Walking After Stroke: Interventions to restore normal gait pattern

Stroke is the leading cause of adult disability and inpatient rehabilitation admissions. In spite of many efforts, approximately 35% of stroke survivors with initial paralysis of the leg do not regain useful walking function. Many (potential) impairments and limitations have caused a marked variation in gait patterns among stroke patients. Hemiparetic gait is characterized by slow and asymmetric steps with poor selective motor control, delayed and disrupted equilibrium reactions and reduced weight bearing on the paretic limb. Although some general characteristics of hemiparetic gait have been identified, individual differences are great, emphasizing the need for individual assessment to identify the problems and design therapeutic interventions to address them. To provide a rationale for the proper selection of therapeutic interventions, we assessed the effectiveness of balance training, electrical stimulation, arm sling and AFO to improve hemiparetic gait pattern after stroke. Treatment outcome was evaluated by relevant clinical assessments together with time-distance, kinematic and kinetic gait characteristics measured by a quantitative three-dimensional gait analysis system. We concluded that task-specific interventions together with external feedback (balance training with force platform feedback) and orthosis, either enabling feedback or substituting a lost function or both (arm sling and AFO) are effective in improvement of postural control and gait symmetry in hemiparetic patients with stroke. However, impairment-focused therapies without any volitional participation of the patients (neuromuscular or somatosensory electrical stimulation) are not superior to a conventional stroke rehabilitation program

The Value of Calcaneal Bone Mass Measurement Using a Dual X-Ray Laser Calscan Device in Risk Screening for Osteoporosis

OBJECTIVE: To evaluate how bone mineral density in the calcaneus measured by a dual energy X-ray laser (DXL) correlates with bone mineral density in the spine and hip in Turkish women over 40 years of age and to determine whether calcaneal dual energy X-ray laser variables are associated with clinical risk factors to the same extent as axial bone mineral density measurements obtained using dual energy x-ray absorbtiometry (DXA). MATERIALS AND METHODS: A total of 2,884 Turkish women, aged 40-90 years, living in Ankara were randomly selected. Calcaneal bone mineral density was evaluated using a dual energy X-ray laser Calscan device. Subjects exhibiting a calcaneal dual energy X-ray laser T- score <-2.5 received a referral for DXA of the spine and hip. Besides dual energy X-ray laser measurements, all subjects were questioned about their medical history and the most relevant risk factors for osteoporosis. RESULTS: Using a T-score threshold of -2.5, which is recommended by the World Health Organization (WHO), dual energy X-ray laser calcaneal measurements showed that 13% of the subjects had osteoporosis, while another 56% had osteopenia. The mean calcaneal dual energy X-ray laser T-score of postmenopausal subjects who were smokers with a positive history of fracture, hormone replacement therapy (HRT), covered dressing style, lower educational level, no regular exercise habits, and low tea consumption was significantly lower than that obtained for the other group (p<0.05). A significant correlation was observed between the calcaneal dual energy X-ray laser T-score and age (r=-0.465, p=0.001), body mass index (BMI) (r=0.223, p=0.001), number of live births (r=-0.229, p=0.001), breast feeding time (r=-0.064, p=0.001), and age at menarche (r=-0.050, p=0.008). The correlations between calcaneal DXL and DXA T-scores (r=0.340, p=0.001) and calcaneal DXL and DXA Z-scores (r=0.360, p=0.001) at the spine, and calcaneal DXL and DXA T- scores (r=0.28, p=0.001) and calcaneal DXL and DXA Z-scores (r=0.33, p=0.001) at the femoral neck were statistically significant. CONCLUSION: Bone mineral density measurements in the calcaneus using a dual energy X-ray laser are valuable for screening Turkish women over 40 years of age for the risk of osteoporosis

Combining neural networks for gait classification

Gait analysis can be defined as the numerical and graphical representation of the mechanical measurements of human walking patterns and is used for two main purposes: human identification, where it is usually applied to security issues, and clinical applications, where it is used for the non-automated and automated diagnosis of various abnormalities and diseases. Automated or semi-automated systems are important in assisting physicians for diagnosis of various diseases. In this study, a semi-automated gait classification system is designed and implemented by using joint angle and time-distance data as features. Multilayer Pereeptrons (MLPs) Combination classifiers are used to categorize gait data into two categories; healthy and patient with knee osteoarthritis. Two popular approaches of combining neural networks are experimented and the results are compared according to different output combining rules. In the first one, same set is used to train all networks and afterwards the features are decomposed into five different sets. These two experiments show that using entire data set produces more accurate results than using decomposed data sets, but complexity becomes an important drawback. However, when a proper combining rule is applied to decomposed sets, results are more accurate than entire set. In this experiment sum rule produces better results than majority vote and max rules as an output combining rule

Ensemble classifiers for medical diagnosis of knee osteoarthritis using gait data

Automated or semi-automated gait analysis systems are important in assisting physicians for diagnosis of various diseases. The objective of this study is to discuss ensemble methods for gait classification as a part of preliminary studies of designing a semi-automated diagnosis system. For this purpose gait data is collected from 110 sick subjects (having knee Osteoarthritis (OA)) and 91 age-matched normal subjects. A set of Multilayer Perceptrons (MLPs) is trained by using joint angle and time-distance parameters of gait as features. Large dimensional feature vector is decomposed into feature subsets and the ones selected by gait expert are used to categorize subjects into two classes; healthy and patient. Ensemble of MLPs is built using these distinct feature subsets and diversification of classifiers is analyzed by cross-validation approach and confusion matrices. High diversifications observed in the confusion matrices suggested that using combining methods would help. Indeed when a proper combining rule is applied to decomposed sets, more accurate results are obtained The result suggests that ensemble of MLPs could be applied in the automated diagnosis of gait disorders in a clinical context

Turkish Adaptation and Reliability of Bad Sobemheim Stress Questionnaire in Adolescents With Idiopathic Scoliosis Using Spinal Brace

Objective: Interest of health professionals has been increased on stress and quality of life. Currently, there is no questionnaire in Turkish language to evaluate the stress level of adolescents with idiopathic scoliosis. Considering this deficiency in the field, the Bad Sobernheim Stress Questionnaire (BSSQ) was translated into Turkish and reliability of the questionnaire was evaluated on adolescents with idiopathic scoliosis using spinal orthoses

An Intelligent Clinical Decision Support System for Analyzing Neuromusculoskeletal Disorders

This study presents a clinical decision support system for detecting and further analyzing neuromusculoskeletal disorders using both clinical and gait data. The system is composed of a database storing disease characteristics, symptoms and gait data of the subjects, a combined pattern classifier that processes the data and user friendly interfaces. Data is mainly obtained through Computerized Gait Analysis, which can be defined as numerical representation of the mechanical measurements of human walking patterns. The decision support system uses mainly a combined classifier to incorporate the different types of data for better accuracy. A decision tree is developed with Multilayer Perceptrons at the leaves. The system is planned to be used for various neuromusculoskeletal disorders such as Cerebral Palsy (CP), stroke, and Osteoarthritis (OA). First experiments are performed with OA. Subjects are classified into four OA-severity categories, formed in accordance with the Kellgren-Lawrence scale: "Normal", "Mild", "Moderate", and "Severe". A classification accuracy of 80% is achieved on the test set. To complete the system, a patient follow-up mechanism is also designed

The Authors Respond [to: Dennison, Hirsch and Hammond]

We have read with interest the comments by Hirsch et al on our paper in their Letter to the Editor. The authors raise a number of interesting points that we would like to comment on. A first comment of Hirsch concerns our exclusion of patients with neglect. We decided to exclude these patients because clinical experience would suggest that patients with a left-sided neglect would not be able to easily practice while looking to their left in a mirror placed in the mid-sagital plane. While we agree with Hirsch that the study by Ramachandran et al on “mirror agnosia” is interesting, it is important to notice that in this study the mirror is used in a crucially different way. While the mirror in our study as other mirror therapy studies is placed mid-sagital in front of the patients, in the 1999 study by Ramachandran, the mirror is “on the patient’s right side in the parasagittal plane, so that when the patient rotates his head rightward and looks into the mirror, he sees the neglected side of the world reflected in the mirror.” While this concept is very interesting and warrants further study, it can not easily be combined with the mirror training in our study. However, it is interesting that in a recent randomized controlled trial on mirror therapy on upper-extremity motor recovery, Dohle et al found positive effects not only motor recovery, but also on the level of sensory and attentional deficits in 36 patients with severe hemiparesis after stroke.As mentioned by Hirsch, in our study, we excluded patients with ideomotor apraxia, defined as a deficit in the temporal and spatial sequencing of an action, to obtain a homogeneous group. However, we agree that studying the effect of mirror training in people with apraxia may be worth further study. It is well known that action-execution and action-observation are encoded by the same brain regions and mirrors may be effective in people with apraxia for recruitment of areas involved in motor planning mechanisms. In a recent functional magnetic resonance imaging study, we reported that mirror training in healthy subjects activates areas in the brain related to the mirror neuron system. On the other hand, in a recent study, Pazzaglia et al demonstrated that patients with limb apraxia, a specific deficit in executing skilled limb movements or gestures, also display a deficit in recognizing observed gestures.Another comment of Hirsch et al deals with a possible difference in the perception of credibility of the intervention in both groups. We agree that this is a valid point since practicing without a mirror will have been less interesting and will have raised less positive expectations than with a mirror. Unfortunately, this aspect is difficult to control in many therapy intervention investigation. Without further study, it is difficult to estimate size of this effect.As a final comment, the authors comment on the use of parametric tests. While we agree that a nonparametric test may have been more suited, we did check that the choice of test did not have a major impact on the statistical significance of our findings.We thank Hirsch for their compliments and interesting comments on our manuscript

Functional evaluation of intraarticular severely comminuted fractures of the calcaneus with gait analysis

Twenty-one patients (23 feet) treated nonsurgically for severely comminuted intraarticular fractures of the calcaneus were evaluated prospectively with a clinical scoring scale and computerized gait analysis. All patients had Sanders type III and type IV fractures. The treatment protocol consisted of no closed reduction, immobilization in removable splint, physiotherapy after edema subsided, and weightbearing after 8 weeks. All patients had a minimum follow-up of 2 years (mean, 38 months). Clinical results were good in 2 patients, fair in 3 patients, and poor in 16 patients. Gait analysis showed that patients were at high risk of gastrocnemius weakness and ankle and knee instability. These results may be useful for comparison with the results of other methods, such as open reduction and internal fixation, nonsurgical closed reduction, and arthrodesis