Sinikka H Peurala, Auli H Karttunen, Tuulikki Sjögren, Jaana Paltamaa, Ari Heinonen
Evidence for the effectiveness of walking training on walking and self-care after stroke: a systematic review and meta-analysis of randomized controlled trials.
J Rehabil Med. 2014 May;46(5):387-99. doi: 10.2340/16501977-1805.
Abstract/Text
OBJECTIVE: To examine the effect of randomized controlled trials of walking training on walking and self-care in patients with stroke.
DATA SOURCES: MEDLINE, CINAHL, Embase, PEDro, OTSeeker, Central, and manual search to the end of August 2012.
STUDY SELECTION: English, Finnish, Swedish, or German language walking training randomized controlled trials for patients over 18 years of age with stroke.
DATA SYNTHESIS: The meta-analyses included 38 randomized controlled trials from 44 reports. There was high evidence that in the subacute stage of stroke, specific walking training resulted in improved walking speed and distance compared with traditional walking training of the same intensity. In the chronic stage, walking training resulted in increased walking speed and walking distance compared with no/placebo treatment, and increased walking speed compared with overall physio-therapy. On average, 24 training sessions for 7 weeks were needed.
CONCLUSION: Walking training improves walking capacity and, to some extent, self-care in different stages of stroke, but the training frequency should be fairly high.
Lu Luo, Shiqiang Zhu, Luoyi Shi, Peng Wang, Mengying Li, Song Yuan
High Intensity Exercise for Walking Competency in Individuals with Stroke: A Systematic Review and Meta-Analysis.
J Stroke Cerebrovasc Dis. 2019 Dec;28(12):104414. doi: 10.1016/j.jstrokecerebrovasdis.2019.104414. Epub 2019 Sep 27.
Abstract/Text
OBJECTIVE: To assess the effects of high intensity exercise on walking competency in individuals with stroke.
DATA SOURCES: A systematic electronic searching of the PubMed, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCOhost), and SPORTSDiscus (EBSCOhost) was initially performed up to June 25, 2019.
STUDY SELECTION: Randomized controlled trials or clinical controlled trials comparing any walking or gait parameters of the high intensity exercise to lower intensity exercise or usual physical activities were included. The risk of bias of included studies was assessed by the Cochrane risk of bias tool. The quality of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system.
DATA EXTRACTION: Data were extracted by 2 independent coders. The mean and standard deviation of the baseline and endpoint scores after training for walking distance, comfortable gait speed, gait analysis (cadence, stride length, and the gait symmetry), cost of walking, Berg Balance Scale , Time Up&Go (TUG) Test and adverse events were extracted.
DATA SYNTHESIS: A total of 22 (n = 952) studies were included. Standardized mean difference (SMD), weighted mean difference (WMD), and odds ratios (ORs) were used to compute effect size and subgroup analysis was conducted to test the consistency of results with different characteristics of exercise and time since stroke. Sensitivity analysis was used to assess the robustness of the results, which revealed significant differences on walking distance (SMD = .32, 95% CI, .17-.46, P < .01, I2 = 39%; WMD = 21.76 m), comfortable gait speed (SMD = .28, 95% CI, .06-.49, P = .01, I2 = 47%; WMD = .04 m/s), stride length (SMD = .51, 95% CI, .13-.88, P < .01, I2 = 0%; WMD = .12 m) and TUG (SMD = -.36, 95% CI, -.72 to .01, P = .05, I2 = 9%; WMD = -1.89 s) in favor of high intensity exercise versus control group. No significant differences were found between the high intensity exercise and control group in adverse events, including falls (OR = 1.40, 95% CI, .69-2.85, P = .35, I2 = 11%), pain (OR = 3.34, 95% CI, .82-13.51, P = .09, I2 = 0%), and skin injuries (OR = 1.08, 95% CI, .30-3.90, P = .90, I2 = 0%).
CONCLUSIONS: This systematic review suggests that high intensity exercise could be safe and more potent stimulus in enhancing walking competency in stroke survivors, with a capacity to improve walking distance, comfortable gait speed, stride length, and TUG compared with low to moderate intensity exercise or usual physical activities.
Copyright © 2019 Elsevier Inc. All rights reserved.
Joshua Wiener, Amanda McIntyre, Scott Janssen, Jeffrey Ty Chow, Cristina Batey, Robert Teasell
Effectiveness of High-Intensity Interval Training for Fitness and Mobility Post Stroke: A Systematic Review.
PM R. 2019 Aug;11(8):868-878. doi: 10.1002/pmrj.12154. Epub 2019 May 30.
Abstract/Text
OBJECTIVE: To evaluate the evidence on the effectiveness of high-intensity interval training (HIIT) in improving fitness and mobility post stroke. TYPE: Systematic review.
LITERATURE SURVEY: Medline, Embase, CINAHL, PsycINFO, and Scopus were searched for articles published in English up to January 2018.
METHODOLOGY: Studies were included if the sample was adult human participants with stroke, the sample size was ≥3, and participants received >1 session of HIIT. Study and participant characteristics, treatment protocols, and results were extracted.
SYNTHESIS: Six studies with a total of 140 participants met inclusion criteria: three randomized controlled trials and three pre-post studies. HIIT protocols ranged 20 to 30 minutes per session, 2 to 5 times per week, and 2 to 8 weeks in total. HIIT was delivered on a treadmill in five studies and a stationary bicycle in one study. Regarding fitness measures, HIIT produced significant improvements in peak oxygen consumption compared to baseline, but the effect was not significant compared to moderate intensity continuous exercise (MICE). Regarding mobility measures, HIIT produced significant improvements on the 10-Meter Walk Test (10MWT), 6-Minute Walk Test (6MWT), Berg Balance Scale (BBS), Functional Ambulation Categories (FAC), Timed Up and Go Test, and Rivermead Motor Assessment compared to baseline. The effect of HIIT was significant compared to MICE on the 10MWT and FAC but not on the 6MWT or BBS.
CONCLUSIONS: There is preliminary evidence that HIIT may be an effective rehabilitation intervention for improving some aspects of cardiorespiratory fitness and mobility post stroke.
LEVEL OF EVIDENCE: I.
© 2019 American Academy of Physical Medicine and Rehabilitation.
Dina Pogrebnoy, Amy Dennett
Exercise Programs Delivered According to Guidelines Improve Mobility in People With Stroke: A Systematic Review and Meta-analysis.
Arch Phys Med Rehabil. 2020 Jan;101(1):154-165. doi: 10.1016/j.apmr.2019.06.015. Epub 2019 Aug 8.
Abstract/Text
OBJECTIVE: To determine if prescribing a combined aerobic and resistance training exercise program in accordance with American Stroke Association physical activity guidelines improves mobility and physical activity levels of people after stroke.
DATA SOURCES: Online database search from earliest available date to August 27, 2018.
STUDY SELECTION: Randomized controlled trials evaluating the effectiveness of exercise programs prescribed in accordance with guidelines for improving mobility and physical activity levels in adults with subacute or chronic stroke.
DATA EXTRACTION: Two independent reviewers completed data extraction. Risk of bias was assessed using the Physiotherapy Evidence Database Scale, and overall quality of evidence was assessed using the Grades of Research, Assessment, Development, and Evaluation approach.
DATA SYNTHESIS: Data was pooled from a total of 499 participants for meta-analysis. There was high-level evidence that exercise programs adhering to guidelines improve habitual walking speed (mean difference, 0.07m/s; 95% CI, -0.01 to 0.16) and walking endurance (mean difference, 39.2m, 95% CI, 17.2-61.2). A sensitivity analysis demonstrated high-level evidence of improvements in walking endurance (mean difference, 51.1m; 95% CI, 19.96-82.24) and moderate-level evidence of improvements on the Timed Up and Go test (standardized mean difference, 0.57; 95% CI, 0.16-0.99). No differences were detected for other mobility outcome measures or physical activity levels. Adherence was high and few adverse events were reported.
CONCLUSION: A combined exercise program comprising aerobic and resistance training that adheres to the American Stroke Association guidelines is safe and should be prescribed in addition to usual care to improve mobility. Further research is needed to understand the relationship between exercise programs and behavior change requirements to improve long-term physical activity levels.
Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Junghoon Lee, Audrey J Stone
Combined Aerobic and Resistance Training for Cardiorespiratory Fitness, Muscle Strength, and Walking Capacity after Stroke: A Systematic Review and Meta-Analysis.
J Stroke Cerebrovasc Dis. 2020 Jan;29(1):104498. doi: 10.1016/j.jstrokecerebrovasdis.2019.104498. Epub 2019 Nov 13.
Abstract/Text
BACKGROUND: Cardiorespiratory fitness, measured as peak oxygen consumption, is a potent predictor of stroke risk. Muscle weakness is the most prominent impairment after stroke and is directly associated with reduced walking capacity. There is a lack of recommendations for optimal combined aerobic training and resistance training for those patients. The purpose of this study was to systematically review and quantify the effects of exercise training on cardiorespiratory fitness, muscle strength, and walking capacity after stroke.
METHODS: Five electronic databases were searched (until May 2019) for studies that met the following criteria: (1) adult humans with a history of stroke who ambulate independently; (2) structured exercise intervention based on combined aerobic training and resistance training; and (3) measured cardiorespiratory fitness, muscle strength, and/or walking capacity.
RESULTS: Eighteen studies (602 participants, average age 62 years) met the inclusion criteria. Exercise training significantly improved all 3 outcomes. In subgroup analyses for cardiorespiratory fitness, longer training duration was significantly associated with larger effect size. Likewise, for muscle strength, moderate weekly frequency and lower training volume were significantly associated with larger effect size. Furthermore, in walking capacity, moderate weekly frequency and longer training duration were significantly associated with larger effect size.
CONCLUSIONS: These results suggest that an exercise program consisting of moderate-intensity, 3 days per week, for 20 weeks should be considered for greater effect on cardiorespiratory fitness, muscle strength, and walking capacity in stroke patients.
Copyright © 2019 Elsevier Inc. All rights reserved.
Suat Erel, Fatma Uygur, Ibrahim Engin Simsek, Yakut Yakut
The effects of dynamic ankle-foot orthoses in chronic stroke patients at three-month follow-up: a randomized controlled trial.
Clin Rehabil. 2011 Jun;25(6):515-23. doi: 10.1177/0269215510390719. Epub 2011 Feb 1.
Abstract/Text
OBJECTIVE: To investigate the short- and long-term effects of dynamic ankle foot orthoses on functional ambulation activities in chronic hemiparetic patients.
DESIGN: Randomized controlled trial.
SETTING: University's neurological rehabilitation outpatient clinic and orthotics department.
SUBJECTS: Twenty-eight chronic hemiparetic patients of level 3-5 according to Functional Ambulation Classification and with a maximum spasticity level of 3 according to Modified Ashworth Scale, were randomly assigned to the study and control groups.
INTERVENTIONS: The control group (n = 14) was assessed with tennis shoes whereas the study group (n = 14) was assessed initially with tennis shoes and after three months with dynamic ankle foot orthosis.
MEASURES: Functional Reach, Timed Up and Go, Timed Up Stairs, Timed Down Stairs, gait velocity and Physiological Cost Index.
RESULTS: In the initial assessment no difference was found between the groups for any of the measured parameters (P > 0.05). After three months, intergroup comparisons while the patients in the study group were wearing dynamic ankle-foot orthosis showed a significant difference in favour of the study group for Timed Up Stairs 12.00 (10.21) seconds study versus 15.00 (7.29) seconds control group; for gait velocity 0.99 (0.45) m/s study versus 0.72 (0.20) m/s control group and for Physiological Cost Index 0.12 (0.06) beats/min study versus 0.28 (0.13) beats/min control group (P < 0.05). No difference was found between the groups for Functional Reach, Timed Up and Go, Timed Down Stairs (P > 0.05).
CONCLUSION: Chronic hemiparetic patients may benefit from using dynamic ankle-foot orthosis.
S Hesse, C Werner, K Matthias, K Stephen, M Berteanu
Non-velocity-related effects of a rigid double-stopped ankle-foot orthosis on gait and lower limb muscle activity of hemiparetic subjects with an equinovarus deformity.
Stroke. 1999 Sep;30(9):1855-61. doi: 10.1161/01.str.30.9.1855.
Abstract/Text
BACKGROUND AND PURPOSE: This study investigated the non-velocity-related effects of a 1-bar rigid ankle-foot orthosis on the gait of hemiparetic subjects, with particular emphasis on the muscle activity of the paretic lower limb.
METHODS: Twenty-one hemiparetic subjects who had been using an ankle-foot orthosis for equinovarus deformity for <1 week participated. Patients walked cued by a metronome at a comparable speed with and without the orthosis. Dependent variables were basic, limb-dependent cycle parameters, gait symmetry, vertical ground reaction forces, sagittal ankle excursions, and kinesiological electromyogram of several lower limb muscles.
RESULTS: The use of the caliper was associated with more dynamic and balanced gait, characterized by longer relative single-stance duration of the paretic lower limb, better swing symmetry, better pivoting over the stationary paretic foot, and better ankle excursions (P<0.05). The functional activity of the paretic quadriceps muscles increased, while the activity of the paretic tibialis anterior muscle decreased (P<0.05).
CONCLUSIONS: The orthosis led to a more dynamic and balanced gait, with enhanced functional activation of the hemiparetic vastus lateralis muscle. The study further supports the functional benefits of a rigid ankle-foot orthosis in hemiparetic subjects as an integral part of a comprehensive rehabilitation approach. However, the reduced activity in the tibialis muscle may lead to disuse atrophy and hence long-term dependence on the orthosis.
Yoo Jin Choo, Min Cheol Chang
Effectiveness of an ankle-foot orthosis on walking in patients with stroke: a systematic review and meta-analysis.
Sci Rep. 2021 Aug 5;11(1):15879. doi: 10.1038/s41598-021-95449-x. Epub 2021 Aug 5.
Abstract/Text
We conducted a meta-analysis to investigate the effectiveness of ankle-foot orthosis (AFO) use in improving gait biomechanical parameters such as walking speed, mobility, and kinematics in patients with stroke with gait disturbance. We searched the MEDLINE (Medical Literature Analysis and Retrieval System Online), CINAHL (Cumulative Index to Nursing and Allied Health Literature), Cochrane, Embase, and Scopus databases and retrieved studies published until June 2021. Experimental and prospective studies were included that evaluated biomechanics or kinematic parameters with or without AFO in patients with stroke. We analyzed gait biomechanical parameters, including walking speed, mobility, balance, and kinematic variables, in studies involving patients with and without AFO use. The criteria of the Cochrane Handbook for Systematic Reviews of Interventions were used to evaluate the methodological quality of the studies, and the level of evidence was evaluated using the Research Pyramid model. Funnel plot analysis and Egger's test were performed to confirm publication bias. A total of 19 studies including 434 participants that reported on the immediate or short-term effectiveness of AFO use were included in the analysis. Significant improvements in walking speed (standardized mean difference [SMD], 0.50; 95% CI 0.34-0.66; P < 0.00001; I2, 0%), cadence (SMD, 0.42; 95% CI 0.22-0.62; P < 0.0001; I2, 0%), step length (SMD, 0.41; 95% CI 0.18-0.63; P = 0.0003; I2, 2%), stride length (SMD, 0.43; 95% CI 0.15-0.71; P = 0.003; I2, 7%), Timed up-and-go test (SMD, - 0.30; 95% CI - 0.54 to - 0.07; P = 0.01; I2, 0%), functional ambulation category (FAC) score (SMD, 1.61; 95% CI 1.19-2.02; P < 0.00001; I2, 0%), ankle sagittal plane angle at initial contact (SMD, 0.66; 95% CI 0.34-0.98; P < 0.0001; I2, 0%), and knee sagittal plane angle at toe-off (SMD, 0.39; 95% CI 0.04-0.73; P = 0.03; I2, 46%) were observed when the patients wore AFOs. Stride time, body sway, and hip sagittal plane angle at toe-off were not significantly improved (p = 0.74, p = 0.07, p = 0.07, respectively). Among these results, the FAC score showed the most significant improvement, and stride time showed the lowest improvement. AFO improves walking speed, cadence, step length, and stride length, particularly in patients with stroke. AFO is considered beneficial in enhancing gait stability and ambulatory ability.
© 2021. The Author(s).
Tao Wu, Jian Hua Li, Hai Xin Song, Yan Dong
Effectiveness of Botulinum Toxin for Lower Limbs Spasticity after Stroke: A Systematic Review and Meta-Analysis.
Top Stroke Rehabil. 2016 Jun;23(3):217-23. doi: 10.1080/10749357.2016.1139294. Epub 2016 Feb 8.
Abstract/Text
OBJECTIVES: To evaluate current evidence of the effectiveness of botulinum toxin (BTX) injection for lower limbs spasticity after stroke.
METHODS: Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations，Ovid MEDLINE(R), Ovid EMBASE, Web of Science, and PubMed (NLM) from database were searched inception through Week 23, 2015. Randomized controlled trials (RCTs) comparing the clinical efficacy of BTX injection to placebo or conventional therapy on lower limbs spasticity after stroke were included. We constructed random effects models and calculated mean difference (MD) or standardized mean difference (SMD) for continuous outcomes.
RESULTS: One thousand three hundred and forty-three records were identified and among them 7 articles (603 patients) were eligible for the final analysis. A statistically significant decrease in muscle tone was observed at week 4 and 12 after injection (Subgroup analysis, SMD = 0.85, 95% CI: 0.2-1.5; p = 0.001; I(2) = 81% and SMD = 0.42, 95% CI: 0.07-0.77; p = 0.02; I(2) = 45%, respectively). Patients who received in BTX therapy were likely to have significant increased Fugl-Meyer score than control group with MD = 3.19 (95% CI: 0.22-6.16, p = 0.04, I(2) = 96%). There was no difference in gait speed between two groups during whole follow-up period.
CONCLUSION: BTX showed more persistent clinical benefits in lower limbs spasticity and Fugl-Meyer score than placebo in patients after stroke. These results suggest that BTX could be a useful and safety strategy for the treatment of lower limbs spasticity after stroke. Further investigation is required to determine the effectiveness of BTX injection for stroke patients with optimal timing and dose of intervention.
Li-Chun Sun, Rong Chen, Chuan Fu, Ying Chen, Qianli Wu, RuiPeng Chen, XueJuan Lin, Sha Luo
Efficacy and Safety of Botulinum Toxin Type A for Limb Spasticity after Stroke: A Meta-Analysis of Randomized Controlled Trials.
Biomed Res Int. 2019;2019:8329306. doi: 10.1155/2019/8329306. Epub 2019 Apr 7.
Abstract/Text
BACKGROUND: Inconsistent data have been reported for the effectiveness of intramuscular botulinum toxin type A (BTXA) in patients with limb spasticity after stroke. This meta-analysis of available randomized controlled trials (RCTs) aimed to determine the efficacy and safety of BTXA in adult patients with upper and lower limb spasticity after stroke.
METHODS: An electronic search was performed to select eligible RCTs in PubMed, Embase, and the Cochrane library through December 2018. Summary standard mean differences (SMDs) and relative risk (RR) values with corresponding 95% confidence intervals (CIs) were employed to assess effectiveness and safety outcomes, respectively.
RESULTS: Twenty-seven RCTs involving a total of 2,793 patients met the inclusion criteria, including 16 and 9 trials assessing upper and lower limb spasticity cases, respectively. For upper limb spasticity, BTXA therapy significantly improved the levels of muscle tone (SMD=-0.76; 95% CI -0.97 to -0.55; P<0.001), physician global assessment (SMD=0.51; 95% CI 0.35-0.67; P<0.001), and disability assessment scale (SMD=-0.30; 95% CI -0.40 to -0.20; P<0.001), with no significant effects on active upper limb function (SMD=0.49; 95% CI -0.08 to 1.07; P=0.093) and adverse events (RR=1.18; 95% CI 0.72-1.93; P=0.509). For lower limb spasticity, BTXA therapy was associated with higher Fugl-Meyer score (SMD=5.09; 95%CI 2.16-8.01; P=0.001), but had no significant effects on muscle tone (SMD=-0.12; 95% CI -0.83 to 0.59; P=0.736), gait speed (SMD=0.06; 95% CI -0.02 to 0.15; P=0.116), and adverse events (RR=1.01; 95% CI 0.71-1.45; P=0.949).
CONCLUSIONS: BTXA improves muscle tone, physician global assessment, and disability assessment scale in upper limb spasticity and increases the Fugl-Meyer score in lower limb spasticity.
Sarah F Tyson, Louise Rogerson
Assistive walking devices in nonambulant patients undergoing rehabilitation after stroke: the effects on functional mobility, walking impairments, and patients' opinion.
Arch Phys Med Rehabil. 2009 Mar;90(3):475-9. doi: 10.1016/j.apmr.2008.09.563.
Abstract/Text
OBJECTIVE: To assess the immediate effects of assistive walking devices on functional mobility, walking impairments, and patients' opinions in nonambulant patients after stroke.
DESIGN: Randomized crossover trial.
SETTING: Inpatient rehabilitation units of 3 United Kingdom hospitals.
PARTICIPANTS: Twenty nonambulant patients with stroke undergoing rehabilitation to restore walking.
INTERVENTIONS: Five walking conditions: (1) Walking with no device (the control condition), (2) walking with a walking cane, (3) ankle foot orthosis, (4) slider shoe, and (5) a combination of all 3 devices.
MAIN OUTCOME MEASURES: Functional mobility (functional ambulation categories), walking impairments (speed, step length of the weak leg), and patients' opinions.
RESULTS: Functional mobility improved with all assistive devices (P<.0001-.005; effect sizes 1.68-0.52; number needed to treat=2-5). Walking impairments were unchanged (P<.800-.988). Participants were generally positive about the devices. They felt their walking, confidence, and safety improved and found the appearance and comfort of the devices acceptable. They would rather walk with the devices than delay walking until a normative gait pattern was achieved without them.
CONCLUSIONS: Assistive walking devices improved functional mobility in nonambulant rehabilitation patients with stroke. No changes in walking impairments were found. Participants were generally positive about using the devices. The results support the use of assistive walking devices to enable early mobilization after stroke; 2 patients would need to be treated with a cane or combined devices for 1 to improve functional mobility.
Shuqin Lin, Qi Sun, Haifeng Wang, Guomin Xie
Influence of transcutaneous electrical nerve stimulation on spasticity, balance, and walking speed in stroke patients: A systematic review and meta-analysis.
J Rehabil Med. 2018 Jan 10;50(1):3-7. doi: 10.2340/16501977-2266.
Abstract/Text
OBJECTIVE: To evaluate the influence of transcutaneous electrical nerve stimulation in patients with stroke through a systematic review and meta-analysis.
METHODS: PubMed, Embase, Web of Science, EBSCO, and Cochrane Library databases were searched systematically. Randomized controlled trials assessing the effect of transcutaneous electrical nerve stimulation vs placebo transcutaneous electrical nerve stimulation on stroke were included. Two investigators independently searched articles, extracted data, and assessed the quality of included studies. The primary outcome was modified Ashworth scale (MAS). Meta-analysis was performed using the random-effect model.
RESULTS: Seven randomized controlled trials were included in the meta-analysis. Compared with placebo transcutaneous electrical nerve stimulation, transcutaneous electrical nerve stimulation supplementation significantly reduced MAS (standard mean difference (SMD) = -0.71; 95% confidence interval (95% CI) = -1.11 to -0.30; p = 0.0006), improved static balance with open eyes (SMD = -1.26; 95% CI = -1.83 to -0.69; p<0.0001) and closed eyes (SMD = -1.74; 95% CI = -2.36 to -1.12; p < 0.00001), and increased walking speed (SMD = 0.44; 95% CI = 0.05 to 0.84; p = 0.03), but did not improve results on the Timed Up and Go Test (SMD = -0.60; 95% CI=-1.22 to 0.03; p = 0.06).
CONCLUSION: Transcutaneous electrical nerve stimulation is associated with significantly reduced spasticity, increased static balance and walking speed, but has no influence on dynamic balance.
Michael Creamer, Geoffrey Cloud, Peter Kossmehl, Michael Yochelson, Gerard E Francisco, Anthony B Ward, Jörg Wissel, Mauro Zampolini, Abdallah Abouihia, Nathalie Berthuy, Alessandra Calabrese, Meghann Loven, Leopold Saltuari
Intrathecal baclofen therapy versus conventional medical management for severe poststroke spasticity: results from a multicentre, randomised, controlled, open-label trial (SISTERS).
J Neurol Neurosurg Psychiatry. 2018 Jun;89(6):642-650. doi: 10.1136/jnnp-2017-317021. Epub 2018 Jan 11.
Abstract/Text
BACKGROUND: Intrathecal baclofen (ITB) is a treatment option for patients with severe poststroke spasticity (PSS) who have not reached their therapy goal with other interventions.
METHODS: 'Spasticity In Stroke-Randomised Study' (SISTERS) was a randomised, controlled, open-label, multicentre phase IV study to evaluate the efficacy and safety of ITB therapy versus conventional medical management (CMM) with oral antispastic medications for treatment of PSS. Patients with chronic stroke with spasticity in ≥2 extremities and an Ashworth Scale (AS) score ≥3 in at least two affected muscle groups in the lower extremities (LE) were randomised (1:1) to ITB or CMM. Both treatment arms received physiotherapy throughout. The primary outcome was the change in the average AS score in the LE of the affected body side from baseline to month 6. Analyses were performed for all patients as randomised (primary analysis) and all randomised patients as treated (safety analysis).
RESULTS: Of 60 patients randomised to ITB (n=31) or CMM (n=29), 48 patients (24 per arm) completed the study. The primary analysis showed a significant effect of ITB therapy over CMM (mean AS score reduction, -0.99 (ITB) vs -0.43 (CMM); Hodges-Lehmann estimate, -0.667(95.1%CI -1.0000 to -0.1667); P=0.0140). More patients reported adverse events while receiving ITB (24/25 patients, 96%; 149 events) compared with CMM (22/35, 63%; 77 events), although events were generally consistent with the known safety profile of ITB therapy.
CONCLUSIONS: These data support the use of ITB therapy as an alternative to CMM for treatment of generalised PSS in adults.
TRIAL REGISTRATION NUMBER: NCT01032239; Results.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
森田定雄：歩行異常のみかた、MB Med Reha 2003;27 : 10-17.
Daroff: Bradley’s Neurology in Clinical Practice, 6th ed.; Chapter 22 - Gait Disorders.
S U Fischer, T F Beattie
The limping child: epidemiology, assessment and outcome.
J Bone Joint Surg Br. 1999 Nov;81(6):1029-34.
Abstract/Text
We investigated the epidemiology, assessment and outcome of acute atraumatic limp in 243 children under the age of 14 years presenting to a paediatric accident and emergency department (AED) over a period of six months. Data were collected at presentation and medical notes were re-examined after 18 to 21 months. The incidence of limp was 1.8 per thousand. The male:female ratio was 1.7:1 and the median age 4.35 years. Limp was mainly right-sided (54%) and painful (80%); 33.7% of the children had localised pain in the hip. A preceding illness was found in 40%. The main diagnosis was 'irritable hip'/transient synovitis (39.5%); Perthes' disease accounted for 2%. Most patients (77%) were managed entirely in the AED. Acute atraumatic limp is a common problem in children presenting to the AED. Most can be safely managed there if guidelines are followed and will have a benign outcome. Further studies are needed to identify the role of preceding illness in the aetiology of acute atraumatic limp.
APPROACH TO THE PATIENT WITH NEUROLOGIC DISEASEROBERT C. GRIGGS, RALPH F. JÓZEFOWICZ,AND MICHAEL J. AMINOFF; Goldman: Goldman’s Cecil Medicine, 24th ed.Chapter 403 2011 Saunders, An Imprint of Elsevier.
Jeffrey R Sawyer, Mukesh Kapoor
The limping child: a systematic approach to diagnosis.
Am Fam Physician. 2009 Feb 1;79(3):215-24.
Abstract/Text
Deviations from a normal age-appropriate gait pattern can be caused by a wide variety of conditions. In most children, limping is caused by a mild, self-limiting event, such as a contusion, strain, or sprain. In some cases, however, a limp can be a sign of a serious or even life-threatening condition. Delays in diagnosis and treatment can result in significant morbidity and mortality. Examination of a limping child should begin with a thorough history, focusing on the presence of pain, any history of trauma, and any associated systemic symptoms. The presence of fever, night sweats, weight loss, and anorexia suggests the possibility of infection, inflammation, or malignancy. Physical examination should focus on identifying the type of limp and localizing the site of pathology by direct palpation and by examining the range of motion of individual joints. Localized tenderness may indicate contusions, fractures, osteomyelitis, or malignancy. A palpable mass raises the concern of malignancy. The child should be carefully examined because non-musculoskeletal conditions can cause limping. Based on the most probable diagnoses suggested by the history and physical examination, the appropriate use of laboratory tests and imaging studies can help confirm the diagnosis.
A I Leet, D L Skaggs
Evaluation of the acutely limping child.
Am Fam Physician. 2000 Feb 15;61(4):1011-8.
Abstract/Text
A limp may be defined as any asymmetric deviation from a normal gait pattern. The differential diagnosis of a limp includes trauma, infection, neoplasia and inflammatory, congenital, neuromuscular or developmental disorders. Initially, a broad differential diagnosis should be considered to avoid overlooking less common conditions such as diskitis or psoas abscess. In any patient with a complaint of knee or thigh pain, an underlying hip condition should be considered. The patient's age can further narrow the differential diagnosis, because certain disease entities are age-specific. Vigilance is warranted in conditions requiring emergent treatment such as septic hip. The challenge to the family physician is to identify the cause of the limp and determine if further observation or immediate diagnostic work-up is indicated.
E Wassmer, E Wright, S Rideout, W P Whitehouse
Idiopathic gait disorder among in-patients with acquired gait disorders admitted to a children's hospital.
Pediatr Rehabil. 2002 Jan-Mar;5(1):21-8. doi: 10.1080/1363849021000007060.
Abstract/Text
Many children are admitted to hospital for treatment of an acquired gait disorder. Some gait disorders have a definite underlying physical cause and some are idiopathic. A literature review shows that there have been few attempts to estimate the incidence or prevalence of idiopathic gait disorder in children. The economic and social impact may be substantial with regard to therapy and investigations and school absence, respectively. This study attempted to estimate the incidence and impact of idiopathic gait disorder in a tertiary children's hospital. It evaluated prospectively all the children admitted with a gait disorder requiring physiotherapy treatment at Birmingham Children's Hospital, using a standardized pro-forma, during a 3-month period between March-June 1999. One hundred and three children (aged 2-16 years) were admitted with gait disorders (57 female and 46 male). Eight had an idiopathic gait disorder. All eight children exhibited significant functional impairment, pain and school absence. Idiopathic gait disorder accounted for 8% of children admitted to hospital with an acquired gait disorder and had an annual incidence of at least 2-4 per 100,000 children. The economic and social impact of these disorders is, therefore, substantial, especially with regard to diagnosis, investigations, treatment and school absence.
Anke H Snijders, Bart P van de Warrenburg, Nir Giladi, Bastiaan R Bloem
Neurological gait disorders in elderly people: clinical approach and classification.
Lancet Neurol. 2007 Jan;6(1):63-74. doi: 10.1016/S1474-4422(06)70678-0.
Abstract/Text
Gait disorders are common and often devastating companions of ageing, leading to reductions in quality of life and increased mortality. Here, we present a clinically oriented approach to neurological gait disorders in the elderly population. We also draw attention to several exciting scientific developments in this specialty. Our first focus is on the complex and typically multifactorial pathophysiology underlying geriatric gait disorders. An important new insight is the recognition of gait as a complex higher order form of motor behaviour, with prominent and varied effects of mental processes. Another relevant message is that gait disorders are not an unpreventable consequence of ageing, but implicate the presence of underlying diseases that warrant specific diagnostic tests. We next discuss the core clinical features of common geriatric gait disorders and review some bedside tests to assess gait and balance. We conclude by proposing a practical three-step approach to categorise gait disorders and we present a simplified classification system based on clinical signs and symptoms.
米本恭三（編）：歩行障害、最新リハビリテーション医学、75－82．医歯薬出版、1999.
J Boudarham, R Zory, F Genet, G Vigné, D Bensmail, N Roche, D Pradon
Effects of a knee-ankle-foot orthosis on gait biomechanical characteristics of paretic and non-paretic limbs in hemiplegic patients with genu recurvatum.
Clin Biomech (Bristol, Avon). 2013 Jan;28(1):73-8. doi: 10.1016/j.clinbiomech.2012.09.007. Epub 2012 Oct 13.
Abstract/Text
BACKGROUND: A knee-ankle-foot orthosis may be prescribed for the prevention of genu recurvatum during the stance phase of gait. It allows also to limit abnormal plantarflexion during swing phase. The aim is to improve gait in hemiplegic patients and to prevent articular degeneration of the knee. However, the effects of knee-ankle-foot orthosis on both the paretic and non-paretic limbs during gait have not been evaluated. The aim of this study was to quantify biomechanical adaptations induced by wearing a knee-ankle-foot orthosis, on the paretic and non-paretic limbs of hemiplegic patients during gait.
METHODS: Eleven hemiplegic patients with genu recurvatum performed two gait analyses (without and with the knee-ankle-foot orthosis). Spatio-temporal, kinematic and kinetic gait parameters of both lower limbs were quantified using an instrumented gait analysis system during the stance and swing phases of the gait cycle.
FINDINGS: The knee-ankle-foot orthosis improved spatio-temporal gait parameters. During stance phase on the paretic side, knee hyperextension was reduced and ankle plantarflexion and hip flexion were increased. During swing phase, ankle dorsiflexion increased in the paretic limb and knee extension increased in the non-paretic limb. The paretic limb knee flexion moment also decreased.
INTERPRETATION: Wearing a knee-ankle-foot orthosis improved gait parameters in hemiplegic patients with genu recurvatum. It increased gait velocity, by improving cadence, stride length and non-paretic step length. These spatiotemporal adaptations seem mainly due to the decrease in knee hyperextension during stance phase and to the increase in paretic limb ankle dorsiflexion during both phases of the gait cycle.
Copyright © 2012 Elsevier Ltd. All rights reserved.
Nicolas Roche, Raphaël Zory, Antoine Sauthier, Celine Bonnyaud, Didier Pradon, Djamel Bensmail
Effect of rehabilitation and botulinum toxin injection on gait in chronic stroke patients: a randomized controlled study.
J Rehabil Med. 2015 Jan;47(1):31-7. doi: 10.2340/16501977-1887.
Abstract/Text
BACKGROUND: Botulinum toxin injections are used to treat spasticity in stroke. Although this treatment is effective on muscle tone, its effect on functional gait-related activities remains uncertain.
OBJECTIVE: The aim of this randomized controlled trial was to determine the effect of a self-rehabilitation programme as an adjunct to botulinum toxin injections on gait-related activities in patients with chronic hemiparesis.
METHODS: Thirty-five outpatients were included. Each patient was randomized to 1 of 2 groups: botulinum toxin + standardized self-rehabilitation programme (R group, n = 19) or botulinum toxin alone (C group, n = 16). Each patient was evaluated with the following tests before botulinum toxin injections and one month afterwards: 10-m timed walk, Timed Up and Go, distance covered in 6 min over an ecological circuit, and the stair test.
RESULTS: There were significant improvements in the R group compared with the C group: maximal gait speed improved by 8% (p = 0.003); distance covered in 6 min over an ecological circuit increased by 7.1% (p = 0.01); and time to ascend and to descend a flight of stairs decreased by 9.8% (p = 0.003) and 6.6% (p = 0.009), respectively. The self-rehabilitation programme was well tolerated and safe.
CONCLUSION: These results strongly suggest that a standardized self-rehabilitation programme constitutes a useful adjunct to botulinum toxin injections in order to improve gait-related activities.
Wu Tao, Dong Yan, Jian-Hua Li, Zhao-Hong Shi
Gait improvement by low-dose botulinum toxin A injection treatment of the lower limbs in subacute stroke patients.
J Phys Ther Sci. 2015 Mar;27(3):759-62. doi: 10.1589/jpts.27.759. Epub 2015 Mar 31.
Abstract/Text
[Purpose] Lower-limb spasticity after stroke may be associated with worse functional outcome. Our study aim was to establish whether a low-dose botulinum toxin A (BTX-A) injection in subacute stroke patients can improve spasticity, gait, and daily living abilities. [Subjects] Twenty-three subacute stroke patients were randomly allocated to BTX-A treatment group (11 patients) and control group (12 patients). [Methods] In the BTX-A treatment group patients, 200 units BTX-A was injected into the triceps surae (150 iu) and posterior tibial (50 iu) by electrical stimulation-guided. The patients in the control group received the same volume of placebo solution into the same injection locations. Gait analysis (step length, cadence, speed), the 6-min walking test, Fugl-Meyer Assessment (FMA) of the lower limbs, modified Ashworth scale assess (MAS) assessment of the lower limbs, surface electromyography (sEMG), and modified Barthel index (MBI) assessment were performed before and at 4,8 weeks after treatment. [Results] We found that the FMA of the low limbs and MBI were significantly improved in both groups. The gait analysis, FMA, and MBI results in the BTX-A treatment group were better than those in the control group. MAS and surface electromyography (sEMG) showed better improvement of spasticity in the treatment group. [Conclusion] Early low-dose botulinum toxin A (BTX-A) injection in subacute stroke patients into the lower-limb may improve gait, spasticity, and daily living abilities.
Jiyao Zhang, Luwen Zhu, Qiang Tang
Electroacupuncture with rehabilitation training for limb spasticity reduction in post-stroke patients: A systematic review and meta-analysis.
Top Stroke Rehabil. 2021 Jul;28(5):340-361. doi: 10.1080/10749357.2020.1812938. Epub 2020 Aug 26.
Abstract/Text
OBJECTIVE: To assess the effectiveness of electroacupuncture (EA) with rehabilitation training in reducing limb spasticity in post-stroke patients.
METHODS: A systematic review was performed by electronically searching six databases (Medline/Pubmed, Embase, Cochrane Library, China National Knowledge Infrastructure, Database for Chinese Technical Periodicals, and Wanfang Data) for randomized controlled trials (RCTs) on EA with rehabilitation training for limb spasticity reduction in post-stroke patients from 1 January 2009 to 1 January 2019. A meta-analysis was performed using SAS 9.3 and RevMan 5.3 software after bibliography screening, data extraction, and risk of bias assessment using the Cochrane handbook. The primary outcome was spasticity.
RESULTS: A total of 31 RCTs (including 2488 participants) were included. Except for Cai et al.'s study, the quality of other RCTs was not high. All studies performed a descriptive analysis, and 29 RCTs conducted a meta-analysis. The odds ratio (OR) for marked efficiency was 2.35 (95% confidence interval [CI] 1.68-3.27, Z = 5.03, P < .00001). The OR for Modified Ashworth Scale (MAS) classification was 2.42 (95% CI 1.89-3.10, Z = 7.03; P < .00001). The weighted mean difference (WMD) for MAS score was -0.68 (95% CI -0.79 - -0.56, Z = 11.24, P < .00001). The WMD for clinical spasticity index score was -1.50 (95% CI -2.28 - -0.72, Z = 3.79, P = .0002).
CONCLUSION: EA with rehabilitation training could be a good strategy for reducing limb spasticity after stroke and is better than EA alone or rehabilitation training alone. However, its effectiveness remains to be further verified by large-sample and high-quality RCTs.
Cameron Lindsay, Aphrodite Kouzouna, Christopher Simcox, Anand D Pandyan
Pharmacological interventions other than botulinum toxin for spasticity after stroke.
Cochrane Database Syst Rev. 2016 Oct 6;10:CD010362. doi: 10.1002/14651858.CD010362.pub2. Epub 2016 Oct 6.
Abstract/Text
BACKGROUND: The long-term risk of stroke increases with age, and stroke is a common cause of disability in the community. Spasticity is considered a significantly disabling impairment that develops in people who have had a stroke. The burden of care is higher in stroke survivors who have spasticity when compared with stroke survivors without spasticity with regard to treatment costs, quality of life, and caregiver burden.
OBJECTIVES: To assess if pharmacological interventions for spasticity are more effective than no intervention, normal practice, or control at improving function following stroke.
SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL, 2016, Issue 5), MEDLINE (1946 to May 2016), Embase (2008 to May 2016), CINAHL (1982 to May 2016), AMED (1985 to May 2016), and eight further databases and trial registers. In an effort to identify further studies, we undertook handsearches of reference lists and contacted study authors and commercial companies.
SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared any systemically acting or locally acting drug versus placebo, control, or comparative drug with the aim of treating spasticity.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the studies for inclusion and extracted the data. We assessed the included studies for both quality and risk of bias. We contacted study authors to request further information when necessary.
MAIN RESULTS: We included seven RCTs with a total 403 participants. We found a high risk of bias in all but one RCT. Two of the seven RCTs assessed a systemic drug versus placebo. We pooled data on an indirect measure of spasticity (160 participants) from these two studies but found no significant effect (odds ratio (OR) 1.66, 95% confidence interval (CI) 0.21 to 13.07; I2 = 85%). We identified a significant risk of adverse events per participant occurring in the treatment group versus placebo group (risk ratio (RR) 1.65, 95% CI 1.12 to 2.42; 160 participants; I2 = 0%). Only one of these studies used a functional outcome measure, and we found no significant difference between groups.Of the other five studies, two assessed a systemic drug versus another systemic drug, one assessed a systemic drug versus local drug, and the final two assessed a local drug versus another local drug.
AUTHORS' CONCLUSIONS: The lack of high-quality RCTs limited our ability to make specific conclusions. Evidence is insufficient to determine if systemic antispasmodics are effective at improving function following stroke.
Mika Yamawaki, Masayoshi Kusumi, Hisanori Kowa, Kenji Nakashima
Changes in prevalence and incidence of Parkinson's disease in Japan during a quarter of a century.
Neuroepidemiology. 2009;32(4):263-9. doi: 10.1159/000201565. Epub 2009 Feb 11.
Abstract/Text
BACKGROUND/AIM: To determine the prevalence and incidence of Parkinson's disease (PD) and compare them with results from our previous studies.
METHODS: We examined epidemiological characteristics of PD patients using a service-based study in Yonago City, and a door-to-door study in Daisen Town. The prevalence days were April 1, 2004 in Yonago, and April 1, 2003 in Daisen.
RESULTS: In Yonago, we identified 254 PD patients. The crude prevalence was 180.3 (95% CI, 158.1-202.4) per 100,000 population. The adjusted prevalence was 145.8 (95% CI, 145.2-146.5) in 1980, 147.0 (95% CI, 146.3-147.6) in 1992, and 166.8 (95% CI, 166.1-167.5) in 2004, when calculated using the Japanese population in 2004. The crude incidence was 18.4 (95% CI, 11.3-25.5) per 100,000 population per year. The crude incidence in 1980 was 10.2 (95% CI, 4.6-15.8), and the adjusted incidence was 9.8 (95% CI, 4.3-15.3) in 1992, and 10.3 (95% CI, 4.7-15.9) in 2004, when calculated using the population in Yonago in 1980. In Daisen, there were 21 PD patients. The crude prevalence was 306.6 (95% CI, 175.7-437.6) and the adjusted prevalence was 192.6 (95% CI, 191.9-193.8).
CONCLUSIONS: The prevalence of PD had increased, primarily because the population had aged. Differences in prevalence between these adjacent areas may have resulted from differences in the methods of investigation.
Claire L Tomlinson, Smitaa Patel, Charmaine Meek, Clare P Herd, Carl E Clarke, Rebecca Stowe, Laila Shah, Catherine M Sackley, Katherine H O Deane, Keith Wheatley, Natalie Ives
Physiotherapy versus placebo or no intervention in Parkinson's disease.
Cochrane Database Syst Rev. 2013 Sep 10;(9):CD002817. doi: 10.1002/14651858.CD002817.pub4. Epub 2013 Sep 10.
Abstract/Text
BACKGROUND: Despite medical therapies and surgical interventions for Parkinson's disease (PD), patients develop progressive disability. Physiotherapy aims to maximise functional ability and minimise secondary complications through movement rehabilitation within a context of education and support for the whole person. The overall aim is to optimise independence, safety, and well-being, thereby enhancing quality of life.
OBJECTIVES: To assess the effectiveness of physiotherapy intervention compared with no intervention in patients with PD.
SEARCH METHODS: We identified relevant trials by conducting electronic searches of numerous literature databases (e.g. MEDLINE, EMBASE) and trial registers, and by handsearching major journals, abstract books, conference proceedings, and reference lists of retrieved publications. The literature search included trials published up to the end of January 2012.
SELECTION CRITERIA: Randomised controlled trials of physiotherapy intervention versus no physiotherapy intervention in patients with PD.
DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from each article. We used standard meta-analysis methods to assess the effectiveness of physiotherapy intervention compared with no physiotherapy intervention. Trials were classified into the following intervention comparisons: general physiotherapy, exercise, treadmill training, cueing, dance, and martial arts. We used tests for heterogeneity to assess for differences in treatment effect across these different physiotherapy interventions.
MAIN RESULTS: We identified 39 trials with 1827 participants. We considered the trials to be at a mixed risk of bias as the result of unreported allocation concealment and probable detection bias. Compared with no intervention, physiotherapy significantly improved the gait outcomes of speed (mean difference 0.04 m/s, 95% confidence interval (CI) 0.02 to 0.06, P = 0.0002); two- or six-minute walk test (13.37 m, 95% CI 0.55 to 26.20, P = 0.04) and Freezing of Gait questionnaire (-1.41, 95% CI -2.63 to -0.19, P = 0.02); functional mobility and balance outcomes of Timed Up & Go test (-0.63 s, 95% CI -1.05 to -0.21, P = 0.003), Functional Reach Test (2.16 cm, 95% CI 0.89 to 3.43, P = 0.0008), and Berg Balance Scale (3.71 points, 95% CI 2.30 to 5.11, P < 0.00001); and clinician-rated disability using the Unified Parkinson's Disease Rating Scale (UPDRS) (total -6.15 points, 95% CI-8.57 to -3.73, P < 0.00001; activities of daily living: -1.36, 95% CI -2.41 to -0.30, P = 0.01; and motor: -5.01, 95% CI -6.30 to -3.72, P < 0.00001). No difference between arms was noted in falls (Falls Efficacy Scale: -1.91 points, 95% CI -4.76 to 0.94, P = 0.19) or patient-rated quality of life (PDQ-39 Summary Index: -0.38 points, 95% CI -2.58 to 1.81, P = 0.73). One study reported that adverse events were rare; no other studies reported data on this outcome. Indirect comparisons of the different physiotherapy interventions revealed no evidence that the treatment effect differed across physiotherapy interventions for any of the outcomes assessed.
AUTHORS' CONCLUSIONS: Benefit for physiotherapy was found in most outcomes over the short term (i.e. < 3 months) but was significant only for speed, two- or six-minute walk test, Freezing of Gait questionnaire, Timed Up & Go, Functional Reach Test, Berg Balance Scale, and clinician-rated UPDRS. Most of the observed differences between treatments were small. However, for some outcomes (e.g. speed, Berg Balance Scale, UPDRS), the differences observed were at, or approaching, what are considered minimal clinically important changes. These benefits should be interpreted with caution because the quality of most of the included trials was not high. Variation in measurements of outcome between studies meant that our analyses include a small proportion of the participants recruited.This review illustrates that a wide range of approaches are employed by physiotherapists to treat patients with PD. However, no evidence of differences in treatment effect was noted between the different types of physiotherapy interventions being used, although this was based on indirect comparisons. A consensus menu of 'best practice' physiotherapy is needed, as are large, well-designed randomised controlled trials undertaken to demonstrate the longer-term efficacy and cost-effectiveness of 'best practice' physiotherapy in PD.
Jorik Nonnekes, Nir Giladi, Anasuya Guha, Urban M Fietzek, Bastiaan R Bloem, Evžen Růžička
Gait festination in parkinsonism: introduction of two phenotypes.
J Neurol. 2019 Feb;266(2):426-430. doi: 10.1007/s00415-018-9146-7. Epub 2018 Dec 7.
Abstract/Text
Gait festination is one of the most characteristic gait disturbances in patients with Parkinson's disease or atypical parkinsonism. Although festination is common and disabling, it has received little attention in the literature, and different definitions exist. Here, we argue that there are actually two phenotypes of festination. The first phenotype entails a primary locomotion disturbance, due to the so-called sequence effect: a progressive shortening of step length, accompanied by a compensatory increase in cadence. This phenotype strongly relates to freezing of gait with alternating trembling of the leg. The second phenotype results from a postural control problem (forward leaning of the trunk) combined with a balance control deficit (inappropriately small balance-correcting steps). In this viewpoint, we elaborate on the possible pathophysiological substrate of these two phenotypes of festination and discuss their management in daily clinical practice.
Michael A Williams, George Thomas, Barbara de Lateur, Hejab Imteyaz, J Gregory Rose, Wendy S Shore, Siddharth Kharkar, Daniele Rigamonti
Objective assessment of gait in normal-pressure hydrocephalus.
Am J Phys Med Rehabil. 2008 Jan;87(1):39-45. doi: 10.1097/PHM.0b013e31815b6461.
Abstract/Text
OBJECTIVES: Gait abnormalities are an early clinical symptom in normal pressure hydrocephalus (NPH), and subjective improvement in gait after temporary removal of CSF is often used to decide to perform shunt surgery. We investigated objective measures to compare gait before and after CSF drainage and shunt surgery.
DESIGN: Twenty patients and nine controls were studied. Quantitative gait measures were obtained at baseline, after 3 days of controlled CSF drainage, and after shunt surgery. Decision to perform surgery was based on response to drainage, and patients were assigned to shunted or unshunted groups for comparison.
RESULTS: There was no improvement after CSF drainage in the unshunted group (n = 4). In the shunted group (n = 15) velocity, double-support time, and cadence improved significantly after drainage, and improved further after shunt surgery. The degree of improvement after drainage significantly correlated to the degree of improvement postshunt for velocity, double-support time, cadence, and stride length.
CONCLUSIONS: There are significant, quantifiable changes in gait after CSF drainage that correspond to improvement after shunt surgery for patients with NPH. Use of objective gait assessment may improve the process of identifying these candidates when response to CSF removal is used as a supplemental prognostic test for shunt surgery.
Anthony Marmarou, Harold F Young, Gunes A Aygok, Satoshi Sawauchi, Osamu Tsuji, Takuji Yamamoto, Jana Dunbar
Diagnosis and management of idiopathic normal-pressure hydrocephalus: a prospective study in 151 patients.
J Neurosurg. 2005 Jun;102(6):987-97. doi: 10.3171/jns.2005.102.6.0987.
Abstract/Text
OBJECT: The diagnosis and management of idiopathic normal-pressure hydrocephalus (NPH) remains controversial, particularly in selecting patients for shunt insertion. The use of clinical criteria coupled with imaging studies has limited effectiveness in predicting shunt success. The goal of this prospective study was to assess the usefulness of clinical criteria together with brain imaging studies, resistance testing, and external lumbar drainage (ELD) of cerebrospinal fluid (CSF) in determining which patients would most likely benefit from shunt surgery.
METHODS: One hundred fifty-one patients considered at risk for idiopathic NPH were prospectively studied according to a fixed management protocol. The clinical criterion for idiopathic NPH included ventriculomegaly demonstrated on computerized tomography or magnetic resonance imaging studies combined with gait disturbance, incontinence, and dementia. Subsequently, all patients with a clinical diagnosis of idiopathic NPH underwent a lumbar tap for the measurement of CSF resistance. Following this procedure, patients were admitted to the hospital neurosurgical service for a 3-day ELD of CSF. Video assessment of gait and neuropsychological testing was conducted before and after drainage. A shunt procedure was then offered to patients who had experienced clinical improvement from ELD. Shunt outcome was assessed at 1 year postsurgery.
CONCLUSIONS: Data in this report affirm that gait improvement immediately following ELD is the best prognostic indicator of a positive shunt outcome, with an accuracy of prediction greater than 90%. Furthermore, bolus resistance testing is useful as a prognostic tool, does not require hospitalization, can be performed in an outpatient setting, and has an overall accuracy of 72% in predicting successful ELD outcome. Equally important is the finding that improvement with shunt surgery is independent of age up to the ninth decade of life in patients who improved on ELD.
Tishya A L Wren, George E Gorton, Sylvia Ounpuu, Carole A Tucker
Efficacy of clinical gait analysis: A systematic review.
Gait Posture. 2011 Jun;34(2):149-53. doi: 10.1016/j.gaitpost.2011.03.027. Epub 2011 Jun 8.
Abstract/Text
The aim of this systematic review was to evaluate and summarize the current evidence base related to the clinical efficacy of gait analysis. A literature review was conducted to identify references related to human gait analysis published between January 2000 and September 2009 plus relevant older references. The references were assessed independently by four reviewers using a hierarchical model of efficacy adapted for gait analysis, and final scores were agreed upon by at least three of the four reviewers. 1528 references were identified relating to human instrumented gait analysis. Of these, 116 original articles addressed technical accuracy efficacy, 89 addressed diagnostic accuracy efficacy, 11 addressed diagnostic thinking and treatment efficacy, seven addressed patient outcomes efficacy, and one addressed societal efficacy, with some of the articles addressing multiple levels of efficacy. This body of literature provides strong evidence for the technical, diagnostic accuracy, diagnostic thinking and treatment efficacy of gait analysis. The existing evidence also indicates efficacy at the higher levels of patient outcomes and societal cost-effectiveness, but this evidence is more sparse and does not include any randomized controlled trials. Thus, the current evidence supports the clinical efficacy of gait analysis, particularly at the lower levels of efficacy, but additional research is needed to strengthen the evidence base at the higher levels of efficacy.
Copyright © 2011. Published by Elsevier B.V.
L Sudarsky
Neurologic disorders of gait.
Curr Neurol Neurosci Rep. 2001 Jul;1(4):350-6.
Abstract/Text
Gait disorders are important because of their prevalence, particularly among the elderly, and the associated risk of falls and injury. Neural networks that organize locomotion and maintain balance are briefly reviewed. Gait disorders can be classified based on observational features or by etiology. Several common disorders are discussed in more detail. Recent progress includes use of botulinum toxin for spastic gait in cerebral palsy, neurosurgical treatment of Parkinson's disease, and newer rehabilitation approaches to gait and balance training.
L Sudarsky
Geriatrics: gait disorders in the elderly.
N Engl J Med. 1990 May 17;322(20):1441-6. doi: 10.1056/NEJM199005173222007.
Abstract/Text
Joseph Jankovic
Gait disorders.
Neurol Clin. 2015 Feb;33(1):249-68. doi: 10.1016/j.ncl.2014.09.007.
Abstract/Text
Gait disorders are frequently accompanied by loss of balance and falls, and are a common cause of disability, particularly among the elderly. In many cases the cause is multifactorial, involving both neurologic and nonneurologic systems. Physical therapy and training, coupled with pharmacologic and surgical therapy, can usually provide some improvement in ambulation, which translates into better quality of life. More research is needed on the mechanisms of gait and its disorders as well as on symptomatic therapies. Better understanding of the pathophysiology of gait disorders should lead to more specific, pathogenesis-targeted therapies.
Copyright © 2015 Elsevier Inc. All rights reserved.
Nir Giladi, Fay B Horak, Jeffrey M Hausdorff
Classification of gait disturbances: distinguishing between continuous and episodic changes.
Mov Disord. 2013 Sep 15;28(11):1469-73. doi: 10.1002/mds.25672.
Abstract/Text
The increased awareness of the importance of gait and postural control to quality of life and functional independence has led many research groups to study the pathophysiology, epidemiology, clinical, and therapeutic aspects of these motor functions. In recognition of the increased awareness of the significance of this topic, the Movement Disorders journal is devoting this entire issue to gait and postural control. Leading research groups provide critical reviews of the current knowledge and propose future directions for this evolving field. The intensive work in this area throughout the world has created an urgent need for a unified language. Because gait and postural disturbances are so common, the clinical classification should be clear, straightforward, and simple to use. As an introduction to this special issue, we propose a new clinically based classification scheme that is organized according to the dominant observed disturbance, while taking into account the results of a basic neurological exam. The proposed classification differentiates between continuous and episodic gait disturbances because this subdivision has important ramifications from the functional, prognostic, and mechanistic perspectives. We anticipate that research into gait and postural control will continue to flourish over the next decade as the search for new ways of promoting mobility and independence aims to keep up with the exponentially growing population of aging older adults. Hopefully, this new classification scheme and the articles focusing on gait and postural control in this special issue of the Movement Disorders journal will help to facilitate future investigations in this exciting, rapidly growing area.
© 2013 Movement Disorder Society.
Alexander K C Leung, Jean François Lemay
The limping child.
J Pediatr Health Care. 2004 Sep-Oct;18(5):219-23. doi: 10.1016/j.pedhc.2004.03.004.
Abstract/Text
A child who limps often presents a diagnostic challenge. The differential diagnosis is extensive. Although the most common cause is trauma, awareness of other potential causes is important. The age of the child and the pattern of the gait help narrow the differential diagnosis. In most cases, a diagnosis can be made from the history and physical examination. If the diagnosis is not obvious after a careful clinical evaluation, plain radiographs provide an excellent means of screening for fracture, joint effusion, lytic lesions, periosteal reaction, and avascular necrosis. Other tests should only be ordered when indicated.
H Baezner, M Oster, O Henning, S Cohen, M G Hennerici
Amantadine increases gait steadiness in frontal gait disorder due to subcortical vascular encephalopathy: a double-blind randomized placebo-controlled trial based on quantitative gait analysis.
Cerebrovasc Dis. 2001;11(3):235-44. doi: 47645.
Abstract/Text
In a randomized, double-blind placebo-controlled trial, 40 patients diagnosed as subcortical vascular encephalopathy (SVE) were given a daily dose of 500 ml i.v. amantadine vs. placebo for 5 days. Both groups were treated with physiotherapy on a daily basis. Quantitative gait analyses were performed at days 1 and 6 to evaluate gait steadiness from cadence, length of heel-to-toe movements, variability of centre of gravity (COG) and double support time. Both placebo- and amantadine-receiving patient groups showed mild improvement in gait parameters after study, which failed to show the superiority of amantadine, when comparing drug-induced changes between both groups. However, analysing the treatment effects from day 0 to day 6 in both groups separately, statistically significant changes could be found in the amantadine group for cadence, length of heel-to-toe movements in single support phase as well as for variability in double support phase and double support time (two-tailed paired t-test, p < 0.05), whereas in the placebo group, a statistically significant effect could only be seen for double support time (p < 0.05). In this small pilot study, amantadine tends to improve gait steadiness as evaluated by cadence, length of heel-to-toe movements in single support phase, variability in double support phase and double support time, in patients with moderate frontal gait disorder due to SVE. Improvements in the placebo group can be interpreted as physiotherapy effect, which improved gait steadiness slightly, however, this was statistically significant only for double support time.
Copyright 2001 S. Karger AG, Basel
Janice J Eng, Pei-Fang Tang
Gait training strategies to optimize walking ability in people with stroke: a synthesis of the evidence.
Expert Rev Neurother. 2007 Oct;7(10):1417-36. doi: 10.1586/14737175.7.10.1417.
Abstract/Text
Stroke is a leading cause of long-term disability. Impairments resulting from stroke lead to persistent difficulties with walking and, subsequently, improved walking ability is one of the highest priorities for people living with a stroke. In addition, walking ability has important health implications in providing protective effects against secondary complications common after a stroke such as heart disease or osteoporosis. This paper systematically reviews common gait training strategies (neurodevelopmental techniques, muscle strengthening, treadmill training and intensive mobility exercises) to improve walking ability. The results (descriptive summaries as well as pooled effect sizes) from randomized controlled trials are presented and implications for optimal gait training strategies are discussed. Novel and emerging gait training strategies are highlighted and research directions proposed to enable the optimal recovery and maintenance of walking ability.
