Rhythmic facilitation of gait training in hemiparetic stroke rehabilitation

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Abstract

Experimental and control groups of 10 hemiparetic stroke patients each underwent a 6 week, twice daily gait training program. The control group participated in a conventional physical therapy gait program. The experimental group trained in the same basic program with the addition of rhythmic auditory stimulation (RAS). Patients entered the study as soon as they could complete 5 strides with hand-held assistance. The training program had to be completed within 3 months of the patients' stroke. In the experimental group RAS was used as a timekeeper to synchronize step patterns and gradually entrain higher stride frequencies. Study groups were equated by gender, lesion site, and age. Motor function was assessed at pretest using Barthel, Fugl-Meyer, and Berg Scales. Walking patterns were assessed during pre- and post-test without RAS present. Pre- vs post-test measures revealed a statistically significant (P<0.05) increase in velocity (164% vs 107%), stride length (88% vs 34%), and reduction in EMG amplitude variability of the gastrocnemius muscle (69% vs 33%) for the RAS-training group compared to the control group. The difference in stride symmetry improvement (32% in the RAS-group vs 16% in the control group) was statistically not significant. The data offer evidence that RAS is an efficient tool to enhance efforts in gait rehabilitation with acute stroke patients.

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The functional anatomy of motor recovery after stroke in humans: a study with positron emission tomography.

R Frackowiak, Robert Wise, Alison Brooks … (1991)

We have studied regional cerebral blood flow changes in 6 patients after their recovery from a first hemiplegic stroke. All had a single well-defined hemispheric lesion and at least a brachial monoparesis that subsequently recovered. Each patient had 6 measurements of cerebral blood flow by positron tomography with 2 scans at rest, 2 during movement of fingers of the recovered hand, and 2 during movement of fingers of the normal hand. When the normal fingers were moved, regional cerebral blood flow increased significantly in contralateral primary sensorimotor cortex and in the ipsilateral cerebellar hemisphere. When the fingers of the recovered hand were moved, significant regional cerebral blood flow increases were observed in both contralateral and ipsilateral primary sensorimotor cortex and in both cerebellar hemispheres. Other regions, namely, insula, inferior parietal, and premotor cortex, were also bilaterally activated with movement of the recovered hand. We have also demonstrated, by using a new technique of image analysis, different functional connections between the thalamic nuclei and specific cortical and cerebellar regions during these movements. Our results suggest that ipsilateral motor pathways may play a role in the recovery of motor function after ischemic stroke.

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Repetitive training of isolated movements improves the outcome of motor rehabilitation of the centrally paretic hand.

Cathrin M Bütefisch, Horst Hummelsheim, Petra Denzler … (1995)

The effect of a standardized training on movements of the affected hand has been studied in 27 hemiparetic patients using a multiple baseline approach across individuals. The training consisted of repetitive hand and finger flexions and extensions against various loads and was carried out twice daily during 15-min periods. Grip strength (p < 0.006), peak force of isometric hand extensions (p < 0.05), peak acceleration (p < 0.05) of isotonic hand extensions as well as contraction velocities as indicators of motor performance significantly improved during the training period. In contrast to the standardized training of hand and finger movements, therapeutic strategies following the Bobath concept aim at reducing enhanced muscle tone without reinforcing the activity in centrally paretic distal muscle groups directly. Patients undergoing this treatment approach alone did not experience a significant improvement in the motor capacity of the hand. Therefore, the results of the present study emphasize the importance of frequent movement repetition for the motor rehabilitation of the centrally paretic hand and challenge conventional physiotherapeutic strategies that focus on spasticity reduction instead of early initiation of active movements.

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Task-specific physical therapy for optimization of gait recovery in acute stroke patients.

Carol Richards, Francine Malouin, Sharon Wood-Dauphinee … (1993)

A randomized controlled pilot trial was conducted to estimate the effects of early, intensive, gait-focused physical therapy on ambulatory ability in acute, stroke patients. Twenty-seven patients with middle cerebral artery infarct of thromboembolic origin confirmed by computed axial tomography scan were stratified and randomly assigned to the experimental group, to a control group that received early, intensive and conventional therapy, or to a group receiving routine conventional therapy that started later and was not intense. Assessments at entry, six weeks, and three and six months by independent evaluators permitted comparisons with reference to clinical measures of motor performance, balance, and functional capacity, and laboratory measures of gait movements. Group results at six weeks demonstrated that gait velocity was similar in the two conventional groups thereby eliminating the timing of the interventions as an important factor. At that point, gait velocity was faster in the experimental group. The difference translated into a moderate effect size of 0.58. The time dedicated to gait training but not to total therapy time was correlated (rs = 0.63) to gait velocity. This effect disappeared at three and six months after stroke. These pilot results justify planning a large trial to test the effectiveness of a therapeutic protocol that focuses on early and intense gait therapy in an effort to facilitate early ambulation following stroke.