Training Conditions Influence Walking Kinematics and Self-Selected Walking Speed in Patients with Neurological Impairments

Improvement in postural alignment is associated with recovery of mobility after complex acquired brain injury: An observational study

PURPOSE

Determine how mobility changes over 6 months in people unable to walk at 8-weeks post-Acquired Brain Injury (ABI); if there is an association over time between postural alignment and mobility post-ABI; and if alignment after ABI becomes closer to healthy alignment over time.

METHODS

Fourteen adults with ABI, evaluated over 6 months, and a reference sample of 30 healthy adults were studied. The primary measure for changes in mobility was the Clinical Outcome Variables Scale (COVS). Secondary measures were sit-to-stand, timed standing holding rails, independent walking speed and number of testing conditions achieved. The Functional Independence Measure (FIM) was scored at rehabilitation admission and discharge. To analyze postural alignment, participants were recorded in sitting and standing, each repeated holding rails, and walking if able. Three-dimensional kinematic data were used to quantify whole-body postural alignment, equal to mean segment displacements from the base of support in the transverse plane. Associations between three-dimensional kinematic alignment scores and COVS scores were calculated using Linear Mixed-Effects Models.

RESULTS

Participants made significant improvements in COVS scores, most secondary mobility scores, and FIM scores over time (p ≤ .001). Relationships between increasing COVS scores and decreasing sitting and standing mal-alignment scores were statistically significant. Visual analysis of graphed segment positions indicated that sitting and standing alignment became more similar to healthy alignment over time; this was not clear for walking.

CONCLUSION

Improvement in postural alignment may be a factor for improving mobility in people with severe impairments after ABI.

Feasibility of Robot-Assisted Gait Training with an End-Effector Type Device for Various Neurologic Disorders

Robots are being used to assist the recovery of walking ability for patients with neurologic disorders. This study aimed to evaluate the feasibility and functional improvement of training with robot-assisted gait training (RAGT) using the Morning Walk^®, an end-effector type robot using footplates and saddle seat support. A total of 189 individuals (65.1% men, 34.9% women; mean age, 53.2 years; age range: 5-87 years) with brain lesions, spinal cord injuries, Parkinson's disease, peripheral neuropathies, and pediatric patients were involved in this retrospectively registered clinical trial. Each participant performed 30 minutes of RAGT, five times a week, for a total of 24 sessions. Failure was defined as an inability to complete all 24 sessions, and the reasons for discontinuation were analyzed. Parameters of Medical Research Council scales and Functional Ambulation Categories were analyzed before and after RAGT training. Among the 189 patients, 22 (11.6%) failed to complete the RAGT. The reasons included decreased cooperation, musculoskeletal pain, saddle seat discomfort, excessive body-weight support, joint spasticity or restricted joint motion, urinary incontinence from an indwelling urinary catheter, and fatigue. Comparison between the pre- and post-training motor and ambulatory functions showed significant improvement. The result of the study indicates that the Morning Walk^® is feasible and safe and useful for functional improvement in patients with various neurologic disorders.

Trial Registration

Clinical Research Information Service Identifier: KCT0003627.

Is there a relationship between postural alignment and mobility for adults after acquired brain injury? A systematic review

PRIMARY OBJECTIVE

To examine the relationship between postural alignment and mobility skills for adults after acquired brain injury (ABI).

METHODS

Systematic review of the literature. Seven electronic databases, grey literature and reference lists of the shortlisted publications were searched. Studies were included if participants were adults with ABI, both postural alignment and mobility were measured and analysis included a relationship between alignment and mobility. Those that met the inclusion criteria were assessed with a critical appraisal tool. The review was registered with PROSPERO, registration number CRD42015019867.

RESULTS

Seven observational studies were included that had examined a relationship between postural alignment and mobility after ABI. Critical appraisal scores were moderate to strong. While some studies reported that improved postural alignment was related to improved mobility after ABI, results varied and there was insufficient evidence to answer the primary question. Heterogeneous study designs did not allow meta-regression.

CONCLUSIONS

A small amount of observational evidence exists for a relationship between postural alignment and mobility after ABI. Results vary, with some studies reporting that a more stable, upright trunk correlates with better mobility, and others providing conflicting or ambiguous results. Further research is needed to establish the relationship between postural alignment and mobility skills after ABI.

A Comparison of Locomotor Therapy Interventions: Partial-Body Weight-Supported Treadmill, Lokomat, and G-EO Training in People With Traumatic Brain Injury

BACKGROUND

Literature in the application of gait training techniques in persons with traumatic brain injury (TBI) is limited. Current techniques require multiple staff and are physically demanding. The use of a robotic locomotor training may provide improved training capacity for this population.

OBJECTIVE

To examine the impact of 3 different modes of locomotor therapy on gait velocity and spatiotemporal symmetry using an end effector robot (G-EO); a robotic exoskeleton (Lokomat), and manual assisted partial-body weight-supported treadmill training (PBWSTT) in participants with traumatic brain injury.

DESIGN

Randomized, prospective study.

SETTING

Tertiary rehabilitation hospital.

PARTICIPANTS

A total of 22 individuals with ≥12 months chronic TBI with hemiparetic pattern able to walk overground without assistance at velocities between 0.2 and 0.6 m/s.

INTERVENTION

Eighteen sessions of 45 minutes of assigned locomotor training.

OUTCOME MEASURES

Overground walking self-selected velocity (SSV), maximal velocity (MV), spatiotemporal asymmetry ratio, 6-Minute Walk Test (6MWT), and mobility domain of Stroke Impact Scale (MSIS).

RESULTS

Severity in walking dysfunction was similar across groups as determined by walking velocity data. At baseline, participants in the Lokomat group had a baseline velocity that was slightly slower compared with the other groups. Training elicited a statistically significant median increase in SSV for all groups compared with pretraining (Lokomat, P = .04; G-EO, P = .03; and PBWSTT, P = .02) and MV excluding the G-EO group (Lokomat, P = .04; PBWSTT, P = .03 and G-EO, P = .15). There were no pre-post significant differences in swing time, stance time, and step length asymmetry ratios at SSV or MV for any of the interventions. Mean rank in the change of SSV and MV was not statistically significantly different between groups. Participants in the G-EO and PBWSTT groups significantly improved their 6MWT posttraining (P = .04 and .03, respectively). The MSIS significantly improved only for the Lokomat group (P = .04 and .03). The data did not elicit between-groups significant differences for 6MWT and MSIS. There was less use of staff for Lokomat than G-EO.

CONCLUSIONS

Locomotor therapy using G-EO, Lokomat, or PBWSTT in individuals with chronic TBI increased SSV and MV without significant changes in gait symmetry. Staffing needed for therapy provision was the least for the Lokomat. A larger study may further elucidate changes in gait symmetry and other training parameters.

LEVEL OF EVIDENCE

II.

Validity of the Microsoft Kinect for providing lateral trunk lean feedback during gait retraining

Gait retraining programs are prescribed to assist in the rehabilitation process of many clinical conditions. Using lateral trunk lean modification as the model, the aim of this study was to assess the concurrent validity of kinematic data recorded using a marker-based 3D motion analysis (3DMA) system and a low-cost alternative, the Microsoft Kinect™ (Kinect), during a gait retraining session. Twenty healthy adults were trained to modify their gait to obtain a lateral trunk lean angle of 10°. Real-time biofeedback of the lateral trunk lean angle was provided on a computer screen in front of the subject using data extracted from the Kinect skeletal tracking algorithm. Marker coordinate data were concurrently recorded using the 3DMA system, and the similarity and equivalency of the trunk lean angle data from each system were compared. The lateral trunk lean angle data obtained from the Kinect system without any form of calibration resulted in errors of a high (>2°) magnitude (mean error=3.2±2.2°). Performing global and individualized calibration significantly (P<0.001) improved this error to 1.7±1.5° and 0.8±0.8° respectively. With the addition of a simple calibration the anatomical position coordinates of the Kinect can be used to create a real-time biofeedback system for gait retraining. Given that this system is low-cost, portable and does not require any sensors to be attached to the body, it could provide numerous advantages when compared to laboratory-based gait retraining systems.