Gait Training In Patients Research Articles

Hip and Knee Joint Trajectories in Sagittal Plan Following Robotic-Assisted Gait Training in Patients with Incomplete Spinal Cord Injury: Preliminary Results

Hip and Knee Joint Trajectories in Sagittal Plan Following Robotic-Assisted Gait Training in Patients with Incomplete Spinal Cord Injury: Preliminary Results

Change of Spasticity Following Robotic-Assisted Gait Training in Patients with Chronic Incomplete Spinal Cord Injury: Preliminary Results

Change of Spasticity Following Robotic-Assisted Gait Training in Patients with Chronic Incomplete Spinal Cord Injury: Preliminary Results

New virtual reality protocol for gait training in patients with multiple sclerosis

Introduction : The purpose of this research project is to evaluate the usefulness of virtual reality (VR) environments as a tool in gait training of individuals with multiple sclerosis (MS). MS is a chronic and progressive neurological disease and its clinical course can lead to severe disability. VR is a relatively new tool in the field of neuro-rehabilitation that has many advantages including the possibility to have a complete variable control management, to monitor motor level achieved by the individual through exercises, to provide challenging and engaging exercises, to run intensive training, but in a protected environment and then to provide feedback to facilitate motor learning. Methods : Ten subjects (9 females) affected by MS (mean age 40.6, range 24-60) were studied. Two patients dropped out due to transportation and family problems, these two individuals participated only to the evaluation session and never started the training and one did not participate at the last follow up. All patients had an EDSS score between 3 and 5.5 and all were treated with natalizumab or azathioprine. Clinical evaluation included the “Six minute walk test”(6MWT), the “Timed up and go test” (TUG), the “Four Square Step Test” (FSST), the “10 meter test” and the Berg Balance Scale Test (BBS). A repeated measures design was used with evaluations at 1 week pre training (pre), one week post training (post) and at one month (post_1) and three months (post_3) follow up. Kinematic and kinetic gait analysis was used to quantify gait performance using a six camera stereophotogrammetric system (Vicon T20) and the Davis marker set with two embedded force platforms (AMTI, Watertown, MA, USA). Subjects were asked to walk under usual gait conditions and during a cognitive dual task condition of serially subtracting the number three from a three digit predefined number. For the delivery of the VR training, inertial sensors (X-SENS) were used for the acquisition of orientation of the feet. Training consisted of having subjects walk on a treadmill while negotiating virtual obstacles and a virtual environment through stereoscopic glasses or on a computer screen. Training was individualized to fit the patients needs and was provided for twelve sessions (twice a week for six weeks) for a total of 45 minutes each session and consisted of three bouts of walking of ten minutes each, with breaks in between of approximately 5 minutes rest. Level of complexity and progression was increased if the individual was able to achieve success in task performance of 80%. Progression included increasing the speed of walking on the treadmill and increasing the complexity of the VR tasks (numbers of bifurcation, obstacles distracters etc). Results: No adverse events were observed during the training. After training improvements on most motor functions were observed. Endurance as measured by the distance walked over 6 minutes improved by an average of 23 meters post training and continued to show improvement at follow up (of 70.75 m from baseline). The results show an improvement of gait and balance with a decrease of fall risk confirming the relevance of rehabilitation in MS patients. Discussion: Overall the group responded positively to the VR intervention. We observed that all improvements gained were not only stable after three months follow up, but further implemented; although it is likely that the improvements gained are to be related to VR systems a control group is needed to verify our hypothesis. This is a preliminary study aimed to determine the efficacy of a VR system and the results are very encouraging to those who hope to use VR with MS patients as a form of therapy.

Robot-Assisted Gait Training in Patients With Parkinson Disease

Background. Gait impairment is a common cause of disability in Parkinson disease (PD). Electromechanical devices to assist stepping have been suggested as a potential intervention. Objective. To evaluate whether a rehabilitation program of robot-assisted gait training (RAGT) is more effective than conventional physiotherapy to improve walking. Methods. A total of 41 patients with PD were randomly assigned to 45-minute treatment sessions (12 in all), 3 days a week, for 4 consecutive weeks of either robotic stepper training (RST; n = 21) using the Gait Trainer or physiotherapy (PT; n = 20) with active joint mobilization and a modest amount of conventional gait training. Participants were evaluated before, immediately after, and 1 month after treatment. Primary outcomes were 10-m walking speed and distance walked in 6 minutes. Results. Baseline measures revealed no statistical differences between groups, but the PT group walked 0.12 m/s slower; 5 patients withdrew. A statistically significant improvement was found in favor of the RST group (walking speed 1.22 ± 0.19 m/s [P = .035]; distance 366.06 ± 78.54 m [P < .001]) compared with the PT group (0.98 ± 0.32 m/s; 280.11 ± 106.61 m). The RAGT mean speed increased by 0.13 m/s, which is probably not clinically important. Improvements were maintained 1 month later. Conclusions. RAGT may improve aspects of walking ability in patients with PD. Future trials should compare robotic assistive training with treadmill or equal amounts of overground walking practice.

Robotic gait training in patients with impaired consciousness due to severe traumatic brain injury

Primary objective: This prospective controlled non-randomized study investigated the effects of robotic gait training on electroencephalographic (EEG) brain activity in patients with impaired consciousness due to severe traumatic brain injury (TBI).Methods: Twelve TBI patients and 14 healthy controls underwent a single training session on a computer-driven gait orthosis (Lokomat®). The sensory pathways were assessed using sensory evoked potentials (SEPs). The global delta-alpha EEG power ratio (DAR) and latency of the P300 component of the event-related potentials was assessed prior to and following a training session.Results: Baseline measurements showed impaired SEPs in the majority of patients and significantly larger DAR in patients compared to healthy controls. Robotic gait training resulted in a reduction of the DAR in healthy subjects but not in patients. No changes were observed in P300 latencies after training in either patients or healthy controls.Conclusion: The study showed that robotic gait training induced measurable changes in the EEG power spectrum in healthy individuals, while no changes were observed in patients with severe TBI. The absence of the EEG changes following training might be an indicator of the severity of brain dysfunction.

Combined transcranial direct current stimulation and robot-assisted gait training in patients with chronic stroke: a preliminary comparison

Objective: To evaluate whether robot-assisted gait training combined with transcranial direct current stimulation is more effective than robot-assisted gait training alone or conventional walking rehabilitation for improving walking ability in stroke patients. Design: Pilot randomized clinical trial. Setting: Rehabilitation unit of a university hospital. Subjects: Thirty patients with chronic stroke. Interventions: All patients received ten 50-minute treatment sessions, five days a week, for two consecutive weeks. Group 1 (n = 10) underwent a robot-assisted gait training combined with transcranial direct current stimulation; group 2 (n = 10) underwent a robot-assisted gait training combined with sham transcranial direct current stimulation; group 3 (n = 10) performed overground walking exercises. Main measures: Patients were evaluated before, immediately after and two weeks post treatment. Primary outcomes: six-minute walking test, 10-m walking test. Results: No differences were found between groups 1 and 2 for all primary outcome measures at the after treatment and follow-up evaluations. A statistically significant improvement was found after treatment in performance on the six-minute walking test and the 10-m walking test in favour of group 1 (six-minute walking test: 205.20 ± 61.16 m; 10-m walking test: 16.20 ± 7.65 s) and group 2 (six-minute walking test: 182.5 ± 69.30 m; 10-m walking test: 17.71 ± 8.20 s) compared with group 3 (six-minute walking test: 116.30 ± 75.40 m; 10-m walking test: 26.30 ± 14.10 s). All improvements were maintained at the follow-up evaluation. Conclusions: In the present pilot study transcranial direct current stimulation had no additional effect on robot-assisted gait training in patients with chronic stroke. Larger studies are required to confirm these preliminary findings.

Virtual reality for enhancement of robot-assisted gait training in children with central gait disorders

To examine the effect of various forms of training interventions, with and without virtual reality, on the initiation and maintenance of active participation during robot-assisted gait training. Intervention study at the Rehabilitation Centre Affoltern a. A., University Children's Hospital, Zurich. Ten patients (5 males, mean age 12.47 years, standard deviation 1.84 years) with different neurological gait disorders and 14 healthy children (7 males, mean age 11.76 years, standard deviation 2.75 years). All participants walked in the driven gait orthosis Lokomat® in 4 different randomly-assigned conditions. Biofeedback values calculated during swing phases were the primary outcome measure and secondary outcomes were derived from a questionnaire assessing the participant's motivation. Findings revealed a significant main effect for training condition in all participants (p < 0.001), for patients (p < 0.05) and for healthy controls (p < 0.01). Overall, both virtual reality-assisted therapy approaches were equally the most effective in initiating the desired active participation in all children, compared with conventional training conditions. Motivation was very high and differed between the groups only in the virtual navigation condition. Novel virtual reality-based training conditions represent a valuable approach to enhance active participation during robot-assisted gait training in patients and healthy controls.

Commentary on gait training in patients with spinal cord injury

There are 2 systematic reviews regarding gait training for persons with spinal cord injury in this issue (“Effectiveness of robot-assisted gait training in persons with spinal cord injury: a systematic review” by Swinnen et al. (1) and “Body weightsupported gait training for restoration of walking in people with an incomplete spinal cord injury: a systematic review “ by Wessels et al. (2)). The question of training for mobility after a spinal cord injury has been described thoroughly by the National Institute for Neurological Disorders and Stroke, as has the ongoing research in the field (available from: http://www. ninds.nih.gov/disorders/sci/detail_sci.htm). What is obvious when reading this site is the frustration experienced by people with spinal cord injuries, and the hope for a cure, which is manifested through research in different areas. In the area of training (which refers to the acquisition of skills and competencies), various methods to restore walking capacity are in focus. In people with spinal cord injuries, activation of brain function, as well as the transport of information in the spinal tract past the site of injury are necessary. Below the site of injury the tract continues, with the anterior horn cells, nerves and muscles; therefore, if the nerve impulses were able to by-pass the break, the nerves could function

Electrical Stimulation During Gait Promotes Increase of Muscle Cross-sectional Area in Quadriplegics: A Preliminary Study

Increases in muscular cross-sectional area (CSA) occur in quadriplegics after training, but the effects of neuromuscular electrical stimulation (NMES) along with training are unknown. Thus, we addressed two questions: (1) Does NMES during treadmill gait training increase the quadriceps CSA in complete quadriplegics?; and (2) Is treadmill gait training alone enough to observe an increase in CSA? Fifteen quadriplegics were divided into gait (n = 8) and control (n = 7) groups. The gait group performed training with NMES for 6 months twice a week for 20 minutes each time. After 6 months of traditional therapy, the control group received the same gait training protocol but without NMES for an additional 6 months. Axial images of the thigh were acquired at the beginning of the study, at 6 months (for both groups), and at 12 months for the control group to determine the average quadriceps CSA. After 6 months, there was an increase of CSA in the gait group (from 49.8 +/- 9.4 cm(2) to 57.3 +/- 10.3 cm(2)), but not in the control group (from 43.6 +/- 7.6 cm(2) to 41.8 +/- 8.4 cm(2)). After another 6 months of gait without NMES in the control group, the CSA did not change (from 41.8 +/- 8.4 cm(2) to 41.7 +/- 7.9 cm(2)). The increase in quadriceps CSA after gait training in patients with chronic complete quadriplegia appears associated with NMES.

The Artificial Muscle as an Innovative Actuator in Rehabilitation Robotics

This paper presents the application of artificial pneumatic muscle actuators in a novel motorized orthosis for an intensive home-based gait training in patients with neurological disorders. Owing to the inherent elasticity of these actuators, they are an ideal choice in realizing a soft and tractable assistance to aid the physiological movements of the lower extremities. Special focus is paid to the modeling of the dynamic nonlinear force characteristics of the muscles as a steerable mass-damper system, and to the approximation of the variation of muscle volume under different operating conditions. The model description uses polynomial functions for which coefficients are identified by minimizing a quadratic performance index. Based on the mechanical model of the knee joint of the apparatus, a nonlinear stability-oriented backstepping control supported by observer-based disturbance compensation is derived and applied to the prototype of the rehabilitation robot.

Gait Training of Patients After Stroke Using an Electromechanical Gait Trainer Combined With Simultaneous Functional Electrical Stimulation

This case report describes the implementation of gait training intervention that used an electromechanical gait trainer with simultaneous functional electrical stimulation (FES) for 2 patients with acute ischemic stroke. Two individuals with post-stroke hemiplegia of less than 6 weeks' duration participated in a 4-week gait training program as an adjunct to physical therapy received at a hospital. After the 4-week intervention, both patients were discharged from the hospital, and they returned after 6 months for a follow-up evaluation. By the end of the 4-week intervention, both patients had shown improvements in scores on the Barthel Index, Berg Balance Scale, Functional Ambulation Categories Scale, 5-m timed walking test, and Motricity Index. In the 6-month follow-up evaluation, both patients continued to have improvements in all outcome measures. This case report shows that, following the use of an electromechanical gait trainer simultaneously with FES, patients after acute stroke had improvements in gait performance, functional activities, balance, and motor control in the long term.

Entrenamiento de la marcha en lesiones medulares incompletas con soporte del peso corporal

A spinal cord injury implies the loss of or alteration to the gait pattern. Stimulating the pattern generating centres in the sublesional spinal cord determines the appearance of flexion and extension automatisms that are useful for gait training in patients with spinal cord injuries. These centres can be stimulated using a treadmill and supporting the body weight by means of a harness. To be able to trigger spinal cord automatisms and to stimulate pattern generating centres. To determine the value of an electromechanical system for mobilising the lower limbs as a complement to the treadmill and body weight support. To study changes in muscle tone. A short gait training programming was carried out with ten individuals with incomplete spinal cord injuries who satisfied eligibility-exclusion criteria using a treadmill in association with a body weight support system and an electromechanical system for mobilising the lower limbs. Spinal cord flexion and extension automatisms were stimulated and an important improvement in spasticity was achieved. Longer programmes are needed in order to evidence changes in the gait pattern and in muscular balance.

Optimal outcomes obtained with body-Weight support combined with treadmill training in stroke subjects

Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Arch Phys Med Rehabil 2003;84:1458–65. Objectives To identify stroke patients who are most likely to benefit from locomotor training with body-weight support (BWS), to determine the extent of carryover from treadmill training to overground locomotion, and to determine the variables that are most likely to influence the recovery of locomotion. Design A randomized clinical trial. Setting Inpatient rehabilitation hospital. Participants Of 100 stroke subjects, 50 were randomized to receive locomotor training with BWS (BWS group), and 50 were randomized to receive locomotor training with full weight bearing (no-BWS group). The subjects were stratified according to their initial overground walking speed and endurance, initial treadmill speed and endurance, functional balance, motor recovery, side of the lesion, and age. Intervention Fifty subjects were trained to walk on a treadmill with up to 40% of their body weight supported by a BWS system with an overhead harness (BWS group), and 50 subjects were trained to walk while bearing their full weight (no-BWS group) Main outcome measures Clinical outcome measures included overground walking speed and endurance, functional balance, and motor recovery. The effect of confounding variables such as age, comorbidity, and depression on locomotor outcome was also investigated. Results After 6 weeks of locomotor training, the BWS group scored significantly higher in all clinical outcomes. When the subjects were stratified according to their initial overground walking speed, endurance, balance, and motor recovery, a significant statistical difference in gait and balance dysfunction of all outcomes occurred in the more severely impaired subjects. An important transfer from treadmill speed to overground walking speed was observed in subjects in the BWS group. Finally, a significantly greater effect was observed in older subjects (65–85y) in the BWS group. Conclusions Retraining gait in severely impaired stroke subjects with a percentage of their body weight supported resulted in better walking and postural abilities than did gait training in patients bearing their full weight. It appears that subjects with greater gait impairments benefited the most from training with BWS, as did the older patients with stroke. There is evidence of transfer from treadmill training to overground locomotion.

Effect of 15% Body Weight Support on Exercise Capacity of Adults Without Impairments

External support of body weight, a technique used for the gait training of patients with neurologic conditions, may also be beneficial for tests of exercise capacity in people whose impairments in motor function and balance have traditionally precluded such testing. The purpose of this study was to investigate the effect of using external support of 15% of body mass during treadmill exercise testing of adults without impairments. Seven men and 8 women (mean age=55.2 years, SD=11.3, range=43-82) performed 3 treadmill tests with random assignment of testing condition: (1) no body weight support (BWS)-standard test, (2) 0% BWS-harness in place but no use of external support, and (3) 15% BWS-use of external support for 15% of body mass. Expired gas was analyzed to determine oxygen uptake, carbon dioxide production, minute ventilation, tidal volume, heart rate, and respiratory exchange ratio. Use of external support for 15% of body mass did not affect the end-expiratory gas exchange variables, although the time to achieve peak values was lengthened. Maximal tidal volume was lower in the 15% BWS test, but maximal minute ventilation was not different. Because 15% BWS did not affect the exercise capacity of adults without known impairments, future study of its application to testing of patients with neurologic injuries is warranted.

Knee position feedback: its effect on management of pelvic instability in a stroke patient

Purpose : This is a case study of improvement in pelvic instability due to a stroke, with treatment. The patient had narrow knee-to-knee distance due to weakness in the pelvic muscles resulting in a narrow base of support. Method : Treatment was focused on pre-gait activities to improve upright posture control followed by gait training involving extrinsic auditory feedback about knee-to-knee distance. Results : After two weeks of therapy with feedback technique incorporated in a functional context of gait therapy, the patient was able to advance his left lower extremity with proper foot placement. Laboratory measurements showed that step width and stride length gotten better after treatment as well. Conclusion : An inclusion of feedback information about knee-to-knee distance could benefit gait training of patients with pelvic instability.

Rhythmic Auditory Stimulation in Gait Training for Patients with Traumatic Brain Injury.

Rhythmic auditory stimulation (RAS) was studied in a frequency entrainment design and as a therapeutic stimulus to facilitate gait patterns in 8 traumatically brain injured individuals (5 male/3 female; mean age 30 +/- 5 years) with persisting gait disorder, 4-24 months postinjury. During entrainment, with RAS frequency matched to baseline cadence, velocity and stride symmetry both increased by an average of 18%. Increases contributing to the velocity improvement were seen in both stride length (7%) and cadence (8%). With RAS accelerated 5% over the fast walking step rate of the patients, 5 patients could entrain to a higher step frequency. The 2 patients with the slowest baseline gait velocity could not entrain to faster RAS frequencies. After 5 weeks of daily RAS training, 5 patients' mean velocity increased significantly (p </=.05) by 51% (38.8 m/min to 57.6 m/min; p </=.43). Cadence (+16%) and stride length (+29%) also showed statistically significant improvement. Stride symmetry improved nonsignificantly by 12%.