Functional electrical stimulation versus ankle foot orthoses for foot-drop: a meta-analysis of orthotic effects

Objective: To compare the effects on walking of Functional Electrical Stimulation (FES) and Ankle Foot Orthoses (AFO) for foot-drop of central neurological origin, assessed in terms of unassisted walking behaviours compared with assisted walking following a period of use (combined-orthotic effects). Data Sources: MEDLINE, AMED, CINAHL, Cochrane Central Register of Controlled Trials, Scopus, REHABDATA, PEDro, NIHR Centre for Reviews and Dissemination and clinicaltrials.gov. plus reference list, journal, author and citation searches. Study Selection: English language comparative Randomised Controlled Trials (RCTs). Data Synthesis: Seven RCTs were eligible for inclusion. Two of these reported different results from the same trial and another two reported results from different follow up periods so were combined; resulting in five synthesised trials with 815 stroke participants. Meta-analyses of data from the final assessment in each study and three overlapping time-points showed comparable improvements in walking speed over ten metres (p=0.04-0.95), functional exercise capacity (p=0.10-0.31), timed up-and-go (p=0.812 and p=0.539) and perceived mobility (p=0.80) for both interventions. Conclusion: Data suggest that, in contrast to assumptions that predict FES superiority, AFOs have equally positive combined-orthotic effects as FES on key walking measures for foot-drop caused by stroke. However, further long-term, high-quality RCTs are required. These should focus on measuring the mechanisms-of-action; whether there is translation of improvements in impairment to function, plus detailed reporting of the devices used across diagnoses. Only then can robust clinical recommendations be made

Functional electrical stimulation and ankle foot orthoses provide equivalent therapeutic effects on foot drop: A meta-analysis providing direction for future research

Objective: To compare the randomized controlled trial evidence for therapeutic effects on walking of functional electrical stimulation and ankle foot orthoses for foot drop caused by central nervous system conditions. Data sources: MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, REHABDATA, PEDro, NIHR Centre for Reviews and Dissemination, Scopus and clinicaltrials.gov. Study selection: One reviewer screened titles/abstracts. Two independent reviewers then screened the full articles. Data extraction: One reviewer extracted data, another screened for accuracy. Risk of bias was assessed by 2 independent reviewers using the Cochrane Risk of Bias Tool. Data synthesis: Eight papers were eligible; 7 involving participants with stroke and 1 involving participants with cerebral palsy. Two papes reporting different measures from the same trial were grouped, resulting in 7 synthesized randomized controlled trials (n= 464). Meta-analysis of walking speed at final assessment (p = 0.46), for stroke participants (p = 0.54) and after 4–6 weeks’ use (p = 0.49) showed equal improvement for both devices. Conclusion: Functional electrical stimulation and ankle foot orthoses have an equally positive therapeutic effect on walking speed in non-progressive central nervous system diagnoses. The current randomized controlled trial evidence base does not show whether this improvement translates into the user’s own environment or reveal the mechanisms that achieve that change. Future studies should focus on measuring activity, muscle activity and gait kinematics. They should also report specific device details, capture sustained therapeutic effects and involve a variety of central nervous system diagnoses

Visual cue training to improve walking and turning after stroke:a study protocol for a multi-centre, single blind randomised pilot trial

Visual information comprises one of the most salient sources of information used to control walking and the dependence on vision to maintain dynamic stability increases following a stroke. We hypothesize, therefore, that rehabilitation efforts incorporating visual cues may be effective in triggering recovery and adaptability of gait following stroke. This feasibility trial aims to estimate probable recruitment rate, effect size, treatment adherence and response to gait training with visual cues in contrast to conventional overground walking practice following stroke.Methods/design: A 3-arm, parallel group, multi-centre, single blind, randomised control feasibility trial will compare overground visual cue training (O-VCT), treadmill visual cue training (T-VCT), and usual care (UC). Participants (n = 60) will be randomly assigned to one of three treatments by a central randomisation centre using computer generated tables to allocate treatment groups. The research assessor will remain blind to allocation. Treatment, delivered by physiotherapists, will be twice weekly for 8 weeks at participating outpatient hospital sites for the O-VCT or UC and in a University setting for T-VCT participants.Individuals with gait impairment due to stroke, with restricted community ambulation (gait spee

Effects of a physiotherapy and occupational therapy intervention on mobility and activity in care home residents: a cluster randomised controlled trial

Objective To compare the clinical effectiveness of a programme of physiotherapy and occupational therapy with standard care in care home residents who have mobility limitations and are dependent in performing activities of daily living

Validation of gait event detection by centre of pressure during target stepping in healthy and paretic gait

Background: Target-stepping paradigms are increasingly used to assess and train gait adaptability. Accurate gait-event detection (GED) is key to locating targets relative to the ongoing step cycle as well as measuring foot-placement error. In the current literature GED is either based on kinematics or centre of pressure (CoP), and both have been previously validated with young healthy individuals. However, CoP based GED has not been validated for stroke survivors who demonstrate altered CoP pattern. Methods: Young healthy adults and individuals affected by stroke stepped to targets on a treadmill, while gait events were measured using three detection methods; verticies of CoP cyclograms, and two kinematic criteria, 1) vertical velocity and position and of the heel marker, 2) anterior velocity and position of the heel and toe marker, were used. The percentage of unmatched gait events was used to determine the success of the GED method. The difference between CoP and kinematic GED methods were tested with two one sample (two-tailed) t-tests against a reference value of zero. Differences between group and paretic and non-paretic leg were tested with a repeated measures ANOVA. Results: The kinematic method based on vertical velocity only detected about 80% of foot contact events on the paretic side in stroke survivors while the method on anterior velocity was more successful in both young healthy adults as stroke survivors (3% young healthy and 7% stroke survivors unmatched). Both kinematic methods detected gait events significantly earlier than CoP GED (p<0.001) except for foot contact in stroke survivors based on the vertical velocity. Conclusions: CoP GED may be more appropriate for gait analyses of SS than kinematic methods; even when walking and varying steps

Comfortably numb? Experiences of people with stroke and lower limb sensation deficits: impact and solutions.

Purpose: To explore personal experiences of loss of foot sensation following stroke in order to inform the focus of clinical assessments and development of a vibrotactile insole. Methods: Qualitative design with an interpretive phenomenological approach to data collection and analysis. Eight community dwelling adults with stroke (>6 months) and sensory impairment in the feet participated. Data was collected via conversational style interviews which were transcribed and analyzed using a thematic framework. Themes were verified with co-researchers and a lay advisory group. Results: Data formed four themes: Sensory deficits are prevalent and constant, but individual and variable; Sensory deficits have a direct impact on balance, gait, mobility and falls; Sensory deficits have consequences for peoples' lives; Footwear is the link between function, the environment and identity. They embraced the concept of discrete vibrotactile insoles, their potential benefits and demonstrated a willingness to try it. Conclusions: Sensory deficit contributes to effects upon physical function, mobility and activity. Clinical outcome measures need to capture the emotional, psychological and social impacts of sensory deficit. Participants demonstrated a resilience and resourcefulness through adaption in daily living and self-management of footwear. The participants focus on footwear provides the opportunity to develop discrete and non-burdensome vibrotactile insoles for this patient group. IMPLICATIONS FOR REHABILITATION Sensory deficits are wide ranging and varied and are not distinct from motor deficits though contribute to the overall effect on physical function, mobility and activity. The physical effects impact on participants' lives emotionally, psychologically and socially. Measurement of outcomes need to capture specific activities that are valued by patients. The participants have revealed resilience and resourcefulness to create a "new normal" for their lives through adaption and self-management with a focus being on footwear as a solution. The participants have revealed the need for insole interventions to be discreet and non-burdensome, welcoming insole technology and contributing to the design and features of such insoles

Foot-placement accuracy during planned and reactive target stepping during walking in stroke survivors and healthy adults

Background: The high prevalence of falls due to trips and slips following stroke may signify difficulty adjusting foot-placement in response to the environment. However, little is known about under what circumstances foot-placement adjustment becomes difficult for stroke survivors (SS), making the design of targeted rehabilitation interventions to improve independent community mobility difficult. Research question: To investigate the effect of planned and reactive target-stepping on foot-placement accuracy in stroke survivors and young and older healthy adults? Methods: Young (N=11, 30±6 years) and older (N=10, 64±8 years) healthy adults and SS (N=11, 67±9 years) walked, at preferred pace, on a force instrumented treadmill. Each participant walked to illuminated targets, visible two steps in advance (planned) or appearing at contralateral midstance (reactive). Foot-placement error (magnitude and bias) and number of missed targets were compared. Results: All participants missed more reactive than planned targets (p=0.05), and SS missed more targets than young (p<0.001) and older (p=0.001) adults. But no interaction showing SS missed more reactive targets than other groups was found. For all groups: reactive adaptations to steps in the anterio-posterior plane resulted in lower error than planned adaptations (p=0.027). Lengthening steps where undershot more than shortening (p<0.001) by all groups. Reactive medio-lateral adaptations over all induced larger error (p=0.029) than planned and changed the direction of bias (p=0.018). Significance: SS experience difficulty making all adjustments, they showed increased error in all conditions but less pronounced difference between planned and reactive stepping. SS may use a reactive control strategy for all adjustments, in contrast to healthy young adults who may plan foot-placement in advance. The likelihood of stroke survivors misplacing a step is large, with 9.8% targets missed; possibly leading to falls. Further investigation is needed to understand foot-placement control strategies used by SS and the role of planning in gait adaptability

Characteristics of voluntary-induced stepping response in persons with stroke compared with those of healthy young and older adults

Background: Impairment of protective steps to recover balance from external perturbation is evident after stroke. Voluntary-induced stepping response (VSR) can be used to practice protective steps by instructing an individual to voluntarily lean their whole body forward until they perceive a loss of balance and automatically induce a step. However, to improve protective stepping performance, detailed characteristics of VSR in healthy persons are required. Research question: What is the difference in VSR between healthy and persons with stroke? Methods: An observational study was conducted in 30 participants, (10 young, 10 older, and 10 persons with stroke). All participants performed VSR for 10 trials. Step length, step width, step duration, CoM position, CoM velocity, trunk-hip displacement, and strategies of response were recorded using a motion capture system and analysed using Matlab software. Statistical analysis was performed using One-way ANOVA and Chi-square. Results: On average, participants with stroke had shorter step lengths and step durations than young and older adults. Step width of older adults and participants with stroke was wider than that of young adults (p<0.05). While multiple steps and losing balance were reported more frequently in participants with stroke than the others, the percentage of trials in which participants grasped the handrails was not significantly different between older adults and participants with stroke. CoM position, CoM velocity, and trunk-hip displacement at foot liftoff were significantly smaller in older adults and participants with stroke than young adults (p<0.05). Participants with stroke tended to use trunk bending rather than trunk leaning strategies to generate VSR in contrast to healthy participant. The prevalence of the trunk bending strategy was also greater in older adults than young adults. Significance: Values obtained from healthy groups can be used as guidelines to set realistic goals during VSR training to improve protective steps in patients with stroke

Estimation of muscle activation during different walking speeds with two mathematical approaches compared to surface EMG

Background Muscle force estimation could improve clinical gait analysis by enhancing insight into causes of impairments and informing targeted treatments. However, it is not currently standard practice to use muscle force models to augment clinical gait analysis, partly, because robust validations of estimated muscle activations, underpinning force modelling processes, against recorded electromyography (EMG) are lacking. Research Question Therefore, in order to facilitate future clinical use, this study sought to validate estimated lower limb muscle activation using two mathematical models (static optimisation SO, computed muscle control CMC) against recorded muscle activations of ten healthy participants. Methods Participants walked at five speeds. Visual agreement in activation onset and offset as well as linear correlation (r) and mean absolute error (MAE) between models and EMG were evaluated. Results MAE between measured and recorded activations were variable across speeds (SO vs EMG 15–68%, CMC vs EMG 13–69%). Slower speeds resulted in smaller deviations (mean MAE &lt; 30%) than faster speeds. Correlation was high (r &gt; 0.5) for only 11/40 (CMC) and 6/40 (SO) conditions (muscles X speeds) compared to EMG. Significance Modelling approaches do not yet show sufficient consistency of agreement between estimated and recorded muscle activation to support recommending immediate clinical adoption of muscle force modelling. This may be because assumptions underlying muscle activation estimations (e.g. muscles’ anatomy and maximum voluntary contraction) are not yet sufficiently individualizable. Future research needs to find timely and cost efficient ways to scale musculoskeletal models for better individualisation to facilitate future clinical implementation