Complex versus simple ankle movement training in stroke using telerehabilitation: a randomized controlled trial

Abstract

Background: Telerehabilitation allows rehabilitative training to continue remotely after discharge from acute care and can include complex tasks known to create rich conditions for neural change.

Objectives: The purposes of this study were: (1) to explore the feasibility of using telerehabilitation to improve ankle dorsiflexion during the swing phase of gait in people with stroke and (2) to compare complex versus simple movements of the ankle in promoting behavioral change and brain reorganization.

Design: This study was a pilot randomized controlled trial.

Setting: Training was done in the participant's home. Testing was done in separate research labs involving functional magnetic resonance imaging (fMRI) and multi-camera gait analysis.

Patients: Sixteen participants with chronic stroke and impaired ankle dorsiflexion were assigned randomly to receive 4 weeks of telerehabilitation of the paretic ankle.

Intervention: Participants received either computerized complex movement training (track group) or simple movement training (move group).

Measurements: Behavioral changes were measured with the 10-m walk test and gait analysis using a motion capture system. Brain reorganization was measured with ankle tracking during fMRI.

Results: Dorsiflexion during gait was significantly larger in the track group compared with the move group. For fMRI, although the volume, percent volume, and intensity of cortical activation failed to show significant changes, the frequency count of the number of participants showing an increase versus a decrease in these values from pretest to posttest measurements was significantly different between the 2 groups, with the track group decreasing and the move group increasing.

Limitations: Limitations of this study were that no follow-up test was conducted and that a small sample size was used.

Conclusions: The results suggest that telerehabilitation, emphasizing complex task training with the paretic limb, is feasible and can be effective in promoting further dorsiflexion in people with chronic stroke.

Trial registration: ClinicalTrials.gov NCT01298583.

Figure 1.

Flow chart showing the number of participants at each stage of the study. MRI=magnetic resonance imaging.

Figure 2.

Left panel: Training at home for a participant in the track group. The training system consisted of a laptop computer (A) (in this instance, showing 1:17 min/s into a participant-selected pause from tracking), an ankle electrogoniometer brace (B), a web camera (C), a single-button control box (in participant's hands, not shown), and a wireless modem (D). Right panel: Telecommunication setup at therapist's location. The therapist could see the participant's tracking performance in one window. Simultaneously in another window, with the participant's camera directed on the ankle, the therapist also could see the actual ankle movement. With the therapist's camera directed on the therapist, the participant could see the therapist. Audio was transmitted in both directions.

Figure 3.

Regions of interest in sagittal, coronal, and transverse images of one participant's brain with left hemisphere stroke. A=anterior, P=posterior, R=right, L=left.

Figure 4.

Median (first quartile, third quartile, minimum, maximum) values of gait variables: (A) dorsiflexion, (B) toe clearance, (C) gait temporal symmetry ratio (GTSR), and (D) stride length.

Figure 5.

Cortical activation at one coronal slice (Y=−30) and 3 transverse slices (Z=65, 60, and 55) for one participant in move group with right hemisphere stroke tracking with paretic left ankle and one participant in track group with left hemisphere stroke tracking with paretic right ankle. Change from pretest to posttest shows reduction in activation with greater focus to the ipsilesional hemisphere in the track group participant compared with the move group participant. R=right, L=left. FDR=false discovery rate.