Sensory Retraining of the Lower Limb After Acute Stroke: A Randomized Controlled Pilot Trial

doi:10.1016/j.apmr.2007.06.010

Archives of Physical Medicine and Rehabilitation

Volume 88, Issue 9, September 2007, Pages 1101-1107

https://doi.org/10.1016/j.apmr.2007.06.010 Get rights and content

Abstract

Lynch EA, Hillier SL, Stiller K, Campanella RR, Fisher PH. Sensory retraining of the lower limb after acute stroke: a randomized controlled pilot trial.

Objective

To determine the effects of a sensory retraining protocol on sensation, postural control, and gait in acute stroke subjects.

Design

Randomized controlled pilot trial.

Setting

Inpatient rehabilitation hospital.

Participants

Twenty-one subjects with sensory deficits in the feet, undergoing rehabilitation for stroke.

Intervention

Sensory retraining of the more affected lower limb versus relaxation (sham intervention).

Main Outcome Measures

Light touch at the sole of the foot (Semmes-Weinstein monofilaments), proprioception (Distal Proprioception Test), postural control (Berg Balance Scale), and gait (timed, Iowa Level of Assistance Scale).

Results

Significant improvements (P<.05) over time were found in light touch at 3 points of the feet and in postural control, timed gait, and walking aid. No significant time effects were observed in proprioception or amount of assistance required to walk. No significant differences were detected between groups in any of the outcome variables, apart from light touch at the first metatarsal. The study had poor power (13%) to detect group effects due to the small sample size.

Conclusions

Results of this pilot study are unable to support or refute the routine use of sensory retraining of the lower limb for people during inpatient rehabilitation after stroke. Further research with a larger sample size is required.

Section snippets

Methods

Ethics approval was obtained from the Royal Adelaide Hospital and the University of South Australia.

Results

Twenty-one subjects were recruited over a 9-month period, with 10 in the sensory retraining group, and 11 in the control treatment group (fig 1). One subject in the sensory retraining group was withdrawn because he developed an acute illness requiring readmission to the acute hospital. His data were collected at follow-up and included in the analysis following the ITT principle.

Results from a retrospective power calculation showed that the current study was strongly (99.7%) powered to detect

Discussion

This pilot study found that a standardized protocol of sensory retraining of the feet was not significantly more effective than relaxation in improving sensation, balance, or walking ability in a sample of acute stroke subjects.

In previous studies investigating the effectiveness of sensory retraining, repeated-measure (single-case study) designs have been used more often than experimental designs with control groups, because stroke subjects are a highly heterogeneous subject group and therefore

Conclusions

The protocol used in the current pilot study to retrain sensation in the feet of people with stroke undergoing inpatient rehabilitation was not found to be more effective than a control group receiving relaxation in improving sensation, balance, or walking ability. No firm recommendations regarding sensory retraining of the feet for stroke subjects undergoing rehabilitation can be made at this point due to the methodologic limitations of the current study and further research is warranted,

Acknowledgment

We thank the Physiotherapy Department, Hampstead Rehabilitation Centre, Royal Adelaide Hospital, and John Petkov, MSc.

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For instance, Kim et al. investigated the influence of ataxia on walking ability after stroke, and all the recruited patients with ataxia had limb muscle strength ≥4 on the Medical Resource Council Scale and NIHSS ≤5 [26]. Lynch et al. investigated the effect of sensory retraining on gait speed, and all the recruited patients had significant sensory impairment and were already able to walk 10 m at baseline [27]. Gait speed is a key indicator of general gait performance and can be used to discriminate among levels of walking disability.
Walking entails orchestration of the sensory, motor, balance, and coordination systems, and walking disability is a critical concern after stroke. How and to what extent these systems influence walking disability after stroke and recovery have not been comprehensively studied.
We retrospectively analyzed patients with stroke in the Post-acute care-Cerebrovascular Diseases (PAC-CVD) program. We compared the characteristics of patient groups stratified by their ability to complete the 5-m walk test across various time points of rehabilitation. We then used stepwise linear regression to examine the degree to which each stroke characteristic and functional ability could predict patient gait performance.
Five hundred seventy-three patients were recruited, and their recovery of walking ability was defined by the timing of recovery in a 5-m walk test. The proportion of patients who could complete the 5-m walk test at admission, at 3 weeks of rehabilitation, at 6 weeks of rehabilitation, between 7 and 12 weeks of rehabilitation, and who could not complete the 5-m walk test after rehabilitation was 52.2%, 21.8%, 8.7%, 8.7%, and 8.6%, respectively. At postacute care discharge, patients who regained walking ability earlier had a higher chance of achieving higher levels of walking activity. Stepwise linear regression showed that Berg Balance Scale (BBS) (β: 0.011, p < .001), age (β: −0.005, p = .001), National Institutes of Health Stroke Scale (NIHSS) (6a + 6b; β: −0.042, p = .018), Mini-Nutritional assessment (MNA) (β: −0.007, p < .027), and Fugl–Meyer upper extremity assessment (FuglUE) (β: 0.002, p = .047) scores predicted patient's gait speed at discharge.
Balance, age, leg strength, nutritional status, and upper limb function before postacute care rehabilitation are predictors of walking performance after stroke.
Ankle Proprioception Deficit Is the Strongest Factor Predicting Balance Impairment in Patients With Chronic Stroke
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To determine the main factor that predicts balance impairment in patients with chronic stroke.
Cross-sectional study.
Inpatient rehabilitation hospital and research laboratory.
A total of 57 patients (42 men, 15 women; mean age 55.7±12.2 years) with chronic symptoms after stroke.
Not applicable.
Primary outcomes were ankle functions, including strength, range of motion, and proprioception, and balance, including Berg Balance Scale score and Timed Up and Go test values. Secondary outcomes included gait kinematics, Fugl-Meyer Scale score, and Fall Efficacy Scale score.
According to the cutoff score <46 on the Berg Balance Scale and the Timed Up and Go test ≥13.5 seconds, 21 patients were classified as having a balance impairment (36.8%). Multivariable logistic regressions showed that ankle proprioception (odds ratio = 3.49; 95% confidence interval, 1.17-10.42) was a significant predictor when coupled with step length (odds ratio = 0.00; 95% confidence interval, 0.00-0.22). A cutoff score of 2.59 for the ankle proprioception value predicts balance impairment in patients with stroke (area under the curve 0.784).
Ankle proprioception can be used to predict balance impairment in patients with stroke.
Functions necessary for gait independence in patients with stroke: A study using decision tree
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On the other hand, the effects of approaches aiming to improve proprioception in stroke patients, especially lower limb proprioception, remain unknown at present. For example, Lynch et al.27 reported that the sensory training of lower limb in acute stroke patients for 2 weeks resulted in significantly improved tactile but not proprioception. In addition, Hiller et al.28 also reported that the sensory training of lower limb in three chronic stroke patients for 2 weeks resulted in significantly changed in light touch appreciation for two subjects but not proprioception.
Little is known about the existence and impact of interactions among multiple impairments to gait independence. The purpose of this study is to reveal the interaction of physical functions and its impact on gait independence in stroke patients.
This retrospective study included 108 subacute stroke patients. We conducted a decision tree analysis to examine the existence of interactions in relation to gait independence among the gross motor function of lower limb, knee extension strength, sensory function, and trunk function. Further, we confirmed the existence and impact of interaction detected via the decision tree after adjusting for the effects of confounding factors using logistic regression.
The knee extension strength and proprioception on the affected side were selected in the first and second level of the decision tree. In addition, the knee extension strength was selected in the third level. The interaction of the knee extension strength and proprioception on the affected side was significantly associated with gait independence, both before and after adjusting for age, visuospatial perception, and cognitive functions.
Our results suggest that the interaction of the knee extension strength and proprioception on the affected side is strongly associated with gait independence in stroke patients.
Somatosensory deficits
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We describe these studies in a separate section because, in most of these studies, motor function improvement, and not somatosensory function, was the primary outcome parameter. The available studies used active movement or balance training (Wong et al., 2012), passive movement training (Beets et al., 2012), somatosensory stimulation training (mostly vibration training, targeting patients with Parkinson disease (Chouza et al., 2011), somatosensory discrimination training (Lynch et al., 2007), or a combination of these (McKenzie et al., 2009)). Although interventions and outcome measures vary greatly, there is converging evidence that proprioceptive training improves somatosensory and sensorimotor function (Aman et al., 2014).
The analysis and interpretation of somatosensory information are performed by a complex network of brain areas located mainly in the parietal cortex. Somatosensory deficits are therefore a common impairment following lesions of the parietal lobe. This chapter summarizes the clinical presentation, examination, prognosis, and therapy of sensory deficits, along with current knowledge about the anatomy and function of the somatosensory system. We start by reviewing how somatosensory signals are transmitted to and processed by the parietal lobe, along with the anatomic and functional features of the somatosensory system. In this context, we highlight the importance of the thalamus for processing somatosensory information in the parietal lobe. We discuss typical patterns of somatosensory deficits, their clinical examination, and how they can be differentiated through a careful neurologic examination that allows the investigator to deduce the location and size of the underlying lesion. In the context of adaption and rehabilitation of somatosensory functions, we delineate the importance of somatosensory information for motor performance and the prognostic evaluation of somatosensory deficits. Finally, we review current rehabilitation approaches for directing cortical reorganization in the appropriate direction and highlight some challenging questions that are unexplored in the field.
The effects of plantar perception training on balance and falls efficacy of the elderly with a history of falls: A single-blind, randomized controlled trial
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Dynamic balance as well as static balance is important for the prevention of falls in the elderly (Daneshjoo, Mokhtar, Rahnama, & Yusof, 2012). In previous studies, standing on rubber mats or sponge mats was used to perform plantar perception training (Lynch, Hillier, Stiller, Campanella, & Fisher, 2007; Gandolfi et al., 2015). However, since balance can be improved even while just standing on them, there was a limitation in confirming whether plantar perception training is effective in improving balance by only the results of these studies.
The purpose of this study was to identify the effects of plantar perception training using a hardness discrimination task on balance and falls efficacy of the elderly who have experienced a fall.
Sixty-two elderly persons 65 years of age or older were randomly allocated to the experimental group (n = 31) or the control group (n = 31). The experimental group performed a hardness discrimination task using five different levels of hardness of sponge mats, while the control group performed the same task except that they were not asked to discriminate hardness levels of sponge mats. All subjects performed 10 sessions for two weeks. Outcome measures were conducted using center of pressure (CoP) sway in the standing position, the Timed Up and Go (TUG) test, and falls efficacy scale (FES) to measure balance and falls efficacy.
There were no significant differences in general characteristics between both groups (p > .05). After 10 sessions, plantar perception was significantly improved in the experimental group (F = 101.18, p < .001). Additionally, changes in CoP sway with eye closed and TUG test were significantly different (p < .05) between the experimental group (CoP sway with eye closed, −208.32 ± 74.89; TUG test, −1.91 ± 0.72) and the control group (CoP sway with eye closed, −14.55 ± 35.44; TUG test, −1.31 ± 0.75).
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Original articleSensory Retraining of the Lower Limb After Acute Stroke: A Randomized Controlled Pilot Trial

Abstract

Objective

Design

Setting

Participants

Intervention

Main Outcome Measures

Results

Conclusions

Section snippets

Methods

Results

Discussion

Conclusions

Acknowledgment

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Aust J Physiother

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Somatosensory loss after stroke

Crit Rev Phys Rehabil Med

Analysis of the clinical factors determining natural and maximal gait speeds in adults with a stroke

Am J Phys Med Rehabil

Recovery of somatosensory deficits in acute stroke

Acta Neurol Scand

Effectiveness of sensory and motor rehabilitation of the upper limb following principles of neuroplasticity: patients stable poststroke

Neurorehabil Neural Repair

A controlled trial of the retraining of the sensory function of the hand in stroke patients

J Neurol Neurosurg Psychiatry

Effects of perceptual learning exercises on standing balance using a hardness discrimination task in hemiplegic patients following stroke: a randomized controlled pilot trial

Clin Rehabil

The impact of physiotherapy on functional outcomes after strokeWhat’s the evidence?

Clin Rehabil

A pilot study of sensory retraining for the hemiparetic foot post stroke

Int J Rehabil Res

Original article
Sensory Retraining of the Lower Limb After Acute Stroke: A Randomized Controlled Pilot Trial