Post-effets et rééducation à la marche chez le sujet hémiparétique

L’asymétrie de longueur de pas est une caractéristique du patron de marche fréquemment observée chez des personnes qui ont subi un accident vasculaire cérébral (AVC). Très peu d’interventions conventionnelles en réadaptation ont démontré leur efficacité sur ce paramètre de marche. Une approche novatrice utilisant un tapis roulant à double courroie (DC) a récemment présenté des effets prometteurs en réduisant, à court et long termes, l’asymétrie de longueur de pas chez des personnes post-AVC. Cependant, une meilleure compréhension des mécanismes sous-jacents aux changements induits par cette intervention est nécessaire avant que l’utilisation de cette intervention soit recommandée en clinique. Ce projet doctoral visait à améliorer les connaissances sur la contribution musculaire et les facteurs biomécaniques impliqués dans les changements immédiats (c.-à-d. les post-effets) et à long terme de l’asymétrie de la longueur de pas chez des personnes post-AVC. Les objectifs principaux étaient 1) d’analyser l’activité musculaire associée aux changements de longueur de pas après la marche sur un tapis à DC avec des vitesses de courroies inégales, 2) d’évaluer les effets d’un entraînement sur un tapis à DC sur l’asymétrie de longueur de pas et sur la capacité de marche au sol et 3) de quantifier la contribution musculaire et les stratégies sous-jacentes aux changements du patron de marche résultant de l’entraînement. L’hypothèse générale était que les muscles distaux des membres inférieurs seraient majoritairement impliqués dans les changements de longueur de pas induits par la marche sur le tapis à DC avec des vitesses de courroies inégales (ratio 2:1) chez les personnes post-AVC. L’étude transversale (article #1) a quantifié l’activité musculaire des membres inférieurs associée aux post-effets observés au niveau de la longueur de pas après six minutes de marche sur le tapis à DC (ratio 2:1) chez 16 personnes post-AVC et 10 personnes saines. Les résultats ont confirmé que les muscles distaux, c.-à-d. les fléchisseurs plantaires et dorsaux, étaient associés aux post-effets de la longueur de pas. Ces effets ont été observés, quel que soit le membre inférieur (c.-à-d. parétique ou non parétique) qui était sur la courroie rapide. La deuxième étude, a démontré que six séances d’entraînement sur le tapis à DC conduisaient à une réduction de l’asymétrie de longueur de pas et amélioraient la vitesse de marche sur le sol chez 12 personnes post-AVC (article #2). Les changements ont persisté un mois après l’entraînement. En outre, les résultats de cette étude pilote ont suggéré une bonne faisabilité de ce protocole d’entraînement dans un environnement clinique (données supplémentaires de l’article #2). Dans l’article #3, il a été démontré que l’amélioration post-entraînement de la symétrie et de la vitesse de marche était associée à une variété de stratégies et de contributions musculaires chez nos participants. Cependant, une contribution prédominante a été observée au niveau du membre inférieur entraîné sur la courroie rapide avec des tailles d’effet modérées obtenues surtout pour les changements de moment et d’activité musculaire des fléchisseurs plantaires pendant la phase d’appui de la marche. Suite à ces résultats et ceux de l’article #1, il a été suggéré que ce groupe musculaire jouait un rôle principal dans l’adaptation locomotrice et la réduction à long terme de l’asymétrie de la longueur de pas chez des personnes post-AVC. Néanmoins, des études cliniques contrôlées avec une population plus importante sont nécessaires afin de préciser la pertinence de l’entraînement sur le tapis à DC ainsi que les différentes stratégies musculaires associées aux changements de l’asymétrie de longueur du pas à long terme chez des personnes post-AVC.Step length asymmetry is a common characteristic of post-stroke gait, but considered as particularly resistant to conventional gait interventions. A recent novel approach using a split-belt treadmill (SBT) showed promising results in short- and long-term reduction of step length asymmetry post-stroke. However, the underlying mechanisms of this intervention and its effects must be better understood before recommending its use in clinical settings. This project aimed to improve our current knowledge about muscular and biomechanical factors contributing to immediate and long-term changes in step length asymmetry in chronic stroke survivors. The main objectives were to: 1) analyze muscle activity associated with changes in step length after walking at unequal belt speeds on a SBT; 2) test the effects of repeated exposure to SBT walking on step length asymmetry and gait ability during walking over ground; and 3) investigate the muscular contributions and strategies involved in these changes. To attain these objectives, a cross-sectional analysis was conducted followed by a pilot training study. The general hypothesis was that distal lower limb muscles are the main contributors to SBT-induced changes in step length asymmetry in chronic stroke survivors using a SBT protocol where two belts were set at unequal speeds with a ratio of 2:1 for a period of time (split-belt configuration). The cross-sectional study analyzed the immediate changes in muscle activity and step length after six minutes of SBT walking in a group of 16 individuals post-stroke and in 10 healthy controls. The findings confirmed that regardless of the side (paretic or non-paretic) walking on the fast belt during split-belt configuration, changes in muscle activity of the ankle plantar- and dorsiflexors were mainly associated with changes in step length symmetry (paper #1). The pilot training study demonstrated that repeated exposure to SBT protocol reduced step length asymmetry and improved walking speed over ground in 12 individuals post-stroke (paper #2). Improvements persisted at least one month post-training. Findings also indicated that from a therapist’s viewpoint the training protocol was easy to use and practical in a clinical environment (supplementary data paper #2). Paper #3 showed that these consistent improvements in gait parameters were achieved by a variety of muscular contributions and strategies which involved both lower limbs with a predominant contribution on the side that was trained on the faster belt. Large effect sizes were found in the plantarflexor group during late stance of gait for both net joint moments and muscle activity in the training study. These results combined with the findings of paper #1 indicate that overall, step length asymmetry post-stroke can be successfully reduced with repeated exposure to the tested SBT protocol with distal lower limb muscles appearing to be strong contributors to locomotor adaptation post-stroke and long-term changes in step length asymmetry. Larger control trials are necessary to confirm the relevance of the use of SBT protocols and to further understand the role of the distal lower limb muscles in improvements in step length symmetry post-stroke

More symmetrical gait after split-belt treadmill walking does not modify dynamic and postural balance in individuals post-stroke

Spontaneous gait is often asymmetrical in individuals post-stroke, despite their ability to walk more symmetrically on demand. Given the sensorimotor deficits in the paretic limb, this asymmetrical gait may facilitate balance maintenance. We used a split-belt walking protocol to alter gait asymmetry and determine the effects on dynamic and postural balance. Twenty individuals post-stroke walked on a split-belt treadmill. In two separate periods, the effect of walking with the non-paretic, and then the paretic leg, on the faster belt on spatio-temporal symmetry and balance were compared before and after these perturbation periods. Kinematic and kinetic data were collected using a motion analysis system and an instrumented treadmill to determine symmetry ratios of spatiotemporal parameters and dynamic and postural balance. Balance, quantified by the concepts of stabilizing and destabilizing forces, was compared before and after split-belt walking for subgroups of participants who improved and worsened their symmetry. The side on the slow belt during split-belt walking, but not the changes in asymmetry, affected balance. Difficulty in maintaining balance was higher during stance phase of the leg that was on the slow belt and lower on the contralateral side after split-belt walking, mostly because the center of pressure was closer (higher difficulty) or further (lower difficulty) from the limit of the base of support, respectively. Changes in spatiotemporal parameters may be sought without additional alteration of balance during gait post-stroke

Vergleich zweier Bandagetechniken bei sekundärem Armlymphödem nach Brustkrebs – Wirkung des Zweilagen-Kompressionssystems „3M Coban 2 Lite“ auf das Ödemvolumen und die Lebensqualität bei brustkrebsbedingtem Armlymphödem im Vergleich zur Dreischichten-Kompressionsbandage : eine Kohortenstudie

Hintergrund Das Armlymphödem ist eine mögliche Folge bei axillärer Lymphknotenentfernung aufgrund von Brustkrebs und führt zu Einschränkungen im Alltag sowie der Lebensqualität. Aktuell ist unklar, durch welches Bandagematerial während der komplexen physikalischen Entstauungstherapie die größere Volumenreduktion bei bestmöglicher Lebensqualität erfolgen kann. Ziel Beantwortung der Frage, ob das Zweilagen-Kompressionssystem „3M™ Coban™ 2 Lite“ bei Patientinnen mit sekundärem Armlymphödem innerhalb einer einwöchigen Intensivphase eine größere prozentuale Ödemvolumenreduktion bewirken kann als die Therapie mit klassischen Kurzzugbinden. Zudem wurde evaluiert, welches der beiden Materialien mit einem besseren Therapieempfinden und einer höheren Lebensqualität verknüpft ist. Methode Von März 2021 bis November 2021 wurden im Kantonsspital Winterthur Intensivphasen bei Frauen mit sekundärem Lymphödem durchgeführt. Im Rahmen der Standardtherapie erhielten sie während einer Woche entweder 3-mal pro Woche eine Coban-Lite-Bandage oder täglich eine klassische Kurzzugbandage. Ausgewertet wurde die prozentuale Ödemvolumenreduktion, die Lebensqualität und das Therapieempfinden nach einer Woche Therapie. Ergebnisse Daten von 34 Patientinnen, jeweils 17 pro Gruppe, wurden ausgewertet. Die prozentuale Ödemvolumenreduktion von 55,1 % in der Coban-Lite-Gruppe und 35,0 % in der Klassische-Bandage-Gruppe (p = 0,067; 95 % KI [−0,646; 28,809]) sowie die Lebensqualität (p = 0,202; 95 % KI [−1,11; 0,22]) unterschieden sich in beiden Gruppen nicht signifikant voneinander. Das Therapieempfinden war jedoch in der Coban-Lite-Gruppe signifikant besser als in der Klassische-Bandage-Gruppe (p = 0,004; 95 % KI [−117; −0,17]) und wies eine mittlere Effektstärke (r = 0,488) auf. Schlussfolgerung Die Anwendung der beiden Bandagetechniken zeigten keinen statistisch signifikanten Gruppenunterschied hinsichtlich der Ödemvolumenreduktion nach einer Woche. Während dieser Zeit wurden mit der Coban-Lite-Bandage weniger Therapiesitzungen durchgeführt als mit der klassischen Bandage. Zudem erzielte die Coban-Lite-Bandage beim Therapieempfinden ein signifikant besseres Ergebnis

Feasibility of an Outpatient Training Program after COVID-19

Long-term physical consequences of coronavirus disease 2019 (COVID-19) are currently being reported. As a result, the focus is turning towards interventions that support recovery after hospitalization. To date, the feasibility of an outpatient program for people recovering from COVID-19 has not been investigated. This study presents data for a physiotherapy-led, comprehensive outpatient pulmonary rehabilitation (PR) program. Patients were recruited after hospital discharge. Training consisted of twice weekly, interval-based aerobic cycle endurance (ACE) training, followed by resistance training (RT); 60–90 min per session at intensities of 50% peak work rate; education and physical activity coaching were also provided. Feasibility outcomes included: recruitment and dropout rates, number of training sessions undertaken, and tolerability for dose and training mode. Of the 65 patients discharged home during the study period, 12 were successfully enrolled onto the program. Three dropouts (25%) were reported after 11–19 sessions. Tolerability of interval-based training was 83% and 100% for exercise duration of ACE and RT, respectively; 92% for training intensity, 83% progressive increase of intensity, and 83% mode in ACE. We tentatively suggest from these preliminary findings that the PR protocol used may be both feasible, and confer benefits to a small subgroup of patients recovering from COVID-19

Lower limb joint moments on the fast belt contribute to a reduction of step length asymmetry over ground after split-belt treadmill training in stroke : a pilot study

The main goal was to investigate changes in muscle activity and joint moments related to step length (SL) symmetry improvements in individuals poststroke following repeated split-belt treadmill (SBT) walking. Twelve individuals with a first unilateral cerebral stroke presenting initial SL asymmetry (ratio = 1.10-2.05), and mean time post stroke 23 (SD 24.7 months) were included. Participants were trained during six sessions of SBT walking using an error-augmentation protocol. The training resulted in a reduction in SL asymmetry during walking over ground retained over 1-month post-training (p = 0.002). Significant increases in SL and joint moments (plantarflexors: 20-60%, knee flexors: 20-60% and hip extensors: 0-20% of the gait cycle) were observed on the side trained on the fast belt (effect size from 0.41 to 0.60). The improvement in SL symmetry was observed with an increase in plantarflexion joint moment symmetry. Changes in muscle activity varied among participants. In contrast to previous findings with a single exposure to SBT-training, our results showed no negative effects on paretic plantarflexors when walking over ground after repeated exposure to SBT walking. These findings justify larger trials to gain more solid information on the current protocol which appears as an efficient training for long-term recovery on SL asymmetry and on affected plantarflexors

Repeated split-belt treadmill walking improved gait ability in individuals with chronic stroke: A pilot study

<p>This study investigated the effects of repeated split-belt treadmill (SBT) walking on gait ability in individuals poststroke. Twelve individuals with a first unilateral cerebral stroke (10 males; mean age 53 (SD 8.74); mean time poststroke 25 months (SD 23.5); 9 left-sided stroke) and initial step length (SL) asymmetry (ratio = 1.10–2.05) volunteered for the study. They were trained by physiotherapists from an outpatient rehabilitation center six times over 2–3 weeks using a SBT protocol. After only six sessions of training, all participants reduced their SL asymmetry from an average ratio of 1.39 to 1.17 (<i>p</i> = 0.002) and increased walking speed (<i>p</i> = 0.043). Improvements in symmetry and speed were retained over 1 month (<i>p</i> ≤ 0.008). No effect was observed in participants’ endurance, assessed with the 6-min walk test. These findings suggest that the present SBT protocol has potential to be an efficient intervention to improve not only SL symmetry but also gait speed, in individuals poststroke.</p

Effects of moderate-intensity aerobic exercise on serum BDNF and motor learning in the upper-limb in patients after chronic-stroke: A randomized, controlled feasibility study with embedded health economic evaluation

Background: Brain-derived neurotrophic factor (BDNF) promotes activity-dependent neuroplasticity and is released following aerobic-exercise. Objective: Feasibility and efficacy of 1.Moderate-Intensity Cycle-Ergometer-Training (MI-ET) and 2.Low-Intensity Circuit-Training (LI-CT) on BDNF-serum-concentration in chronic-stroke and consequently efficacy of motor-learning in varying BDNF-concentrations (neuroplasticity being the substrate for motor-learning) via upper-limb robotic-training (RT) in both groups. Methods: Randomised-control feasibility-study. 12-week, 3x/week intervention, 17 chronic-stroke-survivors randomized into: (1) MI-ET&RT or (2) LI-CT&RT. Both groups completed 40 mins MI-ET or LI-CT followed by 40 mins RT. Feasibility outcomes: (1) screening and enrollment-rates, (2) retention-rates, (3) adherence: (i) attendance-rates, (ii) training-duration, (4) adverse events. Primary clinical outcomes: 1. serum-BDNF changes pre-post training (immediate) and pre-training basal-levels over 12-weeks (long-term). 2.upper-limb performance with Action-Research-Arm-Test (ARAT). Additionally, feasibility of an embedded health economic evaluation (HEE) to evaluate health-costs and cost-effectiveness. Outcomes: cost-questionnaire return-rates, cost-of-illness (COI) and Health-Utitility-Index (HUI). Results: 21.5% of eligible and contactable enrolled. 10 randomized to MI-ET and 7 to LI-CT. 85% of training-sessions were completed in MI-ET (306/360) and 76.3% in LI-CT-group (165/216). 12-weeks: Drop-outs MI-ET-10%, LI-CT-43%. Clinical outcomes: No significant changes in immediate or long-term serum-BDNF in either group. Moderate-intensity aerobic-training did not increase serum-BDNF post-stroke. Individual but no group clinically-relevant changes in ARAT-scores. HEE outcomes at 12-weeks: 100% cost-questionnaires returned. Group-costs baseline and after treatment, consistently favouring MI-ET group. COI: (1-year-time-frame): MI-ET 67382 SD (43107) Swiss-Francs and LI-CT 95701(29473) Swiss-Francs. Conclusion: The study is feasible with modifications. Future studies should compare high-intensity versus moderate-intensity aerobic-exercise combined with higher dosage arm-training

One year follow-up of physical performance and quality of life in patients surviving COVID-19:a prospective cohort study

INTRODUCTION: The coronavirus disease (COVID-19) continues to affect many countries globally, with the long-term impact of the disease now being recognized. According to the latest research, some of the affected individuals continue to experience functional limitations, reduced physical performance and impaired health-related quality of life (HRQoL) even after eight months. This prospective cohort study aimed to describe the longer-term recovery of physical performance and HRQoL in COVID-19 survivors over one year. METHOD: A cohort (n = 43; 32-84 years old) hospitalized with COVID-19 between March and June 2020 was followed over one year and assessed at three time points: hospital discharge, 3 months and 12 months post-admission. Participants experienced mild (10/43) to critical (6/43) pneumonia and stayed in the hospital for a median of 10 days (IQR 9). Participants were assessed for physical performance (six-minute walk test), HRQoL (EQ-5D-5L), COVID-19 related limitations in functionality (PCFS), hospital-related anxiety and depression (HADS-A/-D), lung function (FEV1, FVC) and dyspnea during activity (mMRC). All assessments were conducted by physiotherapists trained in cardio-respiratory rehabilitation. RESULTS: After discharge, 8/34 showed reduced physical performance, 9/42 had lower HRQoL and 14/32 had COVID-19 induced limitations in functionality on the PCFS scale. Physical performance did not change significantly between discharge and 12-month follow-up, but 15/34 participants showed clinically relevant improvements in walking distance (>30 m). However, 16/34 had a decreased walking distance >30 m when comparing 3-month to 12-month follow-up. At 12 months, 12/41 of participants still perceived COVID-19 related limitations in daily life on the PCFS scale. For HRQoL, 12/41 participants still perceived moderate-to-severe symptoms of pain and discomfort and 13/41 slight-to-severe symptoms of anxiety and depression. CONCLUSION: This cohort of adult patients hospitalized for mild to severe COVID-19 in Switzerland was generally mildly affected but still reported some limitations after one year. These results offer preliminary indications for ongoing support after hospitalization and point towards the need for specific, individualized follow-up to support their recovery

Considering non-bladder etiologies of overactive bladder: A functional neuroimaging study

OBJECTIVES To better understand the neuropathophysiology of overactive bladder (OAB) in women by characterizing supraspinal activity in response to bladder distention and cold stimulation. SUBJECTS/PATIENTS AND METHODS We recruited 24 female participants, 12 with OAB [median age 40 years (interquartile range 32 - 42)] and 12 healthy controls (HCs) without lower urinary tract (LUT) symptoms [34 years (28 - 44)], and assessed LUT and cognitive function through neuro-urological examination, 3-day bladder diary, urodynamic investigation, and questionnaires. Functional magnetic resonance (MR) imaging at 3 Tesla scanner was performed in all participants during automated, repetitive bladder filling and draining (block design) with 100mL body-warm (37° C) saline using a MR-compatible and MR-synchronized infusion-drainage device until strong desire to void (HIGH-FILLING / DRAINING) and bladder filling with cold saline (4° C, i.e., COLD). Whole brain and region of interest analyses were conducted using Statistical Parametric Mapping version 12 (SMP12). RESULTS Significant between-group differences were found for 3-day bladder diary [i.e. micturition frequency per 24 hours (p0.05). In OAB patients, the HIGH task elicited activity in the superior temporal gyrus, ventrolateral prefrontal cortex, and mid-cingulate cortex, and the COLD task elicited activity in the ventrolateral prefrontal cortex, cerebellum, and basal ganglia. Compared to HCs, OAB patients showed significantly stronger cerebellar activity during HIGH-FILLING and significantly less activity in the insula and ventrolateral prefrontal cortex during HIGH-DRAINING. CONCLUSIONS The current findings suggest a sensory processing and modulation deficiency in our OAB group, probably as part of their underlying pathophysiology, as they lack activity in essential sensory processing areas such as the insula. Instead, accessory areas such as the cerebellum showed significantly stronger activation compared to HCs, presumably supporting pelvic-floor motor activity to prevent incontinence. The novel findings of this study provide physiologic evidence of the necessity to consider non-bladder etiologies of bladder symptoms