Categorizing knee hyperextension patterns in hemiparetic gait and examining associated impairments in patients with chronic stroke.

BACKGROUND: Post-stroke hemiparetic gait exhibits considerable variations in motion patterns and abnormal muscle activities, notably knee hyperextension during the stance phase. Existing studies have primarily concentrated on its joint angle or moment. However, the underlying causes remain unclear. Thus, the causes of knee hyperextension were explored from a new perspective based on temporal-durational factors. RESEARCH QUESTION: Does the temporal-durational difference of knee hyperextension presence result from specific decreased motor functions? METHODS: Barefoot gait at a comfortable speed was captured using a three-dimensional camera system. Scores of knee hyperextension used a metric with the temporal-durational factor of knee hyperextension presence in each of four stance phases (1st double support, DS1; early single-leg stance, ESS; late single-leg stance, LSS; 2nd double support, DS2). These scores were used in cluster analysis. The classification and regression tree analysis characterizing each knee hyperextension cluster used the clinical measures of the lower limb and trunk motor function, muscle strength, and spasticity as explanatory variables. RESULTS: Thirty patients with hemiparetic chronic stroke who exhibited knee hyperextension during gait were included. Four knee hyperextension clusters were shown: Momentary (almost no hyperextension), Continuous (DS1-DS2), ESS-LSS, and ESS-DS2. Knee flexor strength was lower in the groups with long hyperextension durations (Continuous and ESS-DS2) compared with short durations (ESS-LSS and Momentary). ESS-DS2 exhibited higher trunk motor function than Continuous, whereas more severe spasticity was observed in ESS-LSS than in Momentary. SIGNIFICANCE: This study successfully classified four hemiparetic gait patterns with knee hyperextension based on the temporal-durational factor, providing valuable perspectives for understanding and addressing specific functional physical impairments. These findings offer guidance for focusing on related physical functions when striving for gait improvement with knee hyperextension and are expected to serve as a reference for treatment decision-making.

New Artificial Intelligence-Integrated Electromyography-Driven Robot Hand for Upper Extremity Rehabilitation of Patients With Stroke: A Randomized, Controlled Trial.

BACKGROUND: An artificial intelligence (AI)-integrated electromyography (EMG)-driven robot hand was devised for upper extremity (UE) rehabilitation. This robot detects patients' intentions to perform finger extension and flexion based on the EMG activities of 3 forearm muscles. OBJECTIVE: This study aimed to assess the effect of this robot in patients with chronic stroke. METHODS: This was a single-blinded, randomized, controlled trial with a 4-week follow-up period. Twenty patients were assigned to the active (n = 11) and control (n = 9) groups. Patients in the active group received 40 minutes of active finger training with this robot twice a week for 4 weeks. Patients in the control group received passive finger training with the same robot. The Fugl-Meyer assessment of UE motor function (FMA), motor activity log-14 amount of use score (MAL-14 AOU), modified Ashworth scale (MAS), H reflex, and reciprocal inhibition were assessed before, post, and post-4 weeks (post-4w) of intervention. RESULTS: FMA was significantly improved at both post (P = .011) and post-4w (P = .021) in the active group. The control group did not show significant improvement in FMA at the post. MAL-14 AOU was improved at the post in the active group (P = .03). In the active group, there were significant improvements in wrist MAS at post (P = .024) and post-4w (P = .026). CONCLUSIONS: The AI-integrated EMG-driven robot improved UE motor function and spasticity, which persisted for 4 weeks. This robot hand might be useful for UE rehabilitation of patients with stroke.Clinical Trial Registry Name: The effect of robotic rehabilitation using XMM-HR2 for the paretic upper extremity among hemiparetic patients with stroke.Clinical Trial Registration-URL: https://jrct.niph.go.jp/Unique Identifier: jRCTs032200045.

Robotized Knee-Ankle-Foot Orthosis-Assisted Gait Training on Genu Recurvatum during Gait in Patients with Chronic Stroke: A Feasibility Study and Case Report.

Genu recurvatum (knee hyperextension) is a common problem after stroke. It is important to promote the coordination between knee and ankle movements during gait; however, no study has investigated how multi-joint assistance affects genu recurvatum. We are developing a gait training technique that uses robotized knee-ankle-foot orthosis (KAFO) to assists the knee and ankle joints simultaneously. This report aimed to investigate the safety of robotized KAFO-assisted gait training (Experiment 1) and a clinical trial to treat genu recurvatum in a patient with stroke (Experiment 2). Six healthy participants and eight patients with chronic stroke participated in Experiment 1. They received robotized KAFO-assisted gait training for one or 10 sessions. One patient with chronic stroke participated in Experiment 2 to investigate the effect of robotized KAFO-assisted gait training on genu recurvatum. The patient received the training for 30 min/day for nine days. The robot consisted of KAFO and an attached actuator of four pneumatic artificial muscles. The assistance parameters were adjusted by therapists to prevent genu recurvatum during gait. In Experiment 2, we evaluated the knee joint angle during overground gait, Fugl-Meyer Assessment of lower extremity (FMA-LE), modified Ashworth scale (MAS), Gait Assessment and Intervention Tool (G.A.I.T.), 10-m gait speed test, and 6-min walk test (6MWT) before and after the intervention without the robot. All participants completed the training in both experiments safely. In Experiment 2, genu recurvatum, FMA-LE, MAS, G.A.I.T., and 6MWT improved after robotized KAFO-assisted gait training. The results indicated that the multi-joint assistance robot may be effective for genu recurvatum after stroke.

Factor analysis for construct validity of a trunk impairment scale in Parkinson's disease: a cross-sectional study.

Objectives: To investigate the construct validity of the Trunk Impairment Scale (TIS), which was developed to assess trunk impairment in patients with stroke, in patients with Parkinson's disease (PD). Design: This retrospective, cross-sectional study enrolled consecutive PD inpatients. Correlation analysis was performed to clarify whether the TIS assessment was related to other balance functions, lower extremity muscle strength, or walking ability. Factor analysis was performed to see how the background factors of TIS differ from balance function, lower limb muscle strength, and walking ability. Results: Examining the data of 471 patients with PD, there were relationships between TIS and the Mini-Balance Evaluation Systems Test (r = 0.67), Barthel Index (r = 0.57), general lower limb extension torque (r = 0.51), two-minute walk test (r = 0.54), Hoehn and Yahr stage (r = -0.61), and Movement Disorder Society Unified Parkinson's Disease Rating Scale part III total points (r = -0.59). Factor analysis showed that TIS items were divided into three factors (an abdominal muscles and righting reflex component; a perception and verticality component; and a rotational component), differing from other scales that included clinical assessment items. Conclusion: The TIS can be useful for assessing the underlying trunk impairment as a basis for activities of daily living, gait function, and balance ability in patients with PD.

COVID-19 pandemic and the international classification of functioning in multiple system atrophy: a cross-sectional, nationwide survey in Japan.

The present study aimed to determine the magnitude of and risk factors for the effects of the COVID-19 pandemic on the international classification of functioning, disability and health (ICF) in patients with multiple system atrophy (PwMSA). The study was part of a cross-sectional, nationwide, multipurpose mail survey for Japanese PwMSA from October to December, 2020. The primary outcome was the impact of the early COVID-19 pandemic on ICF functioning, consisting of body function, activity, and participation. Age, sex, disease type, disease duration, and dwelling place were asked as participants' characteristics, and the multiple system impairment questionnaire (MSIQ), patient health questionnaire-2, modified rankin scale, barthel index, life-space assessment (LSA), and EuroQoL were examined. Multivariate logistic regression analyses were performed to identify independent risk factors for a worse function score due to the COVID-19 pandemic for each ICF functioning domain. A total of 155 patients (mean age 65.6 [SD 8.1] years; 43.9% women; mean disease duration 8.0 [SD 6.2] years; 65% MSA with cerebellar ataxia, 13% MSA with parkinsonism, 9% MSA with predominant autonomic features) were analyzed. Of the ICF functioning domains, the respondents reported that the early COVID-19 pandemic affected body function in 17.4%, activity in 17.6%, and participation in 46.0%. The adjusted multivariate model identified MSIQ and LSA as the two variables that independently contributed to all domains. The COVID-19 pandemic affected ICF functioning of PwMSA in Japan, and the severity of disease-related impairments and a large daily living space were common risk factors. These results help support the focus on patient characteristics for medical and social welfare support.

Effects of mouthpiece shape and expiratory threshold loading on contraction of the lateral abdominal muscles: A cross-sectional study.

BACKGROUND: Expiratory tasks may facilitate transversus abdominis (TrA) activity for spinal stabilization. The purpose of this study was to verify whether a combination of pursed-lip breathing (PLB) and use of an expiratory threshold loading (ETL) device to increase expiratory resistance would promote TrA contraction comparable to that for a stabilization exercise. METHODS: Twenty healthy men performed expiratory tasks or an abdominal drawing-in maneuver (ADIM). Expiratory tasks comprised combinations of ETL settings with 0%, 5%, or 15% of maximum expiratory pressure, and mouthpieces with a normal shape or pursed-lip shape. B-mode ultrasound imaging of the TrA, internal oblique, and external oblique muscles was performed to determine percentage changes in muscle thickness. Percentage changes among tasks were statistically compared for each muscle. FINDINGS: TrA thickness increased with normal lips at 15% ETL, with PLB with 5% ETL, and with ADIM (p < 0.01 each). Internal oblique thickness increased under all PLB conditions (p < 0.01 each). No significant differences in external oblique thickness were seen for any tasks. The total thickness of the lateral abdominal muscles was significantly increased not only for 15% ETL tasks and ADIM, but also for PLB with 5% ETL (p < 0.02 each). INTERPRETATION: These results indicated that PLB with 5% ETL could facilitate the same level of TrA activity as the ADIM. PLB with 5% ETL was the only task that simultaneously increased overall lateral abdominal muscles, including the internal obliques, and might be readily applicable in clinical situations.

Clinical Tests for Predicting Fallers Among Ambulatory Patients with Amyotrophic Lateral Sclerosis: A Preliminary Cohort Study.

BACKGROUND: Few studies have examined falls and their predictors in patients with amyotrophic lateral sclerosis (ALS). OBJECTIVE: The aim of this study was to survey fall incidence and to identify variables predicting the presence or absence of falls occurring within 3 months after discharge of patients with ALS from hospital. METHODS: The following variables were evaluated in 14 patients with ALS: timed up and go test (TUG), functional reach test, 10-m comfortable gait speed, single-leg stance time, manual muscle test (MMT) scores for the lower limb, total modified Ashworth scale score for the lower limbs, fear of falling, and pull test score. The primary outcome variable was the occurrence of a fall within 3 months after discharge. The fall rate was calculated based on fall record forms. The specific circumstances of each fall were also recorded. Univariate and multiple regression analyses were used to identify fall predictors. RESULTS: Seven of the 14 ALS patients (50%) experienced a fall within 3 months. Five fallers reported experiencing a fall that had caused injury, and three reported experiencing a fall that had required a hospital visit. Univariate logistic regression analysis identified TUG time, gait speed and MMT of the ankle dorsiflexors as factors associated with falls (p = 0.02-0.04). Multiple linear regression analysis of fall numbers identified age and TUG time as predictor models (p = 0.03). CONCLUSION: TUG time and MMT of ankle dorsiflexors may help predict falls in ALS patients. Validation studies in larger cohorts are needed.

Pelvis-Toe Distance: 3-Dimensional Gait Characteristics of Functional Limb Shortening in Hemiparetic Stroke.

We aimed to investigate whether a newly defined distance in the lower limb can capture the characteristics of hemiplegic gait compared to healthy controls. Three-dimensional gait analyses were performed on 42 patients with chronic stroke and 10 age-matched controls. Pelvis-toe distance (PTD) was calculated as the absolute distance between an anterior superior iliac spine marker and a toe marker during gait normalized by PTD in the bipedal stance. The shortening peak during the swing phase was then quantified as PTDmin. The sagittal clearance angle, the frontal compensatory angle, gait speed, and the observational gait scale were also collected. PTDmin in the stroke group showed less shortening on the affected side and excessive shortening on the non-affected side compared to controls. PTDmin on the affected side correlated negatively with the sagittal clearance peak angle and positively with the frontal compensatory peak angle in the stroke group. PTDmin in stroke patients showed moderate to high correlations with gait speed and observational gait scale. PTDmin adequately reflected gait quality without being affected by apparent improvements due to frontal compensatory patterns. Our results showed that various impairments and compensations were included in the inability to shorten PTD, which can provide new perspectives on gait rehabilitation in stroke patients.

Strategies for learning glossopharyngeal breathing in boys with Duchenne muscular dystrophy: A feasibility case series.

OBJECTIVE: To propose alternative learning strategies for glossopharyngeal breathing in patients with Duchenne muscular dystrophy (DMD) and healthy men. DESIGN: A feasibility study with small case series. SUBJECTS: Five boys with DMD and 7 male physical therapists as healthy controls who had not learned glossopharyngeal breathing. METHODS: Participants were instructed in a glossopharyngeal breathing protocol, including induction methods comprising sucking motions and phonation with inhalation. The protocol consisted of 1-6 sessions (10-15 min each; total 60 min). Criteria for glossopharyngeal breathing mastery were vital capacity with glossopharyngeal insufflation (VCGI)/VC ratio > 1.10 for the DMD group and > 1.05 for the Healthy group. Feasibility outcomes were time required for mastering glossopharyngeal breathing, self-reported outcomes, adverse events and drop-outs. RESULTS: All participants learned glossopharyngeal breathing within the allocated 60 min. Mean VCGI/VC ratio was 1.31 for the DMD group and 1.09 for the Healthy group. No adverse events or drop-outs were encountered during the protocol. In most cases, self-reported outcomes showed that motivation increased and difficulty decreased. CONCLUSION: Induction methods for sucking motions and phonation with inhalation for glossopharyngeal breathing learning are feasible. This paper proposes alternative strategies for glossopharyngeal breathing learning in boys with DMD and their instructors.

Neuromuscular electrical stimulation-enhanced rehabilitation is associated with not only motor but also somatosensory cortical plasticity in chronic stroke patients: an interventional study.

BACKGROUND: Somatosensory function has been frequently overlooked in clinics and research in the field of chronic stroke. The effects of neurorehabilitation interventions on sensory processing have still to be investigated using electrophysiological means.This study investigated the effect of hybrid assistive neuromuscular dynamic stimulation (HANDS) therapy utilizing closed-loop electromyography-controlled neuromuscular electrical stimulation (NMES), on sensory changes and cortical plasticity among patients with chronic stroke. METHODS: This study was a prespecified analysis of 23 participants involved in an ongoing large interventional study. Patients with severe upper limb hemiplegia dues to chronic stroke underwent 3 weeks of inpatient HANDS therapy, where daily treatment consisted of 8 h of NMES combined with wrist splinting, 90 min of comprehensive occupational therapy, and the practice of bimanual activities of daily living. Somatosensory evoked potentials (SEPs) and functional sensory assessments, including the Semmes-Weinstein monofilament test (SWMT) and thumb localizing test (TLT), were compared pre and post-treatment. RESULTS: While no significant recovery of tactile sensation was observed, significant improvements in proprioception and motor function were induced. The number of cortical peaks significantly increased in the median nerve, but not in the tibial nerve. A total of 9 out of 11 participants who initially lacked certain peaks responded to treatment. Further analysis revealed a significant improvement in latency and amplitude of SEP peaks. CONCLUSIONS: Our results suggest that NMES-based neurorehabilitation induces certain plastic changes in the primary sensory cortex and in cortices associated with sensorimotor processing in people with chronic stroke sequelae, which may explain the observed improvements in proprioception.

Quantification of trunk segmental coordination and head stability in laterally unstable sitting identifies aging and cerebellar ataxia.

BACKGROUND: We quantified trunk segmental coordination and head stability in unstable sitting and investigated whether it can discriminate postural control, age-related differences and presence of coordination disorder. METHODS: Subjects were a healthy younger group (n = 7), a healthy elderly group (n = 7), and a cerebellar ataxia group (n = 8). The motion sensors and surface electrodes were located on the trunk and/or head segments to measure angle displacements, acceleration and electromyograms in unstable sitting during a lateral tilt task. Trunk lateral angle cross-correlation and electromyogram cross-correlation for the trunk segmental coordination, head root mean square (RMS) for the head stability, clinical performance scales, and gait parameters (velocity, coefficient of variation, and RMS ratio) were analyzed. FINDINGS: Trunk lateral angle cross-correlation showed a significantly negative correlation in the healthy younger group compared with the two other groups (p < 0.01). Head RMS showed a significantly larger value in the cerebellar ataxia group compared with the two other groups (p < 0.01). Trunk lateral angle cross-correlation had moderate correlation with the clinical performance scale of ataxia and gait parameters; however, it was not correlated with head RMS. Classification using trunk lateral angle cross-correlation and head RMS was validated by discriminant analysis and hierarchical cluster analysis. INTERPRETATION: We found that trunk lateral angle cross-correlation reflected age-related differences and head RMS characterized the pathology of cerebellar ataxia. Trunk segmental coordination and head stability, as two aspects of sitting postural control, can be used to discriminate the degree of aging and cerebellar ataxia.

Effect of Core Stability Training on Trunk Function, Standing Balance, and Mobility in Stroke Patients.

BACKGROUND: Trunk function is important for standing balance, mobility, and functional outcome after stroke, but few studies have evaluated the effects of exercises aimed at improving core stability in stroke patients. OBJECTIVE: To investigate the effectiveness of core stability training on trunk function, standing balance, and mobility in stroke patients. METHODS: An assessor-blinded, randomized controlled trial was undertaken in a stroke rehabilitation ward, with 32 participants randomly assigned to an experimental group or a control group (n = 16 each). The experimental group received 400 minutes of core stability training in place of conventional programs within total training time, while the control group received only conventional programs. Primary outcome measures were evaluated using the Trunk Impairment Scale (TIS), which reflects trunk function. Secondary outcome measures were evaluated by pelvic tilt active range of motion in the sagittal plane, the Balance Evaluation Systems Test-brief version (Brief-BESTest), Functional Reach test, Timed Up-and-Go test (TUG), and Functional Ambulation Categories (FAC). A general linear repeated-measures model was used to analyze the results. RESULTS: A treatment effect was found for the experimental group on the dynamic balance subscale and total score of the TIS ( P = .002 and P < .001, respectively), pelvic tilt active range of motion ( P < .001), Brief-BESTest ( P < .001), TUG ( P = .008), and FAC ( P = .022). CONCLUSIONS: Core stability training has beneficial effects on trunk function, standing balance, and mobility in stroke patients. Our findings might provide support for introducing core stability training in stroke rehabilitation.