Development of Gait Ability Assessment for hemiplegics (GAA) and verification of inter-rater reliability and validity.

Tomida K, Tanino G, Sonoda S, Hirano S, Itoh N, Saitoh E, Kagaya H, Suzuki A, Kawakami K, Miyajima T, Takai M. Development of Gait Ability Assessment for hemiplegics (GAA) and verification of inter-rater reliability and validity. Jpn J Compr Rehabil Sci 2021; 12: 19-26. Objective: To develop the Gait Ability Assessment for hemiplegics (GAA), and to verify its validity and inter-rater reliability. Methods: We developed the GAA, a new method for the assessment of gait ability. Next, we examined the inter-rater reliability of GAA by assessing gait ability of post-stroke patients by two physical therapists. Then, we verified the validity of GAA by comparing with the existing assessments methods comprising Functional Ambulation Categories (FAC), Functional Independence Measure (FIM)-walk, maximum walking speed, motor subscore of the FIM (FIM-M), and total score of affected-side motor function of the Stroke Impairment Assessment Set (SIAS-L/E). Results: Regarding the inter-rater reliability of GAA, κ coefficient was 0.76 and weighted κ coefficient was 0.96. The correlation coefficients between GAA scores and existing assessment methods were: 0.95 for FAC scores, 0.95 for FIM-walk scores, 0.82 for maximum walking speed, 0.89 for FIM-M, and 0.61 for SIAS-L/E, all of which showed a significant correlation (p<0.01). Conclusion: GAA has high inter-rater reliability as well as high validity as a gait ability assessment method, suggesting that it can be applied to research and clinical settings.

Randomized Controlled Trial of Gait Training Using Gait Exercise Assist Robot (GEAR) in Stroke Patients with Hemiplegia.

PURPOSE: This trial aimed to validate the effectiveness of using the Gait Exercise Assist Robot (GEAR) in patients with hemiplegia after primary stroke. METHODS: The study design was open-label randomized controlled trial. Twenty-six patients with hemiplegia after primary stroke admitted to the comprehensive inpatient rehabilitation wards were enrolled and randomized to a group using GEAR in gait training and a control group. The intervention period was 4 weeks. Evaluations were conducted at admission, during intervention period, 8 weeks from start of intervention, and at discharge. Primary outcome measure was improvement efficiency of Functional Independence Measure (FIM)-walk score (FIM-walk improvement efficiency) that was calculated at the time of achieving FIM-walk score 5 (supervision level) during the intervention period or as weekly gain in FIM-walk score during 4 weeks for those who did not achieve score 5. RESULTS: FIM-walk improvement efficiency was .7 ± .4 in GEAR group and .4 ± .3 in control group, and was significantly higher in GEAR group (P = .01). The FIM-walk score gain after 4 weeks was significantly higher in the GEAR group (P = .01), but there were no significant differences between 2 groups after 8 weeks and at discharge. CONCLUSIONS: Gait training using GEAR for 4 weeks improved walking ability of subacute stroke patients. GEAR contributes to early improvement of walking ability probably by the knee flexion assist during swing phase on the paralyzed side thereby increasing the volume of training, and by the finely adjustable stance/swing assist mechanism for the paralyzed limb which optimizes the training difficulty level.

Review of devices used in neuromuscular electrical stimulation for stroke rehabilitation.

Neuromuscular electrical stimulation (NMES), specifically functional electrical stimulation (FES) that compensates for voluntary motion, and therapeutic electrical stimulation (TES) aimed at muscle strengthening and recovery from paralysis are widely used in stroke rehabilitation. The electrical stimulation of muscle contraction should be synchronized with intended motion to restore paralysis. Therefore, NMES devices, which monitor electromyogram (EMG) or electroencephalogram (EEG) changes with motor intention and use them as a trigger, have been developed. Devices that modify the current intensity of NMES, based on EMG or EEG, have also been proposed. Given the diversity in devices and stimulation methods of NMES, the aim of the current review was to introduce some commercial FES and TES devices and application methods, which depend on the condition of the patient with stroke, including the degree of paralysis.

Characteristics of patients with hemiparetic stroke who yield highly reliable muscle strength measurements.

[Purpose] Accurate measurement of unaffected lower extremity muscle strength on the unaffected side is useful in patients with hemiparetic stroke; however, muscle strength measurement results in patients with hemiparetic stroke vary greatly compared with those in healthy individuals. The objective of the present study was to determine the characteristics of patients with hemiparetic stroke who yield highly reliable muscle strength measurements. [Subjects and Methods] The subjects were 55 incipient patients with hemiparetic stroke. Muscle strength was measured twice. Based on the measured changes and on error ranges in repeated measurements in previous studies, the subjects were divided into two groups: subjects whose measurement results were within the acceptable range, and those whose measurement results were not within the acceptable range. Logistic regression analysis was performed with this separation of groups as the dependent variable, and demographic data, physical functioning, and functional independence measure (FIM) as independent variables. [Results] From the analysis results, the FIM cognitive subscore was selected as a criterion for patient selection; the cutoff score was 19. [Conclusion] The results of the present study indicated that muscle strength measurements were highly reliable in patients with hemiparetic stroke with an FIM cognitive subscore of ≥19.

Ability of electrical stimulation therapy to improve the effectiveness of robotic training for paretic upper limbs in patients with stroke.

We investigated whether untriggered neuromuscular electrical stimulation (NMES) can increase the effectiveness of shoulder and elbow robotic training in patients with hemiparesis. Thirty subacute stroke patients were randomly equally allocated to robot only (RO) and robot and electrical stimulation (RE) groups. During training, shoulder and elbow movements were trained by operating the robotic arm with the paretic arm, and the robotic device helped to move the arm. In the RE group, the anterior deltoid and triceps brachii muscles were electrically stimulated at sub-motor threshold intensity. Training was performed (approximately 1h/day, 5 days/week for 2 weeks) in addition to regular rehabilitation. Active range of motion (ROM) values of shoulder flexion and abduction, and Fugl-Meyer assessment (FMA) scores were measured before and after training. Active shoulder ROM was significantly better after than before training in the RE group; however, no such improvement was noted in the RO group. FMA scores were significantly better in both groups, and there was no significant difference between the groups. Untriggered NMES might increase the effectiveness of shoulder and elbow robotic training in patients with hemiparesis. Additionally, NMES at a sub-motor threshold during robotic training might facilitate activation of paretic muscles, resulting in paralysis improvement.

Influence of increased amount of exercise on improvements in walking ability of convalescent patients with post-stroke hemiplegia.

[Purpose] This study aimed to determine the effects of increased amount of physical therapy exercise on improvements in the walking ability of patients with stroke. [Subjects and Methods] The subjects were selected from patients with stroke who were hospitalized in the convalescent rehabilitation ward, and included 91 patients who received physical therapy for 2.5-3 exercise sessions per day during 2005-2006 (PT3unit group), and 86 patients who received physical therapy for 4.5-6 exercise sessions per day during 2010-2015 (PT6unit group). The functional independence measure (FIM) score evaluates the walking ability of patients during hospital admission, 2 and 4 weeks after admission, and at discharge. The FIM score was stratified according to the degree of lower limb motor paralysis and subsequently compared between groups. [Results] Among the patients with complete paralysis and severe paralysis, the FIM-Walking scores at 4 weeks after admission and at discharge were significantly higher in the PT6unit group than in the PT3unit group. No significant differences were found between the PT6unit and PT3unit groups for patients with mild and moderate paralysis. [Conclusion] Higher amounts of physical therapy exercise contributed to improvements in the walking ability of patients with complete and severe lower limb paralysis.

Randomized controlled comparative study on effect of training to improve lower limb motor paralysis in convalescent patients with post-stroke hemiplegia.

[Purpose] The motor paralysis-improving effect on the hemiplegic lower limb was compared among mirror therapy, integrated volitional-control electrical stimulation, therapeutic electrical stimulation, repetitive facilitative exercises, and the standard training method in post-stroke hemiplegia patients. [Subjects and Methods] Eighty one stroke patients admitted to a convalescent rehabilitation ward were randomly allocated to the above 5 treatment groups. Each patient performed functional training of the paralytic lower limb for 20 minutes a day for 4 weeks, and changes in the lower limb function were investigated using the Stroke Impairment Assessment Set. [Results] The hip and knee joint functions did not significantly improve in the standard training control group, but significant improvements were observed after 4 weeks in the other intervention groups. Significant improvement was noted in the ankle joint function in all groups. [Conclusion] Although the results were influenced by spontaneous recovery and the standard training in the control group, the hip and knee joints were more markedly improved by the interventions in the other 4 groups of patients with moderate paralysis, compared to the control group.

Development of an ankle torque measurement device for measuring ankle torque during walking.

[Purpose] To develop a device for measuring the torque of an ankle joint during walking in order to quantify the characteristics of spasticity of the ankle and to verify the functionality of the device by testing it on the gait of an able-bodied individual and an equinovarus patient. [Subjects and Methods] An adjustable posterior strut (APS) ankle-foot orthosis (AFO) was used in which two torque sensors were mounted on the aluminum strut for measuring the anterior-posterior (AP) and medial-lateral (ML) directions. Two switches were also mounted at the heel and toe in order to detect the gait phase. An able-bodied individual and a left hemiplegic patient with equinovarus participated. They wore the device and walked on a treadmill to investigate the device's functionality. [Results] Linear relationships between the torques and the corresponding output of the torque sensors were observed. Upon the analyses of gait of an able-body subject and a hemiplegic patient, we observed toque matrices in both AP and ML directions during the gait of the both subjects. [Conclusion] We developed a device capable of measuring the torque in the AP and ML directions of ankle joints during gait.

How effective is the early fast treadmill gait speed training for stroke patients at the 2nd week after admission: comparison with comfortable gait speed at the 6th week.

[Purpose] The purpose of this study was to find whether a fast treadmill gait training speed is effective for the gait training of stroke patients in the early rehabilitation stage. [Subjects and Methods] Thirty-nine stroke patients were the subjects of our investigation. They walked on a treadmill with handrail supports at a fast speed (130% of their comfortable gait speed in the 2nd week). The treadmill gaits of the patients were recorded using a 3-dimensional analysis system at two and six weeks after their admissions. Intraclass Correlation Coefficients (ICC) of the temporal and spatial parameters of the two periods were statistically analyzed. [Results] For all of the patients, the ICCs of the measured parameters were greater than 0.58. In the case of patients whose gait speeds of the two periods were close, the ICC units were greater than 0.7. [Conclusion] The fast gait speed training allowed us to expose the patients to a gait speed that they were expected to acquire at a later stage of their rehabilitation. This training method was found to be beneficial for the mildly paralyzed patients.

Recovery process of standing postural control in hemiplegia after stroke.

[Purpose] The aim of this study was to investigate the recovery process of standing postural control in hemiplegia after stroke. [Subjects and Methods] Thirty-four inpatients with hemiparesis after first-onset stroke were included in this study. We measured the center of pressure fluctuations during quiet standing using a force platform at 2, 4, and 6 weeks after admission. We assessed weight-bearing asymmetry, and velocity and amplitude of body sway. [Results] Weight-bearing asymmetry diminished in the first 2 weeks of observation. Velocity of body sway also decreased significantly in the first 2 weeks, though its amplitude only decreased significantly after 4 weeks of observation. [Conclusion] Amplitude of body sway requires a longer time for significant improvement than weight-bearing asymmetry and velocity of body sway. Although the loading function of the paretic lower limb improved at an early stage, attainment of optimum postural control, including management of the affected paretic lower limb, requires much time.

Energy analysis reveals the negative effect of delays in passive movement mirror therapy.

Wavelet transform energy analyses of the mean and standard error of the electromyogram (EMG) and electroencephalogram (EEG) of eight subjects were investigated in passive movement mirror therapies with no delay (in-phase) and with delay (out-of-phase) situations in two frequency bands of 7.81-15.62 and 15.62-31.25 Hz. It was found that the energy levels of EEG at electrode C4 in the in-phase situation were lower than those in out-of-phase situations, while the energy levels of flexor and extensor forearm muscle groups were larger. With two exceptions, this pattern could be seen in all other subjects. The difference between the in-phase (D0) and out-of-phase situations (D025 and D05) for the frequency range of 15.62-31.25 Hz was found to be significant at a significance level of 0.05 (paired t-test analysis). The respective elevation and decline of EEG and EGM with regard to the increase of the delay may indicate the necessity for synchronization of passive movement and mirror therapy.

Multi-input/output alarming system for patients with inattention caused by higher cortical function disorder.

BACKGROUND: To apply advanced methods of communication, sensing, and instrumentation technologies to make a system that can help patients suffering from hemispatial neglect caused by higher cortical function disorder. METHOD: By using several sensors and actuators, the objective was to construct a tailor-made system for each patient. The input part of the system consists of sensors, an interface and transmitters. The output part consists of a receiver, logical arithmetic, an output interface and actuators. The information from the input part is sent to the output part in a wireless manner allowing the mobility of the input and output parts. RESULTS: The system and its functionality were realized. Voice alarming and neck muscle stimuli were applied to two patients. We could verify the applicability of the system to remind the patients to put on their wheelchair's brake and raise its footrest before attempting to stand for transferring to their beds. CONCLUSION: The designed and constructed multi-input/output system can be used effectively to alarm the patients.

Validity study of the standing test for imbalance and disequilibrium (SIDE): Is the amount of body sway in adopted postures consistent with item order?

The standing test for imbalance and disequilibrium (SIDE) is a discriminative measure developed for the purpose of identifying balance deficits that may cause falls. The purpose of the present study was to determine the validity of the sequence of postures used in SIDE. Subjects comprised 30 men with a mean (±standard deviation) age of 21.9±3.11 years (range 19-32 years) and 30 women with a mean age of 20.7±1.24 years (range 19-23 years). Center of pressure (COP) was measured using a stabilometer recording for 30s with a 20-Hz sampling frequency. The measurement postures that were similar to postures adopted in the SIDE were: standing with feet 20cm apart; standing with legs close and the insides of both feet touching; two tandem standing positions (with the dominant foot forward and with the non-dominant foot forward); and two single-leg standing positions (on the dominant foot and on the non-dominant foot). We calculated total path length and envelopment area of sway from the COP data. Statistical differences in means were determined using the Tukey-Kramer multiple comparison test. Results indicate that the orders of total path length and envelopment areas of sway in each posture were consistent with the item order of SIDE. Significant differences existed between the means of total path length and envelopment areas of sway in each posture (p<0.05), with the exception of both tandem standing positions and both one-leg standing positions. The item order of SIDE appears to show concurrent validity in terms of the amount of body sway in the adopted postures.

Change in thigh muscle cross-sectional area through administration of an anabolic steroid during routine stroke rehabilitation in hemiplegic patients.

OBJECTIVE: The aim of this study was to clarify the effect of administration of an anabolic steroid (AS) without the addition of specific training in stroke patients by measuring the cross-sectional area (CSA) of the thigh. DESIGN: Twenty-six hemiplegic stroke patients during subacute rehabilitation were randomly assigned to a metenolone enanthate (ME) administration group or a control group (CT group). In the ME group, ME (100 mg) was injected intramuscularly weekly for 6 wks in the ME group. The CSA of the bilateral thigh muscles was measured using computed tomography. Motor subscore of the Functional Independence Measure (FIM-M) was assessed before the experimental period. RESULTS: At the end of 6 wks, the CSA increase in the ME group (13.4%, affected side; 14.5%, unaffected side) was significantly larger than that in the CT group (3.3%, affected side; 5.2%, unaffected side). Correlation coefficients between the initial FIM-M score and the CSA increase at 6 wks were -0.754 for the affected side and -0.567 for the unaffected side in the ME group and 0.199 for the affected side and 0.431 for the unaffected side in the CT group. CONCLUSIONS: ME administration is effective for improving muscle CSA and, thus, muscle strengthening in stroke rehabilitation. The CSA increase in the ME group was most prominent in patients with a low initial FIM-M score.