Modified Emory Functional Ambulation Profile Research Articles

Predictors of ambulatory recovery and walking proficiency in community-dwelling stroke survivors: a cross-sectional study

BackgroundAlthough the major goal of rehabilitation is to return a stroke survivor (SSv) to as close to their pre-stroke functioning, limitation in ambulatory recovery and walking proficiency is the major impediment. Despite the importance of walking to the outcomes in stroke, factors predicting its recovery remain unclear. This study therefore was aimed at exploring the predictors of ambulatory recovery and walking proficiency in community-dwelling SSv.MethodsThis study involved 164 (83females) SSv from four tertiary health institutions in Nigeria. Ambulatory level and status was assessed using Functional Ambulatory Classification, motor function using the Fugl-Myer Assessment scale (lower limb), and ambulatory/waking endurance using the 6-min walk test. Ambulatory capability was assessed using the Lower Extremity Functional Scale, ambulatory self-confidence using the Ambulatory Self-Confidence Questionnaire, and functional ambulatory profile using the Modified Emory Functional Ambulation Profile. Mobility was assessed using the Modified Rivermead Mobility Index, functional mobility using Time Up and Go, balance using the Berg Balance Scale, and cognitive function using the modified Mini-Mental State Examination. Spatial indexes were assessed using the Footprint method and temporal variables using a stopwatch and gait speed on a 10-m walkway. Data was analyzed using multiple regression analysis at p ≤ 0.05.ResultsParticipants (mean age = 54.3±11.36 years) have had stroke for 12.9 ± 17.39 months and spent 9.82 ± 13.19 months in hospital admissions. More (65.2%) had ischemic stroke with 54.3% of them having left hemispheric stroke. The predictors of ambulatory onset in SSv were stroke duration and length of stay in hospital admission contributing 40.3% (β = 0.403) and 17.6% (β = 0.176) respectively to the variance. Mobility (β = 0.249, p < 0.001), gait speed (β = 0.185, p = 0.012), paretic double-limb support time (β = 0.155, p = 0.03), balance (β = 0.334, p < 0.001), and cognition (β = 0.155, p = 0.01) were predictors of ambulatory self-confidence contributing 59.5% to the variance. Balance (β = 0.363, p < 0.001) and mobility (β = 0.155, p = 0.015) were predictors of ambulatory capability contributing 52.9% to the variance. Balance (β = −0.489, p < 0.001), paretic double-limb support time (β = 0.223, p = 0.003), gait speed (β = −0.181, p = 0.022), and paretic swing phase duration (β = 0.177, p = 0.01) were predictors of functional ambulatory profile (p < 0.05) contributing 52.9% to the variance. Gait speed (β = −0.648, p < 0.001) and step length (β = −0.157, p = 0.003) were predictors of walking endurance contributing 76.5% to the variance.ConclusionAmbulatory recovery and walking proficiency depend on the interplay among duration of stroke and length of hospitalization on the one hand and balance performance, cognitive function, and the spatiotemporal integrity of the affected limb on the other hand.

Motor neuroprosthesis for promoting recovery of function after stroke.

Motor neuroprosthesis for promoting recovery of function after stroke.

Early robot-assisted gait retraining in non-ambulatory patients with stroke: a single blind randomized controlled trial.

Restoration of walking function is a primary concern of neurorehabilitation with respect to the aspired social and vocational reintegration. To date, the best practice for improving gait early after stroke is still object of debate. On one hand, repetitive task-specific approaches with higher intensities of walking have been observed to result in greater improvements of gait after stroke. Conversely there is some evidence that conventional gait training would be more effective for facilitating walking ability after stroke. To compare the effects of an early treatment protocol of add-on robot-assisted gait training with add-on conventional overground physiotherapy for improving locomotion in non-ambulatory adult stroke patients. Single-blind randomized controlled trial. Neurorehabilitation hospital. Seventy-four subacute patients with first-ever ischemic stroke. The patients were randomized into two groups. The training program consisted of forty, 2-hour sessions (including 45 minutes basic training, 45 minutes add-on training plus rest periods), 5 days a week, for 8 consecutive weeks. Patients allocated to the add-on robot-assisted gait training were treated by means of the Lokomat. Patients allocated to the add-on conventional overground gait training aimed at improving postural control during gait, body weight transfer, stability during the stance phase, free swing phase, adequate heel contact and gait pattern. Primary outcome was the modified Emory Functional Ambulation Profile. Secondary outcomes were the Rivermead Motor Index, the Mobility Milestones and the Hochzirl Walking Aids Profile. No significant difference was observed between groups with regards to age (P=0.661), time from stroke onset (P=0.413) and the primary outcome (P=0.854) at baseline evaluation. As to the primary outcome, no significant differences were found between groups at the end of the study. As During the 8-week training, within-group comparisons showed significant improvements of mean modified Emory Functional Ambulation Profile in both groups (P<0.001). Our results support the hypothesis that an early treatment protocol of robot-assisted gait retraining is not superior to add-on conventional gait training intervention for improving locomotion in non-ambulatory stroke patients. This study might help to better understand the role of robot-assisted gait training in early phase stroke rehabilitation.

Treadmill-Based Locomotor Training with Leg Weights in People with Chronic Stroke

BACKGROUND OF STUDY: Novel locomotor training strategies for individuals with disorders of the central nervous system have associated with the improved locomotor function. OBJECTIVES: The goal of this study was to find the effects of treadmill-based locomotor training with leg weights in individuals with chronic stroke. We assessed impairment and gait parameters in functional ambulation persons with chronic stroke. METHODS: We used a Pretest-posttest design. Twenty individuals with chronic stroke who were community ambulatory were recruited. Participants underwent 30-minute treadmill-based locomotor training sessions three times per week for four weeks. The training program involved treadmill walking for 30 minutes with partial body weight support as needed. Leg weights, equivalent to 5% of body weight affixed around the paretic leg. Gait parameters such as cadence, step length, and stride length and the Modified Emory Functional Ambulation Profile (mEFAP) as an outcome measures used. RESULTS: Improvements were more significant in cadence than other gait parameters such as step length and stride length. The more significant improvement was seen in step length than in stride length. In mEFAP, 5.98% improvement was seen showing enhanced the functional ambulatory capacity of participants. In Chedokemcmaster Stroke Assessment Activity Inventory, 4.27% improvement was seen. CONCLUSION: This study demonstrates that treadmill-based locomotor training combined with leg weights could be a feasible approach for improving the ability to perform complex walking tasks, such as stair climbing, in individuals with chronic stroke.

Effect of PNF technique for knee muscles on lower limb performance in subacute stroke – an experimental study

AbstractApproximately two-thirds of stroke survivors have sequel of neurological impairments. Although all sequels have direct impact on the performance of activities of daily living, motor deficits of the lower limbs have the most important impact on an individual’s functioning. The objective was to study the effect of proprioceptive neuromuscular facilitation (PNF) technique on lower limb performance in subjects with subacute stroke.Thirteen participants with subacute strokes were recruited. Participants were treated with PNF rhythmic stabilization technique. All participants received 10 days of intervention. Treatment sessions consisted of PNF rhythmic stabilization exercises for knee that utilizes alternating isometric contractions of agonist and antagonist against resistance. Lower limb performances were measured with Modified Emory Functional Ambulation Profile, Five Time Sit To Stand Test and Postural Assessment Scale For Stroke.Lower limb performances were improved after 10 days of intervention as compared to baseline assessment in all the outcome measures.This study suggests that the rhythmic stabilization technique is an effective method to improve lower limb function that can be used as an adjunct with other therapies.

Peroneal Stimulation for Foot Drop After Stroke

The purpose of this systematic review was to summarize the effect of daily use of single-channel foot drop stimulation among persons with stroke. Randomized controlled trials were searched using electronic databases through May 2014. Six randomized controlled trials were included, involving 820 participants. Gait speed was the most common outcome measured. Other common outcomes included Timed Up and Go, modified Emory Functional Ambulation Profile, Berg Balance Scale, Physiologic Cost Index, Six-Minute Walk Test, quality-of-life, and lower extremity Fugl-Meyer. In summary, foot drop stimulation and ankle foot orthoses seem effective and "equivalent" for increasing gait speed. Other outcomes that consistently improved in both groups were the Timed Up and Go and Six-Minute Walk Test. Foot drop stimulation was more effective compared with ankle foot orthosis for decreasing Physiologic Cost Index and seemed to be preferred by participants. Physical therapy may facilitate improvement in both foot drop stimulation and ankle foot orthosis groups.

Long-Term Follow-up to a Randomized Controlled Trial Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. Objective. Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. Methods. Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). Results. A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. Conclusions. At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

The Bobath Concept in Walking Activity in Chronic Stroke Measured Through the International Classification of Functioning, Disability and Health.

The aim of this study is to evaluate the effectiveness of a rehabilitation programme based on the Bobath concept in order to improve walking activity in patients with chronic stroke and to show the usefulness of the International Classification of Functioning, Disability and Health (ICF) as a tool for gathering functioning information. This study is a repeated measures study. The setting of this study is an outpatient neurological rehabilitation centre based on a multidisciplinary approach. Twenty-four participants suffering from chronic stroke (>1 year and a half and <5 years post-stroke) and mean age of 65.58 (standard deviation 10.73) were the participants of the study. Multidisciplinary approach based on the Bobath concept principles with three weekly individual physiotherapy sessions of 45 min each over a 6-month period was the intervention for this study. The measures used were Modified Emory Functional Ambulation Profile, 10-m walk test, 6-min walk test, muscle strength testing and subsequent codification of these results into ICF qualifiers. The results of the study showed significant improvement in activities of walking long distances, on different surfaces and around obstacles. There was no significant improvement in the activity of walking short distances or for muscle power functions. A rehabilitation programme based on the Bobath Concept improved walking activities in people with chronic stroke. For this intervention, the use of the ICF qualifiers was sensitive in perceiving post-treatment changes.

The Effects of Peroneal Nerve Functional Electrical Stimulation Versus Ankle-Foot Orthosis in Patients With Chronic Stroke

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. Objective. To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. Methods. In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. Results. A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. Conclusions. Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Contralaterally Controlled Neuromuscular Electrical Stimulation for Recovery of Ankle Dorsiflexion

The aim of this study was to compare the effects of contralaterally controlled neuromuscular electrical stimulation (CCNMES) vs. cyclic neuromuscular electrical stimulation (NMES) on lower extremity impairment, functional ambulation, and gait characteristics. Twenty-six survivors of stroke with chronic (≥6 mos) foot drop during ambulation were randomly assigned to 6 wks of CCNMES or cyclic NMES. Both groups had ten sessions per week of self-administered home application of either CCNMES or cyclic NMES plus two sessions per week of gait training with a physical therapist. Primary outcomes included lower extremity Fugl-Meyer score, modified Emory Functional Ambulation Profile, and gait velocity. Assessments were made at pretreatment and posttreatment and at 1 and 3 mos after treatment. There were no significant differences between the groups in the outcome trajectories for any of the measures. With data from both groups pooled, there were significant but modest and sustained improvements in the Fugl-Meyer score and the modified Emory Functional Ambulation Profile but not in gait velocity. The results support the hypothesis that gait training combined with either CCNMES or cyclic NMES reduces lower extremity impairment and functional ambulation but do not support the hypothesis that CCNMES is more effective than cyclic NMES in patients with chronic post-stroke hemiplegia.

Randomized Controlled Trial of Surface Peroneal Nerve Stimulation for Motor Relearning in Lower Limb Hemiparesis

ObjectiveTo compare the motor relearning effect of a surface peroneal nerve stimulator (PNS) versus usual care on lower limb motor impairment, activity limitation, and quality of life among chronic stroke survivors. DesignSingle-blinded randomized controlled trial. SettingTeaching hospital of academic medical center. ParticipantsChronic stroke survivors (N=110; >12wk poststroke) with unilateral hemiparesis and dorsiflexion strength of ≤4/5 on the Medical Research Council scale. InterventionsSubjects were stratified by motor impairment level and then randomly assigned to ambulation training with either a surface PNS device or usual care (ankle-foot orthosis or no device) intervention. Subjects were treated for 12 weeks and followed up for 6 months posttreatment. Main Outcome MeasuresLower limb portion of the Fugl-Meyer (FM) Assessment (motor impairment), the modified Emory Functional Ambulation Profile (mEFAP) performed without a device (functional ambulation), and the Stroke Specific Quality of Life (SSQOL) scale. ResultsThere was no significant treatment group main effect or treatment group by time interaction effect on FM, mEFAP, or SSQOL raw scores (P>.05). The time effect was significant for the 3 raw scores (P<.05). However, when comparing average change scores from baseline (t1) to end of treatment (t2, 12wk), and at 12 weeks (t3) and 24 weeks (t4) after end of treatment, significant differences were noted only for the mEFAP and SSQOL scores. The change in the average scores for both mEFAP and SSQOL occurred between t1 and t2, followed by relative stability thereafter. ConclusionsThere was no evidence of a motor relearning effect on lower limb motor impairment in either the PNS or usual-care groups. However, both the PNS and usual-care groups demonstrated significant improvements in functional mobility and quality of life during the treatment period, which were maintained at 6-month follow-up.

Relationship Between Body Mass Index and Rehabilitation Outcomes in Chronic Stroke

The aim of this study was to evaluate the relationship between body mass index (BMI) and change in motor impairment and functional mobility after a gait rehabilitation intervention in chronic stroke subjects. Correlation and linear regression analyses of pretreatment and end-of-treatment Fugl-Meyer scores and modified Emory Functional Ambulation Profile scores from hemiparetic subjects (n = 108, >3 mos post stroke) who participated in a randomized controlled trial comparing two 12-wk ambulation training treatments were generated. A series of linear regression models that controlled for age, sex, stroke type, interval post-stroke, and training device found the change in the Fugl-Meyer score to be significantly negatively associated with pretreatment BMI (β = -0.207, P = 0.036) and the change in the "up and go" modified Emory Functional Ambulation Profile score to be significantly positively associated with BMI (β = 0.216, P = 0.03). Changes in modified Emory Functional Ambulation Profile scores in floor, carpet, obstacles, or stair climbing were not significantly associated with BMI. Chronic stroke subjects with a higher BMI were less likely to demonstrate improvement in motor impairment and up and go functional mobility performance in response to ambulation training, irrespective of treatment intervention. Stroke rehabilitation clinicians should consider BMI when formulating rehabilitation goals. Further studies are necessary to determine whether obesity is a predictor of longer-term post-stroke motor and functional recovery.

Abstract 17: Motor Relearning Effects of Functional Electrical Stimulation in Lower Limb Hemiparesis

Objective: The primary objective of this study was to assess the effect of peroneal nerve stimulation (PNS) on lower limb motor impairment among chronic stroke survivors. The secondary objective was to assess the effect of PNS on lower limb functional mobility (disability) and overall quality of life. Design: A single-blinded randomized controlled trial, which enrolled 110 chronic hemiparetic stroke survivors (&gt;90 days post-stroke), compared the effect of ambulation training with a PNS device to ambulation training with usual care (ankle foot orthosis or no device). Subjects were treated for 12-wks (Device Usage period) and followed for a total of 6-mos post-treatment. Outcome assessments were performed at baseline, end of the Device Usage period, and 3-mos and 6-mos post-treatment. The primary outcome measure was the Fugl-Meyer Motor Impairment scale. Secondary outcome measures were the Modified Emory Functional Ambulation Profile (mEFAP) and the Stroke Specific Quality of Life scale (SSQOL). Change scores were analyzed via repeated measure ANOVA with treatment and baseline dorsiflexion status (absence or presence of partial dorsiflexion) as independent factors and the baseline measure as a covariate. Results: Change in Fugl-Meyer scores was not significantly influenced by either treatment group (PNS or usual care) or by the presence (DP) or absence (DA) of volitional dorsiflexion at baseline. However, there was a significant treatment group by dorsiflexion status interaction (F=13.46, p=.00) on change in mEFAP scores. Post-hoc subset analysis of the DP and DA subjects using treatment group as an independent factor and baseline mEFAP score as covariate showed a significant treatment group effect (DP subjects: F=6.57, p=0.012 and DA subjects: F=4.24, p=.05) on mEFAP changes scores. A series of independent t-tests which compared the mean mEFAP change in the DP subjects relative to treatment group showed significant differences in favor of the usual care group. However, the same series of independent t-tests in the DA subjects showed the opposite effect with significant differences in favor of the PNS group. SSQOL change scores were not significantly influenced by treatment group or dorsiflexion status. Conclusions: Ambulation training for 12 weeks with either PNS or usual care had similar effects on lower limb motor impairment and overall quality of life in chronic stroke survivors. However, post-hoc analysis found that while PNS enhanced functional mobility in chronic stroke survivors with absent dorsiflexion, usual care was superior in chronic stroke survivors who demonstrated preservation of volitional ankle dorsiflexion.

The Therapeutic Effect of Outpatient Use of a Peroneal Nerve Functional Electrical Stimulation Neuroprosthesis in People with Stroke: A Case Series

Purpose: Foot drop is a common problem following a stroke. Although peroneal nerve functional electrical stimulation (pFES) for foot drop has been shown to improve function and gait, the majority of studies have used daily stimulation. There are few studies to show benefit and guide practice for less frequent dosing. Therefore, the purpose of this study was to examine the effect of gait training with pFES on ambulation and lower extremity kinematics when used on a schedule consistent with usual care in an outpatient therapy clinic. Methods: A pFES neuroprosthesis was used with overground gait training 3 times per week for 6 weeks in 2 subjects with foot drop due to chronic stroke (more than 6 months poststroke). Outcomes including functional gait (modified Emory Functional Ambulation Profile [mEFAP]), gait speed, and gait kinematics were assessed at baseline and at 6 weeks without the pFES (therapeutic effect). Results: Both subjects demonstrated decreased ankle plantarflexion at initial heel contact during gait. Both subjects also showed decreased time to complete the mEFAP. Only 1 subject showed increased gait velocity. Conclusion: This case series suggests that the use of neuroprothesis pFES combined with overground gait training on a typical outpatient therapy schedule for 6 weeks may increase foot clearance during gait for persons with chronic stroke. Although the evidence is limited, it may be beneficial for clinicians to use pFES in creative ways during different aspects of treatment.

Clinical measurement of walking balance in people post stroke: a systematic review

Objective: To identify walking balance measures which have been established for use with ambulatory people post stroke and reflect the balance requirements of community walking. Data sources: MEDLINE, Embase, AMED. Review methods: Measures reflecting walking balance, with tasks that include a stepping action in standing, used with people post stroke were reviewed. Measures with clinical utility were evaluated for psychometric properties, including reliability, validity and clinical interpretation. Results: Nine measures (24 papers) were identified that met the requirement of measuring walking balance in people post stroke with demonstrated clinical utility. Outcome measures with multiple tasks (Brunel Balance Assessment, Modified Emory Functional Ambulation Profile, Dynamic Gait Index, Community Balance and Mobility Scale, and mini-Balance Evaluation Systems Test) as opposed to single task measures (Step Test, Side Step Test and Four Square Step Test, Timed Up and Go), reflect a broader range of walking balance required to accommodate the variable challenges which may be expected at the community level of walking. Most tools report excellent reliability when used by physiotherapists. Validity remains far more challenging to establish. Evaluation of clinical interpretation is limited for all measures. Conclusion: The multiple-task outcome measures reviewed reflected walking balance activities often undertaken during community mobility. Single-task measures may be useful as screening measures, identifying walking balance deficits associated with basic/lower levels of walking balance. Construct validity and clinical interpretability of each measure in ambulatory people post stroke requires further research to identify the level of community mobility represented by each measure of walking balance.

Long-Term Effect of an Anterior Ankle-Foot Orthosis on Functional Walking Ability of Chronic Stroke Patients

The objectives of this study are to investigate the long-term effect of anterior ankle-foot orthosis on the functional walking ability of chronic stroke patients and their subjective perception and to identify the type of chronic stroke patients who are better responders to the wearing of anterior ankle-foot orthosis. This is a cross-sectional cohort comparison study. Fifty-two stroke patients wearing an anterior ankle-foot orthosis for at least 5 mos were evaluated using the modified Emory Functional Ambulation Profile and the 6-min walking test with and without an anterior ankle-foot orthosis. Falls Efficacy Scale-International and a self-designed questionnaire were administered to assess subjective perceptions. All modified Emory Functional Ambulation Profile subscores significantly decreased with the anterior ankle-foot orthosis; the mean difference in favor of the anterior ankle-foot orthosis on the floor was -2.88 secs; the carpet, -5.44 secs; "up and go," -5.09 secs; obstacle, -8.42 secs; stairs, -6.45 secs; and in the 6-min walking test, 19.75 m (all P < 0.01). Patients who were of younger age or with low walking ability or both would have more benefits. The total scores of Falls Efficacy Scale-International were significantly lower with anterior ankle-foot orthosis as compared with that without anterior ankle-foot orthosis (31.57 ± 12.79 vs. 39.51 ± 12.65). Around 90% participants perceived that their walking performance improved with the anterior ankle-foot orthosis either indoors or outdoors, and they would recommend the anterior ankle-foot orthosis to other stroke patients. The greatest disadvantage of anterior ankle-foot orthosis is the difficulty in donning and doffing. The effects of the anterior ankle-foot orthosis on stroke patients' functional walking ability and fall efficacy were significant. Patients who were of younger age or with low walking ability or both were more suitable for using the anterior ankle-foot orthosis.

Using Robot-Applied Resistance to Augment Body-Weight–Supported Treadmill Training in an Individual With Incomplete Spinal Cord Injury

The efficacy of task-specific gait training for people with spinal cord injury (SCI) is premised on evidence that the provision of gait-related afferent feedback is key for the recovery of stepping movements. Recent findings have shown that sensory feedback from flexor muscle afferents can facilitate flexor muscle activity during the swing phase of walking. This case report was undertaken to determine the feasibility of using robot-applied forces to resist leg movements during body-weight-supported treadmill training (BWSTT) and to measure its effect on gait and other health-related outcomes. The patient described in this case report was a 43-year-old man with a T11 incomplete chronic SCI. He underwent 36 sessions of BWSTT using a robotic gait orthosis to provide forces that resist hip and knee flexion. Tolerance to the training program was monitored using the Borg CR10 scale and heart rate and blood pressure changes during each training session. Outcome measures (ie, 10-Meter Walk Test, Six-Minute Walk Test, modified Emory Functional Ambulation Profile [mEFAP], Activities-specific Balance Confidence Scale, and Canadian Occupational Performance Measure) were completed and kinematic parameters of gait, lower-extremity muscle strength (force-generating capacity), lower-limb girth, and tolerance to orthostatic stress were measured before and after the training program. The patient could tolerate the training. Overground walking speed, endurance, and performance on all subtasks of the mEFAP improved and were accompanied by increased lower-limb joint flexion and toe clearance during gait. The patient's ambulatory self-confidence and self-perceived performance in walking also improved. These findings suggest that this new approach to BWSTT is a feasible and potentially effective therapy for improving skilled overground walking performance.

Locomotor imagery training improves gait performance in people with chronic hemiparetic stroke: a controlled clinical trial

Objective: The purpose of this study was to evaluate whether locomotor imagery training leads to clinical improvements in gait after stroke. Design: Pretest—posttest matched control design. Participants: A total of 24 people with chronic hemiparetic stroke (13 for experimental and 11 for control) were recruited in this study. Interventions: The subjects in the experimental group participated in videotape-based locomotor imagery training five days a week for four weeks. They also conducted regular physical therapy. Outcome measures: Kinematic gait parameters were collected using a three-dimensional motion analysis system. Functional gait performance was assessed using clinical measures: Activities-specific Balance Confidence Scale, Berg Balance Test, Dynamic Gait Index and modified Emory Functional Ambulation Profile. Results: After training, walking velocity increased 0.07 ± 0.06 m/s in the experimental group and 0.01 ± 0.07 m/s in the control group. In the experimental group, the affected and less affected limb stride lengths increased by 0.09 ± 0.12 m and 0.10 ± 0.07 m respectively, whereas in the control group they decreased by 0.00 ± 0.04 m and increased by 0.02 ± 0.06 m, respectively. Kinematic parameters in the lower extremity joints during walking were more improved after the training in the experimental group. Confidence in balance, postural control, dynamic balance and performance time for different environmental walking situations were also improved more in the experimental group. Conclusion: Locomotor imagery training can be considered as a useful option for restoration of ambulation for individuals with chronic hemiparetic stroke who are unable to participate in physical gait training.

Treadmill-Based Locomotor Training with Leg Weights to Enhance Functional Ambulation in People with Chronic Stroke: A Pilot Study

Novel locomotor training strategies for individuals with disorders of the central nervous system have been associated with improved locomotor function. The purpose of this study was to investigate the effects of treadmill-based locomotor training combined with leg weights on functional ambulation in individuals with chronic stroke. We assessed functional ambulation and muscle activity in ambulatory individuals with chronic stroke. We used a pre/posttest design. Six individuals with chronic stroke who were community ambulators were recruited. Participants underwent a 30-minute treadmill-based locomotor training sessions three times per week for four to 12 weeks. The training program involved treadmill walking for 30 minutes with partial body weight support as needed. Leg weights, equivalent to 5% of body weight, were affixed around the paretic leg. Outcome measures consisted of the 10-m walk test, the modified Emory Functional Ambulation Profile, and temporal gait parameters. Improvements were observed in functional ambulation measures, particularly the stairs subscore of the modified Emory Functional Ambulation Profile. Participants also exhibited an increase in the proportion of time the paretic leg spent in swing. No significant improvements were observed in the 10-m walk test. This pilot study demonstrates that the combination of leg weights and treadmill training is a feasible approach, that is well tolerated by participants. This approach may have the potential to improve some aspects of functional ambulation and the performance of activities requiring hip and knee flexion.

Training of Walking Skills Overground and on the Treadmill: Case Series on Individuals With Incomplete Spinal Cord Injury

Walking in the home and community is an important goal for individuals with incomplete spinal cord injury (iSCI). Walking in the community requires various skills, such as negotiating curbs, doors, and uneven terrain. This case report describes the use of a method to retrain walking overground that is intensive, variable, and relevant to daily walking (skill training). The aims of this case series were to determine the effectiveness of skill training in a small group of people with iSCI and to compare skill training with body-weight-supported treadmill training (BWSTT) in the same individuals. Four individuals who were a median of 2.7 years (interquartile range [IQR]=12.8) after iSCI participated in alternating phases of intervention, each 3 months long. All patients started with BWSTT. Two patients subsequently engaged in skill training while the other 2 patients engaged in BWSTT, after which a third phase of intervention (opposite to the second) was repeated. The Modified Emory Functional Ambulation Profile, the 10-Meter Walk Test, the 6-Minute Walk Test, the Berg Balance Scale, and the Activities-specific Balance Confidence Scale were administered before training, monthly throughout training, and 3 months after training. Overall improvements in walking speed met or exceeded the minimal clinically important difference for individuals with iSCI (> or = 0.05 m/s), particularly during the skill training phase (skill training: median=0.09 m/s, IQR=0.13; BWSTT: median=0.01 m/s, IQR=0.07). Walking endurance, obstacle clearance, and stair climbing also improved with both types of intervention. Three of the 4 patients had retained their gains at follow-up (retention of walking speed: median=92%, IQR=63%). Thus, the findings suggest that skill training was effective in this small group of individuals.