Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait in Stroke Patients
Identifieur interne : 000756 ( Pmc/Curation ); précédent : 000755; suivant : 000757Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait in Stroke Patients
Auteurs : Yuri Cha ; Young Kim ; Yijung ChungSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2014.
Abstract
[Purpose] The aim of this study was to investigate the effects of tempo changes in rhythmic auditory stimulation (RAS) on gait in stroke patients. [Subjects] Forty-one chronic stroke patients who had had a stroke with more than 6 months previously were recruited for this study. [Methods] All participants were asked to walk under 5 different conditions in random order: (1) no RAS (baseline); (2) baseline-matched RAS (0%); and (3) −10%, (4) +10%, and (5) +20% of the baseline. A GAITRite system was used to evaluate the spatial and temporal parameters of gait. [Results] Compared with under the RAS 0% conditions, the gait velocity, cadence, and stride length on the affected side were significantly decreased under the RAS −10% conditions. Gait velocity and cadence were significantly improved, but gait symmetry was significantly decreased under the RAS +10% and +20% conditions compared with under the RAS 0% conditions. [Conclusion] A faster RAS tempo significantly improved gait velocity and cadence, and applying RAS significantly improved the gait symmetry of stroke patients.
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DOI: 10.1589/jpts.26.479
PubMed: 24764615
PubMed Central: 3996403
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait
in Stroke Patients</title><author><name sortKey="Cha, Yuri" sort="Cha, Yuri" uniqKey="Cha Y" first="Yuri" last="Cha">Yuri Cha</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Kim, Young" sort="Kim, Young" uniqKey="Kim Y" first="Young" last="Kim">Young Kim</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Chung, Yijung" sort="Chung, Yijung" uniqKey="Chung Y" first="Yijung" last="Chung">Yijung Chung</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24764615</idno><idno type="pmc">3996403</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996403</idno><idno type="RBID">PMC:3996403</idno><idno type="doi">10.1589/jpts.26.479</idno><date when="2014">2014</date><idno type="wicri:Area/Pmc/Corpus">000756</idno><idno type="wicri:Area/Pmc/Curation">000756</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait
in Stroke Patients</title><author><name sortKey="Cha, Yuri" sort="Cha, Yuri" uniqKey="Cha Y" first="Yuri" last="Cha">Yuri Cha</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Kim, Young" sort="Kim, Young" uniqKey="Kim Y" first="Young" last="Kim">Young Kim</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Chung, Yijung" sort="Chung, Yijung" uniqKey="Chung Y" first="Yijung" last="Chung">Yijung Chung</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="e-ISSN">2187-5626</idno><imprint><date when="2014">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p> [Purpose] The aim of this study was to investigate the effects of tempo changes in
rhythmic auditory stimulation (RAS) on gait in stroke patients. [Subjects] Forty-one
chronic stroke patients who had had a stroke with more than 6 months previously were
recruited for this study. [Methods] All participants were asked to walk under 5 different
conditions in random order: (1) no RAS (baseline); (2) baseline-matched RAS (0%); and (3)
−10%, (4) +10%, and (5) +20% of the baseline. A GAITRite system was used to evaluate the
spatial and temporal parameters of gait. [Results] Compared with under the RAS 0%
conditions, the gait velocity, cadence, and stride length on the affected side were
significantly decreased under the RAS −10% conditions. Gait velocity and cadence were
significantly improved, but gait symmetry was significantly decreased under the RAS +10%
and +20% conditions compared with under the RAS 0% conditions. [Conclusion] A faster RAS
tempo significantly improved gait velocity and cadence, and applying RAS significantly
improved the gait symmetry of stroke patients.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Thaut, Mh" uniqKey="Thaut M">MH Thaut</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kim, Sj" uniqKey="Kim S">SJ Kim</name></author><author><name sortKey="Kwak, Ee" uniqKey="Kwak E">EE Kwak</name></author><author><name sortKey="Park, Es" uniqKey="Park E">ES Park</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thaut, Mh" uniqKey="Thaut M">MH Thaut</name></author><author><name sortKey="Leins, Ak" uniqKey="Leins A">AK Leins</name></author><author><name sortKey="Rice, Rr" uniqKey="Rice R">RR Rice</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fernandez Del Olmo, M" uniqKey="Fernandez Del Olmo M">M Fernandez del Olmo</name></author><author><name sortKey="Cudeiro, J" uniqKey="Cudeiro J">J 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24764615</article-id><article-id pub-id-type="pmc">3996403</article-id><article-id pub-id-type="publisher-id">jpts-2013-410</article-id><article-id pub-id-type="doi">10.1589/jpts.26.479</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original</subject></subj-group></article-categories><title-group><article-title>Immediate Effects of Rhythmic Auditory Stimulation with Tempo Changes on Gait
in Stroke Patients</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Cha</surname><given-names>Yuri</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Kim</surname><given-names>Young</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref></contrib><contrib contrib-type="author"><name><surname>Chung</surname><given-names>Yijung</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physical Therapy, The Graduate School, Sahmyook University, Republic of Korea</aff><aff id="aff2"><label>2)</label> Department of Physical Therapy, College of Health and Welfare, Sahmyook University, Republic of Korea</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding Author: Yijung Chung, epartment of Physical Therapy, College of Health and
Welfare, Sahmyook University: 815 Hwarang-ro, Nowon-gu, Seoul, Republic of Korea. (E-mail: <email xlink:href="yijung36@syu.ac.kr">yijung36@syu.ac.kr</email>)</corresp></author-notes><pub-date pub-type="epub"><day>23</day><month>4</month><year>2014</year></pub-date><pub-date pub-type="ppub"><month>4</month><year>2014</year></pub-date><volume>26</volume><issue>4</issue><fpage>479</fpage><lpage>482</lpage><history><date date-type="received"><day>30</day><month>8</month><year>2013</year></date><date date-type="accepted"><day>16</day><month>10</month><year>2013</year></date></history><permissions><copyright-statement>2014©by the Society of Physical Therapy Science</copyright-statement><copyright-year>2014</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p> [Purpose] The aim of this study was to investigate the effects of tempo changes in
rhythmic auditory stimulation (RAS) on gait in stroke patients. [Subjects] Forty-one
chronic stroke patients who had had a stroke with more than 6 months previously were
recruited for this study. [Methods] All participants were asked to walk under 5 different
conditions in random order: (1) no RAS (baseline); (2) baseline-matched RAS (0%); and (3)
−10%, (4) +10%, and (5) +20% of the baseline. A GAITRite system was used to evaluate the
spatial and temporal parameters of gait. [Results] Compared with under the RAS 0%
conditions, the gait velocity, cadence, and stride length on the affected side were
significantly decreased under the RAS −10% conditions. Gait velocity and cadence were
significantly improved, but gait symmetry was significantly decreased under the RAS +10%
and +20% conditions compared with under the RAS 0% conditions. [Conclusion] A faster RAS
tempo significantly improved gait velocity and cadence, and applying RAS significantly
improved the gait symmetry of stroke patients.</p></abstract><kwd-group><title>Key words</title><kwd>Gait</kwd><kwd>Rhythmic auditory stimulation</kwd><kwd>Stroke</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>Rhythmic auditory stimulation (RAS) is one of the neurological therapeutic methods that has
physiological effects in rehabilitative exercise therapy, which improves movement
control<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>. It is reported to improve gait
in terms of velocity, stride length, and cadence when applied to patients with cerebral
palsy, stroke, and Parkinson’s disease (various kinds of neurologic diseases) as a
rehabilitation therapy<xref rid="r2" ref-type="bibr">2</xref>,<xref rid="r3" ref-type="bibr">3</xref>,<xref rid="r4" ref-type="bibr">4</xref><sup>)</sup>. RAS guides the patients to
hit the ground with their feet as they walk and simultaneously hear an external auditory
cue, synchronizing the time of contact between the foot and ground with the sound<xref rid="r5" ref-type="bibr">5</xref><sup>)</sup>. According to previous researchers, rhythm
is an essential element of motor movement including motor control and output<xref rid="r6" ref-type="bibr">6</xref>, <xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>,
because rhythmic auditory cuing facilitates movement by providing a mechanism for planning
movements<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>. Thaut et al. (2009) studied
the effects of different RAS speeds (3%, 7%, 20%) on tapping in healthy adults and reported
that both sides of the frontal lobe and occipital lobe showed increased neuronal population
activation as the speed increased, and that the increased activity in the occipital lobe
also included synchronized rhythm patterns when the rhythm was increased 20%<xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>. Patients with spinal cord injury (SCI)
showed decreased gait velocity and cadence, and increased stride length at a normal RAS
speed, but these walking abilities all decreased at a 5% faster tempo<xref rid="r9" ref-type="bibr">9</xref><sup>)</sup>. Patients with Parkinson’s disease showed a significantly
decreased gait velocity and cadence, and significantly increased stride length and double
limb support at an RAS speed of −10%. As the RAS tempo was increased, the gait velocity and
cadence significantly increased<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>. Most
of the studies on stroke patients have used RAS with constant speed or time-based
stimulation increase. Research on the effects of tempo changes on gait in stroke patients is
currently insufficient. Therefore, this study attempted to determine the immediate effects
of RAS tempo changes on the walking abilities of stroke patients.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><p>A total of 41 patients who had recently had their first ischemic cerebrovascular accident
(CVA) (24 men and 17 women) were recruited from K, H, and O rehabilitation centers in Korea.
The inclusion criteria were as follows: (1) at least 6 months from the onset of stroke
(ICD-10 code 160 and 163), (2) able to walk more than 10 m independently, (3) no hearing,
visual deficits<xref rid="r10" ref-type="bibr">10</xref>, <xref rid="r11" ref-type="bibr">11</xref><sup>)</sup>, and (4) a Mini-Mental State Examination (MMSE) score of 24 or
higher<xref rid="r10" ref-type="bibr">10</xref>,<xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r12" ref-type="bibr">12</xref><sup>)</sup>. Any patient with one or
more of the following conditions was excluded from the study: (1) symptomatic cardiac
failure, (2) uncontrolled hypertension, (3) significant orthopedic or chronic pain
conditions affecting gait performance, or (4) any neurologic disease except for the first
stroke. Subjects were selected according to the inclusion criteria and were recruited from
December 2010 to February 2011 for this cross-sectional study. <xref rid="tbl_001" ref-type="table">Table 1</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title> General characteristics of subjects (n=41)</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">Subjects (n=41)</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Gender (M/F)</td><td align="center" rowspan="1" colspan="1">24/17</td></tr><tr><td align="left" rowspan="1" colspan="1">Age (years)</td><td align="center" rowspan="1" colspan="1">60.8±19.8</td></tr><tr><td align="left" rowspan="1" colspan="1">Height (cm)</td><td align="center" rowspan="1" colspan="1">165.7±7.5</td></tr><tr><td align="left" rowspan="1" colspan="1">Weight (kg)</td><td align="center" rowspan="1" colspan="1">65.3±7.4</td></tr><tr><td align="left" rowspan="1" colspan="1">Paretic side (right/left)</td><td align="center" rowspan="1" colspan="1">19/22</td></tr><tr><td align="left" rowspan="1" colspan="1">Since onset (months)</td><td align="center" rowspan="1" colspan="1">8.68±2.35</td></tr><tr><td align="left" rowspan="1" colspan="1">MMSE-K<sup>a</sup></td><td align="center" rowspan="1" colspan="1">26.6±1.6</td></tr><tr><td align="left" rowspan="1" colspan="1">Berg Balance Scale</td><td align="center" rowspan="1" colspan="1">43.8±6.4</td></tr><tr><td align="left" rowspan="1" colspan="1">Brunnstrom stage (lower limb)</td><td align="center" rowspan="1" colspan="1">3.2±0.7</td></tr></tbody></table><table-wrap-foot><p>Mean±SD. <sup>a</sup>MMSE-K: Mini Mental State Examination-Korean version</p></table-wrap-foot></table-wrap> lists the general characteristics of the subjects. This research protocol was
approved by the local Human Investigation Committee, and all participating patients signed a
letter of informed consent after receiving a description of the project.</p><p>Subjects were examined under 5 different walking conditions: gait without RAS (baseline)
and gait with RAS at −10%, 0%, +10%, and +20% of the baseline tempo. These conditions were
applied in random order, and the frequency of the metronome was determined by each subject’s
comfortable walking speed<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>. All subjects
were instructed to walk to the beat of the metronome, that is, to step in time with the
rhythm<xref rid="r10" ref-type="bibr">10</xref><sup>)</sup>. To help the patients to adapt
to the rhythm, they listened to the rhythm of the metronome for 30 seconds before walking
with RAS<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>. The purpose, study procedure,
and evaluation tools used in the study were explained to the subjects before the study. For
safety, each patient was assisted by a research assistant, and walking aides (quad cane and
straight cane) were allowed to be used during the experiment.</p><p>A GAITRite system (GAITRite, CIR Systems Inc, USA, 2008), which is an electronic walkway
used to measure the spatial and temporal parameters of gait, was used in this study. It has
been shown to provide valid and reliable data<xref rid="r13" ref-type="bibr">13</xref>,
<xref rid="r14" ref-type="bibr">14</xref><sup>)</sup>. The walkway is 457 cm long, and the
active area is 366 cm in length and 61 cm in width. A series of pressure sensors (16,128
sensors) are embedded in the electronic walkway. The GAITRite system recorded the gait
velocity, cadence, stride length, double limb support (% of cycle), and double single limb
support (% of cycle)<xref rid="r15" ref-type="bibr">15</xref><sup>)</sup>. Each patient
walked on the mat at his/her usual comfortable walking speed. For accurate data collection,
the first and last few steps of each trial were not recorded; patients started walking from
a point 2 m before the mat and stopped at a point 2 m after the mat, and walking aids were
allowed to be used when necessary. Measurement was repeated 3 times, and a 3-minute break
was given in between trials.</p><p>An electronic metronome was used to assess each patient’s walking tempo in order to provide
an accurate rhythm for each patient. The tempo (beats per minute) was set according to the
baseline cadence, and the subjects were to step in time with the beat in two-one time. All
subjects listened to the rhythm of the metronome for 30 seconds before walking to the
beat<xref rid="r1" ref-type="bibr">1</xref><sup>)</sup>.</p><p>In this study, the temporal symmetry ratio proposed by Patterson was used, and the details
are as follows<xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. The gait symmetry ratio
was used to calculate the time of the swing phase/stance phase of the leg on the affected
and unaffected side, separately. The ratio was an the absolute value; gait symmetry
increases as the value gets closer to 1, and it decreases as it gets farther away from
1.</p><p>Data were analyzed using SPSS ver. 12.0 for statistics and processing. The
Kolmogorov-Smirnov test was used for analysis of the general properties and variables of the
subjects. One-way repeated measures ANOVA was used, and the LSD post hoc test was performed.
Significance was set at p<0.05.</p></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p><xref rid="tbl_002" ref-type="table">Table 2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title> Spatiotemporal parameters of gait under the five conditions (n=41)</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" valign="top" rowspan="1" colspan="1"></th><th align="center" valign="top" rowspan="1" colspan="1">Baseline</th><th align="center" valign="top" rowspan="1" colspan="1">-10%</th><th align="center" valign="top" rowspan="1" colspan="1">0%</th><th align="center" valign="top" rowspan="1" colspan="1">+10%</th><th align="center" valign="top" rowspan="1" colspan="1">+20%</th></tr></thead><tbody><tr><td align="left" valign="top" rowspan="1" colspan="1">Gait velocity (cm/sec)</td><td align="center" valign="top" rowspan="1" colspan="1">42.1±23.3</td><td align="center" valign="top" rowspan="1" colspan="1">35.6±19.5*<sup>bcd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">41.3±23.2<sup>acd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">46.3±25.5*<sup>abd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">51.0±28.4*<sup>abc</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Cadence (step/min)</td><td align="center" valign="top" rowspan="1" colspan="1">76.5±19.8</td><td align="center" valign="top" rowspan="1" colspan="1">70.8±20.6*<sup>bcd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">77.1±22.0<sup>acd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">83.6±22.4*<sup>abd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">88.4±23.1*<sup>abc</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Stride length on the affected side (cm)</td><td align="center" valign="top" rowspan="1" colspan="1">63.2±21.6</td><td align="center" valign="top" rowspan="1" colspan="1">59.4±18.9*<sup>bcd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">63.5±20.8<sup>ad</sup></td><td align="center" valign="top" rowspan="1" colspan="1">65.2±22.9<sup>ad</sup></td><td align="center" valign="top" rowspan="1" colspan="1">67.9±25.1*<sup>abc</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Stride length on the unaffected side (cm)</td><td align="center" valign="top" rowspan="1" colspan="1">63.6±21.3</td><td align="center" valign="top" rowspan="1" colspan="1">59.2±18.7*<sup>bcd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">62.9±20.3<sup>ad</sup></td><td align="center" valign="top" rowspan="1" colspan="1">65.0±22.9<sup>a</sup></td><td align="center" valign="top" rowspan="1" colspan="1">66.6±24.3*<sup>ab</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Double limb support (% of cycle)</td><td align="center" valign="top" rowspan="1" colspan="1">39.2±11.9</td><td align="center" valign="top" rowspan="1" colspan="1">41.6±10.6*<sup>bcd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">38.2±10.4<sup>a</sup></td><td align="left" valign="top" rowspan="1" colspan="1">38.6±11.8<sup>ad</sup></td><td align="center" valign="top" rowspan="1" colspan="1">36.5±12.2*<sup>ac</sup></td></tr><tr><td align="left" valign="top" rowspan="1" colspan="1">Gait symmetry (%)</td><td align="center" valign="top" rowspan="1" colspan="1">1.4±1.1</td><td align="center" valign="top" rowspan="1" colspan="1">1.2±0.8<sup>b</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.0±0.6*<sup>acd</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.3±0.7<sup>b</sup></td><td align="center" valign="top" rowspan="1" colspan="1">1.3±0.9<sup>b</sup></td></tr></tbody></table><table-wrap-foot><p>Mean±SD. *Significantly different from baseline (no RAS) tempo (p<0.05).
<sup>a</sup> Significantly different from −10% RAS tempo (p<0.05). <sup>b</sup>Significantly different from 0% RAS tempo (p<0.05). <sup>c</sup> Significantly
different from +10% RAS tempo (p<0.05). <sup>d</sup> Significantly different from
+20% RAS tempo (p<0.05)</p></table-wrap-foot></table-wrap> shows the study results in terms of the spatiotemporal parameters of gait. The
gait with RAS 10% slower than the baseline significantly decreased the gait velocity to
35.6±19.5 cm/sec, cadence to 70.8±20.6 steps/min, stride length on the affected side to
59.4±18.9 cm, and the stride length on the unaffected side to 59.2±18.7 cm. The double limb
support (% of cycle) was significantly increased to 41.6±10.6 (% of cycle). In the gait with
RAS 10% faster than the baseline, the gait velocity was significantly increased to
46.3±25.5 cm/sec, and cadence was significantly increased to 83.6±22.4 steps/min. In the
gait with RAS 20% faster than the baseline, the gait velocity was significantly increased to
51.0±28.4 cm/sec, cadence was significantly increased to 88.4±23.1 steps/min, stride length
on the affected side was significantly increased to 67.9±25.1 cm, stride length on the
unaffected side to 66.6±24.3 cm, and double limb support (% of cycle) was significantly
decreased to 36.5±12.2 (% of cycle) compared with the baseline gait. Gait symmetry was
significantly decreased to 1.0±0.6 in the gait with RAS 0% when compared with the baseline
gait (1.4±1.1). This means that gait symmetry was significantly improved under the RAS 0%
conditions.</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>RAS is reported to improve movement patterns by activating the internal timekeeping
mechanism, which leads to movement synchronization<xref rid="r17" ref-type="bibr">17</xref><sup>)</sup>. Recently, RAS has been clinically applied as a therapeutic
intervention to improve the upper and lower extremity functions in the patients with various
neurological diseases<xref rid="r3" ref-type="bibr">3</xref>, <xref rid="r11" ref-type="bibr">11</xref>, <xref rid="r18" ref-type="bibr">18</xref>,<xref rid="r19" ref-type="bibr">19</xref>,<xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>. Thus, this
study was conducted to determine the effects of RAS tempo variations on the walking
abilities of stroke patients.</p><p>Most of the previous studies reported significant changes in gait velocity at a certain
rhythm tempo. Based on these findings, this study used 4 different tempo variations of RAS
(−10%, 0%, +10% +20%) for higher significance in proving the effects<xref rid="r10" ref-type="bibr">10</xref>, <xref rid="r11" ref-type="bibr">11</xref>, <xref rid="r21" ref-type="bibr">21</xref><sup>)</sup>. The results of this study showed significant improvements
in gait velocity, cadence, stride length on the affected side, double limb support on the
affected side, and gait symmetry as the RAS tempo was increased compared with the no RAS or
RAS 0% condition. When RAS −10% was applied, gait velocity, cadence, and stride length on
the affected side significantly decreased and double limb support on the affected side
significantly increased. Under the RAS +10% conditions, gait velocity and cadence were
significantly increased, and gait symmetry was significantly decreased. When RAS +20% was
applied, the gait velocity and cadence increased, and double limb support on the affected
side and gait symmetry decreased (p<0.05). Increased gait velocity, which is determined
by cadence and stride length, is commonly used as the gait evaluation index<xref rid="r16" ref-type="bibr">16</xref><sup>)</sup>. These results showed that application of
a faster RAS tempo increased gait velocity, revealing the potential to immediately improve
walking abilities. Double limb support was significantly decreased as the gait velocity was
increased. This means that gait function was improved, and therefore application of afaster
RAS tempo can also improve balance and stability.</p><p>A previous study reported no significant difference in walking ability between a no music
group and a 0% speed group in healthy adult subjects<xref rid="r11" ref-type="bibr">11</xref><sup>)</sup>. A study on stroke patients also reported no significant difference
in stride length when RAS equal to the baseline speed was applied<xref rid="r22" ref-type="bibr">22</xref><sup>)</sup>. This means that stimulations with rhythmical tempo
variations have a positive influence on the gaits of stroke patients but that a rhythm
equivalent to the gait velocity does not have significant effects on the gaits of patients.
Previous studies reported improved gait symmetry when RAS was applied<xref rid="r23" ref-type="bibr">23</xref><sup>)</sup>, but they only compared groups with RAS application with
groups without RAS. These studies did not analyze the effects of RAS tempo. However, the
present study applied 4 different RAS tempos (−10%, 0%, +10%, +20%), and found that gait
symmetry was the highest at RAS 0%. Gait velocity improved as the RAS tempo was increased;
RAS 20% showed the highest gait velocity among the four conditions. All of these results
were significantly higher compared to with those under the no rhythm conditions.</p><p>According to the results of previous studies, auditory stimulation plays an important role
in feedback and feed-forward in an unstable posture; it was reported to increase immediate
postural stability by controlling the feedback and sensory response<xref rid="r24" ref-type="bibr">24</xref>, <xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>. The results of
the present study also showed improved gait symmetry as the subjects learned to use
feed-forward control to take steps at the given RAS tempo. RAS can increase the excitability
of spinal motor neurons via the reticulospinal pathway, thereby reducing the amount of time
needed for the muscle to respond to a given motor command. In order to improve the quality
of walking abilities, immediate sensory response is needed, and variations in auditory
stimulation can be effective in improving the quality of gait<xref rid="r26" ref-type="bibr">26</xref><sup>)</sup>.</p><p>RAS was proved to have an effect on cerebral activity by inducing synchronization of
movement and rhythm through sensory stimulation. By applying RAS, a movement can be
synchronized to the beat as the movement is actively repeated at the same rhythm<xref rid="r27" ref-type="bibr">27</xref><sup>)</sup>, and as the person tries to synchronize
their movement with the music, concentration and motor control are both promoted. In terms
of setting of movement goals, the sensory information, visual feedback, and somatosensory
feedback from an auditory cue seemed to be effective in movement relearning, which is based
on motor learning<xref rid="r28" ref-type="bibr">28</xref><sup>)</sup>. RAS has no side
effects, is cost effective, can be used independently or in combination with other
treatments, and can decrease muscle fatigue during physical training<xref rid="r17" ref-type="bibr">17</xref><sup>)</sup>. External stimuli promote the essential energy needed for
movement through synchronized and integrated physical movement<xref rid="r29" ref-type="bibr">29</xref><sup>)</sup>, and auditory stimulation can improve walking abilities by
redefining gait patterns and motor control<xref rid="r19" ref-type="bibr">19</xref>, <xref rid="r30" ref-type="bibr">30</xref><sup>)</sup>. Auditory stimulation can also be used for
cadence to speed up the gait<xref rid="r31" ref-type="bibr">31</xref><sup>)</sup>, and
application of rhythm can improve independent gait and gait pattern<xref rid="r17" ref-type="bibr">17</xref><sup>)</sup>.</p><p>Using music as an auditory stimulation was reported to induce positive effects on
improvement of performance of cognitive tasks<xref rid="r32" ref-type="bibr">32</xref><sup>)</sup> Previous studies also reported that pleasant auditory stimulation
can have effects on coping with stress<xref rid="r33" ref-type="bibr">33</xref><sup>)</sup>and can mediate arousal, emotion, reward, motivation, memory, attention, and executive
functioning<xref rid="r34" ref-type="bibr">34</xref><sup>)</sup>. Such psychological
factors may have influenced the patients’performance in this study, and it is possible that
RAS-related improvements seen in the study were mediated by positive mood or self-efficacy.
However, these factors were not considered in this study, as this was a cross-sectional
study that investigated the immediate effects of different RAS tempos. Further research to
determine the emotional and cognitive effects of RAS is needed.</p><p>The present study also showed that applying RAS to the gait of stroke patients not only
increases the gait velocity but also increases the stride length and gait symmetry at the
same time. The subjects who participated in this study adjusted well to the changing tempo,
and gait improvement was also found at a tempo that was as high as 20% RAS baseline. We
expect to find positive long-term effects after a certain period of training, as Thaut et
al. (2007) reported improvements in gait velocity, stride length, cadence, and symmetry
after applying RAS with a 5% increase from the baseline tempo for 3 weeks<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>. Further studies are needed in order to
ascertain whether using graded increases in tempo throughout the training process will
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