Rehabilitative Assessment Using Gait from Stroke Patients

Rehabilitative Assessment Using Gait from Stroke Patients

Assessment on

“Rehabilitative Assessment Using Gait from Stroke Patients”

Submitted in Partial Fulfilment for the Award of





Tejaswini Dabbara








Research Methods: Rehabilitative Assessment Using Gait from Stroke Patients

Supervisor: Professor Saeid Sanei

Date: 01/05/2020

“In submitting this work, I confirm that I am aware of, and am abiding by, the

University’s expectations for proof-reading”.

Signed:Tejaswini Dabbara.



Part 1:


The ability to move has proved essential for the evolution of the human being, no less important than the development of intellectual and emotional capacities. Movement is one of the crucial aspects of life, without movement one cannot feed, one cannot reproduce, one cannot survive.

One of the principal causes behind the mortality and morbidity in adults is the stroke and its survivor can suffer neurological impairments such as communication disorder, hemiparesis, or cognitive defects. These impairments have an important impact on the life of the patient. A careful assessment of functional impairments is one of the fundamental importance for planning the rehabilitation intervention and for clinical management of the stroke patients. At the same time, the measurement of impairments and disabilities makes it possible to aware healthcare staff, the patient and the family of the level of severity of the initial clinical picture that conditions the subsequent evolution and contributes to determine the objectives of the rehabilitation process.  Instruments for measuring motor and sensory impairments have been developed and are currently used in other conditions pathologies of the central nervous system both for diagnostic purposes and for the design of rehabilitation treatment and for formulation of the prognosis.

The assessment complexity is dependent on how much of brain is damaged, the concomitant of the state of consciousness or the impairment of cognitive and behavioral functions together with injuries and extra nervous pathologies and it is very complex to use the data for the formulation of the prognosis and analyzed the interference between the many health and social factors that determine the outcome of stroke. The multiplicity of possible clinical pictures and methods of evolution makes it further difficult to identify expendable tools indifferently in the clinical evaluation of people who have suffered a serious brain injury. So, it very important to know the clinical evolution of these people to identify criteria to identify standardized sets of clinical assessment tools.

However widespread the awareness of the complexity of the problem and of the shortcomings that still exist from the point of view of the assessment of sensory and motor functions, there are only few works are done on it. While studies on motor impairments clearly prevail the sensorial ones mainly address the problem of balance and instability, in particular to give objectivity to the sensations of disequilibrium complained by patients with a mismatched neurological objectivity.

GAIT Technique:

GAIT analysis is considered to be one of the important technologies for most of the clinical applications for diagnosing & monitoring numbers of disease. Many abnormalities linked with the physical and mental health cause measurable differences in person’s gait. This GAIT analysis has its application in physical rehabilitation, games, sports, surveillance, human recognition, clinical assessment, & other fields. Currently, gait rehabilitation depends largely on physical therapy interventions, with an automated approach that still works only marginally. All the different physical therapies aim to improve the functional environment, generally preferred for training on the floor. In addition to the specific technology used, all approaches require specially designed preparatory exercises, physical therapist observation and direct manipulation of the position of the lower extremities while walking on a normal surface, followed by walking with assistance on the ground.

Aims and objectives:

The main aim of this research work is to perform an analysis of patient with stroke using the GAIT method and understand the bodily activity of the patient and also to observe the brain motion for accurate analysis. In this project, GAIT Rite tool will be used to measure the GAIT.


To complete the project, numerous tasks will be performed. Some of the salient tasks are as follows;

  • Reading the online published research work
  • Analyzed different tools used in place of GAIT technique
  • Analyzed the effectiveness of using GAIT Rite tool

Source of information and resources required:

For this project, I have to conduct a detailed study of different researches done in the past. I also have used the prime resource of text book for understanding the electronic phenomena but majorly, I used the internet sources. I have performed a detailed study and analysis for already work done on similar projects. I used the information available on some of the websites as understanding the GAIT Rite tool and its implementation for assessment. Furthermore, I gathered the information from the different publications and research papers covering a great part of this research.

Project Risk:

Risk Management integrates the procedures of leading risk management plans, investigation, identification of risks, reaction arranging, response execution, and risk monitoring. The targets of risk management are to build a likelihood as well as to analyze the effect of positive risks for abolish the encountered likelihood plus the additional negative risks, for optimizing the project success. (A Project Management guide (PMBOK® Guide), 2017). The potential risk for this project for the given project might involve risk of not meeting the deadlines. The second risk of the project might involve the inaccuracy of real data that might resulted in weak project.


Professional Issue:

With the advent of new technologies there are also issues associated with the normal routine. Such a with the emerging technologies security of the data is one big problem.

Gantt Chart:















 Part 2:


Literature Review

In about two thirds of stroke patients, mobility is at least initially impaired. Numerous different concepts are postulated for rehabilitation. Which rehabilitation methods can be recommended on the basis of the study situation to improve walking ability, walking speed, walking distance and standing and gait security? Systematic literature search for randomized clinical studies and reviews with clinically relevant target criteria for mobility. Formulation of recommendations, separate for target criteria and the phases after a stroke Results (A Project Management guide (PMBOK® Guide), 2017). The core measure for restoring and improving walking ability is a high number of repetitions of walking movements, depending on the severity of the device-supported device. In less affected patients, intensive gait training is recommended to increase walking speed, in which device support is optional but not considered superior. Improving the walking distance requires aerobic, cardiovascular endurance training, imperatively embedded in a functional context. The best strategy to improve the balance is not the isolated balance training, but the intensive gait training in a functional context relevant to everyday life. Additional stimulation procedures are only effective if they are integrated into functionally relevant training. The guideline not only offers clear instructions for action, but also pathophysiological insights into the functional recovery of walking and standing after a stroke. (G. Chen, 2005)

According to the theory of Bershtein N.A. (1947, 1966) there are several levels of motor function control, each of which has its own “feedback” mechanism. The highest level of walking regulation is provided by the cerebral cortex and the subcortical structures associated with it. Its main function is the adaptation of postural and locomotor synergies to specific environmental conditions, the position of the body in space, the intentions of the individualIt can distinguish two main subsystems. The first subsystem is formed by the links of the main motor cortical-subcortical circle. (Regardo, 2011) To allow a direct comparison of the functional images with the gait analysis results, brain recruitment caused by flexion-extension of the ankle, which represents the motor paradigm characterizing gait, was found in fMRI. Through a 1.5T Siemens Magnetom Avanto MRI scanner the neural activity determined by the execution of the task in an active and passive way, both with the paretic limb and with the healthy one, was acquired, respecting an alternating block protocol of action and rest. 2D cinema systems, consisting of commercial cameras that allow a stroboscopic vision through the concatenation of frames by matching the background. The dimensional scale is defined on an object of known size placed in the movement plane. The trajectories of virtual markers identified in the image can be qualitatively analyzed, calculating the angles between segments and estimating linear and angular speeds. 3D cinema systems based on the same principle of 2D cinematography are also available, but the coordinates are obtained in three dimensions thanks to the triangulation of commercial cameras not aligned in space. Both have the advantage of allowing a non-invasive and not limited to laboratory detection, but in the field. Compared to optoelectronic systems, however, they have a lower accuracy and a limited acquisition frequency. (Regardo, 2011)

The C.A.S.T. - Calibrated Anatomical System Technique has been developed to be an experimental protocol linked to the estimation of anatomical reference systems in solidarity with adjacent bone segments. For the reconstruction of joint kinematics, it is in fact necessary to first define a technical reference system for each body segment starting from the coordinates of the markers in the laboratory reference system. This reference system can coincide with the anatomical reference system and can be determined from the position of three non-aligned markers, belonging to a cluster, placed on the surface of the bone segment under analysis. The minimization of leather artifacts was the criterion on which the development of the CAST was based, which is based on the "anatomical calibration" approach. In particular, this protocol envisages positioning the cluster markers in areas where the slippage of the tissues is less than the bone, in order to minimize soft tissue artifacts. The identification of the anatomical landmarks is obtained without applying the markers on them, but by reconstructing their position over time with respect to the previously defined technical systems. (E. Taub and S. Wolf, 1997)

Optoelectronic systems: consisting of coaxial infrared illuminators with IR cameras that detect the waves reflected by markers placed on the subject inside the illuminated volume. They are currently the most used systems in the laboratory, which allow better accuracy and higher acquisition frequencies. This type of system has been used in this thesis, for this reason it will be described in more detail in the next paragraph

Starting from various sections of the cortex, it successively includes the neurons of the striatum, pallidum, thalamus and returns to the additional motor cortex, the structures of this circle are involved in the initiation and maintenance of movement. The additional motor cortex, interacting with other circle structures, provides the preparation and implementation of complex automated, learned locomotor and postural synergies, especially with multi-stage movements, participating in the sequential switching of their phases, as well as in the selection and switching of walking programs when its conditions change. (A Project Management guide (PMBOK® Guide), 2017)

Frontal lobes and basal ganglia play an important role in the selection and implementation of adequate locomotor and postural synergies. Violation of the generation of postural shifts at the first step or turns is one of the main defects in disorders of higher walking type associated with lesions of the frontal lobes and basal ganglia. When the additional motor cortex and basal ganglia are damaged, the automatic choice of an adequate strategy is disrupted, anticipatory and rescue postural synergies are suppressed or slowed, which leads to frequent falls. The condition of the cortical-subcortical motor circle is modulated by the nigrostriatal dopaminergic system.

The main component of the second subsystem of the higher level of walking regulation is the premotor cortex, through which movements are initiated, initiated and realized under the influence of external stimuli. Through numerous cortical-cortical connections, the premotor cortex closely interacts with the associative zones of the parietal cortex, which, based on the received visual, proprioceptive, tactile, vestibular, auditory information, form a diagram of the body and the surrounding space. Through premotor cortex, locomotor synergies are adapted to specific surface conditions and other environmental features. This subsystem is especially important during new unusual movements or when performing learned movements, but in an unusual context, as well as when overcoming obstacles or when external reference points need to be taken into account (for example, when walking through strips drawn on the surface). When the premotor cortex is damaged, the tasks that require visomotor coordination, such as walking on uneven surfaces or overcoming obstacles, are primarily disrupted. The premotor cortex regulates walking through the primary motor cortex. In addition, fibers directly go from it to the reticular formation of the medulla oblongata - a single end path to the spinal walking generators. It has been established that the spinal cord contains spinal generators of locomotor activity (SLH) - interneuron structures that provide stereotypic rhythmic coordinated activity of the muscles of each limb, inter-limb coordination, as well as coordination of the activity of muscles of the limbs and trunk for movement in space. Normally, SLH is activated supraspinally through the reticulospinal and other descending systems, and is corrected by the afferent inflow

Physiological prerequisites for reconstructive treatment of locomotor function

Impairment of motor function may be due to damage to the pyramidal and extrapyramidal systems at various levels. The basis of the restoration of impaired motor function is the mechanism of neuroplasticity - the ability of the nervous tissue to structurally functional restructuring that occurs after its damage. In the process of previous studies, it was proved that the mechanism of neuroplasticity is activated in the process of repeated targeted repetition of movements. It should also be noted that with the complete defeat of the pyramidal pathway during the rehabilitation treatment of motor disorders, activation of the LH of the spinal cord comes to the fore, which is also achieved through long-term targeted muscle training.

In modern neurorehabilitation during the rehabilitation treatment of motor function, more and more preference is given to robotic rehabilitation complexes. In the process of training on robotic complexes, there is a long targeted training of limbs, activation of neuroplasticity processes and spinal generators of locomotor activity, and the effect is fixed using biofeedback (BFB).

Rehabilitation of motor function

The gait analyzes were carried out using the BTS SMART-D 8-camera optoelectronic stereophotogrammetry system, to detect the kinematics of markers positioned in accordance with the LAMB protocol, two Kistler piezolectric force platforms, to measure the forces and moments of reaction on the ground, and a BTS FreeEMG wireless electromyographic system, to measure the activity of the eight main muscles of the paretic lower limb involved in the path. It was thus possible to arrive at an estimate of the most significant kinematic and dynamic parameters that characterize the pathological path, at normal and maximum speed, of the subject studied.

Through gait analysis, the kinematic and dynamic parameters will be analyzed that represent alterations of the biomechanical behavior associated with the change of walking speed, from natural to fast. In fact, the speed can be increased by increasing the stride length and / or cadence, in any case always in association with changes in the mechanical work produced to the proximal joints and / or distal, which may be different from those implemented by healthy subjects. All hemiparetic subjects involved in the study showed, in the free speed walk, a higher cadence and a lower stride length than those of control at the same speed, with a difference that was less the more the speed of the free walk approached that not pathological. (G. Chen, 2005)

Robotic devices for restorative treatment of the upper limb include MIT-MANUS, ARM Trainer, mirror-image motion enable (MIME) robot, Armeo; to restore the lower limb are used - Erigo, Lokomat, Lokohelp, Rehabot, Gait Trainer, Lopes, etc. The most studied are the Erigo and Lokomat robotic systems (Hocoma, Switzerland). In order to facilitate the mobilization of patients with severe motor impairment, the Hocoma company (Switzerland) created the verticalizer table Erigo, which, unlike the classic turntables, is equipped with an integrated robotic orthopedic device that allows simultaneous verticalization of the patient (from 0 to 80 degrees ) to carry out intensive motor therapy in the form of passive dynamic movements of the lower extremities with the possibility of a cyclic load on them. of blood in the lower extremities and prevent the development of orthostatic reactions during the verticalization of patients. The Erigo complex simultaneously solves several global problems: verticalizes and adapts the patient to increasing physical activity, increases muscle strength, reduces pathological tone and begins the process of forming and restoring the physiological walking pattern. The training course on this simulator is a quick rehabilitation start, preparing patients for extended rehabilitation, as well as training on the Lokomat system, which is a treadmill with weight unloading with a robotic walking mechanism.

Currently, many studies have been conducted evaluating the effectiveness of robotic mechanotherapy in the rehabilitation treatment of motor function compared to conservative rehabilitation therapy.

In the work of Mayr A, Kofler M, (2007) studied the effects of using the Lokomat system in 16 patients with post-stroke hemiparesis no more than 1 year old with different localization of the lesion and different etiologies. The main group (8 patients) received 3 weeks of training on the Lokma system, then for 3 weeks - the usual traditional therapy, and then again for 3 weeks - therapy using the Lokomat system. In the control group (8 patients), the sequence of application of traditional therapy and the Lokomat system was different. During the first 3 weeks, patients received traditional rehabilitation, then within 3 weeks - the Lokomat system, and in conclusion - again 3 weeks of traditional rehabilitation. The effects of the treatment were evaluated using point scales and on such indicators of the Lokomat system as walking speed, the degree of unloading of body weight and the degree of reduction of the control effort by Lokomat. A comparative study revealed the advantage of automated training on the Lokomat system in relation to traditional rehabilitation in terms of clinical indicators of walking assessment. The authors believe that training on the Lokomat system is especially useful in the early stages of recovery, when there are problems with balance, expressed by paresis, instability of muscle tone.

A study by Hidler J., Nichols D., (2009) evaluated the effectiveness of therapy with the Lokomat system in 30 patients with post-stroke hemiparesis with a stroke duration of 28 to 200 days. In addition to the generally accepted clinical scales, we used walking estimation using the Paromed Neubeuern system (Germany), analyzed the bioelectrical impedance of the soft tissues of the body, estimated muscle tone according to the Ashfort scale and the activity of daily life using the Barthel index. The study showed that in patients who received training on the Lokomat system, the duration of a single support on the paretic leg increased, which contributed to a more symmetrical gait, increased muscle mass and decreased percentage of fat in the studied tissues. At the same time, statistically significant differences in other dimensions were not noted.

In a multicenter study, the effect of using the Lokomat system on the state of functional mobility was studied in 20 patients with consequences of a spinal cord injury from 2 to 17 years old. The study was conducted in 5 rehabilitation centers (USA, Germany and Switzerland) for 2 years. It should be noted that prior to training using the Lokomat system, 16 out of 20 patients could move at least 10 m using walking aids. Workouts lasted for 8 weeks 3-5once a week for 45 minutes per day. The study showed that the use of the Lokomat system in patients with consequences of a spinal cord injury led to a significant increase in walking speed, endurance and improved performance of functional tasks. At the same time, no correlations were obtained between the increase in walking speed and the degree of paresis and spasticity. It should also be noted that 4 patients who, before starting training on the Lokomat system could not move, did not regain their mobility after completing an 8-week training course.

In 2008 Freivogel S , Mehrholz J  A study was conducted evaluating the effectiveness of the LokoHelp robotic complex. After a course of rehabilitation treatment, a group of patients who were engaged in the LokoHelp robotic complex showed a significantly significant (p = 0.048) improvement in walking ability according to the Functional Ambulation Category from 0.7 to 2.5; significantly significant (p = 0.086) increase in strength in the lower extremities according to the Motricity Index from 94 to 111 units; significantly significant (p = 0.033). an increase in mobility according to the Rivermead Mobility Index from 5 to 7 units.

To devices similar to Erigo, which appeared in Italy in 2010, the BTS ANYMOV system is a robotic hospital bed for the functional rehabilitation of patients after a stroke or head injury. BTS ANYMOV (BTS SpA, Italy) - a rehabilitation robotic hospital bed that allows you to conduct special repetitive workouts built on smooth, passive exercises. The work of this hardware complex provides active, supportive, segmented and multisegmented mobilization of the hip, knees, ankle joint due to active exercises with resistance, commensurate with the capabilities of the patient.

Restoring the walking skill also involves raising and lowering the patient by steps as a necessary element of daily physical activity. In recent years, robots have been developed to train climbing stairs. These include G-EO, Haptic Walker systems. The effectiveness of the G-EO-System robot simulator compared to the work of instructors was confirmed by electromyographic studies in a study by Hesse S., Waldner A., ??Tomelleri C.

Thus, robotic devices are now beginning to occupy a certain important place in the comprehensive rehabilitation of neurological patients with severe motor impairment of various etiologies, however, further studies, both to study the effects and develop methods for using robotic systems, are apparently required. Most authors using robotic devices note that training on this system in no way replaces traditional therapeutic exercises, should be used in combination with other rehabilitation methods. However, it is emphasized that robotic mechanotherapy has significant advantages in teaching walking skills to patients with severe paresis of various etiologies.

One of the ways to improve is the combination of robotic technologies with other methods of activating neuroplasticity mechanisms (functional neuromuscular electrical stimulation and stimulation methods of treatment that affect various levels of the central nervous system).

The use of virtual reality technologies that simulate real conditions using computer techniques allows you to achieve greater training efficiency against the background of feedback sensory communication. Using fMRI, the reorganization of the activity of the motor cortex was confirmed using virtual reality technologies for walking training.











Hachisuka K. Robot-aided training in rehabilitation // J. Brain Nerve -2010.- ? 2.- P.133-140.

Cheatwood J.L., Emerick A.J., Kartje G.L. Neuronal plasticity and functional recovery after ischemic stroke // Topics in stroke rehabilitation. -2008.-Vol.15-P.42-50.

heartwood J.L., Emerick A.J., Kartje G.L. Neuronal plasticity and functional recovery after ischemic stroke // Topics in stroke rehabilitation. -2008.-Vol.15-P.42-50

Westlake K.P., Patten C Pilot study of Lokma versus manual-assisted treadmill training for locomotor recovery post-stroke // J. Neuron Rehabilitation. -2009.- ? .6- P. 6-18.

Hachisuka K. Robot-aided training in rehabilitation // J. Brain Nerve -2010.- ? 2.- P.133-140.

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E. Taub and S. Wolf. ( 1997). Constraint induced movement techniques to facilitate upper extremity use in stroke patients.

G. Chen, C. P. (2005). Gait deviations associated with post-stroke hemiparesis: improvement during treadmill walking using weight support, speed, support stiffness, and handrail hold. (Vol. vol. 22).





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