Effect of Gait Training With Non-paretic Knee Immobilization on Lower Limb and Trunk Acceleration in a Post-stroke Hemiparetic Patient: A Case Report

 Ask your competent? doctor if this is better for gait recovery than split-belt treadmill or unstable shoes. Your competent? doctor doesn't know the answer; YOU DON'T HAVE A FUNCTIONING STROKE DOCTOR, do you!

• split-belt treadmill (14 posts to June 2012)

• unstable shoes (7 posts to May 2012)

Effect of Gait Training With Non-paretic Knee Immobilization on Lower Limb and Trunk Acceleration in a Post-stroke Hemiparetic Patient: A Case Report

Ryosuke Todaka • Tetsu Kajiyama • Naoya Kariu • Masaya Anan

Published: July 09, 2024

DOI: 10.7759/cureus.64193

Peer-Reviewed

Cite this article as: Todaka R, Kajiyama T, Kariu N, et al. (July 09, 2024) Effect of Gait Training With Non-paretic Knee Immobilization on Lower Limb and Trunk Acceleration in a Post-stroke Hemiparetic Patient: A Case Report. Cureus 16(7): e64193. doi:10.7759/cureus.64193

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Abstract

This case report describes a woman in her fifties who experienced a left-sided atherothrombotic cerebral infarction with lesions in the left corona radiata. The patient exhibited motor paralysis of the right upper and lower limbs. After a 10-day acute hospital stay, she was admitted to a rehabilitation facility for an intensive program of physical, occupational, and speech therapy. By day 17 of the onset, she had achieved independence by walking with a cane.

This case was documented to study the effects of gait training with non-paretic knee immobilization on muscle activity and trunk kinematics in post-stroke hemiplegia. Traditional physical therapy was used initially, followed by an intervention phase in which gait training was performed with the non-paretic knee immobilized. This approach was hypothesized to induce beneficial kinematic and muscle activity changes in the paretic limb. The results showed increased muscle activity in the paretic lateral gastrocnemius without compromising trunk stability, suggesting that this method may improve rehabilitation outcomes in similar cases.

Introduction

After stroke, many patients present with motor paralysis, which is characterized by decreased muscle strength in the paretic lower limb [1], gait asymmetry, and decreased gait speed [2]. Motor function, such as muscle strength and the severity of motor paralysis in the paretic lower limb, is thought to be associated with performance measures such as walking speed [3]. Therefore, efforts to improve the functionality of the paretic lower limb are clinically imperative.

In the quest to improve the functionality of the paretic limb, the importance of use-dependent plasticity is emphasized [4]. In the field of upper limb rehabilitation, the effectiveness of constraint-induced movement therapy has been widely documented [5]. Similar to the upper limb, the efficacy of constraint-induced movement therapy as a proactive strategy for using the paretic limb has been reported in the lower limb [6]. Specific methods include exercises such as gait training, sit-to-stand, and stepping under the constraint of the non-paretic lower limb [7-9]. These methods have been reported to increase the anterior-posterior ground reaction force during forward propulsion of the paretic limb and to increase the single-support time of the paretic lower limb during gait [8]. The change in parameters of the paretic lower limb in the stance phase is attributed to the fact that the knee joint of the non-paretic lower limb is immobilized and the knee joint of the non-paretic lower limb does not bend during the swing phase of the non-paretic lower limb. Lateral flexion of the trunk or extension of the knee joint of the paretic lower limb is required to compensate for the lack of flexion of the knee joint of the non-paretic lower limb during the swing phase [9]. The lateral flexion of the trunk to the paretic side and the increased knee extension angle on the paretic side result in a greater load on the paretic lower limb during the stance phase, which could serve as training to strengthen the paretic lower limb. Increased loading during the stance phase on the paretic side may increase the activity of the ankle plantarflexors, which are antigravity muscles.

However, few studies have demonstrated changes in muscle activity with non-paretic knee immobilization. Gait speed in post-stroke patients is related to the severity of motor paralysis in the paretic lower limb, muscle strength [10], muscle strength in the non-paretic lower limb [11], and trunk stability [10]. In particular, because lower limb strength training combined with gait training after stroke is effective in improving gait speed [12], it is clinically relevant for monitoring changes in muscle activity. In addition, trunk kinematics and concurrent contractions during gait compensate for stability, which merits investigation because of their potential impact on gait stability and joint stiffness [10]. Because gait training with non-paretic knee immobilization often results in compensatory movements such as lateral trunk flexion [9], this lateral trunk flexion may cause excessive trunk instability during gait and lead to co-contraction of the ankle plantar and dorsiflexors to compensate for trunk stability [10]. We hypothesized that gait training with immobilization of the non-paretic knee joint would induce kinematic changes in the stance phase of the paretic lower limb as well as changes in muscle activity and trunk kinematics in the background. This case report examined the effects of gait training with non-paretic knee immobilization on trunk and lower limb kinematic parameters in a post-stroke hemiplegic patient.

More at link.

Cognitive-motor exergame training on a labile surface in stroke inpatients: study protocol for a randomized controlled trial

 Labile is an adjective used to describe something that is easily or frequently changed.

 

Didn't your competent? doctor start using these unstable shoes for balance recovery a decade ago? NO? So you don't have a functioning stroke doctor, do you?

Unstable Shoes Increase Energy Expenditure of Obese Patients

The latest here:

Cognitive-motor exergame training on a labile surface in stroke inpatients: study protocol for a randomized controlled trial

Joel Büttiker¹Detlef Marks²Manuel Hanke³Sebastian Ludyga³Petra Marsico⁴Benjamin Eggimann⁵Eleftheria Giannouli^1*

• ¹Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
• ²Rehaklinik Zihlschlacht, Centre for Neurological Rehabilitation, Zihlschlacht, Switzerland
• ³Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
• ⁴Research Department, Swiss Children’s Rehab, University Children’s Hospital Zurich, Zurich, Switzerland
• ⁵OST – Eastern Switzerland University of Applied Sciences, Rapperswil, Switzerland

Background: Cognitive-motor training in form of exergames has been found to be feasible and effective for the improvement of motor and cognitive functioning in older adults and several patient populations. Exergame training under unstable conditions might increase the proprioceptive resources needed and thus might be a superior training approach compared to exergame training on stable ground for stroke patients, who often have proprioceptive deficits.

Objective: Aim of this study is to assess the feasibility and effects of exergame-based cognitive-motor training on a labile platform on physical and cognitive functioning in stroke inpatients.

Methods: This is two-armed pilot randomized controlled trial taking place in an inpatient neurologic rehabilitation clinic. A total of 30 persons that are undergoing inpatient rehabilitation due to a stroke will be randomly assigned to either the intervention group (IG) or the control group (CG). Participants of the IG will receive exergame-based motor-cognitive training on a labile surface, whereas participants of the CG will train on a stable surface. Primary outcome is feasibility comprising measures of adherence, attrition, safety and usability. Secondary outcomes will be measures of cognitive (psychomotor speed, inhibition, selective attention, cognitive flexibility, brain activity) and motor (functional mobility, gait speed, balance, proprioception) functioning.

Results: Data collection started in February 2024 and is expected to be completed by August 2024.

Conclusion: This is the first study looking into exergame training on labile surface in stroke patients. It will give valuable insights into the feasibility and potential added value of this type of training and thus inform further implementation efforts in the context of inpatient rehabilitation.

Clinical trial registration: ClinicalTrials.gov, NCT06296069.

1 Introduction

With the growing number of older adults due to the demographic shift, the risk of cardiovascular and neurologic diseases and especially stroke rises (1). Due to an increasing prevalence and a shift to younger age groups, stroke is the second-leading cause of death and third-leading cause of death and disability combined worldwide (2). The inpatient care, rehabilitation and follow up care of stroke patients is over 3% of the value of lost welfare/gross domestic product in certain regions (3). Twenty-six percent of the persons who suffered a stroke remain with limited ability to perform activities of daily living (ADLs) and 50% have reduced mobility due to hemiparesis (4). Post-stroke cognitive impairment (PSCI) is the occurrence of cognitive deterioration after a stroke, which can range from minor impairment to dementia. Studies show that PSCI occurs in up to 60% (cumulative incidence) in the first year (5) as well as 10 years (6) after stroke. PSCI can severely limit the motor and cognitive functioning of the patients and reduce their independence by affecting memory, attention and executive functions (7). Furthermore, the presence of any degree of cognitive impairment (MCI) be a risk factor for falls and other comorbidities of the musculoskeletal system (8).

As a result of the impairment in cognitive and motor functioning after a stroke, the balance ability worsens and gait becomes unsteady. Of all complications following a stroke, falls are one of the most prevalent. Between 14–65% of people with stroke fall at least once during hospitalization and between 37–73% fall during the first six-months after discharge (9). Fall risk is up to two times higher even at later stages after stroke compared to similarly aged individuals (10). Thus, there is also an increased need for interventions in this population.

Balance training is an established form of exercise in people suffering from stroke and other neurological disabilities (11). However, cognitive-motor training is superior to single physical training in improving motor functioning, e.g., gait speed and walking endurance in stroke patients (12). More specifically, compared to sequential (e.g., cycling followed by cognitive training) and simultaneous-additional (e.g., cycling while solving an arithmetical task), simultaneous-incorporated motor-cognitive training (e.g., any type of training in which the cognitive task is “incorporated” into the motor task, i.e., the cognitive task is a relevant prerequisite to successfully solve the motor-cognitive task) (13) seems to be the most promising training type for improving gait speed, walking endurance, cadence and stride length in stroke patients (12).

Exergames (video games which are played by body movements) are an excellent tool for the delivery of simultaneous-incorporated cognitive-motor training and they have already been used in the context of several frail and neurologic populations (14–18), including stroke patients (19, 20).

Proprioception is used to stabilize the body by sensing its position in space via the sense of joint and limb positioning. Proprioception training addresses the balance and somatosensory stimulation and can therefore build a possible prevention strategy for further falls and of managing ADLs (21). Combining proprioceptive training with simultaneous cognitive tasks could have additional positive outcomes in stroke rehabilitation. Indeed, a recent systematic review concluded that proprioceptive combined with dual-task exercises stimulate and promote postural balance, gait, and quality of life and reduce the risk of falls in stroke patients compared with traditional rehabilitation programs (22).

There is currently just one study that has looked into the effects of exergame-based cognitive-motor training with the additional proprioceptive stimulation by playing the exergames on a labile platform (23). They found that compared to the training on a stable platform and to a passive control group, training on an instable platform is more effective for the improvement of reactive balance and functional mobility under dual-task conditions in healthy, community-dwelling older adults. The feasibility and effects of this type of exergame training on labile surface and thus rich in proprioceptive stimulation in stroke patients remains unknown.

Therefore, the aim of this study is to assess the feasibility and effects of exergame-based cognitive-motor training on a labile platform on physical and cognitive functioning in stroke inpatients.

We hypothesize that exergame-based cognitive-motor on a labile surface will be feasible within the context of inpatient rehabilitation of stroke patients. In addition, we hypothesize that compared to training on stable surface, training on a labile platform will be more effective for the improvement of motor and cognitive functioning in stroke inpatients.

More at link.

Unstable Footwear Affects Magnitude and Structure of Variability in Postural Control

Your doctor probably has ignored these 6 posts on unstable shoes back to May 2012.  So any falls since then are on your doctors' shoulders.
http://journals.humankinetics.com/doi/abs/10.1123/mc.2016-0021

Michael Buchecker ^*1, Stefan Wegenkittl ^*2, Thomas Stöggl ^*1, and Erich Müller ^*1Affiliations¹University of Salzburg²University of Applied Sciences Salzburg

*Buchecker, Stöggl, and Müller are with the Dept. of Sport Science and Kinesiology/USI, University of Salzburg, Hallein/Rif, Austria. Wegenkittl is with the Dept. of Applied Image and Signal Processing, University of Applied Sciences Salzburg, Puch, Austria.

Address author correspondence to Michael Buchecker at michael.buchecker@sbg.ac.at.

Volume: 22 Issue: 1 Pages: 1-17

https://doi.org/10.1123/mc.2016-0021

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This study evaluated the amount, and particularly, the structure of variability in postural control accompanying an unstable shoe (US) application. Mediolateral and anterior–posterior center of pressure signals plus electromyographic profiles of the tibialis anterior and gastrocnemius medialis were recorded in 29 asymptomatic men while wearing both US and flat shoes. Statistical analysis included common measures of dispersion as well as sample entropy and largest Lyapunov exponent estimates. Data were compared by two-way repeated-measures analysis of variance. Corresponding main effects of footwear revealed that, in contrast to the flat shoes condition, the US intervention consistently increased center of pressure and electromyographic net fluctuations and rendered the overall system less complex, as reflected by the lower sample entropy and higher Lyapunov exponent values observed throughout. Accordingly, employing US in stance should be functional concerning motor development; however, the greater sensitivity of US users to external perturbations must not be overlooked and warrants further investigation.

Israeli Team Develops Shoe to Stop Seniors from Falling

How is your therapist making sure you don't fall? Fall prevention training? Unstable shoes? Waiting for this to come out? Not walking?

http://www.jspacenews.com/israeli-team-develop-shoe-stop-seniors-falling/

Yonathan Manor’s father was the inspiration for his latest invention, the B-Shoe, a shoe that promotes stability and stops wearers from falling.
A biomechanical engineer, Manor was concerned when his aging father, like millions of elderly persons worldwide, started struggling with mobility and began to fall a lot. So he decided to do something about it.
Working with physiotherapists and doctors, Manor theorized that when people age, they lose the ability to keep themselves stable and as a result are unable to make the minor adjustments needed to prevent falls.
Digging out the heel from an old sneaker for his first prototype, Manor joined with electronic engineer partners Abraham Stamper and Aharon Shapiro to develop a system that corrects an elderly person’s gait.
“We built prototypes of shoes that can save lives,” Stamper said of the design that has been six years in development.
He also explained how the B-Shoe works. “The main electronic mechanism is in the heel, and the rechargeable battery will be embedded in the sole along with the pressure sensors,” Stamper explained. “The sensors can detect that the center of pressure is going beyond the back line of support. If there is no reaction from the wearer for more than a few milliseconds, the shoes begin moving backwards five to seven centimeters until stability is regained.”
Manor and the B-Shoe team has already secured patent for its products in both Israel and the United States and has launched a crowd-funding campaign to get the financing needed to bring the high-tech shoe to market.
If all goes well, the B-Shoe may be available in the US and Israeli markets in as little as two years, helping to keep seniors, and others with stability issues, safer.

First study on the effects of unstable shoes with curved soles on trunk muscles and lumbar lordosis

How would this help our balance and prevent falls? Your PT will need to run a clinical trial to find out.
http://www.alphagalileo.org/ViewItem.aspx?ItemId=152768&CultureCode=en
The study shows that the unstable shoes – compared to normal shoes – improve trunk muscle activity in order to maintain balance, which in turn favours spine stability and can help reduce low back pain. The research project, led by researchers at the University CEU Cardenal Herrera in cooperation with the University of Valencia, has been accepted for publication in the European Journal of Physical Rehabilitation and Medicine. The few studies that have been conducted so far on this type of footwear have focused on the positive effects the shoes have on leg muscles, but so far no study had analysed the effects they have on the lumbar region.
Since the mid-nineties various companies have introduced a special kind of “unstable footwear” onto the market, which is characterised by its curved sole and its flexible outsole. This curvature of the sole provides an unstable base for the feet to simulate walking barefoot, compared to conventional shoes that contribute to the stability and thus can weaken the muscles that develop this stabilising function because they are rarely used.
The possible long-term effects of those shoes, such as easing pain or preventing injuries are of interest for biomechanics, doctors, physiotherapists and trainers.
The few existing scientific studies on unstable shoes have focused on analysing the effects on leg muscles. Now researchers of Physical Therapy at the University CEU Cardenal Herrera and the University of Valencia have carried out the first global study on the effects of this type of footwear on the lumbar region. Their research work titled “Effects of Unstable Shoes on Trunk Muscle Activity and Lumbar Spine Kinematics”, has been accepted for publication in the European Journal of Physical Rehabilitation and Medicine.
The research team, led by the Vice Dean of Medicine at the University CEU Cardenal Herrera, Juan Francisco Lisón, has studied the changes that wearing this type of shoes have on the electromyographic activity of erector spinae (ES), rectus abdominis (RA) and lumbar spine sagittal plane range of motion (ROM).
According to the professor of Physiotherapy at the University CEU Cardenal Herrera, Pablo Salvador, coauthor of the paper, “increased co-contraction of the trunk muscles increases spine stability and is related to low back pain”.
The study involving 48 healthy test persons, 24 men and 24 women, who had not worn this type of unstable shoes before, was carried out by comparing muscle activity when walking with a control shoe. During the tests a measurement protocol of the lumbar spine was conducted by means of electromyography. Additionally, by means of electrogoniometry, the level of lumbar lordosis was examined during walking with both types of shoes.
Main results
The results obtained in this study determine that the unstable shoe – compared to the control shoe - improves the activity and strength of the trunk muscles (erector spinae and rectus abdominis) in every phase of walking.
“The footwear with curved soles, which simulates an unstable surface, requires a constant muscle activity of the trunk to stabilize the lumbar area and maintain balance. This increase in co-contraction of the trunk muscles improves the stability of the spine, which can help prevent or ease low back pain,” said Professor Pablo Salvador.
The researchers of the Faculty of Heath Sciences at the University CEU Cardenal Herrera, Juan Francisco Lisón and Pablo Salvador, and of the Departments of Physical Education and Anatomy at the University of Valencia, Pedro Pérez, Salvador Llana and Daniel Sánchez-Zuriaga, have also observed significant effects on the curvature of the spine or lumbar lordosis when wearing this footwear. “This natural biomechanical mechanism is considered to be the best adjustment for the spine to absorb the vertical impact when walking,” added the professor of University CEU Cardenal Herrera Pablo Salvador.

Shoes for seniors go high-tech to prevent falls

You will need one of these since your therapists refuse to allow you to practice fall prevention or get  unstable shoes.  Once again working on compensation rather than recovery. But you really don't think your therapist and doctor will find out about this for 30 years unless you tell them?
http://medcitynews.com/2014/01/shoes-seniors-go-high-tech-prevent-falls/?
Sensors and apps designed for seniors and their caretakers may be able to detect when falls occur, but Dr. Yonatan Manor wanted to take that a step further.
He assembled a team of doctors and engineers to prototype a smart shoe that they think might be able to prevent falls when they’re about to occur.
The so-called B-Shoe is a walking shoe that incorporates pressure sensors, a microprocessor, an algorithm, a motion device and a rechargeable battery. When the sensor and algorithm detect imbalance, they prompt the motion device to perform a backward step to help the wearer regain balance. It operates only when imbalance is detected and is designed for use by seniors or by people who are injured, physically challenged, sick or in post-surgery recovery.
According to the CDC, falls are the leading cause of both fatal and nonfatal injuries among older adults.
[Image credit: B-Shoe Technologies]

Read more: http://medcitynews.com/2014/01/shoes-seniors-go-high-tech-prevent-falls/#ixzz2rM01UntJ

Training to walk amid uncertainty with Re-Step: measurements and changes with perturbation training for hemiparesis and cerebral palsy

Your doctor will be able to contrast and compare this new one to  these previous ones
1. Unstable Shoes Increase Energy Expenditure of Obese Patients
2. Compelled BodyWeight Shift Technique to Facilitate Rehabilitation of Individuals with Acute Stroke
3. Documenting abnormal anticipatory control prior to gait initiation in sub-acute stroke
4.  spnKiX motorized shoes edge closer to production
5. Motivation through Inclusion of Failure in Stroke Rehabilitation


So have a person walk beside you and at random intervals give you a shove. Or your dog or child. But only under your doctors supervision.
http://informahealthcare.com/doi/abs/10.3109/17483107.2012.754954

Abstract

Purpose: To describe Re-Step™, a novel mechatronic shoe system that measures center of pressure (COP) gait parameters and complexity of COP dispersion while walking, and to demonstrate these measurements in healthy controls and individuals with hemiparesis and cerebral palsy (CP) before and after perturbation training. Method: The Re-Step™ was used to induce programmed chaotic perturbations to the feet while walking for 30 min for 36 sessions over 12-weeks of training in two subjects with hemiparesis and two with CP. Results: Baseline measurements of complexity indices (fractal dimension and approximate entropy) tended to be higher in controls than in those with disabilities, while COP variability, mean and variability of step time and COP dispersion were lower. After training the disabled subjects these measurement values tended toward those of the controls, along with a decrease in step time, 10 m walk time, average step time, percentage of double support and increased Berg balance score. Conclusions: This pilot trial reveals the feasibility and applicability of this unique measurement and perturbation system for evaluating functional disabilities and changes with interventions to improve walking.Implication for Rehabilitation

• Walking, of individuals with cerebral palsy and hemiparesis following stroke, can be viewed in terms of a rigid motor behavior that prevents adaptation to changing environmental conditions.
• Re-Step system (a) measures and records linear and non-linear gait parameters during free walking to provide a detailed evaluation of walking disabilities, (b) is an intervention training modality that applies unexpected perturbations during walking.
• This perturbation intervention may improve gait and motor functions of individuals with hemiparesis and cerebral palsy.

Read More: http://informahealthcare.com/doi/abs/10.3109/17483107.2012.754954

Unstable Shoes Increase Energy Expenditure of Obese Patients

I know this is a stupid idea but  would these types of shoes correct our balance problems faster because we would need to engage all the muscles of our feet and legs to stay upright? Never mind, the fall risk would prevent any type of testing of this for stroke rehab. I do wonder what makes them unstable. Maybe like this?

http://www.amjmed.com/article/S0002-9343%2812%2900008-3/fulltext

Abstract 

Background

Ergonomic unstable shoes, which are widely available to the general population, could increase daily non-exercise activity thermogenesis as the result of increased muscular involvement. We compared the energy expenditure of obese patients during standing and walking with conventional flat-bottomed shoes versus unstable shoes.

Methods

Twenty-nine obese patients were asked to stand quietly and to walk at their preferred walking speed while wearing unstable or conventional shoes. The main outcome measures were metabolic rate of standing and gross and net energy cost of walking, as assessed with indirect calorimetry.

Results

Metabolic rate of standing was higher while wearing unstable shoes compared with conventional shoes (1.11±0.20 W/kg⁻¹vs 1.06±0.23 W/kg⁻¹, P=.0098). Gross and net energy cost of walking were higher while wearing unstable shoes compared with conventional shoes (gross: 4.20±0.42 J/kg⁻¹/m⁻¹vs 4.01±0.39 J/kg⁻¹/m⁻¹, P=.0035; net: 3.37±0.41 J/kg⁻¹/m⁻¹vs 3.21±0.37 J/kg⁻¹/m⁻¹; P=.032).

Conclusion

In obese patients, it is possible to increase energy expenditure of standing and walking by means of ergonomic unstable footwear. Long-term use of unstable shoes may eventually prevent a positive energy balance.