Walking adaptability therapy after stroke: study protocol for a randomized controlled trial

Background: Walking in everyday life requires the ability to adapt walking to the environment. This adaptability is often impaired after stroke, and this might contribute to the increased fall risk after stroke. To improve safe community ambulation, walking adaptability training might be beneficial after stroke. This study is designed to compare the effects of two interventions for improving walking speed and walking adaptability: treadmill-based C-Mill therapy (therapy with augmented reality) and the overground FALLS program (a conventional therapy program). We hypothesize that C-Mill therapy will result in better outcomes than the FALLS program, owing to its expected greater amount of walking practice.Methods: This is a single-center parallel group randomized controlled trial with pre-intervention, post-intervention, retention, and follow-up tests. Forty persons after stroke (≥3 months) with deficits in walking or balance will be included. Participants will be randomly allocated to either C-Mill therapy or the overground FALLS program for 5 weeks. Both interventions will incorporate practice of walking adaptability and will be matched in terms of frequency, duration, and therapist attention. Walking speed, as determined by the 10 Meter Walking Test, will bethe primary outcome measure. Secondary outcome measures will pertain to walking adaptability (10 Meter Walking Test with context or cognitive dual-task and Interactive Walkway assessments). Furthermore, commonly used clinicalmeasures to determine walking ability (Timed Up-and-Go test), walking independence (Functional Ambulation Category), balance (Berg Balance Scale), and balance confidence (Activities-specific Balance Confidence scale) will be used, as well as a complementary set of walking-related assessments. The amount of walking practice (the number of steps taken per session) will be registered using the treadmill’s inbuilt step counter (C-Mill therapy) and video recordings (FALLS program). This process measure will be compared between the two interventions.Discussion: This study will assess the effects of treadmill-based C-Mill therapy compared with the overground FALLS program and thereby the relative importance of the amount of walking practice as a key aspect of effective intervention programs directed at improving walking speed and walking adaptability after stroke.Trial registration: Netherlands Trial Register NTR4030. Registered on 11 June 2013, amendment filed on 17 June 2016.Keywords: Exercise, Rehabilitation, Stroke, Therapy, Walking adaptability, Walking spee

Arm load magnitude affects selective shoulder muscle activation

For isometric tasks, shoulder muscle forces are assumed to scale linearly with the external arm load magnitude, i.e., muscle force ratios are constant. Inverse dynamic modeling generally predicts such linear scaling behavior, with a critical role for the arbitrary load sharing criteria, i.e., the "cost function". We tested the linearity of the relation between external load magnitude exerted on the humerus and shoulder muscle activation. Six isometric force levels ranging from 17 to 100% of maximal arm force were exerted in 24 directions in a plane perpendicular to the longitudinal axis of the humerus. The direction of maximum muscle activation, the experimentally observed so called Principal Action (PA), was determined for each force magnitude in 12 healthy subjects. This experiment was also simulated with the Delft Shoulder and Elbow Model (DSEM) using two cost functions: (1) minimizing muscle stress and (2) a compound, energy related cost function. PA, both experimental (P

Assessing longitudinal change in coordination of the paretic upper limb using on-site 3-dimensional kinematic measurements

Background and Purpose. It is largely unknown how adaptive motor control of the paretic upper limb contributes to functional recovery after stroke. This paucity of knowledge emphasizes the need for longitudinal 3-dimensional (3D) kinematic studies with frequent measurements to establish changes in coordination after stroke. A portable 3D kinematic setup would facilitate the frequent follow-up of people poststroke. This case report shows how longitudinal kinematic changes of the upper limb can be measured at a patient's home using a portable 3D kinematic system in the first 6 months poststroke. Case Description. The outcomes of the upper-limb section of the Fugl-Meyer Motor Assessment (FMA), the Action Research Arm Test (ARAT), and 3D kinematic analyses were obtained from a 41-year-old man with a left hemispheric stroke. Three-dimensional kinematic data of the paretic upper limb were collected during a reach-to-grasp task using a portable motion tracker in 5 measurements during the first 6 months after stroke. Data from an individual who was healthy were used for comparison. Outcomes. The FMA and ARAT scores showed nonlinear recovery profiles, accompanied by significant changes in kinematic outcomes over time poststroke. Specifically, elbow extension increased, forward trunk motion decreased, peak hand speed increased, peak hand opening increased, and peak hand opening occurred sooner after peak hand speed. Discussion. This case report illustrates the feasibility of frequently repeated, on-site 3D kinematic measurements of the paretic upper limb. Early after stroke, task performance was mainly driven by adaptive motor control, whereas adaptations were mostly reduced at 26 weeks poststroke. The presented approach allows the investigation of what is changing in coordination and how these changes are related to the nonlinear pattern of improvements in body functions and activities after stroke. © 2012 American Physical Therapy Association

Relation between shoulder proprioception, kinematics and pain after stroke

Purpose: To identify a possible relationship between chronic Post-Stroke Shoulder Pain (PSSP), scapular resting pose and shoulder proprioception. Methods: A total of 21 inpatients with stroke and 10 healthy control subjects were included and kinematics and proprioception of both shoulders were measured. Results: The contralateral (i.e. paretic) shoulder of patients with PSSP showed more scapular lateral rotation and larger errors on proprioception tests compared to both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation compared to control subjects whereas their ipsilateral (i.e. unaffected) shoulder showed more scapular lateral rotation when compared to both control subjects and patients with good proprioception. Conclusions: A clear relation between affected shoulder kinematics, affected proprioception and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateralshoulder since it could be used in determining the risk of developing PSSP in the contralateral shoulder

Relation between shoulder proprioception, kinematics and pain after stroke

Purpose: To identify a possible relationship between chronic Post-Stroke Shoulder Pain (PSSP), scapular resting pose and shoulder proprioception. Methods: A total of 21 inpatients with stroke and 10 healthy control subjects were included and kinematics and proprioception of both shoulders were measured. Results: The contralateral (i.e. paretic) shoulder of patients with PSSP showed more scapular lateral rotation and larger errors on proprioception tests compared to both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation compared to control subjects whereas their ipsilateral (i.e. unaffected) shoulder showed more scapular lateral rotation when compared to both control subjects and patients with good proprioception. Conclusions: A clear relation between affected shoulder kinematics, affected proprioception and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateralshoulder since it could be used in determining the risk of developing PSSP in the contralateral shoulder

The monosynaptic Ia afferent pathway can largely explain the stretch duration effect of the long latency M2 response

Sudden stretch of active muscle typically results in two characteristic electromyographic responses: the short latency M1 and the long latency M2. The M1 response originates from the monosynaptic Ia afferent reflex pathway. The M2 response is less well understood and is likely a compound response to different afferent inputs mediated by spinal and transcortical pathways. In this study the possible contribution of the Ia afferent pathway to the M2 response was investigated. A mechanism was hypothesized in which the M1 response synchronizes the motoneurons, and therewith their refractory periods. Stretch perturbation experiments were performed on the wrist and results were compared with a computational model of a pool of motoneurons receiving tonic and Ia afferent input. The simulations showed the same stretch amplitude, velocity, and duration-dependent characteristics on the M2 as found experimentally. It was concluded that the stretch duration effect of the M2 likely originates from the proposed Ia afferent mediated mechanism.Biomechanical EngineeringMechanical, Maritime and Materials Engineerin

Characterizing the protocol for early modified constraint-induced movement therapy in the EXPLICIT-stroke trial

Item does not contain fulltextConstraint-induced movement therapy (CIMT) is a commonly used rehabilitation intervention to improve upper limb function after stroke. CIMT was originally developed for patients with a chronic upper limb paresis. Although there are indications that exercise interventions should start as early as possible after stroke, only a few randomized controlled trials have been published on either CIMT or modified forms of CIMT (mCIMT) during the acute phase after stroke. The implementation of (m)CIMT in published studies is very heterogeneous in terms of content, timing and intensity of therapy. Moreover, mCIMT studies often fail to provide a detailed description of the protocol applied. The purpose of the present paper is therefore to describe the essential elements of the mCIMT protocol as developed for the EXplaining PLastICITy after stroke (EXPLICIT-stroke) study. The EXPLICIT-stroke mCIMT protocol emphasizes restoring body functions, while preventing the development of compensatory movement strategies. More specifically, the intervention aims to improve active wrist -and finger extension, which is assumed to be a key factor for upper limb function. The intervention starts within 2 weeks after stroke onset. The protocol retains two of the three key elements of the original CIMT protocol, that is, repetitive training and the constraining element. Repetitive task training is applied for 1 hour per working day, and the patients wear a mitt for at least 3 hours per day for three consecutive weeks