Interesting, I was just immediately given an AFO, then a hinged AFO. I seriously believe that an AFO actually hinders recovery, you do no training of your dorsiflexion while wearing an AFO. I went cold turkey on using one on a 21 day canoe trip in Canada and Alaska, 3 years after stroke. It forced me to immediately strengthen my ankle to keep it from rolling and get toe clearance. Didn't fall on that trip.
Real-time foot clearance biofeedback to assist gait rehabilitation following stroke: a randomized controlled trial protocol
- Rezaul BeggEmail authorView ORCID ID profile,
- Mary P. Galea,
- Lisa James,
- W. A. Tony Sparrow,
- Pazit Levinger,
- Fary Khan and
- Catherine M. Said
- Received: 20 December 2018
- Accepted: 6 May 2019
- Published: 31 May 2019
Abstract
Background
The risk of falling is
significantly higher in people with chronic stroke and it is, therefore,
important to design interventions to improve mobility and decrease
falls risk. Minimum toe clearance (MTC) is the key gait cycle event for
predicting tripping-falls because it occurs mid-swing during the walking
cycle where forward velocity of the foot is maximum.
High forward velocity coupled
with low MTC increases the probability of unanticipated foot-ground
contacts. Training procedures to increase toe-ground clearance (MTC)
have potential, therefore, as a falls-prevention intervention. The aim
of this project is to determine whether augmented sensory information
via real-time visual biofeedback during gait training can increase MTC.
Methods
Participants will be aged
> 18 years, have sustained a single stroke (ischemic or hemorrhagic)
at least six months previously, able to walk 50 m independently, and
capable of informed consent. Using a secure web-based application
(REDCap), 150 participants will be randomly assigned to either
no-feedback (Control) or feedback (Experimental) groups; all will
receive 10 sessions of treadmill training for up to 10 min at a
self-selected speed over 5–6 weeks. The intervention group will receive
real-time, visual biofeedback of MTC during training and will be asked
to modify their gait pattern to match a required “target” criterion.
Biofeedback is continuous for the first six sessions then progressively
reduced (faded) across the remaining four sessions. Control participants
will walk on the treadmill without biofeedback. Gait assessments are
conducted at baseline, immediately following the final training session
and then during follow-up, at one, three, and six months. The primary
outcome measure is MTC. Monthly falls calendars will also be collected
for 12 months from enrolment.
Discussion
The project will contribute to
understanding how stroke-related changes to sensory and motor processes
influence gait biomechanics and associated tripping risk. The research
findings will guide our work in gait rehabilitation following stroke and
may reduce falls rates. Treadmill training procedures incorporating
continuous real-time feedback may need to be modified to accommodate
stroke patients who have greater difficulties with treadmill walking.
Trial registration
Australia New Zealand Clinical Trials Registry, ACTRN12617000250336. Registered on 17 February 2017.
Keywords
- Gait
- Stroke
- Biofeedback
- Falls
- Tripping
- Minimum toe clearance (MTC)
Background
Stroke affects > 60,000 Australians every year, with 50% unable to walk one week following the event [1].
Impaired walking impacts independence by reducing the ability to
perform everyday activities and limiting community participation [2, 3]. Falls risk is significantly higher in people with chronic stroke [4] and approximately 50% of people living at home after a stroke will fall within 12 months [9],
with up to half sustaining multiple falls. Furthermore, in
community-dwelling people with stroke, up to 77% of falls occurred
during walking. While there has been considerable research investigating
falls risk management for older people generally, high-risk groups,
such as those who have had a stroke, have not been extensively studied
with respect to targeted falls prevention. Traditional exercise-based
falls-prevention programs are useful for the general older adult
community but are not effective in people with stroke. For example,
Batchelor et al. found that a multifactorial intervention including a
home-based balance and strength program did not reduce falls in people
with stroke [10].
Another study confirmed that a group- and home-based exercise program
incorporating balance and strength training did not reduce falls [11]. This suggests that alternative, targeted treatments to reduce falls risk in people with stroke are urgently needed.
Stroke
adversely affects sensorimotor function and muscle strength, inhibiting
the capacity to activate appropriate muscles and increasing the risk of
contact between the foot and either the supporting surface or objects
on it. Said et al. [15]
found, for example, that stroke participants who had difficulty in
stepping over small obstacles (4 cm high) had greater falls rates. The
key gait variable for predicting tripping-falls is minimum toe clearance
(MTC), an event mid-swing in the walking cycle [5, 6, 7, 8]. Low MTC increases the probability of unanticipated foot-ground contacts [7].
Given that tripping directly results from unsuccessful toe clearance,
previous research with both young and older populations has focused on
toe trajectory control during walking [6, 7, 8, 12, 13, 14]. Training individuals to increase MTC, therefore, has potential as a falls-prevention intervention.
The
aim of this project is to determine whether real-time biofeedback of
toe clearance during gait training can significantly minimize tripping
risk in people with stroke. We will test the efficacy of real-time
biofeedback as an intervention to increase MTC using a randomized
controlled trial (RCT) design incorporating both a training or
“acquisition” phase with biofeedback. Retention tests will be conducted
to confirm learning, as demonstrated by the longer-term or “relative permanence” of the targeted behavior.
The
primary objective is to determine whether real-time biofeedback of MTC
during gait training will significantly increase MTC in people with
stroke. We will also determine whether changes in MTC achieved on a
treadmill transfer to overground walking. It is hypothesized that,
compared to no-biofeedback training, visual biofeedback of foot
clearance parameters during gait training will significantly increase
toe-ground clearance (MTC) and MTC during biofeedback training will be
retained in the longer term. It is also hypothesized that increases in
MTC demonstrated in treadmill training will transfer to overground
walking, such that tripping-risk in people with stroke is significantly
reduced.
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