. In the present study physiotherapy based on the Bobath concept, applied to MS patients with balance and gait problems, was evaluated. The ability of different functional tests to demonstrate change was evaluated. Method . A single‐subject experimental study design with ABAA phases was used, and two patients with relapsing–remitting MS in stable phase were treated. Tests were performed 12 times, three at each phase: A (at baseline); B (during treatment); A (immediately after treatment); and A (after two months). The key feature of treatment was facilitation of postural activity and selective control of movement. Several performance and self‐report measures and interviews were used. Results . After intervention, improved balance was shown by the Berg Balance Scale (BBS) in both patients, and improved quality of gait was indicated by the Rivermead Visual Gait Assessment (RVGA). The patients also reported improved balance and gait function in the interviews and scored their condition as ‘much improved’. Gait parameters, recorded by an electronic walkway, changed, but differently in the two patients. Among the physical performance tests the BBS and the RVGA demonstrated the highest change, while no or minimal change was demonstrated by the Rivermead Mobility Index (RMI) and Ratings of Perceived Exertion (RPE). Conclusion . The findings indicate that balance and gait can be improved after physiotherapy based on the Bobath concept, but this should be further evaluated in larger controlled trials of patients with MS. Copyright © 2006 John Wiley & Sons, Ltd.     

A mechanized gait trainer for restoration of gait

The newly developed gait trainer allows wheel-chair-bound subjects the repetitive practice of a gait-like movement without overstressing therapists. The device simulates the phases of gait, supports the subjects according to their abilities, and controls the center of mass (CoM) in the vertical and horizontal directions. The patterns of sagittal lower limb joint kinematics and of muscle activation for a normal subject were similar when using the mechanized trainer and when walking on a treadmill. A non-ambulatory hemiparetic subject required little help from one therapist on the gait trainer, while two therapists were required to support treadmill walking. Gait movements on the trainer were highly symmetrical, impact free, and less spastic. The vertical displacement of the CoM was bi-phasic instead of mono-phasic during each gait cycle on the new device. Two cases of non-ambulatory patients, who regained their walking ability after 4 weeks of daily training on the gait trainer, are reported.     

Temporal symmetries during gait initiation and termination in nondisabled ambulators and in people with unilateral transtibial limb loss

This study investigated the temporal characteristics of gait initiation and gait termination. Ten nondisabled adult volunteers and ten people with unilateral transtibial limb loss performed starting and stopping for slow, normal, and fast walking speeds. We used kinematic and anthropomorphic data to determine the body center of mass (BCOM) position of each subject. The BCOM acceleration was derived by double-differentiating the position data. An averaged BCOM acceleration was calculated by a filtering of the instantaneous acceleration data at a cutoff frequency set by the cadence for elimination of the step-to-step variation. We used this averaged acceleration to calculate the time the volunteers needed to initiate and terminate gait. The results support the hypothesis that both nondisabled ambulators and the subjects with unilateral transtibial limb loss initiate and terminate gait in approximately two steps, regardless of the steady-state walking speed.     

Exploration of paretic gait by differential loading in normals

OBJECTIVE: To determine if the gait patterns of artificially loaded healthy subjects resemble those of patients with weak ambulatory muscles. DESIGN: The gaits of artificially loaded healthy subjects and their controls were compared with the gaits of amputees and paretic patients, using analysis of variance. BACKGROUND: Muscle weakness due to paresis or limb amputation results in a misrelation between muscle power and body weight borne during ambulation. When body weight is increased by artificial loading of a normal subject, a misrelation between muscle strength and body weight results. METHODS: The gaits of paretic patients and artificially loaded normal subjects were recorded in the laboratory, by means of foot-switches. Stride length and stride frequency were used to calculate stride ratio which was used to compare the different gaits. RESULTS: Mean stride ratios of paraparetics, peroneal paretics and healthy subjects who carried load in the hand showed no statistically significant difference, while the ratio for hemiparetics differed significantly from the value for the artificially loaded healthy subjects. Below-knee amputees had a similar stride ratio to normal subjects who carried load on the ankles, while the above-knee stride ratio differed significantly from ankle-loaded normal subjects. CONCLUSION: Paraparetic and peroneal paretic gaits were approximated by the gaits of normal subjects who carried artificial load in the hand while the below-knee amputee gait was mimicked by normal subjects who carried load on the ankles. The two models of artificial loading could not generate any semblance with hemiparetic and above-knee gaits.     

Invariant characteristics of gait initiation

Studies were undertaken first to describe the invariant characteristics of gait initiation and second to better understand the function of each limb in the process of gait initiation. Analysis of variance indicated significant main effects for speed for time to onset of EMG activity and force plate recordings, time to swing toe-off and heel-strike and stance toe-off. However, when the dependent variables were expressed as a percentage of the initiation cycle, no significant main effects were noted. For the second study, two force plates were utilized, and reflective markers were placed on the sacrum and anterior superior iliac spines. The timing of heel-strike of the swing limb and toe-off of the stance limb showed a high degree of coordination in both experiments (r = 0.95 and 0.98). It was concluded that the relative invariance of selected parameters indicates that gait initiation is centrally programmed. It also appears that the swing limb, although forces were very small, is responsible for the initial weight shift to the stance limb and that the stance limb is then primarily responsible for the generation of momentum.     

Lower-leg inertial properties in transtibial amputees and control subjects and their influence on the swing phase during gait

OBJECTIVES: To identify the factors that constitute optimal inertial properties for a lower-limb prosthesis. DESIGN: Experimental, controlled; simulation using a subject-specific double-pendulum model based on individual kinematic data and leg inertial properties. Simulation outcomes were compared with gait analysis data. SETTING: A gait laboratory. PARTICIPANTS: Ten transtibial amputees and 10 matched healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Inertial properties of the lower leg; kinematics and kinetics of the swing phase; and kinematics of double-pendulum model simulations. RESULTS: In all amputees, inertial properties were reduced. No between-group differences existed in kinematics; hip and knee joint torques and powers were reduced in the amputees. Deviations between the double-pendulum model and experimental data were larger in the amputees than in the control subjects. CONCLUSIONS: Although current lightweight prostheses have less optimal pendular behavior, their light weight requires smaller joint torques to influence the pendular trajectory. Therefore, optimal inertial properties, in terms of swing phase kinematics and kinetics, will be a compromise between pendular properties and efficient control.     

The implementation of inertial sensors for the assessment of temporal parameters of gait in the knee arthroplasty population

BackgroundThe use of inertial measurement units for the evaluation of temporal parameters of gait has been studied in many populations. However, currently no studies support the use of inertial measurement units for this purpose in the knee arthroplasty population. The objective of the present study was to investigate the agreement between an inertial measurement and camera based system for the assessment of temporal gait parameters in a knee arthroplasty population.MethodsSixteen knee arthroplasty patients performed 3 gait trials at a self-selected speed along a 6 m walk-way. During the gait trials, gyroscope data from shank-worn inertial measurement units and motion data from optoelectronic cameras were collected simultaneously. A custom-made peak detection algorithm was used to identify gait events from gyroscope data, in order to compute cycle time, stance time and swing time. A marker and coordinate based algorithm was used to calculate temporal gait parameters from kinematical data derived from the camera system. Temporal variables were compared between both methods by calculating intra-class correlation coefficients, mean errors and root mean squared errors. Furthermore, Bland-Altman plots were constructed to assess the agreement between both methods.FindingsOverall good to excellent intra-class correlation values (0.826–0.972) were found. Root mean square errors between both methods ranged from 0.036 to 0.055 s. High levels of agreement were observed for all variables.InterpretationThese findings suggest that inertial measurement units can be used for outside laboratory assessment (e.g. in a hospital environment) of temporal gait parameters in the knee arthroplasty population.     

Contribution of accelerated body masses to able-bodied gait

OBJECTIVE: The objectives of this study were to demonstrate that data from a video-based system could be used to estimate the net effect of the external forces during gait, to determine the contribution of the trunk and upper and lower limbs using their accelerated body masses, and to test the hypothesis that the thigh mainly assumed lower limb propulsion during able-bodied locomotion. METHODS: The gait of 16 able-bodied subjects was assessed using an eight-camera video-based system and two force plates. The right limb was the leading limb, and there were two trials per subject. Although data from all the body segments were used to answer the first two objectives, only right limb information was used to address the third objective. RESULTS: Pearson's coefficients of correlation and root mean square errors were calculated to determine the difference between the curves obtained from the sum of the external forces and that of the accelerated masses. These were >0.85, and the mean root mean square error was <4 N. Analyses of variance were performed on the peak forces developed by the trunk and the upper and lower limbs along each axis. Tukey's posthoc tests (P < 0.05) revealed that the trunk was the principal contributor of external forces in the frontal and transverse planes, whereas the lower limbs were found to be more important in the plane of progression. Analyses of variance and Tukey's posthoc tests (P < 0.05) were performed on the peak forces developed by each segment of the right limb. In decreasing order, the thigh, shank, and foot displayed the highest mass-acceleration products in the right limb during gait. CONCLUSIONS: A video-based system was able to determine the net effect of the external forces with the summation of the mass-acceleration products during able-bodied gait. The trunk and lower limbs were the dominant body segments responsible for the production of external forces during able-bodied gait, whereas the thighs contributed more to the ground reaction force than the foot and shank for forward progression in able-bodied gait.     

Gait with light and heavy fracture bandages on the lower leg

Using an instrumented treadmill which measured ground reaction forces, ten normal subjects were tested wearing conventional plaster-of-Paris bandages on the lower leg and lightweight crus-plastic bandages. Two different types of heels were also tested. From calculation of gait parameters it was found that the free walking speed was lowest with a conventional bandage with heel. The external work of gait was lowest with the lightweight bandage. Ataxia was least while wearing the lightweight bandage. The lightweight bandage is preferable from a biomechanical point of view, in accordance with the opinion of the subjects.     

Evaluation of the effectiveness of a novel gait trainer in increasing the functionality of individuals with motor impairment: A case series

Regaining the ability to independently ambulate following a physical disability can increase functional ability and participation of patients in daily life. Gait trainers are assistive devices that enable body support and provide safety during gait. However, most conventional gait trainers are pre-configured to a constant position, therefore not suitable for practicing sit-to-stand function, and require assistance from a caregiver in order to mount the device from a sitting position. We therefore evaluated the effectiveness of a dynamically-adjusting gait trainer, designed to provide independence and safety during gait and various activities, in both lab setting and at home in four subjects (one female, three males, ages 32–79 years) with limited ambulation. Spatiotemporal parameters and gait symmetry were recorded, as well as activity levels, actual use of device, and satisfaction. Although gait parameters and physical activity levels were not notably improved, and in one case were worsened, three subjects reported positive experience with the gait trainer. The new gait trainer may have advantages in supporting users with limited mobility during walking and various functions and decrease the risk for falls. A longer practice time and individual fitting process are recommended for better accommodation to the new possibilities.