Non-paretic Side Research Articles

Effects of spasticity and hemiplegic posture on median nerve and carpal tunnel in stroke patients: Electrophysiological and ultrasonographic evaluation

This study aims to evaluate whether the upper extremity spasticity and hemiplegic posture have any effect on the morphology of the carpal tunnel and median nerve in stroke patients. Nerve conduction studies (NCS) were performed in 46 stroke patients and compared to those of 30 healthy controls. The cross-sectional area (CSA) of the carpal tunnel (CT) and median nerve (wrist/mid-forearm levels) was assessed by ultrasonography. The mean ages of the stroke and control group were 55.6 ± 13.5 and 56 ± 12.1 years, respectively. The median spasticity score of the forearm pronators and wrist flexor muscles was 2 (0–4) according to the Modified Ashworth Scale (MAS). The compound muscle action potential (CMAP) of the median nerve was reduced (10,093 ± 4,451 mV) when compared to non-paretic side (11,615 ± 4,397 mV) (p:0.02) and the CSA of the CT was thinner on the paretic side (1.9 ± 0.3 cm2 vs 2.08 ± 0.2 cm2) (p:0.03). Pronator spasticity had no significant effect on the CSA of the median nerve and NCS at the forearm level. The CSA of the median nerve at the wrist was significantly thicker in patients with the wrist flexor spasticity graded II (MAS) and above compared to those with spasticity graded I and below (9.5 ± 1.7 mm2 and 8.7 ± 1.7 mm2 respectively) (p:0.03). However, the thickening of the median nerve didn’t cause significant abnormalities in NCS. This study shows that in stroke patients, wrist flexor spasticity and hemiplegic wrist posture can cause explicit morphological changes in the CT and median nerve albeit normal findings on NCS.

Upper Limb Three-Dimensional Reachable Workspace Analysis Using the Kinect Sensor in Hemiplegic Stroke Patients

A reachable workspace evaluation using the Kinect sensor was previously introduced as a novel upper limb outcome measure in neuromuscular and musculoskeletal conditions. This study investigated its usefulness in hemiplegic stroke patients. Forty-one patients with hemiplegic stroke were included. Kinect-based reachable workspace analysis was performed on both paretic and nonparetic sides. Upper limb impairment was measured using the Fugl-Meyer Assessment and the Motricity Index on the paretic side. Disability was assessed using the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire. Correlations between the relative surface areas, impairment scores, and disability were analyzed. Quadrants 1, 3, and 4 as well as the total relative surface area of the paretic side were significantly reduced compared with the nonparetic side. The total relative surface area of the paretic side correlated with the Fugl-Meyer Assessment scores, the Motricity Index for Upper Extremity, and the Disabilities of the Arm, Shoulder, and Hand questionnaire score. Furthermore, quadrant 3 was the most important determinant of upper limb impairment and disability. A reachable workspace (a sensor-based measure that can be obtained relatively quickly and unobtrusively) could be a useful and alternative outcome measure for upper limb in hemiplegic stroke patients.

Limited fascicle shortening and fascicle rotation may be associated with impaired voluntary force-generating capacity in pennate muscles of chronic stroke survivors

BackgroundMuscle weakness is one of the most common motor impairments after stroke. A variety of progressive muscular changes are reported in chronic stroke survivors, and it is now feasible to consider these changes as an added source of weakness. However, the net contributions of such muscular changes towards muscle weakness have not been fully quantified. MethodsAccordingly, this study aims: (1) to compare muscle architecture of the human medial gastrocnemius between paretic and non-paretic sides in seven chronic hemispheric stroke survivors under passive conditions; (2) to characterize fascicle behavior (i.e., fascicle shortening and fascicle rotation) of the muscle during voluntary isometric contractions; and (3) to assess potential associations between muscle architectural parameters and muscle weakness. Muscle architecture of the medial gastrocnemius (including fascicle length, fascicle pennation angle, and muscle thickness) was characterized using B-mode ultrasonography, and fascicle behavior was then quantified as a function of isometric plantarflexion torque normalized to body mass. FindingsOur experimental results showed that under passive conditions, there was a significant difference in fascicle length and muscle thickness between paretic and non-paretic muscles, but no difference in resting fascicle pennation angle. However, during isometric contraction, both fascicle shortening and fascicle rotation on the paretic side were significantly decreased, compared to the non-paretic side. Moreover, the relative (i.e., paretic/non-paretic) fascicle rotation-shortening ratio (i.e., fascicle rotation per fascicle shortening) was strongly correlated with the relative maximum voluntary isometric plantarflexion torque. InterpretationThis association implies that such fascicle changes could impair the force-generating capacity of the muscle in chronic stroke survivors.

Differences of Passive Ankle Stiffness in Post-Stroke Hemiplegia by Varying Angular Velocity between the Paretic and Non-Paretic Side

Background/Objectives: The purpose of this study was to investigate the effect of passive stiffness on joint function by analyzing the in the passive stiffness of the PS and NPS ankle joint at various angular velocity.Method/Statistical Analysis: The differences of the stiffness of ankle according to different angular velocity in both sides were compared and analyzed in 11 hemiplegic patients. Analyses on the difference of stiffness of ankle joint at each angular velocity between the P and NP side were performed using a paired t-test. The ANOVA with repeated measure was performed to analyze the differences of the stiffness. Statistical significance was defined as P< .05.Findings: In the comparison on the passive stiffness of ankle joint, the paretic side was turned out to be higher in the passive stiffness than the non-paretic side at all angular velocity (20, 40, 60 deg/sec, P< .05). In addition, the analysis on the differences of the stiffness according to the changes in angular velocity showed that the stiffness was found to be the largest at 60 deg/sec and the smallest at 20 deg/sec in both paretic and non-paretic side indicating that the stiffness increases in the higher velocity (P< .05).These results indicate that the range of movement of paralyzed muscles caused by stroke is limited due to the increased passive ankle stiffness and that the velocity of movement is related to the joint function.Improvements/Applications: This study can be exploited as a basis to evaluate the passive ankle stiffness of paretic muscles of stroke patients affecting joint function and as a data for rehabilitation program.

Effects of Changes in Ankle Joint Angle on the Relation Between Plantarflexion Torque and EMG Magnitude in Major Plantar Flexors of Male Chronic Stroke Survivors.

The slope of the EMG-torque relation is potentially useful as a parameter related to muscular contraction efficiency, as a greater EMG-torque slope has often been reported in stroke-impaired muscles, compared to intact muscles. One major barrier limiting the use of this parameter on a routine basis is that we do not know how the EMG-torque slope is affected by changing joint angles. Thus, the primary purpose of this study is to characterize the EMG-torque relations of triceps surae muscles at different ankle joint angles in both paretic and non-paretic limbs of chronic hemispheric stroke survivors. Nine male chronic stroke survivors were asked to perform isometric plantarflexion contractions at different contraction intensities and at five different ankle joint angles, ranging from maximum plantarflexion to maximum dorsiflexion. Our results showed that the greater slope of the EMG-torque relations was found on the paretic side compared to the non-paretic side at comparable ankle joint angles. The EMG-torque slope increased as the ankle became plantarflexed on both sides, but an increment of the EMG-torque slope (i.e., the coefficient a) was significantly greater on the paretic side. Moreover, the relative (non-paretic/paretic) coefficient a was also strongly correlated with the relative (paretic/non-paretic) maximum ankle plantarflexion torque and with shear wave speed in the medial gastrocnemius muscle. Conversely, the relative coefficient a was not well-correlated with the relative muscle thickness. Our findings suggest that muscular contraction efficiency is affected by hemispheric stroke, but in an angle-dependent and non-uniform manner. These findings may allow us to explore the relative contributions of neural factors and muscular changes to voluntary force generating-capacity after stroke.

Treatment of Upper Limb Paresis With Repetitive Peripheral Nerve Sensory Stimulation and Motor Training: Study Protocol for a Randomized Controlled Trial.

Background: Repetitive peripheral nerve sensory stimulation (RPSS) has emerged as a potential adjuvant strategy to motor training in stroke rehabilitation. The aim of this study is to test the hypothesis that 3 h sessions of active RPSS associated with functional electrical stimulation (FES) and task-specific training (TST) distributed three times a week, over 6 weeks, is more beneficial to improve upper limb motor function than sham RPSS in addition to FES and TST, in subjects with moderate to severe hand motor impairments in the chronic phase (>6 months) after stroke.Methods: In this single-center, randomized, placebo controlled, parallel-group, double-blind study we compare the effects of 18 sessions of active and sham RPSS as add-on interventions to FES and task-specific training of the paretic upper limb, in 40 subjects in the chronic phase after ischemic or hemorrhagic stroke, with Fugl-Meyer upper limb scores ranging from 7 to 50 and able to voluntarily activate any active range of wrist extension. The primary outcome measure is the Wolf Motor Function Test (WMFT) after 6 weeks of treatment. The secondary outcomes are the WMFT at 3, 10, and 18 weeks after beginning of treatment, as well as the following outcomes measured at 3, 6, 10, and 18 weeks: Motor Activity Log; active range of motion of wrist extension and flexion; grasp and pinch strength in the paretic and non-paretic sides (the order of testing is randomized within and across subjects); Modified Ashworth Scale; Fugl-Meyer Assessment-Upper Limb in the paretic arm; Barthel Index; Stroke Impact Scale.Discussion: This project represents a major step in developing a rehabilitation strategy with potential to have impact on the treatment of stroke patients with poor motor recovery in developing countries worldwide. The study preliminarily evaluates a straightforward, non-invasive, inexpensive intervention. If feasibility and preliminary efficacy are demonstrated, further investigations of the proposed intervention (underlying mechanisms/ effects in larger numbers of patients) should be performed.Trial Registration: NCT02658578.

Architecture of the medial gastrocnemius muscle in people who have had a stroke: A diffusion tensor imaging investigation

MRI techniques (diffusion tensor imaging and mDixon imaging) were used to obtain muscle volume, fascicle length, pennation angle, physiological cross-sectional area and curvature in 14 stroke patients (mean age 60 SD 13years) and 18 control participants (mean age 66 SD 12years). On average, the ankle on the paretic side had 11° (95% confidence interval 8 to 13°) less dorsiflexion range than on the non-paretic side, and 6° (1 to 13°) less dorsiflexion range than ankles of control participants. The medial gastrocnemius muscles on the paretic side were, on average, 15% (35.2cm3, 95% confidence interval 5.2 to 65.2cm3) smaller in volume than the muscles on the non-paretic side, and 16% (36.9cm3, 95% confidence interval 3.1 to 70.6cm3) smaller than in control participants. No statistically significant differences between paretic, non-paretic and control muscles were detected for fascicle length, pennation angle, physiological cross-sectional area or curvature. People with hemiparetic stroke and reduced range of motion have, on average, a smaller medial gastrocnemius muscle on the paretic side than on the non-paretic side. Other muscle architectural parameters appear unchanged.

An Omnidirectional Assistive Platform Integrated With Functional Electrical Stimulation for Gait Rehabilitation: A Case Study.

This paper presents a novel omnidirectional platform for gait rehabilitation of people with hemiparesis after stroke. The mobile platform, henceforth the "walker", allows unobstructed pelvic motion during walking, helps the user maintain balance and prevents falls. The system aids mobility actively by combining three types of therapeutic intervention: forward propulsion of the pelvis, controlled body weight support, and functional electrical stimulation (FES) for compensation of deficits in angular motion of the joints. FES is controlled using gait data extracted from a set of inertial measurement units (IMUs) worn by the user. The resulting closed-loop FES system synchronizes stimulation with the gait cycle phases and automatically adapts to the variations in muscle activation caused by changes in residual muscle activity and spasticity. A pilot study was conducted to determine the potential outcomes of the different interventions. One chronic stroke survivor underwent five sessions of gait training, each one involving a total of 30 minutes using the walker and FES system. The patient initially exhibited severe anomalies in joint angle trajectories on both the paretic and the non-paretic side. With training, the patient showed progressive increase in cadence and self-selected gait speed, along with consistent decrease in double-support time. FES helped correct the paretic foot angle during swing phase, and likely was a factor in observed improvements in temporal gait symmetry. Although the experiments showed favorable changes in the paretic trajectories, they also highlighted the need for intervention on the non-paretic side.

Whole-body vibration modulates leg muscle reflex and blood perfusion among people with chronic stroke: a randomized controlled crossover trial

This study aimed to investigate the acute effect of whole-body vibration (WBV) on the reflex and non-reflex components of spastic hypertonia and intramuscular blood perfusion among individuals with chronic stroke. Thirty-six people with chronic stroke (age: 61.4 ± 6.9 years) participated in this randomized controlled cross-over study. Each participant underwent two testing conditions: static standing for 5 minutes with WBV (30 Hz, 1.5 mm) or no-vibration. We assessed the soleus H-reflex, shear modulus (ultrasound elastography) and vascular index (color power Doppler ultrasound) of the medial gastrocnemius (MG) muscle on either paretic or non-paretic side at baseline and every 1-min post-intervention up to 5 minutes. The results revealed a significant inhibition of the H/M ratio bilaterally for the WBV condition (absolute change on paretic side: 0.61 ± 0.35, p = 0.001; non-paretic side: 0.34 ± 0.23, p = 0.001), but not the control condition. The inhibition of H-reflex was sustained up to 4 minutes and 3 minutes on the paretic and non-paretic side, respectively. The vascular index of MG muscle was significantly increased only for the WBV condition [paretic: from 0.55 ± 0.07 to 1.08 ± 0.18 (p = 0.001); non-paretic: from 0.82 ± 0.09 to 1.01 ± 0.13 (p < 0.001)], which lasted for 3 minutes and 5 minutes, respectively. No significant change of the shear modulus in the MG muscle was observed, regardless of the testing condition. Based on our results, WBV had an acute effect on modulating spastic hypertonia dominated by hyperreflexia in people with chronic stroke and facilitating greater intramuscular blood perfusion. No acute effect on passive muscle stiffness was observed.

An investigation into the validity and reliability of mHealth devices for counting steps in chronic stroke survivors

Objective: To investigate the validity and test–retest reliability of mHealth devices (Google Fit, Health, STEPZ, Pacer, and Fitbit Ultra) to estimate the number of steps in individuals after chronic stroke and to compare whether the measurement of the number of steps is affected by their location on the body (paretic and non-paretic side). Design: Observational study with repeated measures. Setting: University laboratory. Subjects: Fifty-five community-dwelling individuals with chronic stroke. Intervention: Not applicable. Main measures: The number of steps was measured using mHealth devices (Google Fit, Health, STEPZ, Pacer, and Fitbit Ultra), and compared against criterion-standard measure during the Two-Minute Walk Test using habitual speed. Results: Our sample was 54.5% men, mean age of 62.5 years (SD 14.9) with a chronicity after stroke of 66.8 months (SD 55.9). There was a statistically significant association between the actual number of steps and those estimated by the Google Fit, STEPZ Iphone and Android applications, Pacer iphone and Android, and Fitbit Ultra (0.30 ⩽ r ⩾ 0.80). The Pacer iphone application demonstrated the highest reliability coefficient (ICC(2,1) = 0.80; P < 0.001). There were no statistically significant differences in device measurements that depended on body location. Conclusions: mHealth devices (Pacer–iphone, Fitbit Ultra, Google Fit, and Pacer–Android) are valid and reliable for step counting in chronic stroke survivors. Body location (paretic or non-paretic side) does not affect validity or reliability of the step count metric.

Bone mineral density and fragility fractures in stroke patients

The aim was to study the parameters of bone mineral density (BMD) and frequency of fragility fractures in males and females with ischemic stroke depending on a side of brain injury and duration of post-stroke period. Materials and methods. We examined 140 patients aged 50–80 years old, divided into 2 groups: I – subjects without any diseases influencing the bone state and II – patients after ischemic stroke. BMD indexes (BMDs) were measured using dual-energy X-ray absorbtiometry method. Results. The males with stroke had significantly lower parameters of total body, upper extremity and trunk BMDs compared to indexes of the control group without any differences in lower extremities BMDs in contrast to women with stroke who had lower BMDs of total body, trunk and upper/lower extremities compared to parameters of the control group. Almost all measured BMDs were significantly lower on a paretic side compared to BMDs on a non-paretic side, except distal radius and total lower extremities BMDs in men with stroke in contrast to women who demonstrated significantly lower femoral neck and total femur BMDs compared to the control group. Most BMDs were decreased in females with post-stroke period duration of more than 1 year in contrast to data in men who did not show any BMD differences, except significantly decreased BMD of upper extremities compared to the control group. Fragility fractures were revealed in 21.4 % of patients after stroke (31.8 % in women and 10.0 % in men, P < 0.05), their frequency was higher only in women compared to the control group patients. Conclusions. BMDs in stroke patients are lower and frequency of osteoporosis is higher with some sex differences that should be taken into account in their assessment and development of rehabilitation programs for older age subjects.

The effect of aquatic and treadmill exercise in individuals with chronic stroke

ABSTRACT We compared the effect of gait training on treadmill versus deep water on balance and gait in 12 ischemic stroke chronic survivors randomly sorted to the Pool or Treadmill Groups. Berg Scale (BBS) and timed up and go test (TUG) were applied before and after the interventions. Just one person applied all tests and she was blinded for the aims of the study. Surface EMG of the paretic and non-paretic (NP) side muscles were recorded during walking on a treadmill. Three 100-ms epochs were extracted from the EMG related to gait phases: weight acceptance; propulsion; and pre-strike. For each epoch, we calculated the RMS of the EMG signal. Participants did gait training for 9 weeks (3 times/week, 40 minutes/session). The Pool group did the deep-water walking with a swimming belt. The Treadmill group walked on the treadmill at the maximum speed they could stand. The Manova group compared the effect of training, group, side, muscles, and gait phase into the EMG. Anova was used to test the effect of training, group side, and gait phase into BBS, TUG and EMG variables. Pool and Treadmill had increased balance and agility. The highest EMG RMS occurred at the paretic side, for the Treadmill and after training. The mm. tibialis anterior, gastrocnemius lateralis, vastus lateralis, and biceps femoris presented the highest RMS for the NP side; while for mm. rectus femoris and semitendinosus, the paretic side presented the highest RMS. Thus, the both types of exercise lead to similar functional adaptations with different muscular activations during walking.

Effects of visual feedback training using transient Fresnel prism glasses on balance ability in stroke patients without hemispatial neglect.

The center of mass of the body in patients with stroke was oriented toward the nonparetic side. Abnormal weight shift increases the risk of falls. Therefore, many therapists make an effort to help their functional recovery through balance training. Our aim was to investigate the effect of visual feedback intervention using a Fresnel prism on static and dynamic balance in stroke patients without hemispatial neglect. Participants were assigned to control group (n=10) and experimental group (n=9). In the control group, neurodevelopmental therapy was performance for 30 min. In the experimental group, Fresnel prism glasses were applied with neurodevelopmental therapy for 30 min. We executed motor-free visual perception test for visual perception, balancia for static balance ability, and functional reach test and Berg balance test for dynamic balance ability, respectively. All tests were measured immediately after intervention. The visual perception function showed significant difference between unaffected side performance behaviors and visual perceptual processing time (P<0.05). In the static balance, there was a significant difference in sway velocity and sway distances (P<0.05). Dynamic balance was also significant different between groups (P<0.05). Visual feedback using Fresnel prism helps to control the static and dynamic balance ability by inducing weight shift toward the affected side in stroke patients. Therefore, a Fresnel prism may be suggested as an intervention tool to assist weight training for patients with stroke.

Reflections of mirror therapy on the functional recovery after stroke

Introduction Motor function after stroke is improved after mirror therapy. During mirror therapy, a mirror is placed in the mid-sagittal plane thus reflecting movements of non-paretic side as if it were the affected side. Objectives To evaluate the effectiveness of mirror therapy on upper extremity motor recovery and hand related functioning of patients with sub-acute stroke. Method A total of 60 patients with stroke were randomly selected, all within 6 months post stroke, with 30 patients in each, experimental and control group. Each day, 30 min of mirror therapy was given to patients in experimental group consisting of wrist and finger flexion and extension movements in addition to conventional stroke rehabilitation program, 6 days a week, 1 h a day for 4 weeks, while those in control group didn't receive mirror therapy program. Main Outcome Measures- The Brunnstrom stages of motor recovery & Hand- related functioning (Self-care items of FIM instrument) Results Mean age of the patients was 55 years. The scores of the Brunnstrom stages for hand and upper extremity and FIM self - care score improved more in experimental group than in control group after 4 weeks of treatment (by 0.81, 0.86 and 4.1 respectively; all P Conclusion Hand functioning improved more after mirror therapy compared with control group after 4 weeks of treatment and at 6 month follow up.

Effects of Ankle and Hip Strategy Training on Improving the Center of Pressure Movements and Limits of Stability in Stroke Patients

Background: Stroke patients have leg muscle weakness and impaired balance resulting in compensatory changes. To restore balance in these patients, functional training using postural strategy is needed. Objective: To examine the effects of ankle and hip strategy training on the center of pressure (COP) movement and limits of stability (LOS) in standing posture in stroke patients. Design: The study was an assessor-blinded and randomized-controlled clinical trial. Methods: Thirty patients were randomly assigned to an ankle strategy training group and a ankle/ hip strategy training group. Patients in the ankle strategy training group underwent ankle strategy exercise for 30 min, and those in the ankle/ hip strategy training group underwent 15 min of ankle strategy exercise and 15 min of hip strategy exercise. Both groups underwent training thrice a week for four weeks. Forward, backward, paretic side, and non-paretic side COP movements and LOS were measured using BioRescue. Results: After the intervention, except for the backward area in the ankle strategy training group, the COP movement area and the LOS were significantly improved in both the groups. In addition, these improvements were significantly higher in ankle/ hip strategy training group than that in the ankle strategy training group. Conclusions: Ankle strategy training in addition to hip strategy training improves COP movement (forward-backward, paretic side area, and nonparetic side area) and LOS in stroke patients.

Correlation between Affected Arm Muscle Activity and Global Synkinesis in Patients with Stroke

Background: Although there are interventions available for the improvement of arm functions of patients with stroke, measuring changes in global synkinesis (GS) according to changes in the muscle activity of paretic and nonparetic side muscles is an important factor and studies to investigate such potential factors are evaluated necessary. Objective: To examine the correlation between the affected arm muscle activity and GS changes in patients with stroke. Design: Randomized controlled trial Methods: In order to measure muscle activities of 30 stroke patients, anterior deltoid, posterior deltoid, biceps brachii and triceps brachii of the affected arms were measured using surface electromyography (EMG) and for analyzing GS, biceps brachii and triceps brachi of the affected arms were measured using the same instrument. Results: When the correlations between the muscle activity and GS of the affected arm were analyzed, the results showed significant correlations between the posterior deltoid and the triceps brachii(p < .01) and between the triceps brachii and GS(p < .05). Conclusion: : The results of this study suggest that the efficient movements of the affected arms of stroke patients, it is possible to increase extensor activity by improving smooth antagonism of the arm.

Tarsal fusion for pes equinovarus deformity improves gait capacity in chronic stroke patients

BackgroundGait impairments are common and disabling in chronic stroke patients. Pes equinovarus deformity is one of the primary motor deficits underlying reduced gait capacity after stroke. It predisposes to stance-phase instability and subsequent ankle sprain or falls. This instability is most pronounced when walking barefoot. Tarsal fusion is a recommended treatment option for varus deformity, but scientific evidence is sparse. We therefore evaluated whether a tarsal fusion improved barefoot walking capacity in chronic stroke patients with pes equinovarus deformity.MethodsTen patients with a pes equinovarus deformity secondary to supratentorial stroke underwent surgical correction involving a tarsal fusion of one or more joints. Instrumented gait analysis was performed pre- and postoperatively using a repeated-measures design. Primary outcome measure was gait speed.ResultsWalking speed significantly improved by 32% after surgery (0.38 m/s ± 0.20 to 0.50 m/s ± 0.17, p = 0.007). Significant improvement was also observed when looking at cadence (p = 0.028), stride length (p = 0.016), and paretic step length (p = 0.005). Step length on the nonparetic side did not change. Peak ankle moment increased significantly on the nonparetic side (p = 0.021), but not on the paretic side (p = 0.580). In addition, functional ambulation scores increased significantly (p = 0.008), as did satisfaction with gait performance (p = 0.017).ConclusionsTarsal fusion for equinovarus deformity in chronic stroke patients improves gait capacity, and the degree of improvement is of clinical relevance. Our results suggest that the improved gait capacity may be related to better prepositioning and loading of the paretic foot, leading to larger paretic step length and nonparetic ankle kinetics.

Therapeutic approaches for pusher syndrome after a stroke: a literature review

Introduction: Pusher syndrome is a disorder that is clinically present in 5-52% of stroke patients, characterized by active pushing using the non-paretic side towards the paretic side, and resistance to the passive correction of posture. This disorder can pose an unfavorable effect on the rehabilitation of stroke patients. Hence, finding effective therapeutic approaches for pusher syndrome is crucial. This study aimed to identify the existing therapeutic approaches for pusher syndrome and investigate their effectiveness.Methods: A literature review was carried out, where studies were identified through searching the PubMed database from database inception to 2019 using the keywords: “pusher syndrome”, “pusher behaviour”, “contraversive pushing”, “ipsilateral pushing”, “lateropulsion”, “physiotherapy”, “physical therapy”, “treatment”, “therapeutic approach”, “therapy” and “training”.  The literatures were analyzed systematically based on the results of previous studies.Results: Several approaches were identified for treating pusher syndrome post-stroke, including robot-assisted gait training (RAGT), galvanic vestibular stimulation (GVS), visual feedback (VF), and physiotherapy with additional components such as relaxation therapy in the prone position and lateral stepping with body weight–supported treadmill training (LS-BWSTT). RAGT and VF training appear to be promising adjunctive approaches for treating pusher syndrome. Conventional physiotherapy with additional components such as relaxation therapy and LS-BWSTT have also led to positive effects. However, the effect of GVS has not been established.Conclusion: There is evidence that some therapeutic approaches can be beneficial for improving pusher syndrome and outcomes of stroke patients, in particular when combined with conventional physiotherapy. However, the number of studies is still very limited. Further research with methodological rigor is needed.

Validity and Reproducibility of Inertial Physilog Sensors for Spatiotemporal Gait Analysis in Patients With Stroke

Spatiotemporal gait analysis can provide quantitative information to assess treatment outcomes in stroke survivors. Therefore, clinicians need a portable, easy-to-use and low-cost tool that accurately and reliably measures spatiotemporal gait parameters. This paper examined the concurrent validity and reproducibility of the Gait Up gait analysis package for the spatiotemporal gait analysis in subacute stroke survivors. Twenty-five subacute stroke survivors participated in two walking tests. Spatiotemporal gait parameters were synchronously measured by 2 foot-worn inertial sensors (Physilog) and three-dimensional motion capturing (Vicon). Intraclass correlation coefficients, standard errors of measurement, smallest detectable changes, limits of agreement, and the Bland-Altman plots were calculated for the paretic and non-paretic side. After removing a consistent outlier (i.e., data of the paretic side of subject 36 who dragged his foot), agreement between both devices was good to excellent for paretic and non-paretic gait cycle time, cadence, stride length, stride velocity, and double support and moderate for paretic and non-paretic stance and swing. The Bland-Altman plots supported these findings. Test-retest reliability was good to excellent for most parameters, except paretic stance and swing. In conclusion, the Gait Up gait analysis package is a valid and reliable tool to measure paretic and non-paretic gait cycle time, cadence, stride length, and stride velocity in subacute patients with stroke, who do not exhibit severe dragging of the paretic foot. However, the algorithm should be improved for the analysis of paretic stance and swing phase.

Insufficient Balance Recovery Following Unannounced External Perturbations in Persons With Stroke

Background. Persons with stroke (PwS) are at increased risk of falls, especially toward the paretic side, increasing the probability of a hip fracture. The ability to recover from unexpected loss of balance is a critical factor in fall prevention. Objectives. We aimed to compare reactive balance capacity and step kinematics between PwS and healthy controls. Methods. Thirty subacute PwS and 15 healthy controls were exposed to forward, backward, right, and left unannounced surface translations in 6 increasing intensities while standing. Single step threshold, multiple step threshold, and fall threshold (ie, perturbation intensity leading to a fall into harness system) were recorded as well as reactive step initiation time, step length, and step velocity. Results. Twenty-five PwS fell into harness system during the experiment while healthy controls did not fall. Fourteen out of 31 falls occurred in response to surface translations toward the nonparetic side, that is, falling toward the paretic side. Compared with healthy controls, PwS demonstrated significantly lower fall threshold and multiple step threshold in response to forward, backward, and lateral surface translations. Impairments were more pronounced in response to forward surface translation and toward the nonparetic side (ie, loss of balance toward the paretic side). A trend toward significant shorter step length in response to lateral surface translations was found in PwS compared with healthy controls. Conclusions. Findings highlight the importance of assessing reactive balance capacity in response to perturbations in different directions and intensities in addition to the routine assessment in PwS.