COMPENSATORY GAIT MOVEMENTS POST STROKE: [PDF]

flexion, hip flexion, and ankle dorsiflexion) compromise toe clearance during swing. Compensatory frontal plane movement

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COMPENSATORY GAIT MOVEMENTS POST STROKE: THE INFLUENCE OF SYNERGIES Theresa Hayes Cruz, MS 1,2, Yasin Dhaher, PhD 1,2 1 Northwestern University, 2Rehabilitation Institute of Chicago, Chicago, IL, USA E-mail: [email protected] Web: www.ric.org/smpp INTRODUCTION Although most patients regain the ability to walk after stroke, several sagittal plane impairments (i.e. reduced paretic knee flexion, hip flexion, and ankle dorsiflexion) compromise toe clearance during swing. Compensatory frontal plane movements, including circumduction and hip hiking, may be employed to facilitate toe clearance (Perry 1992; Kerrigan, Frates et al. 2000). Despite the recovery of walking, persistent gait disorders are linked to increased energy expenditure (Olney and Richards 1996; Chen, Patten et al. 2005), which can negatively impact endurance and rehabilitation. Given this clinical significance, the goal of this study is to quantify the differential effects of sagittal and frontal plane joint strength measures on compensatory kinematics. Additionally, the frontal and sagittal plane deviations in gait kinematics suggest that abnormal multi-joint synergistic torque coupling previously observed in the lower limbs of stroke subjects may contribute to overground gait behaviors (Cruz and Dhaher 2008). We hypothesize that paretic hip sagittal plane weakness and abnormal acrossjoint coupling will relate to gait deviations. Delineating the effects of these impairments may improve future rehabilitation therapies. METHODS Eighteen stroke subjects (>12 months post monohemispheric CVA) and eight agematched controls were tested. Data collection consisted of two parts: gait analysis and isometric strength measures. Overground gait analysis was performed using standard

procedures and equipment (Cleveland Clinic marker set and an eight camera Motion Analysis Corp, data sampled at 120 Hz). Subjects walked with comfortable shoes on a 10m walkway at a self-selected walking speed for a minimum of five trials. Stroke subjects were tested without ankle-foot-orthoses (AFOs) and canes when possible. Given that walking is a dynamic task influenced by many factors, the rates of change of compensatory movements at the initiation of the swing phase were selected as outcome measures. Specifically, the deviations from the normal rate of change of hip abduction/adduction angle and hip pelvic obliquity angle at toeoff were used. For the isometric data collection, stroke subjects’ lower limbs were secured in an instrumented exoskeleton locked in the standing toeoff posture (Cruz and Dhaher 2008). Subjects were instructed to produce maximum hip frontal and sagittal plane torque and hold for 200ms, while receiving real-time visual feedback. Subjects were unaware that knee flexion/ extension torque measurements were recorded simultaneously, providing a measure of across joint coupling. Paretic knee and ankle sagittal plane strength was measured using a Biodex® chair. To determine which strength measures were related to compensatory kinematics, multiple linear regression models were used as follows: ∆ = βiαi + ε, where ∆ is the deviation in the rate of change of the kinematic variable, βi are the coefficients for the αi variables and ε is the error.

RESULTS AND DISCUSSION

SUMMARY/CONCLUSIONS

The groups significantly differed in pelvic joint angle at toeoff (p = 0.005, see Figure 1), but not in frontal plane angle (p = 0.44). The stepwise regression procedure found four of the ten variables to be related to the deviation from normal in the rate of change of pelvic obliquity angle at toeoff in the stroke group, including hip flexion and extension strength, knee flexion strength, and abnormal hip adduction\knee extension hip\knee coupling. As expected, the regression model revealed that abnormal coupling resulted in increased deviations from normal, while increases in paretic hip extension and flexion, and paretic knee flexion strength reduced the deviations from normal, see Table 1. The regression algorithms were unable to find a relationship between the strength variables and the deviation from normal in the rate of change of hip frontal plane angle at toeoff. These findings reveal that proximal joint sagittal plane strength measures are the most important factors when determining abnormal pelvic frontal plane compensatory kinematics.

This study suggests that given the relationships among abnormal across joint coupling, single joint strength, and gait kinematics, task specific training may improve the quality of gait following stroke. The subsequent reduction of compensatory movements is anticipated to lessen energetic costs and improve rehabilitation potential. These findings also support the hypothesis that pelvic movement is a major compensatory strategy post stroke.

α4 Control Stroke

α1

Pelvic Obliquity

Degrees Up (+) / Down (-)

8

α3

Control Stroke

6

α2

Rates of Change

0 0

20

40

60

80

100

-2 -4

Chen, G., C. Patten, et al. (2005). Gait Posture 22(1): 51-6. Cruz, T. and Y. Dhaher (2008). Stroke 39(1): 139-47. Kerrigan, D. C., E. P. Frates, et al. (2000). Am J Phys Med Rehabil 79(3): 247-52. Olney, S. and C. Richards (1996). Gait Posture 4: 136-48. Perry, J. (1992). Gait Analysis: Normal and Pathological Function. Thorofare, NJ, SLACK ACKNOWLEDGEMENTS

4 2

REFERENCES

% Gait Cycle

Funding for this project was provided by the American Heart Association, the National Institute on Disability and Rehabilitation Research, National Institute of Child Health & Human Development, and the Searle Fund.

Figure 1: Mean (SE) pelvic frontal plane angle for one gait cycle (heelstrike= 0% and toeoff = 60%) and mean strength measures from Table 1.

Table 1 – ANOVA for Multiple Regression Model for Pelvic Obliquity Source (αi) Hip Flexion (α1) Hip Adduction/Knee Extension Ratio (α2) Knee Flexion (α3) Hip Extension (α4) Model (Intercept)

Coefficient (βi) -0.01 -0.08 -0.31 -0.02 1.38

R2

.957

Probability Level 0.002 0.000 0.000 0.000 0.000

Power 5% .966 1.00 .993 1.00 1.00

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