Mt Jahnke

Treadmill Training With Partial Body Weight Support Compared With Physiotherapy in Nonambulatory Hemiparetic Patients

BACKGROUND AND PURPOSE Treadmill training with partial body weight support is a new and promising therapy in gait rehabilitation of stroke patients. The study intended to investigate its efficiency compared with gait training within regular physiotherapy in nonambulatory patients with chronic hemiparesis. METHODS An A-B-A single-case study design compared treadmill training plus partial body weight support (A) with physiotherapy based on the Bobath concept (B) in seven nonambulatory hemiparetic patients. The minimum poststroke interval was 3 months, and each treatment phase lasted 3 weeks. Variables were gait ability assessed by the Functional Ambulation Category, other motor functions tested by the Rivermead Motor Assessment, muscle strength assessed by the Motricity Index, muscle tone rated by the Modified Ashworth Spasticity Scale, and gait cycle parameters. RESULTS Treadmill training was more effective with regard to restoration of gait ability (P < .05) and walking velocity (P < .05). Other motor functions improved steadily during the study. Muscle strength did not change, and muscle tone varied in an unsystematic way. The ratio of cadence to stride length did not alter significantly. CONCLUSIONS Treadmill training offers the advantages of task-oriented training with numerous repetitions of a supervised gait pattern. It proved powerful in gait restoration of nonambulatory patients with chronic hemiparesis. Treadmill training could therefore become an adjunctive tool to regain walking ability in a shorter period of time.

Botulinum toxin type A and short-term electrical stimulation in the treatment of upper limb flexor spasticity after stroke: a randomized, double-blind, placebo-controlled trial

Objective: To investigate whether the combined approach of botulinum toxin type A (BtxA) and electrical stimulation was more effective than the toxin alone in the treatment of chronic upper limb spasticity after stroke. Design: Randomized, placebo-controlled study with four treatment groups: 1000 units BtxA (Dysport®) + electrical stimulation (A), 1000 units BtxA (B), placebo + electrical stimulation (C) and placebo (D). Setting: A neurological rehabilitation clinic. Subjects: Twenty-four stroke patients with chronic upper limb spasticity after stroke, six patients in each treatment group. Interventions: Intramuscular injection of either toxin or placebo into six upper limb flexor muscles. In group A and C additional electrical stimulation of the injected muscles with surface electrodes, three times half an hour each day for three days. Main outcome measures: Muscle tone rated with the modified Ashworth score, limb position at rest and difficulties encountered during three upper limb motor tasks assessed before and 2, 6 and 12 weeks after injection. Results: Most improvements were observed in patients of group A. Cleaning the palm (p = 0.004) differed across groups. Pairwise comparison for this target variable showed that group A differed from group B and D (p <0.01), but not from C. Indicative across-group differences were obtained for elbow spasticity reduction (p = 0.011), and improvement of putting the arm through a sleeve (p = 0.020). Conclusions: The placebo-controlled trial favours the conceptthat electrical stimulation enhances the effectiveness of BtxA in the treatment of chronic upper limb flexor spasticity after stroke.

Ankle Muscle Activity Before and After Botulinum Toxin Therapy for Lower Limb Extensor Spasticity in Chronic Hemiparetic Patients

BACKGROUND AND PURPOSE Recent studies have been made of the novel treatment of lower limb spasticity after stroke with botulinum toxin A, and the results were based mostly on the clinical assessment made before and after treatment. This study investigated the effects of toxin on ankle muscle activity during gait in patients with severe extensor spasticity. The questions posed were whether the toxin particularly diminishes the so-called premature muscle activity as a major cause of equinovarus deformity and whether different types of altered motor control allow a prediction of the outcome of the treatment. METHODS In 12 chronic hemiparetic outpatients with pronounced lower limb spasticity, we injected 400 U botulinum toxin A into the soleus and tibialis posterior muscles and both heads of the gastrocnemius muscles. Ankle spasticity and complex gait analysis including kinematic electromyography (EMG) of the soleus and tibialis muscles were assessed before treatment and 4 weeks after the injection. RESULTS Nine patients profited with a reduction of spasticity, improved gait ability, and a more normal temporal pattern of muscle activity with a prominent reduction of the premature activity of the plantar flexors. Eight patients exhibited a qualitative pattern (type I) corresponding to an increased stretch-reflex excitability. Three patients did not profit; their muscle tone, gait ability, and muscle activation remained stable or even deteriorated. CONCLUSIONS This study further supports the beneficial effects of botulinum toxin in the treatment of lower limb extensor spasticity. A correlation was observed between the clinical reduction of muscle tone, functional gait parameters, and a more normal EMG pattern with a predominant reduction of the premature activity of the plantar flexors. The qualitative type of EMG pattern corresponding to an increased stretch-reflex excitability (type I) was a positive predictor for the outcome.

Short-term electrical stimulation enhances the effectiveness of Botulinum toxin in the treatment of lower limb spasticity in hemiparetic patients ☆

The study tested the spasmolytic effect of Botulinum toxin A in two groups of hemiparetic patients with lower limb spasticity: in the first group (n = 5) 2000 U Dysport were injected into the soleus, tibialis posterior and both heads of gastrocnemius muscles alone; the second (n = 5) received additional repetitive alternating electrical stimulation of M. tibialis anterior and plantar flexors for 30 min six times per day during the 3 days following the injection. Muscle tone, rated by the Ashworth spasticity score, and gait analysis including recording of vertical ground reaction forces, were assessed before and 4 weeks after injection. The combined treatment proved to be more effective with respect to the clinically assessed reduction of muscle tone, gait velocity, stride length, stance- and swing-symmetry (P < 0.05). The result is discussed with reference to animal experiments demonstrating enhanced toxin uptake and accelerated onset of its paralytic effect by electrical stimulation.

Gait outcome in ambulatory hemiparetic patients after a 4-week comprehensive rehabilitation program and prognostic factors.

Although gait training is prominent in the rehabilitation of hemiparetic stroke patients, little is known about its outcome and prognostic factors in mildly affected patients. We therefore intended to assess gait in ambulatory stroke patients before and after a 4-week inpatient rehabilitation program based on the neurodevelopmental technique. Methods We measured vertical ground reaction forces by force plates in 148 stroke patients. Variables were stance durations, peak vertical ground reaction forces at heel strike (Fzl) and toe-off (Fz2), loading and deloading rates, time to Fzl, and time to Fz2. The absolute changes for both legs and symmetry outcome were calculated. In addition, we assessed maximal walking speed, walking endurance, stair climbing ability, and the Motricity Index. Results Stance duration, weight acceptance, push-off of both legs, and the stance duration symmetry improved independent of changes of gait velocity. The symmetry of the ground reaction forces did not improve. Results were even worse for Fzl and the loading rate at the end of treatment. Sex, age, side of hemiparesis, motor strength, stroke interval, and sensory impairment had no influence on the outcome of symmetry. Functional performance did not improve considerably. Conclusions The absolute changes of the ground reaction forces indicated better weight acceptance and push-off of both legs and thus confirmed the efficacy of the neurodevelopmental technique. The symmetry outcome and the functional performance at the end of treatment, however, challenge the efficacy of intensive rehabilitation therapy for 4 weeks in its attempts to restore physiological gait in these mildly affected patients.

Asymmetry of gait initiation in hemiparetic stroke subjects

OBJECTIVE To investigate symmetry of gait initiation in healthy and hemiparetic subjects. DESIGN Survey. SETTING Kinematic laboratory affiliated with a hospital-based department of rehabilitation. PATIENTS OR OTHER PARTICIPANTS Ten healthy and 14 hemiparetic stroke subjects starting five times with their right and left leg, respectively. MAIN OUTCOME MEASURES Duration of defined periods, step length, center of pressure, and center of mass were recorded and calculated using two triaxial force plates, contact switches, and a video camera system. RESULTS Healthy subjects displayed a high degree of independence of kinetic and kinematic parameters of the starting limb. Hemiparetic patients showed differences with respect to the starting limb: when starting with the nonaffected leg, the swing period and step length was shorter and the center of pressure displayed a more marked medio-lateral sway with no corresponding initial movement of the center of mass; when starting with the affected leg the movement pattern of the center of pressure and center of mass was comparable to that of normal subjects. CONCLUSIONS The trajectories of the center of pressure and center of mass and the symmetry parameters are in accordance with a higher degree of uncertainty when starting with the non-affected limb in hemiparetic subjects.

Immediate effects of therapeutic facilitation on the gait of hemiparetic patients as compared with walking with and without a cane

OBJECTIVES Although the neurodevelopmental technique (Bobath) is the most widely used approach in the gait rehabilitation of hemiparetic subjects in Europe, there is little neurophysiological evidence for its presumed effects on gait symmetry and facilitation of paretic muscles during the therapeutic intervention. The study, therefore, investigated the immediate effects of gait entrainment by a physical therapist on the gait of hemiparetic subjects. METHODS Cycle parameters, gait symmetry, hip joint movement and the electromyographic activity of several lower limb muscles were assessed in 22 patients during a classic intervention by five Bobath therapists and while walking with and without a cane. RESULTS Multivariate statistics revealed that, while being assisted by the therapist, patients walked faster (P = 0.022), with a longer relative stance period of the affected leg (P = 0.005), a higher symmetry (P = 0.002), larger hip extension (P = 0.001) and more activation (P = 0.026) of the Mm. triceps surae, vastus lateralis, biceps femoris and gluteus medius as compared to walking with and without a cane. Extensor spasticity of the plantar-flexor tended to increase (n.s.). In five subjects, no after-effect could be documented 1 h after a gait training of 30 min. CONCLUSIONS The study confirmed a more balanced walking pattern in conjunction with facilitation of various weight bearing muscles during the therapeutic intervention. A prolonged single stance period of the affected leg, an unobstructed hip movement, enhanced weight acceptance and a faster gait seemed to be responsible for the observed immediate effects of the therapeutic intervention.

Gait symmetry and functional walking performance in hemiparetic patients prior to and after a 4-week rehabilitation programme

Abstract Gait symmetry was examined in 40 hemiparetic stroke patients before and after a 4-week inpatient rehabilitation programme based on the neurodevelopmental technique (NDT) according to Bobath. Vertical ground reaction forces were measured with force plates, and symmetry ratios (affected versus non-affected leg) were calculated for peak vertical ground reaction forces at heel strike (Fz1) and toe-off (Fz2), loading and deloading rates and time to peak Fz1 (t1) and Fz2 (t2) in relation to the duration of the stance phase. In addition to these measurements conventional gait assessment was performed (maximal walking speed, endurance, stair climbing), and the motricity index was assessed prior and after the in-patient therapy programme. Although the training of gait symmetry functions is an integral part of the Bobath technique, there was no significant improvement in the gait symmetry parameters after 4-weeks training, with an amount of training sessions typical for rehabilitation hospitals in Germany and other countries. Endurance was also not increased, whereas other functional gait parameters (maximal speed, stair climbing velocity) and the motricity index showed significant improvement. The implications of these results for physiotherapy are discussed.

Standing-up in healthy subjects: symmetry of weight distribution and lateral displacement of the centre of mass as related to limb dominance

Abstract Weight symmetry and avoidance of lateral displacement of the centre of mass during standing-up are prominent in rehabilitation of disabled persons. This study therefore investigated both variables in individual healthy subjects. They showed a distinct across-subject variability. Some subjects systematically preferred one limb or side unexplainable by limb dominance. Speed of ascent did not influence weight distribution, drift of centre of mass and relative occurrence of seat-off. Normative baselines of ‘normal’ individuals should be used cautiously for therapy planning. The probable existence of an individual motor strategy of standing-up suggests a treatment method tailored for individual subjects rather than trying to achieve perfect symmetry by all means.

Dependences of ground reaction force parameters on habitual walking speed in hemiparetic subjects

Abstract Dependences of vertical and horizontal ground reaction force parameters on habitual walking speed were studied in samples of 144 and 23 hemiparetic stroke patients admitted to our rehabilitation unit. Statistical correlations across subjects were not significant for the normalized vertical force peaks and for the maximum of the mediolateral shear force. Correlations between the vertical loading and deloading rates, as well as the anteriorposterior braking and propulsive force peaks, and translational impulse were substantial and significant across subjects, with degrees of predictability between 46 and 83% for the dependent variables on the basis of speed × body mass. After a 4-week period of comprehensive rehabilitation according to the Bobath concept (neurodevelopmental technique), changes in symmetry parameters were, for all practical concerns, uncorrelated to changes in spontaneous walking speed. It is concluded that measurement of gait symmetry may provide additional, unredundant information about therapeutic effects that cannot be gained by measurement of walking speed alone. It remains a conceptual problem whether parameters of symmetry or the functional change in walking speed should be regarded as more important for the assessment of improvement or deterioration.