title: Meaningful Gait Speed Improvement During the First 60 Days Poststroke: Minimal Clinically Important Difference Effects of virtual reality training on gait biomechanics of individuals post-stroke. Improvements in Speed-Based Gait Classifications Are Meaningful Effects of Training With a Robot-Virtual Reality System Compared With a Robot Alone on the Gait of Individuals After Stroke Effectiveness of Virtual Reality Using Wii Gaming Technology in Stroke Rehabilitation: A Pilot Randomized Clinical Trial and Proof of Principle Effect of Nintendo Wii™-based motor and cognitive training on activities of daily living in patients with Parkinson's disease: a randomised clinical trial. Understanding physical factors associated with participation in community ambulation following stroke Effects of treadmill training with optic flow on balance and gait in individuals following stroke: randomized controlled trials Virtual reality-based training improves community ambulation in individuals with stroke: a randomized controlled trial. Virtual Walking Training Program Using a Real-world Video Recording for Patients with Chronic Stroke: A Pilot Study Use of Virtual Reality to Enhance Balance and Ambulation in Chronic Stroke: A Double-Blind, Randomized Controlled Study
abstract: Background When people with stroke recover gait speed , they report improved function and reduced disability . However , the minimal amount of change in gait speed that is clinical ly meaningful and associated with an important difference in function for people poststroke has not been determined . Objective The purpose of this study was to determine the minimal clinical ly important difference ( MCID ) for comfortable gait speed ( CGS ) associated with an improvement in the modified Rankin Scale ( mRS ) score for people between 20 to 60 days poststroke . Design This was a prospect i ve , longitudinal , cohort study . Methods The participants in this study were 283 people with first-time stroke prospect ively enrolled in the ongoing Locomotor Experience Applied Post Stroke ( LEAPS ) multi-site r and omized clinical trial . Comfortable gait speed was measured and mRS scores were obtained at 20 and 60 days poststroke . Improvement of ≥1 on the mRS was used to detect meaningful change in disability level . Results Mean ( SD ) CGS was 0.18 ( 0.16 ) m/s at 20 days and 0.39 ( 0.22 ) m/s at 60 days poststroke . Among all participants , 47.3 % experienced an improvement in disability level ≥1 . The MCID was estimated as an improvement in CGS of 0.16 m/s anchored to the mRS . Limitations Because the mRS is not a gait-specific measure of disability , the estimated MCID for CGS was only 73.9 % sensitive and 57.0 % specific for detecting improvement in mRS scores . Conclusions We estimate that the MCID for gait speed among patients with subacute stroke and severe gait speed impairments is 0.16 m/s . Patients with subacute stroke who increase gait speed ≥0.16 m/s are more likely to experience a meaningful improvement in disability level than those who do not . Clinicians can use this reference value to develop goals and interpret progress in patients with subacute stroke OBJECTIVE To evaluate gait biomechanics after training with a virtual reality ( VR ) system and to eluci date underlying mechanisms that contributed to the observed functional improvement in gait speed and distance . DESIGN A single blind r and omized control study . SETTING Gait analysis laboratory in a rehabilitation hospital and the community . PARTICIPANTS Fifteen men and three women with hemiparesis caused by stroke . INTERVENTIONS Subjects trained on a six-degree of freedom force-feedback robot interfaced with a VR simulation . Subjects were r and omized to either a VR group ( n=9 ) or non-VR group ( NVR , n=9 ) . Training was performed three times a week for 4 weeks for approximately 1h each visit . MAIN OUTCOME MEASURES Kinematic and kinetic gait parameters . RESULTS Subjects in the VR group demonstrated a significantly larger increase in ankle power generation at push-off as a result of training ( p=0.036 ) . The VR group had greater change in ankle ROM post-training ( 19.5 % ) as compared to the NVR group ( 3.3 % ) . Significant differences were found in knee ROM on the affected side during stance and swing , with greater change in the VR group . No significant changes were observed in kinematics or kinetics of the hip post-training . CONCLUSIONS These findings are encouraging because they support the potential for recovery of force and power of the lower extremity for individuals with chronic hemiparesis . It is likely that the effects of training included improved motor control at the ankle , which enabled the cascade of changes that produced the functional improvements seen after training Background and Purpose — Gait velocity is a powerful indicator of function and prognosis after stroke . Gait velocity can be stratified into clinical ly meaningful functional ambulation classes , such as household ambulation ( < 0.4 m/s ) , limited community ambulation ( 0.4 to 0.8 m/s ) , and full community ambulation ( > 0.8 m/s ) . The purpose of the current study was to determine whether changes in velocity-based community ambulation classification were related to clinical ly meaningful changes in stroke-related function and quality of life . Methods — In subacute stroke survivors with mild to moderate deficits who participated in a r and omized clinical trial of stroke rehabilitation and had a baseline gait velocity of 0.8 m/s or less , we assessed the effect of success versus failure to achieve a transition to the next class on function and quality of life according to domains of the Stroke Impact Scale ( SIS ) . Results — Of 64 eligible participants , 19 were initially household ambulators , and 12 of them ( 68 % ) transitioned to limited community ambulation , whereas of 45 initially limited community ambulators , 17 ( 38 % ) became full community ambulators . Function and quality -of-life SIS scores after treatment were significantly higher among survivors who achieved a favorable transition compared with those who did not . Among household ambulators , those who transitioned to limited or full community ambulation had significantly better SIS scores in mobility ( P=0.0299 ) and participation ( P=0.0277 ) . Among limited community ambulators , those who achieved the transition to full community ambulatory status had significantly better scores in SIS participation ( P=0.0085 ) . Conclusions — A gait velocity gain that results in a transition to a higher class of ambulation results in better function and quality of life , especially for household ambulators . Household ambulators possibly had more severe stroke deficits , reducing the risk of “ ceiling ” effects in SIS-measured activities of daily living and instrumental activities of daily living . Outcome assessment based on transitions within a mobility classification scheme that is rooted in gait velocity yields potentially meaningful indicators of clinical benefit . Outcomes should be selected that are clinical ly meaningful for all levels of severity Background and Purpose — Training of the lower extremity ( LE ) using a robot coupled with virtual environments has shown to transfer to improved overground locomotion . The purpose of this study was to determine whether the transfer of training of LE movements to locomotion was greater using a virtual environment coupled with a robot or with the robot alone . Methods — A single , blind , r and omized clinical trial was conducted . Eighteen individuals poststroke participated in a 4-week training protocol . One group trained with the robot virtual reality ( VR ) system and the other group trained with the robot alone . Outcome measures were temporal features of gait measured in a laboratory setting and the community . Results — Greater changes in velocity and distance walked were demonstrated for the group trained with the robotic device coupled with the VR than training with the robot alone . Similarly , significantly greater improvements in the distance walked and number of steps taken in the community were measured for the group that trained with robot coupled with the VR . These differences were maintained at 3 months ’ follow-up . Conclusions — The study is the first to demonstrate that LE training of individuals with chronic hemiparesis using a robotic device coupled with VR improved walking ability in the laboratory and the community better than robot training alone Background and Purpose — Hemiparesis result ing in functional limitation of an upper extremity is common among stroke survivors . Although existing evidence suggests that increasing intensity of stroke rehabilitation therapy results in better motor recovery , limited evidence is available on the efficacy of virtual reality for stroke rehabilitation . Methods — In this pilot , r and omized , single-blinded clinical trial with 2 parallel groups involving stroke patients within 2 months , we compared the feasibility , safety , and efficacy of virtual reality using the Nintendo Wii gaming system ( VRWii ) versus recreational therapy ( playing cards , bingo , or “ Jenga ” ) among those receiving st and ard rehabilitation to evaluate arm motor improvement . The primary feasibility outcome was the total time receiving the intervention . The primary safety outcome was the proportion of patients experiencing intervention-related adverse events during the study period . Efficacy , a secondary outcome measure , was evaluated with the Wolf Motor Function Test , Box and Block Test , and Stroke Impact Scale at 4 weeks after intervention . Results — Overall , 22 of 110 ( 20 % ) of screened patients were r and omized . The mean age ( range ) was 61.3 ( 41 to 83 ) years . Two participants dropped out after a training session . The interventions were successfully delivered in 9 of 10 participants in the VRWii and 8 of 10 in the recreational therapy arm . The mean total session time was 388 minutes in the recreational therapy group compared with 364 minutes in the VRWii group ( P=0.75 ) . There were no serious adverse events in any group . Relative to the recreational therapy group , participants in the VRWii arm had a significant improvement in mean motor function of 7 seconds ( Wolf Motor Function Test , 7.4 seconds ; 95 % CI , −14.5 , −0.2 ) after adjustment for age , baseline functional status ( Wolf Motor Function Test ) , and stroke severity . Conclusions — VRWii gaming technology represents a safe , feasible , and potentially effective alternative to facilitate rehabilitation therapy and promote motor recovery after stroke OBJECTIVES To investigate the effect of Nintendo Wii ™ -based motor cognitive training versus balance exercise therapy on activities of daily living in patients with Parkinson 's disease . DESIGN Parallel , prospect i ve , single-blind , r and omised clinical trial . SETTING Brazilian Parkinson Association . PARTICIPANTS Thirty-two patients with Parkinson 's disease ( Hoehn and Yahr stages 1 and 2 ) . INTERVENTIONS Fourteen training sessions consisting of 30 minutes of stretching , strengthening and axial mobility exercises , plus 30 minutes of balance training . The control group performed balance exercises without feedback or cognitive stimulation , and the experimental group performed 10 Wii Fit ™ games . MAIN OUTCOME MEASURE Section II of the Unified Parkinson 's Disease Rating Scale ( UPDRS-II ) . R AND OMISATION Participants were r and omised into a control group ( n=16 ) and an experimental group ( n=16 ) through blinded drawing of names . STATISTICAL ANALYSIS Repeated- measures analysis of variance ( RM-ANOVA ) . RESULTS Both groups showed improvement in the UPDRS-II with assessment effect ( RM-ANOVA P<0.001 , observed power=0.999 ) . There was no difference between the control group and the experimental group before training { 8.9 [ st and ard deviation ( SD ) 2.9 ] vs 10.1 ( SD 3.8 ) } , after training [ 7.6 ( SD 2.9 ) vs 8.1 ( SD 3.5 ) ] or 60 days after training [ 8.1 ( SD 3.2 ) vs 8.3 ( SD 3.6 ) ] . The mean difference of the whole group between before training and after training was -0.9 ( SD 2.3 , 95 % confidence interval -1.7 to -0.6 ) . CONCLUSION Patients with Parkinson 's disease showed improved performance in activities of daily living after 14 sessions of balance training , with no additional advantages associated with the Wii-based motor and cognitive training . Registered on http://www . clinical trials.gov ( identifier : NCT01580787 ) Purpose . This study examined the association between impaired physical function and participation in  community ambulation  following stroke . We hypothesised that participation would be significantly less following stroke , and that physical impairments would be associated with participation . Method . Using a case – control design 30 survivors of stroke aged 45 and older and 30 controls provided health status information and a self-report of participation in community ambulation  ( number of trips and walking-related activities ( WRA ) reported prospect ively over a 12-day period ) . The association of physical impairments ( strength , range of motion , sensation , muscle tone , vision , and activity limitations ( gait speed and performance on complex walking tasks ) ) with level of participation was analysed using negative binomial regression and goodness of fit . Results . Participants included 30 individuals with and 30 without stroke , average age 68 years , majority were Caucasian women . Average time  since stroke was 40 months . Participation in survivors of stroke was characterised by fewer trips and WRA and lower satisfaction ( p < 0.001 ) . Usual gait speed , balance , muscle strength and muscle length were impaired ( p < 0.001 ) in stroke vs. controls , and associated with number of trips and WRA ( p < 0.05 ) . However , these factors explained less than very little of the variance in participation . Conclusions . While individual factors were associated with level of participation , results failed to accurately predict participation in community ambulation following stroke . Other factors , such as depression , cognition and self-efficacy may be stronger determinants of participation Objective : This study examined the effects of treadmill training with optic flow on the functional recovery of balance and gait in stroke patients . Design : R and omized controlled experimental study . Participants : Thirty patients following stroke were divided r and omly into the treadmill with optic flow group ( n = 10 ) , treadmill group ( n = 10 ) and control group ( n = 10 ) . Interventions : The subjects in the experimental group wore a head-mounted display to receive speed-modulated optic flow during treadmill training for 30 minutes , while those in the treadmill group and control group received treadmill training and regular therapy for the same time , three times a week for four weeks . Main measures : The data were collected using timed up- and -go test , functional reach test , 10-m walk test , and six-minute walk test before and after treatment . Results : The timed up- and -go test in the treadmill with optic flow group ( 5.55 ± 2.04 ) improved significantly greater than the treadmill ( 1.50 ± 0.93 ) and control ( 0.40 ± 0.84 ) groups . The functional reach test in the treadmill with optic flow group ( 2.78 ± 1.44 ) was significantly higher than the control group ( 0.20 ± 0.16 ) only . The gait velocity in the treadmill with optic flow group ( 0.21 ± 0.06 ) showed a significant decrease compared to the treadmill ( 0.03 ± 0.02 ) and control ( 0.01 ± 0.02 ) groups . Finally , the six-minute walk test in the treadmill with optic flow group ( 24.49 ± 11.00 ) showed significant improvement compared to the treadmill training ( 4.65 ± 3.25 ) and control ( 1.79 ± 3.08 ) groups . Conclusion : Treadmill using optic flow speed modulation improves the balance and gait significantly in patients with stroke who are able to participate in physical gait training This is a single blind r and omized controlled trial to examine the effect of virtual reality-based training on the community ambulation in individuals with stroke . Twenty subjects with stroke were assigned r and omly to either the control group ( n=9 ) or the experimental group ( n=11 ) . Subjects in the control group received the treadmill training . Subjects in the experimental group underwent the virtual reality-based treadmill training .  Walking speed , community walking time , walking ability question naire ( WAQ ) , and activities-specific balance confidence ( ABC ) scale were evaluated . Subjects in the experimental group improved significantly in walking speed , community walking time , and WAQ score at posttraining and 1-month follow-up periods . Their ABC score also significantly increased at posttraining but did not maintain at follow-up period . Regarding the between-group comparisons , the experimental group improved significantly more than control group in walking speed ( P=0.03 ) and community walking time ( P=0.04 ) at posttraining period and in WAQ score ( P=0.03 ) at follow-up period . Our results support the perceived benefits of gait training programs that incorporate virtual reality to augment the community ambulation of individuals with stroke Objective The purpose of this study was to investigate the effectiveness of the virtual walking training program using a real-world video recording on walking balance and spatiotemporal gait parameters in patients with chronic stroke . Design Fourteen patients with chronic stroke were r and omly assigned to either the experimental group ( n = 7 ) or the control group ( n = 7 ) . The subjects in both groups underwent a st and ard rehabilitation program ; in addition , the experimental group participated in the virtual walking training program using a real-world video recording for 30 mins a day , three times a week , for 6 wks , and the control group participated in treadmill gait training for 30 mins a day , three times a week , for 6 wks . Walking balance was measured using the Berg Balance Scale ( BBS ) and the Timed Up and Go test . Gait performance was measured using an electrical walkway system . Results In walking balance , greater improvement on the Berg Balance Scale ( experimental group : 4.14 vs. control group : 1.85 ) and the Timed Up and Go test ( −2.25 vs. −0.94 ) was observed in the experimental group compared with the control group ( P < ; 0.05 ) . In the spatiotemporal gait parameters , greater improvement on velocity ( 25.40 vs. 9.74 ) and cadence ( 26.71 vs. 11.11 ) was observed in the experimental group compared with the control group ( P < ; 0.05 ) . Conclusions This study demonstrated the positive effects of the virtual walking training program using a real-world video recording on gait performance . These findings suggest that the virtual walking training program using a real-world video recording may be a valid approach to enhance gait performance in patients with chronic stroke Kim JH , Jang SH , Kim CS , Jung JH , You JH : Use of virtual reality to enhance balance and ambulation in chronic stroke : A double-blind , r and omized controlled study . Objective : To examine an additive effect of virtual reality on balance and gait function in patients with chronic hemiparetic stroke . Design : Twenty-four adults with hemiparetic stroke were r and omly assigned to either an experimental group ( n = 12 ) or a control group . Both groups underwent conventional physical therapy , 40 mins a day , 4 days a week for 4 wks . The experimental group received an additional 30 mins of virtual reality therapy each session . Balance performance was determined by the Balance Performance Monitor and Berg Balance Scale tests . Gait performance was determined by the 10-m walking test and Modified Motor Assessment Scale , and spatiotemporal parameters were obtained using GAITRite . Analysis of variance and correlation statistics were performed at P < 0.05 . Results : In the balance test , the experimental group had improved Berg Balance Scale scores , balance and dynamic balance angles ( ability to control weight shifting ) compared with the controls ( P < 0.05 ) . In the gait performance test , the experimental group showed significant improvements in velocity , Modified Motor Assessment Scale scores , cadence , step time , step length , and stride length ( P < 0.05 ) . Improvement in dynamic balance angles was correlated with velocity and cadence ( P < 0.01 ) . Conclusions : This study demonstrates that virtual reality has an augmented effect on balance and associated locomotor recovery in adults with hemiparetic stroke when added to conventional therapy
target: CONCLUSIONS : This review provided evidence that walking training associated with virtual reality-based training was effective in increasing walking speed after stroke , and result ed in better results than non-virtual reality interventions
background: OBJECTIVE : To systematic ally review the available evidence on the efficacy of walking training associated with virtual reality-based training in patients with stroke .
  The specific questions were : Is walking training associated with virtual reality-based training effective in increasing walking speed after stroke ?
  Is this type of intervention more effective in increasing walking speed , than non-virtual reality-based walking interventions ?