Jaap Buurke

The Effectiveness of the Bobath Concept in Stroke Rehabilitation: What is the Evidence?

Background and Purpose— In the Western world, the Bobath Concept or neurodevelopmental treatment is the most popular treatment approach used in stroke rehabilitation, yet the superiority of the Bobath Concept as the optimal type of treatment has not been established. This systematic review of randomized, controlled trials aimed to evaluate the available evidence for the effectiveness of the Bobath Concept in stroke rehabilitation. Method— A systematic literature search was conducted in the bibliographic databases MEDLINE and CENTRAL (March 2008) and by screening the references of selected publications (including reviews). Studies in which the effects of the Bobath Concept were investigated were classified into the following domains: sensorimotor control of upper and lower limb; sitting and standing, balance control, and dexterity; mobility; activities of daily living; health-related quality of life; and cost-effectiveness. Due to methodological heterogeneity within the selected studies, statistical pooling was not considered. Two independent researchers rated all retrieved literature according to the Physiotherapy Evidence Database (PEDro) scale from which a best evidence synthesis was derived to determine the strength of the evidence for both effectiveness of the Bobath Concept and for its superiority over other approaches. Results— The search strategy initially identified 2263 studies. After selection based on predetermined criteria, finally, 16 studies involving 813 patients with stroke were included for further analysis. There was no evidence of superiority of Bobath on sensorimotor control of upper and lower limb, dexterity, mobility, activities of daily living, health-related quality of life, and cost-effectiveness. Only limited evidence was found for balance control in favor of Bobath. Because of the limited evidence available, no best evidence synthesis was applied for the health-related quality-of-life domain and cost-effectiveness. Conclusions— This systematic review confirms that overall the Bobath Concept is not superior to other approaches. Based on best evidence synthesis, no evidence is available for the superiority of any approach. This review has highlighted many methodological shortcomings in the studies reviewed; further high-quality trials need to be published. Evidence-based guidelines rather than therapist preference should serve as a framework from which therapists should derive the most effective treatment.

Objective Evaluation of the Quality of Movement in Daily Life after Stroke

Background Stroke survivors are commonly left with disabilities that impair activities of daily living. The main objective of their rehabilitation program is to maximize the functional performance at home. However, the actual performance of patients in their home environment is unknown. Therefore, objective evaluation of daily life activities of stroke survivors in their physical interaction with the environment is essential for optimal guidance of rehabilitation therapy. Monitoring daily life movements could be very challenging, as it may result in large amounts of data, without any context. Therefore, suitable metrics are necessary to quantify relevant aspects of movement performance during daily life. The objective of this study is to develop data processing methods, which can be used to process movement data into relevant metrics for the evaluation of intra-patient differences in quality of movements in a daily life setting. Methods Based on an iterative requirement process, functional and technical requirements were formulated. These were prioritized resulting in a coherent set of metrics. An activity monitor was developed to give context to captured movement data at home. Finally, the metrics will be demonstrated in two stroke participants during and after their rehabilitation phases. Results By using the final set of metrics, quality of movement can be evaluated in a daily life setting. As example to demonstrate potential of presented methods, data of two stroke patients were successfully analyzed. Differences between in-clinic measurements and measurements during daily life are observed by applying the presented metrics and visualization methods. Heel height profiles show intra-patient differences in height, distance, stride profile, and variability between strides during a 10-m walk test in the clinic and walking at home. Differences in distance and stride profile between both feet were larger at home, than in clinic. For the upper extremities, the participant was able to reach further away from the pelvis and cover a larger area. Discussion Presented methods can be used for the objective evaluation of intra-patient differences in movement quality between in-clinic and daily life measurements. Any observed progression or deterioration of movement quality could be used to decide on continuing, stopping, or adjusting rehabilitation programs.

The effect of an ankle-foot orthosis on walking ability in chronic stroke patients: a randomized controlled trial

Objective: Regaining walking ability is a major goal during the rehabilitation of stroke patients. To support this process an ankle-foot orthosis (AFO) is often prescribed. The aim of this study is to investigate the effect of an AFO on walking ability in chronic stroke patients. Design: Cross-over design with randomization for the interventions. Methods: Twenty chronic stroke patients, wearing an AFO for at least six months, were included. Walking ability was operationalized as comfortable walking speed, scores on the timed up and go (TUG) test and stairs test. Patients were measured with and without their AFO, the sequence of which was randomized. Additionally, subjective impressions of self-confidence and difficulty of the tasks were scored. Clinically relevant differences based on literature were defined for walking speed (20 cm/s), the TUG test (10 s). Gathered data were statistically analysed using a paired t-test. Results: The mean difference in favour of the AFO in walking speed was 4.8 cm/s (95% CI 0.85–8.7), in the TUG test 3.6 s (95% CI 2.4 4.8) and in the stairs test 8.6 s (95% CI 3.1 –14.1). Sixty-five per cent of the patients experienced less difficulty and 70% of the patients felt more self-confident while wearing the AFO. Conclusions: The effect of an AFO on walking ability is statistically significant, but compared with the a priori defined differences it is too small to be clinically relevant. The effect on self-confidence suggests that other factors might play an important role in the motivation to use an AFO.

Training modalities in robot-mediated upper limb rehabilitation in stroke: a framework for classification based on a systematic review

Robot-mediated post-stroke therapy for the upper-extremity dates back to the 1990s. Since then, a number of robotic devices have become commercially available. There is clear evidence that robotic interventions improve upper limb motor scores and strength, but these improvements are often not transferred to performance of activities of daily living. We wish to better understand why. Our systematic review of 74 papers focuses on the targeted stage of recovery, the part of the limb trained, the different modalities used, and the effectiveness of each. The review shows that most of the studies so far focus on training of the proximal arm for chronic stroke patients. About the training modalities, studies typically refer to active, active-assisted and passive interaction. Robot-therapy in active assisted mode was associated with consistent improvements in arm function. More specifically, the use of HRI features stressing active contribution by the patient, such as EMG-modulated forces or a pushing force in combination with spring-damper guidance, may be beneficial.Our work also highlights that current literature frequently lacks information regarding the mechanism about the physical human-robot interaction (HRI). It is often unclear how the different modalities are implemented by different research groups (using different robots and platforms). In order to have a better and more reliable evidence of usefulness for these technologies, it is recommended that the HRI is better described and documented so that work of various teams can be considered in the same group and categories, allowing to infer for more suitable approaches. We propose a framework for categorisation of HRI modalities and features that will allow comparing their therapeutic benefits.

Ambulatory Estimation of Center of Mass Displacement During Walking

The center of mass (CoM) and the center of pressure (CoP) are two variables that are crucial in assessing energy expenditure and stability of human walking. The purpose of this study is to estimate the CoM displacement continuously using an ambulatory measurement system. The measurement system consists of instrumented shoes with 6 DOF force/moment sensors beneath the heels and the fore-feet. Moreover, two inertial sensors are rigidly attached to the force/moment sensors for the estimation of position and orientation. The estimation of CoM displacement is achieved by fusing low-pass filtered CoP data with high-pass filtered double integrated CoM acceleration, both estimated using the instrumented shoes. Optimal cutoff frequencies for the low-pass and high-pass filters appeared to be 0.2 Hz for the horizontal direction and 0.5 Hz for the vertical direction. The CoM estimation using this ambulatory measurement system was compared to CoM estimation using an optical reference system based on the segmental kinematics method. The rms difference of each component of the CoM displacement averaged over a hundred trials obtained from seven stroke patients was (0.020 plusmn 0.007) m (mean plusmn standard deviation) for the forward x-direction, (0.013 plusmn 0.005) m for the lateral y-direction, and (0.007 plusmn 0.001) m for the upward z-direction. Based on the results presented in this study, it is concluded that the instrumented shoe concept allows accurate and continuous estimation of CoM displacement under ambulatory conditions.

Electromyography in the biomechanical analysis of human movement and its clinical application.

This article introduces the area of scientific study of human movement. It is primarily intended for readers who wish to form a judgement on the usefulness of scientific movement analysis techniques in the treatment process of patients with abnormal movement patterns. With a focus on the analysis of human locomotion, the paper outlines the historical development of a biomechanical approach towards the understanding of human movement patterns. This approach alone proves to be inadequate in supplying reliable information on neuromuscular control of movement. It follows that electromyographic techniques are essential for this purpose. Scientific literature reveals relevant practical usability of such information. This is the rationale for a review of the historical, physiological, technical and methodological background of electromyographic analysis of movement. The field of management and rehabilitation of motor disability is identified as one important application area. On the basis of relevant literature, the present paper asserts that scientific analysis of human movement patterns can materially affect patient treatment. It provides evidence that patient management and rehabilitation processes in central neurological disorders can be improved through electromyographic techniques. In particular, this evidence supports the use of electromyography for surgical planning in children with cerebral palsy. The paper concludes with a view on future directions in research, development and applications of scientific analysis of human movement. Copyright 1998 Elsevier Science B.V.

The Effects on Kinematics and Muscle Activity of Walking in a Robotic Gait Trainer During Zero-Force Control

“Assist as needed” control algorithms promote activity of patients during robotic gait training. Implementing these requires a free walking mode of a device, as unassisted motions should not be hindered. The goal of this study was to assess the normality of walking in the free walking mode of the LOPES gait trainer, an 8 degrees-of-freedom lightweight impedance controlled exoskeleton. Kinematics, gait parameters and muscle activity of walking in a free walking mode in the device were compared with those of walking freely on a treadmill. Average values and variability of the spatio-temporal gait variables showed no or small (relative to cycle-to-cycle variability) changes and the kinematics showed a significant and relevant decrease in knee angle range only. Muscles involved in push off showed a small decrease, whereas muscles involved in acceleration and deceleration of the swing leg showed an increase of their activity. Timing of the activity was mainly unaffected. Most of the observed differences could be ascribed to the inertia of the exoskeleton. Overall, walking with the LOPES resembled free walking, although this required several adaptations in muscle activity. These adaptations are such that we expect that Assist as Needed training can be implemented in LOPES.

Recovery of Gait After Stroke: What Changes?

Background. Little is known about whether changes in coordination patterns of muscle activation after stroke are related to functional recovery of walking. Objective . The present study investigated the longitudinal relationship between changes in neuromuscular activation patterns of paretic muscles in hemiplegic gait and improvement in walking ability after stroke. Methods. Thirteen patients diagnosed with a first unilateral ischemic stroke had their recovery of walking measured by the Rivermead Mobility Index, Functional Ambulation Categories, Barthel Index, Trunk Control Test, Motricity Index, and comfortable walking speed. Surface electromyography (SEMG) of the erector spinae, gluteus maximus, gluteus medius, rectus femoris, vastus lateralis, semitendinosus, gastrocnemius, and tibialis anterior muscles of both legs was used to quantify coordination patterns in comfortable walking mode. All clinical and electromyography-related measurements were taken at 3, 6, 9, 12, and 24 weeks poststroke. Timing parameters of the SEMG patterns were calculated, using an objective burst detection algorithm, and analyzed with the measures of functional recovery. Results . All functional measures, except Trunk Control Test, showed statistically significant improvement over time, whereas SEMG patterns did not change significantly over time. Conclusion. The lack of significant change in SEMG patterns over time suggests that functional gait improvements may be more related to compensatory strategies in muscle activation of the unaffected leg and biomechanical changes than by restitution of muscle coordination patterns in the affected leg.

Disentangling the contribution of the paretic and non-paretic ankle to balance control in stroke patients

During stroke recovery, restoration of the paretic ankle and compensation in the non-paretic ankle may contribute to improved balance maintenance. We examine a new approach to disentangle these recovery mechanisms by objectively quantifying the contribution of each ankle to balance maintenance. Eight chronic hemiparetic patients were included. Balance responses were elicited by continuous random platform movements. We measured body sway and ground reaction forces below each foot to calculate corrective ankle torques in each leg. These measurements yielded the Frequency Response Function (FRF) of the stabilizing mechanisms, which expresses the amount and timing of the generated corrective torque in response to sway at the specified frequencies. The FRFs were used to calculate the relative contribution of the paretic and non-paretic ankle to the total amount of generated corrective torque to correct sway. All patients showed a clear asymmetry in the balance contribution in favor of the non-paretic ankle. Paretic balance contribution was significantly smaller than the contribution of the paretic leg to weight bearing, and did not show a clear relation with the contribution to weight bearing. In contrast, a group of healthy subjects instructed to distribute their weight asymmetrically showed a one-on-one relation between the contribution to weight bearing and to balance. We conclude that the presented approach objectively quantifies the contribution of each ankle to balance maintenance. Application of this method in longitudinal surveys of balance rehabilitation makes it possible to disentangle the different recovery mechanisms. Such insights will be critical for the development and evaluation of rehabilitation strategies.

Ankle-foot orthoses in stroke: Effects on functional balance, weight-bearing asymmetry and the contribution of each lower limb to balance control

BACKGROUND Ankle-foot orthoses are often provided to improve walking in stroke patients, although the evidence of effects on walking and balance control is still inconsistent. This could be caused by a lack of insight into the influence of orthoses on the underlying impairments. These impairments can be assessed with dual plate posturography to determine the relative contribution of each lower limb to balance control and weight-bearing. This study examined the effects of ankle-foot orthoses on functional balance, static and dynamic weight-bearing asymmetry and dynamic balance control of the paretic and non-paretic lower limbs. METHODS Twenty stroke subjects (time since stroke 5-127 months) completed the study. Subjects were assessed with and without ankle-foot orthosis. Functional balance was assessed using the Berg Balance Scale, Timed Up & Go test, Timed Balance Test, 10-m walking test and Functional Ambulation Categories. Weight-bearing asymmetry and dynamic balance control were assessed with force plates on a movable platform. FINDINGS No significant effects of ankle-foot orthoses were found for weight-bearing asymmetry and dynamic balance control, but significant differences in favour of ankle-foot orthosis use were found for most functional tests. INTERPRETATION Although ankle-foot orthoses had no effect on weight-bearing asymmetry or dynamic balance contribution of the paretic lower limb, functional tests were performed significantly better with orthoses. Apparently, improvements at functional level cannot be readily attributed to a greater contribution of the paretic lower limb to weight-bearing or balance control. This finding suggests that ankle-foot orthoses influence compensatory mechanisms.