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Improving walking symmetry in people with stroke : a pilot study Ip, Alvin; Chen, Zhen; Lam, Tania 2012

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Improving	
  walking	
  symmetry	
  in	
   people	
  with	
  stroke:	
  	
   a	
  pilot	
  study	
   Alvin	
  Ip	
   Dr.	
  Zhen	
  Chen,	
  MD,	
  PhD	
  	
   Dr.	
  Tania	
  Lam,	
  PhD	
   	
    UBC	
  MURC	
  	
  |	
  	
  March	
  24,	
  2012	
    Stroke	
   •  Occurs	
  when	
  blood	
  flow	
  to	
  a	
  part	
  of	
  the	
  brain	
   stops	
   •  Brain	
  cells	
  die	
  without	
  access	
  to	
  blood	
  and	
   oxygen	
   •  Causes	
  permanent	
  damage	
  to	
  one	
  side	
  of	
  the	
   brain,	
  resulOng	
  in	
  motor	
  impairments	
  to	
  the	
   other	
  half	
  of	
  the	
  body	
    Walking	
  asymmetry	
  	
   •  Hallmark	
  characterisOc	
  of	
  stroke	
  paOents	
   (PaSerson	
  et	
  al.,	
  2008)	
    1.  Weaker	
  leg	
  spends	
  less	
  Ome	
  in	
  single-­‐support	
   stance	
  phase	
  (Beauchamp	
  et	
  al.,	
  2009)	
   2.  Weaker	
  leg	
  has	
  a	
  shorter	
  stride	
  length	
  (Reisman	
   et	
  al.,	
  2007)	
    	
    Weaker	
  Leg	
  =	
  Less	
  SUPPORT	
  and	
  Less	
  PROPULSION	
    Why	
  does	
  it	
  maSer?	
   •  Walking	
  asymmetry	
  leads	
  to:	
  	
   – Impaired	
  balance	
  (PlaSs	
  et	
  al.,	
  2006)	
   – Decreased	
  bone	
  strength	
  (Jorgenson	
  et	
  al.,	
  2000)	
   – Joint	
  problems	
  (PaSerson	
  et	
  al.,	
  2008)	
   – Increased	
  falls	
  (Poole,	
  2002)	
    Aim	
   •  To	
  improve	
  walking	
  symmetry	
  by	
  increasing	
   the	
  use	
  of	
  the	
  weaker	
  leg	
   •  How?	
  	
   •  By	
  placing	
  resistance	
  (more	
  weight)	
  against	
   the	
  stronger	
  leg,	
  making	
  it	
  harder	
  to	
  use	
    Hypothesis	
   •  When	
  resistance	
  is	
  applied	
  against	
  the	
   stronger	
  leg,	
  the	
  weaker	
  leg	
  will	
  be	
  used	
  more	
   •  Increased	
  single-­‐support	
  stance	
  Ome	
  of	
  the	
   weaker	
  leg	
   •  Increased	
  stride	
  length	
  of	
  the	
  weaker	
  leg	
    Methods	
    ParOcipants	
   •  6	
  people	
  with	
  stroke	
   – Ambulatory	
   – All	
  subjects	
  gave	
  wriSen	
  informed	
  consent	
    Equipment	
   •  Lokomat	
  gait	
  therapy	
  device	
    Equipment	
   •  Lokomat	
   •  Force-­‐sensiOve	
  resistors	
  (FSR)	
   –  Placed	
  under	
  feet	
   –  Detect	
  when	
  feet	
  are	
  on	
  ground	
  to	
  measure	
   length	
  of	
  Ome	
  spent	
  in	
  single-­‐support	
  stance	
    •  MoOon	
  capture	
  cameras	
   –  Placed	
  infrared	
  markers	
  on	
  feet	
   –  Record	
  foot	
  trajectory	
  to	
  measure	
  stride	
  length	
    	
    Protocol	
   •  ParOcipants	
  walked	
  consecuOvely	
  for:	
  	
   –  50	
  strides	
  with	
  no	
  resistance	
   –  50	
  strides	
  with	
  resistance	
  against	
  the	
  stronger	
  leg	
  	
   –  50	
  strides	
  with	
  resistance	
  removed	
    •  Resistance	
  was	
  scaled	
  to	
  10%	
  of	
  the	
   individual’s	
  hip	
  and	
  knee	
  flexors'	
  maximal	
   voluntary	
  contracOon	
    Results	
    When	
  resistance	
  is	
  applied,	
  the	
  weaker	
  leg	
  will	
   have	
  increased	
  single-­‐support	
  stance	
  Ome	
    Time	
  (s)	
    0.8	
    PareFc	
  single-­‐support	
  stance	
  Fme	
    0.7	
    0.6	
    0.5	
    Baseline	
    First	
  5	
  strides	
  of	
   Last	
  5	
  strides	
  of	
   First	
  5	
  strides	
  of	
   Resistance	
   Resistance	
   Aeer-­‐Effects	
    CondiFons	
    When	
  resistance	
  is	
  applied,	
  the	
  weaker	
  leg	
  will	
   have	
  increased	
  stride	
  length	
   PareFc	
  stride	
  length	
    Stride	
  length	
  (cm)	
    700	
    600	
    500	
    400	
   Baseline	
    First	
  5	
  strides	
  of	
   Last	
  5	
  strides	
  of	
   First	
  5	
  strides	
  of	
   Resistance	
   Resistance	
   Aeer-­‐Effects	
    CondiFons	
    PareOc	
  stride	
  length	
  (adaptaOon	
  to	
   resistance)	
    800	
    Stride	
  length	
  (cm)	
    700	
   600	
   500	
   400	
   300	
   200	
   1	
    10	
    19	
    28	
    37	
    46	
    55	
    64	
    73	
    Stride	
  number	
  (against	
  resistance)	
    82	
    91	
    PareOc	
  stride	
  length	
  (adaptaOon	
  to	
   resistance)	
    800	
    Stride	
  length	
  (cm)	
    700	
   600	
   500	
   400	
   300	
   200	
   1	
    10	
    19	
    28	
    37	
    46	
    55	
    64	
    73	
    Stride	
  number	
  (against	
  resistance)	
    82	
    91	
    PareOc	
  stride	
  length	
  (adaptaOon	
  to	
   resistance)	
    800	
    Stride	
  length	
  (cm)	
    700	
   600	
   500	
   400	
   300	
   200	
   1	
    10	
    19	
    28	
    37	
    46	
    55	
    64	
    73	
    Stride	
  number	
  (against	
  resistance)	
    82	
    91	
    PareOc	
  single-­‐support	
  stance	
  Ome	
   (adaptaOon	
  to	
  resistance)	
   1.2	
    Time	
  (s)	
    1	
   0.8	
   0.6	
   0.4	
   1	
    10	
    19	
    28	
    37	
    46	
    55	
    64	
    73	
    Stride	
  number	
  (against	
  resistance)	
    82	
    91	
    PareOc	
  single-­‐support	
  stance	
  Ome	
   (adaptaOon	
  to	
  resistance)	
   1.2	
    Time	
  (s)	
    1	
   0.8	
   0.6	
   0.4	
   1	
    10	
    19	
    28	
    37	
    46	
    55	
    64	
    73	
    Stride	
  number	
  (against	
  resistance)	
    82	
    91	
    PareOc	
  single-­‐support	
  stance	
  Ome	
   (adaptaOon	
  to	
  resistance)	
   1.2	
    Time	
  (s)	
    1	
   0.8	
   0.6	
   0.4	
   1	
    10	
    19	
    28	
    37	
    46	
    55	
    64	
    73	
    Stride	
  number	
  (against	
  resistance)	
    82	
    91	
    Conclusions	
  and	
   Future	
  DirecOons	
    Conclusions	
   1.  Applying	
  resistance	
  to	
  the	
  stronger	
  leg	
  can	
   increase	
  the	
  use	
  of	
  the	
  weaker	
  leg	
  to	
  propel	
   and	
  support	
  the	
  body	
  during	
  walking	
   2.  Aspects	
  of	
  the	
  study	
  design	
  can	
  be	
  improved	
   –  More	
  than	
  50	
  strides	
  of	
  walking	
  against	
  resistance	
   may	
  be	
  required	
   –  Verbal	
  cueing	
  to	
  ensure	
  that	
  parOcipant	
  responds	
   in	
  the	
  intended	
  way	
  to	
  training	
    Future	
  DirecOons	
   •  More	
  research	
  on	
  this	
  novel	
  intervenOon	
  to	
   improve	
  walking	
  symmetry	
  in	
  people	
  with	
   stroke	
   •  Use	
  the	
  knowledge	
  and	
  experience	
  gained	
   from	
  this	
  pilot	
  study	
  to	
  inform	
  a	
  larger	
  study	
    References	
   Beauchamp	
  MK,	
  Skrela	
  M,	
  Southmayd	
  D,	
  Tick	
  J,	
  Van	
  Kessel	
  M,	
  Brunton	
  K,	
   	
  Inness	
  E,	
  and	
  McIlroy	
  WE.	
  Immediate	
  effects	
  of	
  cane	
  use	
  on	
  gait	
   	
  symmetry	
  in	
  individuals	
  with	
  subacute	
  stroke.	
  Physiother	
  Can	
  61:	
   	
  154-­‐160,	
  2009.	
   Jorgenson	
  L,	
  Jacobsen	
  BK,	
  Wilsgaard	
  T,	
  and	
  Magnus	
  JH.	
  Walking	
  aeer	
  stroke:	
   	
  does	
  it	
  maSer?	
  Changes	
  in	
  bone	
  mineral	
  density	
  within	
  the	
  first	
  12	
  months	
   	
  aeer	
  stroke:	
  a	
  longitudinal	
  study.	
  Osteopros	
  Int	
  11:	
  381-­‐387,	
  2000.	
  	
   PaSerson	
  KK,	
  Parafianowicz	
  I,	
  Danells	
  CJ,	
  Closson	
  V,	
  Verrier	
  MC,	
  Staines	
  WR,	
   	
  Black	
  SE,	
  and	
  McIlroy	
  WE.	
  Gait	
  asymmetry	
  in	
  community-­‐ambulaOng	
   	
  stroke	
  survivors.	
  Arch	
  Phys	
  Med	
  Rehabil	
  89:	
  304-­‐310,	
  2008.	
   Poole	
  KES,	
  Reeve	
  J,	
  and	
  Warburton	
  EA.	
  Falls,	
  fractures,	
  and	
  osteoporosis	
   	
  aeer	
  stroke:	
  Time	
  to	
  think	
  about	
  protecOon?	
  Stroke	
  33:	
  1432-­‐1436,	
  2002.	
    References	
   Sungkarat	
  S,	
  Fisher	
  BE,	
  and	
  Kovindha	
  A.	
  Efficacy	
  of	
  an	
  insole	
  shoe	
  wedge	
  and	
   	
  augmented	
  pressure	
  sensor	
  for	
  gait	
  training	
  in	
  individuals	
  with	
  stroke:	
  a	
   	
  randomized	
  controlled	
  trial.	
  Clin	
  Rehabil	
  25:	
  360-­‐369,	
  2011.	
   PlaSs	
  MM,	
  Rafferty	
  D,	
  and	
  Paul	
  L.	
  Metabolic	
  cost	
  of	
  overground	
  gait	
  in	
   	
  younger	
  stroke	
  paOents	
  and	
  healthy	
  controls.	
  Med	
  Sci	
  Sports	
  Exerc	
  38:	
   	
  1041-­‐1046,	
  2006.	
   Reisman	
  DS,	
  Wityk	
  R,	
  Silver	
  K,	
  and	
  BasFan	
  AJ.	
  Locomotor	
  adaptaOon	
  on	
  a	
   	
  split-­‐belt	
  treadmill	
  can	
  improve	
  walking	
  symmetry	
  post-­‐stroke.	
  Brain	
  130:	
   	
  1861-­‐1872,	
  2007.	
   	
    Thank	
  you!	
   Alvin	
  Ip	
   	
    

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