Ren Fujii

Robot-assisted gait training (RAGT) has been increasingly applied as an intervention method for stroke hemiplegia patients' abnormal gait patterns. We describe an intervention strategy that attempts the precise adjustment of tasks' difficulty according to the severity of gait impairment by progressively adapting two types of robots in accordance with the subject's recovery process. This case report describes a 53-year-old man who presented with left hemiplegia due to a right lacunar infarction. He was admitted to our rehabilitation hospital 14 days after stroke onset and underwent a staged gait-training program from days 14 to 77 after stroke onset, including treadmill-driven RAGT from days 16 to 28 and orthosis-mounted RAGT from days 55 to 69. At his initial assessment, the patient required assistance with walking due to moderate motor paralysis. In the early stages of intervention, a treadmill-driven robot was introduced with the goal of improving the patient's walking independence. Subsequently, after supervised walking had been achieved and residual gait abnormalities persisted during conventional gait training, the patient transitioned to flat-ground walking practice using an orthosis-mounted robot with the goal of optimizing walking patterns. The sequential intervention was associated with improvement in walking independence, with the Functional Ambulation Category increasing from 1 to 5 by discharge, and improvements in stiff-knee gait and toe clearance were also observed. These findings suggest that stage-specific selection of robotic devices according to therapeutic goals may be a feasible approach for addressing both walking independence and residual gait abnormalities after stroke.

Ankle-foot orthoses (AFOs) are widely used to improve gait; nonetheless, it remains unclear how specific settings, particularly the dorsiflexion angle, affect gait kinematics in individuals with stroke. This study investigated the effect of different AFO dorsiflexion angles on gait kinematics in ambulatory adults with hemiparesis. Twenty-six individuals with post-stroke hemiparesis walked on a treadmill while wearing the same type of AFO at four ankle dorsiflexion angles: 0°, 5°, 10°, and 15°. Temporal-spatial variables, joint angles, and toe clearance and its components were quantified using three-dimensional analysis. The double-stance time before the paretic swing shortened significantly with increasing dorsiflexion angle, whereas the mean stride time and length did not significantly change. During the swing phase, increased AFO dorsiflexion was associated with reduced maximal knee flexion, in addition to its direct effect on ankle angles. The absolute toe clearance height was unaffected by the AFO settings; however, the contribution of ankle dorsiflexion to limb shortening increased stepwise from 0° to 15°, and the hip elevation and compensatory movement ratio declined. In conclusion, increasing the AFO dorsiflexion angle significantly altered gait kinematics, with distal ankle mechanics replacing inefficient hip compensation and reducing double-stance time.

This study investigated the effects of ankle dorsiflexion angle adjustments in ankle–foot orthoses (AFOs) on the gait of healthy individuals. Fifteen healthy participants engaged in treadmill walking tasks while wearing AFOs with dorsiflexion angles set at 0°, 5°, 10°, and 15°. Three-dimensional treadmill gait analysis was used to collect data during treadmill walking. The analysis focused on toe clearance and the contribution of the vertical component of limb shortening (LS), and compared them across different dorsiflexion angles. The results indicated a significant increase in toe clearance at 10° (median [interquartile change]: 5.03 [0.90] vs. 5.98 [1.18], p < 0.01) and 15° (5.03 [0.90] vs. 5.82 [1.11], p < 0.01) dorsiflexion angle conditions compared to the 0° condition. Similarly, LS demonstrated significant increases at 10° (4.89 [1.97] vs. 5.87 [1.31], p < 0.01) and 15° (4.89 [1.97] vs. 5.61 [1.65], p < 0.01) conditions when compared with the 0° condition. These findings support the notion that higher dorsiflexion angles in AFOs lead to increased toe clearance and LS, suggesting the effectiveness of dorsiflexion angle adjustments as a strategy to address reduced toe clearance.

Gait asymmetry in post-stroke patients is an important gait characteristic that is associated with their balance control, inefficiency, and risks of musculoskeletal injury to the non-paretic lower limb and falling. Unfortunately, most stroke patients retain an asymmetrical gait pattern, even though their gait independence and gait speed improve. We describe the clinical course of a subacute stroke patient who achieved a symmetrical gait at discharge after undergoing both gait training with orthoses and robot-assisted gait training from the early intervention phase. A Korean woman in her 50s developed a right frontal subcortical hemorrhage. She had severe left upper- and lower-extremity motor paralysis and was unable to walk independently. Her gait pattern was also observed to have a knee extension thrust pattern and a resulting asymmetric gait pattern. The gait interventions consisted of gait training with a knee-ankle-foot orthosis (KAFO) and an ankle-foot orthosis (AFO), in addition to robot-assisted gait training from the early onset. The control of the knee joint's movement was obtained by the attachment of the knee-ankle-foot robot to the paretic lower limb. Following these interventions, the patient was able to walk independently and had a symmetrical gait pattern at the time of discharge. The combination of robot-assisted gait training and gait training with orthoses for subacute stroke patients, as is widely used in general populations, may prevent the patients' mislearning of gait movements and contribute to the acquisition of a symmetrical gait pattern.

Background: There is a call for gathering more evidence on the effectiveness of telerehabilitation in stroke. In particular, a previous systematic review reported substantial variability in the types of technologies used in telerehabilitation interventions. The purpose of this study will be to summarize and synthesize findings on the effects of telerehabilitation based on real-time intervention between therapist and participants for patients with stroke. Methods and analysis: This systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. This systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on 25 May 2023 (registration number: CRD420234265527). Electronic searches will be performed in the following databases: MEDLINE, Pubmed, Web of Science, PsycINFO and CINAHL electronic databases, using a date range from inception to November 2023. We will include only randomized controlled trials for patients diagnosed with stroke who received telerehabilitation based on real-time interaction between therapist and patients. The exploration will be restricted to publications in the English language. Physical function, activities of daily living and quality of life are the outcomes. We will examine the changes of the outcomes at baseline, at the end of the intervention, and at specific time points during the follow-up after the intervention. Discussion: This systematic review will provide evidence regarding telerehabilitation for people with stroke.

Rationale: Corticospinal tract (CST) and corticoreticular pathway (CRP) injury patterns (i.e., the continuity of the nerve fibers) are associated with gait disturbance in post-stroke patients. In this case series study, we examined the case of 3 patients with different CST and CRP injury patterns and analyzed the characteristics of gait disturbance in each patient. Patient concerns: Patient 1 (P1) was a 73-year-old woman who presented with paralysis of the right upper and lower extremities due to a left lacunar infarction. Patient 2 (P2) was a 41-year-old man who presented with paralysis of the right upper and lower extremities due to a left putamen hemorrhage. Patient 3 (P3) was a 57-year-old man who presented with paralysis of the left upper and lower extremities due to a right putamen hemorrhage. Diagnosis: In P1, the CRP in the affected hemisphere was intact, but the CST was discontinuous. In P2, the CST in the affected hemisphere was intact, but the CRP was discontinuous. P3 was discontinuous in both CST and CRP in the affected hemisphere. Outcomes: Over time, all 3 patients improved to the level of gait independence, but they exhibited different gait patterns. Among them, P3 showed a markedly abnormal gait pattern that included spatiotemporal gait asymmetry, lateral shift of the trunk, and hip hiking. Lessons: This case series study demonstrated that even if both the CST and CRP were injured, gait recovered to some extent (i.e., independent level-ground gait), but the abnormal gait pattern might remain remarkable.

We report a case (a worker with low back pain) who was provided patient education and therapeutic exercise, and we performed a detailed kinematic analysis of his work-related activity over time. The subjects were one 28-year-old male worker with low back pain. In addition, to clearly identify impaired trunk movement during work-related activity in the low back pain subject, 20 age-matched healthy males (control group) were also included as a comparison subject. He received pain neurophysiology education and exercise instruction. We analyzed the subject’s trunk movement pattern during a lifting task examined by a three-dimensional–motion capture system. In addition, task-specific fear that occurred during the task was assessed by the numerical rating scale. The assessment was performed at the baseline phase (4 data points), the intervention phase (8 data points), and the follow-up phase (8 data points), and finally at 3 and 8 months after the follow-up phase. No intervention was performed in the control group; they underwent only one kinematic evaluation at baseline. As a result, compared to the control group, the low back pain subject had slower trunk movement velocity (peak trunk flexion velocity = 50.21 deg/s, extension velocity = −47.61 deg/s), and his upper-lower trunk segments indicated an in-phase motion pattern (mean absolute relative phase = 15.59 deg) at baseline. The interventions reduced his pain intensity, fear of movement, and low back pain–related disability; in addition, his trunk velocity was increased (peak trunk flexion velocity = 82.89 deg/s, extension velocity = −77.17 deg/s). However, the in-phase motion pattern of his trunk motor control remained unchanged (mean absolute relative phase = 16.00 deg). At 8 months after the end of the follow-up, the subject’s in-phase motion pattern remained (mean absolute relative phase = 13.34 deg) and his pain intensity had increased. This report suggests that if impaired trunk motor control remains unchanged after intervention, as in the course of the low back pain subject, it may eventually be related to a recurrence of low back pain symptoms.

Fujii R, Tamari M, Nonaka Y, Tamiya F, Hosokawa H, Tanaka S. Influence of gait exercise using a walkingassist robot for swing-leg motion in hemiplegic stroke patients: A preliminary study focusing on the immediate effect. Jpn J Compr Rehabil Sci 2022; 13: 49-55. Objective: We analyzed the effect of gait training using a walking-assist robot that assists a subject's knee joint movement and leg swing to achieve toe clearance of the paralyzed-side lower limb during treadmill walking. Methods: The subjects were 10 hemiplegic stroke patients in a rehabilitation ward. The intervention consisted of gait training using the Welwalk WW-1000 (Welwalk) robot for 40 min. Immediately before and after this intervention, a gait analysis of the patients' treadmill walking was performed by a three-dimensional motion capture system. Statistical analyses compared the foot-to-floor distance and the shortening of hip-toe length (SHTL) of the paralyzed side before and after the intervention, and examined the relationship between the change of lower-limb joint kinematics and toe clearance before and after the intervention. Results: The post-intervention SHTL was significantly lower compared to before the intervention, and there was a significant negative correlation between the change in the SHTL and the knee flexion angle from before to after the intervention. Conclusion: Gait exercise using the Welwalk could contribute to the acquisition of more normal leg-swing strategies.

Purpose: To identify impaired trunk movement during work-related activity in individuals with low back pain (LBP) and investigate whether abnormalities were caused by generalized fear of movement-related pain. Methods: This cross-sectional study was conducted at a hospital in Japan. We recruited 35 participants with LBP (LBP group; 26 males, 9 females) and 20 healthy controls (HC group) via posters at our hospital. The task required lifting an object. We used a 3D motion capture system to calculate the peak angular velocity of trunk flexion and extension during a lifting task. Pain-related factors for the LBP group were assessed using the visual analogue scale (VAS) for pain intensity over the past 4 weeks and during the task, the Tampa Scale for Kinesiophobia (TSK), the Pain Catastrophizing Scale (PCS), and the Pain Anxiety Symptoms Scale-20 (PASS-20). We compared kinematic variables between groups with a generalized linear mixed model and investigated the relationship between kinematic variables, VAS scores, and psychological factors by performing a mediation analysis. Results: The peak angular velocity of trunk extension showed significant main effects on the group factors (LBP group vs. HC group) and their interactions; the value of the kinematic variable was lower at Trial 1 in the LBP group. No LBP participant reported pain during the experiment. The mediation analysis revealed that the relationship between the VAS score for pain intensity over the past 4 weeks and the peak angular velocity of trunk extension in the first trial was completely mediated by the TSK (complete mediation model, 95% bootstrapped CI: 0.07–0.56). Conclusion: Individuals with LBP had reduced trunk extension during a lifting task. Generalized fear of movement-related pain may contribute to such impaired trunk movement. Our findings suggest that intervention to ameliorate fear of movement may be needed to improve LBP-associated disability.