Research Papers

Cyclogram-Based Joint Symmetry Assessment After Utilization of a Foot Drop Stimulator During Post-stroke Hemiplegic Gait

[+] Author and Article Information
Rakesh Pilkar

Human Performance and Engineering Research,
Kessler Foundation 1199 Pleasant Valley Way,
West Orange, NJ 07052;
Department of Physical Medicine
and Rehabilitation,
Rutgers—New Jersey Medical School,
Newark, NJ 07103
e-mail: rpilkar@kesslerfoundation.org

Arvind Ramanujam

Human Performance and Engineering Research,
Kessler Foundation 1199 Pleasant Valley Way,
West Orange, NJ 07052
e-mail: aramanujam@kesslerfoundation.org

Kathleen Chervin

Human Performance and Engineering Research,
Kessler Foundation 1199 Pleasant Valley Way,
West Orange, NJ 07052
e-mail: kgoworek@kesslerfoundation.org

Gail F. Forrest

Human Performance and Engineering Research,
Kessler Foundation 1199 Pleasant Valley Way,
West Orange, NJ 07052;
Department of Physical Medicine
and Rehabilitation,
Rutgers—New Jersey Medical School,
Newark, NJ 07103
e-mail: gforrest@kesslerfoundation.org

Karen J. Nolan

Human Performance and Engineering Research,
Kessler Foundation 1199 Pleasant Valley Way,
West Orange, NJ 07052;
Department of Physical Medicine
and Rehabilitation,
Rutgers—New Jersey Medical School,
Newark, NJ 07103
e-mail: knolan@kesslerfoundation.org

1Corresponding author.

Manuscript received December 21, 2017; final manuscript received June 26, 2018; published online September 25, 2018. Assoc. Editor: Tammy L. Haut Donahue.

J Biomech Eng 140(12), 121005 (Sep 25, 2018) (8 pages) Paper No: BIO-17-1597; doi: 10.1115/1.4040774 History: Received December 21, 2017; Revised June 26, 2018

In the absence of standardized symmetry assessments, quantifying symmetry based on the kinematic evolution of lower extremity joints can elucidate gait irregularities. The objective was to develop a novel cyclogram-based symmetry (CBS) method to quantify lower extremity joints' symmetry and assess the effect of six-month utilization of foot drop stimulator (FDS) on CBS of the lower limbs during hemiplegic gait poststroke. Twenty-four participants (13 stroke and 11 healthy controls (HC)) performed ten walking trials at a free cadence on level ground. Symmetry values were computed using geometric properties of bilateral cyclograms obtained from normalized sagittal ankle, knee, and hip kinematics. CBS and traditional temporospatial symmetry values were compared between the two groups using independent sample t-test. The effect of FDS utilization on the symmetry was assessed by a paired sample t-test computed at baseline and six-month follow up. The CBS method successfully showed that the HC group was significantly more symmetrical at the ankle (p = 0.001), knee (p = 0.001), and hip (p < 0.005) compared with the stroke group. The stroke group showed significant increment in the hip symmetry with FDS at the baseline but did not show any significant CBS changes at follow up. Pearson correlations revealed that hip and knee CBS had a significant influence on the overall walking speed. The CBS method presents a unique approach to calculate the symmetry based on the kinematics of lower extremities during gait.

Copyright © 2018 by ASME
Your Session has timed out. Please sign back in to continue.


Morone, G. , Fusco, A. , Di Capua, P. , Coiro, P. , and Pratesi, L. , 2012, “ Walking Training With Foot Drop Stimulator Controlled by a Tilt Sensor to Improve Walking Outcomes: A Randomized Controlled Pilot Study in Patients With Stroke in Subacute Phase,” Stroke Res. Treat., 2012, p. 523564. [PubMed]
Stein, R. B. , Everaert, D. G. , Thompson, A. K. , Chong, S. L. , Whittaker, M. , Robertson, J. , and Kuether, G. , 2010, “ Long-Term Therapeutic and Orthotic Effects of a Foot Drop Stimulator on Walking Performance in Progressive and Nonprogressive Neurological Disorders,” Neurorehabil. Neural Repair, 24(2), pp. 152–167. [CrossRef] [PubMed]
Nolan, K. J. , Savalia, K. K. , Lequerica, A. H. , and Elovic, E. P. , 2009, “ Objective Assessment of Functional Ambulation in Adults With Hemiplegia Using Ankle Foot Orthotics After Stroke,” PM R, 1(6), pp. 524–529. [CrossRef] [PubMed]
Nolan, K. J. , and Yarossi, M. , 2011, “ Weight Transfer Analysis in Adults With Hemiplegia Using Ankle Foot Orthosis,” Prosthet. Orthotics Int., 35(1), pp. 45–53. [CrossRef]
Stein, R. B. , Chong, S. , Everaert, D. G. , Rolf, R. , Thompson, A. K. , Whittaker, M. , Robertson, J. , Fung, J. , Preuss, R. , Momose, K. , and Ihashi, K. , 2006, “ A Multicenter Trial of a Footdrop Stimulator Controlled by a Tilt Sensor,” Neurorehabil. Neural Repair, 20(3), pp. 371–379. [CrossRef] [PubMed]
Everaert, D. G. , Stein, R. B. , Abrams, G. M. , Dromerick, A. W. , Francisco, G. E. , Hafner, B. J. , Huskey, T. N. , Munin, M. C. , Nolan, K. J. , and Kufta, C. V. , 2013, “ Effect of a Foot-Drop Stimulator and Ankle-Foot Orthosis on Walking Performance After Stroke: A Multicenter Randomized Controlled Trial,” Neurorehabil. Neural Repair, 27(7), pp. 579–591.
Everaert, D. G. , Thompson, A. K. , Chong, S. L. , and Stein, R. B. , 2010, “ Does Functional Electrical Stimulation for Foot Drop Strengthen Corticospinal Connections?,” Neurorehabil. Neural Repair, 24, pp. 168–177. [CrossRef] [PubMed]
Sabut, S. K. , Lenka, P. K. , Kumar, R. , and Mahadevappa, M. , 2010, “ Effect of Functional Electrical Stimulation on the Effort and Walking Speed, Surface Electromyography Activity, and Metabolic Responses in Stroke Subjects,” J. Electromyogr. Kinesiol., 20(6), pp. 1170–1177. [CrossRef] [PubMed]
Chae, J. , 2003, “ Neuromuscular Electrical Stimulation for Motor Relearning in Hemiparesis,” Phys. Med. Rehabil. Clin. North Am., 14(Suppl. 1), pp. S93–109. [CrossRef]
Daly, J. J. , and Ruff, R. L. , 2007, “ Construction of Efficacious Gait and Upper Limb Functional Interventions Based on Brain Plasticity Evidence and Model-Based Measures for Stroke Patients,” Sci. World J., 7, pp. 2031–2045. [CrossRef]
Peckham, P. H. , and Knutson, J. S. , 2005, “ Functional Electrical Stimulation for Neuromuscular Applications,” Annu. Rev. Biomed. Eng., 7(1), pp. 327–360. [CrossRef] [PubMed]
Sheffler, L. R. , and Chae, J. , 2007, “ Neuromuscular Electrical Stimulation in Neurorehabilitation,” Muscle Nerve, 35(5), pp. 562–590. [CrossRef] [PubMed]
Pilkar, R. , Yarossi, M. , and Nolan, K. J. , 2014, “ EMG of the Tibialis Anterior Demonstrates a Training Effect After Utilization of a Foot Drop Stimulator,” Neurorehabilitation, 35(2), pp. 299–305. [PubMed]
Kottink, A. I. , Hermens, H. J. , Nene, A. V. , Tenniglo, M. J. , van der Aa, H. E. , Buschman, H. P. , and Ijzerman, M. J. , 2007, “ A Randomized Controlled Trial of an Implantable 2-Channel Peroneal Nerve Stimulator on Walking Speed and Activity in Poststroke Hemiplegia,” Arch. Phys. Med. Rehabil., 88(8), pp. 971–978. [CrossRef] [PubMed]
Kottink, A. I. , Oostendorp, L. J. , Buurke, J. H. , Nene, A. V. , Hermens, H. J. , and IJzerman, M. J. , 2004, “ The Orthotic Effect of Functional Electrical Stimulation on the Improvement of Walking in Stroke Patients With a Dropped Foot: A Systematic Review,” Artif. Organs, 28(6), pp. 577–586. [CrossRef] [PubMed]
Hausdorff, J. M. , and Ring, H. , 2008, “ Effects of a New Radio Frequency-Controlled Neuroprosthesis on Gait Symmetry and Rhythmicity in Patients With Chronic Hemiparesis,” Am. J. Phys. Med. Rehabil., 87(1), pp. 4–13. [CrossRef] [PubMed]
Patterson, K. K. , Gage, W. H. , Brooks, D. , Black, S. E. , and McIlroy, W. E. , 2010, “ Evaluation of Gait Symmetry After Stroke: A Comparison of Current Methods and Recommendations for Standardization,” Gait Posture, 31(2), pp. 241–246. [CrossRef] [PubMed]
Patterson, K. K. , Parafianowicz, I. , Danells, C. J. , Closson, V. , Verrier, M. C. , Staines, W. R. , Black, S. E. , and McIlroy, W. E. , 2008, “ Gait Asymmetry in Community-Ambulating Stroke Survivors,” Arch. Phys. Med. Rehabil., 89(2), pp. 304–310. [CrossRef] [PubMed]
Goswami, A. , 1998, “ A New Gait Parameterization Technique by Means of Cyclogram Moments: Application to Human Slope Walking,” Gait Posture, 8(1), pp. 15–36. [CrossRef] [PubMed]
Kutilek, P. , Viteckova, S. , Svoboda, Z. , and Smrcka, P. , 2013, “ Kinematic Quantification of Gait Asymmetry in Patients With Peroneal Nerve Palsy Based on Bilateral Cyclograms,” J. Musculoskeletal Neuronal Interact., 13(2), pp. 244–250. http://www.ismni.org/jmni/pdf/52/13KUTILEK.pdf
Oken, O. , and Yavuzer, G. , 2008, “ Spatio-Temporal and Kinematic Asymmetry Ratio in Subgroups of Patients With Stroke,” Eur. J. Phys. Rehabil. Med., 44(2), pp. 127–132. https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2008N02A0127 [PubMed]
Ramanujam, A. , Pilkar, R. , Chervin, K. , and Nolan, K. J. , 2013, “ Kinematic Symmetry Assessment of Lower Limb Motions in Individuals With Stroke,” Arch. Phys. Med. Rehabil., 94(10), p. e33. [CrossRef]
Wall, J. C. , and Turnbull, G. I. , 1986, “ Gait Asymmetries in Residual Hemiplegia,” Arch. Phys. Med. Rehabil., 67(8), pp. 550–553. https://www.archives-pmr.org/article/0003-9993(86)90556-3/pdf [PubMed]
Weingarden, H. P. , and Hausdorff, J. M. , 2007, “ FES Neuroprosthesis Versus an Ankle Foot Orthosis: The Effect on Gait Stability and Symmetry,” Physiotherapy, 93(Suppl. 1), p. S359. https://www.bioness.com/Documents/press/AFO_L300_WCPT_Abstract_FNL_2.pdf
Viteckova, S. , Kutilek, P. , Svoboda, Z. , Krupicka, R. , Kauler, J. , and Szabo, Z. , 2018, “ Gait Symmetry Measures: A Review of Current and Prospective Methods,” Biomed. Signal Process. Control, 42, pp. 89–100. [CrossRef]
Grieve, D. W. , 1969, “ The Assessment of Gait,” Physiotherapy, 55(11), pp. 452–460. [PubMed]
Hershler, C. , and Milner, M. , 1980, “ Angle-Angle Diagrams in Above-Knee Amputee and Cerebral Palsy Gait,” Am. J. Phys. Med., 59(4), pp. 165–183. https://www.ncbi.nlm.nih.gov/pubmed/7416239 [PubMed]
Hershler, C. , and Milner, M. , 1980, “ Angle-Angle Diagrams in the Assessment of Locomotion,” Am. J. Phys. Med., 59(3), pp. 109–125. https://www.ncbi.nlm.nih.gov/pubmed/7395971 [PubMed]
Davis , R. B., III , Ounpuu, S. , Tyburski, D. , and Gage, J. R. , 1991, “ A Gait Analysis Data Collection and Reduction Technique,” Hum. Mov. Sci., 10(5), pp. 575–587. [CrossRef]
Schmid, A. , Duncan, P. W. , Studenski, S. , Lai, S. M. , Richards, L. , Perera, S. , and Wu, S. S. , 2007, “ Improvements in Speed-Based Gait Classifications are Meaningful,” Stroke, 38(7), pp. 2096–2100. [CrossRef] [PubMed]
Crenshaw, S. J. , and Richards, J. G. , 2006, “ A Method for Analyzing Joint Symmetry and Normalcy, With an Application to Analyzing Gait,” Gait Posture, 24(4), pp. 515–521. [CrossRef] [PubMed]
Roth, E. J. , Merbitz, C. , Mroczek, K. , Dugan, S. A. , and Suh, W. W. , 1997, “ Hemiplegic Gait. Relationships Between Walking Speed and Other Temporal Parameters,” Am. J. Phys. Med. Rehabil., 76(2), pp. 128–133. [CrossRef] [PubMed]
Awad, L. N. , Palmer, J. A. , Pohlig, R. T. , Binder-Macleod, S. A. , and Reisman, D. S. , 2015, “ Walking Speed and Step Length Asymmetry Modify the Energy Cost of Walking After Stroke,” Neurorehabil. Neural Repair, 29(5), pp. 416–423. [CrossRef] [PubMed]


Grahic Jump Location
Fig. 1

(a) Bilateral sagittal knee angle profiles during gait for a 21 yr old healthy participant, (b) a cyclogram with its geometric parameters for symmetry calculations, and (c) overall symmetry represented in a three-dimensional polar coordinate system comprised of ankle, knee, and hip symmetry. r: normalized radial distance of a point (Sankle,Sknee,Ship) from the origin (0, 0, 0). Point P represents the perfect symmetry, HC represents the overall symmetry of a representative 21 yr old healthy participant and ST represents the overall symmetry calculated for a 76 yr old individual with hemiplegia poststroke.

Grahic Jump Location
Fig. 2

Averaged bilateral cyclogram plots of: (a) ankle, (b) knee, and (c) hip angles in sagittal plane for the stroke group (n = 13) (solid gray) and the HC group (n = 11) (solid black). Line of symmetry at 45 deg passing through origin is shown.

Grahic Jump Location
Fig. 3

The effect of walking speed on cyclogram based: (a) ankle symmetry, (b) knee symmetry, (c) hip symmetry, and (d) overall symmetry (radial distance). Total sample size considered for this analysis, N = 63 (13 subjects poststroke ×4 conditions (with and without FDS at baseline and follow up) + 11 (HC)). The entire dataset is divided into two groups based on walking speed as (1) community ambulators (walking speed ≥ 0.8 m/s) [30] shown as circles and (2) limited community ambulators (walking speed < 0.8 m/s) [30] shown as squares.

Grahic Jump Location
Fig. 4

(a) Synchronized cyclogram with the symmetry measures derived using Kutelik et al. IA: inclination angle derived from the linear fit and SI derived from bilateral ROM ratio; and (b) nonsynchronized cyclograms with CBS value for a 20 yr old HC participant.

Grahic Jump Location
Fig. 5

(a) A case representing an altered hip cyclograms with the use of FDS at baseline and after 6-month FDS utilization for ST4 (b) Similarly, altered knee cyclograms for ST11 with FDS at baseline and after 6-month FDS utilization. Both cases show improved CBS values with the immediate and 6-month utilization of FDS.



Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging and repositioning the boxes below.

Related Journal Articles
Related eBook Content
Topic Collections

Sorry! You do not have access to this content. For assistance or to subscribe, please contact us:

  • TELEPHONE: 1-800-843-2763 (Toll-free in the USA)
  • EMAIL: asmedigitalcollection@asme.org
Sign In