Concurrent validity of Physiological Cost Index in walking over ground and during robotic training in subacute stroke patients.

Physiological Cost Index (PCI) has been proposed to assess gait demand. The purpose of the study was to establish whether PCI is a valid indicator in subacute stroke patients of energy cost of walking in different walking conditions, that is, over ground and on the Gait Trainer (GT) with body weight support (BWS). The study tested if correlations exist between PCI and ECW, indicating validity of the measure and, by implication, validity of PCI. Six patients (patient group (PG)) with subacute stroke and 6 healthy age- and size-matched subjects as control group (CG) performed, in a random sequence in different days, walking tests overground and on the GT with 0, 30, and 50% BWS. There was a good to excellent correlation between PCI and ECW in the observed walking conditions: in PG Pearson correlation was 0.919 (p < 0.001); in CG Pearson correlation was 0.852 (p < 0.001). In conclusion, the high significant correlations between PCI and ECW, in all the observed walking conditions, suggest that PCI is a valid outcome measure in subacute stroke patients.

Physiological responses and energy cost of walking on the Gait Trainer with and without body weight support in subacute stroke patients.

BACKGROUND: Robotic-assisted walking after stroke provides intensive task-oriented training. But, despite the growing diffusion of robotic devices little information is available about cardiorespiratory and metabolic responses during electromechanically-assisted repetitive walking exercise. Aim of the study was to determine whether use of an end-effector gait training (GT) machine with body weight support (BWS) would affect physiological responses and energy cost of walking (ECW) in subacute post-stroke hemiplegic patients. PARTICIPANTS: six patients (patient group: PG) with hemiplegia due to stroke (age: 66 ± 15y; time since stroke: 8 ± 3 weeks; four men) and 6 healthy subjects as control group (CG: age, 76 ± 7y; six men). INTERVENTIONS: overground walking test (OWT) and GT-assisted walking with 0%, 30% and 50% BWS (GT-BWS0%, 30% and 50%). MAIN OUTCOME MEASURES: heart rate (HR), pulmonary ventilation, oxygen consumption, respiratory exchange ratio (RER) and ECW. RESULTS: Intervention conditions significantly affected parameter values in steady state (HR: p = 0.005, V'E: p = 0.001, V'O2: p < 0.001) and the interaction condition per group affected ECW (p = 0.002). For PG, the most energy (V'O2 and ECW) demanding conditions were OWT and GT-BWS0%. On the contrary, for CG the least demanding condition was OWT. On the GT, increasing BWS produced a decrease in energy and cardiac demand in both groups. CONCLUSIONS: In PG, GT-BWS walking resulted in less cardiometabolic demand than overground walking. This suggests that GT-BWS walking training might be safer than overground walking training in subacute stroke patients.

After vs. priming effects of anodal transcranial direct current stimulation on upper extremity motor recovery in patients with subacute stroke.

PURPOSE: Transcranial direct current stimulation (tDCS) of the motor cortex seems to be effective in improving motor performance in patients with chronic stroke, while some recent findings have reported conflicting results for the subacute phase. We aimed to verify whether upper extremity motor rehabilitation could be enhanced by treatment with tDCS administered before a rehabilitative session. METHODS: Hand dexterity and force in 16 individuals with subacute stroke were assessed before (T0) and after anodal stimulation (T1) and after a successive session of motor rehabilitation (T2) in a double-blind, randomized, sham-controlled, crossover trial. To confirm the value of the device as a specific effector, behavioral tests were also administered. RESULTS: Anodal and sham stimulation plus rehabilitation significantly improved manual dexterity (repeated-measure Anova: A-tDCS: p = 0.005; S-tDCS: p = 0.042). Post hoc analysis revealed a significant stimulation effect only for A-tDCS (p = 0.013 between T0 and T1) and not for S-tDCS, whereas the rehabilitation effect (between T1 and T2) was not significant in either group. Hand force and behavioral features were unchanged. CONCLUSIONS: Anodal brain stimulation improves hand dexterity but does not increase the effectiveness of the rehabilitation directly. These results suggest the presence of aftereffects, not priming effects, of A-tDCS superimposed onto motor learning phenomena.

Influence of psychologic features on rehabilitation outcomes in patients with subacute stroke trained with robotic-aided walking therapy.

OBJECTIVE: The aim of this study was to investigate whether the rehabilitation outcomes with robotic-aided gait therapy may be affected by patients' and caregivers' psychologic features after subacute stroke. DESIGN: This is a controlled, longitudinal, observational pilot study conducted on 42 patients divided in robotic-assisted gait training plus conventional physical therapy group, robotic-assisted gait training dropout group, and conventional physical therapy group. The outcome measures were walking ability (Functional Ambulation Category) and independency in activities of daily living (Barthel Index) measured before and after intervention. Psychologic features were measured before intervention using the Hospital Anxiety and Depression Scale, the Eysenck Personality Questionnaire, and recovery locus of control in the patients and the State-Trait Anxiety Inventory and the Beck Depression Inventory in the caregivers. RESULTS: Patient anxiety was significantly higher in those who refused/abandoned robotic therapy (P = 0.002). In the subjects allocated to the robotic group, the recovery of walking ability was significantly affected by the perceived recovery locus of control (P = 0.039, odds ratio = 14); and the recovery of independency in activities of daily living, by anxiety (P = 0.018, odds ratio = 0.042). Conversely, psychologic factors did not significantly affect the outcomes of conventional rehabilitation. CONCLUSIONS: Psychologic features, particularly recovery locus of control and anxiety, affected the rehabilitative outcomes of the patients involved in robotic treatment more than those in conventional rehabilitation.

Assessment of upper-body dynamic stability during walking in patients with subacute stroke.

The analysis of upper-body acceleration is a promising and simple technique to quantitatively assess dynamic gait stability. However, this method has rarely been used for people with stroke, probably because of some technical issues still not addressed. We evaluated the root-mean-square (RMS) and harmonic ratio of trunk accelerations for a group of 15 inpatients with subacute stroke who were able to walk (61.4 +/- 14.9 yr) and compared them with those of an age-matched group of nondisabled subjects (65.1 +/- 8.8 yr) and those of a highly functional group of young nondisabled subjects (29.0 +/- 5.0 yr). Small (<2%) but significant (p < 0.03) differences were found in RMS values obtained by applying the two most common computational approaches: (1) averaging among individual-stride RMS values and (2) computing the RMS value over the entire walking trial without stride partitioning. We found that the intersubject dependency of acceleration RMS values by selected walking speed was specific for each group and for each of the three body axes. The analysis of ratios between these three accelerations provided informative outcomes correlated with clinical scores and not affected by walking speed. Our findings are an important step toward transferring accelerometry from human movement analysis laboratories to clinical settings.

Who may have durable benefit from robotic gait training?: a 2-year follow-up randomized controlled trial in patients with subacute stroke.

BACKGROUND AND PURPOSE: Robotic-assisted walking training after stroke aims to enhance the odd of regaining independent gait. Recent studies have suggested that this approach is more effective than conventional therapy alone only in severely affected patients. We determined whether these results persist at long-term follow-up. METHODS: Forty-eight nonambulant participants after subacute stroke were stratified by motricity index into high (<29) and low (≥29) motor impairment groups. Each arm was randomized to a robotic or control group at a mean of 20 days after stroke. All patients underwent 2 therapy sessions per day, 5 days per week, for 3 months. Robotic group subjects underwent 20 sessions of robotic-assisted gait training in the first 4 weeks of inpatient therapy and abbreviated conventional therapy, whereas control group patients received only conventional gait training. The primary outcome was Functional Ambulation Category, and secondary measures were the Rivermead Mobility Index and Barthel Index scores. The scales were administered before and after the inpatient stay and 2 years after discharge. RESULTS: At follow-up, as at discharge, the low motricity robotic group improved more than the control group counterpart with regard to functional ambulation category (4.7±0.5 versus 3.1±1.5, P=0.002), Barthel Index (76.9±11.5 versus 64.7±14.0, P=0.024), and Rivermead Mobility Index (11.8±3.5 versus 7.0±3.6, P=0.010), whereas conventional and robotic therapies were equally effective in the high motricity groups. CONCLUSIONS: The higher efficacy of the combination of robotic therapy and conventional therapy versus conventional therapy alone that was observed at discharge only in patients with greater motor impairments was sustained after 2 years.

Driving electromechanically assisted Gait Trainer for people with stroke.

Electromechanically assisted gait training is a promising task-oriented approach for gait restoration, especially for people with subacute stroke. However, few guidelines are available for selecting the parameter values of the electromechanical Gait Trainer (GT) (Reha-Stim; Berlin, Germany) and none is tailored to a patient's motor capacity. We assessed 342 GT sessions performed by 20 people with stroke who were stratified by Functional Ambulatory Category. In the first GT session of all patients, the body-weight support (BWS) required was higher than that reported in the literature. In further sessions, we noted a slow reduction of BWS and a fast increment of walking speed for the most-affected patients. Inverse trends were observed for the less-affected patients. In all the patients, the heart rate increment was about 20 beats per minute, even for sessions in which the number of strides performed was up to 500. In addition, the effective BWS measured during GT sessions was different from that initially selected by the physiotherapist. This difference depended mainly on the position of the GT platforms during selection. Finally, harness acceleration in the anteroposterior direction proved to be higher in patients with stroke than in nondisabled subjects. Our findings are an initial step toward scientifically selecting parameters in electromechanically assisted gait training.

Who may benefit from robotic-assisted gait training? A randomized clinical trial in patients with subacute stroke.

BACKGROUND: Robotic-assisted walking training after stroke aims to enable highly impaired patients to walk independently, but results have been mixed. OBJECTIVE: The authors aimed to identify the characteristics of patients who may be most likely to benefit. METHODS: A total of 48 participants with motor and gait dysfunction following subacute stroke were stratified by the motricity index into high (<29) and low (≥ 29) motor impairment groups. Each arm was randomized to a robotic or control group (RG or CG) at a mean of 20 days after stroke. All patients underwent 2 therapy sessions per day, 5 days per week for 3 months. Those in the RG underwent 20 sessions of robotic-assisted gait training in the first 4 weeks of inpatient therapy using controlled endpoint trajectories and abbreviated conventional therapy, whereas the CG received only conventional gait training. The primary outcome was the functional ambulation category (FAC), and secondary measures were the Rivermead mobility index (RMI) and 6-minute walking distance, all evaluated at hospital admission and at discharge. RESULTS: The lower motricity group assigned to an electromechanical device significantly improved in the FAC (P < .001), RMI (P = .001), and walking distance (P = .029). Conventional and robotic therapies were equivalent in the higher motricity arm. CONCLUSION: Robotic therapy combined with conventional therapy may be more effective than conventional therapy alone in patients with greater motor impairment during inpatient stroke rehabilitation.

Quantification of the probability of reaching mobility independence at discharge from a rehabilitation hospital in nonwalking early ischemic stroke patients: a multivariate study.

BACKGROUND: This study was designed to quantify the probability of recovery of mobility in admission nonwalking stroke survivors. METHODS: We evaluated 437 of 500 consecutive patients admitted for sequelae of first ischemic stroke within the first month. We performed several logistic regressions using mobility status at discharge (independence in stair climbing; walking outside and inside, without aid or supervision; walking with cane or other aid, or need for wheelchair) as dependent variable, and several independent variables, including stratification of patients according to their Barthel Index (BI) score into 6 classes (< or =10; 11-20; 21-30; 31-40; 41-50; 51-60). RESULTS: At discharge, 4.58% of patients were independent in stair climbing, 8.70% were able to walk outside, 14.41% to walk inside, and 27.46% to walk with cane or other aid, while 44.85% remained in wheelchair. Very low BI scores at admission were associated with a high risk of need for wheelchair, whereas patients with BI score 51-60 showed a high probability to reach independence in stair climbing (OR = 5.60). Age, severity of neurological impairment, global aphasia, unilateral spatial neglect, male gender and vocational status also played a prognostic role. CONCLUSIONS: The probability of potential mobility recovery can be quantified at admission with better accuracy for independence in stair climbing and walking outside without any aid (percentages correctly predicted 95.4 and 91.8%, respectively). Stratification of BI score may be useful to better quantify the risk for each patient.

Is sex a prognostic factor in stroke rehabilitation? A matched comparison.

BACKGROUND AND PURPOSE: We sought to assess the specific influence of sex on rehabilitation results. METHODS: A case-control study in 440 consecutive patients with sequelae of first ischemic stroke were enrolled in 2 subgroups (males and females) and matched for severity of stroke (evaluated by means of the Canadian Neurological Scale), age (within 1 year), and onset-admission interval (within 3 days). Functional data, evaluated by means of the Barthel Index and the Rivermead Mobility Index, were compared between subgroups. Logistic regressions were used to clarify the role of sex in affecting global autonomy and mobility. RESULTS: After rehabilitation treatment, a sex-related difference was observed essentially in the higher levels of response. Indeed, more men than women reached independence in both stair climbing and activities of daily living (ADL), with a higher response and effectiveness on mobility. In multivariate analyses, male patients had a 3 times higher probability than female patients of good autonomy in both stair climbing and ADL (odds ratio [OR]=3.22; 95% CI, 1.67 to 6.18 and OR=2.92; 95% CI, 1.63 to 5.42, respectively). Conversely, female patients had a higher risk of walking with a cane (OR=1.69; 95%, CI 1.04 to 2.76) or of partial autonomy with respect to ADL (OR=1.90; 95% CI, 1.25 to 2.91). No significant difference was found for the other functional parameters. CONCLUSIONS: Female sex is a mildly unfavorable prognostic factor in rehabilitation results after stroke.

Rehabilitation of left brain-damaged ischemic stroke patients: the role of comprehension language deficits. A matched comparison.

BACKGROUND: Aphasia is considered a risk factor for disability after stroke. The aim of this study was to assess the specific influence of aphasia on rehabilitation results. METHOD: A case-control study in consecutive left brain-damaged stroke inpatients, enrolled in three homogeneous subgroups [nonaphasic (NA) patients, aphasic with comprehension deficit (CD), and without comprehension deficit (NCD)] matched for age and onset-admission interval. Rehabilitation results (gain, efficiency, effectiveness of treatment, percentage and odds ratio of dropouts and of each degree of therapeutic response, assessed by Barthel Index and Rivermead Mobility Index) were compared among the subgroups. RESULTS: Two hundred and forty patients with sequelae of a first stroke were enrolled. CD patients, as compared with NCD and NA ones, had a significantly more severe basal neurological and functional status at admission, minor effectiveness on ADL and mobility, a higher percentage of low responders on ADL and urinary incontinence at discharge, and a risk of low therapeutic response on ADL nearly 4 times higher than the other patients (OR = 4.22, 95% CI = 1.90-9.38). The rehabilitative behavior between NCD and NA was similar. However, all subgroups (NA, CD and NCD) showed a significant improvement (p < 0.001) between their basal and discharge score, both on BI and RMI. CONCLUSIONS: Comprehension language deficit was confirmed to be a strong negative rehabilitation prognostic factor despite the speech therapy done by all CD patients.

Functional outcome of ischemic and hemorrhagic stroke patients after inpatient rehabilitation: a matched comparison.

BACKGROUND AND PURPOSE: The goal of this study was to assess the specific influence of stroke etiology on rehabilitation results. METHODS: This was a case-control study of 270 inpatients with sequelae of first stroke who were enrolled in homogeneous subgroups and matched for stroke severity, basal disability, age (within 1 year), sex, and onset admission interval (within 3 days) who were different only in terms of stroke origin, infarction versus hemorrhage. We compared the groups' length of stay, efficiency and effectiveness of treatment, and percentage of low and high responder patients. Odds ratios of dropouts and of low and high therapeutic response were also quantified. RESULTS: Compared with ischemic patients, hemorrhagic patients had significantly higher Canadian Neurological Scale and Rivermead Mobility Index scores at discharge; higher effectiveness and efficiency on the Canadian Neurological Scale, Barthel Index, and Rivermead Mobility Index; and a higher percentage of high responders on the Barthel Index. Hemorrhagic patients showed a probability of a high therapeutic response on the Barthel Index that was approximately 2.5 times greater than that of ischemic patients (odds ratio, 2.48; 95% confidence interval, 1.19 to 5.20; accuracy on prediction, 87.06%). CONCLUSIONS: The results of this study provide further evidence of better functional prognosis in stroke survivors with hemorrhagic stroke.

Aging and stroke rehabilitation. a case-comparison study.

The aim of this study was to assess the specific influence of age on basal functional status and rehabilitation results. We conducted a case-comparison study on 150 stroke inpatients. They were enrolled in homogeneous subgroups, matched for severity of stroke (measured by Canadian Neurological Scale - CNS) and onset admission interval (within 3 days) and divided into five subgroups according to age: or=85 years. Even when severity of stroke was the same, increasing age was associated with greater disability in activities of daily living (ADL) and mobility, minor results of rehabilitation treatment and shorter length of stay. Patients >or=85 years were nearly ten times as likely to show a low response in ADL (OR = 9.28, 95% CI = 2.89-29.76) and nearly six times in mobility (OR = 6.13, 95% CI = 2.18-17.25) than younger patients. However, rehabilitation treatment was efficacious also in patients >or=85 years, with effectiveness of treatment 27.96% on ADL and 18.64% on mobility. On one hand our results confirm the unfavorable influence of age on functional outcome and on the other that inpatient rehabilitation is substantially effective also for very old patients, although less than for younger ones.