Stepping to the Beat: Feasibility and Potential Efficacy of a Home-Based Auditory-Cued Step Training Program in Chronic Stroke

Well, if feasible, well tolerated and effective, then write up a protocol on it and get it distributed to all stroke doctors in the world.  Writing an article is not enough. No ones reads and implements from research articles.  You researchers have to take on this task since we have fucking failures of stroke associations failing at doing just that.
http://journal.frontiersin.org/article/10.3389/fneur.2017.00412/full?

Rachel L. Wright^1,2*, Simone Briony Brownless¹, David Pratt³, Catherine M. Sackley⁴ and Alan M. Wing¹

• ¹School of Psychology, University of Birmingham, Birmingham, United Kingdom
• ²School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
• ³West Midlands Rehabilitation Centre, Birmingham Community Healthcare Trust, Birmingham, United Kingdom
• ⁴Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom

Background: Hemiparesis after stroke typically results in a reduced walking speed, an asymmetrical gait pattern and a reduced ability to make gait adjustments. The purpose of this pilot study was to investigate the feasibility and preliminary efficacy of home-based training involving auditory cueing of stepping in place.

Methods: Twelve community-dwelling participants with chronic hemiparesis completed two 3-week blocks of home-based stepping to music overlaid with an auditory metronome. Tempo of the metronome was increased 5% each week. One 3-week block used a regular metronome, whereas the other 3-week block had phase shift perturbations randomly inserted to cue stepping adjustments.

Results: All participants reported that they enjoyed training, with 75% completing all training blocks. No adverse events were reported. Walking speed, Timed Up and Go (TUG) time and Dynamic Gait Index (DGI) scores (median [inter-quartile range]) significantly improved between baseline (speed = 0.61 [0.32, 0.85] m⋅s⁻¹; TUG = 20.0 [16.0, 39.9] s; DGI = 14.5 [11.3, 15.8]) and post stepping training (speed = 0.76 [0.39, 1.03] m⋅s⁻¹; TUG = 16.3 [13.3, 35.1] s; DGI = 16.0 [14.0, 19.0]) and was maintained at follow-up (speed = 0.75 [0.41, 1.03] m⋅s⁻¹; TUG = 16.5 [12.9, 34.1] s; DGI = 16.5 [13.5, 19.8]).

Conclusion: This pilot study suggests that auditory-cued stepping conducted at home was feasible and well-tolerated by participants post-stroke, with improvements in walking and functional mobility. No differences were detected between regular and phase-shift training with the metronome at each assessment point.

Introduction

Stroke is a leading cause of long-term functional disability (1), with 70% of individuals post-stroke being classified as household or limited community ambulators based on their walking function (2, 3). Hemiparesis secondary to stroke typically results in a reduced walking speed and gait is generally asymmetrical with abnormal gait biomechanics (4). Gait asymmetry remains resistant to rehabilitation (5), and temporal asymmetry is present in over half of independent ambulatory stroke survivors (6). Large swing time asymmetries are associated with slower walking velocities (7) and with lower scores on the Berg Balance Scale (8), suggesting that this measure is an important marker for diminished balance. Rehabilitation of these gait features is a key goal for therapists as gait and balance are important for independent mobility and to reduce the risk of falling (9), as well as for quality of life (10).

The conventional view is that gait improves over the first 3–6 months following a stroke and then plateaus (11, 12). This view is widely used to discharge patients from motor rehabilitation programs after the initial acute phase (13). However, there is evidence that there are benefits of higher doses of training on outcome measures and that this is not influenced by time since stroke (14) (i.e., months or even years post-stroke). Furthermore, there is convincing evidence that gait training in the chronic phase can lead to continued improvement in walking speed (15, 16) and cardiovascular fitness (17, 18).

Auditory rhythm can produce an effect on the motor system, and studies have demonstrated the ability to synchronize lower limb movements to auditory cues (19, 20). Auditory cueing has been investigated as a means to improve hemiparetic gait. Chronic stroke participants are able to synchronize to a metronome during treadmill walking (21–23), and improvements in temporal symmetry were observed with acoustic pacing (21). Stepping in place to an auditory cue results in immediate reductions in both step time asymmetry and variability in participants with post-stroke hemiparesis consistent with those observed during cued walking (24). Auditory cueing has been used in stroke gait rehabilitation programs, with significantly greater improvements in walking speed and stride length in gait training with auditory cueing compared to conventional gait training (25) and Bobath training (26) and has been proposed as one of the most promising approaches to improving gait coordination (27).

Stepping in place is a skill that requires components found in gait, such as reciprocal flexion and extension of the lower limbs by timely coordination and synchronization to create a single limb support phase, a swing phase, and a step frequency (28). Therefore, this suggests stepping in place is an appropriate form of locomotor training for rehabilitation. The temporal asymmetries typically seen in hemiparetic walking are also shown during stepping in place (24, 28), suggesting that targeting asymmetry during stepping in place may have carry-over effects on everyday walking. If this is the case, it is possible that step training could be used to ensure high movement repetition where space is limited (e.g., in the home) as part of walking rehabilitation.

The ability to adapt walking to the demands of the environment is a key component of everyday mobility. Gait adaptability is reduced in people with stroke (22, 29, 30), which may contribute to the high incidence of falls during walking in stroke survivors (31, 32). Previous research involving correction to a phase shift in a metronome has shown that individuals with stroke delay correction if the perturbation occurs on the paretic limb (23) and that there is a preference for a slower step response when a faster step may be more optimal (22). The use of a variable metronome (e.g., with phase shifts) may help to simulate the temporal stepping adjustments encountered during community walking (i.e., curbs, uneven terrain). Therefore, repeated training of stepping adjustments may result in an improved ability to adapt gait during community walking.

The purpose of this pilot study was to investigate the feasibility and preliminary efficacy of home-based training involving auditory cueing with and without phase-shift adjustments of stepping in place. We hypothesized that the training would be tolerated by most individuals with minimal adverse events. In terms of efficacy of training, we formulated two research questions:

1. Does training of auditory cued stepping result in improved walking function?

2. Does training with auditory-cueing of stepping with phase-shift adjustments result in improved gait adaptability compared to standard auditory-cued step training?

We hypothesized that stepping training to an auditory metronome would lead to improvements in walking speed and functional mobility. We also hypothesized that training with phase-shift adjustments would improve scores on a measure of gait adaptability.