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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 262-266

Alteration in ankle kinematics during uneven surface ambulation in stroke survivors: An exploratory observational study


1 JSS Physical Medicine and Rehabilitation Centre, JSS Hospital, JSS College of Physiotherapy, Mysuru, Karnataka, India
2 Centre for Health, Activity and Rehabilitation Research, School of Physiotherapy, University of Otago, Dunedin, New Zealand

Date of Submission24-Feb-2020
Date of Decision09-May-2020
Date of Acceptance11-Jun-2020
Date of Web Publication28-Jul-2020

Correspondence Address:
Dr. Muhammed Rashid
Research Assistant, JSS College of Physiotherapy, JSS Hospital Campus, M.G Road, Agrahara, Mysuru - 570 004, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_20_20

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  Abstract 

BACKGROUND: Impaired walking ability is a common disability in stroke survivors and is a known risk factor of fall. Navigation of uneven terrain is essential for rural residents of regions in much of the developing world even for basic activities of daily living.
AIMS: This is a preliminary exploratory study to evaluate kinematic gait parameters of the ankle joint in stroke survivors in comparison to typical adults.
MATERIALS AND METHODS: Seven chronic adult stroke survivors and seven age-matched typical adults were recruited for the study. Measurement of ankle and subtalar joint kinematics at different events of the gait cycle was recorded and analyzed using a motion analyzing software, Kinovea 0.8.15. Settings and Design: This is a prospective pilot study. Statistical Analysis Used: Descriptive statistics.
RESULTS: During different events of the gait cycle, a large difference in range of motion in ankle and subtalar joints was noticed between stroke survivors and typical participants on pebbles and sand.
CONCLUSIONS: The impact of gait deviations on joint kinetics is a future direction that will inform rehabilitation professionals on strategies to prevent joint loading, leading to dysfunction. Early intervention strategies to improve joint kinematics on different surfaces can potentially reduce the risk of fall, making the patient safe to ambulate on uneven terrains.

Keywords: Gait alterations, joint kinematics, outdoor ambulation, uneven terrains, uneven walking


How to cite this article:
Rashid M, Mathew J, Raja K. Alteration in ankle kinematics during uneven surface ambulation in stroke survivors: An exploratory observational study. Int J Health Allied Sci 2020;9:262-6

How to cite this URL:
Rashid M, Mathew J, Raja K. Alteration in ankle kinematics during uneven surface ambulation in stroke survivors: An exploratory observational study. Int J Health Allied Sci [serial online] 2020 [cited 2020 Aug 6];9:262-6. Available from: http://www.ijhas.in/text.asp?2020/9/3/262/290715




  Introduction Top


Impaired walking ability is a common disability in stroke survivors and is a known risk factor of fall.[1] Navigation of uneven terrain is essential for rural residents of regions in much of the developing world even for basic activities of daily living. Literature suggests that kinematic and kinetic variables are altered and that increased biomechanical adaptations are required during ambulation on uneven terrains. During outdoor ambulation, stroke survivors are exposed to additional risk factors of fall, due to compromised ability to step over objects and decreased endurance.[2] These factors can result in enforced confinement to the house which can negatively impact their quality of life (QOL).

The international classification of functioning, disability, and health listed 'walking on different surfaces' in the brief coreset for stroke. This underpins the importance of the function.

Gait parameters during uneven surface ambulation have not been adequately described in literature. Hence, this study is an attempt to evaluate kinematic gait parameters at the ankle in stroke survivors, in comparison to typical adults. Since this is a preliminary exploratory study, sample size for typical individuals was limited to data saturation.


  Subjects and Methods Top


Methodological descriptions of this observational exploratory study (cross-sectional design) followed the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines [3] with an objective to compare kinematic gait characteristics between stroke survivors and typical adults during level and uneven surface ambulation. The study setting was a simulated laboratory with a level walkway measuring 10 m and a raised platform of pebbles and sand measuring 10 m × 3 m were constructed for the study to mimic the terrains commonly encountered in the rural plain areas. The terrain in hilly areas is difficult to simulate in a laboratory and hence was not attempted in this study. The study incorporated convenience sampling strategy and recruited seven chronic adult stroke survivors and seven age- and gender-matched typical adults. Measurement of ankle and subtalar joint kinematics at different events of the gait cycle was recorded and analyzed using a motion analyzing software, Kinovea 0.8.15.

The video recording was achieved using two Logitech 720 HD web cameras mounted on two tripods to the parallel to the ankle joint during stance phase. The cameras were connected to two laptops 32-bit Toshiba. The relevant bony landmarks were marked using color tape markers to allow for accurate identification and measurements using software.

Stroke survivors were recruited for the study if they fulfilled the following criteria:

  • Able to walk independently without orthotics and with or without assistive devices or walking aids on the level and uneven surfaces (functional ambulatory category 4 and 5)
  • Utilizing walking as the major mode of ambulation with functional range of motion (ROM) and muscle strength in the lower extremity
  • Did not have any other pathologies or comorbidities that might influence gait pattern including sensory-perceptual problems that may impair safety as identified in clinical examination
  • Did not have any orthopedic dysfunction, fractures, vascular complications in the lower limb, lower limb or abdominal surgeries, and cognitive impairments that may affect safety
  • Had the stroke more than 2 years previously (postnatural recovery phase of stroke)[4]
  • Spasticity of more than one on a modified Ashworth scale in the lower extremity
  • Age above 18 years.


Typical participants who did not have any condition that could potentially affect gait, including orthopedic, systemic illnesses, and cardiopulmonary morbidities, were recruited to match the stroke survivors in age and gender.

Procedure

Participants

Ethical clearance was obtained from the Institutional ethical committee (Registration number 09_T046_95969) of JSS University. Seven typical adults and seven chronic stroke survivors were recruited as per criteria. The participants were informed about the study, and written informed consent was obtained before the study commencement.

Equipment and study protocol

The study was performed in the gait laboratory of the institution with a raised platform filled with pebbles and sand (10 m × 3 m), which was expected to simulate uneven terrain in our region.

Two web cameras of logistics 720 HD [5],[6] were connected to two laptops. Both the cameras were mounted to tripods. One camera with the tripod (Cam. 1) was placed at 3 m from the midway of the study platform and 55 cm above the floor to cover anterior and posterior views.[7] The second camera (Cam. 2) was placed at a distance of 3 m lateral to the mid portion of the platform and 55 cm above the floor to cover lateral view. The walkway and camera placement are illustrated in [Figure 1]. To ensure the technical aspects of recording and adjustments, both laptops were operated by separate technicians. Greatest visualization of the lower limb joints was ensured by fixing the optical axis of the camera in relation to knee joint 5. The gait was captured at a frame rate of 30 fps (frames per second) and with a frame width of 1280 × 720 pixels [Figure 1].
Figure 1: Schematic representation of the walkway and camera placements to record the gate of the participants

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Participant preparation

Relevant bony land marks were exposed and marked with fluorescent color tape markers of 25 mm.[7] The bony landmarks are given in [Table 1].
Table 1: List of bony landmarks identified

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Video recording

Video recording was completed under two phases

In Phase 1, stroke participants were allowed to become accustomed to the walkway. Following this, the participants were instructed to walk two laps at self-selected speed on the platform in bare foot condition. Recording on both cameras was done simultaneously. A care giver accompanied the participant for safety but did not make any contact. Gait belts were secured as per protocol.

In Phase 2, the same procedure was repeated with age- and gender-matched typical adults.

Video analysis

Videos of typical participants were imported to Kinovea 0.8.15 version [8] for analysis to draw normative values of ROM at ankle and subtalar joints, which was essential to make comparison with stroke survivors. Using different tools, the required points of the platform were remarked on the software for better understanding (starting point, mid portion etc.). Each event of the gait cycle was analyzed in terms of kinematics and recorded. The initial and final three to four cycles were not taken into consideration for analysis in order to control for initiation and fatigue. Thus, the cycles covered in the middle 6 m (three to four cycles) were analyzed.

Joint kinematics was measured and recorded using different tools available in the software. Joint angles at the same event were taken from at least three consecutive cycles to increase the accuracy in measurement.

Likewise the Phase 1 (stroke survivors), videos were also imported to the software and analyzed and recorded.

Data analysis

Descriptive statistics was used to compile the ranges of motion at ankle and subtalar joint during the stance phase events of the gait cycle.


  Results Top


Participant characteristics and demographic details are depicted in [Table 2].
Table 2: Participant characteristics and demographic details

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The study included 42.85% of males and 57.14% of females. The mean ages of the male participants were 73 ± 0.9 and female participants were 71 ± 0.4. The average chronicity of the person with stroke was 2 ± 1.

There was consistency of ROM between typical participants. The kinematic profiles of typical adults and person with stroke are shown in [Table 3].
Table 3: Kinematic profiles of typical adults and person with stroke on uneven surface

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During analysis, one patient showed drastic deviation in kinematic variables of gait from the other six. Hence, this person's data were excluded for analysis. The reason for this is unclear, but the habituation of this pattern cannot be discounted. During LR, there is a large difference in kinematics at ankle joint between the stroke survivors (6oDF–9.3oPF) and typical participants (12 o–13.3 PF) on pebbles. During ambulation on sand, the kinematic profiles of the stroke survivors are much greater than the typical participants in all the events of the stance at ankle joint. The subtalar ROM is considerably reduced for stroke survivors on both sand and pebbles in comparison with typical individuals.


  Discussion Top


We examined the differences in kinematic profiles of ankle and subtalar joint during gait performance on uneven surfaces between typical participants and survivors. This was a prospective explorative study and we have considered the human body as a kinematic chain. Any change or alteration in any part of the kinematic chain would automatically influence the nearby joints. Alterations to the proximal joints are usually secondary to the most distal joints (ankle and foot). Reduced or altered ROM at the primary joints can be explained on the basis of excessive over activity of ankle plantar flexors, etc.[9],[10],[11],[12],[13] This was the reason for choosing the ankle joint as an indicator of gait deviation.

This study demonstrates that stroke survivors show vast deviations from typical adults in ankle ROM. These results are consistent with existing literatures that stroke survivors have limited ROM in primary joints and the compensatory movements may increase ROM in secondary joints.[8]

Typical adults show bilaterally symmetrical kinematic characteristics. Stroke survivors show similar ROM to typical adults on the unaffected side. The compensatory mechanisms seen in the affected side during the gait are reversal of dorsiflexion and plantar flexion, knee flexion (14 degree to 20 degree), hip flexion (20 degree to 30 degree), and trunk hyperextension. The primary intention of gait evaluation and analysis is to provide early intervention to improve performance of patients. This study suggests that gait evaluation on uneven surface normally negotiated by the patient must form a part of routine evaluation.

Increased plantar flexion during swing resulting in foot drag is routinely considered during rehabilitation. Stance phase abnormalities are less often considered. Hence, this paper focused on stance phase alterations only.

This is a clinical study without use of instrumented gait analysis. Further analysis using instrumentation is warranted in future research in order to develop a clinical assessment tool for evaluation of gait on outdoor surfaces.


  Conclusions Top


This is an exploratory study of seven individuals and no definitive conclusions can be drawn. However, the findings of this study are important, as the deviations were remarkable and identify major fall risk, thereby having an impact on the QOL of stroke survivors. Analysis of gait on uneven surface ambulation must be taken up as a large-scale study given the burden of stroke survivors in India. The impact of gait deviations on joint kinetics is a future direction that will inform rehabilitation professionals on strategies to prevent joint loading leading to dysfunction. Early intervention strategies to improve joint kinematics on different surfaces can potentially reduce the risk of fall, making the patient safe to ambulate on uneven terrains.

Acknowledgment

The authors acknowledge our sincere thanks to Raja sisters, Mr. Sijo Joy and Mrs. Roopa, for their help and support during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping over obstacles to improve walking in individuals with poststroke hemiplegia. J Rehabil Res Dev 2004;41:283-92.  Back to cited text no. 1
    
2.
Jacob E. Medifocus Guidebook on Stroke Rehabilitation. 1st ed. Silver Spring, Md.: Om; 2010. p. 28-30.  Back to cited text no. 2
    
3.
von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Epidemiology 2007;18:800-4.  Back to cited text no. 3
    
4.
Skilbeck CE, Wade DT, Hewer RL. Recovery after stroke. J Neurol Neurodurg Psychiatry 1983;46:5-8.  Back to cited text no. 4
    
5.
Patricoski C, Ferguson AS. Selecting a digital camera for telemedicine. Telemed e-Health 2009;15:465-75.  Back to cited text no. 5
    
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Nielsen DB, Daugaard M. Comparison of angular measurements by 2D and 3D gait analysis. Jönköping, spring 2008.  Back to cited text no. 6
    
7.
Baker R. Gait analysis methods in rehabilitation. J Neuroeng Rehabil 2006;3:4.  Back to cited text no. 7
    
8.
Kinovea. France: Kinovea Corporation; 2016.  Back to cited text no. 8
    
9.
Kim HS, Chung SC, Choi MH, Gim SY, Kim WR, Tack GR, et al. Primary and secondary gait deviations of stroke survivors and their association with gait performance. J Phys Ther Sci Orig 2016;28:2634-40.  Back to cited text no. 9
    
10.
Boudarham J, Roche N, Pradon D, Bonnyaud C, Bensmail D, Zory R. Variations in kinematics during clinical gait analysis in stroke patients. PloS one. 2013;8:e66421-e.  Back to cited text no. 10
    
11.
Yavuzer MG. Waking after stroke: Interventions to restore normal gait pattern. Erasmus Univ Rotterdam 2006.  Back to cited text no. 11
    
12.
Tranberg R. Analysis of Body Motions Based on Optical Markers Applications. Göteborg: Intellecta Infolog, Göteborg, Sweden; 2010. p. 1-70. Available from: http://hdl.handle.net/2077/22941. [Last accessed on 2020 Jun 30].  Back to cited text no. 12
    
13.
Cappozzo A, Della Croce U, Leardini A, Chiari L. Human movement analysis using stereophotogrammetry. Part 1: theoretical background. Gait Posture 2005;21:186-96.  Back to cited text no. 13
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
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