Stefano Carda

Walking After Stroke: What Does Treadmill Training With Body Weight Support Add to Overground Gait Training in Patients Early After Stroke?. A Single-Blind, Randomized, Controlled Trial

Background and Purpose— This study aimed to assess the effectiveness of gait training using body weight support on a treadmill compared with conventional gait training for people with subacute stroke who were unable to walk. Methods— This was a single-blind, randomized, controlled trial with a 6-month follow-up. Ninety-seven subjects were recruited within 6 weeks of stroke onset and were randomly assigned to conventional rehabilitative treatment plus gait training with body weight support on a treadmill (experimental group; n=52) and conventional treatment with overground gait training only (control group; n=45). All subjects were treated in 60-minute sessions every weekday for 4 weeks. Outcome measures were Motricity Index, Trunk Control test, Barthel Index, Functional Ambulation Categories, 10-meter and 6-minute Walk Tests, and Walking Handicap Scale. Assessments were made at baseline, after 20 sessions of treatment, 2 weeks after treatment, and 6 months after stroke. Results— After treatment, all patients were able to walk. Both groups showed improvement in all outcome measures (P<0.0063) at the end of the treatment and at follow-up. No differences were seen between the 2 groups before, during, and after treatment and at follow-up. Conclusions— In subacute patients with stroke, gait training on a treadmill with body weight support is feasible and as effective as conventional gait training. However, the need for more personnel for treadmill training makes the use of robotically assisted systems more compelling.

A single-blinded, randomized pilot study of botulinum toxin type A combined with non-pharmacological treatment for spastic foot.

OBJECTIVE To explore the effect of treatment after botulinum toxin type A combined with treatments for the spastic foot. DESIGN Single-blind, randomized trial, with 3-month follow-up. SUBJECTS Twenty-three chronic hemiplegic adult patients with spastic equinus foot. METHODS Following botulinum toxin type A injection at the medial and lateral gastrocnemius, patients were assigned randomly to 3 groups, and treated with taping, electrical stimulation or stretching. They were evaluated before treatment (t0), and at 10 (t1), 20 (t2) and 90 (t3) days after treatment. Outcome measures were: Modified Ashworth Scale; passive range of motion at the ankle; measurement of muscle action potential at the gastrocnemius medialis; and measurement of maximum ankle dorsiflexion angle in stance using gait analysis. RESULTS The group treated with electrical stimulation performed better at t1 on the Modified Ashworth Scale. The taping and electrical stimulation groups performed better in all outcome measures at t3. The taping group performed better mainly for maximum ankle dorsiflexion angle in stance. The stretching group showed a less durable result, with some worsening at the t3 evaluation compared with the assessment performed before treatment. CONCLUSIONS This pilot study indicates that combining botulinum toxin type A administration for the ankle plantar flexors with taping and electrical stimulation might be beneficial.

Osteoporosis after Stroke: A Review of the Causes and Potential Treatments

Osteoporosis is a known consequence of stroke, associated with an increased incidence of fractures, mainly of the hip, leading to further disability. The pattern of bone loss seen in stroke patients is different from that usually encountered with postmenopausal osteoporosis, since it is limited to the paretic side and more evident in the upper extremities. Several factors appear to have an influence on bone mass in stroke patients, such as the degree of paresis, gait disability and the duration of immobilization. The pathogenesis of osteoporosis after stroke remains unclear. Paresis, reduced mobility and reduced bone load seem to play a major role. Other factors such as nutritional and iatrogenic ones may also play an important part. In this paper, the clinical evidence, pathophysiology and possible treatments of poststroke osteoporosis will be reviewed.

Taping versus electrical stimulation after botulinum toxin type A injection for wrist and finger spasticity. A case—control study

Objective: To compare results from two approaches used in conjunction with botulinum toxin type A administration in rehabilitation: the application of a taping system and the electrical stimulation of the injected muscles and splinting. Design: Case—control study. Setting: Two tertiary care rehabilitation hospitals in Italy. Subjects: Sixty-five adult subjects affected by spasticity of the wrist and finger flexors. Interventions: After injection with botulinum toxin type A, the group at hospital A (n = 33) was treated with adhesive taping for six days and those at hospital B (n = 32) with electrical stimulation and splinting for six days. Spastic hypertonia at the injected muscles was assessed before treatment, one week and one month post injection. Main measures: Modified Ashworth Scale. Results: In group A, the mean Modified Ashworth Scale reduction was 2.76 ± 0.94 for wrist flexors and 2.45 ± 0.92 for finger flexors; in group B the mean Modified Ashworth Scale reduction was 2.18 ± 1.11 for wrist flexors and 2.1 ± 0.98 for finger flexors. The observed difference between the two groups was statistically relevant (p < 0.05). Conclusions: Patients treated with adhesive taping and botulinum toxin type A achieved a greater reduction in spastic hypertonia as measured with Modified Ashworth Scale, with less time dedicated for the treatment.

Robotic gait training is not superior to conventional treadmill training in parkinson disease: a single-blind randomized controlled trial.

Background. The use of robots for gait training in Parkinson disease (PD) is growing, but no evidence points to an advantage over the standard treadmill. Methods. In this randomized, single-blind controlled trial, participants aged <75 years with early-stage PD (Hoehn-Yahr <3) were randomly allocated to 2 groups: either 30 minutes of gait training on a treadmill or in the Lokomat for 3 d/wk for 4 weeks. Patients were evaluated by a physical therapist blinded to allocation before and at the end of treatment and then at the 3- and 6-month follow-up. The primary outcome measure was the 6-minute walk test. Results. Of 334 screened patients, the authors randomly allocated 30 to receive gait training with treadmill or the Lokomat. At baseline, the 2 groups did not differ. At the 6-month follow-up, both groups had improved significantly in the primary outcome measure (treadmill: mean = 490.95 m, 95% confidence interval [CI] = 448.56-533.34, P = .0006; Lokomat: 458.6 m, 95% CI = 417.23-499.96, P = .01), but no significant differences were found between the 2 groups (P = .53). Discussion. Robotic gait training with the Lokomat is not superior to treadmill training in improving gait performance in patients with PD. Both approaches are safe, with results maintained for up to 6 months.

Gait changes after tendon functional surgery for equinovarus foot in patients with stroke: assessment of temporo-spatial, kinetic, and kinematic parameters in 177 patients.

Carda S, Bertoni M, Zerbinati P, Rossini M, Magoni L, Molteni F: Gait changes after tendon functional surgery for equinovarus foot in patients with stroke: Assessment of temporo-spatial, kinetic, and kinematic parameters in 177 patients. Objective:In patients with hemiplegic stroke, equinovarus foot is one of the most frequent deformities. Outcome evidence for surgical correction of equinovarus foot is scarce, and results are usually assessed only clinically. Moreover, concerns about possible loss of function after elongation of the plantar flexor muscles are still at issue. The objective of this study was to verify if surgical correction of equinovarus foot can improve gait speed and function. Design:We used a retrospective, nonrandomized design. One hundred seventy-seven chronic hemiplegic patients who underwent surgical correction of equinovarus foot were evaluated before and 1 yr after surgery. Outcome measures were walking handicap score, temporal-spatial parameters, gait kinematics and kinetics, and paretic propulsion. Results:After surgery, walking handicap and temporal-spatial parameters significantly improved, as did ankle kinematic data and gait kinetic data. Patients’ gait at follow-up was faster, with a more normal base of support and with better foot advancement. Paretic propulsion increased significantly after surgery, even if ankle power at push-off was reduced. We also observed a low complication rate. Conclusions:Surgical correction of equinovarus foot deformity in patients with stroke is a safe and effective procedure. Even if the power generation at the ankle decreased, overall gait function and parameters improved after surgery.

Efficacy of a Hip Flexion Assist Orthosis in Adults With Hemiparesis After Stroke

Background During gait, the hip flexors generate 40% of the total power. Nevertheless, no device has been tested extensively for clinical purposes to cope with weakness in the hip flexors in patients with stroke. Objective The purpose of this study was to assess the efficacy and safety of a newly developed hip flexion assist orthosis in adult patients with hemiparesis after stroke. Design The study used a prospective, randomized, before-after trial design. The inclusion criteria were hemiparesis resulting from stroke (onset ≥8 weeks); ability to walk, even if with assistance; and hip flexion weakness (Medical Research Council Scale score ≤4). Methods The main outcome measures were the 10-Meter Walk Test and the Six-Minute Walk Test. Patients also were evaluated with the Trunk Control Test, the Functional Ambulation Categories, the Motricity Index, and hip flexor strength on the Medical Research Council Scale. Sixty-two survivors of stroke were tested in random order with and without the orthosis. Any adverse event associated with its use was recorded. Results Both the Six-Minute Walk Test and the 10-Meter Walk Test scores improved with the use of the orthosis. A significant negative correlation was found for improvement between scores on the 2 main outcome measures with the orthosis and the Functional Ambulation Categories scores. The improvement in Six-Minute Walk Test scores with the orthosis was related inversely to hip flexor strength. Conclusions The data showed that the use of a hip flexion assist orthosis can improve gait in patients with poststroke hemiparesis, particularly those with more severe walking impairment.

Determinants of Neurological Functional Recovery Potential after Stroke in Young Adults

Background/Objectives: Despite recent progress in stroke prevention and acute treatment, neurorehabilitation remains one of the main methods of treatment in the management of stroke patients. The aim of this study is to point out some important predicting factors of in-hospital neurorehabilitation outcomes. Methods: A rehabilitation registry including all patients who had undergone a standardized program of neurorehabilitation at the neurorehabilitation unit of the Lausanne University Hospital, Lausanne, Switzerland, was created. Patients aged <65 years and having experienced a first ever nontraumatic stroke from 2005 to 2010 were admitted. Using logistical regression models, predicting factors for each patient were compared to the exit Functional Independence Measure (FIM) score. Results: Age >55 years, gender, aphasia, hemilateral spatial neglect, spasticity, complications, length of stay >70 days, entry FIM >100 and relative possible FIM gain/week of >10% were considered to be significant and independent predicting factors of the neurorehabilitation outcome. Discussion/Conclusion: Some factors of the in-hospital rehabilitation period have been identified before (spasticity, complications, length of stay, relative possible FIM gain/week) and should be considered for a better management of the neurorehabilitation therapy. In addition, a personalized rehabilitation strategy based on the patients individual needs should be aimed at. The question of resource allocation can also be addressed with regard to the present findings.

A multidirectional gravity-assist algorithm that enhances locomotor control in patients with stroke or spinal cord injury

A robotic harness optimizing gravity-dependent gait interactions enables natural locomotion across activities of daily living in people with spinal cord injury or stroke. Greater gait with gravity Often taken for granted, gravity—the force that keeps you on the ground—becomes a notable challenge during rehabilitation from injury. Mignardot et al. “harnessed” gravity to test whether upward and forward forces, applied to the torso via a robotic body weight supportive device, assist with locomotion. Patients recovering from stroke or spinal cord injury demonstrated improved gait performance with the robotic harness. An important component of the gravity-assistive approach is an algorithm that adjusts the forces provided by the robotic harness according to the patient’s needs. Patients unable to walk without assistance (nonambulatory) were able to walk naturally with the harness, whereas ambulatory patients exhibited improved skilled locomotion such as balance, limb coordination, foot placement, and steering. A clinical trial using this robot-assistive rehabilitation approach for patients with spinal cord injury is currently under way. Gait recovery after neurological disorders requires remastering the interplay between body mechanics and gravitational forces. Despite the importance of gravity-dependent gait interactions and active participation for promoting this learning, these essential components of gait rehabilitation have received comparatively little attention. To address these issues, we developed an adaptive algorithm that personalizes multidirectional forces applied to the trunk based on patient-specific motor deficits. Implementation of this algorithm in a robotic interface reestablished gait dynamics during highly participative locomotion within a large and safe environment. This multidirectional gravity-assist enabled natural walking in nonambulatory individuals with spinal cord injury or stroke and enhanced skilled locomotor control in the less-impaired subjects. A 1-hour training session with multidirectional gravity-assist improved locomotor performance tested without robotic assistance immediately after training, whereas walking the same distance on a treadmill did not ameliorate gait. These results highlight the importance of precise trunk support to deliver gait rehabilitation protocols and establish a practical framework to apply these concepts in clinical routine.

Does altering inclination alter effectiveness of treadmill training for gait impairment after stroke? A randomized controlled trial

Objective: To assess whether a downhill walking training programme is more effective than the same amount of training applied uphill in chronic stroke survivors. Design: Randomized, single-blind study. Setting: Outpatient rehabilitation service. Methods: Thirty-eight adults with hemiplegia from stroke lasting more than three months were randomly allocated to one of the two groups: ‘UP’ – 45 minutes of physical therapy + 30 minutes of treadmill with 5% ascending slope; and ‘DOWN’ – 45 minutes of physical therapy + 30 minutes of treadmill with 5% descending slope. Both groups were treated 5 times a week for six weeks. Patients were evaluated before treatment, at the end of treatment and after three months. Outcome measures: Primary outcome measure was the number of patients showing an improvement in 6-minute walking test (6MWT) greater than 50 m. Secondary outcome measures were: (1) number of patients showing a clinically relevant improvement of gait speed during 10-m walking test (10mWT); (2) number of patients showing an improvement in timed up and go (TUG) greater than minimal detectable change. Results: Both groups had a significant improvement after treatment and at follow-up. At the end of treatment, compared to UP group, more patients in the DOWN group showed clinically significant improvements in primary and secondary outcomes (16/19 patients for 6MWT, 11/19 patients for 10mWT and 9/19 patients for TUG compared with 3/19, 4/19 and 2/19 patients, respectively, P < 0.01). At follow-up, results were similar except for 10mWT. Conclusions: In chronic stroke patients, downhill treadmill training produces a bigger effect than uphill training.