Movement strategies during obstacle crossing in people with Parkinson disease: A systematic review with meta-analysis.

OBJECTIVE: Navigating obstacles involves adjusting walking patterns, particularly when stepping over them. This task may be particularly challenging for people with Parkinson disease (PD) for several reasons. This review aims to compare the spatiotemporal gait parameters of people with and without PD while stepping over obstacles. LITERATURE SURVEY: A systematic literature search was conducted in six databases (PubMed, Scopus, Web of Science, EBSCO, Embase, and SciELO) from inception to September 2023. METHODOLOGY: Studies were selected that evaluated gait parameters of people with and without PD while walking over obstacles. Two independent researchers evaluated the eligibility and extracted gait parameters during obstacle crossing. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal Checklist. Heterogeneity was assessed using I2-tests. Random effects models were determined for effect sizes as standardized mean differences (SMD). SYNTHESIS: Twenty-five studies were included in the review and 17 in the meta-analysis. Most of the studies (58%) showed a low risk of bias. People with PD exhibit a shorter step when landing after crossing an obstacle (SMD = -0.50 [-0.69 to -0.31]). Compared to people without PD, people with PD also widen their support base (SMD = 0.27 [0.07-0.47]) and reduce gait velocity (SMD = -0.60 [-0.80 to -0.39]) when crossing the obstacle. CONCLUSIONS: People with PD adopt a more conservative motor behavior during obstacle crossing than those without PD, with a shorter step length when landing after crossing an obstacle, greater step width and lower crossing speed.

Improvement of gait and balance function in chronic post-stroke patients induced by Lower Extremity - Constraint Induced Movement Therapy: a randomized controlled clinical trial.

OBJECTIVE: To evaluate the effects of Lower Extremity - Constraint Induced Movement Therapy on gait function and balance in chronic hemiparetic patients. METHODS: Randomized, controlled, single-blinded study. We recruited chronic post stroke patients and allocated them to Lower Extremity - Constraint Induced Movement Tharapy (LE-CIMT) or Control Group. The LE-CIMT group received this protocol 2.5 hour/day for 15 followed days, including: 1) intensive supervised training, 2) use of shaping as a strategy for motor training, and 3) application of a transfer package. The control group received conventional physiotherapy for 2.5 hours/day for 15 followed days. Outcomes were assessed at baseline, after the interventions, and after 6 months, through 6-minute walk test and Mini-Balance Evaluation Systems Test; 10-meter walk test, Timed Up and Go, 3-D gait analysis, and Lower Extremity - Motor Activity Log. RESULTS: LE-CIMT was superior on the Assistance and confidence subscale of Lower Extremity - Motor Activity Log, Mini-BESTest and 6-minute walk test. The effect size for all outcomes was small when comparing both groups. LE-CIMT showed clinically significant differences in daily activities, balance, and gait capacity, with no clinically significant difference for spatiotemporal parameters. CONCLUSION: The LE-CIMT protocol had positive outcomes on balance, performance, and confidence perception.

Action observation and motor imagery have no effect on balance and freezing of gait in Parkinson's disease: a randomized controlled trial.

BACKGROUND: Combining action observation (AO) and motor imagery (MI) training may induce greater brain activity in areas usually involved in Parkinson's disease (PD) and lead to greater behavioral and neurophysiological effects than when used separately. AIM: To determine the effects of combining AO, MI, and gait training on balance and freezing of gait in individuals with PD. DESIGN: This is a single-blinded, randomized controlled clinical trial. SETTING: Laboratory of Intervention and Analysis of Movement (LIAM) from the Department of Physical Therapy of a Brazilian University. POPULATION: Study sample consisted of individuals diagnosed with idiopathic PD by a neurologist specialized in movement disorders. METHODS: 39 individuals with PD were divided into experimental (EG=21) and control groups (CG=18). EG performed 12 sessions of AO, MI, and gait training, whereas CG watched PD-related educational videos and performed 12 sessions of gait training. Balance (measured using the Mini Balance Evaluation Systems Test [MiniBESTest]) and freezing of gait (measured using the Freezing of Gait Questionnaire) were reassessed one day after the end of the intervention. RESULTS: We did not observe significant intra- and intergroup differences in freezing of gait. For the EG, we observed a significant intragroup difference in the total score of MiniBESTest (F=5.2; P=0.02), and sensory orientation (F=4.5; P=0.04) and dynamic gait (F=3.6; P=0.03) domains. MiniBESTest domains were not different between groups. CONCLUSIONS: Combining AO, MI, and gait training was not more effective than isolated gait training for balance and freezing of gait in individuals with PD. CLINICAL REHABILITATION IMPACT: MI training can moderate AO effects and enhance motor learning when both therapies are combined. Therefore, this approach may still have the potential to be included in the treatment of PD. New studies should investigate whether the factors that influence these results are related to the protocol's sensitivity in changing the evaluated parameters or to the time and intensity of AO and MI training.

Os efeitos da reabilitação baseada em exercícios sobre a marcha de pacientes com doença de Parkinson: uma revisão sistemática / The effects of exercise-based rehabilitation on the gait of patients with Parkinson's disease: a systematic review

Introdução: Mais de 85% das pessoas com Doença de Parkinson (DP) desenvolvem dificuldades de locomoção dentro de 3 anos após o diagnóstico, sendo os distúrbios da marcha considerados os sintomas motores mais incapacitantes da DP, levando a um declínio substancial na mobilidade e independência. Objetivo: Realizar uma revisão sistemática sobre os efeitos encontrados após reabilitação baseada em exercícios na marcha em pacientes com DP. Métodos: Foi realizada uma revisão sistemática buscando artigos nas bases de dados Pubmed, Lilacs, PEDro, Scielo e Scopus, com estudos publicados nos últimos dez anos. Os termos usados para pesquisa foram selecionados de acordo com o DeCS/MeSH (Descritores em Ciências da Saúde/ Medical Subject Headings). Resultados: A busca resultou em 514 estudos e 58 desses estudos foram apropriados para inclusão. Após avaliação metodológica dos 58 estudos, apenas trabalhos classificados como de alta qualidade metodológica foram incluídos. Foi verificado que programa com treinamento de marcha, fortalecimento, dupla tarefa, equilíbrio e resistência demonstram em sua maioria efeitos positivos na velocidade, cadência, comprimento da passada, comprimento do passo, capacidade e resistência da marcha. Conclusão: Os estudos apresentados nesta revisão demonstram em sua maioria efeitos positivos após reabilitação baseada em exercícios na marcha de pacientes com DP. (AU)

Gait parameters of Parkinson's disease compared with healthy controls: a systematic review and meta-analysis.

We systematically reviewed observational and clinical trials (baseline) studies examining differences in gait parameters between Parkinson's disease (PD) in on-medication state and healthy control. Four electronic databases were searched (November-2018 and updated in October-2020). Independent researchers identified studies that evaluated gait parameters measured quantitatively during self-selected walking speed. Risk of bias was assessed using an instrument proposed by Downs and Black (1998). Pooled effects were reported as standardized mean differences and 95% confidence intervals using a random-effects model. A total of 72 studies involving 3027 participants (1510 with PD and 1517 health control) met the inclusion criteria. The self-selected walking speed, stride length, swing time and hip excursion were reduced in people with PD compared with healthy control. Additionally, PD subjects presented higher cadence and double support time. Although with a smaller difference for treadmill, walking speed is reduced both on treadmill (.13 m s-1) and on overground (.17 m s-1) in PD. The self-select walking speed, stride length, cadence, double support, swing time and sagittal hip angle were altered in people with PD compared with healthy control. The precise determination of these modifications will be beneficial in determining which intervention elements are most critical in bringing about positive, clinically meaningful changes in individuals with PD (PROSPERO protocol CRD42018113042).

Spinal cord stimulation improves motor function and gait in spastic paraplegia type 4 (SPG4): Clinical and neurophysiological evaluation.

INTRODUCTION: Hereditary spastic paraplegia is a heterogeneous group of genetic disorders characterized by degeneration of the corticospinal tracts, coursing with progressive weakness and spasticity of the lower limbs. To date, there are no effective treatments for progressive deficits or disease-modifying therapy for those patients. We report encouraging results for spastic paraparesis after spinal cord stimulation. METHODS: A 51-year-old woman suffering from progressive weakness and spasticity in lower limbs related to hereditary spastic paraplegia type 4 underwent spinal cord stimulation (SCS) and experienced also significant improvement in motor function. Maximum ballistic voluntary isometric contraction test, continuous passive motion test and gait analysis using a motion-capture system were performed in ON and OFF SCS conditions. Neurophysiologic assessment consisted of obtaining motor evoked potentials in both conditions. RESULTS: Presurgical Spastic Paraplegia Rating Scale (SPRS) score was 26. One month after effective SCS was initiated, SPRS went down to 15. At 12 months follow up, she experienced substantial improvement in motor function and in gait performance, with SPRS scores 23 (OFF) and down to 20 (ON). There was an increased isometric muscle strength (knee extension, OFF: 41 N m; ON: 71 N m), lower knee extension and flexion torque values in continuous passive motion test (decrease in spastic tone) and improvement in gait (for example, step length increase). CONCLUSION: Despite being a case study, our findings suggest innovative lines of research for the treatment of spastic paraplegia.

Cortical thickness as predictor of response to exercise in people with Parkinson's disease.

We previously showed that dual-task cost (DTC) on gait speed in people with Parkinson's disease (PD) improved after 6 weeks of the Agility Boot Camp with Cognitive Challenge (ABC-C) exercise program. Since deficits in dual-task gait speed are associated with freezing of gait and gray matter atrophy, here we performed preplanned secondary analyses to answer two questions: (a) Do people with PD who are freezers present similar improvements compared to nonfreezers in DTC on gait speed with ABC-C? (b) Can cortical thickness at baseline predict responsiveness to the ABC-C? The DTC from 39 freezers and 43 nonfreezers who completed 6 weeks of ABC-C were analyzed. A subset of 51 participants (21 freezers and 30 nonfreezers) with high quality imaging data were used to characterize relationships between baseline cortical thickness and delta (Δ) DTC on gait speed following ABC-C. Freezers showed larger ΔDTC on gait speed than nonfreezers with ABC-C program (p < .05). Cortical thickness in visual and fronto-parietal areas predicted ΔDTC on gait speed in freezers, whereas sensorimotor-lateral thickness predicted ΔDTC on gait speed in nonfreezers (p < .05). When matched for motor severity, visual cortical thickness was a common predictor of response to exercise in all individuals, presenting the largest effect size. In conclusion, freezers improved gait automaticity even more than nonfreezers from cognitively challenging exercise. DTC on gait speed improvement was associated with larger baseline cortical thickness from different brain areas, depending on freezing status, but visual cortex thickness showed the most robust relationship with exercise-induced improvements in DTC.

Aerobic Exercise After Left-Sided Stroke Improves Gait Speed and Endurance: A Prospective Cohort Study.

OBJECTIVE: The aim of the study was to investigate the effects of aerobic exercise on individuals who have had a stroke and showed baseline scores lower than the standard scores for the 6-min and 10-meter walk tests. DESIGN: Individuals were assigned to groups according to gait performance, defined by the standard values in the 6-min and 10-meter walk tests (standard baseline score and lower baseline score), and brain injury side. Aerobic exercise, 30 mins per day, 2 times a week, for a total of 12 wks. The 6-min and 10-meter walk tests in five assessments: initial, after 4, 8, 12 wks, and 4 wks of follow-up, analyzed by multivariate analysis, with P value of less than 0.05. RESULTS: The 6-min walk test data showed an increase in endurance for lower baseline score and left-brain injury, during assessments 4, and follow-up, compared with standard baseline score (F4,84 = 14.64). Lower baseline score showed endurance increase for assessments 2, 3, 4, and follow-up compared with assessment 1 (F4,84 = 7.70). The 10-meter walk test data showed an increase in speed for lower baseline score and left-brain injury, during assessments 3, 4, and follow-up, compared with assessment 1, 4, and follow-up, compared with assessment 2 (F4,84 = 5.33). CONCLUSIONS: Aerobic exercise increases gait endurance and speed in individuals who have had a stroke, with left-brain injury, and lower baseline score in the 6-min and 10-meter walk tests.

Motor imagery for gait rehabilitation after stroke.

BACKGROUND: Motor imagery (MI) is defined as a mentally rehearsed task in which movement is imagined but is not performed. The approach includes repetitive imagined body movements or rehearsing imagined acts to improve motor performance. OBJECTIVES: To assess the treatment effects of MI for enhancing ability to walk among people following stroke. SEARCH METHODS: We searched the Cochrane Stroke Group registry, CENTRAL, MEDLINE, Embase and seven other databases. We also searched trial registries and reference lists. The last searches were conducted on 24 February 2020. SELECTION CRITERIA: Randomized controlled trials (RCTs) using MI alone or associated with action observation or physical practice to improve gait in individuals after stroke. The critical outcome was the ability to walk, assessed using either a continuous variable (walking speed) or a dichotomous variable (dependence on personal assistance). Important outcomes included walking endurance, motor function, functional mobility, and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently selected the trials according to pre-defined inclusion criteria, extracted the data, assessed the risk of bias, and applied the GRADE approach to evaluate the certainty of the evidence. The review authors contacted the study authors for clarification and missing data. MAIN RESULTS: We included 21 studies, involving a total of 762 participants. Participants were in the acute, subacute, or chronic stages of stroke, and had a mean age ranging from 50 to 78 years. All participants presented at least some gait deficit. All studies compared MI training versus other therapies. Most of the included studies used MI associated with physical practice in the experimental groups. The treatment time for the experimental groups ranged from two to eight weeks. There was a high risk of bias for at least one assessed domain in 20 of the 21 included studies. Regarding our critical outcome, there was very low-certainty evidence that MI was more beneficial for improving gait (walking speed) compared to other therapies at the end of the treatment (pooled standardized mean difference (SMD) 0.44; 95% confidence interval (CI) 0.06 to 0.81; P = 0.02; six studies; 191 participants; I² = 38%). We did not include the outcome of dependence on personal assistance in the meta-analysis, because only one study provided information regarding the number of participants that became dependent or independent after interventions. For our important outcomes, there was very low-certainty evidence that MI was no more beneficial than other interventions for improving motor function (pooled mean difference (MD) 2.24, 95% CI -1.20 to 5.69; P = 0.20; three studies; 130 participants; I² = 87%) and functional mobility at the end of the treatment (pooled SMD 0.55, 95% CI -0.45 to 1.56; P = 0.09; four studies; 116 participants; I² = 64.2%). No adverse events were observed in those studies that reported this outcome (seven studies). We were unable to pool data regarding walking endurance and all other outcomes at follow-up. AUTHORS' CONCLUSIONS: We found very low-certainty evidence regarding the short-term benefits of MI on walking speed in individuals who have had a stroke, compared to other therapies. Evidence was insufficient to estimate the effect of MI on the dependence on personal assistance and walking endurance. Compared with other therapies, the evidence indicates that MI does not improve motor function and functional mobility after stroke (very low-certainty evidence). Evidence was also insufficient to estimate the effect of MI on gait, motor function, and functional mobility after stroke compared to placebo or no intervention. Motor Imagery and other therapies used for gait rehabilitation after stroke do not appear to cause significant adverse events.

Clinical assessment, management, and rehabilitation of walking impairment in MS: an expert review.

INTRODUCTION: One of the most common and life-altering consequences of Multiple Sclerosis (MS) is walking impairment. The distance, speed, and Gait pattern functions are components of the International Classification of Functioning, Disability, and Health (ICF) and are also predictors of dependency in terms of daily living activities in patients with MS (pwMS). AREAS COVERED: This article provides an overview of walking impairment in pwMS, with focus on the assessment of gait and the rehabilitation approaches. EXPERT OPINION: The authors recommend that pwMS undergo gait assessment integrating the ICF perspective using validated clinical outcome measures that cover spatiotemporal gait parameters. Moreover, assessment of walking speed with short walking capacity tests such as the timed 25-foot walk (T25FW) or the 10-m walk test (10 MWT) and tests for walking distance with middle distance tests such as the 2-min walk test (2MWT) and the 6-min walk test (6MWT). This review further highlights strategies that may restore walking function including pharmacological symptomatic treatment and non-pharmacological rehabilitation approaches such as exercise and task-specific training providing an appraisal of mobility targeted therapies to be considered when planning multidisciplinary comprehensive-care of pwMS. Finally, new and novel strategies such as motor imagery and rhythmic auditory stimulation have been developed to improve walking speed and distance in pwMS.

The effects of dual task gait and balance training in Parkinson's disease: a systematic review.

In patients with Parkinson's disease (PD), the ability to perform simultaneous tasks may be impaired. However, there is no consensus as to whether the strategy of use dual task (DT) should be used with PD patients during gait and balance training because DT can increase the risk of falls. Therefore, it is necessary to critically analyze the relevant studies and evaluate the indications for the use of DT and its effects as a therapeutic strategy. The aim of this systematic review was to explore the effects of DT gait and balance training in individuals with PD. A total of 602 studies were found. After applying the eligibility criteria, seven studies were selected (three clinical trials, one uncontrolled clinical trial, and three pilot studies). Despite the poor methodological quality, the studies indicated the use of DT during gait and balance training may be beneficial for people with mild to moderate PD in compare of single-task or no intervention. The use of DT during training presented benefits related to gait (gait speed, step length and cadence) and balance (mediolateral and anteroposterior balance in closed-eyes tests). The current scenario shows that using DT in the training seems not to be harmful and could be part of the rehabilitation of PD patients. Further clinical trials are needed to confirm the findings, and it would be the most importance that these studies stratify individuals with degrees of disease severity to verify the effect of using the DT during training.

Effects of Load Addition During Gait Training on Weight-Bearing and Temporal Asymmetry After Stroke: A Randomized Clinical Trial.

OBJECTIVE: The aim of the study was to evaluate the effects of adding load to restrain the nonparetic lower limb during gait training on weight-bearing and temporal asymmetry after stroke. DESIGN: Thirty-eight subjects were randomized into treadmill training with load (5% of body weight) on the nonparetic limb (experimental group) and treadmill training without load (control group). Interventions lasted 30 mins/d for 2 wks (9 sessions). Both groups performed home-based exercises and were instructed to increase the use of paretic limb in daily life situations. Ground reaction force was obtained by a force plate during standing position (static) and gait (dynamic). Temporal gait parameters were assessed by a motion system analysis. Outcome measures were evaluated at baseline, posttraining, and after a 40-day follow-up. RESULTS: The experimental group increased static ground reaction force of the paretic limb at posttraining (P = 0.037) and the control group increased dynamic ground reaction force of the paretic limb at posttraining (P = 0.021), both with maintenance at follow-up. Neither group showed a change in the swing time symmetry ratio after training (P = 0.190). CONCLUSIONS: Treadmill training associated with behavioral strategies/home-based exercises seemed to be useful to minimize weight-bearing asymmetry, but not to improve temporal gait asymmetry. Load addition did not show additional benefits.

Cognitive and motor effects of Kinect-based games training in people with and without Parkinson disease: A preliminary study.

OBJECTIVE: Purpose of this study is to evaluate the effects of training with six commercial Xbox KinectTM games on cognitive and motor aspects in Parkinson's disease (PD) patients and to compare the effects with a group of paired healthy subjects. METHODS: This study was a quasi-experimental, controlled trial. Eight individuals with PD (mean age 68.9 ± 7.9) and eight older adults without PD, matched by age (mean age 67.6 ± 7.3) were enrolled in the study. Ten sessions of six Xbox 360 KinectTM commercial games were performed for 5 weeks. Subjects were evaluated before and 7 and 30 days after intervention. They were assessed using Montreal Cognitive Assessment, Frontal Assessment Battery (FAB), Timed Up and Go test, Ten Meters Walking test, and Balance Berg Scale. The Freezing of Gait Questionnaire, the Movement Disorder Society Unified Parkinson Disease Rating Scale, and the Parkinson's disease Questionnaire were also applied to PD group. RESULTS: Significant improvement was found for cognitive aspects measured by Montreal Cognitive Assessment and FAB in both groups but without retention on FAB in PD group. No significant improvements were found for motor aspects in none group. CONCLUSION: Motor-cognitive training using Xbox KinectTM games is a feasible resource to improve executive functions in PD patients and in older healthy people.

Effect of Plantar Flexor Muscle Strengthening on the Gait of Children With Idiopathic Toe Walking: A Study Protocol.

PURPOSE: To evaluate the effect of plantar flexor strengthening associated with conventional physical therapy treatment in participants with idiopathic toe walking. METHODS: Thirty participants, of both sexes diagnosed with idiopathic toe walking, aged 5 and 11 years, will be recruited and randomized into 2 groups: the control group, who will undergo gait training, triceps surae muscle stretching, anterior tibial muscle strengthening, and motor sensory training, and the intervention group, who will undergo the same training as the control group and, additionally, triceps surae muscle strengthening. The intervention will be performed twice a week for 8 weeks. The participants will undergo a 3-dimensional gait kinematic analysis, passive amplitude of dorsiflexion movement, isometric dynamometry of the anterior tibial and triceps surae muscles, motor coordination, quality of life, and perception of the parents regarding the equinus gait at baseline and at the end of treatment. Quality of life will be reevaluated during a 24-week follow-up.

Ankle torque steadiness and gait speed after a single session of robot therapy in individuals with chronic hemiparesis: a pilot study.

Background: Anklebot therapy has proven to be effective in improving hemiparetic gait. However, neither ankle torque steadiness nor the relationship between changes in force control and functional tasks after therapy with Anklebot were described.Objective: To assess whether a single session of robotic therapy promotes short-term ankle adaptations that influence ankle torque steadiness and walking speed in individuals with chronic hemiparesis.Methods: A sample of participants who had residual hemiparesis deficits (hemiparesis group; n = 13) and age- and sex-matched healthy control participants (control group; n = 13). For sample characterization, balance, mobility, sensorimotor impairment, and daily living activities performance were measured.Results: Differences in functional tests were identified only when the control and hemiparesis groups (F = 29.1; p = .001) were compared during the 10-metre Walking Test. Regarding the pre- and post-robotic assistance session, no significant difference was observed for any comparison (p > .05), except for the steadiness test, as demonstrated by the standard deviation (F = 7.10; p = .01) and coefficient of variation (F = 6.20; p = .02). The hemiparesis group showed better torque steadiness during dorsiflexion post-robotic assistance therapy (p ≥ 0.02) when compared with pre-robotic assessment. Correlations were identified between steadiness and walking speed variables.Conclusion:  People with chronic hemiparesis presented short-term performance gains in torque steadiness, especially during dorsiflexion, after a single robotic therapy session. The robotic therapy did not influence the walking speed, although low to moderate correlations between torque steadiness variables and walking speed were observed.

The kinematics of paretic lower limb in aquatic gait with equipment in people with post-stroke hemiparesis.

BACKGROUND: Devices are commonly used in aquatic gait rehabilitation; therefore, investigating the effect of these devices is important. We evaluated the combined use of buoyancy cuffs and ankle weights during aquatic gait on paretic leg kinematics in people with hemiparesis. METHODS: Fifteen adults (58.6 ±â€¯4.8 years) in the chronic phase post-stroke walked on a 4.5 m walkway with underwater immersion at the height of the xiphoid process in five conditions: (1) without equipment; (2) with ankle weights or (3) buoyancy cuffs on both legs; (4) with a buoyancy leg cuff on the non-paretic leg and an ankle weight on the paretic leg; (5) with an ankle weight on the non-paretic leg and a buoyancy leg cuff on the paretic leg. Five trials were performed for each condition for a total of 25 trials and the kinematic data were recorded. Analysis of covariance was used with walking velocity as a covariate to analyze spatiotemporal and angular variables of the paretic leg. FINDINGS: The condition with buoyancy cuff on the paretic leg increased (~20°) the maximum angle of knee flexion in the mid-swing phase compared to that seen with weights on both legs or weight on the paretic leg. Buoyancy cuffs on the paretic leg increased the step length by 5.6 cm. The ankle weights on the paretic leg condition increased the total (6%) and single support (4%) duration compared to that seen with a buoyancy cuff on the paretic leg. INTERPRETATION: Aquatic gait with buoyancy cuffs on both legs or on the paretic leg can modify gait kinematics compared to that with weight on both legs or on the paretic leg. Long term effects of training with those conditions needs further research.

Noninvasive brain stimulation combined with other therapies improves gait speed after stroke: a systematic review and meta-analysis.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS) are noninvasive brain stimulation (NIBS) techniques able to modulate cortical excitability. OBJECTIVE: To determine the effects of NIBS combined with other therapies on gait speed after stroke. METHODS: Electronic databases searched were PUBMED, EMBASE, COCHRANE, SCOPUS, SCIELO and PEDro. Eligibility criteria were randomized controlled trials that reported the effects of tDCS and rTMS combined with other therapies for improving gait speed, walking cadence, functional ambulation category (FAC) and motricity index (MI-LE) after stroke. Risk of bias was assessed by Cochrane risk of bias assessment tool. Mean differences (MD) and 95% confidence intervals were calculated. Quality of evidence was assessed by Grades of Researches, Assessment, Development and Evaluation approach. RESULTS: Ten studies (226 subjects) were included in the meta-analysis. NIBS combined with other therapies was effective for improving gait speed (MD 0.09 m/s [95% CI, 0.05 to 0.13; I2 0%, p < 0.0001]). Gait speed improved in both acute/subacute (MD 0.08 m/s [95% CI, 0.02 to 0.14]) and chronic phases (MD 0.08 m/s [95% CI, 0.03 to 0.13]). Furthermore, inhibitory (MD 0.09 m/s [95% CI, 0.04 to 0.14]) and excitatory (MD 0.07 m/s [95% CI, 0.02 to 0.12]) protocols were effective to improve gait speed. NIBS was also effective to improve walking cadence but was unable to modify other outcomes (FAC and MI-LE). CONCLUSIONS: This systematic review with meta-analysis synthesizes moderate-quality evidence that NIBS combined with other therapies are effective to improve gait speed after stroke. Systematic Review registration number: PROSPERO registration number CDR42015024237.

Evaluation of biomechanical gait parameters of patients with Cerebral Palsy at three different levels of gait assistance using the CPWalker.

BACKGROUND: Cerebral Palsy (CP) is the most common cause of permanent serious physical disability in childhood. Although many platforms have been developed, so far there are still not precise guidelines for the rehabilitation of the population with CP. The CPWalker is a robotic platform for the rehabilitation of children with CP, through which they can start experiencing autonomous locomotion in the rehabilitation environment. It allows the possibility of free movement and includes physical and cognitive interfaces into the therapy. The main objective of this work is to evaluate the effects of the CPWalker-based rehabilitation intervention in children with CP by comparing different gait parameters before, during and after the use of the platform. FINDINGS: The evaluation was divided in three stages where the gait parameters and symmetry indexes of eight subjects with CP were evaluated. In the first stage patients walked only with the help they receive normally in daily life. During the second stage they walked with the CPWalker and finally, in the third stage, they repeated their gait without the platform. In all stages they wore an inertial G-Sensor Ⓡ while walking through the hospital facilities. The results showed statistical significant differences in several spatio-temporal parameters, pelvic angles and general gait cycle parameters, with and without the use of the robotic device. For the eight patients: cadence, speed and stride length presented similar values when comparing before and after the therapy. However, they decreased during the intervention (both means and standard deviations). No significant differences were found in the symmetry indexes with the use of the platform. In spite of this, a reduction in the pelvic angles ranges and propulsion was observed. CONCLUSIONS: The effect of using the device was analyzed for spatio-temporal parameters, pelvic girdle angles and general gait cycle parameters. Among the eighteen initial parameters, seven presented a statistical significant difference when comparing stage 2 of the intervention with stages 1 and 3. Those changes showed the potential of the CPWalker to improve muscular strength and gait patterns of the patients with CP in the long term and to provide useful information for the design of the future generations of rehabilitation robotic devices.

Effects of isokinetic muscle strengthening on muscle strength, mobility, and gait in post-stroke patients: a systematic review and meta-analysis.

OBJECTIVE:: To investigate whether isokinetic muscle strengthening improves muscle strength, mobility, and gait in post-stroke patients. METHODS:: We searched for randomized controlled trials at PubMed/Medline, SciELO, PEDro, and Cochrane Central Register of Controlled Trials, from the earliest date available to June 2018. Randomized controlled trials that examined the effects of isokinetic muscle strengthening versus other rehabilitation interventions or control in post-stroke patients were included. Study quality was evaluated using the PEDro scale. Weighted mean difference (WMD) and 95% confidence intervals (CIs) were calculated, and heterogeneity was assessed using the I2 test. RESULTS:: In total, 13 studies (347 patients) focusing on the use of isokinetic in rehabilitation following stroke were included. All trials were of low-to-moderate quality. Isokinetic muscle strengthening improved muscle strength WMD 0.8 (95% CI: 0.2, 1.4; N = 96), mobility WMD -2.03 seconds (95% CI: -2.9, -1.1; N = 111) and gait speed WMD 0.9 m/s (95% CI: 0.05, 1.8; N = 87). CONCLUSION:: Isokinetic muscle strengthening seems to be a useful strategy for improving muscle strength, mobility, and gait in post-stroke patients.

Gait initiation and partial body weight unloading for functional improvement in post-stroke individuals.

BACKGROUND: To better understand gait initiation in individuals with stroke and suggest possible training strategies, we compared the gait initiation of individuals with stroke and age-matched controls, and we examined the influence of different amounts of body weight support (BWS) during the execution of gait initiation in individuals with stroke. MATERIALS AND METHODS: Twelve individuals with stroke and 12 age-matched controls initiated gait after a verbal command at a self-selected and comfortable speed, and individuals with stroke also initiated gait wearing a harness with 0%, 15%, and 30% of BWS. Length and velocity of the first step, distance between heels, and weight bearing in both lower limbs in the initial position were calculated. We also assessed the displacement and average velocity of the center of pressure (CoP) in the medial-lateral (ML) and anterior-posterior (AP) directions in 3 distinct sections during gait initiation, which correspond to the CoP position toward the swing limb, stance limb and progression line, respectively. RESULTS: Individuals with stroke presented shorter and slower step, shorter and slower CoP-ML and CoP-AP toward swing limb and Cop-ML towards stance limb, and longer and faster CoP-AP toward stance limb compared to their peers. The BWS lead individuals with stroke to decrease step length and to increase CoP-ML displacement and average velocity toward stance limb. CONCLUSION: Individuals with stroke present impairments in executing gait initiation mainly during the preparation period and the employment of an overground BWS system promotes a better performance. These results suggest that BWS is a functional strategy that enables individuals with stroke to modulate gait initiation and it could be adopted for gait intervention.