Gunilla Frykberg

Gait post-stroke: Pathophysiology and rehabilitation strategies

We reviewed neural control and biomechanical description of gait in both non-disabled and post-stroke subjects. In addition, we reviewed most of the gait rehabilitation strategies currently in use or in development and observed their principles in relation to recent pathophysiology of post-stroke gait. In both non-disabled and post-stroke subjects, motor control is organized on a task-oriented basis using a common set of a few muscle modules to simultaneously achieve body support, balance control, and forward progression during gait. Hemiparesis following stroke is due to disruption of descending neural pathways, usually with no direct lesion of the brainstem and cerebellar structures involved in motor automatic processes. Post-stroke, improvements of motor activities including standing and locomotion are variable but are typically characterized by a common postural behaviour which involves the unaffected side more for body support and balance control, likely in response to initial muscle weakness of the affected side. Various rehabilitation strategies are regularly used or in development, targeting muscle activity, postural and gait tasks, using more or less high-technology equipment. Reduced walking speed often improves with time and with various rehabilitation strategies, but asymmetric postural behaviour during standing and walking is often reinforced, maintained, or only transitorily decreased. This asymmetric compensatory postural behaviour appears to be robust, driven by support and balance tasks maintaining the predominant use of the unaffected side over the initially impaired affected side. Based on these elements, stroke rehabilitation including affected muscle strengthening and often stretching would first need to correct the postural asymmetric pattern by exploiting postural automatic processes in various particular motor tasks secondarily beneficial to gait.

Temporal coordination of the sit-to-walk task in subjects with stroke and in controls.

OBJECTIVES To explore events and describe phases for temporal coordination of the sit-to-walk (STW) task, within a semistandardized set up, in subjects with stroke and matched controls. In addition, to assess variability of STW phase duration and to compare the relative duration of STW phases between the 2 groups. DESIGN Cross-sectional. SETTING Research laboratory. PARTICIPANTS A convenience sample of persons with hemiparesis (n=10; age 50-67y) more than 6 months after stroke and 10 controls matched for sex, age, height, and body mass index. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Relative duration of STW phases, SE of measurement in percentage of the mean, and intraclass correlation coefficients (ICCs). RESULTS Four STW phases were defined: rise preparation, transition, primary gait initiation, and secondary gait initiation. The subjects with stroke needed 54% more time to complete the STW task than the controls did. ICCs ranged from .38 to .66 and .22 to .57 in the stroke and control groups, respectively. SEs of measurement in percentage of the mean values were high, particularly in the transition phase: 54.1% (stroke) and 50.4% (controls). The generalized linear model demonstrated that the relative duration of the transition phase was significantly longer in the stroke group. CONCLUSIONS The present results extend existing knowledge by presenting 4 new phases of temporal coordination of STW, within a semistandardized set-up, in persons with stroke and in controls. The high degree of variability regarding relative STW phase duration was probably a result of both the semistandardized set up and biological variability. The significant difference in the transition phase across the 2 groups requires further study.

Neuroplasticity in action post-stroke: Challenges for physiotherapists

Abstract Knowledge regarding neuroplasticity post-stroke is increasingly expanding. In spite of this, only a few physiotherapy interventions have been able to demonstrate effectiveness in achieving recovery of lost sensorimotor control. The aims of this review article are to highlight and discuss challenges for physiotherapists working with patients post-stroke, to question some current assessment methods and treatment approaches, and to pose critical questions indicating a possible new direction for physiotherapists in stroke rehabilitation. Differentiation between recovery and compensation post-stroke is increasingly being emphasized. Implementation of this goal in the clinic is insufficient, with a lack of assessment tools with potential to discriminate between the concepts. Large-scale reviews are performed without considering whether functional gains are achieved through “more effective” compensatory strategies or through recovery. Cortical plasticity in neurorehabilitation research and voluntary control in contemporary treatment methods are in focus. Challenges for physiotherapists in stroke rehabilitation consist of rethinking, including looking upon the body under the influence of gravity, focusing on implicit factors that impact movement control and developing new assessment tools. The introduction of a new assessment and treatment concept aiming at expanding the boundaries of center of mass movements towards the paretic side is proposed. In conclusion, we need to assume our responsibilities and step forward as the experts in movement science that we have the potential to be.

Impact of stroke on anterior–posterior force generation prior to seat-off during sit-to-walk

Force generation during sit-to-walk (STW) post-stroke is a poorly studied area, although STW is a common daily transfer giving rise to a risk of falling in persons with disability. The purpose of this study was to describe and compare strategies for anterior-posterior (AP) force generation prior to seat-off during the STW transfer in both subjects with stroke and in matched controls. During STW at self-selected speed, AP force data were collected by 4 force plates, beneath the buttocks and feet from eight subjects with stroke (>6 months after onset) and 8 matched controls. Subjects with post-stroke hemiparesis and matched controls generated a similar magnitude of total AP force impulses (F(1,71)=0.67; p=0.42) beneath buttocks and feet prior to seat-off during STW. However, there were significant group differences in AP force impulse generation beneath the stance buttock (i.e. the non-paretic buttock in the stroke group), with longer duration (F(1,71)=8.78; p<0.005), larger net AP impulse (F(1,71)=6.76; p<0.05) and larger braking impulse (F(1,71)=7.24; p<0.05) in the stroke group. The total braking impulse beneath buttocks and feet was about 4.5 times larger in the stroke group than in the control group (F(1,71)=8.84; p<0.005). An intra- and inter-limb dys-coordination with substantial use of braking impulses was demonstrated in the stroke group. This motor strategy differed markedly from the smooth force interaction in the control group. These results might be important in the development of treatment models related to locomotion post-stroke.

Disorders of Consciousness: Recommendations Are Welcome but Further Guidance is Needed

tance of repeated assessments 2 is a limitation. Together with the emphasis on “reasonable time” for administration, there is a risk that behaviors inconsistent with vegetative state may continue to be missed. The Recommendations do state that “extended or repeated assessment with a DOC scale is likely to improve diagnostic accuracy.” However, no concrete guidance is given regarding the recommended number of such assessments in clinical practice. “Extended or repeated” may be variously interpreted as anything from 2 assessments on the same day, upward to daily assessments over a number of weeks. A helpful addition to the Recommendations would be a statement of current expert opinion regarding a minimum number of assessments and/or time spent in behavioral assessment before a conclusion can be reached about the patient’s functional level. Most assessment scales (Sensory Modality And Rehabilitation Technique [SMART] 3 excepted) do not, themselves, make a specific recommendation on this point. Indeed, this aspect of SMART is overlooked in the Recommendations, which state somewhat misleadingly that assessment time for SMART is 60 minutes or more. In fact, 10 assessments, each of 60 minutes, are required. A clearer indication of the role of assessment scales in the broader clinical diagnostic process would also be welcome. Even the most recent of previous guidelines 4 on DOC diagnosis are now several years old and predate developments in magnetic resonance imaging and neurophysiologic techniques. The important point in the Recommendations, that current evidence is insufficient to allow a recommendation on the use of these scales for diagnostic classification, is absent from the conclusions in the abstract. 1 It is especially important to highlight this when, for example, the Coma Recovery Scale-Revised (CRS-R) specifically yields a diagnostic classification. Thus, the CRS-R is recommended for patient assessment, but not for diagnosing a patient with a DOC. This somewhat subtle distinction is at risk of being overlooked by clinicians with less experience in assessment of DOC, presumably a group to whom the Recommendations are directed. We join others 5 in a call for a broader update of guidance on diagnosis of DOC, including but not limited to, behavioral assessment.

Physiotherapy treatment of the diabetic shoulder: health-related quality of life and measures of shoulder function regarding patients with type 1 diabetes

Abstract Purpose: The aim of this study was to investigate how health-related quality of life (HRQoL) and functional shoulder range of motion are affected among patients with diabetes with shoulder problems, treated with a specific physiotherapy programme. A further aim was to investigate how health-related quality of life, functional shoulder range of motion, pain intensity, and shoulder function correlate within the group of patients after the treatment period. Method: A pre–post treatment design was applied for a study group of ten patients with type 1 diabetes and shoulder problems. The physiotherapy treatment consisted of exercises promoting enhanced micro-circulation in the shoulder tissues, optimal shoulder co-ordination, and muscle relaxation. The Short Form-36 (SF-36), shoulder range of motion measures, the Shoulder Rating Scale – Swedish version, and pain intensity measures were used. The results regarding SF-36 were compared with the results of a control group of patients having either type 1 or type 2 diabetes and shoulder problems that did not receive any specific physiotherapy treatment. Results: As a potential result of physiotherapy training, a significant change towards higher scores was observed in the physical component summary (PCS) measure of SF-36. There was a significant improvement regarding PCS in the study group as compared with the control group. There were negative correlations between the four aspects of pain intensity and PCS and Shoulder Rating Scale – Swedish version, respectively, but a positive correlation between PCS and Shoulder Rating Scale – Swedish version. “Hand-raising” and “hand-behind-back” were significantly improved, and proved to be positively correlated with Shoulder Rating Scale – Swedish version. Conclusions: The results of this study indicate that patients with type 1 diabetes and shoulder problems, treated with a specific physiotherapy programme, may improve with respect to physical aspects of health-related quality of life, and partially regain their range of motion in the shoulder joint. Based on these results, the associated treatment protocol may be recommended for physiotherapy treatment in such patients. Implications for Rehabilitation Diabetes is a significant risk factor in the development of shoulder pain and disability. Health-related quality of life (HRQoL) is affected in patients with diabetes and shoulder problems. A specific physiotherapy programme may improve physical aspects of HRQoL in patients with diabetes and shoulder problems. Specific physiotherapy intervention may also improve range of motion in the shoulder joint in patients with diabetes and shoulder problems.