THE EFFECTS OF TRAINING ON DIFFERENT SURFACES, ON BALANCE AND GAIT PERFORMANCE IN STROKE HEMIPLEGIA

ABSTRACT Although many studies have focused on balance exercises for elderly or stroke patients, no comprehensive studies have investigated the use of training on different surfaces (TDS) with analysis of gait performance in elderly male stroke patients. The active properties of balance and subjective reporting of functional gait ability were used to identify the effects of TDS. Static balance (SB), dynamic balance (DB) and gait analysis was measured in 30 elderly stroke patients. The patients were divided into the TDS group (n=15) and a control group (CG, n=15). Fifteen elderly stroke patients underwent TDS five times a week for 12 weeks. The data was analyzed using repeated measures analysis of variance. Significant differences were observed between the two groups (TDS and Control): SB (p < 0.0001), DB (OSI: p < 0.0001, APSI: p < 0.001, MLSI: p < 0.004) and gait analysis (right: temporal step time: p < 0.0001, temporal cycle time: p < 0.001, temporal double support time: p < 0.0001; left: temporal step time: p < 0.0001, temporal cycle time: p < 0.0001, temporal double support time: p < 0.0001). TDS in elderly male stroke patients suggests that the characteristics of gait performance in these patients may be improved by increasing static balance, dynamic balance and gait velocity. It is hoped that the results of this trial will provide new information on the effects of TDS on balance stability and gait ability in stroke patients, through changes in stability of the lower extremities. Level III, Case-control Study.

Immediate Effects of Ankle Non-elastic Taping on Balance and Gait Ability in Patients With Chronic Stroke: A Randomized, Controlled Trial

OBJECTIVE

The purpose of this study was to determine the immediate effects of ankle non-elastic taping on balance and gait ability in patients with chronic stroke.

METHODS

Thirty patients (inpatients and outpatients) with stroke were randomly assigned to 2 groups: the non-elastic taping group (n = 15) and the placebo-taping group (n = 15). Patients in the non-elastic taping group received Endura sports taping for their ankle joint, and patients in the placebo-taping group received Endura fix tape for their ankle joint. The Balance System SD assessed balance, and the GAITRite system assessed gait ability. We recorded measurements before and after intervention.

RESULTS

The non-elastic taping group showed a significant improvement in static and dynamic standing balance (P ≤ .001) after intervention; in addition, this group showed significant increases in the velocity, cadence, step length, and stride length of gait (P ≤ .001) after intervention. However, the placebo-taping group showed no significant improvements in standing balance and gait ability after intervention (P >.05). Furthermore, significant differences in static and dynamic standing balance, cadence, and velocity were observed between the 2 groups after intervention (P ≤ .001).

CONCLUSIONS

Our results demonstrate that the application of ankle non-elastic taping is effective at improving balance and gait abilities in patients with stroke. Ankle non-elastic taping appears to be an effective method to facilitate active rehabilitation in patients with hemiplegia.

Effects of visual feedback training using transient Fresnel prism glasses on balance ability in stroke patients without hemispatial neglect

The center of mass of the body in patients with stroke was oriented toward the nonparetic side. Abnormal weight shift increases the risk of falls. Therefore, many therapists make an effort to help their functional recovery through balance training. Our aim was to investigate the effect of visual feedback intervention using a Fresnel prism on static and dynamic balance in stroke patients without hemispatial neglect. Participants were assigned to control group (n=10) and experimental group (n=9). In the control group, neurodevelopmental therapy was performance for 30 min. In the experimental group, Fresnel prism glasses were applied with neurodevelopmental therapy for 30 min. We executed motor-free visual perception test for visual perception, balancia for static balance ability, and functional reach test and Berg balance test for dynamic balance ability, respectively. All tests were measured immediately after intervention. The visual perception function showed significant difference between unaffected side performance behaviors and visual perceptual processing time (P<0.05). In the static balance, there was a significant difference in sway velocity and sway distances (P<0.05). Dynamic balance was also significant different between groups (P<0.05). Visual feedback using Fresnel prism helps to control the static and dynamic balance ability by inducing weight shift toward the affected side in stroke patients. Therefore, a Fresnel prism may be suggested as an intervention tool to assist weight training for patients with stroke.

Effects of Posturographic Platform Biofeedback Training on the Static and Dynamic Balance of Older Stroke Patients

BACKGROUND

The aim of the experiment was to analyze the influence of posturographic platform biofeedback training on the static and dynamic balance of patients who experienced ischemic stroke.

MATERIALS AND METHODS

The study included 20 patients treated at the Rehabilitation Center of the District Hospital in Białogard, in the Ward of Neurological Rehabilitation with the Stroke Division. The age of the patients (10 in the experimental group and 10 in the control group) ranged between 60 and 72 years. The level of balance was determined with one-leg standing test and timed up & go test. The experimental group was subjected to the biofeedback training, practicing maintenance of body balance ("forced sway training") on posturographic platform for 15 consecutive days.

RESULTS

The static balance on right leg and dynamic balance in group E improved to a markedly greater extent (P < .05) compared with conventionally rehabilitated group C.

CONCLUSIONS

The effects of feedback mechanisms during training on a posturographic platform can be reflected by enhanced stimulation and further improvement of the control of different, more complicated performed motor tasks.

Comparison of the effects of visual feedback training and unstable surface training on static and dynamic balance in patients with stroke

[Purpose] This study compared the effects of visual feedback training and unstable surface training on the static and dynamic balance of stroke patients. [Subjects and Methods] The study enrolled 20 stroke patients and randomly assigned them to visual feedback training and unstable surface training groups. Both groups performed 30 minutes of conventional exercise therapy twice a week for 4 weeks. In addition, the subjects in the visual feedback training group completed a visual feedback training regimen and the subjects in the unstable surface training group completed training on an unstable surface (30-minute session three times a week for 4 weeks in both groups). Static and dynamic balance parameters were recorded immediately before and after the 4 weeks of training. For data analysis, the paired and independent t-test was used to compare the two groups. [Results] In the visual feedback training group, the sway line at the postural sway of the center of pressure and trace length decreased significantly after training. In both groups, the sway range at the limits of stability in the anteroposterior and mediolateral directions increased significantly after training. [Conclusion] Visual feedback training was better at improving static and dynamic balance than unstable surface training in stroke patients.

Effects of continuous visual feedback during sitting balance training in chronic stroke survivors

BACKGROUND

Postural control deficits are common in stroke survivors and often the rehabilitation programs include balance training based on visual feedback to improve the control of body position or of the voluntary shift of body weight in space. In the present work, a group of chronic stroke survivors, while sitting on a force plate, exercised the ability to control their Center of Pressure with a training based on continuous visual feedback. The goal of this study was to test if and to what extent chronic stroke survivors were able to learn the task and transfer the learned ability to a condition without visual feedback and to directions and displacement amplitudes different from those experienced during training.

METHODS

Eleven chronic stroke survivors (5 Male - 6 Female, age: 59.72 ± 12.84 years) participated in this study. Subjects were seated on a stool positioned on top of a custom-built force platform. Their Center of Pressure positions were mapped to the coordinate of a cursor on a computer monitor. During training, the cursor position was always displayed and the subjects were to reach targets by shifting their Center of Pressure by moving their trunk. Pre and post-training subjects were required to reach without visual feedback of the cursor the training targets as well as other targets positioned in different directions and displacement amplitudes.

RESULTS

During training, most stroke survivors were able to perform the required task and to improve their performance in terms of duration, smoothness, and movement extent, although not in terms of movement direction. However, when we removed the visual feedback, most of them had no improvement with respect to their pre-training performance.

CONCLUSIONS

This study suggests that postural training based exclusively on continuous visual feedback can provide limited benefits for stroke survivors, if administered alone. However, the positive gains observed during training justify the integration of this technology-based protocol in a well-structured and personalized physiotherapy training, where the combination of the two approaches may lead to functional recovery.

Lateral weight transference exercises following acute stroke: a preliminary study of clinical effectiveness

Objectives: To evaluate a training programme aimed at improving lateral weight transference in patients following acute stroke to determine main treatment effects, if any, to inform the design of future studies.

Design: A single-blind randomized controlled trial.

Setting: The Stroke Unit at The James Cook University Hospital, Middlesbrough, UK.

Subjects: Thirty-five patients with an acute stroke.

Interventions: All subjects received their usual care, including physiotherapy. The treatment group (n / 17) received 12 additional therapy sessions (over four weeks) comprising exercises aimed at improving lateral weight transference in sitting delivered by trained physiotherapy assistants.

Main outcome measures: Measures of dynamic reaching, sitting and standing, and static standing balance were undertaken by a blind independent observer.

Results: Specific measures of weight displacement in standing and reaching, and timed standing up and sitting down did not detect any differences over time regardless of group. Neither were there any significant changes over time, except for sway during static standing (p B=0.01) and time to return to their original position during dynamic reaching (p / 0.01).

Conclusions: A training programme aimed at improving lateral weight transference did not appear to enhance the rehabilitation of acute stroke patients. Improvements observed in postural control in standing and sitting may be attributable to usual care or natural recovery.

Effect of dual tasks on balance ability in stroke patients

[Purpose] The purpose of this study was to determine the effects of training using dual tasks on balance ability in stroke patients. [Subjects] Forty stroke patients were divided into a dual-task training group (N = 20) and a single task training group (N = 20) randomly. [Methods] The subjects in the single-task traing group stood in a comfortable position, faced a therapist, then threw a Swiss ball back and forth. They then performed balance training in which they raised and lowered their ankles while facing forward or moved objects from one table to another. The DTG performed dual tasks, which involved performing a task on an unstable surface using a balance pad. Both groups received training 30 min per day, five times per week, for eight weeks. [Results] The DTG showed significant increases in weight distribution rate, anterior limit of stability, posterior limit of stability, and BBS scores compared with the STG. [Conclusion] According to the results of this study, dual-task training and single-task training were effective in improving balance in stroke patients, dual task training is more effective for increasing balance ability.

Measurements of Weight Bearing Asymmetry Using the Nintendo Wii Fit Balance Board Are Not Reliable for Older Adults and Individuals With Stroke

BACKGROUND

Clinicians and researchers have used bathroom scales, balance performance monitors with feedback, postural scale analysis, and force platforms to evaluate weight bearing asymmetry (WBA). Now video game consoles offer a novel alternative for assessing this construct. By using specialized software, the Nintendo Wii Fit balance board can provide reliable measurements of WBA in healthy, young adults. However, reliability of measurements obtained using only the factory settings to assess WBA in older adults and individuals with stroke has not been established.

PURPOSE

To determine whether measurements of WBA obtained using the Nintendo Wii Fit balance board and default settings are reliable in older adults and individuals with stroke.

METHODS

Weight bearing asymmetry was assessed using the Nintendo Wii Fit balance board in 2 groups of participants-individuals older than 65 years (n = 41) and individuals with stroke (n = 41). Participants were given a standardized set of instructions and were not provided auditory or visual feedback. Two trials were performed. Intraclass correlation coefficients (ICC), standard error of measure (SEM), and minimal detectable change (MDC) scores were determined for each group.

RESULTS

The ICC for the older adults sample was 0.59 (0.35-0.76) with SEM95 = 6.2% and MDC95 = 8.8%. The ICC for the sample including individuals with stroke was 0.60 (0.47-0.70) with SEM95 = 9.6% and MDC95 = 13.6%.

DISCUSSION

Although measurements of WBA obtained using the Nintendo Wii Fit balance board, and its default factory settings, demonstrate moderate reliability in older adults and individuals with stroke, the relatively high associated SEM and MDC values substantially reduce the clinical utility of the Nintendo Wii Fit balance board as an assessment tool for WBA.

CONCLUSIONS

Weight bearing asymmetry cannot be measured reliably in older adults and individuals with stroke using the Nintendo Wii Fit balance board without the use of specialized software.

Wii Fit balance training or progressive balance training in patients with chronic stroke: a randomised controlled trial

[Purpose] The aim of this study was to compare the effects of Wii Fit balance training (WBT) and progressive balance training (PBT) approaches on balance functions, balance confidence, and activities of daily living in chronic stroke patients. [Subjects] A total of 30 patients were randomized into the WBT (n=15) and PBT (n=15) groups. [Methods] All of the subjects received exercise training based on a neurodevelopemental approach in addition to either Wii Fit or progressive balance training for total of 1 hour a day, 3 days per week for 4 weeks. Primary measurements were static balance function measured with a Wii Balance Board and dynamic balance function assessed with the Berg Balance Scale, Timed Up and Go test, Dynamic Gait Index, and Functional Reach Test. Secondary measures were balance confidence assessed with the Activities-specific Balance Confidence scale and activities of daily living evaluated with the Frenchay Activity Index. [Results] There was not remarkable difference between the two treatments in dynamic balance functions, balance confidence, and activities of daily living. [Conclusion] Although both of the approaches were found to be effective in improving the balance functions, balance confidence, and activities of daily living, neither of them were more preferable than the other for the treatment of balance in patients with chronic stroke.

Effect of Task Specific Exercises, Gait Training, and Visual Biofeedback on Equinovarus Gait among Individuals with Stroke: Randomized Controlled Study

Background and Purpose. Equinovarus foot is a common sign after stroke. The aim of this study is to investigate the effect of task specific exercises, gait training, and visual biofeedback on correcting equinovarus gait among individuals with stroke. Subjects and Methods. Sixteen subjects with ischemic stroke were randomly assigned to two equal groups (G1 and G2). All the patients were at stage 4 of motor recovery of foot according to Chedoke-McMaster Stroke Assessment without any cognitive dysfunction. E-med pedography was used to measure contact time, as well as force underneath hind and forefoot during walking. Outcome measures were collected before randomization, one week after the last session, and four weeks later. Participants in G1 received task specific exercises, gait training, and visual biofeedback and a traditional physical therapy program was applied for participants in G2 for 8 weeks. Results. Significant improvement was observed among G1 patients (P ≤ 0.05) which lasts one month after therapy termination. On the other hand, there were no significant differences between measurements of the participants in G2. Between groups comparison also revealed a significant improvement in G1 with long lasting effect. Conclusion. The results of this study showed a positive long lasting effect of the task specific exercises, gait training, and visual biofeedback on equinovarus gait pattern among individuals with stroke.

Influence of posturographic platform biofeedback training on the dynamic balance of adult stroke patients

The aim of the experiment was to analyze the influence of posturographic platform biofeedback training on the dynamic balance of patients who experienced ischemic stroke. The study included 21 patients treated at the Rehabilitation Center of the District Hospital in Białogard, in the Ward of Neurological Rehabilitation with the Stroke Division. The age of the patients (11 in the experimental and 10 in the control group) ranged between 55 and 65 years. The level of dynamic balance was determined with Timed Up and Go Test. The experimental group was subjected to the biofeedback training, practicing maintenance of body balance (forced sway training) on posturographic platform for 15 consecutive days. The perception of dynamic balance in the group subjected to biofeedback training improved to a markedly greater extent (P < .05) as compared with conventionally rehabilitated group. Participation in biofeedback training exerted stronger effect on the dynamic balance of patients who experienced the stroke of the left hemisphere with right-sided hemiparesis than in those with right hemisphere stroke and left-sided hemiparesis. The utilization of feedback mechanisms during training on a posturographic platform can be reflected by enhanced stimulation and further improvement of the control of performed motor tasks.

Efficacy of treatment with a kinaesthetic ability training device on balance and mobility after stroke: a randomized controlled study

Objective: To investigate whether the addition of a kinaesthetic ability training device could enhance the effect of a conventional rehabilitation programme on balance and mobility in hemiparetic patients late after stroke.

Design: Randomized, controlled, assessor-blinded trial.

Setting: The rehabilitation ward of a university hospital. Thirty hemiparetic patients (mean age (SD) of 57.4 (8.1) years) late after stroke (mean time since stroke (SD) 545.2 (99.9) days) were assigned randomly to an experimental or a control group.

Interventions: The control group (n = 15) participated in a conventional rehabilitation programme. The experimental group (n = 15) participated in balance training with a kinaesthetic ability training device in addition to a conventional rehabilitation programme for four weeks, five days a week.

Outcome measures: Kinaesthetic ability training static and dynamic balance indices, balance and lower extremity subscores of the Fugl-Meyer Stroke Assessment Instrument (FMA), total motor and locomotor subitem scores of the Functional Independence Measure (FIM) were evaluated at baseline and after treatment.

Results: The experimental group had greater improvement in measures of balance including static (P = 0.045) and dynamic balance index (P = 0.001) and FMA balance score (P = 0.001) than the control group. No between-group differences were detected in subscore of FMA, total motor and locomotor subscores of FIM. There were significant improvements in balance subscores of FMA, static and dynamic balance indexes in the experimental group and in sub-item scores of FIM and lower extremity scores of FMA in both groups.

Conclusion: Kinaesthetic ability training in addition to a conventional rehabilitation programme is effective in improving balance late after stroke. However, this improvement is not reflected in individual functional status.

Weight distribution in standing and sitting positions, and weight transfer during reaching tasks, in seated stroke subjects and healthy subjects

BACKGROUND AND PURPOSE

The recovery of sitting balance after a stroke is assumed to be essential to obtain independence in other vital functions. The purpose of the present study was to investigate weight distribution while sitting and standing still, and weight transfer during seated reaching tasks performed by stroke subjects and healthy subjects.

METHOD

The study was cross-sectional. Twenty-one stroke subjects and 21 healthy subjects, matched by age and gender, participated. Main measures were weight distribution while standing and sitting still, and displacements of centre ofpressure (COP) during seated reaching tasks. Data were collected using a balance performance monitor (BPM), including software.

RESULTS

Stroke subjects had less symmetrical weight distribution in standing than that of healthy subjects (p < 0.001). No significant differences between the groups were found while sitting still, and no associations between asymmetries in standing still and sitting positions within individual stroke subjects were found. Neither did the degree of weight distribution in sitting correspond to COP displacements in seated reaching tasks. However, COP displacement patterns in reaching tasks in the seated position were different in stroke subjects from those of healthy subjects. Stroke subjects showed more lateral displacement when reaching forwards (p < 0.001), and less lateral displacement when reaching sideways to the unaffected side (p = 0.01).

CONCLUSION

COP displacement patterns in stroke subjects deviate more than those of healthy subjects in seated reaching tasks. The deviating COP displacement patterns are discussed as a possible dysfunction in the ability to make postural adjustments and learn an efficient movement pattern.

Task-Oriented Intervention in Chronic Stroke

OBJECTIVE

The objective of this study was to evaluate whether, after a task-oriented exercise program, the changes in clinical measures of balance and mobility were paralleled by changes in biomechanical parameters in subjects with chronic stroke.

DESIGN

Ten stroke subjects took part in an 8-wk exercise program aimed at improving balance and mobility through various functional tasks. Subjects were evaluated before and after the exercise intervention. Clinical measures included the Berg Balance Scale and the Timed-Up-and-Go and laboratory measures included ground reaction forces and center of pressure displacement during four functional tasks.

RESULTS

Stroke subjects showed significant improvements (P < 0.05) in the clinical measures after completing the exercise program. Significant improvements (P < 0.05) were also found in postural steadiness during tandem stance and stool touch and in force production through the paretic lower limb during sit-to-stand. This last result was strongly correlated (r = -0.93) with the improvements on the Timed-Up-and-Go after exercise intervention. In contrast, the increase in postural steadiness was poorly correlated with the improvements on the Berg Balance Scale.

CONCLUSIONS

A task-oriented exercise program might improve both clinical and laboratory measures of balance and mobility in stroke subjects. However, several correlations between the changes in clinical and laboratory measures after exercise intervention were generally weak, indicating that these outcome measures assessed different components of improvements.

Restoration of weight-shifting capacity in patients with postacute stroke: A rehabilitation cohort study

OBJECTIVES

To identify and interrelate recovery characteristics of voluntary weight shifting after stroke and to examine whether the assessment of weight shifting adds information about balance recovery compared with the assessment of quiet standing.

DESIGN

Exploratory study using an inception cohort with findings related to reference values from healthy elderly persons.

SETTING

Dutch rehabilitation center.

PARTICIPANTS

Thirty-six inpatients (mean age, 61.8 y; mean time poststroke, 10 wk) with a first hemispheric intracerebral infarction or hematoma who were admitted to retrain standing balance and walking.

INTERVENTION

Individualized therapy.

MAIN OUTCOME MEASURES

Center of pressure (COP) displacements were registered during voluntary frontal-plane weight shifting guided by visual COP feedback using a dual-plate force platform. Besides the speed (number of weight shifts) and imprecision (normalized average lateral COP displacement per weight shift), the weight-transfer time asymmetry and the spatiotemporal distribution were determined. Assessments took place as soon as patients could stand unassisted for at least 30 seconds and at 2, 4, 8, and 12 weeks later.

RESULTS

During the 12-week training period, the stroke patients increased both their speed (2.3 hits/30 s; 95% confidence interval [CI], 1.1-3.4) and precision (37.7 mm/hit; 95% CI, 10.4-65.0) of weight shifting. Although the speed appeared to stabilize at a suboptimal level after 8 weeks, precision reached normal reference values after 12 weeks. Both older age (>/=65 y) and the presence of visuospatial hemineglect negatively affected weight-shifting speed but not its relative improvement in time. During the training period, a small degree of weight-transfer time asymmetry persisted (mean change, .07; 95% CI, -.21 to .36), with an average of 23% slower weight shifts toward the paretic leg, but the spatiotemporal distribution remained symmetrical. The correlations between weight-shifting and quiet-standing control at the end of training were moderate (Spearman rho range, .50-.77).

CONCLUSIONS

Even subjects with severe stroke who are selected for inpatient rehabilitation are able to improve their speed and precision of weight shifting by reducing the weight-transfer time toward both legs in a proportionate manner. The observed correlations between weight shifting and quiet standing indicate that the assessment of weight-shifting capacity provides unique information about balance recovery after stroke.

[Interest of visual biofeedback training in rehabilitation of balance after stroke]

OBJECTIVE

The aim of this study was the assessment of visual biofeedback in the management of balance disorders after stroke.

MATERIAL AND METHODS

This is a prospective randomised trial, which compares visual biofeedback training and traditional balance training. Twenty-seven patients took part in this study: 13 in the first group and 14 in the second group. The rehabilitation program in the first group consists in an association of visual biofeedback and traditional training during 3 weeks. For the second group traditional training was used alone. Clinical, functional and forceplate assessments were performed before and after the program of rehabilitation.

RESULTS

All the patients had a clinical and functional improvement. However, patients who have benefited from biofeedback training had a significant improvement of the forceplate parameters with closed eyes.

DISCUSSION AND CONCLUSION

Those results confirm the interest of rehabilitation in balance disorders after stroke. The use of biofeedback training incorporated into functional physiotherapy affords added benefits probably by a best integration of proprioceptive informations.

Effects of visual feedback rhythmic weight-shift training on hemiplegic stroke patients

OBJECTIVE

To assess the balance function of hemiplegic stroke patients and to investigate whether visual feedback rhythmic weight-shift training following acute stroke can decrease falls among patients with hemiplegic stroke.

DESIGN

A prospective study, using a Balance Master.

SETTING

Hospital-based rehabilitation units.

SUBJECTS

Fifty-two hemiplegic stroke patients (28 in the training group and 24 in the control group).

INTERVENTIONS

Conventional stroke rehabilitation programme plus visual feedback rhythmic weight-shift training. Training effect was evaluated by assessing the static and dynamic balance performance as well as comparing the occurrence of falls in the training and control groups at six-month follow-up.

MAIN MEASURES

Occurrence of falls; static balance in different sensory conditions; and dynamic balance performance, including on-axis velocity and directional control during rhythmic weight-shift.

RESULTS

Significant improvement in dynamic balance performance was found in hemiplegic patients in the training group. The improvement was sustained for six months. With regarding to static balance function, no significant improvement was found. At six-month follow-up, 5 of 28 patients (17.8%) in the training group had fallen, compared with 10 of 24 patients (41.7%) in the control group. The occurrence of falls decreased, although not statistically significantly (p=0.059).

CONCLUSIONS

Visual feedback rhythmic weight-shift training may improve dynamic balance function for hemiplegic stroke patients. The effects of training may be sustained for six months. The occurrence of falls decreased in the training group, but not statistically significantly.

Effects of perceptual learning exercises on standing balance using a hardness discrimination task in hemiplegic patients following stroke: a randomized controlled pilot trial

OBJECTIVE

To investigate the effect of perceptual learning exercises for hardness discrimination by the soles on standing balance in stroke patients with hemiplegia.

SUBJECTS

Twenty-eight subjects were randomly assigned to an experimental or a control group and participated in a rehabilitation programme.

INTERVENTION

The experimental group received perceptual learning exercises on hardness discrimination using three different levels of hardness of a rubber sponge for 10 days.

MAIN MEASURES

Length, enveloped area and rectangular area of the parameter of postural sway were measured by a stabilometer on entry into the study and after 10 days.

RESULTS

Twenty-six subjects completed the study. Data indicate that more parameters indicating postural sway were significantly decreased in the experimental group than in the control group. Also, there was a significant difference between the groups in change scores (pre-exercise minus post-exercise) of length and enveloped area.

CONCLUSION

The plantar perception exercise used as a method in this study is considered to be effective as a supplemental exercise for standing balance. The possibility of clinical application using the hardness discrimination task with rubber as a balance exercise is therefore suggested.

Intensive, time-series measurement of upper limb recovery in the subacute phase following stroke

OBJECTIVES

To discover if intensive monitoring of wrist extension would produce consistent recovery curves during the subacute period, and whether any impact of additional physiotherapy could be detected. We also investigated improved approaches to statistical analysis in single-case experiments.

DESIGN

A randomized multiple-baseline experiment with very frequent assessment.

SETTING

Stroke rehabilitation unit.

SUBJECTS

Four patients with some active wrist movement less than seven weeks after stroke.

INTERVENTIONS

Wrist extension was measured twice daily with an electrogoniometer for 3-4 weeks. Additional upper limb physiotherapy 115 minutes, twice per day) commenced after a randomly determined period.

MAIN OUTCOME MEASURES

Speed and range of wrist movement.

RESULTS

A logarithmic function was fitted to the data to produce recovery curves. In all cases, active range and maximum velocity of wrist extension rose gradually over time. Mean variability in range was <5%, but with occasional outliers. Range of passive movement decreased in two cases in association with pain and increased tone. There were no large improvements coinciding with additional physiotherapy but autoregression analysis indicated statistically significant changes in three cases. A randomization test confirmed an increase in active range associated with additional physiotherapy.

CONCLUSIONS

Intensive electrogoniometry provided a detailed recovery pattern for each of these patients. The data were surprisingly consistent over time, showing that it is feasible to use a time-series approach to investigate subacute recovery. Changes associated with additional physiotherapy were observed on some measures, demonstrating the potential of this approach for exploratory evaluation of interventions.

Training symmetry of weight distribution after stroke: a randomized controlled pilot study comparing task-related reach, Bobath and feedback training approaches

OBJECTIVE

To determine (1) the most effective of three treatment approaches to retrain seated weight distribution long-term after stroke and (2) whether improvements could be generalized to weight distribution in standing.

SETTING

Inpatient rehabilitation unit.

DESIGN

Forty asymmetrical acute stroke subjects were randomly allocated to one of four groups in this pilot study. Changes in weight distribution were compared between the 10 subjects of each of three treatment groups (task-specific reach, Bobath, or Balance Performance Monitor [BPM] feedback training) and a no specific treatment control group. One week of measurement only was followed by two weeks of daily training sessions with the treatment to which the subject was randomly allocated. Measurements were performed using the BPM daily before treatment sessions, two weeks after cessation of treatment and 12 weeks post study. Weight distribution was calculated in terms of mean balance (percentage of total body weight) or the mean of 300 balance points over a 30-s data run.

RESULTS

In the short term, the Bobath approach was the most effective treatment for retraining sitting symmetry after stroke (p = 0.004). Training with the BPM and no training were also significant (p = 0.038 and p = 0.035 respectively) and task-specific reach training failed to reach significance (p = 0.26). At 12 weeks post study 83% of the BPM training group, 38% of the task-specific reach group, 29% of the Bobath group and 0% of the untrained group were found to be distributing their weight to both sides. Some generalization of symmetry training in sitting to standing was noted in the BPM training group which appeared to persist long term.

CONCLUSIONS

Results should be treated with caution due to the small group sizes. However, these preliminary findings suggest that it might be possible to restore postural symmetry in sitting in the early stages of rehabilitation with therapy that focuses on creating an awareness of body position.

Symmetrical body-weight distribution training in stroke patients and its effect on fall prevention

OBJECTIVE

To determine the role of symmetrical body-weight distribution training in preventing falls among patients with hemiplegic stroke.

DESIGN

A prospective study using a standing biofeedback trainer.

SETTING

Hospital-based rehabilitation units.

PATIENTS

Fifty-four patients with hemiplegic stroke (30 in the training group, 24 in the control group).

INTERVENTIONS

Conventional stroke rehabilitation program, plus symmetrical standing training and repetitive sit-to-stand training, with a standing biofeedback trainer. Training effect was evaluated by assessing the sit-to-stand performance and comparing the occurrence of falls in the 2 groups at a 6-month follow-up.

MAIN OUTCOME MEASURES

Occurrence of falls, sit-to-stand performance, including body-weight distribution, rate of rise in force, and sway in center of pressure (COP).

RESULTS

Significant improvement in sit-to-stand performance was found in patients in the training group. Body weight was distributed more symmetrically in both legs, with less mediolateral sway in the COP when rising and sitting down. The mean difference in body-weight distribution between the left and right legs while subjects were rising from a chair significantly decreased, from 49.5% +/- 18.9% to 38.6% +/- 15.8% of body weight (BW) (p < .005). The rate of rise in force while rising from a chair significantly increased, from 28.3% +/- 13.5%BW/s to 53.6% +/- 20.5%BW/s (p < .001). At the 6-month follow-up, 10 of 24 patients (41.7%) in the control group had fallen, compared with only 5 of 30 patients (16.7%) in the training group (p < .05).

CONCLUSIONS

Symmetrical body-weight distribution training may improve sit-to-stand performance and, consequently, decrease the number of falls by stroke patients.

Validity of weight distribution and sway measurements of the Balance Performance Monitor

BACKGROUND AND PURPOSE

The Balance Performance Monitor (BPM) is a device which provides auditory and visual feedback on weight distribution and the magnitude of lateral and anterior-posterior sway during quiet standing. This study investigated the validity of the measurements provided by the BPM using a Kistler force plate (KFP) as the gold standard.

METHOD

Percentage weight distribution between the BPM foot plates was validated using both a series of calibration weights and the vertical component of ground reaction force, measured by the KFP, during normal standing in 18 young normal subjects. The lateral and anterior-posterior sway indices from the BPM were validated against the standard deviation of the position of the centre of pressure, again obtained using the KFP, during normal standing with eyes open and eyes closed and standing with feet together with eyes open. Concurrent validity of the percentage weight distribution measurements was assessed by calculating the 'limits of agreement' between the corresponding measurements from the BPM and KFP and the 95% confidence intervals for these 'limits'. Differences in the units of measurement obtained from the BPM and KFP resulted in the concurrent validity of the sway indices being assessed using correlation and regression.

RESULTS

Excellent agreement was found between the percentage weight distribution values provided by the BPM and the KFP, which showed that the BPM may read only 3% of body weight above or below that given by the KFP. High correlations (r = 0.61-0.99) were found between both the lateral and anterior-posterior sway indices from the BPM and the motion of the centre of pressure from the KFP in the respective direction. Despite this, further analysis of regression equations and the 95% prediction intervals showed poor concurrent validity of the BPM sway indices in relation to KFP measurements. This was thought to be due to the different methods by which the sway indices and the motion of the centre of pressure were calculated.

CONCLUSIONS

The BPM may be used to provide a valid measure of the symmetry aspect, but not necessarily the steadiness aspect of postural control.

Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights

OBJECTIVE

To examine and compare the effect of stepping on stairs of various heights on lower extremity weight bearing in hemiparetic patients.

SETTING

Flieman Geriatric Rehabilitation Hospital, Haifa, Israel.

SUBJECTS

Fifteen ambulatory hemiparetic patients following an acute cerebrovascular accident, and 16 age-matched healthy controls.

INTERVENTIONS

Each subject was tested twice on two consecutive days in five weight-bearing positions which included level stance and stepping with either leg on 10-cm- and 17-cm-high steps. Data concerning weight distribution on the lower extremities were collected by two computerized forceplates.

MAIN OUTCOME MEASURE

Weight borne by each foot expressed as percentage of overall body weight.

RESULTS

In the attempted symmetrical level stance, the percentage of body weight borne by the paretic limb of the stroke patients was significantly lower than that of the nonparetic limb. Placing one foot on a step induced a weight shift to the foot placed on the floor regardless of step height. Weight shifting to the paretic limb was, however, significantly lower than to the nonparetic limb. Weight shifting to the nonparetic limb was significantly lower than to the corresponding limb of healthy individuals. Step height had no significant effect on weight distributions on the feet.

CONCLUSIONS

Raising a foot on a step appears to be an appropriate strategy for weight shift training of stroke patients. Since weight shifting to both the paretic and nonparetic limb of stroke patients is impaired, treatment strategies should include training in weight shifting to both lower extremities.

Inter- and intra-tester reliability of the Balance Performance Monitor in a non-patient population

BACKGROUND AND PURPOSE

There is a growing interest in the measurement and evaluation of balance deficits and a number of instruments for measurement are now available. However, few data exist that accurately describe the reliability when using these measurement tools. This study was designed to evaluate the inter- and intra-tester reliability of using the Balance Performance Monitor (BPM) (SMS Healthcare) in a non-patient population.

METHODS

A total of 58 subjects (mean age 29.83 years (+/- 9.44 years)) and three testers participated in two separate experiments. Intra Class Correlation Coefficients (ICCs) and coefficients of variation were used to describe the reliability of two different protocols for positioning subjects on the footplates of the BPM.

RESULTS

Measurements of weight distribution showed high and significant inter- and intra-tester reliability for both protocols (ICCs ranging from 0.720 to 0.868). Sway measurements showed more limited reliability (ICCs ranging from 0.183 to 0.775). Coefficients of variation were low for weight distribution measurements and high for sway measurements.

CONCLUSIONS

Taking the mean of three measurements is recommended for both the weight distribution and the sway measurements as it has shown to produce acceptable measurement results.

Single blind randomized controlled trial of visual feedback after stroke: effects on stance symmetry and function

A number of before and after and single case design studies of visual feedback have shown improvements in stance symmetry after stroke, an associated improvement in function has been demonstrated. This study examines this promising technique further using a single-blind controlled trial. Twenty-six patients were recruited from a register of consecutive admissions and randomized into treatment and control groups. Both groups received additional therapy, only the treatment group received visual feedback. Assessments were carried out independently. Significant improvements were seen in the treatment group in measures of stance symmetry and sway and motor and ADL function. Between group differences had disappeared at three months. The results indicate that feedback training incorporated into functional physiotherapy treatment can improve stance symmetry and sway. Transfer of training was indicated by improvements in ADL and gross motor function. Three months later the improvement was maintained, but did not automatically continue without treatment.