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Real-Time Visual Kinematic Feedback During Overground Walking Improves Gait Biomechanics in Individuals Post-Stroke

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Abstract

Treadmill-based gait rehabilitation protocols have shown that real-time visual biofeedback can promote learning of improved gait biomechanics, but previous feedback work has largely involved treadmill walking and not overground gait. The objective of this study was to determine the short-term response to hip extension visual biofeedback, with individuals post-stroke, during unconstrained overground walking. Individuals post-stroke typically have a decreased paretic propulsion and walking speed, but increasing hip extension angle may enable the paretic leg to better translate force anteriorly during push-off. Fourteen individuals post-stroke completed overground walking, one 6-min control bout without feedback, and three 6-min training bouts with real-time feedback. Data were recorded before and after the control bout, before and after the first training bout, and after the third training bout to assess the effects of training. Visual biofeedback consisted of a display attached to eyeglasses that showed one horizontal bar indicating the user’s current hip angle and another symbolizing the target hip extension to be reached during training. On average, paretic hip extension angle (p = 0.014), trailing limb angle (p = 0.025), and propulsion (p = 0.011) were significantly higher after training. Walking speed increased but was not significantly higher after training (p = 0.089). Individuals demonstrated a greater increase in their hip extension angle (p = 0.035) and propulsion (p = 0.030) after the walking bout with feedback compared to the control bout, but changes in walking speed did not significantly differ (p = 0.583) between a control walking bout and a feedback bout. Our results show the feasibility of overground visual gait feedback and suggest that feedback regarding paretic hip extension angle enabled many individuals post-stroke to improve parameters important for their walking function.

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Abbreviations

TLA:

Trailing limb angle

COP:

Center of pressure

COM:

Center of mass

GRF:

Ground reaction force

MDC:

Minimal detectable change

References

  1. Alingh, J. F., B. E. Groen, E. H. F. F. V. Asseldonk, A. C. H. H. Geurts, and V. Weerdesteyn. Effectiveness of rehabilitation interventions to improve paretic propulsion in individuals with stroke—a systematic review. Clin. Biomech. 71:176–188, 2020.

    Article  CAS  Google Scholar 

  2. Bowden, M. G., C. K. Balasubramanian, R. R. Neptune, and S. A. Kautz. Anterior-posterior ground reaction forces as a measure of paretic leg contribution in hemiparetic walking. Stroke. 37:872–876, 2006.

    Article  PubMed  Google Scholar 

  3. Bowman, T., E. Gervasoni, C. Arienti, S. G. Lazzerini, S. Negrini, S. Crea, D. Cattaneo, and M. C. Carrozza. Wearable devices for biofeedback rehabilitation: a systematic review and meta-analysis to design application rules and estimate the effectiveness on balance and gait outcomes in neurological diseases. Sensors. 21:3444, 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Chen, G., C. Patten, D. H. Kothari, and F. E. Zajac. Gait differences between individuals with post-stroke hemiparesis and non-disabled controls at matched speeds. Gait Posture. 22:51–56, 2005.

    Article  PubMed  Google Scholar 

  5. Genthe, K., C. Schenck, S. Eicholtz, L. Zajac-cox, S. Wolf, and T. M. Kesar. Effects of real-time gait biofeedback on paretic propulsion and gait biomechanics in individuals post-stroke. Top. Stroke Rehabil. 25:186–193, 2018.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Go, A. S., D. Mozaffarian, V. L. Roger, E. J. Benjamin, J. D. Berry, M. J. Blaha, S. Dai, E. S. Ford, C. Gillespie, S. M. Hailpern, J. A. Heit, J. Virginia, S. J. Kittner, D. T. Lackland, D. J. Magid, G. M. Marcus, and A. Marelli. Heart disease and stroke statistics 2014 update. Circulation. 129:e28–e292, 2014.

    PubMed  Google Scholar 

  7. Hedrick, E. A., S. M. Parker, H. Hsiao, and B. A. Knarr. Mechanisms used to increase propulsive forces on a treadmill in older adults. J. Biomech. 115:110139, 2021.

    Article  PubMed  Google Scholar 

  8. Hsiao, H., B. A. Knarr, R. T. Pohlig, J. S. Higginson, and S. A. Binder-Macleod. Mechanisms used to increase peak propulsive force following 12-weeks of gait training in individuals poststroke. J. Biomech. 49:388–395, 2016.

    Article  PubMed  Google Scholar 

  9. Kim, J.-S., and D.-W. Oh. Use of real-time visual feedback during overground walking training on gait symmetry and velocity in patients with post-stroke hemiparesis. Int. J. Rehabil. Res. 43:247–254, 2020.

    Article  PubMed  Google Scholar 

  10. Lang, C. E., C. L. Holleran, M. J. Strube, T. D. Ellis, C. A. Newman, M. Fahey, T. R. DeAngelis, T. J. Nordahl, D. S. Reisman, G. M. Earhart, K. R. Lohse, and M. D. Bland. Improvement in the capacity for activity versus improvement in performance of activity in daily life during outpatient rehabilitation. J. Neurol. Phys. Therapy. 47:16–25, 2023.

    Article  Google Scholar 

  11. Lewek, M. D., C. Raiti, and A. Doty. The presence of a paretic propulsion reserve during gait in individuals following stroke. Neurorehabil. Neural Repair. 32:1011–1019, 2018.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Lewek, M. D., and R. Sykes. Minimal detectable change for gait speed depends on baseline speed in individuals with chronic stroke. J. Neurol. Phys. Therapy. 43:122–127, 2019.

    Article  Google Scholar 

  13. Liu, J., H. B. Kim, S. L. Wolf, and T. M. Kesar. Comparison of the immediate effects of audio, visual, or audiovisual gait biofeedback on propulsive force generation in able-bodied and post-stroke individuals. Appl. Psychophysiol. Biofeedback. 45:211–220, 2020.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Liu, J., V. Santucci, S. Eicholtz, and T. M. Kesar. Comparison of the effects of real-time propulsive force versus limb angle gait biofeedback on gait biomechanics. Gait Posture. 83:107–113, 2021.

    Article  PubMed  Google Scholar 

  15. Middleton, A., S. L. Fritz, and M. Lusardi. Walking speed: the functional vital sign. J. Aging Phys. Act. 23:314–322, 2015.

    Article  PubMed  Google Scholar 

  16. Miller, A., R. T. Pohlig, and D. S. Reisman. Relationships among environmental variables, physical capacity, balance self-efficacy, and real-world walking activity post-stroke. Neurorehabil. Neural Repair. 36:535–544, 2022.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Olney, S. J., and C. Richards. Hemiparetic gait following stroke. Part I: Characteristics. Gait Posture. 4:136–148, 1996.

    Article  Google Scholar 

  18. Ovbiagele, B., and M. N. Nguyen-Huynh. Stroke epidemiology: advancing our understanding of disease mechanism and therapy. Neurotherapeutics. 8:319–329, 2011.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Peterson, C. L., J. Cheng, S. A. Kautz, and R. R. Neptune. Leg extension is an important predictor of paretic leg propulsion in hemiparetic walking. Gait Posture. 32:451–456, 2010.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Silva, M. R. E., and J. Jacinto. Velocity determinants in spastic patients after stroke—a gait analysis study. Neurol. Int. 12:48–54, 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Spencer, J., S. L. Wolf, and T. M. Kesar. Biofeedback for post-stroke gait retraining: a review of current evidence and future research directions in the context of emerging technologies. Front. Neurol. 2021. https://doi.org/10.3389/fneur.2021.637199.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Tyrell, C. M., M. A. Roos, K. S. Rudolph, and D. S. Reisman. Influence of systematic increases in treadmill walking speed on gait kinematics after stroke. Phys. Therapy. 91:392–403, 2011.

    Article  Google Scholar 

  23. Vaz, J. R., B. R. Groff, D. A. Rowen, B. A. Knarr, and N. Stergiou. Synchronization dynamics modulates stride-to-stride fluctuations when walking to an invariant but not to a fractal-like stimulus. Neurosci. Lett. 704:28–35, 2019.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Vaz, J. R., B. A. Knarr, and N. Stergiou. Gait complexity is acutely restored in older adults when walking to a fractal-like visual stimulus. Hum. Mov. Sci. 74:102677, 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Vestling, M., B. Tufvesson, and S. Iwarsson. Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. J. Rehabil. Med. 35:127–131, 2003.

    Article  PubMed  Google Scholar 

  26. Winstein, C. J., and R. A. Schmidt. Reduced frequency of knowledge of results enhances motor skill learning. J. Exp. Psychol.: Learn. Mem. Cognit. 16:677–691, 1990.

    Google Scholar 

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Acknowledgements

This study was supported by the Center of Research in Human Movement Variability of the University of Nebraska at Omaha and the National Institutes of Health (P20GM109090 [NS and BK supported by this], U54 GM115458 [BK], R15 HD094194 [BK]).

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Authors and Affiliations

  1. University of Nebraska at Omaha, Omaha, NE, USA

    Erica H. Hinton, Russell Buffum, David Kingston, Nick Stergiou & Brian A. Knarr

  2. Emory University, Atlanta, GA, USA

    Trisha Kesar

  3. University of Nebraska Medical Center, Omaha, NE, USA

    Samuel Bierner

  4. Aristotle University, Thessaloníki, Greece

    Nick Stergiou

Authors
  1. Erica H. Hinton
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  2. Russell Buffum
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  3. David Kingston
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  7. Brian A. Knarr
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Correspondence to Erica H. Hinton.

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Associate Editor Thurmon E. Lockhart oversaw the review of this article.

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Hinton, E.H., Buffum, R., Kingston, D. et al. Real-Time Visual Kinematic Feedback During Overground Walking Improves Gait Biomechanics in Individuals Post-Stroke. Ann Biomed Eng 52, 355–363 (2024). https://doi.org/10.1007/s10439-023-03381-0

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