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Positive effects of backward downhill treadmill training on spastic equinus gait
ESMAC Abstracts 2015 / Gait & Posture 42S (2015) S1–S101
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Session OS17 Feedback based Rehabilitation Positive effects of backward downhill treadmill training on spastic equinus gait M. Hösl ∗ , H. Böhm, J. Eck, L. Döderlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Aschau i.Chiemgau, Germany
Fig. 1. Hip, knee, and ankle moments and powers averaged over all children with CP for OG (cyan) and TM (red).
Materials and methods: 9 CP (11.6 ± 2.1 y, GMFCS I–II) and 11 TD children (10.6 ± 2.2 y) walked in random order (1) OG in a conventional gait lab; and (2) on a dual-belt instrumented TM (R-Mill, Forcelink) with virtual reality screen, in self-paced mode [2]. 3D motion data were collected using identical systems in both labs (Optotrak, Northern Digital Inc.). Joint moments and powers were calculated using ISB definitions [3] and averaged over 5 strides for each lab. Condition (OG/TM), group (TD/CP) and interaction effects were determined using an ANOVA for repeated measures. Results: Walking speed did not differ significantly between OG and TM. Peak hip extension moment was increased in TM by 35% (p < 0.001, Fig. 1). Peak ankle extension moments were decreased by 7% in TD but increased by 9% in CP (interaction p = 0.039). Total net hip work tended to increase in TM (p = 0.09), while total net ankle work decreased from net neutral to a net dissipation of −0.07 J/kg (p < 0.001). Hip and knee abduction moments were 35% increased in TM (p < 0.01). Discussion: Kinetics differed considerably between TM and OG walking. A shift was observed from ankle to hip work, indicating that subjects relied more heavily on a hip strategy in TM. Hip extension moments were considerably larger in TM, which seemed the result of a 3◦ more forward lean of the trunk on the TM, possibly due to looking more downward. Similar increases in hip moments in TM were found previously for TD children [4]. The increased ankle moments in CP are consistent with previously found increases in ankle dorsiflexion angles [1]. The results show that kinetic data collected on a TM cannot be readily compared with OG data. Since both OG and TM are highly controlled settings, the question which setting is most relevant and useful for clinical treatment decision and evaluations remains open. References [1] [2] [3] [4]
Research question: Is backward downhill treadmill training [BDTT] a more effective stimulus than static manual stretch for improving calf function in spastic cerebral palsy (CP)? Introduction: Manual stretching is popular in CP but if patients functionally benefit is subject to controversy [1]. Recently, combined cyclic stretch and strengthening with robotics showed pos. effects on equinus gait [2]. In this regard, BDTT may induce repetitive dynamic stretch to the eccentrically contracting calf [3]. Thereby active ankle stiffness and calf stretch sensitivity may be modulated. Materials and methods: 10 participants with CP and equinus (age: 12.0 SD 4.2 y, GMFCS I/II) were included in a randomized crossover-study. All were allocated to static calf stretch (7 exercises) and to progressive (increased slope & belt speed) BDTT for 9 weeks (3× per week), intersected by a 5 week wash-out (no therapy). Before and after therapy, 3DGA was performed at comfortable (CWS) and at ‘fastest’ speed (FWS). Ankle and knee kinematics were captured and Gastrocnemius (GAS) muscle-tendon velocities calculated during swing as marker of dynamic spasticity [4]. Ankle stiffness was calculated as slope of PF moment-angle relationships. In addition, Timed Up and Go (TUG) and GMFM tests were done. Results: While CWS was not altered, FWS increased only with BDTT (Fig. 1). After stretching, ankle joint stiffness at CWS deteriorated. In contrast, after BDTT GAS lengthening velocities during swing phase were increased. Positive effects on GAS velocities were even more pronounced at FWS. Dorsiflexion and knee extension during stance or swing did however not show sign. changes with BDTT or stretching, at CWS or FWS. Still, GMFM Scores (Dim. D&E) and TUG time improved only after BDTT. Discussion: BDTT improved gait in particular at FWS while manual static stretch was ineffective. BDTT likely provides stretch and muscle contraction simultaneously [3]. Higher GAS lengthening velocities may indicate that after BDTT spastic stretch reflex thresholds went down and so faster walking speeds can be reached [4]. Walking down, or up inclines [5], seems to have pos. neuromuscular effects. BDTT also transfers to better ambulatory mobility
van der Krogt MM, et al. Gait Posture 2014;40(4):587–93. Sloot LH, et al. Gait Posture 2014;39(1):478–84. Cappozzo A, et al. Clin Biomech 1995;10(4):171–8. Rozumalski A, et al.ESMAC-SIAMOC. 2014.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.155
Fig. 1. Results of 3DGA at fastest (FWS) and comfortable walking speed (CWS), as well as tests of functional ambulatory mobility.
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ESMAC Abstracts 2015 / Gait & Posture 42S (2015) S1–S101
and can be easily done in practice. It needs to be shown if muscle morphometrics respond since eccentric training can promote growth of fascicles, too [6]. References [1] [2] [3] [4] [5] [6]
Novak. Dev Med Child Neurol 2013;55:885–910. Sukal-Moulton. Arch Phys Med Rehabil 2014;95:1433–40. Hoffman. J Appl Physiol 2014;116:1455–62. Bar-On. Res Dev Disabil 2014;35:3354–64. Willerslev-Olsen. NeuroRehab 2014;35:643–55. Butterfield. J Appl Physiol 2006;100:1489–98.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.156
Fig. 1. Study design.
Session OS17 Feedback based Rehabilitation An Anti-Gravity Treadmill following fractures of the foot or ankle: Does its use enhance gait rehabilitation?
these positive adaptions cannot be transferred to walking with full bodyweight. The gait of AG was even less physiological than the gait of SG, which trained with full bodyweight. Normal stress and pain perceptions seem to be required when relearning a physiological gait pattern. References
L. Niklaus ∗ , J.S. Lange, T.L. Milani Technische Universität Chemnitz, Chemnitz, Germany Research question: An Anti-Gravity Treadmill following fractures of the foot or ankle: does its use enhance gait rehabilitation? Introduction: The rehabilitation of foot and ankle fractures commonly requires partial body weight unloading to prevent the development of gait pathomechanisms. Previous methods of unloading, e.g. harness systems or walking in water, have been shown to alter kinetics, kinematics and muscle activity patterns of normal gait [1,2]. The Anti-Gravity Treadmill (AGT) pretends to maintain normal gait and to enhance rehabilitation [3]. So far there is no evidence whether an AGT is superior to a standard treadmill (ST) concerning gait rehabilitation. Therefore, this study compared the short-term recovery outcome after four weeks of additional gait training utilizing either an AGT or an ST. Materials and methods: 18 patients with fractures of the foot or ankle participated in the study. They were randomly assigned to either the AGT (AG) or the ST group (SG). Furthermore, a similar cohort of unaffected controls matched in age and anthropometrical data was recruited (CG; n = 17). AG and ST trained daily for four weeks on the assigned treadmill. Gait was evaluated weekly using plantar pressure measurement (zebris FDM 1.5; Fig. 1). Spatiotemporal gait parameters and sensation of pain were analysed. Results: Neither gait nor pain differed in the baseline test between AG and SG (p = 0.091). Almost all parameters improved after the four-week gait training in both groups, although SG attained better results (Table 1). After the intervention the gait parameters of SG were similar to those of the healthy controls. The gait of AG remained inferior. Discussion: Bodyweight unloading using an AGT lead subjectively to an almost physiological gait that was perceived as comfortable and free of pain. Considering the results of this study,
[1] Van Hedel, et al. Gait Posture 2006;24:35–45. [2] Colby, et al. Gait Posture 1999;10:200–5. [3] alterg.com.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.157
Session OS17 Feedback based Rehabilitation A 6-week unsupervised home-based exergaming training program to improve balance of older adults C. Lamoth 1,∗ , M. van Diest 2 , J. Stegenga 3 , B. Verkerke 4 , K. Postema 4 1
University of Groningen, University Medical Centre Groningen, Groningen, Netherlands 2 INCAS, University of Groningen, University Medical Center Groningen, Groningen, Netherlands 3 INCAS3, Assen, Netherlands 4 Center for Rehabilitation, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands Research question: Does balance of older adults improve after a 6-week unsupervised home-based exergaming training program? Introduction: Over the last decade, exercise videogames (exergames) have gained in popularity as a tool for improving balance ability [1–3]. Exergames are computer games that are controlled through bodily movements. We recently developed an exergame, enabling community dwelling older adults to train balance in their home environment without supervision and using affordable technology.
Table 1 Comparison of gait parameter at different measurement times and between the groups. Gait parameter
AG: pre–post
SG: pre–post
AG–SG
AG–CG
SG–CG
Velocity Stride length Difference step length Difference stance duration Duration double support Perceived pain
↑ ↑* from M4 ↓* from M5 ↓* from M3 ↓ ↓* from M4
↑* ↓* ↓* ↓* ↓ ↓*
AG < SG* from M2 = all M = all M = all M = all M AG > CG* all M
AG < CG* all M AG < CG* all M AG > CG* all M AG > CG* all M AG > CG* all M SG > CG* all M
= from M5 = from M2 SG > CG* all M = from M4 SG > CG* all M SG > CG* all M
from M2 from M2 from M2 from M4 from Mc
M, measurement; ↑, enhancement; ↓, worsening; <, smaller; >, bigger; =, same. * Statically significant (p > 0.05).
S85
Session OS17 Feedback based Rehabilitation Positive effects of backward downhill treadmill training on spastic equinus gait M. Hösl ∗ , H. Böhm, J. Eck, L. Döderlein Orthopaedic Hospital for Children, Behandlungszentrum Aschau GmbH, Aschau i.Chiemgau, Germany
Fig. 1. Hip, knee, and ankle moments and powers averaged over all children with CP for OG (cyan) and TM (red).
Materials and methods: 9 CP (11.6 ± 2.1 y, GMFCS I–II) and 11 TD children (10.6 ± 2.2 y) walked in random order (1) OG in a conventional gait lab; and (2) on a dual-belt instrumented TM (R-Mill, Forcelink) with virtual reality screen, in self-paced mode [2]. 3D motion data were collected using identical systems in both labs (Optotrak, Northern Digital Inc.). Joint moments and powers were calculated using ISB definitions [3] and averaged over 5 strides for each lab. Condition (OG/TM), group (TD/CP) and interaction effects were determined using an ANOVA for repeated measures. Results: Walking speed did not differ significantly between OG and TM. Peak hip extension moment was increased in TM by 35% (p < 0.001, Fig. 1). Peak ankle extension moments were decreased by 7% in TD but increased by 9% in CP (interaction p = 0.039). Total net hip work tended to increase in TM (p = 0.09), while total net ankle work decreased from net neutral to a net dissipation of −0.07 J/kg (p < 0.001). Hip and knee abduction moments were 35% increased in TM (p < 0.01). Discussion: Kinetics differed considerably between TM and OG walking. A shift was observed from ankle to hip work, indicating that subjects relied more heavily on a hip strategy in TM. Hip extension moments were considerably larger in TM, which seemed the result of a 3◦ more forward lean of the trunk on the TM, possibly due to looking more downward. Similar increases in hip moments in TM were found previously for TD children [4]. The increased ankle moments in CP are consistent with previously found increases in ankle dorsiflexion angles [1]. The results show that kinetic data collected on a TM cannot be readily compared with OG data. Since both OG and TM are highly controlled settings, the question which setting is most relevant and useful for clinical treatment decision and evaluations remains open. References [1] [2] [3] [4]
Research question: Is backward downhill treadmill training [BDTT] a more effective stimulus than static manual stretch for improving calf function in spastic cerebral palsy (CP)? Introduction: Manual stretching is popular in CP but if patients functionally benefit is subject to controversy [1]. Recently, combined cyclic stretch and strengthening with robotics showed pos. effects on equinus gait [2]. In this regard, BDTT may induce repetitive dynamic stretch to the eccentrically contracting calf [3]. Thereby active ankle stiffness and calf stretch sensitivity may be modulated. Materials and methods: 10 participants with CP and equinus (age: 12.0 SD 4.2 y, GMFCS I/II) were included in a randomized crossover-study. All were allocated to static calf stretch (7 exercises) and to progressive (increased slope & belt speed) BDTT for 9 weeks (3× per week), intersected by a 5 week wash-out (no therapy). Before and after therapy, 3DGA was performed at comfortable (CWS) and at ‘fastest’ speed (FWS). Ankle and knee kinematics were captured and Gastrocnemius (GAS) muscle-tendon velocities calculated during swing as marker of dynamic spasticity [4]. Ankle stiffness was calculated as slope of PF moment-angle relationships. In addition, Timed Up and Go (TUG) and GMFM tests were done. Results: While CWS was not altered, FWS increased only with BDTT (Fig. 1). After stretching, ankle joint stiffness at CWS deteriorated. In contrast, after BDTT GAS lengthening velocities during swing phase were increased. Positive effects on GAS velocities were even more pronounced at FWS. Dorsiflexion and knee extension during stance or swing did however not show sign. changes with BDTT or stretching, at CWS or FWS. Still, GMFM Scores (Dim. D&E) and TUG time improved only after BDTT. Discussion: BDTT improved gait in particular at FWS while manual static stretch was ineffective. BDTT likely provides stretch and muscle contraction simultaneously [3]. Higher GAS lengthening velocities may indicate that after BDTT spastic stretch reflex thresholds went down and so faster walking speeds can be reached [4]. Walking down, or up inclines [5], seems to have pos. neuromuscular effects. BDTT also transfers to better ambulatory mobility
van der Krogt MM, et al. Gait Posture 2014;40(4):587–93. Sloot LH, et al. Gait Posture 2014;39(1):478–84. Cappozzo A, et al. Clin Biomech 1995;10(4):171–8. Rozumalski A, et al.ESMAC-SIAMOC. 2014.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.155
Fig. 1. Results of 3DGA at fastest (FWS) and comfortable walking speed (CWS), as well as tests of functional ambulatory mobility.
S86
ESMAC Abstracts 2015 / Gait & Posture 42S (2015) S1–S101
and can be easily done in practice. It needs to be shown if muscle morphometrics respond since eccentric training can promote growth of fascicles, too [6]. References [1] [2] [3] [4] [5] [6]
Novak. Dev Med Child Neurol 2013;55:885–910. Sukal-Moulton. Arch Phys Med Rehabil 2014;95:1433–40. Hoffman. J Appl Physiol 2014;116:1455–62. Bar-On. Res Dev Disabil 2014;35:3354–64. Willerslev-Olsen. NeuroRehab 2014;35:643–55. Butterfield. J Appl Physiol 2006;100:1489–98.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.156
Fig. 1. Study design.
Session OS17 Feedback based Rehabilitation An Anti-Gravity Treadmill following fractures of the foot or ankle: Does its use enhance gait rehabilitation?
these positive adaptions cannot be transferred to walking with full bodyweight. The gait of AG was even less physiological than the gait of SG, which trained with full bodyweight. Normal stress and pain perceptions seem to be required when relearning a physiological gait pattern. References
L. Niklaus ∗ , J.S. Lange, T.L. Milani Technische Universität Chemnitz, Chemnitz, Germany Research question: An Anti-Gravity Treadmill following fractures of the foot or ankle: does its use enhance gait rehabilitation? Introduction: The rehabilitation of foot and ankle fractures commonly requires partial body weight unloading to prevent the development of gait pathomechanisms. Previous methods of unloading, e.g. harness systems or walking in water, have been shown to alter kinetics, kinematics and muscle activity patterns of normal gait [1,2]. The Anti-Gravity Treadmill (AGT) pretends to maintain normal gait and to enhance rehabilitation [3]. So far there is no evidence whether an AGT is superior to a standard treadmill (ST) concerning gait rehabilitation. Therefore, this study compared the short-term recovery outcome after four weeks of additional gait training utilizing either an AGT or an ST. Materials and methods: 18 patients with fractures of the foot or ankle participated in the study. They were randomly assigned to either the AGT (AG) or the ST group (SG). Furthermore, a similar cohort of unaffected controls matched in age and anthropometrical data was recruited (CG; n = 17). AG and ST trained daily for four weeks on the assigned treadmill. Gait was evaluated weekly using plantar pressure measurement (zebris FDM 1.5; Fig. 1). Spatiotemporal gait parameters and sensation of pain were analysed. Results: Neither gait nor pain differed in the baseline test between AG and SG (p = 0.091). Almost all parameters improved after the four-week gait training in both groups, although SG attained better results (Table 1). After the intervention the gait parameters of SG were similar to those of the healthy controls. The gait of AG remained inferior. Discussion: Bodyweight unloading using an AGT lead subjectively to an almost physiological gait that was perceived as comfortable and free of pain. Considering the results of this study,
[1] Van Hedel, et al. Gait Posture 2006;24:35–45. [2] Colby, et al. Gait Posture 1999;10:200–5. [3] alterg.com.
http://dx.doi.org/10.1016/j.gaitpost.2015.06.157
Session OS17 Feedback based Rehabilitation A 6-week unsupervised home-based exergaming training program to improve balance of older adults C. Lamoth 1,∗ , M. van Diest 2 , J. Stegenga 3 , B. Verkerke 4 , K. Postema 4 1
University of Groningen, University Medical Centre Groningen, Groningen, Netherlands 2 INCAS, University of Groningen, University Medical Center Groningen, Groningen, Netherlands 3 INCAS3, Assen, Netherlands 4 Center for Rehabilitation, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands Research question: Does balance of older adults improve after a 6-week unsupervised home-based exergaming training program? Introduction: Over the last decade, exercise videogames (exergames) have gained in popularity as a tool for improving balance ability [1–3]. Exergames are computer games that are controlled through bodily movements. We recently developed an exergame, enabling community dwelling older adults to train balance in their home environment without supervision and using affordable technology.
Table 1 Comparison of gait parameter at different measurement times and between the groups. Gait parameter
AG: pre–post
SG: pre–post
AG–SG
AG–CG
SG–CG
Velocity Stride length Difference step length Difference stance duration Duration double support Perceived pain
↑ ↑* from M4 ↓* from M5 ↓* from M3 ↓ ↓* from M4
↑* ↓* ↓* ↓* ↓ ↓*
AG < SG* from M2 = all M = all M = all M = all M AG > CG* all M
AG < CG* all M AG < CG* all M AG > CG* all M AG > CG* all M AG > CG* all M SG > CG* all M
= from M5 = from M2 SG > CG* all M = from M4 SG > CG* all M SG > CG* all M
from M2 from M2 from M2 from M4 from Mc
M, measurement; ↑, enhancement; ↓, worsening; <, smaller; >, bigger; =, same. * Statically significant (p > 0.05).