Impact of Intensive Gait Training With and Without Electromechanical Assistance in the Chronic Phase After Stroke-A Multi-Arm Randomized Controlled Trial With a 6 and 12 Months Follow Up.

Introduction: Movement related impairments and limitations in walking are common long-term after stroke. This multi-arm randomized controlled trial explored the impact of training with an electromechanically assisted gait training (EAGT) system, i.e., the Hybrid Assistive Limb® (HAL), when integrated with conventional rehabilitation focused on gait and mobility. Material and Methods: Participants, aged 18-70 years with lower extremity paresis but able to walk with manual support or supervision 1-10 years after stroke, were randomized to (A) HAL-training on a treadmill, combined with conventional rehabilitation interventions (HAL-group), or (B) conventional rehabilitation interventions only (Conventional group), 3 days/week for 6 weeks, or (C) no intervention (Control group). Participants in the Control group were interviewed weekly regarding their scheduled training. Primary outcome was endurance in walking quantified by the 6 Minute Walk Test (6MWT). A rater blinded to treatment allocation performed assessments pre- and post-intervention and at follow-ups at 6 and 12 months. Baseline assessment included the National Institute of Health Stroke Scale (NIHSS) and the Modified Ranking Scale (MRS). Secondary outcomes included the Fugl Meyer Assessment- Lower Extremity, 10 Meter Walk Test, Berg Balance Scale (BBS), Barthel Index (BI) and perceived mobility with the Stroke Impact Scale. Results: A total of 48 participants completed the intervention period. The HAL-group walked twice as far as the Conventional group during the intervention. Post-intervention, both groups exhibited improved 6 MWT results, while the Control group had declined. A significant improvement was only found in the Conventional group and when compared to the Control group (Tukey HSD p = 0.022), and not between the HAL group and Conventional group (Tukey HSD p = 0.258) or the HAL- group and the Control group (Tukey HSD p = 0.447). There was also a significant decline in the Conventional group from post-intervention to 6 months follow up (p = 0.043). The best fitting model to predict outcome included initial balance (BBS), followed by stroke severity (NIHSS), and dependence in activity and participation (BI and MRS). Conclusion: Intensive conventional gait training induced significant improvements long-term after stroke while integrating treadmill based EAGT had no additional value in this study sample. The results may support cost effective evidence-based interventions for gait training long-term after stroke and further development of EAGT. Trial registration: Published on clinicaltrials.gov (NCT02545088) August 24, 2015.

Long-term follow-up of patients with prior polio over a 17-year period.

OBJECTIVE: Follow-up of the health of patients with prior polio over a 17-year period. DESIGN: Follow-up study. PATIENTS: Patients with prior polio. METHODS: The study questionnaire was answered in 1995 by 270 patients. In 2012 the questionnaire was sent again to the surviving patients. RESULTS: Of the patients who answered the questionnaire in 1995, 116 (40%) were still alive in 2012. The group of patients who had died was older, and had a mean age of 70 years in 1995. A total of 60 patients participated in the study by answering the questionnaire in both 1995 and 2012. Most of these patients (84%) reported that they felt progressively worse, with poor mobility and increased muscle weakness in 2012 compared with 1995, and more than half reported a lower quality of life in 2012. The number of wheelchair users had increased significantly. Furthermore, the patients experienced increasing problems with activities of daily living (ADL) function. CONCLUSION: More than half of the patients with prior polio had died between 1995 and 2012. These patients were, on average, older than patients surviving in 2012. When interviewed in 2012 most of the patients felt progressively worse, with poor mobility and increased muscle weakness.

Characteristics of Patients at First Visit to a Polio Clinic in Sweden.

AIM: Describe polio patients visiting a polio clinic in Sweden, a country where vaccination was introduced in 1957. DESIGN: A consecutive cohort study. PATIENTS: Prior polio patients. METHODS: All patients (n = 865) visiting the polio clinic at Sahlgrenska University Hospital, Gothenburg Sweden, between 1994 and 2012 were included in this study. Data at first visit regarding patient characteristics, polio classification, data of electromyography, origin, assistive devices and gait speed as well as muscle strength were collected for these patients. Twenty-three patients were excluded because no polio diagnosis could be established. A total of 842 patients with confirmed polio remained in the study. RESULTS: More than twenty percent of the patients were from countries outside the Nordic region and considerably younger than those from the Nordic region. The majority of the emigrants were from Asia and Africa followed by Europe (outside the Nordic region). Of all patients included ninety-seven percent (n = 817) had polio in the lower extremity and almost 53% (n = 444) had polio in the upper extremity while 28% (n = 238) had polio in the trunk, according to clinical classification of polio. Compared with a sample of the normal population, the polio patients walked 61-71% slower, and were 53-77% weaker in muscle strength of the knee and foot as well as grip strength. CONCLUSION: The younger patients with polio emigrating from countries with different cultures may lead to a challenge for the multi professional teams working with post-polio rehabilitation and are of importance when planning for the care of polio patients the coming years.

Gait training early after stroke with a new exoskeleton--the hybrid assistive limb: a study of safety and feasibility.

BACKGROUND: Intensive task specific training early after stroke may enhance beneficial neuroplasticity and functional recovery. Impaired gait after hemiparetic stroke remains a challenge that may be approached early after stroke by use of novel technology. The aim of the study was to investigate the safety and feasibility of the exoskeleton Hybrid Assistive Limb (HAL) for intensive gait training as part of a regular inpatient rehabilitation program for hemiparetic patients with severely impaired gait early after stroke. METHODS: Eligible were patients until 7 weeks after hemiparetic stroke. Training with HAL was performed 5 days per week by the autonomous and/or the voluntary control mode offered by the system. The study protocol covered safety and feasibility issues and aspects on motor function, gait performance according to the 10 Meter Walking Test (10MWT) and Functional Ambulation Categories (FAC), and activity performance. RESULTS: Eight patients completed the study. Median time from stroke to inclusion was 35 days (range 6 to 46). Training started by use of the autonomous HAL mode in all and later switched to the voluntary mode in all but one and required one or two physiotherapists. Number of training sessions ranged from 6 to 31 (median 17) and walking time per session was around 25 minutes. The training was well tolerated and no serious adverse events occurred. All patients improved their walking ability during the training period, as reflected by the 10MWT (from 111.5 to 40 seconds in median) and the FAC (from 0 to 1.5 score in median). CONCLUSIONS: The HAL system enables intensive training of gait in hemiparetic patients with severely impaired gait function early after stroke. The system is safe when used as part of an inpatient rehabilitation program for these patients by experienced physiotherapists.

Gait characteristics and influence of fatigue during the 6-minute walk test in patients with post-polio syndrome.

OBJECTIVE: To evaluate gait in patients with post-polio syndrome, using the 6-minute walk test (6MWT) combined with three-dimensional kinematic analysis. DESIGN: Descriptive study. SUBJECTS: Eighteen patients and 11 healthy controls. METHODS: Kinematic data were obtained during a 6MWT by a Vicon motion capture system. Distance, heart rate, leg tiredness, dyspnoea and exertion were also recorded. RESULTS: Patients with post-polio syndrome showed larger increases in leg tiredness (p < 0.001) and dyspnoea (p < 0.05) as a result of the 6MWT than did controls. Walking speed decreased by 14.1% in patients vs 4.7% in controls (p < 0.05). Fourteen out of 18 patients displayed plantar-flexed ankle at initial contact (1/11 controls). At foot-off, the patients had a flexed hip (extended in controls) and a more flexed knee. Walking speed in patients correlated with hip angle at foot-off, at the start (r = -0.60, p < 0.001) and the end of the 6MWT (r = -0.74, p < 0.001), being higher the more the hip was extended. CONCLUSION: The 6MWT is fatiguing for patients with post-polio syndrome, and this was reflected in the kinematic data. Walking speed was negatively correlated with the increased hip flexion, but not with the ankle plantar-flexion at foot-off in the patients with post-polio syndrome. The three-dimensional results underscore the importance of hip function in this patient group.