Noel Rao

Task-specific modulation of anticipatory postural adjustments in individuals with hemiparesis

OBJECTIVES To study adaptation of anticipatory postural adjustments (APAs) in paretic and non-paretic muscles of individuals with hemiparesis to changes in the direction of the self-initiated perturbation and additional manual support. METHODS Electrical activity of leg and trunk muscles on both sides of the body and ground reaction forces were recorded in 10 patients with hemiparesis and a group of matched control subjects. Subjects released a standard load, held in the hand of the extended relatively unimpaired arm. The load was released either in front of the body or to the side, with or without the impaired arm touching an external stable surface. RESULTS APAs were reduced in individuals with hemiparesis, especially on the paretic side. In paretic muscles, the modulation of APAs with the direction of the perturbation was decreased or showed atypical patterns. Also the effects of touch were decreased in patients. Center of pressure displacements shortly after load release were similar in control subjects and patients. CONCLUSIONS The results suggest that the ability of individuals with hemiparesis to prepare for a self-initiated predictable perturbation is reduced and that they may use alternative strategies of postural stabilization.

Pregait balance rehabilitation in acute stroke patients

Rehabilitation interventions designed to enhance balance control in individuals with acute stroke are quite limited. The goal was to develop and assess a technique of early pregait balance training involving the use of a combination of force platform visual feedback and the unweighting system in individuals with recent stroke. A total of 28 individuals with acute stroke were randomly divided into the experimental and control groups: individuals included in the experimental group received 1 week of treatment on the basis of retraining balance utilizing visual biofeedback (Balance Master) while provided with a body weight support harness system, whereas the individuals in the control group received conventional treatment. Both the groups undertook identical tests (Fugl-Meyer Balance test, Functional Independence Measure test for gait, and Fugl-Meyer lower extremity assessment) before the start of treatment and after its completion. Individuals in the experimental group showed larger gains as seen in the increased scores of the Fugl-Meyer Balance test and the Functional Independence Measure test for gait as compared with the control group. The outcome of the study provides a basis for future investigations of the applicability of the intervention in early balance rehabilitation of individuals with neurological disorders. Interventionen in der Rehabilitation zur Verbesserung der Gleichgewichtskontrolle von Personen nach akutem Schlaganfall sind beschränkt. Das Ziel der vorliegenden Studie war die Konzipierung und Evaluierung einer Technik für das frühzeitige gangvorbereitende Gleichgewichtstraining mit der Verwendung einer Kombination aus Kraftmessdruckplatten, visuellem Feedback und der Gewichtsentlastung bei Personen nach kürzlich erfolgtem Schlaganfall. Insgesamt 28 Personen nach akutem Schlaganfall wurden randomisiert Versuchs- und Kontrollgruppen zugeordnet: Die Personen in der Versuchsgruppe wurden eine Woche lang auf der Basis des Gleichgewichts-Neutrainings mittels visuellem Biofeedback (Balance Master) mit einem Körpergewicht-Stützgurt behandelt, die Personen in der Kontrollgruppe dagegen mittels einer konventionellen Therapie. Beide Gruppen wurden vor Therapiebeginn und danach identischen Tests unterzogen (Fugl-Meyer Gleichgewichtstest, funktionaler Selbständigkeitsindex-Test für den Gang und Fugl-Meyer-Test der unteren Extremität). Die Personen in der Versuchsgruppe wiesen im Vergleich zur Kontrollgruppe größere Nutzen auf, wie die erhöhten Scores des Fugl-Meyer Gleichgewichtstests und der funktionale Selbständigkeitsindex-Test für den Gang zeigten. Das Ergebnis der Studie liefert eine Grundlage für weitere Untersuchungen der Anwendbarkeit der Interventionen bei der frühen Rehabilitation des Gleichgewichts von Personen mit neurologischen Störungen. Las intervenciones de rehabilitación diseñadas para mejorar el control del equilibrio en individuos con accidente cerebrovascular agudo son bastante limitadas. El objetivo de este estudio fue desarrollar y evaluar una técnica de entrenamiento temprano del equilibrio pre-marcha, mediante la combinación del feedback visual de una plataforma de fuerza y un sistema de descarga de peso en individuos con accidente cerebrovascular reciente. Se dividió de forma aleatoria entre el grupo experimental y el grupo control a un total de 28 individuos con accidente cerebrovascular agudo: los sujetos incluidos en el grupo experimental recibieron una semana de tratamiento mediante reentrenamiento del equilibrio a partir de biofeedback visual (Balance Master) y el uso de un sistema de arneses de sujeción del peso corporal, mientras que los sujetos del grupo control recibieron un tratamiento convencional. Ambos grupos fueron sometidos a pruebas similares (el test de equilibrio de Fugl-Meyer, el test de medida de independencia funcional de la marcha y la evaluación de las extremidades inferiores de Fugl-Meyer) antes de comenzar el tratamiento y tras finalizarlo. Los individuos del grupo experimental presentaron un mayor grado de mejora, tal y como muestra el incremento de las puntuaciones del test de equilibrio de Fugl-Meyer y el test de medida de independencia funcional de la marcha, en comparación con el grupo control. El resultado del estudio ofrece una base para futuras investigaciones sobre la aplicabilidad de la rehabilitación temprana del equilibrio en individuos con trastornos neurológicos. Les interventions de rééducation visant à améliorer le contrôle de l’équilibre chez les personnes ayant subi un AVC aigu sont très limitées. L’objectif était de développer et d’évaluer une technique d’entraînement à l’équilibre avant-marche impliquant l’utilisation d’une combinaison de rétroaction visuelle d’une plate-forme de force et du système d’allègement chez les personnes ayant subi un AVC récent. 28 personnes ayant subi un AVC aigu ont été réparties de façon aléatoire dans des groupes expérimentaux et témoins: les participants du groupe expérimental ont reçu 1 semaine de traitement reposant sur la rééducation de l’équilibre au moyen de la bio-rétroaction visuelle (Balance Master), combinée avec le port d’un harnais de support de poids corporel , tandis que les sujets du groupe témoin ont reçu un traitement conventionnel. Les deux groupes ont effectué des tests identiques (test d’équilibre de Fugl-Meyer, mesure d’indépendance fonctionnelle de la marche et évaluation des extrémités inférieures de Fugl-Meyer) avant le début du traitement et après son achèvement. Les sujets du groupe expérimental ont présenté des gains plus importants que les groupe témoin, comme en témoignent leurs scores accrus au test d’équilibre de Fugl-Meyer et au test de mesure de l’indépendance fonctionnelle pour la marche. Les résultats de l’étude fournissent une base pour de futures études de l’applicabilité d’une intervention précoce de rééducation de l’équilibre chez les personnes souffrant de troubles neurologiques.

The Effect of Ankle-Foot Orthoses on Balance Impairment: Single-Case Study.

Instability and balance impairment is common in patients with diabetic sensory neuropathy placing them at a higher risk of falling when performing more challenging daily tasks. The report describes the results of a dynamic balance tests of a subject with neuropathy due to the long-standing diabetes. The Computerized Dynamic Posturography was performed with and without ankle-foot orthoses (AFOs). The apparatus provided six test conditions designed to systematically manipulate vestibular, somatosensory, or visual information. With no orthoses the patient had falls performing most of the tests. Bilateral orthoses improved his balance: a derived composite balance score increased four times. In view of these findings, AFOs, in addition to correcting the patients foot placement during locomotion, could also be expected to improve the maintenance of balance during quiet stance or dynamic perturbation.

The Effects of Two Different Ankle-Foot Orthoses on Gait of Patients with Acute Hemiparetic Cerebrovascular Accident

Objective. To compare the effects of two types of ankle-foot orthoses on gait of patients with cerebrovascular accident (CVA) and to evaluate their preference in using each AFO type. Design. Thirty individuals with acute hemiparetic CVA were tested without an AFO, with an off-the-shelf carbon AFO (C-AFO), and with a custom plastic AFO (P-AFO) in random order at the time of initial orthotic fitting. Gait velocity, cadence, stride length, and step length were collected using an electronic walkway and the subjects were surveyed about their perceptions of each device. Results. Subjects walked significantly faster, with a higher cadence, longer stride, and step lengths, when using either the P-AFO or the C-AFO as compared to no AFO (P < 0.05). No significant difference was observed between gait parameters of the two AFOs. However, the subjects demonstrated a statistically significant preference of using P-AFO in relation to their balance, confidence, and sense of safety during ambulation (P < 0.05). Moreover, if they had a choice, 50.87 ± 14.7% of the participants preferred the P-AFO and 23.56 ± 9.70% preferred the C-AFO. Conclusions. AFO use significantly improved gait in patients with acute CVA. The majority of users preferred the P-AFO over the Cf-AFO especially when asked about balance and sense of safety.

A textured insole improves gait symmetry in individuals with stroke

Abstract Purpose: Gait asymmetry is a common consequence of stroke and improving gait symmetry is an important goal of rehabilitation. We investigated the effect of a single textured insole in improving gait symmetry in individuals with stroke. Method: Seventeen individuals with stroke who had asymmetrical gait were recruited and required to walk with a textured insole positioned in the shoe on the unaffected side or without the insole. Gait parameters were evaluated using the instrumented walkway. Gait velocity, cadence, and symmetry indices for the spatial and temporal parameters of gait and center of pressure displacements were obtained. Results: When walking with a textured insole, symmetry indexes for stance, single support phases of gait, as well as center of pressure displacements improved significantly. While using a textured insole, the duration of the stance phase and a single support phase decreased on the unaffected side and increased on the affected side significantly. Gait velocity and cadence were not affected by the use of the insole. Conclusions: Individuals with stroke walking with a textured insole placed in the shoe on the unaffected side improved the symmetry of their gait. The outcome provides a foundation for future investigations of the efficacy of using a single textured insole in gait rehabilitation of individuals with unilateral impairment. Implications for Rehabilitation A single textured insole positioned in the shoe on the unaffected side improved gait symmetry in individuals with stroke. Gait velocity and cadence were not affected by the use of the insole.

Ankle-Foot Orthoses: Proprioceptive Inputs and Balance Implications.

Individuals with a loss of sensation in the lower limbs frequently experience postural instability, altered gait patterns, and an increased risk of falling culminating in a decreased quality of life. Previous studies have documented that using ankle-foot orthoses (AFOs) help such individuals to maintain their balance. This study was conducted to investigate whether somatosensory cues delivered to the intact tissues of the lower limbs above the ankle joints enhance the control of posture in individuals with peripheral neuropathy. The study involved 12 individuals with sensory neuropathy because of diabetes who participated in static and dynamic balance tests with and without specially designed AFOs that provided auxiliary sensory cues to the lower limbs without stabilizing the ankle joints. During the tests, the subjects were required to alternately stand on a fixed and moving platform with their eyes alternately open or closed. Equilibrium scores and response latencies were obtained. The results showed that equilibrium scores were significantly higher in experiments with the specially modified AFOs compared with conditions without AFOs. Smaller latency scores were recorded in conditions with AFOs as well. The outcome indicates that AFOs that substitute for the lack of proprioceptive feedback may improve automatic postural responses in individuals with diabetic peripheral neuropathy. It also highlights the need for further research focused on the design of assistive means that could improve the balance and the performance of activities of daily living in individuals with proprioceptive deficits.

Role of ankle foot orthoses in functional stability of individuals with stroke

Abstract Purpose: Ankle foot orthoses (AFOs) are frequently prescribed to improve ambulation in individuals with stroke. However, the role of AFOs in balance control is not completely understood. The aim of the study was to evaluate the contribution of the AFOs in functional stability of individuals with stroke. Methods: Twenty three individuals with unilateral hemiparesis due to stroke were assessed using the Functional Reach Test. The subjects performed reaches forward, left and right while standing with or without an AFO. Results: When provided with AFO, individuals with stroke improved the maximal reaching distance in all the directions (p < 0.05). Conclusions: The study found that individuals with unilateral stroke clearly demonstrated improvements in functional stability when they were provided with AFOs. This outcome could be used in the optimization of balance rehabilitation of individuals with stroke. Implications for Rehabilitation Functional stability is impaired in individuals with stroke. Functional Reach Test (FRT) was used to assess the role of ankle foot orthoses (AFOs) in balance control. Individuals with stroke improved their functional stability while they were provided with AFOs. Functional Reach Test could assist clinicians in the evaluation of postural stability associated with the use of AFOs.

Poster 13: Early surgery for heterotopic ossification in traumatic brain injury with 10-year follow-up: a report of 2 cases1

Abstract Setting: Freestanding rehabilitation hospital. Patients: A 54-year-old man and a 48-year-old woman. Case Description: We studied the cases of 2 patients who were admitted in 1987 (patient A) and 1990 (patient B) to our institution for traumatic brain injury rehabilitation. Both patients had heterotopic ossification (HO) of the hip. Patient B could achieve a maximum hip flexion of 20° to 30° before surgery with intensive physical therapy (PT) during inpatient rehabilitation. Patient As right hip range of motion (ROM) was 65° of flexion during inpatient rehabilitation. Over next 6 to 8 months, during outpatient treatment, patient As ROM decreased to 50° of flexion at hip. Both underwent early surgical excision of immature HO (patient B at 7mo; patient A at 12mo after injury) secondary to severe limitation in ROM at the hip leading to pain and dysfunction. Assessment/Results: After resection of HO, patient As right hip ROM increased to 90° and patient Bs left hip ROM increased to 55°. With intensive PT over the next 3 months, hip flexion improved to 85° for patient B. Both patients were independent community ambulators with a straight cane at the time of discharge from outpatient rehabilitation. Discussion: At 10-year follow-up, functional and ROM gains were maintained in both patients without any recurrence after surgery. Conclusions: Early surgical intervention is beneficial in patients with HO, which causes severe limitation in ROM and functional loss. The benefits far outweigh the risks of recurrence and are long lasting.