Interventions for improving coordination of axial segments and lower limbs during walking following stroke: Systematic Review

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Executive SummaryBackgroundImpairments in gait coordination may be a factor in falls and mobility limitations after stroke. Therefore, rehabilitation targeting lower limb coordination may be a mechanistic way to improve walking post-stroke. This review sought to examine what treatments currently exist to target impairments of gait coordination, the theoretical basis on which they are derived and the potential efficacy of such interventions.Review Objectives: This review sought to determine the effectiveness of current interventions in improving coordination of axial segments and lower limbs following stroke and to examine any evidence to indicate whether improvements in locomotor performance can be brought about using interventions for the restoration of deficits in motor coordination. To address this objective we sought to examine the best available evidence in regards to therapeutic interventions for stroke subjects to improve:Coordination of axial segments (head, trunk and pelvis) and stepping patterns during walkingCoordination of axial segments (head, trunk and pelvis) and stepping patterns specifically while turning during walkingInclusion CriteriaWe included studies investigating effects of a physiotherapeutic intervention on gait coordination in participants with stroke, regardless of lesion location or time since stroke. We included study designs such as; randomised and quasi-randomised controlled trials, case-control studies, cohort studies, in order to compare evidence for the effect of treatment on gait coordination compared to no treatment. Studies were required to include at least one outcome measure of gait co-ordination.Search StrategyThe search strategy, conducted in the timeframe of 1980 to September Week 1, 2009 used a combination of controlled vocabulary (MeSH) and free text terms, was limited to English papers with human participants and was used for MEDLINE and modified to suit other databases (CINAHL, AMED,EMBASE, PEDro and Cochrane Databases).Critical appraisalTwo authors independently assessed the methodological quality of selected studies using a modified version of the Joanna Briggs Institute (JBI) critical appraisal checklist for cohort/case control. For rigour and detail, additional questions from Downs and Black's checklist were added.Data extractionTwo authors independently extracted means and standard deviations from each outcome measure as well as participant demographics and details of the trial design.Data synthesisDue to the range of study designs included we limited the influence of heterogeneity in experimental design and control comparators by restricting meta-analyses to pre- and post-test comparisons of experimental interventions only. In this way we obtained an estimate of the effect of interventions compared to no treatment.ResultsFew high quality RCTs with a low risk of bias specifically targeting and measuring restoration of coordinated gait were found. Nine RCTs and 24 quasi-experimental studies were included. Four main intervention types that directly target gait coordination impairments were identified: task specific locomotor training (including over ground and treadmill training with or without body weight support), ankle foot orthotics and functional electrical stimulation, auditory cueing and exercise. Overall, the interventions improved both coordination and gait function (speed). When considered individually each type of intervention also improved gait function (speed) but for co-ordination, the only intervention to show a significant benefit was auditory cueing.ConclusionsThe fact that overall improvements in gait coordination were found to coincide with increased walking speed lends support to the hypothesis that rehabilitation targeted at gait coordination gait may be a mechanistic way of improving overall walking ability post-stroke.Implications for practiceInterventions involving repetitive task-specific practice and/or auditory cueing appeared to be the most promising approaches to promote recovery of gait coordination.Implications for researchEstablishing the mechanism for improved locomotor control requires a better understanding of the nature of both neuroplasticity and coordination deficits in functional tasks after stroke. Future research requires the measurement of impairment, activity and cortical activation in an effort to establish the mechanism by which functional gains are achieved.

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