Whatever the useless weasel word 'Neurocognitive Rehabilitation' means.
Changes in Gait Metrics and Motor Strategies Post-Neurocognitive Rehabilitation in Subacute Stroke: A Retrospective Mixed-Methods Study
Keisuke Goto • Tsubasa Kawasaki • Hiroyuki Hamada • Vivian Sihan Lim • Ryusuke Shimada •
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Abstract
Background
It is known that neurocognitive rehabilitation (NCR) improves post-stroke functional outcomes. However, systematic evaluations of changes in stride regularity and step regularity remain limited. Furthermore, a few studies have combined quantitative gait metrics with qualitative analyses of self-reported motor strategies, particularly in individuals with subacute stroke.
Objective
To examine immediate changes in key gait metrics - specifically vertical stride regularity and walking speed - as well as self-reported motor strategies following a single-session NCR intervention targeting hip and trunk proprioception in individuals with subacute stroke using a retrospective observational design.
Methods
Using a convergent mixed-methods design within a retrospective framework, we concurrently analyzed quantitative gait and qualitative interview data, which were subsequently integrated during the interpretation phase. Clinical data from 39 patients with subacute stroke were analyzed. Each participant underwent a single-session NCR intervention. Clinical records included trunk accelerometry-based gait assessments and self-reported motor strategies collected through semi-structured interviews. Quantitative gait data were analyzed as time series, and qualitative interview data were processed using text mining techniques. The findings were integrated via correspondence analysis, with patients categorized based on the percentage change in vertical stride regularity from baseline to immediately post-intervention.
Results
Statistically significant immediate changes in stride regularity (vertical and anteroposterior axes) and step regularity (vertical, mediolateral, and anteroposterior axes) were observed from pre- to post-intervention (T0 to T1), with medium to large effect sizes. Gait speed showed a statistically significant increase post-intervention to the following day (T1 to T2). Co-occurrence network analysis of interview data revealed a shift in reported motor strategies post-intervention, from distal segments (such as “feet” and “toes”) to proximal segments (such as “hip joint,” “waist,” and “trunk”). The correspondence analysis suggested that patients with greater changes in vertical stride regularity described strategies emphasizing proximal control, whereas those with smaller changes referenced distal segments or fall prevention-oriented strategies.
Conclusions
A single session of NCR focusing on hip and trunk proprioception was associated with immediate changes in gait regularity and symmetry, as well as patients’ awareness of their motor strategies in subacute stroke. The integration of objective and subjective assessments may support more personalized rehabilitation planning. Prospective studies are warranted to further investigate these findings.
Introduction
In post-stroke rehabilitation, training approaches that emphasize the integration of sensation and motor function are widely employed to support motor recovery. Previous research suggests that combining sensory-focused training with conventional motor-oriented approaches may yield better functional outcomes [1]. However, evidence regarding the effects of sensory training remains limited, and the specific contributions of interventions such as sensory discrimination training and perceptual learning require further investigation. In particular, given that regaining walking ability is a major goal for individuals post-stroke, the relationship between sensory training and motor strategy modifications during gait remains unclear and warrants further exploration [2]. Addressing this gap requires research into how active sensory inputs are processed and integrated into movement patterns, especially in complex tasks like gait.
In response to these challenges, neurocognitive rehabilitation (NCR) has garnered attention as a practical model of active sensory training [3]. NCR encourages patients to actively reprocess sensory information and reconstruct motor strategies through cognitive tasks involving perception and attention [3,4]. This approach is based on the concept of "perception-action coupling," where perception and action dynamically interact [5]. It is hypothesized that active sensory processing by the patient facilitates more coordinated motor execution. The emphasis on active patient engagement and cognitive involvement distinguishes NCR from more passive or purely motor-focused interventions. Interventions based on NCR principles have been associated with various outcomes, including changes in muscle strength, balance ability [6], proprioception, spasticity, gait speed [7], and indicators of brain neuroplasticity [8]. These findings support the notion that NCR is an effective intervention for promoting functional recovery in post-stroke rehabilitation.
According to existing studies on NCR-based gait rehabilitation, gait speed has been the most commonly used outcome measure, whereas the consistency and rhythmicity of gait patterns remain underexplored. In stroke rehabilitation, promoting stable and symmetrical gait patterns, rather than simply increasing gait speed, is considered a crucial therapeutic goal [9,10]. Recent advances in wearable sensor technology, particularly triaxial accelerometry, have enabled more objective evaluation of gait characteristics such as gait regularity and symmetry, which were previously difficult to assess [11]. Among these measures, the autocorrelation coefficient (AC), derived from trunk acceleration data, is regarded as a sensitive indicator of the regularity of the gait cycle at different temporal scales. Specifically, as described by Moe-Nilssen and Helbostad (2004), it is possible to quantify both the regularity from one full stride to the next (termed stride regularity) and the regularity from one step to the next (termed step regularity) [12]. These metrics are associated with trunk function and balance ability in patients in the early stages of stroke, suggesting a potential relationship between trunk control recovery and changes in gait control [13]. Understanding how NCR relates to such changes could provide deeper insights into its role in rehabilitation practices.
Another challenge is that prior studies rarely integrated objective motor measures with patients' self-reported motor strategies at the group level. Given that NCR targets internal sensory and cognitive processes, it is critical to not only document motor outcomes but also explore how patients perceive and reconstruct their movements. Understanding patients' subjective experiences is essential for clarifying the nature of observed changes. Recently, mixed-methods approaches that combine objective data with subjective experiences have increasingly been advocated in rehabilitation research to optimize individualized treatment strategies [14]. In this context, it is important to capture both measurable changes in gait control and subjective reports of motor strategy changes following NCR to gain a more comprehensive understanding of its effects.
Therefore, this study aimed to investigate group-level associations between changes in key gait metrics - specifically vertical stride regularity and gait speed - and self-reported motor strategies following a single-session NCR intervention in individuals with subacute stroke. Using a retrospective observational design and a mixed-methods approach, we analyzed clinical data to explore these associations. By linking quantitative gait outcomes with patient-reported motor strategies, this study seeks to inform more individualized and mechanism-based approaches to stroke rehabilitation.
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