Impaired reciprocal gait in patients with ischemic stroke: a single-session recovery trial

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BACKGROUND

Locomotion in mammals is an automatic function generated in the spinal cord, enabling rhythmical, cyclic, and repetitive movements. The motor cortex, cerebellum, and brainstem provide for more precise control of walking [1]. Under normal conditions, the automaticity of walking ensures symmetrical biomechanical parameters on both sides. This means that one step cycle is delayed relative to the other by exactly half a period (half the time of the step cycle) [2]. The energy requirement of walking is low in healthy individuals owing to the optimized, integrated interlimb coordination, which is one of the basic functions of the automaticity of walking [3]. This function is called a reciprocal gait.

Researchers use the term “symmetrical gait” to describe a synergistic, rhythmical walking pattern. Some international publications use terms such as “reciprocal gait pattern,” “reciprocal extremity activity,” or “reciprocal interlimb influence” [4–6]. Reciprocal gait is defined as coordinated, symmetrical alternating movements of the upper and lower limbs, maintaining the body’s balance around a vertical axis and facilitating forward movement. Disorders such as stroke-related central nervous system injuries result in impaired reciprocal gait. Hemiparetic gait is a common gait impairment that is reported in more than 80% of patients after a middle cerebral artery stroke [7]. It is associated with spatiotemporal asymmetry, a decrease in joint angle, and muscle weakness in the affected lower limb [8, 9]. Clinical signs include the Wernicke–Mann posture with transverse hip abduction and impaired triple flexion of the lower limb during the swing phase. Insufficient flexion in the joints lengthens the leg, allowing it to only move forward by hip abduction (hemiplegic gait). Another typical sign is that the unaffected leg is more involved in the stance phase, whereas the paretic leg is more involved in the swing phase [8], with considerable step length asymmetry. The stance and swing phases show asymmetry as well [8, 9]. The stance phase on the paretic is considerably longer than on the unaffected side, which is inverted during the swing phase. Such a gait resembles side-stepping. The paretic leg is extended as far forward as possible, and the unaffected one is quickly put next to it. As a result, the unaffected leg begins its step cycle much earlier than the midpoint of the paretic leg’s cycle. In contrast, the paretic leg begins its step cycle after the midpoint of the unaffected leg’s cycle [8]. This mechanism is necessary for unloading the affected side. In other words, during the paretic leg’s step cycle, the unaffected limb “comes to the rescue” earlier than under normal conditions, whereas the paretic limb “takes its time” to begin the stance phase. Persistent spatiotemporal gait asymmetry is reported in approximately 50% of post-stroke patients [10].

Biomechanical gait parameters that reflect automatic reciprocity include temporal (the beginning of one leg’s step cycle relative to the other [11]), spatial (changes in single step length [12]), and dynamic (a shorter stance phase for the paretic limb [13, 14]) metrics. Many researchers have described the asymmetry of these parameters, which is characteristic of post-stroke patients [8, 9, 15]. A study by Patterson et al. [16] found significant temporal and spatial asymmetry in half and one-third of participants, respectively.

Spatiotemporal gait asymmetry requires treatment because a persistent incorrect walking pattern can result in falls, limited mobility in everyday life, and compensatory postural adjustments. Importantly, delayed restoration of spatiotemporal parameters may promote muscle strength asymmetry and changes in walking patterns, confirming the progression of motor dysfunction [17]. Special training equipment, such as split-belt and single-belt treadmills, is widely used to restore step length symmetry during walking [18]. Training with these treadmills can improve walking speed and step length on the paretic side. Cycling exercises are another method to improve step length symmetry in post-stroke patients [19]. The repetitive, reciprocal movements during cycling exercises facilitate symmetrical, coordinated movements of both limbs, which are necessary for walking. Furthermore, stair climbing can improve the swing phase of the affected lower limb, reducing temporal asymmetry, which can be beneficial in clinical rehabilitation [20].

A metronome can be used to facilitate reciprocal gait, better understand the tasks, and improve the rhythm and cadence of walking. The majority of studies use a metronome and music, and the therapeutic approaches vary [21–24]. Rhythmic auditory stimulation effectively improves walking speed, step length, and other parameters. Wright et al. [25] assessed training with one-tone vs. two-tone auditory stimulation. Preliminary findings indicate that a one-tone metronome may be preferable owing to more consistent rhythm perception, improving step symmetry and stability in post-stroke patients. Another study [26] assessed the effect of gait training with bilateral rhythmic auditory stimulation on lower extremity rehabilitation in post-stroke patients. There was a significant increase in step time symmetry, but not step length symmetry, in the treatment group compared to the control group. There was an improvement in walking speed and walking cadence in both groups, with more significant changes in the treatment group. In a study [27] that compared the effects of stimulation using a metronome and a haptic device on the wrist, there was an improvement in gait performance owing to increased walking speed and step length and decreased double support time. To summarize these findings, a metronome can be sufficiently effective in improving reciprocal gait in patients with hemiparesis. The limitations of studies assessing the effect of rhythmic auditory stimulation include small sample sizes, the absence of specific rehabilitation protocols based on disease severity, and insufficient follow-up to investigate long-term effects [28].

Wearable devices with rhythmic auditory stimulation are currently being developed, as are protocols for interventions in home and community settings to help patients ambulate safely beyond their front door [29, 30].

Metronome-cued gait training is an accessible technique that requires no complex equipment and can be used in a variety of settings. However, its successful use necessitates careful selection of eligible patients. If used unreasonably, it can result in wasted rehabilitation time and poor clinical outcomes.

Long-term training programs are not always available, and their effect can be delayed or variable; therefore, a preliminary single-session intervention using objective assessment tools is advisable. This approach can predict the efficacy of metronome-cued therapy in a specific patient and provide a selection algorithm based on inclusion and exclusion criteria, improving rehabilitation and restoring gait symmetry in post-stroke patients.

The work aimed to assess the possibility of improving reciprocal gait in patients after ischemic stroke using a metronome during a single training session.

METHODS

Study Design

A prospective, non-randomized, interventional, longitudinal pilot study was conducted.

Study Setting

The study was conducted at the Laboratory of Biomechanics, Research Center for Medical Rehabilitation, Federal Center of Brain Research and Neurotechnologies.

The study period was from January to July 2025.

Eligibility Criteria

Inclusion criteria: patients with hemiparesis after ischemic stroke; age < 75 years; functional readiness for verticalization; adequate response to an orthostatic test; ability to walk independently (walking aids are allowed); clear consciousness with a level of alertness sufficient to understand and follow instructions during the study; no cognitive impairments that interfere with understanding the tasks set by the investigator; no sensorimotor aphasia; no decompensated medical conditions, ischemic changes on electrocardiogram, or heart failure (Killip class II or higher); no central and peripheral nervous system diseases (other than stroke) with neurological deficit (consequences of injuries, tumors, polyneuropathies, etc.); no orthopedic pathology (joint deformities and contractures, severe pain, amputation of extremities, etc.).

Exclusion criteria: recurrent stroke; concomitant motor disorders that impair walking; age >75 years; mild hemiparesis with no considerable impact on walking; nearly normal biomechanical parameters; errors in biomechanical data recording.

Intervention

The study included 22 patients who had a single metronome-cued training session to improve reciprocal gait after a middle cerebral artery hemispheric stroke.

Study Outcomes

Main study outcome: parameter synchronization (second double support time [SDST]; improvement in reciprocal gait) in the walking cycle in post-stroke patients after a single training session.

Additional study outcomes: this study only assessed one (main) outcome.

Outcomes registration. The following gait assessment tools were used: Timed Up and Go Test (TUG; Peggy, 2017); Hauser Ambulation Index (HAI; Hauser, 1983); 10 Meter Walk Test (10MWT; Watson, 2002); and Dynamic Gait Index (DGI; Shumway-Cook, 2001). Additionally, the Medical Research Council Weakness Scale (MRC; Paternostro-Sluga, 2008) and the International Classification of Functioning, Disability, and Health (ICF; World Health Organization, 2001) were used.

The objective gait assessment included three biomechanical studies: the first was performed before training, the second after a single metronome-cued training session, and the third for the final assessment (without the metronome). The Steadys system (Neurosoft, Russia) was used. Two Neurosens inertial sensors were attached to the outer ankle using elastic bands and cuffs. After the sensors were attached, calibration was performed in a neutral position: standing straight, feet shoulder-width apart, arms along the body, hip and knee joints extended, and gaze directed forward.

Biomechanical parameters were recorded during a self-paced 10-meter walk test. At the end of the distance, the patient turned around and continued walking. The data processing algorithm automatically excluded steps with unstable parameters (acceleration and deceleration phases). The remaining walking cycles were analyzed. Data recording was stopped after 40 stable walking cycles for each leg were achieved. A neural network algorithm identified the step cycle (SC) for each leg and used it to calculate other gait parameters.

Reciprocal gait (second double support time, SDST) reflects the displacement of one step relative to another. Under normal conditions, SDST is approximately 50%. Thus, one step cycle is half a period away from the other, and changing this parameter allows for the assessment of reciprocal gait.

Additional temporal biomechanical parameters included SC time (in seconds), walking cadence (WC, steps/min), and walking rhythmicity coefficient. Individual SC times were measured as a percentage of SC: stance phase (SP) and single support phase (SSP). Additional spatial biomechanical parameters included foot lift (FL, cm) and walking speed (V, km/h).

Single training session procedure. After the initial gait assessment, patients were explained how to take symmetrical steps of similar length. A 5–7-minute training session without a metronome was then performed, and the above parameters were monitored. If the task was successfully completed and a subjective improvement in step length symmetry was observed, the patient proceeded to the next stage of the training. The metronome rhythm was set using a smartphone application, based on the individual walking cadence recorded during the initial assessment. Patients were instructed to take one step for each metronome sound. The metronome rhythm was set based on the walking cadence recorded during the baseline biomechanical assessment so that a patient would place each foot on a support in response to metronome sounds. After a brief period of adjustment to the metronome rhythm, a patient performed a 5–7-minute supervised gait training session. If the patient could keep up with the rhythm, take steps with the required cadence, and simultaneously control their length, a repeated metronome-cued assessment was performed. Each training session lasted no more than 20 min. Fig. 1 shows the training procedure, with all stages of a single training session presented in Fig. 2.

 

Fig. 1. Single training session (paretic right limb), where А≠Б is a typical hemiparetic gait with step length asymmetry; А=Б is step length symmetry by bringing the unaffected limb forward; tA=tБ is metronome-cued walking with equal step length; A is the paretic limb’s step length; Б is the contralateral limb’s step length; tA is the paretic limb’s step cycle time; tБ is the contralateral limb’s step cycle time.

 

Fig. 2. Single training session stages.

 

Statistical Analysis

Planned sample size: the sample size was not calculated in advance.

Statistical methods. Statistical analysis was performed using Statistica 12.0 (StatSoft, Tulsa, USA). The Shapiro–Wilk test was used for normality testing, which revealed non-normal distribution. Therefore, all data are presented as medians and first and third quartiles. The Wilcoxon test was used to compare gait parameters obtained during the initial, metronome-cued, and repeated assessment. The Mann–Whitney U test was used to compare all scores between the “positive effect” and “no effect” groups. P < 0.05 was considered significant.

RESULTS

Study Sample

Patients were divided into two subgroups based on the effect of a single gait training session. The “positive effect” group included patients with objective improvement in SDST (reciprocal gait). The “no effect” group included patients for whom the gait training session had no positive effect. The “positive effect” (n = 15) and “no effect” (n = 7) groups included patients with hemiparesis in subacute (n = 14) and chronic (n = 5) phases of hemispheric stroke recovery. There were no significant intergroup differences in terms of sex, age, biometric parameters, and disease duration. However, the “positive effect” group had significantly more patients in the subacute phase of stroke recovery (Table 1).

 

Table 1

Characteristics of the study groups

Parameters	Group
	“Positive effect” n=15	“No effect” n=7	Total n=22
Sex: male female	13 2	5 2	18 4
Hemisphere: right left	7 8	6 1	13 9
Phase of stroke recovery: subacute chronic	11 4	3 4	14 5
Disease duration, days	162 [124; 208]	187 [90; 222]	-
Age, years	57 [53; 63]	58 [53; 63]	-
Height, m	1.78 [1.7; 1.82]	1.76 [1.65; 1.77]	-
Body weight, kg	90 [79; 90]	70 [64; 86]	-

 

Primary Results

No differences were found between the “positive effect” and “no effect” groups when comparing gait assessment scores after a single metronome-cued training session (Table 2). The MRC and ICF scores also showed no significant intergroup differences (Table 3).

 

Table 2

Gait assessment scores

Scales	Group
	“Positive effect”	“No effect”
Dynamic Gait Index (DGI)	14 [13; 15]	11 [10; 14]
Hauser Ambulation Index (HAI)	4 [3; 4]	4.5 [3.75; 5]
Timed Up and Go Test (TUG)	39 [16; 46]	36 [35; 38]
10 Meter Walk Test (10MWT), m/s	0.66 [0.55; 0.8]	0.75 [0.675; 0.8]

 

Table 3

MRC and International Classification of Functioning, Disability, and Health domains

Parameters	Group
	“Positive effect”	“No effect”
Muscle group
Hip, flexors	3 [3; 4]	3 [3; 4]
Hip, extensors	3 [3; 4]	3 [3; 4]
Knee, flexors	3 [3; 4]	3 [2; 4]
Knee, extensors	3 [3; 4]	3 [2; 4]
Ankle, dorsal flexors	3 [2; 4]	2 [1; 2]
Ankle, plantar flexors	3 [2; 4]	2 [1; 2]
ICF domains
b770 Gait pattern functions	2 [2; 2]	3 [3; 3]
d4551 Climbing	33 [23; 34]	33 [23; 33]
d4500 Walking short distances	23 [22; 23]	22 [22; 22]
d4501 Walking long distances	22 [22; 33]	33 [22; 44]

Note. ICF, International Classification of Functioning, Disability, and Health.

 

In the “positive effect” group, the following significant differences were found between the initial and metronome-cued assessments: an increase in SC for both limbs (p = 0.0007) and a decrease in WC (p = 0.0007) and walking speed (p = 0.008).

When comparing the initial and repeated assessment findings, there was a minor increase in SC for both limbs (p = 0.016), a moderate decrease in WC (p = 0.009), and an improvement in walking rhythmicity coefficient (p = 0.011). Moreover, there was a minor significant decrease in SSP on the contralateral side (p = 0.02).

Changes in SDST. Fig. 3 shows changes in SDST for the paretic and contralateral sides reported during the initial, metronome-cued, and repeated assessment. During the training session, there was a decrease in the interquartile range for SDST of the paretic (p = 0.047) and contralateral (p = 0.027) limbs, with a shift of medians towards the normal value (50%), which was statistically confirmed.

 

Fig. 3. Changes in second double support time: significant differences (*) with the same parameter at initial assessment (р < 0.05). SDST, second double support time.

 

Outcomes in the “no effect” group after a single training session. The “no effect” group included patients who had no improvement in reciprocal gait after a single training session to improve SDST; they were excluded from further analysis. The following are the main causes that could explain this unfavorable outcome. Patient K., 44 years old, who was in the subacute phase of stroke recovery (42 days from the disease onset) and had left-sided hemiparesis, was excluded due to grade III–IV hearing loss (the patient was unable to hear the metronome). Patient S., 66 years old, who was in the chronic phase of stroke recovery (187 days from the disease onset) and had left-sided hemiparesis, was excluded due to moderate cognitive impairment, which made it difficult to understand the tasks and instructions. Patients D. (58 years old) and F. (61 years old), who were in the chronic phase of stroke recovery (220 and 340 days from the disease onset, respectively) and had left-sided hemiparesis, were excluded due to persistent incorrect walking pattern even though they understood and followed the instructions. Patients U. (64 years old) and Sh. (57 years old), who were in the subacute phase of stroke recovery (73 and 106 days from the disease onset, respectively) and had left-sided hemiparesis, were excluded due to a severe medical condition, fatigue, and inadequate cardiovascular response to training. Patient Z. (48 years old), who was in the chronic phase of stroke recovery (223 days from the disease onset) and had right-sided hemiparesis, was excluded due to inadequate response to training.

Supplement 1 shows typical graphs of changes in SDST in this group.

DISCUSSION

Summary of Primary Results

A comparison of clinical scores showed no significant differences between the “positive effect” and “no effect” groups. The findings are consistent with asymmetry of primary gait parameters and were typical for hemiparetic gait during all assessments [2, 3].

Interpretation

Gait training provided a significant increase in SC for both limbs and a decrease in WC. Changes in both of these parameters indicate additional cognitive load [31], resulting in decreased walking speed. During the third test, when there was no additional cognitive load, walking speed returned to normal.

A comparison of SC values found a minor decrease in SSP on the contralateral side after training. This change indicates a shift in load from the contralateral side to the paretic side.

The target parameter (SDST of both limbs) reached the normal median value of 50% after training. The median SDST of the paretic limb increased from 44.7% to 47.2%, while the median SDST of the contralateral limb decreased from 55.5% to 51.8%. In addition to changes in median SDST, there was a decrease in the interquartile range during assessments. At the start of training, the paretic and contralateral limbs’ first quartiles for SDST were 38.5% and 52.6%, respectively. After training, the former increased to 45.7%, whereas the latter decreased to 50.8%. Moreover, there were changes in the third quartile for SDST of both limbs. The paretic limb’s third quartile for SDST increased from 47.7% to 48.7%, whereas the contralateral limb’s third quartile for SDST decreased from 63.2% to 53.5%. This indicates a bilateral improvement in step asymmetry. The study identified various patterns of SDST improvement. Some of them are shown in Supplement 2. Fig. A shows an improvement in SDST of both limbs with minimal abnormalities at baseline. Fig. B shows an atypical distribution of SDST values at baseline, with SDST of the paretic limb higher than that of the contralateral limb. After training, the pattern becomes more typical and eventually returns to normal during the repeated assessment. Changes shown in Figs. C and D indicate a decrease in the distribution of SDST values by the end of training, compared to considerable differences at baseline. Notably, during the metronome-cued assessment, this parameter virtually returned to normal in both cases (table 4).

 

Table 4

Spatiotemporal gait parameters

Score	Limb	Gait parameters
		SC	FL	WC	RC	V	SP	SSP
Initial	P	1.9 [1.4; 2.1]	11 [7; 12]	32 [28; 43]	0.73 [0.61; 0.89]	1.4 [0.87; 1.95]	66.4 [63.7; 68.6]	22.7 [19.2; 29.5]
	C	1.9 [1.4; 2.1]	12 [11; 13]				76.4 [69.9; 83.4]	33.2 [32.1; 36.2]
Metronome-cued	P	2.1 [1.7; 2.8]*	11 [7; 12]	29 [22; 36]*	0.8 [0.62; 0.89]	1.26 [0.63; 1.94]*	67.5 [65; 78.4]	24.7 [16.6; 31.6]
	C	2.1 [1.7; 2.8]*	12 [11; 12]				77.2 [68; 85.6]	32.1 [20.3; 35.7]
Repeated	P	2 [1.6; 2.4]*	11 [6; 12]	30 [25; 37]*	0.78 [0.64; 0.93]*	1.53 [1.15; 2.12]	66.7 [65; 76.4]	24.4 [18.3; 31.7]
	C	2 [1.6; 2.4]*	12 [11; 13]				76.1 [69.3; 81.6]	32 [25.9; 35.6]*

Note. *, significant differences with the same parameter at initial assessment (р < 0.05). C, contralateral; FL, foot lift; P, paretic; RC, walking rhythmicity coefficient; SC, step cycle; SP, stance phase; SSP, single support phase; V, walking speed; WC, walking cadence.

 

Metronome-cued training to improve gait symmetry has been widely used in rehabilitation programs since the 1990s. There are several ways to use rhythmic auditory stimulation in the treatment of patients with various neurological deficits. In the majority of studies, this approach is used throughout the rehabilitation period [26, 30, 32]. A more favorable effect has been reported in treatment groups compared to controls [28, 30]. Prolonged auditory stimulation during training has been proven effective; however, some patients are insensitive to rhythm, which may result in poor training outcomes and wasted time.

Some studies used a single metronome-cued training session, like in our work. Wright et al. [25] found that metronome-cued stepping in place effectively improved temporal gait parameters in the chronic phase of stroke recovery. The authors concluded that a one-tone beat can reduce gait asymmetry and variability even in severe cases. Another study compared the effect of metronome beat and vibration on gait parameters in patients with ischemic and hemorrhagic stroke [27]. A single metronome-cued training session reduced gait variability and helped stabilize it. The effect was more pronounced in the more severe disorder. The mean disease duration was 9.5 years. Therefore, the authors believe that this training will be effective even in the long term.

There are various training techniques, such as treadmill exercises, stepping in place, and assistive devices [25, 26, 33]. As technology advances, new solutions emerge to make training easier, from specialty laboratories with multiple equipment [25, 26] to wearable devices [34, 35]. Our study used a conventional metronome with personalized settings based on biomechanical parameters. However, measuring walking cadence using special software is not always necessary to select the required rhythm; it can be done simply based on the patient’s comfort and adjustment. Importantly, the patient must be able to keep up with the rhythm, which is not always possible after stroke [36].

Compared to other neurological disorders, metronome-cued training in stroke was introduced relatively recently. The majority of research focuses on rehabilitation in the chronic phase of stroke recovery [25, 35]. Available publications do not address possible contraindications for this training. In our study, there was a group of patients with disease duration of 6 months or more who did not benefit from this training. Considering the published data on the efficacy of metronome-cued training in subacute and chronic phases of stroke recovery, it is critical to understand the causes of this unfavorable outcome.

Many studies assess improvements in spatial asymmetry, i.e., an increase in step length on the paretic side [27, 35]. Moreover, some studies offer methods to improve temporal asymmetry [25, 36]. Importantly, temporal asymmetry is more resistant to treatment [36]. We used a combined, stepwise approach to modify the gait pattern: the first stage of training aimed to improve step length symmetry, which was followed by personalized rhythmic stimulation.

Hearing impairment was found to be a critical barrier to metronome-cued training and a reason for exclusion from the study, which is consistent with other studies [25, 36].

Similar to earlier works, patients in our study had a standardized training session with equal time intervals. This approach is technically feasible. However, we believe that immediately enforcing a standardized rhythm of placing the foot on support is challenging for patients and may be impossible for some. Therefore, we consider this training option non-adaptive. This training is actually an auditory biofeedback training. However, unlike an adaptive approach, this non-adaptive protocol does not adjust to a patient’s parameters in real time, gradually increasing task complexity, but rather uses strictly defined parameters, making its impact more directive and intense. As a result, a patient either can or cannot keep up with the rhythm. Therefore, we consider this work a functional test of responsiveness and ability to follow the proposed normal rhythm. This work demonstrates the use of non-adaptive biofeedback in rehabilitation during different phases of stroke recovery. It is reasonable to use a single training session to assess the patient’s rehabilitation capacity early on and determine the optimal method for improving reciprocal gait.

In addition to clinically significant hemiparesis, it is essential to consider the brain lesion site and the phase of stroke recovery. For example, right hemisphere lesions frequently result in impaired spatial orientation, impulsiveness, and attention deficit, reducing the patient’s ability to consistently synchronize their movements with an external rhythm [37]. Another critical aspect is a specific auditory-motor synchronization impairment, i.e., the inability to synchronize steps with metronome sounds as a result of disregarding the auditory stimulus. Left hemisphere damage frequently does not disrupt basic attention and rhythm control functions; however, it affects voluntary motor control, making auditory stimulation more effective in these patients [37–39]. This explains better outcomes in patients with left hemisphere stroke, highlighting the need for a case-specific approach to rehabilitation.

In the subacute phase of stroke recovery (within 6 months of disease onset), the brain has increased neuroplasticity, providing a unique therapeutic window [40, 41]. During this period, metronome-cued training can effectively improve reciprocal gait and facilitate a correct walking pattern before the patient develops pathological compensatory changes. At later stages, when movement patterns have already formed and neuroplasticity has decreased, it is far more difficult to improve the gait pattern. However, our findings indicate that the phase of stroke recovery is not an absolute criterion for selecting patients for this intervention.

The issue of patient selection remains debatable. The mechanism of rhythm perception is not fully understood, necessitating additional examination methods. It is critical to understand which patients will not benefit from this training and why. Neither our study nor available publications found a direct correlation with the phase of stroke recovery. The question remains whether a single training session can provide a sustained improvement in gait pattern or if several rhythmic auditory stimulation sessions are required. Several biofeedback training strategies are currently available, including those to improve reciprocal gait. In the latter case, adaptive biofeedback is possible. The question of whether it can be used in patients with no response during the initial assessment remains unresolved.

Study Limitations

This study had several limitations. The study power was limited by the small sample size; as a result, the true effect size may have been underestimated, and it was not possible to comprehensively assess all reported changes. Additional data is necessary to confirm the study findings.

When forming the study sample, it was not possible to determine whether impaired rhythm perception was caused by stroke or was initially present in a specific patient. Moreover, the study did not assess changes in patient condition at discharge to determine the short-term sustainability of the effect.

CONCLUSION

Impaired reciprocal gait is common in patients with hemiparesis after ischemic stroke. A single training session can be used to assess whether subsequent systemic training will result in sustained improvement. Given the available biofeedback training strategies to improve reciprocal gait, this assessment is necessary before initiating a training program. If auditory stimulation fails to improve reciprocal gait, targeted metronome-cued gait training is not recommended.

Further research is warranted to assess the potential of adaptive reciprocal gait training based on the patient’s current condition and the efficacy of systemic training.

ADDITIONAL INFORMATION

Supplement 1. Graphs of the terminal double limb stance phase of patients from the “No effect” group.

doi: 10.17816/clinpract690583-4406516

Supplement 2. Variations in synchronization the terminal double limb stance phase parameter.

doi: 10.17816/clinpract690583-4406517

Author contributions: D.V. Skvortsov, research design, literature search and processing, manuscript writing; A.R. Khudaigulova, literature search and processing, manuscript writing, research implementation, and data processing; G.E. Ivanova, general management and research design. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Ethics approval: The study was approved by the local ethics committee of the Federal Center of Brain Research and Neurotechnologies of the Federal Medical and Biological Agency of Russia (Protocol No. 7 dated July 19, 2021). All study participants signed an informed consent form before being included in the study.

Funding sources: The work was carried out as part of the state assignment of the Federal Medical and Biological Agency of Russia (Development of New Technologies for Medical Rehabilitation in Patients with Brain Injuries and Diseases”), AAAAA19-119042590030-2.

Disclosure of interests: The authors declare that they have no competing interests.

Statement of originality: The authors did not use previously published information (text, illustrations, data) while conducting this work.

Data availability statement: The editorial policy regarding data sharing does not apply to this work, data can be published as open access.

Generative AI: Generative AI technologies were not used for this article creation.

About the authors

Dmitry V. Skvortsov

Federal Center of Brain Research and Neurotechnologies; The Russian National Research Medical University named after N.I. Pirogov; Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: dskvorts63@mail.ru
ORCID iD: 0000-0002-2794-4912
SPIN-code: 6274-4448

MD, PhD, Professor

Russian Federation, Moscow; Moscow; Moscow

Aliya R. Khudaigulova

The Russian National Research Medical University named after N.I. Pirogov

Author for correspondence.
Email: lady.aliya1998@gmail.com
ORCID iD: 0009-0008-4367-567X
SPIN-code: 1116-1915
Russian Federation, Moscow

Galina E. Ivanova

Federal Center of Brain Research and Neurotechnologies; The Russian National Research Medical University named after N.I. Pirogov

Email: reabilivanova@mail.ru
ORCID iD: 0000-0003-3180-5525
SPIN-code: 4049-4581

MD, PhD, Professor

Russian Federation, Moscow; Moscow

References

Supplementary files