Stepping to the Beat Improves Spatiotemporal Characteristics of Gait in Stroke Patients with Hemiparesis: A Proof of Concept Case Study of a Home-based Training Intervention

Abstract

Hemiparetic gait due to stroke is characterized by temporal asymmetry and variability. Research shows this can be improved by auditory cueing, whereby participants train to step in time and space with a visual or auditory cue. This particular method is effective in training a symmetrical gait and helps to improve coordination and speed. We describe a pilot study that investigates the possibility of training with an auditory rhythmical metronome embedded in music, during stepping in place within a home- based setting. Stepping in place incorporates aspects of movements that are also important for a successful gait, such as reciprocal flexion and extension of the legs in timely coordination and synchronization, creating a step frequency, a swing phase and single limb support. Stepping in place may also provide a valuable method for home-based training, as little space in the home is required and, therefore, participants are less likely to fall. This case study seeks to obtain proof of the concept that stepping in place within a home setting may be a useful tool for locomotor training after stroke.A hemiparetic stroke patient, PF, successfully completed 6 weeks of home-based training for 15minutes a day, 5 days a week (with 5% weekly increments in music tempo). PF (aged 58) is a male, right handed, chronic stroke survivor, who presented left sided hemiparesis. He was recruited from a local stroke club based on the inclusion criteria that he was able to walk independently without supervision (but able to use a gait aid such as a cane or walker) and was free from hearing impairments. Finally, PF was also able to complete a 3 m Timed Up and Go, which is typically used as an indicator of falls and provides an indication of the patient's ability during turns. He was assessed five times during the 12 week period of the study, which included baseline, three weeks of training, three weeks of rest (used to measure resting effects), a second three-week training period and finally after another three weeks of rest. During each assessment, PF was tested for his gait speed during a 10 m walking task. During these tests, we also captured the spatiotemporal parameters of his gait using six accelerometer sensors (OPAL, APDM). The sensors were placed around the trunk, the lumbar, and the left and right shins and feet and have been designed to measure walking. The use of such motion capture systems is intended to provide a more sensitive and objective measure of the changes in movement that might occur following gait rehabilitation, compared to the use of standard clinical measures. We also used the following clinical assessments: The Dynamic Gait Index (which measures balance during walking), and The Rivermead Motor Scale (measuring general walking ability).The results showed significant improvements in all spatiotemporal aspects of PF's gait. There was a 10 s speed increase in his 10 m walking, between his baseline and final assessment. Furthermore, changes in PF's gait cycle were shown after 6 weeks of training stepping in place, suggesting improvements towards a more symmetrical gait pattern. For example, an increase in cadence was revealed, which likely follows increases in the gait speed during 10 m walking. A decrease in the overall gait cycle time, decreases in double support, and further decreases in stride length asymmetry and swing asymmetry were also observed. These findings might be expected based on previous work investigating changes in spatiotemporal parameters after gait rehabilitation and suggest that training stepping in place generalizes to walking ability. Furthermore, no changes were observed in any of the clinical assessments, suggesting the need for more sensitive measures of functional ability in capturing improvements of lower limb function after training stepping in place. These preliminary data show promising results for stepping in place in the home, as a method of training a symmetrical gait after stroke. This method also provides a cheap addition to other rehabilitation techniques such as physiotherapy, as it can be conducted within the home, without the need for a therapist and will provide patients with more intensive rehabilitation after stroke. Lastly, it is important to note, based on patient feedback that presenting the rhythmical beat in a music context was likely a key factor in motivating the patient to complete his training. As compliance is of high importance in rehabilitation, incorporating music should be taken into consideration for future investigations whereby the training provided may be repetitive in nature.