Potential of Hybrid Assistive Limb Treatment for Ataxic Gait Due to Cerebellar Disorders Including Hemorrhage, Infarction, and Tumor.

Cerebellar hemorrhage (CH) is a severe life-threatening disorder, and surgical treatment is often required in an emergency situation. Even in cases in which the surgical procedure is successful, functional recovery is likely to be delayed because of cerebellar symptoms such as ataxia and gait disturbance. Here, we briefly review the efficacy of hybrid assistive limb (HAL) treatment in neurosurgical practice and propose a new comprehensive treatment strategy for CH to facilitate early neurological recovery. We have experienced cases of ataxic gait due to various etiologies, treated with rehabilitation using the HAL, and our data showed that HAL treatment potentially improves ataxic gait and balance problems. HAL treatment seems to be an effective and promising treatment modality for selected cases. Future studies should evaluate gait appearance and balance, in addition to walking speed, to assess improvement in cerebellar symptoms.

Use of dynamic movement orthoses to improve gait stability and trunk control in ataxic patients.

BACKGROUND: Patients with cerebellar ataxia show increased upper body movements, which have an impact on balance and walking. AIM: In this study, we investigated the effect of using dynamic movement orthoses (DMO), designed as elastic suits, on trunk motion and gait parameters. DESIGN: Longitudinal uncontrolled study. SETTING: Outpatient rehabilitation unit. POPULATION: Eleven patients (7 men, 4 women; mean age: 49.9±9.5 years) with degenerative cerebellar ataxia were enrolled in this study. METHODS: Linear overground gait of patients was recorded by means of an optoelectronic gait analysis system before DMO use (DMO-) and during DMO use (DMO+). Time-distance parameters, lower limb joint kinematics, body sway, trunk oscillations, and gait variability (coefficient of variation [CV]) were recorded. Patient satisfaction with DMO device was measured using Quebec user evaluation of satisfaction with assistive technology. RESULTS: When using the DMO, patients showed a significant decrease in stance phase duration, double support phase duration, swing phase CV, pelvic range of motion (ROM), body sway, and trunk ROMs. A significant increase was observed in the swing phase duration and knee joint ROM. Out of 11 patients, 10 were either quite satisfied (8 points) or very satisfied (2 points) with the assistive device. CONCLUSIONS: The DMO reduce the upper body motion and in improve balance-related gait parameters. CLINICAL REHABILITATION IMPACT: We propose use of DMO as an assistive/rehabilitative device in the neurorehabilitation of cerebellar ataxia to improve the trunk control and gait stability. DMO may be considered a prototype that can be modified in terms of material characteristics, textile layers, elastic components, and diagonal and lateral seams.

A wearable proprioceptive stabilizer for rehabilitation of limb and gait ataxia in hereditary cerebellar ataxias: a pilot open-labeled study.

The aim of this pilot study is to test the feasibility and effectiveness of a wearable proprioceptive stabilizer that emits focal mechanical vibrations in patients affected by hereditary cerebellar ataxias. Eleven adult patients with a confirmed genetic diagnosis of autosomal dominant spinocerebellar ataxia or Friedreich's ataxia were asked to wear an active device for 3 weeks. Assessments were performed at baseline, after the device use (T1), and 3 weeks after (T2). SARA, 9-HPT, PATA, 6MWT, and spatial and temporal gait parameters, measured with a BTS-G-Walk inertial sensor, were used as study endpoints. As expected, no adverse effects were reported. Statistically significant improvements in SARA, 9HPT dominant hand, PATA test, 6MWT, cadence, length cycle, support right/cycle, support left/cycle, flight right/cycle, flight left/cycle, double support right/cycle, double support left/cycle, single support right/cycle, and single support left/cycle were observed between T0 and T1. All parameters improved at T1 did not show statistically significant differences a T2, with the exception of length of cycle. This small open-labeled study shows preliminary evidence that focal mechanical vibration exerted by a wearable proprioceptive stabilizer might improve limb and gait ataxia in patients affected by hereditary cerebellar ataxias.

Biodex Fall Risk Assessment in the Elderly With Ataxia: A New Age-Dependent Derived Index in Rehabilitation: An Observational Study.

The aim of this study was to evaluate if the Biodex Fall Risk Assessment could provide an age-adjusted index useful for classifying patients at "risk of fall."This was a cohort study conducted on 61 chronic patients, in stable conditions, having a history of ataxia, difficulty in walking or loss of balance, and aged >64 years. These patients were coming from home to our Institute undergoing a period of in-hospital standard rehabilitation. Assessment of clinical parameters was performed at entry. Functional scales (Functional Independence Measure [FIM] for motor and cognitive function, Barthel G, Tinetti POMA), and the Biodex Fall Risk Index (FRI) were performed at entry and discharge. The Normalized FRI, obtained adjusting FRI to the reported maximum predictive FRI for the relevant age, identified 2 types of patients: those with a greater risk of fall than expected for that age, labeled Case 1 (Normalized FRI>1); and those with an equal or even lesser risk of fall than expected for that age, labeled Case 0 (Normalized FRI≤1).FRI, Normalized FRI as well as independent variables as age, sex, pathology group, FIM, BarthelG, were considered in a multiple regression analysis to predict the functional improvement (i.e., delta Tinetti Total score) after rehabilitation.Normalized FRI is useful in assessing patients at risk of falls both before and after rehabilitation. At admission, the Normalized FRI evidenced high fall risk in 46% of patients (Case 1) which decreased to 12% after rehabilitation, being greater than age-predicted in 7 patients (Case 1-1) despite the functional improvement observed after the rehabilitation treatment. Normalized FRI evidenced Case 1-1 patients as neurological, "very old" (86% in age-group 75-84 years), and with serious events at 18 to 24 months' follow-up. Normalized FRI, but not FRI, at admission was a predictor of improvement in Tinetti Total scores.The normalized FRI effectively indicated patients at higher risk of fall, in whom health deterioration, falls, or cognitive decline was later documented at follow-up. The normalized FRI could be a standardized measure for identifying frailer patients becoming a further criterium of discharge home and marker of fall risk at home.

Functional recovery and rehabilitation of postural impairment and gait ataxia in patients with acute cerebellar stroke.

Studies about recovery from cerebellar stroke are rare. The present study assessed motor deficits in the acute phase after isolated cerebellar stroke focusing on postural impairment and gait ataxia and outlines the role of lesion site on motor outcome, the course of recovery and the effect of treadmill training. 23 patients with acute and isolated cerebellar infarction participated. Deficits were quantified by ataxia scores and dynamic posturography in the acute phase and in a follow up after 2 weeks and 3 months. MRI data were obtained to correlate lesion site with motor performance. Half of the patients that gave informed consent and walked independently underwent a 2-week treadmill training with increasing velocity. In the acute phase patients showed a mild to severe ataxia with a worse performance in patients with infarction of the superior in comparison to the posterior inferior cerebellar artery. However, after 3 months differences between vascular territories were no longer significant. MRI data showed that patients with larger infarct volumes had a significantly more severe ataxia. In patients with ataxia of stance, gait and lower limbs lesions were more common in cerebellar lobules IV to VI. After 3 months a mild ataxia in lower limbs and gait, especially in gait speed persisted. Because postural impairment had fully recovered, remaining gait ataxia was likely related to incoordination of lower limbs. Treadmill training did not show significant effects. Future studies are needed to investigate whether intensive coordinative training is of benefit in patients with cerebellar stroke.

Gait ataxia--specific cerebellar influences and their rehabilitation.

It is well known that the cerebellum is important for movement control and plays a critical role in balance and locomotion. As such, one of the most characteristic and sensitive signs of cerebellar damage is gait ataxia. However, characterizing ataxic gait is no easy task, because gait patterns are highly variable. This variability seems to result from the interaction of different factors, namely, (1) the primary motor deficits in balance control and multi-joint coordination and oculomotor dysfunction, (2) the safety strategies used, and (3) inaccurate adjustments in patients with loss of balance. In this report, we review different approaches to analyzing ataxic gait and studies to identify and quantify the different factors contributing to this movement disorder. We also discuss the influence of the cerebellum in adaptive locomotor control, the interaction between cognitive load and gait in dual-task paradigms, and the recent advances in rehabilitation of gait and posture for patients with cerebellar degeneration. In the second part, we discuss open questions concerning cerebellar mechanisms in multi-joint coordination during different walking conditions. Furthermore, we point out potential future directions in motor rehabilitation, with the objective of identifying predictors of rehabilitation outcome and the development of individualized training programs that potentially involve rehabilitation technology.

Rehabilitation of a U.S. Army soldier diagnosed with cerebellar atrophy with an ataxic gait.

BACKGROUND AND PURPOSE: Balance impairments can disrupt the careers of U.S. Army soldiers and put themselves and their mates in danger. The purpose of this case report is to review the rehabilitation process and outcome of a U.S. Army soldier diagnosed with gait ataxia secondary to cerebellar atrophy. CASE DESCRIPTION: The patient is a 35-year-old active duty U.S. Army male who presented with an ataxic gait pattern and had magnetic resonance image evidence of cerebellar atrophy. OUTCOMES: Over the course of 7 months of rehabilitation, the patient showed improvement in ambulation and balance as evidenced by improved dynamic gait index and Propriotest dynamic motion analysis scores. DISCUSSION: This relatively young, active duty soldier was able to improve with physical therapy intervention. However, even in this young, highly motivated patient, it took several months of rehabilitation to achieve his goals.

Feasibility and safety of acute phase rehabilitation after stroke using the hybrid assistive limb robot suit.

Acute phase rehabilitation is an important treatment for improving the functional outcome of patients after stroke. The present cohort study analyzed the feasibility and safety of acute phase rehabilitation using the hybrid assistive limb robot suit in 22 patients, 7 males and 15 females (mean age 66.6 ± 17.7 years). Neurological deterioration, mortality, or other accidents were recorded as adverse events. Baseline characteristics of each patient were recorded at the first hybrid assistive limb rehabilitation. Hybrid assistive limb rehabilitation was conducted for 12.1 ± 7.0 days with the patients in stable condition. Acute phase hybrid assistive limb rehabilitation was performed a total of 84 times with no adverse events recorded except for orthostatic hypotension. Good functional outcomes were obtained in 14 patients. Orthostatic hypotension was observed during the first hybrid assistive limb rehabilitation in four patients, and was significantly associated with intracerebral hemorrhage (p = 0.007) and lower Brunnstrom stage (p = 0.033). Acute phase rehabilitation using the hybrid assistive limb suit is feasible and safe. Patients with intracerebral hemorrhage and lower Brunnstrom stage should be carefully monitored for orthostatic hypotension.

Balance training in ataxic neuropathies. Effects on balance and gait parameters.

A rehabilitation program including foot sensory stimulation, balance and gait training with limited vision was followed by 30 patients with ataxic neuropathy in order to stimulate multi-sensory compensation in a no-controlled and no-blinded study. Ataxic neuropathy was graded by a pallesthetic score. The evaluation of patients and healthy subjects was performed with clinical tests (Berg Balance Scale, Functional Reach Test and Timed up and Go test) and instrumental tests for balance (force platform) and gait (Locometre). All patients exhibited impairments in balance and gait parameters compared to control group values. A high pallesthetic score correlated with increased sway area when standing with the eyes open on a firm surface. At the end of the training program, significant changes were observed in balance control assessed using the three clinical tests (Wilcoxon test, p<0.001). A tendency towards a reduction of the Romberg sign was noticed and limited changes were observed after training in instrumental tests for balance and for gait parameters. Age induced some limitations in balance and gait parameters but had no effect on training results. These results show that ataxic patients are impaired in balance and gait but can improve clinical balance parameters following training with a multisensory approach without limitation due to age or degree of sensory impairment. Only limited correlations were noticed between the pallesthetic score and some balance parameters, suggesting that various levels of compensation occur in these patients. The effectiveness of this training program has to be evaluated in the future in a controlled study to ascertain the contribution of the placebo effect in these data.

[The use of stabilizing platforms in the correction of atactic disorders in patients with vertebrobasilar stroke].

Results of the treatment of atactic gait and balance disorders in post-stroke patients are presented. A method of neurorehabilitation using stabilizing platforms based on the excluding ankle joint postural strategy and support square is proposed. The efficacy of this method assessed by the computerized stabilometry and functional balance scale was comparable with the results of the generally accepted computerized dynamic posturography with visual biofeedback.

Use of trunk stabilization and locomotor training in an adult with cerebellar ataxia: a single system design.

The purpose of this study is to describe the effects of trunk stabilization training and locomotor training (LT) using body-weight support on a treadmill (BWST) and overground walking on balance, gait, self-reported function, and trunk muscle performance in an adult with severe ataxia secondary to brain injury. There are no studies on the effectiveness of these combined interventions in persons with ataxia. The subject was a 23-year-old male who had a traumatic brain injury 13 months prior. An A-B-A withdrawal single-system design was used. Outcome measures were Berg Balance Test (BBT), timed unsupported stance, Functional Ambulation Category (FAC), 10-meter walk test (10-MWT), Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL), transverse abdominis (TrA) thickness, and isometric trunk endurance tests. Performance on the BBT, timed unsupported stance, FAC, 10-MWT, and OPTIMAL each improved after 10 weeks of intervention. In additions, TrA symmetry at rest improved as did right side-bridge endurance time. LT, using BWST and overground walking, and trunk stabilization training may be effective in improving balance, gait, function, and trunk performance in individuals with severe ataxia. Further research with additional subjects is indicated.

Weight bearing on the affected lower limb in residents of a geriatric rehabilitation hospital.

OBJECTIVES: The purpose of the study was to determine whether and to what extent the treatment goal of enhancement of weight bearing on an affected lower limb is achieved in the gait rehabilitation of patients with poststroke hemiparesis, postprosthetic fitting due to unilateral transtibial amputation, or postunilateral hip or knee arthroplasty. DESIGN: Nonrandomized prepost study. Subjects were 26 residents of a geriatric rehabilitation hospital in the initial stage of gait rehabilitation after poststroke hemiparesis (n = 9), unilateral total hip or knee joint replacement (n = 11), or unilateral transtibial amputation with a fitted prosthesis (n = 6). Weight bearing on the hindfoot and forefoot of the affected limb was measured by using the SmartStep system version 2.2.0, at least once a week, both before and immediately after a gait-training session. Measurements were performed with the patients using their assistive devices. RESULTS: In the patients with hemiparesis, there was no significant difference found between the initial pretraining maximal weight bearing on the afflicted limb (39% and 50% of body weight on the hindfoot and forefoot, respectively) and that at discharge (47% and 50% of body weight, respectively). In patients after hip or knee arthroplasty and in those who underwent prosthetic fitting, there was a substantial increase found in the loading of the forefoot, but not of the hindfoot, from the initial evaluation to the time of discharge (from 43% to 54% of body weight, P = 0.05, in the arthroplasty group, and from 49.6% to 69.5%, P = 0.09, in the prosthetic group). CONCLUSIONS: For elderly individuals belonging to the studied diagnostic groups, the goal of enhancing normal weight bearing on the afflicted limb during the time course of 2-3 wks might be unrealistic.

Postural compensation for vestibular loss.

To what extent can remaining sensory information and/or sensory biofeedback (BF) compensate for loss of vestibular information in controlling postural equilibrium? The primary role of the vestibulospinal system is as a vertical reference for control of the trunk in space, with increasing importance as the surface becomes increasingly unstable. Our studies with patients with bilateral loss of vestibular function show that vision or light touch from a fingertip can substitute as a reference for earth vertical to decrease variability of trunk sway when standing on an unstable surface. However, some patients with bilateral loss compensate better than others, and found that those with more complete loss of bilateral vestibular function compensate better than those with measurable vestibulo-ocular reflexes. In contrast, patients with unilateral vestibular loss (UVL) who reweight sensory dependence to rely on their remaining unilateral vestibular function show better functional performance than those who do not increase vestibular weighting on an unstable surface. Light touch of <100 grams or auditory biofeedback can be added as a vestibular vertical reference to stabilize trunk sway during stance. Postural ataxia during tandem gait in patients with UVL is also significantly improved with vibrotactile BF to the trunk, beyond improvements due to practice. Vestibular rehabilitation should focus on decreasing hypermetria, decreasing an overdependence on surface somatosensory inputs, increasing use of any remaining vestibular function, substituting or adding alternative sensory feedback related to trunk sway, and practicing challenging balance tasks on unstable surfaces.

[Dynamic stabilometry as a monitoring of movement and coordination disorders in the rehabilitation of patients with multiple sclerosis].

Disorders of movement and coordination are the most frequent and debilitating symptoms of multiple sclerosis. It has been shown that distinct changes of balance support are typical of the disease. This report includes an analysis of preliminary positive results of the use of stabilometry and biological feedback for the correction of balance in multiple sclerosis. A test "balance" has been used at baseline of the stabilometric study. After the rehabilitation, the positive changes of balance maintenance were seen in patients with low disability (EDSS<3,5). This test may be used as a measure of rehabilitation effectiveness. The results of the study may provide further determination of the approaches to the development of rehabilitation stabilometric algorithms.

Efeito do peso para membros inferiores no equilíbrio estático e dinâmico nos portadores de ataxia / The effect of weights on lower limbs in static and dynamic balance for ataxia sufferers

O objetivo da pesquisa foi avaliar o efeito do uso do peso em membros inferiores durante a marcha, nos indivíduos com ataxia. Acredita-se que o peso em membros inferiores traz benefícios na qualidade da marcha nos pacientes atáxicos, alterando a programação motora e conexões neurais cerebelares que são possíveis de alterações na aprendizagem motora. Divididos aleatoriamente, 21 indivíduos em 2 grupos: com peso (GP n=10) e sem peso (SP n=11). Todos realizaram 20 sessões de fisioterapia, avaliados antes (primeira avaliação), depois do tratamento (segunda) e após 30 dias (terceira), através das escalas de Equilíbrio de Berg, Dynamic Gait Index, Equiscale, International Cooperative Ataxia Rating Scale e Medida de Independência Funcional. Foi utilizada a análise ANOVA para medidas repetidas para comparar a evolução das variáveis ao longo do tempo, com nível de significância p ? 0.05. Os indivíduos do GP conseguiram melhores resultados após o tratamento quanto ao equilíbrio, coordenação e independência funcional comparados ao SP, sendo estatisticamente significantes. O GP conseguiu manter o ganho da primeira para a terceira avaliação demonstrada por quase todas as escalas, exceto a DGI. O estudo comprovou a efetividade do peso, melhorando o equilíbrio estático e dinâmico, coordenação da marcha e independência funcional.

The object of this research was to evaluate the effect of ataxia sufferers using weights on the lower members while walking. It is believed that weights on lower members benefits the gait quality of ataxia patients, altering the motor programming and neural connections in the cerebellum that are alterable in motor learning. Twenty-one individuals were randomly divided into two groups: with weights (GP n=10) and without weights (SP n=11). Everyone did 20 sessions of physiotherapy and were evaluated before (first evaluation), after treatment (second evaluation), and after 30 days (third evaluation), by means of the Berg Balance, Dynamic Gait Index, Equiscale, International Cooperative Ataxia Rating Scale, Functional Independence Measure. The ANOVA analysis was used for repeated measurements to compare the evolution of variables over time, with a significance level of p ? 0.05. After treatment and with statistical significance, the GP individuals managed better results with balance, coordination, and functional independence than those without weights. The GP group managed to maintain the benefit from the first through third evaluations on all scales except the DGI. The study proved the effectiveness of weights in improving the static and dynamic balance, the gait coordination, and functional independence.

The immediate effect of attentional, auditory, and a combined cue strategy on gait during single and dual tasks in Parkinson's disease.

OBJECTIVE: To compare the effect of rhythmic auditory and attentional cues, and a combination of both cues on gait, in people with Parkinson's disease (PD) during single and dual tasks. DESIGN: A repeated-measures study requiring participants to perform single and dual-motor tasks under different cueing conditions. SETTING: Human movement analysis laboratory. PARTICIPANTS: Fifteen participants with idiopathic PD and a comparison group of 12 healthy participants. INTERVENTIONS: Three cueing strategies were compared: a rhythmic auditory cue (walking in time to a metronome beat), an attentional strategy (asked to focus on taking big step), and a combination cue (asked to walk in time to a metronome beat while taking big steps). MAIN OUTCOME MEASURES: Walking speed, step amplitude, and step frequency. RESULTS: Walking speed of PD participants improved significantly compared with noncued walking in the single- and dual-task condition with the attentional (P<.001, P=.037) and combination cue strategies (P=.013, P=.028). Step amplitude also increased significantly with the attentional and combination cue strategies in single- (P<.001, P<.001) and dual-task (P<.001, P<.001) conditions. Step frequency was reduced significantly with the attentional strategy (P=.042) in the single and dual tasks (P<.001) and combination cue strategy (P=.009) in the dual task. The rhythmic auditory cue alone did not alter significantly any parameter of gait in the single or dual tasks. CONCLUSIONS: The attentional strategy and the combination of a rhythmic auditory cue with an attentional strategy were equally effective, and improved walking speed and step amplitude significantly during both single and dual tasks. The combination cue, however, may still be a useful alternative in situations of increased attentional demand, or where problems exist with executive function.

Wavelet-based feature extraction for support vector machines for screening balance impairments in the elderly.

Trip related falls are a prevalent problem in the elderly. Early identification of at-risk gait can help prevent falls and injuries. The main aim of this study was to investigate the effectiveness of a wavelet based multiscale analysis of a gait variable [minimum foot clearance (MFC)] in comparison to MFC histogram plot analysis in extracting features for developing a model using support vector machines (SVMs) for screening of balance impairments in the elderly. MFC during walking on a treadmill was recorded on 13 healthy elderly and 10 elderly with a history of tripping falls. Features extracted from MFC histogram and then multiscale exponents between successive wavelet coefficient levels after wavelet decomposition of MFC series were used as inputs to the SVM to classify two gait patterns. The maximum accuracy of classification was found to be 100% for a SVM using a subset of selected wavelet based features, compared to 86.95% accuracy using statistical features. For estimating the relative risk of falls, the posterior probabilities of SVM outputs were calculated. These results suggest superior performance of SVM in the detection of balance impairments based on wavelet-based features and it could also be useful for evaluating for falls prevention intervention.

Walking and disability after rehabilitation in patients with cerebellar stroke.

AIM: Aim of this study is to verify if the presence of extracerebellar stroke lesions negatively affects walking and functional capacities recovery of patients with cerebellar stroke. METHODS: This study was carried out on 43 patients. Patients' selection was made through CT and MRI scans. Neuroimaging data were used to divide patients into 2 groups: 1) a group composed of 20 patients with isolated cerebellar involvement (group C); (2) a group composed of 23 patients with cerebellar plus extracerebellar involvement (group C+E). Patients were assessed through trunk control test (TCT), Lindmark scale and Rankin scale at admission and at discharge. Before rehabilitation, there were no significant differences in disability, TCT and Lindmark scores between the 2 groups of patients. RESULTS: After rehabilitation, Lindmark scale (P=0.022) and TCT (P=0.015) scores of group C were statistically higher than those of group C+E. Disability was greater in group C+E (P=0.036). In these patients disability was absent in 17.4% of subjects, moderate-slight in 47.8% and severe in 34.8%. In group C disability was absent in 40% of subjects, slight-moderate in 55% and severe in 5%. Effectiveness in walking was 79.1% in group C and 57% in group C+E. Efficiency in walking was 0.13 in C group and 0.07 in C+E subjects. Effectiveness (P=0.008) and efficiency (P=0.008) of group C were significantly greater than of group C+E. CONCLUSIONS: The study shows that the rehabilitation prognosis of cerebellar stroke is affected by the presence of extracerebellar stroke lesions.