RIMS Keynotes

KN 01 | Workshop: How to design a trial in motor/exercise rehabilitation (#44)

V. de Groot^1,2

¹VU University Medical Center Rehabilitation medicine, P.O. Box 7057, 1007 MB Amsterdam, Netherlands

²VU University Medical Center MS Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, Netherlands

Objective: Randomised Clinical Trials (RCT) are important for building the evidence base in rehabilitation. They are necessary in order to improve the treatment of patients. Therefore, it is important that all clinicians are able to read, interpret and apply the results of RCTs. However, for most clinicians reading and interpreting the results of an RCT remains challenging. The aim of this workshop is to increase the knowledge of clinicians on how an RCT in exercise rehabilitation should be designed. This knowledge will help them to read and interpret the results of RCTs.

Methods: After an introductory lecture on the general principles of designing an RCT, participants will work in small subgroups on their own “research proposal”. They can choose their own motor or exercise intervention, and work out a first draft of their proposal using the CONSORT (CONsolidated Standards Of Reporting Trials) checklist as basis. At the end of the workshop, all subgroups will give a short presentation that is open for discussion by the other participants.

Results: This interactive format will enhance the understanding of the participant of the challenges in RCTs in rehabilitation medicine, and thus also help them to interpret the results of published RCTs.

KN 02 | Workshop: How to design a trial in neuropsychological rehabilitation (#97)

P. Hämäläinen

Masku Neurological Rehabilitation Centre, Vaihemäentie 10, 21250 Masku, Finland

Objective: Cognitive deficits are common in MS occurring in about 50-60% of patients. Deficits can have a multidimensional impact on patients’ activities of daily living and should be taken into account in the treatment and rehabilitation regimen. Neuropsychological rehabilitation aims at 1) reducing cognitive deficits; 2) reducing the harmful effects of cognitive impairments; and 3) supporting patients’ awareness and ability to take cognitive impairments into account in daily living.

A recent review* based on 14 trials indicates low level positive evidence for the effectiveness of neuropsychological rehabilitation in MS. The review raised concerns about the quality of the studies evaluating the effects of neuropsychological rehabilitation in MS. Thus, more well-conducted trials on the effects of neuropsychological rehabilitation in MS are needed to strengthen the evidence. On the basis of the results of the review, some specific actions can be recommended to improve the quality of future studies. These include determining the aim of the intervention as well as primary outcome variables beforehand, collecting a sufficiently big and cognitively homogeneous sample, conducting adequate randomization and objective baseline measurement of cognitive status, blinding the assessor, detailed reporting of essential disease variables as well as intervention and assessment methods and timing, and conducting longitudinal follow-up to evaluate the permanence of the treatment effects. One of the important recommendations is to find and use measures which reflect the effects of treatment not only to cognitive tests but to everyday functions. Unifying the assessment and report practices concerning the effectiveness of interventions can be regarded as a golden aim.

During the workshop, the recommendations will be discussed and a trial on the effects of neuropsychological rehabilitation in MS will be designed.

References

*Rosti-Otajärvi EM, Hämäläinen PI. Neuropsychological rehabilitation for multiple sclerosis. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD009131. DOI: 10.1002/14651858.CD009131.pub2

KN 03 | Shared decision making as the basic approach to patient centred care – opportunities and limitations (#148)

A. Barratt

The University of Sydney Sydney School of Public Health, Sydney Medical School, Rm 323a, Edward Ford Building A27, 2006 NSW, Australia

Objective: Shared decision making (SDM) is fast becoming the theoretical standard of care for health care practice in western countries, although implementation in practice remains limited. In SDM, health care choices are made jointly by the patient and his or her health care practitioner. SDM provides a number of important opportunities. First SDM can shift health care practice in an ethical direction which explicitly recognises and values patient autonomy and the variability in patient preferences. SDM may also realise important practical benefits if evidence continues to emerge that SDM can improve health outcomes. Policy makers may support SDM because it may help shift practice towards more effective and more cost-effective care, thus helping to contain health care budgets.

To date, SDM has been operationalised largely through decision aids. The updated Cochrane Systematic Review shows that decision aids lead to improvements in patient knowledge, health care choices that are more consistent with patient preferences, patients participating more in decision making and positive effects on communication between patients and health care practitioners. Decision aids have variable effects on consultation length. Another approach has been to train doctors to behave in ways that promote SDM. To date, however, there is very limited evidence that this approach may be effective.

We have undertaken two projects to implement SDM using alternative approaches. In my talk I will present these studies as illustrative examples of innovative ways to implement SDM, and comment on the opportunities they present. One project harnessed the power of consumers rather than doctors to shift the consultation towards SDM. The study evaluated three questions posed by consumer advocate Karen Carey. The questions are designed to prompt doctors to discuss evidence that patients need to make health care decisions and thus to involve patients in decision making. We evaluated the questions in a trial using standardised patients who visited real family physicians and covertly audiorecorded their consultations. We found the questions were effective in increasing patient involvement as measured by the OPTION scale and succeeded in prompting doctors to present relevant evidence. In the second study, we built a website that enables cancer patients to search for cancer clinical trials they may wish to participate in, http://www.australiancancertrials.gov.au/. Cancer consumer groups in Australia lobbied for years for the website, believing it would be good for patients and for the community by promoting awareness of clinical trials and the benefits of participating in a trial as a treatment option. Australian Cancer Trials downloads data from the two main registries of clinical trials in Australia (the Australian New Zealand Clinical Trials Registry and the US based ClinicalTrials.gov) to provide a searchable set of trials that is always up to date. We evaluated the website in a cluster randomised trial with medical oncologists and their patients in two Australian states and found a trend towards a positive effect and strong support among consumers for the website.

In addition to the opportunities presented there are limitations to SDM. These include obvious and immediate limitations relating to the costs of implementing SDM and the impact on the nature and duration of consultations. Further limitations may be more subtle and may include individual, social and ethical challenges which will also be discussed.

KN 04 | Evidence-based patient information as a prerequisite for SDM (#151)

I. Mühlhauser

Universität Hamburg, MIN-Fakultät Gesundheitswissenschaft, Martin-Luther-King-Platz 6, 20146 Hamburg, Germany

Objective: Deliberating treatment options without evidence-based information is like negotiating about the emperor’s nose that nobody has ever seen. Physicians may be perfectly trained in communication skills but still use inappropriate information.

Medical information is often biased, incomplete and misleading. A systematic review has shown that information in decision aids is frequently not evidence-based.

Most striking examples demonstrating lack of evidence of medical content are previous decision aids on menopausal hormone therapy. Evaluation studies claimed improvement of women’s knowledge and satisfaction with decisions. However, the provided information was wrong. On the benefit side a substantial reduction of cardiovascular disease was promised based on invalid interpretations of cohort studies. Later randomised controlled trials showed an increase of cardiovascular and other diseases.

Evidence-based patient information refers to both content and presentation of information. Criteria for the development have been defined. For example, the information should cover personalised risk and natural course of the disease, and all available options, including the option not to intervene. Information on possible benefit and harm should be presented as numbers, and using natural frequencies rather than changes in relative risk, with comparable reference populations and timeframes.

Even high quality clinical guidelines and associated patient guidelines do not provide the information necessary for informed decision making.

Tools for critical appraisal of decision aids such as IPDASi cannot be used to evaluate the evidence of the information content. Therefore, the quality of the core component of evidence-based patient information remains obscure.

For most preference sensitive medical decisions evidence-based decision support is still not available. In addition, often information is complex such as treatment options for patients with multiple sclerosis or most cancers. This requires information management outside the physician encounter and without time-pressure. Comprehension of the information should be documented before making decisions, both for health care providers and patients.

Development of up-to-date decision aids is time consuming. Identification, appraisal and synthesis of the evidence base are major resource limiting barriers. Study fact sheets as produced by independent institutions should be made freely accessible for users of evidence worldwide.

KN 05 | Cognitive behavioural interventions as a treatment choice for people with MS (#146)

R. Moss-Morris

King’s College London Institute of Psychiatry, London Bridge, London, SE1 9RT, Great Britain

Objective: Cognitive Behaviour Therapy (CBT) originated as a treatment for emotional disorders. However, it is increasingly used to help people with chronic illnesses manage symptoms and improve quality of life. The purpose of this presentation is to present evidence to argue that CBT is an effective treatment choice for reducing distress and fatigue for people with MS (pwMS).

Methods: Three trials conducted by my group will be presented. 1) A randomised controlled trial (n=72) comparing 8 sessions of CBT for MS fatigue with 8 sessions of relaxation therapy, both delivered by a clinical psychologist. 2) A pilot RCT (n=40) of a web based version of our CBT for MS fatigue intervention compared to treatment as usual (TAU), 3) a RCT (n=94) comparing 8 sessions of nurse-led CBT for adjusting to MS with 8 sessions of supportive listening (SL).

Results: In all three studies CBT was shown to be more effective at reducing the primary outcomes (fatigue and distress) than the comparison arms (TAU, SL, and relaxation therapy). Although effects were sustained at longer term follow-up (6 months for the RCT of CBT for fatigue and one year for the RCT of CBT for adjustment) there was a drop of in treatment gains during follow- up.

Conclusion: CBT appears to be an effective treatment for fatigue and distress associated with MS. Follow-up sessions after the end of therapy may be needed to sustain treatment effects. Increasing access to psychological therapies for pwMS provides an effective treatment option for improving symptom and distress management.

KN 06 | The role of shared decision making in palliative care in advanced multiple sclerosis (#68)

E. Silber¹, A. van Nunen²

¹KIngs College Hospital Neurology, Denmark Hill, London, SE5 9RS, Great Britain

²Nationaal Multiple Sclerose Centrum vzw, Van Heylenstraat 16, 1820 Melsbroek, Belgium

Objective: Until recently the issue of palliative care in multiple sclerosis has not been widely discussed. Reasons for this include the young age of onset, the long disease duration and the considerable variation in disease course. There has also been considerable emphasis on early diagnosis and treatment of people with MS, leading some with advanced disease to feel that their needs are underestimated. There is growing support for the role of palliative care, either provided by palliative care specialists or incorporated into MS care by neurology and rehabilitation services.

Methods: This talk incorporates experience from our centres and will address the following issues: 1. Discussing the role of palliative care in neurological conditions, in particular MS and the differences with conventional palliative care. 2. Identifying the triggers for palliative care, including both symptom control, in particular pain, addressing complex psychological and social needs, and planning and decision making concerning end-of-life care. 3. Identifying specific symptoms that may be helped by palliative care input. 4. Addressing how and when patients and their families/ carers are involved in advanced care planning and end of life decisions. 5. Discussing specific laws that govern the role of patients in decision making in our countries, in particular in advanced care planning.

Results: We will incorporate specific cases that highlight these particularly challenging area of practice.

Conclusion: This will add to our experience in the management of palliative issues in patients with advanced multiple sclerosis.

KN 07 | SDM in MS care/rehab: Beyond patient-physician encounters. (#77)

V. Matthews

MS Trust MS, Spirella Buidlings, Letchworth garden City, SG6 4ET, Great Britain

Objective: There are many mediators/moderators that influence the suitability and durability of shared decisions made within the clinical setting. This presentation will consider those extrinsic and intrinsic factors unique to the individual that may have a role to play in determining the right decision; sometimes the right decision is the hardest to make.

This presentation will reflect on the skills/attributes required of the MS clinician to enable successful decision making that endures beyond the medical model into the life yet to be lived and those other decisions yet to be made.

Methods: By using case studies this presentation will provide insight into those behaviours and approaches, beyond clinical acumen, that can support the clinician to develop skill in facilitating the shared decision making process.

The presentation will explore the “therapeutic use of self” and “sense of self” within the shared decision making process

Results: There are no study results for this presentation.

Participants will have increased understanding of the insights and skills that will enhance their role within the shared decision making process and will have greater awareness of those extrinsic and intrinsic factors that influence any decision making

Conclusion: There is no conclusion for this presentation as it will be an interactive session with more of a workshop format. It is anticipated that participants will have a greater understanding of internal factors that influence, and those of the person living with MS.

References

References will be provided within the presentation slide deck

KN 08 | Shared Decision Making in occupation reintegration programs in medical rehabilitation (#41)

S. Neuderth, M. Lukasczik, C. Gerlich

University of Wuerzburg, Institute for Psychotherapy and Medical Psychology Rehabilitation Sciences Section, Klinikstr. 3, 97070 Wuerzburg, Germany

Objective: Vocationally oriented medical rehabilitation (VOMR) has become an integral part of inpatient medical rehabilitation in the German health care system (Lukasczik et al. 2011). But the motivation of patients to deal with vocational problems during their stay in the rehabilitation centre cannot always be taken for granted. Shared decision making (SDM) may prove to be a valuable tool for increasing patients’ motivation and satisfaction with vocationally oriented therapeutic measures.

The objective of the study was to examine the influence of SDM on the motivation to deal with vocational problems during inpatient rehabilitation as well as on patients’ satisfaction.

Methods: We measured patients’ motivation and satisfaction before and after implementing SDM in inpatient medical rehabilitation. Physicians and therapeutic staff were trained to involve VOMR patients in the decision-making process. Analysis of the data before and after implementing SDM showed no effect. However, we conducted a latent class analysis with the questionnaire measuring subjective participation (SDM-Q-9; Kriston et al., 2010), with a total of 283 patients (average age 50 yrs., 68% females) in order to identify different types of patient participation.

Results: The SDM training concept for the medical staff will be presented. Although the expected training effect could not be confirmed, patients differed with regard to subjective participation:

(1) 42% reported a formal involvement in terms of SDM;

(2) 16% reported a patient-oriented interaction in line with SDM (i.e., disclosing that a decision needs to be made and formulating the equality of partners, but no involvement in the actual decision, assuming not wanting to get involved);

(3) 15% reported no formal involvement (i.e., no disclosure that a decision needs to be made, no formulation of equality of partners) but a patient-oriented interaction and finally experienced the actual decision as a shared decision;

(4) 28% reported neither formal nor informal participation.

The different kinds of subjective participation were related to patients’ satisfaction but not to motivation.

Conclusion: In VOMR, both patients’ satisfaction and the selection of vocationally oriented measures corresponding to the patients’ subjective needs is associated with a patient-oriented interaction and the participation in the decision making process (but not in the actual decision itself). The impact on the concept of SDM is discussed.

References

Lukasczik, M., Wolf, H.D., Gerlich, C., Löffler, S., Vogel, H., Faller, H., Neuderth, S. (2011). Current state of vocationally oriented medical rehabilitation - a German perspective. Disability & Rehabilitation, 33, 2646–2655.

Kriston, L., Scholl, I., Hölzel, L., Simon, D., Loh, A., Härter, M. (2010). The 9-item Shared Decision Making Questionnaire (SDM-Q-9). Development and psychometric properties in a primary care sample. Patient Education and Counseling, 80, 94–99.

KN 09 | SDM as a major concept in goal setting (#150)

D. Playford

UCL Institute of Neurology National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, Great Britain

Objective: To consider how goal setting can be used to support shared decision making.

Methods: The literature around shared decision making and goal setting will be reviewed and similarities and differences identified.

Results: Goal setting may be defined is a process of discussion and negotiation in which the patient and staff determine the key priorities for that individual and agree the performance level to be attained by the patient for defined activities within a specified time frame. There are two elements to this definition and this paper will focus on the first element – that is the process of discussion and negotiation.

Shared decision making is a process in which clinicians and patients work together to select tests, treatments, management or support packages based on the clinical evidence and the patient’s informed preferences. Guidance in the GMC’s Good Medical Practice states that doctors should ‘work in partnership’, and that this includes listening to patients, respecting their views, discuss diagnosis, prognosis, treatment and care, and maximizing patients opportunities and ability to make decisions for themselves.

It is clear that goal setting and shared decision have many elements in common. The factors that facilitate, and the barriers to using goal setting as a form of shared decision, will be identified and discussed.

Conclusion: Goal setting can be used as a form of shared decision making.

KN 10 | Integrating goal setting and outcome measures in daily practice (#153)

K. Luyckx

Rehabilitationszentrum Valens Teamleitung Therapien Neurologie, 7317 Valens, Switzerland

Objective: Several frameworks and problem solving tools in rehabilitation has been proposed for clinical practice in rehabilitation^{1, 2}. The first step within these rehabilitation approaches is to identify the personal needs and expectations of the patient and relatives. The different disciplines of the rehabilitation team examine and diagnose at the level of impairment, activity limitation, participation restriction and the environmental context³. Expectations of the patient, the results of the examination and prognosis form the basis for defining long- and short-term goals together with the patient. Goal-setting need to be specific, measurable, achievable, realistic and time framed (SMART) and defined together with the patient. To evaluate the effectiveness of the interventions and the attainment of the goals, each defined goal should be linked with a valid outcome measure. A validated core set of the ICF for multiple sclerosis (MS) has been recently developed⁴ and can be used to supplement information for relevant health areas in MS and to individually define rehabilitation goals and outcome assessment⁵

Methods: Requirements on medical and therapeutic documentation are increasing. Documentation should be narrow and informative and at the same time sufficient to achieve the legal requirements and orders. Hence it is recommended to use standard forms, likely even in an electronic form.

Results: In the rehabilitation center Valens we developed an interdisciplinary form resembling a goal-centred rehabilitation approach. It offers a structured documentation of the goal-setting based on the ICF-categories and provides a linking to established assessments⁶, thereby enabling an evaluation from admission to discharge.

Conclusion: Present experiences made with this tool in our rehabilitation centre enable the rehabilitation team to convey a patient-centred care and increase the active engagement of our patients. Additional advantages are an improved information flow and communication within the interdisciplinary team.

References

1. Use of the ICF Model as a Clinical Problem-Solving Tool in Physical Therapy and Rehabilitation Medicine: W. Steiner et al. Physical Therapy. 2002; 82:1098–1107

2. Guide to Physical Therapist Practice. APTA, 2003

3. World Health Organisation. International classification of functioning, disability and health: ICF. Geneva: WHO, 2001

4. The development of ICF core sets for multiple sclerosis: results of the International Consensus Conference. M. Coenen et al. J Neurol 2011; Mar 4.

5. Rehabilitation measures in MS. S. Beer, F. Khan and J. Kesselring. MS Rehab J Neurol 2012: in Press

6. Assesments in der Rehabilitation – Band 1: Neurologie. S. Schädler et al. Verlag Hans Huber, Bern Book 2009

KN 11 | What can we learn from system neurosciences (fMRI, TMS) (#149)

F. Hummel

Universitätsklinikum Hamburg-Eppendorf Klinik und Poliklinik für Neurologie, Martinistraße 52, 20246 Hamburg, Germany

In the last years neurorehabilitation got more and more into the focus of system neuroscience. As for a long period neurorehabilitation was not addressed by neuroscientific approaches, most of the understanding and knowledge in the filed came from therapeutic approaches and clinical observations and evaluations. However, the understanding of underlying mechanisms was still poor and furthermore the degree of functional recovery based on the therapeutic strategies was not satisfactory with a need of development of additional therapeutic strategies.

To develop novel therapeutic strategies to enhance functional recovery and bring more patients after brain lesions back to their normal life it is of great importance to better understand the mechanism of functional reorganization and recovery after neurological diseases such as stroke or multiple sclerosis. By applying modern methods of systems neuroscience the understanding has been clearly enhanced in the last years, although there are still several open questions.

In the present talk examples will be presented how the use of systems neuroscience by means of functional brain imaging and brain stimulation can enhance the mechanistic understanding which is a crucial basis for the development of novel innovative therapeutic strategies. Nevertheless, it has to be pointed out that there are still several open questions which have to be clarified with the goal to achieve an understanding which allows to provide individualized innovative therapies adjusted to the needs and characteristics of the single patient, such as individual lesion site, impairment, time after lesion etc.

KN 12 | Neuroplasticity in MS (#152)

J. Claßen

Universitätsklinikum Leipzig Klinik und Poliklinik für Neurologie, Liebigstraße 20, 04103 Leipzig, Germany

Multiple Sclerosis (MS) leads to demyelinating and axonal injury of the central nervous system. A significant portion of the brain injury in MS is chronically progressive allowing gradual adaptation mechanisms to compensate for dysfunctional neuronal substrate. The presence of such mechanisms is suggested by the fact that disability may not easily be deduced from structural markers of brain lesion load. Using transcranial magnetic stimulation techniques adaptive mechanisms can be studied on multiple scales. Short-term plasticity, resembling long-term potentiation of excitatory neuronal synapses is induced by paired associative stimulation. In patients with mild-to-moderate MS, such rapid-onset neuronal plasticity was uncompromised, despite several plasticity-impeding factors. Functional activation studies in MS patients have demonstrated that performance of simple motor tasks may activate non-canonical brain regions. Virtual lesion induction by transcranial magnetic stimulation provided evidence suggesting that this activation is functionally relevant. Kinematic analysis of finger movements evoked by TMS allows for detailed analysis of how efficiently the central nervous system generates dexterous movements. Efficacy of precision or power grasping movement representation was differentially affected in mild-to-moderate MS. While power grasping organization was retained, neuronal organization of precision grasping movements was impaired, and impairment correlated with indices of brain injury, but not with indices of timed and accuracy of movement performance. Formation of long-range neuronal connections and recruitment of non-canonical brain regions likely are mechanisms underlying compensation of brain injury in MS. Reduced efficiency of motor control of dexterous movements may provide a pathophysiological model for impairment of movement independent of conventional functional assessments.

KN 13 | Arm rehabilitation using combined technologies: experiences with stroke, potential for use with MS (#147)

A. M. Hughes¹, K. L. Meadmore², C. T. Freeman², J. H. Burridge¹, E. Rogers²

¹University of Southampton Health Sciences, University Road, Southampton, SO17 1BJ, Great Britain

²University of Southampton Physical and Applied Sciences, University Road, Southampton, SO17 1BJ, Great Britain

Upper limb dysfunction impacts on many activities of daily living such as feeding and dressing, and ultimately personal independence. The application of new technologies holds considerable promise for the provision of neurorehabilitation, which can reduce dysfunction. These technologies are being designed using neurophysiological principles and evidence based components that optimise recovery of function: increasing central nervous system (CNS) excitability; intensity of practice; early intervention; motivation both to maximise engagement and effort to comply with the training programme; and performance of functional and relevant personalised tasks.

Evidence already exists for the effectiveness of several different technologies in reducing neurological impairments, but can synergies be obtained by combining different types of technologies? Robots have the ability to provide repetitive practice and are being combined with iterative learning control (ILC) and electrical stimulation (ES). ILC is an advanced control system that uses previous performance to calculate ES parameters required to increase motor accuracy trial by trial. In this way, ILC provides enough ES to assist performance, whilst also encouraging participants to exert maximum voluntary effort for completing the task, an important factor associated with increased positive therapeutic effects. Robots are also being combined with non-invasive brain stimulation e.g. transcranial direct current stimulation (tDCS) to increase CNS excitability. Constraint induced movement therapy (CIMT), in which the user wears a glove on the hand of the unaffected limb to force use of the hemiplegic limb, is being combined with an internet-based application to motivate adherence to a rehabilitation programme.

Clinical results and participant perceptions from these feasibility and pilot studies are generating key findings which can be used to inform trials of the technologies for people with MS.

KN 14 | Biomechanics to understand gait rehabilitation (#43)

V. de Groot^1,2

¹VU University Medical Center Rehabilitation medicine, P.O. Box 7057, 1007 MB Amsterdam, Netherlands

²VU University Medical Center MS Center Amsterdam, P.O. Box 7057, 1007 MB Amsterdam, Netherlands

Objective: The complexity of walking becomes apparent when the ability to walk is reduced as a result of various impairments in the neuromuscular system, such as the presence of spasticity and contractures, ataxia and muscle weakness. Several types of interventions are available to treat these walking limitations. However, decisions on which intervention to choose are not always straightforward and the working mechanisms of the interventions are not always clear.

This presentation will show how gait analysis can help to understand the working mechanisms of interventions that can be applied in neurorehabilitation, and support the diagnostic work up of patients with walking problems.

Methods: A method of analysing walking problems based on the framework of the International Classification of Functioning and Health will be used to understand what causes the walking problems and to show how specific interventions exert their effects. Using examples from orthotic management and electromyographic biofeedback, the effects of these interventions will be evaluated at the levels of body functions & structures and activities. If properly indicated, these interventions should lead to improvements walking ability. Because reduced walking ability is an activity limitation, the effects of the AFO should at least be evaluated at activity level. However, because the interventions are expected to promote walking ability by compensating for impairments, these impairments should also be evaluated. The knowledge that is needed to improve these interventions can best be obtained by concurrently performing a mechanical evaluation, an evaluation at activity level, and preferably an evaluation at participation level.

Results: An example of the diagnostic work up using gait analysis will be shown. Next, an example of a study that was performed to show the effects of an energy-storing ankle foot orthosis, will show that an energy storing ankle foot orthosis can reduce the energy cost of walking, despite the fact that push off power at the ankle is not improved. Subsequently, an example of a study on the effect of electromyographic biofeedback training of the calf muscle in stroke patients will shows how this training improves push off power and increases walking speed.

Conclusion: A comprehensive analysis of walking problems including gait analysis should be applied in future research in order to improve treatments to improve walking ability, and can improve the identification of and treatment plans for walking problems.