Tools for Observational Gait Analysis in Patients With Stroke a Systematic Review
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| Year : 2019 | Volume : 67 | Result : 4 | Page : 1033-1040 | ||
Post-stroke Visual Gait Measure for Developing Countries: A Reliability and Validity Study
1 Department of Occupational Therapy, Pandit Deendayal Upadhyaya National Institute for Persons with Physical Disabilities, New Delhi, Republic of india
2 Department of Statistics, University of Lucknow, Lucknow, Uttar Pradesh, Republic of india
| Appointment of Web Publication | ten-Sep-2019 |
Correspondence Address:
Dr. Kamal Narayan Arya
Pandit Deendayal Upadhyaya National Institute for Persons with Physical Disabilities, iv VD Marg, New Delhi - 110 002
India
Source of Back up: None, Conflict of Involvement: None
DOI: 10.4103/0028-3886.266273
Background: Visual gait assessment is a cost-effective clinical method to appraise postal service-stroke gait deviations. The Rivermead Visual Gait Cess (RVGA) is a one such measure that assesses the kinematic aspect of the gait deviations in stroke. However, the available information on psycho-clinocometric properties of the measure is not acceptable.
Objective: To establish reliability and validity of RVGA using walking-videos of the postal service-stroke subjects.
Methods: Design: Observational study.
Setting: A rehabilitation institute Participants: A convenience sample of 40 chronic stroke patients.
Outcome Measures: RVGA, Fugl–Meyer assessment (lower extremity), 10-m walk test, Time upward and get exam, and Berg balance scale (Bulletin board system).
Procedure: Walking was video-taped from the anterior attribute, posterior aspect, affected side, and less-afflicted side. After coding the tapes, a enquiry staff member provided them to four dissimilar raters in a random club. Each rater scored the coded video on the RVGA data collection sail twice: one at the baseline and another after 1 month to eliminate any recollection of the initial assessment.
Results: The findings showroom that there was good-to-fantabulous agreement between the scores of the raters and also between the assessments (correlation coefficient = 0.94 to 0.95; P < 0.001). The mensurate besides exhibits acceptable validity when correlated with scores of BBS (r = 0.4; P < 0.001).
Conclusion: Video-based RVGA is a reliable and valid tool to appraise gait-related damage in post-stroke hemiparesis. This cost-constructive measure may be incorporated in the clinical and research practice to discern and quantify complex miracle of the gait deviation. RVGA may exist considered as a useful tool, specially in developing countries where expensive gait analyzer is ordinarily non available.
Keywords: Gait assessment, rehabilitation, reliability, stroke, validity
Key Bulletin: Cess of post.stroke gait deviations is a complex phenomenon. RVGA is a uncomplicated and economic clinical tool exhibiting skilful psychometric properties.
How to cite this article:
Arya KN, Pandian S, Kumar V, Agarwal G G, Asthana A. Post-stroke Visual Gait Measure out for Developing Countries: A Reliability and Validity Written report. Neurol India 2019;67:1033-40
How to cite this URL:
Arya KN, Pandian South, Kumar V, Agarwal G G, Asthana A. Postal service-stroke Visual Gait Measure for Developing Countries: A Reliability and Validity Study. Neurol India [series online] 2019 [cited 2022 Apr 17];67:1033-40. Available from: https://www.neurologyindia.com/text.asp?2019/67/four/1033/266273
Gait difference is a mutual manifestation of post-stroke hemiparesis. The deviation occurs considering of the asymmetry caused by the half-side torso paresis.[i] In addition to the paresis, abnormal musculus activation, synergy, increased tone, imbalance betwixt agonist and antagonist muscles, and contracture besides contribute to the hemiparetic gait.[2] Foot drop, knee joint hyperextension, and pelvis hiking are some of the ordinarily observed disturbances in stroke patients.[2],[3],[four] Every bit and when patients beginning walking, they commonly adopt a stereotypical abnormal gait pattern. Most spatiotemporal variables such every bit stance fourth dimension and step length on the affected leg and walking speed are altered. The pathomechanics leads to inefficient, unsafe, or nonfunctional walking.[1] Furthermore, post-stroke patients have low or no perception for the bodily gait asymmetries.[5] Most subjects do not accomplish functional and community ambulation.[6] The inability further affects the quality of life.[vii] Post-stroke gait rehabilitation primarily depends upon determining the specific deviations. Thus, an objective investigation is essential to programme a successful intervention programme.
Diverse methods are available in clinical and enquiry practice to identify and quantify the harm.[8] A complex phenomenon such equally gait, beingness a complex dynamic phenomenon, can exist analyzed by sophisticated kinematic and kinetic assay. However, gait assay are likewise expensive to use in the regular practice, especially in developing countries.
Visual gait observation, a clinical and toll-effective technique, is very useful in discerning deviations during walking among mail-stroke hemiparetic subjects.[9],[10],[11] Although clinical observation of the gross deviations can be performed past the naked center, the detection and quantification of all the possible impairments crave a structured arroyo. At that place are few observation-based tools bachelor to assess gait related impairments for neurological disorders including stroke. The Rivermead Visual Gait Cess (RVGA), the Gait Cess and Intervention Tool, the adapted New York Medical School Orthotic Gait Analysis work canvass, the Hemiplegic Gait Analysis Form, and the Wisconsin Gait Scale are some of the identified measures for observational gait evaluation in stroke. RVGA assesses kinematic attribute of the gait deviations and is considered to be the clinically useful measure out. The calibration has items for the upper limb, trunk, pelvis, hip, articulatio genus, and ankle to discern typical alterations exhibited by a hemiparetic subject during walking. The head-to-toe order of items allows an assessor to exist at ease during visualizing the impairment. The items are separately categorized for stance and swing phases of the gait. The RVGA also has a provision to evaluate opposite aspects of deviation; for instance, knee excessive flexion or extension as well as ankle in backlog plantar flexion or dorsi flexion.[10] The extremes allow the measurement possible deviations that might be adapted by the different stroke patients. The vision of examiner is the medium to recognize and compute the gait-deviations. Thus, underlying knowledge and expertise in gait-biomechanics play a decisive part for a skillful rater.
The programmer of RVGA has already established its initial reliability and validity.[10] No farther studies have been conducted to confirm and expand the findings. The bachelor data on psycho-clinocometric backdrop of the measure is not adequate.[11] Further, the gait assessment by RVGA may be enhanced using videos. Still, the reliability and validity of the same has not been established nonetheless. The objective of the report was to establish the reliability and validity of the video-based RVGA in postal service-stroke subjects.
| � Methods |  |
Participants
Subjects were recruited from a lower extremity trial conducted in a rehabilitation institute. The nowadays written report was canonical by the ideals committee of Pandit Deendayal Upadhyaya National Establish for Persons with Physical Disabilities, New Delhi, India. The participants were enrolled in the report if they met the following inclusion criteria: (i) unilateral stroke of >6 months, (ii) hemiparesis of either correct or left side, (iii) historic period betwixt thirty to threescore years, (4) normal ambulation prior to stroke, and (v) able to walk for at least x g without whatsoever physical assistance, foot orthosis, and walking-device. The subjects were excluded if they exhibited the following features: (i) whatever neurological or orthopedic disorder affecting locomotion and balance, (2) severe cerebral and perceptual deficit, and (3) cardiovascular instability.
Blueprint
The present study was a prospective observational blueprint.
Instruments
The Rivermead visual gait assessment
The RVGA, a visual-based gait measure used to discern gait deviations in neurologically disorders, specially stroke. It consists of xx items (2 arms, eleven opinion phase, and 7 swing phase) which assess the deviations on the affected side. Each item is scored on 4-betoken calibration ranging from 0 to 3 (0 = normal, 1 = mild divergence, two = moderate difference, and iii = severe departure). Only detail 2 is scored up to moderate alteration; thus, the total score varies from 0 (normal gait) to 59 (severely afflicted gait). Visual observations are made on the impaired lower limb while the patient walks at a normal identify with orthotic devices as applicative.[x] However, in the present study, participants having power to walk without any such appliances for at least 10 m were recruited. This allowed for the true presentation of gait difference as well and increased visibility of the ankle-human foot for observation were clearly visible for the ascertainment.
In the preliminary study, the developer of the RVGA adamant it to be it a reliable and valid tool for the cess of gait divergence in a history of a neurological problems, such as stroke or multiple sclerosis patients.[10]
Validity related measures
Fugl–Meyer assessment (lower extremity)
The Fugl–Meyer assessment (FMA) is the most commonly used motor measure to quantify recovery of mail-stroke hemiparetic patients.[12] The FMA comprises subsection exclusively for the lower extremity (FMA-LE). In general, FMA-LE has half-dozen items non varying from reflex activity, pure and combined synergistic movements, and voluntary performance. The particular farther consists of 17 sub-items in total. The motor performance is scored on a three-indicate ordinal scale (0, no performance to 2, faultless performance) with a maximum score of 34 indicating good motor recovery and minimum score of 0 signifying poor recovery.
The FMA has been establish to be a reliable (0.95 to 0.99) and valid (0.71 to 0.76) tool.[13],[14] Specifically, FMA-LE exhibited adequate reliability and validity to appraise motor recovery of the lower limb post-stroke.[15]
Gait speed
The 10-meter walk test (10MWT) was used to estimate the gait speed, through analysis of the time taken to cover the x M distance.[16],[17] The participants were to walk at their comfortable and maximal speed for a distance of 10 m. The time was not considered for the get-go and the final 1 grand to let for dispatch and deceleration, respectively. The mean time of three readings was calculated for the performance time. The gait speeds [comfy (Speed C) and maximal (Speed G)] in meter/2nd (m/south) were estimated using the relation = 8/the hateful fourth dimension of performance. The 10MWT exhibited considerable reliability (0.95 to 0.99) and validity (0.60 to 0.94) in patients with stroke.[18],[19],[20]
Fourth dimension upwards and go test
The Time up and go exam (TUG) is a time measure of sit-to-stand and 3-m walk, to and fro. The test is demonstrated to have excellent reliability (0.95) and considerable validity (0.62 to 0.96) in stroke patients.[21],[22]
Berg Balance Calibration
The Berg Balance Calibration (BBS) assesses remainder and autumn risks amongst stroke subjects. Although the scale was developed for elderly, it is commonly used and found to exist reliable and valid in postal service-stroke patients.[23] This 14-item performance-based measure is scored on a 5-signal ordinal scale range from 0 (poor balance) to 4 (skillful balance).[24] BBS showed good to first-class reliability (0.72 to 0.95) and validity (0.82 to 0.94).[25],[26],[27]
Assessment protocol
Reliability
Prior to the trial intervention, all the participants were made to walk at comfortable speed on a 15-m obstacle-free pathway. A reference line was fatigued on the flooring to provide a guiding direction during walking. The lower dress of the subjects was folded up to above knee to have a clear view of the lower leg and joints. A bicolor VELCRO strap was also tied around the waist (along the line joining both inductive and posterior superior iliac spines) to view the departure related to pelvis level. The participants were not allowed to wear any foot article of clothing during the test. The walking was video-taped from anterior aspect, posterior attribute, affected side, and less-afflicted side. Four carve up rounds of the walking were conducted to have the videos from each view. The videotaping was conducted past staff not function of the study at the research site at the research-site. After coding the tapes, the staff provided them to the 4 different raters in random guild. 2 raters had more than 20 years of experience in neurorehabilitation, and the others were novice in the field. A mutual discussion on each item of RVGA was held to clarify the observation and scoring as per the guidelines of the calibration developers. Prior to the study, iii trial videos were scored by the raters to accustom with the method of assessment.
Each rater scored the coded video on the RVGA data drove sheets twice, i at the baseline and other later on one month to eliminate any recollection of the initial assessment. The assessors were not informed about the paretic side of the subjects to reduce any bias of negligible to balmy deviations. During each scoring session, the rater played the coded video clip of a subject using VLC Media Player version 2.2.i. The playing speed of prune was slowed to half. The reduced speed of video allowed the assessor to perceive the deviations more accurately for each body part during every phase of the gait cycle. Only one clip was scored past each rater in a day to avert any possible error considering of stereotypical observations. Further, each rater scored the mensurate separately on an individual computer system.
Validity
10MWT, TUG, and BBS were conducted in a separate session as per the standard guidelines of each measure.
Intervention
The assessments were considered from an ongoing trial in which as conventional management, the affected lower extremity received motor therapy according to neurophysiological approaches such as Brunnstorm and Bobath.[28],[29] The intervention comprised of reflexive, synergistic, out-of-synergy, agile, weight bearing, and anti-deformity movements. The experimental protocol consisted of task-based mirror therapy. Object based movements such as ball rolling, rocking-on-board, wiping, pedaling, shifting were performed past the less-affected side in sitting/long sitting position in front end of a mirror frame while hiding the affected limb. The movement of the less-afflicted lower limb was reflected and perceived as the affected extremity.
Data analysis
Reliability and validity analysis of the data in addition definition of the descriptive and inferential statistics was conducted using IBM SPSS, Version 22.0. The reliability for the global RVGA score and validity was analyzed using the Pearson correlation coefficient (r). Start assessments of all the raters were considered for validity interpretation. A P value ≤0.05 was considered as significant. The coefficients 0.50 to 0.69, 0.70 to 0.89, and >0.09 were considered every bit moderately, highly, and very highly correlated, respectively.[30] Furthermore, level of agreement between and within raters for individual RVGA detail was calculated by the Kappa measure of agreement (κ). The κ value of <0.2, 0.21 to 0.4, 0.41 to 0.6, 0.61 to 0.viii, and > 0.viii were considered every bit poor, fair, moderate, substantial, and perfect understanding, respectively.[31]
| � Results | |
All enrolled subjects signed the informed consent form and completed the assessment protocol. Out of forty subjects, there were 34 males and 6 female person, the average age of the participants was 52 years. The mean post-stroke duration was nineteen months, with 30 subjects having ischemic stroke and 22 patients exhibiting right side paresis. The detail demographic characteristics of the participants are given in [Table 1].
 | Table 1: Demographic and clinical characteristics of the report participants Click here to view |
Inter-rater reliability
The analysis for total RVGA scores between the experienced raters exhibited a very high correlation (r = 0.940 P < 0.001). Similar strength of relation was likewise plant for the novice raters (r = 0.941, P < 0.001). The individual item analysis demonstrated κ value ranging from 0.213 (P = 0.013) to 0.903 (P < 0.001) for the experienced raters. The individual particular analysis for the novice therapist varied from 0.278 (P = 0.006) to 0.774 (P < 0.001). Still, three and four items of RVGA showed no understanding for the experienced and novice therapists, respectively [Table ii]a and [Table two]c.
Intra-rater reliability
The correlation between the kickoff and the 2d assessment was institute to exist very high for all the raters, r ranging from 0.951 to 0.958 (P < 0.001). The κ for private RVGA detail varied from 0.222 (P = 0.018) to 0.776 (P < 0.001) and 0.252 (P = 0.05) to 0.695 (P < 0.001) for both the experienced raters, respectively. For the novice raters, the agreement level was plant to be 0.393 (P < 0.001) to 0.788 (P < 0.001) and 0.212 (P = 0.001) to 0.624 (P < 0.001) [Table 2]b and [Table 2]c. I item of RVGA each for an experienced rater and a novice rater did not prove whatever understanding.
Concurrent validity
The total RVGA score exhibited significant positive relation with Bulletin board system for all the raters (r = 0.386 to 0.477, P = 0.014 to 0.002). Notwithstanding, RVGA was non institute to exist correlated with FMA-LE, 10MWT, or TUG (P > 0.05) [Table iii].
| � Discussion | |
Gait impairment amid postal service-stroke survivors interferes with the functional recovery and increases the inability level.[1] Management requires critical assessment of the deficits. Various tools of diverse merit and demerit available ranging from the observational to sophisticated analysis. Because the gait is a complex and swift phenomenon, observational scales are usually considered as less reliable as compared to the machine-based measures. Gait-analysis are costly, circuitous, and time-taking tools. Considering of the inclusion of smart phones in daily life, obtaining video of walking is quite piece of cake and economical for clinicians. RVGA is an sometime gait measure out for neurologically impaired subjects, particularly stroke, adult at a time when videography was more than difficult to capture effortless. Although the items of RVGA are well-nigh appropriate for post-stroke gait evaluation, the chances of missing a deviation are common during the eye-ascertainment method. Thus, the nowadays study was conducted to validate the assessment process of RVGA using gait videos.
The findings suggest that the RVGA is a reliable and valid fashion of assessing gait in patients with stroke. These results confirmed the preliminary psychometric reports conducted on a small sample by the developers of the scale.[x] The present study is the first investigation to utilize the items of RVGA for quantifying deviations by videography. The scale is useful in evaluating array of gait-deviations exhibited by post-stroke hemiparetic subjects. The tiresome-movement assessment of video-tape from four different views (anterior, posterior, affected side, and less-affected side) allowed raters to decisively discern the deviations without causing discomfort to the patient.
Observational gait measures are commonly used in clinical practise.[32] In addition to RVGA, other measures are also recommended. Video-based cess using scales such every bit Wisconsin Gait Calibration and the Gait Aberration Rating Scale accept too been conducted. Both the measures were found to be reliable and valid using video-protocol.[33],[34] In addition, there are a range of gait related measures used in postal service-stroke studies; however, most of them are nonvideo-based.[16],[17],[35] The tools are described in [Table 4]. All they should exist considered based on their advanatges and disadvangates and and so used. The video-based validation of RVGA was a need. The nowadays study authenticates the use of RVGA offshoot by videos in stroke-gait assessment.
The inter-rater reliability of RVGA was institute to be good by its developer.[10] Yet, the reliability was observed up to very loftier in the present written report. This may be because of the utilize of gait videos. This validates the utilize of videos in the observational gait assessment. The feel of rater was non found to be an important factor for using RVGA. Few swing-phase items did not prove any agreement between the raters, two (trunk flexion and pelvis backward rotation) of them are common between the experience and novice raters. This could be because of the dynamic and circuitous attribute of the swing stage which was difficult to be discerned by the raters. Both the group of therapists demonstrated almost aforementioned level of intra-rater reliability. All the raters exhibited adequate agreement for almost all the items. The majority of the items had fair to substantial agreement followed by negligible perfect and poor agreement.
The relation between RVGA and Bulletin board system is in concordance with that of the developer studies. Yet, no association of RVGA was observed with FMA-LE, 10MWT, or TUG. This could be attributed to the constructs of the measures. The FMA-LE assesses the motor recovery components in the static positions such as lying, sitting, and standing. Further, it does not consider the torso condition and less-affected limb. In contrast, the RVGA examines the deviations involving the trunk, pelvis, lower limbs, and upper limbs in various dynamic aspects. In addition, the post-stroke gait difference is a maladaptive learned beliefs that may not be influenced by the recovery of individual FMA-LE particular. The construct of 10MWT and TUG is non stroke-specific. Mail-stroke subjects maintain the speed of walking for functional achievements despite the deviations. Furthermore, TUG has exhibited no relation with the kinetic and kinematic variables in stroke.[47]
In view of the cost and fourth dimension factor for gait analyses, video-based RVGA may have a wider application in developing countries. In the nowadays written report, the videos were captured using a smart-phone. Structured procedures to tape the clips need to be developed in the future. The RVGA exhibited no relation with the speed measures of gait. This indicates that the post-stroke subject could maintain functional walking in spite of the gait deviations. Although recognition of deviations was undemanding, the raters occasionally experienced difficulty in separating the mild and moderate deviations. The RVGA can only be practical to independent ambulatory post-stroke subjects. Futurity studies are recommended to institute the validity of RVGA using gait analyzer. The other type of validity is also needed to be determined. Further, there is a need to develop a standard grooming manual for the RVGA using videos to take uniformity.
| � Conclusion | |
The RVGA is a reliable and valid tool to appraise the gait-related impairment in post-stroke hemiparetic patients. Information technology is a simple and economic method to assess the stroke-gait, a complex phenomenon in clinical and research purpose.
Financial support and sponsorship
Pandit Deendayal Upadhyaya National Plant for Persons with Physical Disabilities, New Delhi, India.
Conflicts of interest
There are no conflicts of interest.
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[Tabular array one], [Table 2], [Table three], [Table four]
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Source: https://neurologyindia.com/article.asp?issn=0028-3886;year=2019;volume=67;issue=4;spage=1033;epage=1040;aulast=Arya;type=3
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