Sensory Electrical Stimulation Improves Foot Placement during Targeted Stepping Post-Stroke

Proper foot placement is vital for maintaining balance during walking, requiring the integration of multiple sensory signals with motor commands. Disruption of brain structures post-stroke likely alters the processing of sensory information by motor centers, interfering with precision control of foot placement and walking function for stroke survivors. In this study, we examined whether somatosensory stimulation, which improves functional movements of the paretic hand, could be used to improve foot placement of the paretic limb. Foot placement was evaluated before, during, and after application of somatosensory electrical stimulation to the paretic foot during a targeted stepping task. Starting from standing, twelve chronic stroke participants initiated movement with the non-paretic limb and stepped to one of five target locations projected onto the floor with distances normalized to the paretic stride length. Targeting error and lower extremity kinematics were used to assess changes in foot placement and limb control due to somatosensory stimulation. Significant reductions in placement error in the medial–lateral direction (p = 0.008) were observed during the stimulation and post-stimulation blocks. Seven participants, presenting with a hip circumduction walking pattern, had reductions (p = 0.008) in the magnitude and duration of hip abduction during swing with somatosensory stimulation. Reductions in circumduction correlated with both functional and clinical measures, with larger improvements observed in participants with greater impairment. The results of this study suggest that somatosensory stimulation of the paretic foot applied during movement can improve the precision control of foot placement

The Rehabilitation Of A 75-Year-Old Male Presenting With A Right Hip Flexor Strain Concomitant With Numerous Psychosocial Factors: A Case Report

Background: Musculoskeletal disorders, often well understood, are a leading cause of disability worldwide. Concomitant psychosocial factors add a layer of complexity to the treatment of musculoskeletal disorders. The purpose of this case report is to highlight the potential impact psychological factors have in the rehabilitation of musculoskeletal disorders, specifically the rehabilitation of a right hip flexor strain. Case Description: The patient was a 75-year-old male referred to outpatient physical therapy for the assessment of a right hip flexor strain, presenting with psychosocial factors including anxiety and kinesiophobia. Procedural interventions included patient education, neuromuscular re-education, therapeutic exercise, and manual therapy, but lacked psychosocial assessment. Outcomes: The patient was seen for 16 visits over eight week’s time, including the initial evaluation. His pain rating score improved from 8/10 on initial evaluation to 6/10 on discharge in accordance to the Numeric Pain Rating Scale (NPRS). After four weeks of continued physical therapy intervention after his re-evaluation, he was referred back to his primary care provider for further diagnostic testing as his progress began to plateau. Discussion: This case report highlights how psychosocial factors such as kinesiophobia and anxiety can complicate patient care. While physical therapists are often well versed in the treatment of musculoskeletal disorders, numerous external factors make it difficult for physical therapists to properly assess psychosocial factors. Further research should be conducted regarding the importance of psychosocial assessment in the context of musculoskeletal disorder rehabilitation

Characterizing the Variability of Kinematic Outcome Measures and Compensatory Movements using Inertial Measurement Units

Cost-effective wearable sensors to measure movement have gained traction as research and clinical tools. The potential to quantify movement with a portable and inexpensive way could provide benefits to patient populations (e.g. amputees) to supplement or replace current clinical evaluations. For example, characterization of frontal plane kinematic outcome measures is a relevant movement pattern to a complex amputee population. The ability to capture such movements could have important therapeutic opportunities. The current research worked towards characterizing frontal plane compensatory movement patterns with kinematic outcome measures described by inertial measurement units (IMU) data in healthy adults. This was an initial step towards developing a future toolkit that could characterize normal and aberrant movement patterns in clinical populations. The thesis is comprised of two related studies. The first study set out to evaluate the numerical accuracy of IMU estimated spatial measures when compared to a gold standard system. Six subjects completed six different movement tasks while instrumented with optical motion capture and IMUs. Each movement task probed the accuracy of specific deviations (e.g. vertical deviation). The hypothesis was that outcome measures would be strongly associated (r>0.8) and mean error would not be significantly different from zero and the coefficient of repeatability would be within priori set limits of agreement (±18 mm). Kinematic outcome measures had small mean error bias compared to gold standard measures and range of subject specific mean errors showed minimal differences. Task specific differences were evident when movement patterns exhibit large transverse rotations. These results showed the devices have a level of accuracy that may be suitable to characterize changes in movement patterns clinically. The second study aimed to utilize the same techniques from study 1 to describe compensatory kinematic outcome measures during a clinical obstacle avoidance task to differentiate between compensatory and normal movement patterns. Twelve subjects wore IMUs bilaterally on the ankles and on the belt above the right hip. An off the shelf orthotic knee brace was used to restrict lower limb knee joint kinematics (reduce range of motion). Participants completed 15 walking trials for three different brace conditions (No Brace, Unlocked Brace, Locked Brace) and two obstacle task conditions (Level Ground Walking and Obstacle Avoidance) to elicit a comparison of normal and compensatory movements. During the walking task, IMUs were able to characterize compensatory movements typical of the amputee population. Lateral deviation of the swinging foot was significantly larger during obstacle crossing with a locked brace compared to no brace. Maximum elevation of the limb was significantly larger while crossing obstacles compared to level ground walking and was precise enough to discern elevation differences of No Brace elevation from both Unlocked and Locked Brace conditions. Hip hiking was also significantly larger in the locked brace obstacle crossing from no brace obstacle crossing. Swing time was longer when the limb was braced and during obstacle crossing when compared to level ground walking. Healthy subjects had no significant changes to double support time compared those exhibited by amputees during walking. Overall, differences between IMU and gold standard measures are present. Mean error differences are present for certain tasks and criteria for agreeability between devices is not satisfied. Descriptive analysis of low subject mean error ranges across the majority of tasks indicate a potential utility in these measures to distinguish between movement patterns. During the clinical task, when knee mobility was manipulated compensatory movements were significantly different across conditions. This study provides evidence for the utility of IMU devices to support clinical gait analysis with quantifiable measures

Dynamic balance control during treadmill walking in chronic stroke survivors

Maintaining dynamic balance is an important component of walking function that is likely impaired in chronic stroke survivors, evidenced by an increased prevalence of falls. Dynamic balance control requires maintaining the center of mass (COM) within the base of support during movement. During walking, dynamic balance control is achieved largely by modifying foot placement to adjust the base of support. However, chronic stroke survivors have difficulty with both precision control of foot placement, as well as reduced control of COM movement. The objective of this dissertation was to characterize dynamic balance control strategies during walking in chronic stroke survivors. Additionally, we evaluated whether altered sensory feedback could be used to improve balance control in stroke survivors. Dynamic balance control was characterized during challenging walking conditions in stroke survivors and age-matched neurologically intact individuals. Adaptations to perturbations in frontal plane COM, induced using a custom cable-driven device, were used to further probe mechanisms of dynamic balance control. Despite larger amounts of COM movement and step widths, chronic stroke survivors produced a similar ratio of step width to COM sway, indicating that simply increasing step width does not produce a safer walking pattern for the stroke group. Placement of the paretic limb was unchanged in response to the external perturbations of trunk movement, which might underlie deficits in dynamic balance control. Augmented sensory feedback improved paretic foot placement and COM control, when applied during a stepping or treadmill walking task. These results provide insight into differences in dynamic balance control in stroke while also demonstrating that augmented sensory feedback signals might be used to improve balance control, and thus walking function for chronic stroke survivors

Inpatient Physical Therapy Management For A Patient With Chronic Pulmonary Complications Secondary To Multiple Lobectomies: A Case Report

Background and Purpose: Bronchiectasis is a disease defined by abnormal dilation of the bronchi from recurrent infections and/or chronic inflammation, which can lead to irreversible lung damage. Based upon severity and patient response to conservative treatment, a lobectomy may be required to resolve their symptoms. Though surgery may provide symptom relief and improve overall quality of life, patients are likely to have long-term pulmonary complications. There are several studies regarding the treatment of patients with pulmonary limitations secondary to a lobectomy. However, there is little to no evidence regarding the long-term treatment of patients who have undergone multiple lobectomies. The purpose of this case report was to describe an appropriate intervention program for an 82-year-old female who suffered from multiple pulmonary complications secondary to multiple lobectomies. Case Description: The patient was an 82-year-old female who had multiple lobectomies at age 18 secondary to bronchiectasis. She was admitted to a skilled nursing facility (SNF) with a diagnosis of a chronic obstructive pulmonary disease (COPD) exacerbation. Her primary symptoms included generalized weakness and increased dyspnea. The prescribed intervention program included cardiovascular endurance training, dynamic standing balance activities and bilateral lower extremity (BLE) strengthening. Outcomes: The distance on the 6-Minute Walk Test (6MWT) increased by 36.0 meters (m) (140.8m to 176.8m), dynamic standing balance increased from fair+ to good, BLE strength increased from 3+/5 to 4/5 (fair to good) and ambulation distance improved from 150 ft using a two-wheeled walker (2WW) to 300 ft using a four-wheeled walker (4WW). Discussion: Incorporating cardiovascular endurance training, dynamic standing balance exercises and BLE strength training appeared to have improved this 82-year-old woman’s independence with functional mobility at discharge

Comparison of muscle coordination between individuals post-stroke and kinematically constrained walking

Abnormal motor coordination affects motor function following stroke, yet we lack a complete characterization of how such abnormal coordination affects movements such as gait. Previous research found that post-stroke gait exhibited fewer movement primitives, or muscle modules, than healthy individuals, suggesting abnormal coordination may affect gait function. However, aside from abnormal coordination, the reduced number of modules could also be due to compensations in response to other impairments such as increased muscle tone and spasticity. Our previous research compared gait in those with post-stroke Stiff-Knee Gait (SKG) to healthy individuals with kinematically constrained knee flexion. While healthy individuals compensated with pelvic obliquity, those with post-stroke SKG also exhibited greater hip abduction, suggesting the motion may be related to neural impairments such as abnormal coordination. We hypothesize that abnormal coordination, not the compensations due to restricted ranges of motion induced by other impairments, is associated with reduced gait function. In this experiment, we compared muscle coordination patterns emerging from healthy individuals with and without restricted knee kinematics to a cohort of individuals post-stroke, both with and without SKG. We predicted the number of muscle modules would be fewer than healthy individuals with similar gait kinematics and found that mechanical knee restriction reduced the number of modules similar to those with post-stroke SKG in walking. Constraining healthy motions resulted in similar muscular coordination patterns to unrestricted gait suggesting the robustness of muscle recruitment despite a kinematic perturbation. The composition of modules in the pre-swing phase between those with SKG and the mechanically restricted group differed (Spearman’s ρ = -0.024), whereas comparisons between post-stroke individuals without SKG (NSKG) and the healthy group were similar (Spearman’s ρ = 0.833). We found those with SKG relied less on hamstrings than healthy counterparts, suggesting an altered motor command beyond adaptation. Muscle coordination patterns in constrained motions during gait were not similar to SKG while the NSKG group showed greater similarity to normal walking. Thus, our data suggests that abnormal coordination may play a greater role in SKG than those without SKG. The results of this comparison will help develop more accurate interventions for clinical treatment.Mechanical Engineerin

Effects of a soft robotic exosuit on the quality and speed of overground walking depends on walking ability after stroke

\ua9 2023, BioMed Central Ltd., part of Springer Nature.Background: Soft robotic exosuits can provide partial dorsiflexor and plantarflexor support in parallel with paretic muscles to improve poststroke walking capacity. Previous results indicate that baseline walking ability may impact a user’s ability to leverage the exosuit assistance, while the effects on continuous walking, walking stability, and muscle slacking have not been evaluated. Here we evaluated the effects of a portable ankle exosuit during continuous comfortable overground walking in 19 individuals with chronic hemiparesis. We also compared two speed-based subgroups (threshold: 0.93 m/s) to address poststroke heterogeneity. Methods: We refined a previously developed portable lightweight soft exosuit to support continuous overground walking. We compared five minutes of continuous walking in a laboratory with the exosuit to walking without the exosuit in terms of ground clearance, foot landing and propulsion, as well as the energy cost of transport, walking stability and plantarflexor muscle slacking. Results: Exosuit assistance was associated with improvements in the targeted gait impairments: 22% increase in ground clearance during swing, 5\ub0 increase in foot-to-floor angle at initial contact, and 22% increase in the center-of-mass propulsion during push-off. The improvements in propulsion and foot landing contributed to a 6.7% (0.04 m/s) increase in walking speed (R 2 = 0.82). This enhancement in gait function was achieved without deterioration in muscle effort, stability or cost of transport. Subgroup analyses revealed that all individuals profited from ground clearance support, but slower individuals leveraged plantarflexor assistance to improve propulsion by 35% to walk 13% faster, while faster individuals did not change either. Conclusions: The immediate restorative benefits of the exosuit presented here underline its promise for rehabilitative gait training in poststroke individuals

Restoring Functional Mobility For A Patient Following A Comminuted Patella Fracture Status Post Open Reduction Internal Fixation: A Case Report

Background and Purpose: The patella serves an important role in the protection and biomechanics of the knee joint. A fracture of the patella typically requires surgery and immobilization, which can have detrimental impacts on functional mobility. The purpose of this case study was to document a rehabilitation program following a comminuted patella fracture status post open reduction internal fixation (ORIF).Case Description: The patient was a 62-year-old female who sustained a comminuted patella fracture following a traumatic fall down the stairs, and underwent ORIF to her right patella. She was prescribed a straight knee immobilizer for eight weeks leaving her unable to take daily walks, play with her grandchildren, and drive. Physical therapy (PT) interventions, which began four weeks post-operatively, were chosen based on deficits in range of motion (ROM) and strength, quadriceps atrophy, knee extensor lag, and an antalgic gait pattern. The interventions included a lower extremity (LE) strengthening program, ROM, manual therapy, and gait training.Outcomes: The patient demonstrated gains in right knee flexion active ROM (48 ̊ to 120 ̊) and passive ROM (46 ̊ to 125 ̊). Strength gains were demonstrated through manual muscle testing of knee flexion (4-/5; full ROM against gravity, mild resistance) and knee extension (4/5; moderate resistance). Treatment continued beyond the time of publication, but progress notes suggested improvements in strength and ROM, despite persistent functional deficits.Discussion: The outcomes suggested a holistic LE strengthening program appeared to be successful in decreasing knee extensor lag, preparing the limb for ambulation without the immobilizer, and increasing functional mobility. Consistent with the literature, this patient had persistent functional deficits. Future research should focus on earlier PT intervention and effective approaches for increasing quadriceps muscle activity