Leben ist Bewegung - Liv är rörelse. Life is movement - PDF

To Rajul Leben ist Bewegung - Liv är rörelse Life is movement from Funktionelle Bewegungslehre (1984), written by the Swiss physiotherapist Susanne Klein-Vogelbach . List of Papers This thesis is based

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To Rajul Leben ist Bewegung - Liv är rörelse Life is movement from Funktionelle Bewegungslehre (1984), written by the Swiss physiotherapist Susanne Klein-Vogelbach . List of Papers This thesis is based on the following papers, which are referred to in the text by their Roman numerals. I Frykberg GE, Aberg AC, Halvorsen K, Borg J, Hirschfeld H. Temporal coordination of the sit-to-walk task in subjects with stroke and in controls. Arch Phys Med Rehabil. 2009;90(6): II Frykberg GE, Åberg AC, Thierfelder T, Halvorsen K, Hirschfeld H, Borg J. Locomotor coordination during the sit-to-walk transfer is different in subjects with stroke and controls. Manuscript. III Frykberg GE, Lindmark B, Lanshammar H, Borg J. Correlation between clinical assessment and force plate measurement of postural control after stroke. J Rehabil Med. 2007;39(6): IV Frykberg GE, Thierfelder T, Åberg AC, Halvorsen K, Borg J, Hirschfeld H. Impact of stroke on strategies for force generation prior to seat-off during sit-to-walk. Submitted for publication. Reprints of Papers I and III were made with the permission of the publishers. The figure on the cover page was created in collaboration with Lotta Sjölander Contents INTRODUCTION...11 General introduction...11 Stroke...12 Stroke-related disability...12 Challenges in stroke rehabilitation...14 Movement control...16 Motor control...19 Postural control...20 Clinical measures...21 Laboratory measures...23 Relations between clinical and laboratory measures...24 Forward-oriented movements during daily life...26 Sit-To-Stand...26 Gait Initiation from standing...28 Sit-To-Walk...28 Rationale and scope of this research...30 Aims...31 The two principal aims of this research work...31 The specific aims...31 METHODS...32 Designs and subjects of Studies I-IV...32 Studies I, II, and IV...33 Study III...34 Procedures and data collection...35 Studies I, II, and IV...35 Study III...41 Data processing in Studies I-IV...43 Force data kinetics...43 Study I processing of vertical force data...43 Study IV processing of anterior-posterior force data...43 Study III processing of horizontal force data...44 Movement data kinematics...44 Studies I, II, and IV...44 Study III...46 Statistical analyses...46 RESULTS and DISCUSSION...48 Study I STW from a temporal perspective...48 Study II STW from a movement perspective...54 Study IV STW from a force perspective...56 Studies II III Relations between clinical and laboratory measures...60 GENERAL DISCUSSION...63 Kinetic, kinematic, and temporal aspects of the sit-to-walk transfer...63 Relations between clinical and laboratory measures...69 Summary and conlusions...72 Methodological considerations...73 Clinical implications...74 Future studies...74 Appendix Fluidity scale for the rise-to-walk task...76 Appendix Rating scale of weight distribution in quiet stance...77 SAMMANFATTNING PÅ SVENSKA (Summary in Swedish)...78 Tema I...78 Tema II...79 ACKNOWLEDGEMENTS...81 REFERENCES...84 Abbreviations ADL AP BBS COG COM COP DoF FI FS GI GMF GRF ICC ICF ML PHM PVM SEM% STS STW TO TUG WHO Activities of Daily Living Anterior-posterior Berg Balance Scale Centre of gravity Centre of mass Centre of pressure Degrees of freedom Fluidity Index Fluidity Scale Gait Initiation (from standing) General Motor Function assessment scale Ground reaction forces Intraclass correlation International Classification of Functioning, disability, and health Medio-lateral Peak horizontal momentum Peak vertical momentum Standard error of measurement in percentage of the mean Sit-to-stand Sit-to-walk Toe-off Timed Up and Go World Health Organisation Definitions of concepts Centre of pressure, COP the point location of the vertical ground reaction force vector (Winter, 1995) Centre of mass, COM a point representing the weighted average of the COM of each body segment in a 3D space (Winter, 1995) Impulse the area under a force-time graph (N*s) (Enoka, 2008) Kinematic referring to a description of motion in terms of position, velocity, and acceleration (Enoka, 2008) Kinetic relating to motion, a description that includes consideration of force as the cause of motion (Enoka, 2008) Momentum the quantity of motion possessed by an object, a vector quantity (Enoka, 2008) Pp measure percentage contribution from the paretic leg to total propulsion during walking (Bowden, Balasubramanian, Neptune & Kautz, 2006) INTRODUCTION General introduction Human beings are constantly interacting with the environment, using movements as means to reach everyday goals (Brooks, 1986). In physiotherapy, movement is one of the central concepts (European region of the World Confederation for Physical Therapy). Movement analysis is used by physiotherapists to evaluate disabilities in individuals with movement disorders. The disabilities can be divided into different categories: prerequisites for movement, movement ability, and/or movement behaviour (Tyni-Lenné, 1987). Movements are used as therapeutic tools in the interaction with the patient (Sahrmann, 1998), with the aim of reaching goals in everyday life such as being able to move more safely indoors and outdoors, to walk faster in order to catch a bus, or to fetch things from a cupboard with less pain and more precision, and so on. Sometimes the goal can even be to experience joy of movement. Stroke (brain infarction and/or haemorrhage) influences many different aspects of a person s being: physical, perceptional, emotional and cognitive (Strokeboken, 2001). Being afflicted by stroke often implies being unable to move in the same way in everyday activities as before the onset. During the 1980s, research on neuronal plasticity (Bach-y-Rita, 1980) resulted in new and challenging knowledge about the capacity of the central nervous system to reorganise after a brain injury. Different mechanisms of such reorganisation have been described and are suggested to be utilised in the recovery process after stroke (Nudo, 2006). In rehabilitation, interventions are made to promote motor recovery in the individual, by some researchers called restitution. However, true motor recovery is difficult to discriminate from motor compensation due to lack of precision in measurement (Levin, Kleim & Wolf, 2009). There are advanced laboratory methods, such as different neuroimaging techniques and force and movement analysis systems that offer possibilities of obtaining new knowledge in stroke research. However, these methods are far from always available in clinical reality. Physiotherapists in clinical settings use standardised assessment instruments that provide information about different aspects of the patient s movement disorder. Some researchers (Latash, 1993; Garland, Willems, Ivanova & Miller, 2003; Leroux, Pinet & Nadeau, 2006) consider that the theoretical basis of 11 movements can be enhanced by studying relations between clinical and laboratory measures. Thus, there seems to be a need to explore these relations further, with the aim of revealing information of relevance to movement control after stroke. Investigation of the coordination of posture and voluntary movements during everyday motor tasks, such as transfers, is considered to be important for the development of neurological rehabilitation (Hirschfeld, 2007). Regarding forward-oriented locomotion this is not an easy task, as motor coordination is extremely complex, considering that human beings transport and balance their bodies in a 3D space, often on a small support area defined by the feet. In the following section the area of research is outlined. Stroke The World Health Organisation (WHO) defines stroke as rapidly developing signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death), with no apparent nonvascular cause (Thorvaldsen, Kuulasmaa, Rajakangas, Rastenyte, Sarti & Wilhelmsen, 1997). Stroke is the most common acutely acquired brain injury in adults in the western world and an important cause of disability. Stroke includes brain infarction ( 85 %), intracerebral haemorrhage (c. 10%), and subarachnoid haemorrhage (c. 5%) (National Stroke Register in Sweden, 2008). The incidence of stroke in Sweden is about per year. Approximately 70% of these cases are first-ever stroke and the remainder are recurrent stroke. Since the year 2000, the proportion of first-ever stroke has decreased by about 10% in both men and women. The decline is most evident in the elderly age group. The mean age at incidence of stroke is 73.2 years for men and 78.3 years for women. The same proportions of men (50.1%) and women (49.9%) are afflicted by stroke (National Stroke Register in Sweden, 2008). About 20% of persons suffering from stroke are younger than 65 years. In this age group, there is a male predominance (65%) of stroke (Medin, Nordlund & Ekberg, 2004). Stroke-related disability The symptoms post-stroke are varied and mainly comprise sensorimotor dysfunctions, problems in swallowing, perceptional deficits, affected vision and dizziness, emotional and cognitive disturbances, and communication difficulties (Stroke-boken, 2001). Fatigue (Choi-Kwon, Han, Kwon & Kim, 12 2005) and depression (Jönsson, Lindgren, Hallström, Norrving & Lindgren, 2005) are common symptoms after stroke, and have a considerable impact on daily activities. Walking function post-stroke is impaired in 67% of the patients and most of the improvement of walking occurs within the first three months after the stroke onset (Jörgensen, Nakayama, Raaschou & Olsen, 1995a). Approximately half of all surviving patients have residual disabilities concerning activities in daily living (Jörgensen, Nakayama, Raaschou, Vive-Larsen, Stöier & Olsen, 1995b). The consequences of a stroke may influence body function and structure, activity, and participation, as defined in the International Classification of Functioning, disability, and health, ICF (WHO, 2001). The corresponding components of dysfunction are described as impairment, activity limitation, and participation restriction. This classification was developed to facilitate communication and documentation among health professionals worldwide. Within the body function and structure component of ICF, muscle weakness post-stroke is considered to be a major contributor to limitation of physical activity (Ada, Dorsch & Canning, 2006). Moderate to strong correlation between knee muscle strength and walking ability has been reported (Flansbjer, Downham & Lexell, 2006), thus reflecting association between different ICF components. After stroke, muscle strength has been shown to be impaired bilaterally (Andrews & Bohannon, 2000). Spasticity occurs in about 20% of stroke patients (Sommerfeld, Eek, Svensson, Holmqvist & von Arbin, 2004; Lundström, Terént & Borg, 2008). About 4% of the patients experience disabling spasticity, i.e. an increased muscle tone with a pronounced impact on everyday life, one year after stroke onset (Lundström, Terént & Borg, 2008). Spasticity used to be in focus in stroke rehabilitation, and treatment methods aimed at inhibiting this sympton were developed. Currently however, stroke rehabilitation is focused on how to improve muscle strength and physical activity (Van Peppen, Kwakkel, Wood-Dauphinée, Hendriks, Van der Wees & Dekker, 2004). Impaired postural control is a common stroke-related disability (de Haart, Geurts, Huidekoper, Fasotti & van Limbeek, 2004). It influences daily life activities with respect to the ability to maintain a position (Genthon, Rougier, Gissot, Froger, Pélissier & Pérennou, 2008), to perform voluntary movements such as reaching for an object (Kussofsky, Apel & Hirschfeld, 2001), climbing over obstacles (Cameron, Bohannon, Garrett, Owen & Cameron, 2003), as well as regaining balance after external perturbations (Holt, Simpson, Jenner, Kirker & Wing, 2000). Moreover, loss of balance is often reported as a cause of falls (Hyndman, Ashburn & Stack, 2002). There is a high risk for falls during all stages after stroke onset (Weerdesteyn, de Niet, van Duijnhoven & Geurts, 2008). During the rehabilitation period, falls most often occur during transfers indoors (Nyberg & Gustafson, 1995; Suzuki, Sonoda, Misawa, Saitoh, Shimizu & Kotake, 2005), whereas community-dwelling individuals fall while walking (Harris, 13 Eng, Marigold, Tokuno & Louis, 2005). Many different risk factors are suggested as predictive of falls after stroke, including fall-related selfefficacy (Hellström & Lindmark, 1999; Pang & Eng, 2008; Andersson, Kamwendo & Appelros, 2008). Within the participation component of ICF, it has been demonstrated that impairments of the lower and upper extremities post-stroke correlate with handicap (i.e. participation in the updated version of ICF) (Desrosiers, Malouin, Bourbonnais, Richards, Rochette & Bravo, 2003). Disability of the leg was found to be more strongly associated with handicap than was disability of the arm. Long-term participation after stroke is reported to be best predicted by lower extremity coordination as well as by age, comorbidity and affect (Desrosiers, Noreau, Rochette, Bourbonnais, Bravo & Bourget, 2006). These research results emphasise the importance of improving locomotion in order to enable integration into the community after stroke. Challenges in stroke rehabilitation Assumptions concerning the potential for functional recovery after stroke have changed over time. According to the Copenhagen Stroke Study (Jörgensen, Nakayama, Raaschou, Vive-Larsen, Stöier & Olsen, 1995b), a valid prognosis of walking function in stroke patients with initially mild or moderate leg paresis is possible three weeks post-injury. It was suggested by the investigators that no further recovery should be expected after nine weeks. Later, a quite different view of functional recovery after stroke based on studies of plasticity within the brain emerged (Dobkin, 2004). There is increasing evidence for functional and structural changes in the brain, socalled adaptive plasticity, after brain injury. Even in the chronic period after stroke, reorganisation of cortical function is possible, but is likely to be widespread and not just confined to the peri-infarct regions (Nudo, 2003). Several studies during the past decade have shown correlations between cortical reorganisation and clinical outcomes in stroke patients regarding both upper extremity function (Liepert, Bauder, Wolfgang, Miltner, Taub & Weiller, 2000; Lindberg, Schmitz, Forssberg, Engardt & Borg, 2004) and gait (Miyai, Yagura, Oda, Konishi, Eda, Suzuki et al. 2002). There are many areas in the field of stroke rehabilitation where research and development of treatment approaches are ongoing. Improved postural control is considered a key characteristic of functional recovery after stroke (Fong, Chan & Derrick, 2001). In a recent Cochrane review of 21 studies (Pollock, Baer, Pomeroy & Langhorne, 2007) it was concluded that there is no evidence confirming that a single physiotherapy approach is better than another for improving balance, muscle strength in the 14 leg, walking speed, or the performance of everyday tasks. However, the results were better after physiotherapy where components from different treatment approaches were used as compared with no treatment or use of placebo. The concept of walking competency, including different aspects of walking such as endurance, obstacle avoidance, and cognitive tasks concomitant with walking, is an area of study in physiotherapy research (Malouin & Richards, 2004). Further, locomotor treadmill training with partial body-weight support is also under investigation in stroke rehabilitation. Promising results have been obtained in a pilot study (McCain, Pollo, Baum, Coleman, Baker & Smith, 2008). Overground gait training is often performed in stroke rehabilitation, but there is no evidence (States, Pappas & Salem, 2009) as to whether this type of training really improves gait function. Insufficient evidence also applies to repetitive task training (French, Thomas, Leathley, Sutton, McAdam, Forster et al, 2007), which is implemented intensively and aimed at improving functional ability after stroke. In constraint-induced movement therapy, where movement of the unaffected arm and hand is restricted, the subject with stroke is forced to use the paretic limb. Short-term improvements have been demonstrated, but there is no evidence of long-term benefits (Sirtori, Corbetta, Moja & Gatti, 2009). Mental practice with motor imagery and training in a virtual reality environment are areas in focus within stroke rehabilitation and these methods are investigated with both clinical and laboratory measures (Malouin & Richards, 2004). The role of robotics in neuro-rehabilitation is still unclear and constitutes another challenge within stroke research, which needs to be further investigated (Pignolo, 2009). In a systematic review of 151 studies, including many randomised controlled trials and some clinical controlled trials, the impact of physical therapy on functional outcomes after stroke was investigated. Strong evidence for task-oriented programmes aimed at restoring balance and gait was found. However, the effects were mainly observed in the tasks being trained. One of the conclusions in the review was that a more thorough theoretical understanding of the underlying mechanisms of disordered movements is needed in order to be able to develop more specific treatment approaches (Van Peppen, Kwakkel, Wood-Dauphinée, Hendriks, Van der Wees & Dekker, 2004). 15 Movement control Movements and postures are critical for humans in their interaction with the environment. Thoughts and emotions are expressed through movements and postures (Brooks, 1986). Movement is said to emerge through interplay between an individual, a task to be performed, and the environment in which it all takes place (Shumway-Cook & Woollacott, 2007a), as illustrated in Figure 1. Within the individual, many systems dealing with perception, cognition, and action interact to produce goal-directed everyday movements. The present thesis is mainly focused on action during the everyday sit-to-walk (STW) transfer. Figure 1. Factors within the individual (I), characteristics of the task (T), and constraints in the environment (E) contribute to the organisation of movement (M). Figure from Shumway-Cook & Woollacott, 2007 used with permission from the publisher Lippincott Williams & Wilkins. Movement science is proposed as a foundation for physiotherapy practice (Carr, Shepherd, Gordon, Gentile & Held, 1987). Previously, physiotherapists had to extract scientific information from the research of other professionals. However, physiotherapists are now developing their own scientifically based body of knowledge related to movement and 16 movement disorders in humans, and physiotherapy is evolving into a clinical science within the rehabilitation sciences (Sahrmann, 1998; Richards, 2005). As a movement scientist, the physiotherapist is involved in research on human movement (Carr, Shepherd, Gordon, Gentile & Held, 1987). In the textbook Motor control Translating research into clinical practice, Shumway-Cook and Woollacott state understanding motor control and, specifically, the nature and control of movement is critical to clinical practice (2007a). However, understanding the nature of movement and movement control requires interdisciplinary research collaboration (Winstein & Knecht, 1990), and physiotherapy is one of many important disciplines contributing to the rehabilitation sciences in this area (Richards, 2005). Movements can be studied from a kinematic perspective, i.e. without considering the causes of movements. Exact descriptions of movements in terms of positions, velocities, and accelerations of different body segments or of the whole body, for example during gait, are frequently reported (Enoka, 2008). A kinetic perspective, on the other hand, represents an approach where movem
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