How to improve walking, balance and social participation following stroke: a comparison of the long term effects of two walking aids--canes and an orthosis TheraTogs--on the recovery of gait following acute stroke. A study protocol for a multi-centre, single blind, randomised control trial.

BACKGROUND: Annually, some 9000 people in Switzerland suffer a first time stroke. Of these 60% are left with moderate to severe walking disability. Evidence shows that rehabilitation techniques which emphasise activity of the hemiplegic side increase ipsilesional cortical plasticity and improve functional outcomes. Canes are commonly used in gait rehabilitation although they significantly reduce hemiplegic muscle activity. We have shown that an orthosis "TheraTogs" (a corset with elasticated strapping) significantly increases hemiplegic muscle activity during gait. The aim of the present study is to investigate the long term effects on the recovery of gait, balance and social participation of gait rehabilitation with TheraTogs compared to gait rehabilitation with a cane following first time acute stroke. METHODS/DESIGN: Multi-centre, single blind, randomised trial with 120 patients after first stroke. When subjects have reached Functional Ambulation Category 3 they will be randomly allocated into TheraTogs or cane group. TheraTogs will be applied to support hip extensor and abductor musculature according to a standardised procedure. Cane walking held at the level of the radial styloid of the sound wrist. Subjects will walk throughout the day with only the assigned walking aid. Standard therapy treatments and usual care will remain unchanged and documented. The intervention will continue for five weeks or until patients have reached Functional Ambulation category 5. Outcome measures will be assessed the day before begin of intervention, the day after completion, 3 months, 6 months and 2 years. PRIMARY OUTCOME: Timed "up and go" test, secondary outcomes: peak surface EMG of gluteus maximus and gluteus medius, activation patterns of hemiplegic leg musculature, temporo-spatial gait parameters, hemiplegic hip kinematics in the frontal and sagittal planes, dynamic balance, daily activity measured by accelerometry, Stroke Impact Scale. Significance levels will be 5% with 95% CI's. IntentionToTreat analyses will be performed. Descriptive statistics will be presented. DISCUSSION: This study could have significant implications for the clinical practice of gait rehabilitation after stroke, particularly the effect and appropriate use of walking aids.The results could be important for the development of clinical guidelines and for the socio-economic costs of post-stroke care. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT01366729.

Gait analysis in ankle osteoarthritis and total ankle replacement.

BACKGROUND: Little information is available about gait changes in ankle osteoarthritis and total ankle replacement, and also about total ankle replacement patients' rehabilitation in the first year after surgery. METHODS: Thirty subjects were included in this study: 15 unilateral post-traumatic ankle osteoarthritis patients and 15 age-/gender-matched control subjects. Patients were followed prospectively: preoperatively, at 3, 6, 9, and 12 months after total ankle replacement. The clinical-functional level was assessed by the American Orthopaedic Foot and Ankle Society ankle and the Short-Form-36 health survey score. 3D ankle-hindfoot kinematic-kinetic analysis was performed using a motion analysis and a two-plate force-platform system. Statistics included repeated measures analysis of variances, independent sample and paired Student's t-tests (significance alpha=0.05). FINDINGS: Compared to normal subjects, ankle osteoarthritis caused significant reduction of the American Orthopaedic Foot and Ankle Society and Short-Form-36 score. In gait analysis, ankle osteoarthritis showed a significant deficiency in six of seven spatiotemporal variables, a decrease of the tri-planar ankle movement, a decrease of the second active maximal vertical and the maximal medial ground reaction force, a reduction of the sagittal and transverse ankle joint moments, a reduction of the ankle joint power. Three months after total ankle replacement surgery patients experienced a worsening of gait. At 12 months follow-up, all spatiotemporal variables were not different from the normal subjects (full rehabilitation); in six of 11 kinematic and kinetic variables there was a partial rehabilitation. INTERPRETATION: This study provides data for the clinical-biomechanical understanding of the normal, arthritic, and total ankle replacement treated ankle during walking and the first year of rehabilitation.

Muscular lower leg asymmetry in middle-aged people.

BACKGROUND: The purpose of this study was to determine whether muscular asymmetries were present in the lower legs of recreationally active middle-aged people grouped by leg dominance. METHODS: Twelve healthy middle-aged subjects were analyzed bilaterally. The clinical variables included leg dominance, sports level, range of motion, lower leg alignment, calf circumference, and AOFAS (American Orthopaedic Foot and Ankle Society) ankle score. The biomechanical variables included maximal voluntary isometric ankle joint torque and surface electromyography (EMG) with determination of mean EMG frequency and intensity of four lower leg muscles: anterior tibial (AT), medial gastrocnemius (MG), soleus (SO), and peroneus longus (PL). RESULTS: The mean EMG frequency was significantly lower in the dominant leg for the AT (dominant, 148.6 Hz; nondominant, 157.8 Hz) and MG muscles (dominant, 183.9 Hz; nondominant, 196.8 Hz). A significantly higher plantarflexion torque was found in the dominant leg (27.1 Nm) compared to the nondominant leg (22.9 Nm). Higher (not significant) dorsiflexion torque was found in the dominant leg (dominant, 27.3 Nm; nondominant, 24.8 Nm). The calf circumference was marginally significantly higher (p =0.039) in the dominant leg (34.2 cm; nondominant leg, 33.8 cm). The dominant leg had a higher but not significantly different mean EMG intensity for all four muscles. CONCLUSIONS AND CLINICAL RELEVANCE: Differences in muscle EMG and torque were found between the dominant and nondominant lower leg. These results might be applicable to treatment, rehabilitation, and future research of lower leg and foot and ankle disorders.

Lower leg muscle atrophy in ankle osteoarthritis.

The aim of this study was to determine changes in the lower leg muscles associated with ankle osteoarthritis. Fifteen unilateral ankle osteoarthritis patients and fifteen age-gender-matched normal subjects were assessed with clinical [osteoarthritis latency time, pain, alignment, AOFAS ankle score, ankle range of motion (ROM), calf circumference], radiological (ankle osteoarthritis grading), and muscular-physiological parameters [isometric maximal voluntary ankle torque, surface electromyography of the anterior tibial (AT), medial gastrocnemius (MG), soleus (SO), and peroneus longus (PL) muscle]. The osteoarthritis patients had increased pain (6.8 points) and reduced AOFAS score (33.7 points) compared to the control group. Compared to the contralateral healthy leg, the arthritic leg showed reduced mean dorsi-/plantar flexion ROM (16.0 degrees), reduced mean calf circumference (2.1 cm), smaller mean dorsiflexion (16.4 Nm) and plantar flexion (15.8 Nm) torques, lower mean electromyography frequency for all muscles (AT -22.6 Hz; MG -27.3 Hz; SO -25.9 Hz; PL -28.5 Hz), and lower mean electromyography intensity in the AT [-28.0x10(3) (microv)2], MG [-13.3x10(3) (microv)2], and PL [-12.8x10(3) (microv)2]. SO mean electromyography intensity was not significantly changed [+2.0x10(3) (microv)2]. Unilateral ankle osteoarthritis is associated with atrophic changes of the lower leg muscles. This study supports previous observations on muscle dysfunction in knee osteoarthritis.

Changes in EMG signals for the muscle tibialis anterior while running barefoot or with shoes resolved by non-linearly scaled wavelets.

The purpose of this project was to study the EMG pattern of the tibialis anterior muscle in heel-toe running. Specifically, EMG changes in time, intensity and frequency shortly before and after heel-strike were addressed using an EMG-specific non-linearly scaled wavelets analysis. This method allowed extracting the time, intensity and frequency information inherent in the EMG signal at any time. The EMG signals of 40 male subjects were recorded for running barefoot and with shoes. The results confirmed that the pre-heel-strike EMG activities were typically seen at higher EMG frequencies (60-270Hz) while the post-heel-strike EMG activities resulted in lower frequency signals (10-90Hz). The timing of the pre-heel-strike EMG activities was not influenced by the used shoe conditions. The timing of the post-heel-strike EMG activities was significantly delayed when wearing shoes. The intensity of the pre-heel-strike muscle activity increased compared to the post-heel-strike one when wearing shoes. One can conclude that the activity of the tibialis anterior adjusts specifically to exterior conditions. The frequency shift between pre- and post heel-strike muscle activity were discussed with respect to activation of different motor units.

[Secondary stability of cemented and non-cemented acetabular implants ex-vivo under dynamic load].

OBJECTIVE: To measure the bone-prosthetic implant interface micromovement during the application of physiological load by using a material testing system (MTS). METHODS: The cadaveric hip specimens were used to simulate a single leg stance and the joint in the neutral position. Micromovement was recorded via a 3-dimensional transducer in the acetabula of postmortem specimens, which had been preserved in formalin. The study data of the cemented and uncemented prosthsis refereed to the lone-term clinical process and the radiological status and experimental results. RESULTS: Cemented cups showed higher transverse relative motion up to 90 microm, whereas the maximum transverse movement of the non-cemented cup was 60 microm. Orthogonal motion perpendicular to the implant surface showed compression for all cups at all sites. CONCLUSION: The results indicate that there are large differences in survival time between 2 groups. That could not be compared statistically in secondary stability. Nevertheless, according to the results, the amount of micromotion of press-fit cup is relatively less than that of cemented polyethylene cup, which is instrumental in bone ingrowth and secondary stability.