Gait pattern in the early recovery period after stroke

The gait patterns of eighteen patients who had had a single infarct due to obstruction of the middle cerebral artery were evaluated within one week after the patients had resumed independent walking and before a gait rehabilitation program had been initiated. Gait was analyzed with use of motion analysis, force-plate recordings, and dynamic surface electromyographic studies of the muscles of the lower extremities. The patterns of motion of the lower extremity on the hemiplegic side had a stronger association with the clinical severity of muscle weakness than with the degree of spasticity, balance control, or phasic muscle activity. There was a delay in the initiation of flexion of the hip during the pre-swing phase, and flexion of the hip and knee as well as dorsiflexion of the ankle progressed only slightly during the swing phase. During the stance phase, there was decreased extension of the hip that was related to decreased muscle effort and a coupling between flexion of the knee and dorsiflexion of the ankle. The abnormal patterns of motion altered the velocity, the length of the stride, the cadence, and all phases of the gait cycle. The duration of the pre-swing phase was prolonged for the patients who had the slowest gait velocities. There also were abnormal movements of the upper extremity, the trunk, the pelvis, and the lower extremity on the unaffected side in an effort to compensate for the decreased velocity on the hemiplegic side. As velocity improved, these abnormal movements decreased. Therefore, the goal of therapy should be to improve muscle strength and coordination on the hemiplegic side, especially during the pre-swing phase.     

Effect of N-acylethanolamines with different acyl-chains on DPPC multilamellar liposomes

Relationships between lower extremity strength and stride characteristics were studied in 24 patients with post-polio syndrome. Maximum isometric torques were measured in the ankle plantar flexors, hip and knee extensors, and hip abductors. Gait velocity, stride length, and cadence were recorded during free and fast walking. Step-wise regression analysis was performed to determine which muscle groups best predicted ambulatory function. Plantar flexion torque was the best predictor of velocity (r = .55 free walking and r = .76 fast) and cadence (r = .46 free and r = .58 fast). The combination of plantar flexion and hip abduction torques was the best predictor of fast stride length (r = .78). These findings emphasize the important role of the plantar flexor muscles in gait. Knee extension torque was the poorest predictor for each of the gait parameters. Several patients demonstrated gait deviations that minimized the penalty of quadriceps weakness. Without a contracture or an orthosis, however, no adequate substitution exists for weak plantar flexion.     

Muscle strength in healthy people and in patients suffering from recent-onset inflammatory arthritis

Neuromuscular function was compared among 20 patients with relatively recent onset (symptomatic period 17 +/- 24 months) rheumatoid arthritis (RA) (experimental group; EG), and 20 age- and sex-matched healthy people (control group; CG). The comparison was repeated after a period of 6 months, when 16 patients had carried out progressive strength training. At baseline maximal grip strength and maximal dynamic unilateral strength of the knee extensors in the EG were significantly (P < 0.05) lower in comparison to the CG. The groups did not differ from each other in maximal isometric strength of the trunk flexors and extensors or the knee extensors. The 6-month dynamic strength training in the EG resulted in significant increases in maximal dynamic strength of the knee extensors (P < 0.001), in isometric grip strength (P < 0.001) and in isometric strength of the trunk flexors (P < 0.05) and extensors (P < 0.05) to the level of the healthy controls. Only minor changes took place in explosive strength and maximal isometric strength of the knee extensors. Erythrocyte sedimentation rate (P < 0.001), Ritchie's articular index (P < 0.01) and modified health assessment questionnaire (P < 0.01) improved significantly during the training period. The results suggest that inflammatory arthritis decreases dynamic and/or isometric muscle strength in selected muscle groups of the body already in the early stages of disease. However, progressive dynamic strength training rapidly increases the neuromuscular performance capacity of the patients even to the level of healthy people without detrimental effects on disease activity.     

Enteral absorption of insulin in rats from mucoadhesive chitosan-coated liposomes

Whole muscle contractile characteristics and fatigue resistance were studied in male patients with chronic heart failure (n = 6) and in healthy control subjects (n = 6). Maximum voluntary isometric strength in the major muscle groups of leg (plantar flexors and knee extensors) and arm (elbow extensors and elbow flexors), was found to be similar for both groups of subjects. However, a faster isometric twitch time course was observed in the plantar flexor and knee extensor muscles of heart failure chronic patients. The poor resistance to fatigue in the knee extensors of chronic heart failure patients was confirmed in the present study, but using twitch interpolation this was shown not to be due to poor activation. The plantar flexors of chronic heart failure patients also showed a tendency to be less resistant to fatigue, even when the muscle was activated by direct electrical stimulation. The present study shows that independent of muscle strength, patients with chronic heart failure may possess muscles that are faster to contract and less resistant to fatigue. However, it seems this increased fatigability is not due to poor muscle activation.     

Sensory nerve recording for closed-loop control to restore motor functions

A method is developed for using neural recordings to control functional electrical stimulation (FES) to nerves and muscles. Experiments were done in chronic cats with a goal of designing a rule-based controller to generate rhythmic movements of the ankle joint during treadmill locomotion. Neural signals from the tibial and superficial peroneal nerves were recorded with cuff electrodes and processed simultaneously with muscular signals from ankle flexors and extensors in the cat's hind limb. Cuff electrodes are an effective method for long-term chronic recording in peripheral nerves without causing discomfort or damage to the nerve. For real-time operation we designed a low-noise amplifier with a blanking circuit to minimize stimulation artifacts. We used threshold detection to design a simple rule-based control and compared its output to the pattern determined using adaptive neural networks. Both the threshold detection and adaptive networks are robust enough to accommodate the variability in neural recordings. The adaptive logic network used for this study is effective in mapping transfer functions and therefore applicable for determination of gait invariants to be used for closed-loop control in an FES system. Simple rule-bases will probably be chosen for initial applications to human patients. However, more complex FES applications require more complex rule-bases and better mapping of continuous neural recordings and muscular activity. Adaptive neural networks have promise for these more complex applications.     

Chronic nitric oxide inhibition model six years on

The gait pattern in 10 patients with cerebellar degenerations was studied and the results were compared with 10 matched normal subjects, seeking the principal patterns in this disorder. Gait at natural speed was studied in a biomechanics laboratory using a video-based kinematic data acquisition system for measuring body movements. Patients showed a reduced step and stride length with a trend to reduced cadence. Heel off time, toe off time, and time of peak flexion of the knee in swing were all delayed. Range of motion of ankle, knee, and hip were all reduced, but only ankle range of motion reached significance. Multijoint coordination was impaired, as indicated by a relatively greater delay of plantar flexion of the ankle compared with flexion of the knee and a relatively late knee flexion compared with hip flexion at the onset of swing. The patients also showed increased variability of almost all measures. Although some of the deviations from normal were simply the result of slowness of walking, the gait pattern of patients with cerebellar degeneration shows incoordination similar to that previously described for their multijoint limb motion.     

Studies on the corticospinal control of human walking. I. Responses to focal transcranial magnetic stimulation of the motor cortex

Experiments were done to determine the extent to which the corticospinal tract is linked with the segmental motor circuits controlling ankle flexors and extensors during human walking compared with voluntary motor tasks requiring attention to the level of motor activity. The motor cortex was activated transcranially using a focal magnetic stimulation coil. For each subject, the entire input-output (I-O) curve [i.e., the integral of the motor evoked-potential (MEP) versus stimulus strength] was measured during a prescribed tonic voluntary contraction of either the tibialis anterior (TA) or the soleus. Similarly, I-O curves were measured in the early part of the swing phase, or in the early part of the stance phase of walking. The I-O data points were fitted by the Boltzmann sigmoidal function, which accounted for >/=80% of total data variance. There was no statistically significant difference between the I-O curves of the TA measured during voluntary ankle dorsiflexion or during the swing phase of walking, at matched levels of background electromyographic (EMG) activity. Additionally, there was no significant difference in the relation between the coefficient of variation and the amplitude of the MEPs measured in each task, respectively. In comparison, during the stance phase of walking the soleus MEPs were reduced on average by 26% compared with their size during voluntary ankle plantarflexion. Furthermore, during stance the MEPs in the inactive TA were enhanced relative to their size during voluntary ankle plantarflexion and in four of six subjects the TA MEPs were larger than those of the soleus. Finally, stimulation of the motor cortex at various phases of the step cycle did not reset the cycle. The time of the next step occurred at the expected moment, as determined from the phase-resetting curve. One interpretation of this result is that the motor cortex may not be part of the central neural system involved in timing the motor bursts during the step cycle. We suggest that during walking the corticospinal tract is more closely linked with the segmental motor circuits controlling the flexor, TA, than it is with those controlling the extensor, soleus. However, during voluntary tasks requiring attention to the level of motor activity, it is equally linked with the segmental motor circuits of ankle flexors or extensors.     

Gait analysis of adult patients with complete congenital dislocation of the hip

Comprehensive gait analysis is valuable in understanding the performance of patients with lower limb disorders. The gait pattern of adult patients with untreated congenital dislocation of the hip (CDH) has not yet been reported. We studied the gait pattern in nine women (mean age 31.4 years) with Crows group IV CDH. Six had unilateral and three had bilateral involvement. They were not treated during childhood and had no pain at the time of study. A control group comprised 15 normal female subjects of the same age group. Gait was studied using a motion-analysis system, force plateforms, and computer calculation during level walking. Common abnormal gait patterns seen in patients with both unilateral and bilateral CDH were slower walking velocity, which was due to a shorter stride length, less forward tilting of the pelvis, insufficient flexion, and excessive internal rotation of the hips. The patients with unilateral CDH had a shorter step length, lower pelvis, a lateral shift of the ground reaction force, decreased maximum adduction moments of the hip and knee on the diseased side, and increased maximum adduction moments of the hip and knee on the unaffected side. This asymmetry may have been due to leg length inequality. Thus, correlation of the leg length discrepancy may be important for unilateral CDH patients in improving their gait.     

Effect of ethanol, haloperidol, and lorazepam on cardiac conduction and contraction

We retrospectively evaluated seven children who had low-lumbar-level spina bifida and who had undergone bilateral transfer of tibialis anterior to the calcaneus. The mean age at the time of operation was 8 years (range, 3-12), and the patients were monitored for an average of 40 months (range, 24-60). All children underwent a postoperative gait analysis to assess the function of the transfer and the need for continued postoperative bracing. Transfer of the tibialis anterior muscle to the calcaneus arrested progression of the calcaneal deformity; however, the transfer could not prevent excessive dorsi-flexion of the ankle during stance. The use of a pretibial ankle-foot orthosis improved velocity, increased stride length, decreased quadriceps activity at terminal stance, and led to decreased energy expenditure. We conclude that continued bracing is necessary to provide a more normal appearing and energy-efficient gait.     

Three-dimensional gait analysis in spina bifida

This study was designed to determine gait patterns in children with lumbar and sacral neurologic level spina bifida. We studied a group of 28 children: 10 had L4-level lesions and a mean age of 11 years; eight had L5-level lesions and a mean age of 8 years; and 10 had S1-level lesions with a mean age of 12 years. A group of 15 normal children, mean age 10 years, was used for comparison. Each child underwent three-dimensional gait analysis using the Vicon system. We found that there were recognisable gait patterns for each level of spina bifida and that the abnormalities accurately reflected the muscle deficiencies present. The gait patterns approximated more closely to those of the normal group as the neurological level descended. The most important findings were of increased pelvic obliquity and rotation with hip abduction in stance (reflecting the gross Trendelenburg-type gait seen in these children) and persistent knee flexion throughout stance as a result of the absence of the plantar flexion-knee extension couple. We found that gait was not improved by tendon transfers performed either at the hip (posterolateral psoas transfer) or at the ankle (tibialis anterior transfer).     

Functional evaluation of normal and pathologic knees during gait

The functional performance of the knee joints of 29 normal volunteers, 65 patients with degenerative joint disease and 30 patients with rheumatoid arthritis was studied according to clinical (historical, physical and roentgenographic) and biomechanical gait parameters. Temporal and distance gait factors (velocity, cadence and stride length) were significantly reduced in patients with diseased knees. Sagittal plane knee motion was markedly reduced, as was stance phase flexion, indicating poor tolerance of loading the flexed knee in the patient groups. There was no correlation between passive motion of the diseased knee and the amount of motion used during gait. Patients with rheumatoid arthritis generally showed more compromise of knee joint function than did patients with degenerative joint disease. Statistically, significant correlations between various clinical and biomechanical gait parameters suggest that the techniques used are an objective measurement of knee joint function and may be employed as a means of evaluating various treatment modalities for the diseased knee.     

Tendon transfer for equinovarus deformed foot caused by cerebrovascular disease

Surgical correction was performed on 125 patients who had equinovarus deformity caused by a cerebrovascular accident and who needed an ankle foot orthosis for walking. The operative procedures involved anterior transfer of the long toe flexors (flexor hallux longus and flexor digitorum longus; long toe flexor group) or lateral transfer of the anterior tibial tendon (anterior tibial tendon group), combined with lengthening of the Achilles tendon. On evaluation more than 2 years after surgery, 83 of 110 patients of the long toe flexor group and eight of 15 patients of the anterior tibial tendon group were able to walk without a brace. Five patients of the anterior tibial tendon group who had shown strong contraction of the anterior tibial muscle during the swing phase before surgery, needed a brace because of a drop foot after surgery. Thus, lateral transfer of the anterior tibial tendon was abandoned in 1984. Recurrence of varus deformity was seen in approximately 15% of the patients in both groups. Anterior transfer of the long toe flexors, using them as dorsiflexor tendons or for tenodesis, seemed to produce better results.     

Leptin is an endogenous protective protein against the toxicity exerted by tumor necrosis factor

Decrements in muscle strength as a result of prolonged bed rest are well defined, but little is known about potential countermeasures for preventing loss of strength under this condition. The purpose of this study was to determine whether testosterone administration would preserve protein balance and muscle strength during prolonged bed rest. Ten healthy men (age, 36 +/- 2 yr; height, 177.2 +/- 3.4 cm; weight, 80.5 +/- 3.9 kg; mean +/- SE) were admitted to our in-patient metabolic unit. After a 1-week ambulatory run-in period, each subject was confined to bed for 28 days at 6 degree head-down tilt while receiving a daily oral dose of T3 (50 microg/day). During the bed rest/T3 period, six of the men were randomized to receive testosterone enanthate by i.m. injection (T; 200 mg/week) while four received placebo in a double blind fashion. Nitrogen balance was determined throughout, and whole body [13C]leucine kinetics were assessed at baseline and on day 26 of bed rest. Before bed rest and on the third day of reambulation, the muscle strength of the knee extensors and flexors and shoulder extensors and flexors was determined at 60 degrees/s on a Cybex isokinetic dynamometer. Despite improved [13C]leucine kinetics and maintenance of nitrogen balance and lean body mass in T-treated subjects, little preservation of muscle strength, particularly in the knee extensors, was noted. Muscle strength [reported as the best work repetition in foot-pounds (FtLb)] for right knee extensors declined (P = 0.011) similarly in both groups; from 165 +/- 15 to 126 +/- 18 FtLb in T-treated men and from 179 +/- 22 to 149 +/- 13 FtLb in placebo-treated men. Overall, there was less of a decline in extension and flexion strength of the shoulder compared to the knee, with no benefit from T. These results suggest that in the absence of daily ambulatory activity, T administration will not increase or, in the case of this bed rest model, preserve muscle strength.     

Gait analysis and muscle strength in children with surgically treated clubfeet

Twenty-three children who had unilateral surgery for idiopathic clubfeet underwent gait analysis and isokinetic muscle-strength testing at an average of 10 years after surgical release. Ankle sagittal-plane kinematics were disturbed in 20 clubfeet. Fifteen children had an internal foot-progression angle. Genu valgum and knee hyperextension were common. Plantarflexion power was decreased by 23% on the side of surgery (p = 0.00005). Quadriceps weakness (defined as a decrease in strength >10% of the nonoperated-on limb's strength) was seen in nine of 22 operated-on limbs and hamstring weakness in eight of 22. Gastrocsoleus weakness exceeded 10% in 16 of 21 clubfeet. Average weakness of the gastrocsoleus was 27% (p < 0.05). Ten-year analysis of children treated with clubfoot releases revealed disturbances in ankle motion and strength. Loss of plantarflexion power and gastrocsoleus strength can be predicted by Achilles tendon lengthening. Knee kinematic abnormalities and weakness also were seen. These abnormalities produce functional difficulties in gait and may lead to degenerative changes later.     

Locomotion of autistic adults

OBJECTIVE: To assess gait in patients with autism. DESIGN: Clinical and physiologic assessment. SETTING: Research hospital. PATIENTS AND SUBJECTS: Five adults with autism and five healthy, age-matched control subjects. MAIN OUTCOME MEASURE(S): Clinical and biomechanical assessment. RESULTS: Clinical assessment showed mild clumsiness in four patients and upper limb posturing during gait in three patients. The velocity of gait, step length, cadence, step width, stance time, and vertical ground reaction forces were normal in all patients. The only significant abnormality was decreased range of motion of the ankle. Some patients exhibited slightly decreased knee flexion in early stance. Clinically, the gait appeared to be irregular in three patients, but the variability was not significantly increased. CONCLUSIONS: The findings in patients with autism indicate a nonspecific, neurological disturbance involving the motor system. The normal velocity of gait and the normal step length argue against a parkinsonian-type disturbance, whereas the clinical picture suggests a disturbance of the cerebellum.     

Force and motion analysis of the normal, diseased, and prosthetic ankle joint

A 2-dimensional motion and force study of the ankle joint during gait has been carried out on normal subjects and patients with ankle joint disease, before and 1 year following total ankle replacemetn. The methods employed involved the use of high-speed motion picture film, force plate and foot-switch data. The Achilles and anterior tibial tendon forces, the compressive and tangential (shear) forces across the ankle during stance phase of gait were determined, based on a quasi-static analysis. During stance phase of gait normal subjects used a mean of 24.4 degree of sagittal plane ankle motion. Patients with ankle joint disease showed reduced motion which returned to near normal values 1 year following total ankle replacement. Compressive force across the ankle joint rose to about 5 times body weight during the latter part of stance phase. Backward, or aft, shear forces or nearly full body weight were demonstrated during all but the last 20% of stance phase. Patients with ankle joint disease apparently altered their gait to markedly reduce these forces. Following total ankle replacement, shear forces returned toward more normal values, but compressive forces were not significantly changed.     

Gender differences in strength and muscle fiber characteristics

Strength and muscle characteristics were examined in biceps brachii and vastus lateralis of eight men and eight women. Measurements included motor unit number, size and activation and voluntary strength of the elbow flexors and knee extensors. Fiber areas and type were determined from needle biopsies and muscle areas by computerized tomographical scanning. The women were approximately 52% and 66% as strong as the men in the upper and lower body respectively. The men were also stronger relative to lean body mass. A significant correlation was found between strength and muscle cross-sectional area (CSA; P < or = 0.05). The women had 45, 41, 30 and 25% smaller muscle CSAs for the biceps brachii, total elbow flexors, vastus lateralis and total knee extensors respectively. The men had significantly larger type I fiber areas (4597 vs 3483 microns2) and mean fiber areas (6632 vs 3963 microns2) than the women in biceps brachii and significantly larger type II fiber areas (7700 vs 4040 microns2) and mean fiber areas (7070 vs 4290 microns2) in vastus lateralis. No significant gender difference was found in the strength to CSA ratio for elbow flexion or knee extension, in biceps fiber number (180,620 in men vs 156,872 in women), muscle area to fiber area ratio in the vastus lateralis 451,468 vs 465,007) or any motor unit characteristics. Data suggest that the greater strength of the men was due primarily to larger fibers. The greater gender difference in upper body strength can probably be attributed to the fact that women tend to have a lower proportion of their lean tissue distributed in the upper body.(ABSTRACT TRUNCATED AT 250 WORDS)     

Therapeutic intervention and signaling

To examine the effects of rapid dehydration on isometric muscular strength and endurance, seven men were tested at baseline (control) and after a dehydration (dHST) and a euhydration (eHST) heat stress trial. The dHST consisted of intermittent sauna exposure until 4% of body mass was lost, whereas the eHST consisted of intermittent sauna exposure (same duration as dHST) with water replacement. Peak torque was determined for the knee extensors and elbow flexors during three isometric maximal voluntary contractions. Time to fatigue was determined by holding a maximal voluntary contraction until torque dropped below 50% peak torque for 5 s. Strength and endurance were assessed 3.5 h after the HSTs (no food or water intake). Body mass was decreased 3.8+/-0.4% post dHST and 0.4+/-0.3% post eHST. Plasma volume was decreased 7.5+/-4.6% and 5.7+/-4.4%, 60 and 120 min post dHST, respectively. A small (1.6 mEq x L[-1]) but significant increase was found for serum Na+ concentration 60 min post dHST but had returned to predehydration level 120 min post dHST. Serum K+ and myoglobin concentrations were not affected by HSTs. Peak torque was not different (P > 0.05) among control, dHST, and eHST for the knee extensors (Mean (Nm)+/-SD, 285+/-79, 311+/-113, and 297+/-79) and elbow flexors (79+/-12, 83+/-15, and 80+/-12). Time to fatigue was not different (P > 0.05) among control, dHST and eHST for the knee extensors (Mean (s)+/-SD. 42.4+/-11.5, 45.3+/-7.6, and 41.8+/-6.0) and elbow flexors (48.2+/-8.9, 44.0+/-9.4, and 46.0+/-6.4). These results provide evidence that isometric strength and endurance are unaffected 3.5 h after dehydration of approximately 4% body mass.     

Motor patterns for human gait: backward versus forward locomotion

Seven healthy subjects walked forward (FW) and backward (BW) at different freely chosen speeds, while their motion, ground reaction forces, and electromyographic (EMG) activity from lower limb muscles were recorded. We considered the time course of the elevation angles of the thigh, shank, and foot segments in the sagittal plane, the anatomic angles of the hip, knee, and ankle joints, the vertical and longitudinal ground reaction forces, and the rectified EMGs. The elevation angles were the most reproducible variables across trials in each walking direction. After normalizing the time course of each variable over the gait cycle duration, the waveforms of all elevation angles in BW gait were essentially time reversed relative to the corresponding waveforms in FW gait. Moreover, the changes of the thigh, shank, and foot elevation covaried along a plane during the whole gait cycle in both FW and BW directions. Cross-correlation analysis revealed that the phase coupling among these elevation angles is maintained with a simple reversal of the delay on the reversal of walking direction. The extent of FW-BW correspondence also was good for the hip angle, but it was smaller for the knee and ankle angles and for the ground reaction forces. The EMG patterns were drastically different in the two movement directions as was the organization of the muscular synergies measured by cross-correlation analysis. Moreover, at any given speed, the mean EMG activity over the gait cycle was generally higher in BW than in FW gait, suggesting a greater level of energy expenditure in the former task. We argue that conservation of kinematic templates across gait reversal at the expense of a complete reorganization of muscle synergies does not arise from biomechanical constraints but may reflect a behavioral goal achieved by the central networks involved in the control of locomotion.