Combined effects of myofeedback and isokinetic training on hand function in spastic hemiplegic children

Background and purpose: Hand function is necessary for activities of daily life. Hemiplegic cerebral palsied children who constitute a large portion in our country show evidence of defective hand function. So, it is worth finding a solution for such a problem. This study was conducted to determine the combined effects of myofeedback and isokinetic training on hand function in spastic hemiplegic children.Subjects and methods: Thirty spastic hemiplegic children from both sexes ranging in age from five to seven years represented the sample of the study. The degree of spasticity ranged from 1 to 1+ according to the Modified Ashworth Scale. The affected upper limb was free from any structural deformities; however, children demonstrated variable degrees of tightness. They were assigned randomly into two groups of equal number (A and B). Evaluation was conducted for each child of the two groups before and after six months of treatment. The strength of the triceps brachii muscle was evaluated by using the biodex isokinetic dynamometer. The range of motion of wrist extension was evaluated by using digital electro-goniometer. Both groups received a designed physical therapy program with isokinetic training for the triceps brachii muscle for 60 min, in addition group B received myofeedback training.Results: The post treatment results revealed significant improvement in the measured variables of both groups when comparing their pre and post treatment mean values, while significant results were observed in favor of group B when comparing the post treatment results of the two groups.Conclusions: Myofeedback training combined with isokinetic training is an excellent supplement for improving hand function in spastic hemiplegic children.Keywords: Hemiplegic children; Hand function; Isokinetic training; Myofeedbac

Markerless Kinematics of Pediatric Manual Wheelchair Mobility

Pediatric manual wheelchair users face substantial risk of orthopaedic injury to the upper extremities, particularly the shoulders, during transition to wheelchair use and during growth and development. Propulsion strategy can influence mobility efficiency, activity participation, and quality of life. The current forefront of wheelchair biomechanics research includes translating findings from adult to pediatric populations, improving the quality and efficiency of care under constrained clinical funding, and understanding injury mechanisms and risk factors. Typically, clinicians evaluate wheelchair mobility using marker-based motion capture and instrumentation systems that are precise and accurate but also time-consuming, inconvenient, and expensive for repeated assessments. There is a substantial need for technology that evaluates and improves wheelchair mobility outside of the laboratory to provide better outcomes for wheelchair users, enhancing clinical data. Advancement in this area gives physical therapists better tools and the supporting research necessary to improve treatment efficacy, mobility, and quality of life in pediatric wheelchair users. This dissertation reports on research studies that evaluate the effect of physiotherapeutic training on manual wheelchair mobility. In particular, these studies (1) develop and characterize a novel markerless motion capture-musculoskeletal model systems interface for kinematic assessment of manual wheelchair propulsion biomechanics, (2) conduct a longitudinal investigation of pediatric manual wheelchair users undergoing intensive community-based therapy to determine predictors of kinematic response, and (3) evaluate propulsion pattern-dependent training efficacy and musculoskeletal behavior using visual biofeedback.Results of the research studies show that taking a systems approach to the kinematic interface produces an effective and reliable system for kinematic assessment and training of manual wheelchair propulsion. The studies also show that the therapeutic outcomes and orthopaedic injury risk of pediatric manual wheelchair users are significantly related to the propulsion pattern employed. Further, these subjects can change their propulsion pattern in response to therapy even in the absence of wheelchair-based training, and have pattern-dependent differences in joint kinematics, musculotendon excursion, and training response. Further clinical research in this area is suggested, with a focus on refining physiotherapeutic training strategies for pediatric manual wheelchair users to develop safer and more effective propulsion patterns

Treadmill training augmented with real-time visualisation feedback and function electrical stimulation for gait rehabilitation after stroke : a feasibility study

Motor rehabilitation typically requires patients to perform task-specific training, in which biofeedback can be instrumental for encouraging neuroplasticity after stroke. Treadmill training augmented with real-time visual feedback and functional electrical stimulation (FES) may have a beneficial synergistic effect on this process. This study aims to develop a multi-channel FES (MFES) system with stimulation triggers based on the phase of gait cycle, determined using a 3D motion capture system. A feasibility study was conducted to determine whether this enhanced treadmill gait training systemis suitable for stroke survivors in clinical practice. The real-time biomechanical visual feedback system with computerised MFES was developed using six motion-capture cameras installed around a treadmill.;This system was designed to stimulate the pretibial muscle for correcting foot drop problems, gastro-soleus for facilitating push-off, and quadriceps and hamstring for improving knee stability. Dynamic avatar movement and step length/ratio were displayed on a monitor, providing patients with real-time visual biofeedback. Participants received up to 20 minutes of enhanced treadmill training once or twice per week for 6 weeks. Training programme, pre- and post-training ability, and adverse events of each participant were recorded. Feedback was also collected from participants and physiotherapists regarding their experience. Eight out of ten participants fully completed their programme.;In total, 67 training sessions were carried out. All participants had a good attendance rate. The number and duration of training sessions ranged from 5 to 20, and 11 to 20 minutes, respectively. The MFES system successfully improved gait patterns during training, and feedback from participants and physiotherapists regarding their experience of the research intervention was overwhelmingly positive. In conclusion, this enhanced treadmill gait training system is feasible for use in gait rehabilitation after stroke. However, a well-designed clinical trial with a larger sample size is needed to determine clinical efficacy on gait recovery.Motor rehabilitation typically requires patients to perform task-specific training, in which biofeedback can be instrumental for encouraging neuroplasticity after stroke. Treadmill training augmented with real-time visual feedback and functional electrical stimulation (FES) may have a beneficial synergistic effect on this process. This study aims to develop a multi-channel FES (MFES) system with stimulation triggers based on the phase of gait cycle, determined using a 3D motion capture system. A feasibility study was conducted to determine whether this enhanced treadmill gait training systemis suitable for stroke survivors in clinical practice. The real-time biomechanical visual feedback system with computerised MFES was developed using six motion-capture cameras installed around a treadmill.;This system was designed to stimulate the pretibial muscle for correcting foot drop problems, gastro-soleus for facilitating push-off, and quadriceps and hamstring for improving knee stability. Dynamic avatar movement and step length/ratio were displayed on a monitor, providing patients with real-time visual biofeedback. Participants received up to 20 minutes of enhanced treadmill training once or twice per week for 6 weeks. Training programme, pre- and post-training ability, and adverse events of each participant were recorded. Feedback was also collected from participants and physiotherapists regarding their experience. Eight out of ten participants fully completed their programme.;In total, 67 training sessions were carried out. All participants had a good attendance rate. The number and duration of training sessions ranged from 5 to 20, and 11 to 20 minutes, respectively. The MFES system successfully improved gait patterns during training, and feedback from participants and physiotherapists regarding their experience of the research intervention was overwhelmingly positive. In conclusion, this enhanced treadmill gait training system is feasible for use in gait rehabilitation after stroke. However, a well-designed clinical trial with a larger sample size is needed to determine clinical efficacy on gait recovery

The Effectiveness of Balance Training Exercise in Post Stroke Individuals Using the Neurocom Balance Master® System

A case study was completed on a 51-year-old female who suffered a stroke in 1996 and exhibited left-sided hemiplegia. The case study examined the effects of a six-week balance training program on an individual at least six months post stroke using a force platform system called the NeuroCom Balance Master®. Individuals suffering a stroke often times exhibit deficits in balance due to weakness, sensory loss, impaired righting reflexes, and visuospatial distortion. The goal of the training program was to improve the subject\u27s balance deficits by focusing on areas of symmetrical weight bearing, weight shifting, and coordination of movement. Initial and final assessments were conducted using the NeuroCom Balance Master® and the Tinnetti Assessment Tool to assess any change in the subject\u27s balance. At the conclusion of the six-week training program, the subject improved in areas of static and dynamic balance and the ability to weight shift in the anterior direction and to her hemiparetic left side. The subject\u27s gait pattern also improved in terms of step length, step width, and step speed. Therefore, the results of this study seem to indicate that post stroke individuals of at least six months may have the ability to improve their overall balance with continued postural training. However, further research is necessary to determine the functional outcomes of postural feedback training and the reasons for improvement seen on the NeuroCom Balance Master.

Can Simple Postural Instructions Modify Running Forms in Recreational Runners

Purpose/Hypothesis: Recent research suggests that alteration of trunk angle and foot strike pattern during running may result in beneficial changes that prevent running related injuries due to reduction in vertical ground reaction forces (vGRF). For example, running form emphasizing a forward trunk lean and a midfoot or forefoot strike pattern has been shown to be effective in reducing knee stress and the risks of other impact-related running injuries. In clinical practice however, it is currently unknown if simple postural cues given to runners can elicit motor learning that leads to modification of running form. The purpose of this study was to analyze the biomechanical changes in the running form of recreational runners after being instructed to run with a forward trunk lean and a forefoot strike pattern over a 4-week training period. Methods: Eighteen runners, 11 females and 7 males, mean age 28.5±6.10 years, mean body mass index= 23.18 kg/m2, that run at least five miles per week and are injury free at the time of the study participated. During a 4-week training period, the runners received the following simple postural instructions: 1) lean your trunk forward and 2) land on the front part of your foot. The runners were asked to focus on these postural cues whenever they ran on their own during the 5-week study period. Participants were assessed at the following time points: prior to training (PRE), immediately after receiving the instructions (iPST), at 2 weeks (2WK) and 4 weeks (4WK), and 7-10 days after the conclusion of training (RET). Assessment consisted of an initial running trial on a treadmill during which trunk angle and peak vertical ground reaction force (vGRF) in stance phase were assessed using a 3D motion capture system and a force plate-instrumented treadmill. The runners were assessed at their self-selected running speed and a predetermined speed of 2.5 m/s during which three 20-second trials were collected for each speed. One-way repeated measures ANOVA tests were used to compare the changes in trunk angle and peak vGRF over time. Results: There was a significant increase in forward trunk angle during running immediately after receiving the instructions for both running speeds (PRE vs. iPST, self-selected speed: 6.69º vs. 9.76º, p=0.001; 2.5m/s: 6.78º vs. 9.14º, p=0.005). When compared toPRE, there was a significant increase in trunk flexion angle at 4WK (PRE vs. 4WK, self-selected running speed: 6.69º vs. 9.94º, p=0.031; 2.5 m/s: 6.78º vs. 10.05º, p=0.002). When compared to PRE, there was a significant increase in trunk flexion angle at RET at 2.5 m/s speed (PRE vs. RET: 6.78º vs. 9.99º, p=0.044), however there was no significant increase in trunk flexion angle at RET for the self-selected speed (PRE vs. RET: 6.69º vs. 9.45º, p=0.111). There was no significant change in vGRF over the course of the training for the self-selected and 2.5 m/s speeds (p=0.644 and 0.187, respectively). Conclusions: Based on our findings, we conclude that simple postural instructions and training over 4 weeks can induce changes in trunk angle during running in recreational runners. However, vGRF may not significantly change after alteration of trunk posture. Clinical Relevance: This study demonstrated that simple postural instructions can induce short- and mid-term changes in running form in recreational runners

Efficacy of Functional Activity Based Exercise and added Sit to Stand Exercise on the Functional Ambulation in Chronic Hemiparetic Stroke Patients: An Experimental study

INTRODUCTION: Stroke is characterized as a neurological condition attributed to an acute focal injury of the central nervous system (CNS) by a vascular cause, including cerebral infarction, intracerebral haemorrhage (ICH), and is a major cause of disability. Stroke is one of the leading causes of death in the worldwide population. NEED OF THE STUDY: Current treatment approaches primarily focus on the functional strengthening methods. Sit to stand exercise training is a new concept applied as functional strengthening application in stroke clients. The quantitative analysis in terms of improvement brought about in functional performance in stroke clients between task-specific exercise and functional strengthening exercises have not been clearly delineated. STATEMENT OF THE PROBLEM: 1. To determine the effectiveness of functional activity on activity of daily living of lower extremity among the stroke clients. 2. To determine the effectiveness of functional integrated exercises with added sit to stand exercise on functional performance of lower extremity among the stroke clients. 3. To determine the effectiveness of functional productivity with added sit to stand exercise in relation to overall ability along with functional performance of lower-extremity among the stroke clients. MATERIALS AND METHODOLOGY METHODOLOGY: Study Design : An Experimental study design. Study Setting : Neuro ward and Special Ward of Sri Ramakrishna Hospital, Coimbatore, Study Duration : The study was carried out for the period of 4 weeks. Sampling : Convenient Random Sampling Sample Size : The study includes 30 in-patients (27 males and 3 females) with chronic stroke who has gait impairments was randomly assigned into two groups : Group A (control group I): Task-Specific Exercises, Group B (experimental group II): Task-Specific Exercises with added Stepping-up exercise. CRITERIA FOR SAMPLE SELECTION: Inclusion Criteria: • Age-45 to 55 years, • Both male and female, • Chronic Stroke patients with gait impairment, • Modified Ashworth Scale of spasticity stage 2. • Patients with mini mental state examination score greater than 23. • Patients who were medically stable. • Able to understand and follow simple verbal instructions. • Ambulatory before stroke. Exclusion Criteria: • Uncooperative patients due to cognitive impairments. • Patients with previous medical history of other neurological impairment eg, MS, mysthenia Grevis, MND. • Any visual defects. • Presence of severe contractures and deformity in lower extremity. • Who has Pusher syndrome. RESULT: By comparing the post-test results of group A and group B with respect to Fugl-meyer motor assessment scale, five repetitions sit-to stand and modified time 'up and go' test, Group B received Sit to Stand exercises along with functional activity based training protocols showed a significant improvement in the gait parameters of chronic hemiparetic stroke individuals. CONCLUSION: Functional activity based exercise with added sit to stand exercise applied in stroke patients showed that they are highly beneficial than the Functional activity based exercise alone when motor recovery is compared between the two groups for 4 weeks. Both techniques did not contribute the muscle tone at the end of 4 weeks

Cerebral Palsy

Nowadays, cerebral palsy (CP) rehabilitation, along with medical and surgical interventions in children with CP, leads to better motor and postural control and can ensure ambulation and functional independence. In achieving these improvements, many modern practices may be used, such as comprehensive multidisciplinary assessment, clinical decision making, multilevel surgery, botulinum toxin applications, robotic ambulation applications, treadmill, and other walking aids to increase the quality and endurance of walking. Trainings are based on neurodevelopmental therapy, muscle training and strength applications, adaptive equipment and orthotics, communication, technological solves, and many others beyond the scope of this book. In the years of clinical and academic experiences, children with cerebral palsy have shown us that the world needs a book to give clinical knowledge to health professionals regarding these important issue. This book is an attempt to fulfill and to give “current steps” about CP. The book is intended for use by physicians, therapists, and allied health professionals who treat/rehabilitate children with CP. We focus on the recent concepts in the treatment of body and structure problems and describe the associated disability, providing suggestions for further reading. All authors presented the most frequently used and accepted treatment methods with scientifically proven efficacy and included references at the end of each chapter

Doctor of Philosophy

dissertationIndividuals recovering from total knee arthroplasty (TKA) perform compensatory strategies defined as interlimb asymmetries, resulting in lower functional performance and accelerated arthritic changes in other joints. This body of work focuses on factors related to the performance of the surgical limb by: 1) investigating how the demand of the mobility task influences compensation, 2) comparing the effectiveness of two biofeedback modes in correcting compensation, 3) evaluating if biofeedback can normalize compensation to similar levels as healthy matched pers (HMP), and 4) studying the relationship of modifiable risk factors to the compensations following TKA. A total of 46 patients with TKA and 15 HMP were assessed in three separate clinical studies. In Study #1, compensation was compared between low- (level) and high- (decline) demand walking tasks in patients with TKA and HMP. In Study #2, we compared the efficacy of two modes of biofeedback on improving compensation and compared between groups. In Study #3, we tested whether risk factors considered modifiable (i.e., lower limb strength, power, residual knee pain, and/or balance confidence) help explain the level of compensation following TKA. Study #1 showed greater total support moment (MS), knee extensor moment (MK), and vertical ground reaction force (vGRF) differences during decline walking compared to level walking in patients with TKA. Greater MS, MK, vGRF, and knee joint angle differences were present in patients with TKA compared to HMP during decline walking. Study #2 showed patients with TKA exposed to internal knee extensor moment (IKEM) biofeedback demonstrated improvement in MS and MK symmetry compared to vGRF biofeedback. Additionally, IKEM biofeedback could normalize the level of compensation similar to HMP during decline walking. Study #3 concluded that knee extensor strength asymmetry showed a strong relationship on both MS and MK asymmetry following surgery. Lower limb power, residual knee pain, and balance confidence had no relationship on compensation. These results suggest that compensation is amplified during more physically demanding mobility and can be normalized using knee kinetic biofeedback. Further, it seems intuitive to continue to focus on knee extensor strength and integrate into functional movement retraining with knee kinetic biofeedback to effectively correct compensatory movement strategies during rehabilitation

Effect of Task Specific Exercises, Gait Training, and Visual Biofeedback on Equinovarus Gait among Individuals with Stroke: Randomized Controlled Study

Background and Purpose. Equinovarus foot is a common sign after stroke. The aim of this study is to investigate the effect of task specific exercises, gait training, and visual biofeedback on correcting equinovarus gait among individuals with stroke. Subjects and Methods. Sixteen subjects with ischemic stroke were randomly assigned to two equal groups (G 1 and G 2 ). All the patients were at stage 4 of motor recovery of foot according to Chedoke-McMaster Stroke Assessment without any cognitive dysfunction. E-med pedography was used to measure contact time, as well as force underneath hind and forefoot during walking. Outcome measures were collected before randomization, one week after the last session, and four weeks later. Participants in G 1 received task specific exercises, gait training, and visual biofeedback and a traditional physical therapy program was applied for participants in G 2 for 8 weeks. Results. Significant improvement was observed among G 1 patients ( ≤ 0.05) which lasts one month after therapy termination. On the other hand, there were no significant differences between measurements of the participants in G 2 . Between groups comparison also revealed a significant improvement in G 1 with long lasting effect. Conclusion. The results of this study showed a positive long lasting effect of the task specific exercises, gait training, and visual biofeedback on equinovarus gait pattern among individuals with stroke

Effects of Early Strengthening Activities and Feedback on Improving Balance in Clients with Stroke: A Case study

AIM: To identify the effectiveness of early strengthening and feedback in improving balance in hemiplegics post stroke METHODOLOGY: Five clients affected with stroke with poor balance were taken for the study. They were screened using Berg balance Scale, Folstein test (Mini Mental Status Examination, MMSE), and Brunnstrom’s stages. Clients who matched the inclusion criteria (BBS score 20 and Brunnstrom’s stage of zero) were taken into the study. The clients were provided with the treatment using the biomechanical frame of reference with the aid of feedback techniques. After completion of treatment protocol, they underwent a post-test using Berg Balance Scale. The acquired data was analysed. RESULTS: All the five clients taken in the study shifted from a high fall risk to medium fall risk level. The client, who showed the highest change in balance score in the whole group is Client A, had a score change of 14, while Client B had a score of 12. Client C and E had a change score of 7. Client D did not show much improvement, with score of only 3. CONCLUSION: This study shows that there is a change in the balance grades among the clients with stroke when using the strengthening activities. Activities based on Biomechanical Frame of Reference coupled with components of feedback techniques works for improving balance in clients with stroke. Even with limited client numbers and limited time duration of the study, this response was elicitable. Thus, the study suggests that this intervention can be further dealt with in future researches and can be combined in future treatment protocols to work on clients with stroke