Effects of the addition of functional electrical stimulation to ground level gait training with body weight support after chronic stroke

ISSN 1413-3555 Rev Bras Fisioter, São Carlos, v. 15, n. 6, p. 436-44, Nov./Dec. 2011 © Revista Brasileira de Fisioterapia Original Article Effects of the addition of functional electrical stimulation to ground level gait training with body weight support after chronic stroke Efeitos da adição da estimulação elétrica funcional ao treino de marcha em piso fixo com suporte parcial de peso após acidente vascular encefálico crônico Christiane L. Prado-Medeiros1, Catarina O. Sousa1, Andréa S. Souza1, Márcio R. Soares1, Ana M. F. Barela2, Tania F. Salvini1 Abstract Background: The addition of functional electrical stimulation (FES) to treadmill gait training with partial body weight support (BWS) has been proposed as a strategy to facilitate gait training in people with hemiparesis. However, there is a lack of studies that evaluate the effectiveness of FES addition on ground level gait training with BWS, which is the most common locomotion surface. Objective: To investigate the additional effects of commum peroneal nerve FES combined with gait training and BWS on ground level, on spatialtemporal gait parameters, segmental angles, and motor function. Methods: Twelve people with chronic hemiparesis participated in the study. An A1-B-A2 design was applied. A1 and A2 corresponded to ground level gait training using BWS, and B corresponded to the same training with the addition of FES. The assessments were performed using the Modified Ashworth Scale (MAS), Functional Ambulation Category (FAC), Rivermead Motor Assessment (RMA), and filming. The kinematics analyzed variables were mean walking speed of locomotion; step length; stride length, speed and duration; initial and final double support duration; single-limb support duration; swing period; range of motion (ROM), maximum and minimum angles of foot, leg, thigh, and trunk segments. Results: There were not changes between phases for the functional assessment of RMA, for the spatial-temporal gait variables and segmental angles, no changes were observed after the addition of FES. Conclusion: The use of FES on ground level gait training with BWS did not provide additional benefits for all assessed parameters. Article registered in the ClinicalTrials.gov under the number NCT 01106755. Keywords: stroke; physical therapy; rehabilitation; intervention; kinematics. Resumo Contextualização: A adição da estimulação elétrica funcional (EEF) ao treino de marcha em esteira, com sistema de suporte parcial de peso corporal (SPPC), tem sido proposta como estratégia para melhorar a marcha em hemiparéticos. Entretanto, nenhum estudo verificou a eficácia da adição da EEF ao treino de marcha com SPPC em piso fixo, a superfície mais habitual de locomoção. Objetivo: Investigar os efeitos da adição da EEF do nervo fibular comum, ao treino de marcha com SSPC, em piso fixo, sobre os parâmetros espaço-temporais da marcha, ângulos segmentares e função motora. Métodos: Participaram do estudo 12 hemiparéticos crônicos. O sistema adotado foi o A1-B-A2. A1 e A2 corresponderam ao treino em piso fixo com SPPC, e B, ao mesmo treino, associado à EEF. As avaliações foram realizadas por meio da Escala de Ashworth Modificada (EAM), da Categoria de Deambulação Funcional (CDF), da Avaliação Motora de Rivermead (AMR) e de filmagens. As variáveis cinemáticas analisadas foram: velocidade média de locomoção; comprimento do passo; comprimento, velocidade e duração da passada; duração dos períodos de apoio duplo inicial e final, apoio simples e balanço; ângulos máximos e mínimos e amplitude de movimento (ADM) dos segmentos pé, perna, coxa e tronco. Resultados: Na AMR, não houve alterações entre as fases. Para as variáveis espaço-temporais e ângulos segmentares, não houve nenhuma alteração após a adição da EEF. Conclusão: A adição da EEF ao treino de marcha em piso fixo com SPPC não promoveu melhora adicional nos parâmetros mensurados. Artigo registrado no ClinicalTrials.gov sob o número NCT 01106755. Palavras-chave: acidente vascular encefálico; fisioterapia; reabilitação; intervenção; cinemática. Received: 01/20/2011 – Revised: 05/11/2011 – Accepted: 08/01/2011 1 Physical Therapy Department, Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil 2 Institute of Physical Activity and Sport Science, Universidade Cruzeiro do Sul, São Paulo, SP, Brazil Correspondence to: Christiane Lanatovitz Prado Medeiros, Laboratório de Plasticidade Muscular, Departamento de Fisioterapia, Universidade Federal de São Carlos, Rodovia Washington Luis, km 235, CEP: 13565-905, São Carlos, SP, Brasil, e-mail: 436 Rev Bras Fisioter. 2011;15(6):436-44. Gait training and functional electrical stimulation in hemiparesis Introduction Stroke is a global public health problem1,2. Stroke patients present difficulties in performing functional tasks, which impairs their independence on daily activities. Among those tasks, gait is the most impaired one. For that reason, the major goal in a post-stroke rehabilitation program is the walking ability recovery3. The use of a harness attached to a body weight support (BWS) has been used to assist gait training. BWS has been combined with a treadmill, which stimulates rhythmic and repetitive steps in attempt to provide symmetry between limbs and spatial-temporal gait improvements4-7. BWS supports a percentage of body weight, allowing patients to endure the rest of their weight easily; therefore, knee collapse or excessive hip flexion during the affected single-limb stance are avoided4,6. BWS also provides better balance control, and reduces the risk of falls8. Recently, the BWS on a treadmill has also been used combined with functional electrical stimulation (FES), showing gait improvements9-13. The first FES system was implemented by Liberson et al.14 to promote the drop foot correction. Electrical signs activate peripheral nerves and control voluntary movements. This technique makes use of afferent feedback during muscle contraction, a process in which the patient’s help may maximize motor relearning during active training of repeated movements15,16. Thus, the FES of the common peroneal nerve would be able to favor dorsiflexion and eversion movements of the paretic ankle. In a recent study, Lindquist et al.13 evaluated gait training on a treadmill combining BWS and FES of the common peroneal nerve in people following stroke. This study presented advantages in using that combination as improvements in motor skills, in spatial-temporal variables (stride duration, stance phase, cadence and gait symmetry), and the patients’ preference due to the facilitation of the affected foot placement during walking. However, the type of training surfaces used by patients is crucial, and this consideration may facilitate skills to be transfered into daily life activities10,17. Ground level is the most common locomotion surface and there are differences in several aspects between walking on treadmill and on ground level18. For example, the requirements (...truncated)