Applying a pelvic corrective force induces forced use of the paretic leg and improves paretic leg EMG activities of individuals post-stroke during treadmill walking
Introduction
Walking dysfunction is one of the commonly reported physical limitations after stroke (Perry et al., 1995). Individuals with post-stroke hemiparesis typically demonstrate slow gait velocity, reduced stride and step length, and decreased period of stance and increased period of swing of the paretic leg (Balaban and Tok, 2014, Patterson et al., 2010a). As walking dysfunction can increase the risk of falls (Hausdorff et al., 2001), restrict functional mobility and negatively affect quality of life (Maclean et al., 2000, Perry et al., 1995, Schmid et al., 2007), an important goal of stroke rehabilitation is to improve symmetrical gait patterns.
The asymmetrical gait characteristics after stroke are associated with reduced weight bearing toward the paretic leg (Hendrickson et al., 2014, Olney and Richards, 1996, Tyson, 1999) and altered timing and amplitude of paretic leg muscle activation (Burridge et al., 2001, Hsu et al., 2003, Lamontagne et al., 2007). Reduced weight bearing toward the paretic leg may be a consequence of a “learned nonuse”, (Aruin et al., 2012) which can be reversed by forced use and intensive function training of the paretic leg (Schaechter, 2004, Taub et al., 2006).
Constraint induced movement therapy has been used to induce a forced use of the paretic arm in individuals with post-stroke hemiparesis (Taub et al., 2006, Wolf et al., 2008). This training paradigm has not been transferred to paretic leg because restraint of the non-paretic leg does not allow bipedal locomotion. Recent studies indicated that using a shoe insole under the non-paretic leg may promote body weight shift towards the paretic leg (Aruin et al., 2012, Mohapatra et al., 2012). However, the positive effects of shoe insole on walking function may be limited (Aruin et al., 2012), suggesting the shoe insole may not be effective in inducing forced use of the paretic leg during locomotion.
It has been reported that giving a downward force on the pelvis could induce a prolonged stance phase of gait in infants (Yang et al., 1998) and enhance soleus muscle activity in neurological intact adults (Stephens and Yang, 1999). Potentially, applying additional loading to the paretic leg during stance phase would enhance muscle activity of the paretic leg. Therefore, the purpose of this study was to determine whether applying a mediolateral corrective force to the pelvis during treadmill walking would facilitate weight shifting toward the paretic leg, and thereby enhance muscle activity of the paretic leg and improve gait symmetry in individuals with post-stroke hemiparesis. The pelvic corrective force was applied through a customized cable-driven robotic system (Wu et al., 2011). We hypothesized that the application of pelvic corrective force toward the paretic side during early stance phase of gait would facilitate weight shifting toward the paretic leg, enhance muscle activity of the paretic leg and improve gait symmetry in individuals with post-stroke hemiparesis.
Section snippets
Subjects
A total of 15 subjects with hemiparesis due to chronic stroke (>6 months) were recruited from the Sensory Motor Performance Program (SMPP) stroke database and the Rehabilitation Institute of Chicago (RIC) outpatient clinic. Demographic information for the subjects is shown in Table 1. The inclusion criteria were: (1) age 21–75 years, (2) unilateral, supratentorial, ischemic or hemorrhagic stroke confirmed with radiography, (3) no prior history of stroke, (4) independent ambulation with/without
Integrated EMG
The integral of the EMG activity is presented from 14 subjects. The EMG data from 1 subject could not be reliably analyzed due to artifact. Visual inspection of individual subject data indicated that there were no systematic changes in the timing of muscle activity (activation onset and duration) and thus only changes in amplitude of muscle activity are reported. Muscle activation patterns of each muscle for all sessions from a representative subject are shown in Fig. 3. There was typically
Discussion
The results of this study indicate that additional pelvic corrective force toward the paretic side during early stance phase of gait enhanced EMG activity of the paretic leg, particularly hip abductor, medial hamstrings, tibialis anterior, soleus, and rectus femoris muscles. The muscle activity improved progressively with increases in pelvic corrective force. In addition, pelvic corrective force improved the symmetry of pelvis displacement. Results from this study suggest that applying pelvis
Conclusions
This study applied the concept of forced use to the paretic leg during treadmill training and reported effects of this innovative approach on lower leg muscle activity, spatial-temporal characteristics of gait and pelvis lateral displacement. The results of this study demonstrated that providing corrective force at the pelvis could improve lower leg muscle activity and pelvis displacement symmetry. Additionally, higher pelvic corrective force appeared to result in greater magnitude of
Acknowledgements
This study was funded by the National Institutes of Health, R01HD082216.
Conflict of interest: No potential conflict of interest was reported by the authors.
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