Relationships between fear of falling, balance confidence, and control of balance, gait, and reactive stepping in individuals with sub-acute stroke

The effect of age and proprioceptive illusion susceptibility on gait

OBJECTIVE

Age-related gait decline has been associated with impaired proprioception, one's internal awareness of spatial location and movement. Although impaired proprioception has further been linked to greater susceptibility to proprioceptive illusions, it is unclear the impact such susceptibility has on gait and its interaction with age. The purpose of this study was to address these uncertainties.

METHODS

We measured proprioceptive illusions induced by muscle spindle manipulation and gait in young and older adults. We also compared illusory measures with traditionally used joint position matching to examine if illusory susceptibility can reveal proprioceptive impairments.

RESULTS

We found no effect of age on proprioceptive illusion susceptibility or joint position matching error. Compared to non-perceivers, illusion perceivers across both age groups showed greater joint matching error, suggesting reduced proprioceptive acuity. Consistent with previous studies, older adults had reduced cadence, gait velocity, and step length compared to young adults in both single- and dual-task walking. Interestingly, illusion perceivers, regardless of age, showed reduced cadence and step width compared to non-perceivers.

CONCLUSIONS

Our results suggest that gait impairments observed in those who perceive these proprioceptive illusions are age-independent, potentially rooted in deteriorated proprioception.

SIGNIFICANCE

This is the first study to examine these relations.

Experiencing Cerebrovascular Diseases like Stroke and Fear of Falling: Longitudinal Results from the Survey of Health, Ageing and Retirement in Europe

Objective: The aim of this study was to clarify the link between experiencing cerebrovascular diseases (strokes as an explicit example) and fear of falling (FOF) among middle-aged and older adults in Europe. Methods: Longitudinal data were used from wave 5 to wave 7 of the representative Survey of Health, Ageing and Retirement in Europe (SHARE). Self-reported tools were used to quantify the key variables. Fear of falling was similarly assessed using a dichotomous yes or no question, "For the past six months at least, have you been bothered by any of the health conditions on this card", with fear of falling being one of the options. It was adjusted for various sociodemographic and health-related factors. In particular, to account for unobserved heterogeneity, conditional fixed effect regressions (FE) were used. Accordingly, change in an individual's FOF status over the included waves was analysed and correlated with the reported change of all the included time-varying independent variables within the same individual, including experiencing stroke or other cerebrovascular diseases. The final analytical sample equalled n = 22.071 observations. Results: Conditional logistic FE regressions showed that the onset of a stroke or other forms of cerebrovascular disease was not associated with an increased likelihood of experiencing fear of falling (OR = 1.25, p = 0.095). However, stratified by sex, such an association was present in men (OR = 1.79, p = 0.006), though not in women (OR = 0.94, p = 0.732). Conclusions: The onset of a stroke or other cerebrovascular diseases was associated with an increased likelihood of experiencing FOF in men but not women. Efforts are required to assist older men in avoiding FOF after the onset of stroke or other cerebrovascular pathologies.

Sensor-Based Balance Training with Exergaming Feedback in Subjects with Chronic Stroke: A Pilot Randomized Controlled Trial

BACKGROUND

As one of the leading causes of disability in the world, stroke can determine a reduction of balance performance with a negative impact on daily activity and social life. In this study, we aimed to evaluate the effects of sensor-based balance training with exergaming feedback on balance skills in chronic stroke patients.

METHODS

21 individuals (11F, 57.14 ± 13.82 years) with a single event of ischemic stroke were randomly assigned to the sensor-based balance training group (SB-group) or the usual care balance training group (UC-group). Both groups received 10 add-on sessions with exergaming feedback (SB-group) or conventional training (UC-group). Clinical and instrumental evaluation was performed before (t0), after (t1), and after one month (t2) from intervention. Participation level was assessed using the Pittsburgh Rehabilitation Participation Scale at the end of each session.

RESULTS

The SB-group showed an improvement in postural stability (p = 0.02) when compared to the UC-group. In the evaluation of motivational level, the score was statistically higher in the SB-group with respect to the UC-group (p < 0.01).

CONCLUSION

Except for the improvement in postural stability, no difference was recorded in clinical score, suggesting a comparable gain in both groups. However, patients undergoing sensor-based training exhibited a higher participation score, ultimately indicating the use of this training to improve the adherence to rehabilitation settings, especially in patients with lower compliance.

Measurement Properties of the Activities-Specific Balance Confidence Scale in Adults From the General Population With Concussion: A Report From the Toronto Concussion Study

OBJECTIVE

The aim of this study was to establish the internal consistency and construct validity of the Activities-specific Balance Confidence (ABC) Scale and ABC-6 in adults from the general population with concussion.

DESIGN

Prospective analysis.

SETTING

Outpatient concussion care clinic.

PARTICIPANTS

Adults from the general population with concussion referred to a concussion care clinic within 7 days of injury (N=511).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Balance confidence was assessed with the Activities-specific Balance Confidence (ABC) Scale and the ABC-6. Concussion symptoms were characterized using the Sport Concussion Assessment Tool version 5 (SCAT5) symptom checklist. Instrumented measures of balance and gait included center of pressure velocity and double support time, respectively. Balance was also assessed using the mBESS.

RESULTS

The ABC and ABC-6 were strongly correlated (ρ=0.980, P<.001). Cronbach α for ABC and ABC-6 was 0.966 and 0.940, respectively. Factor analysis verified the existence of 2 components of the ABC, 1 including all items of the ABC-6 as well as 3 additional items. ABC and ABC-6 were moderately significantly correlated with SCAT5 symptom number, severity, and symptom domain (ρ=-0.350 to -0.604). However, correlations between ABC and ABC-6 with instrumented measures of balance and gait were not statistically significant, except for double support time during dual-task gait with ABC-6 (ρ=-0.218).

CONCLUSIONS

In community-dwelling adults with concussion, the ABC and ABC-6 have good internal consistency. Convergent validity is stronger for symptom endorsement measures within SCAT5 domains, which has a similar construct (subjectivity) to balance confidence. Both the ABC and ABC-6 are valid measures of balance self-efficacy in adults from the general population with concussion. The ABC-6 may be a useful tool for characterizing the effect of concussion on perceptions of the ability to perform functional tasks that challenge balance and mobility.

Characteristics of unsuccessful reactive responses to lateral loss of balance in people with stroke

PURPOSE

The effectiveness of reactive responses to a sudden loss of balance is a critical factor that determines whether a fall will occur. We examined the strategies and kinematics associated with successful and unsuccessful balance recovery following lateral loss of balance in people with stroke (PwS).

METHODS

Eleven PwS were included in the analysis. They were exposed to unannounced right and left horizontal surface translations and demonstrated both successful and unsuccessful balance responses at the same perturbation magnitude. Reactive step strategies and kinematics were investigated comparatively in successful and unsuccessful recovery tests.

RESULTS

The crossover strategy was used in most of the unsuccessful tests (7/11) while the unloaded-leg side-step in the successful tests (6/11). There were no significant differences in the reactive step initiation time in unsuccessful vs. successful tests. However, the step execution time, step length and center of mass displacement were significantly higher during the first recovery step in unsuccessful tests.

CONCLUSIONS

PwS have difficulties in controlling and decelerating the moving center of mass following a lateral loss of balance. The increased step time and step length of the first reactive step in unsuccessful vs. successful tests suggest the crossover step strategy may be ineffective for PwS.

The Effects of Exergaming on Fear of Falling and the Balance Function in Anxious and Non-Anxious Older Adults: A Pilot Study

BACKGROUND

Anxiety can exacerbate fear of falling and balance issues, potentially affecting intervention efficacy. This study examines exergaming's impact on fear of falling and balance in anxious and non-anxious older adults.

MATERIALS AND METHODS

Twenty older adults (10 anxious, 10 non-anxious) participated in six weeks of balance-oriented gaming. Fear of falling was assessed using the Falls Efficacy Scale and the Activities-specific Balance Confidence Scale. Balance was measured with the Berg Balance Scale and the Timed Up and Go Test before, after, and six weeks post-intervention.

RESULTS

Both groups showed significant improvements in balance and mobility, sustained during follow-up. However, only the non-anxious group exhibited significant reductions in fear of falling and increased balance confidence. Anxiety was linked to reduced enjoyment, lower efficacy perception, and heightened tension during the intervention.

CONCLUSION

Exergaming improves balance and reduces fear of falling in non-anxious older adults. Anxiety may diminish these benefits.

CLINICAL IMPLICATIONS

Assessing anxiety levels is crucial when prescribing exergaming interventions. Tailoring treatments to address anxiety could enhance outcomes.

Overestimation of Balance Ability Among Older Adults at Risk for Falls

Objective: This study examined alignment of subjective balance confidence with Stopping Elderly Accidents, Deaths and Injuries (STEADI) fall risk. Methods: Cross-sectional analysis of 155 community-dwelling adults (60 + y/o) from 2016 to 2018 who completed a STEADI fall assessment. Descriptive statistics, Chi-Square analysis, and biserial point correlations were applied. Results: Adults who overestimate balance confidence, 55.6% (n = 50) reported a fall in the past year, 62.2% (n = 56) were worried about falling, 48.9% (n = 44) felt unsteady when standing/walking, and 70.0% (n = 63) had a score of ≥4 on the Stay Independent Questionnaire (SIQ). Physical performance for these adults were mean TUG score 10.9s (SD = 3.4), mean 30 second chair stands 10.8 (SD = 3.5), and mean 4-stage balance score 3.1 (SD = .76). Discussion: Older adults are more likely to overestimate their subjective balance confidence. Individuals are equally likely to have reported a fall in the past year if they were "at fall risk," regardless of their subjective balance confidence.

Examining the association between balance self-efficacy and virtual balance performance in individuals with stroke: a cross-sectional study

BACKGROUND

Balance self-efficacy is a strong predictor of fall risk after stroke and is related to performance on balance and walking tests. The use of telerehabilitation for delivering stroke rehabilitation has increased in recent years and there is a need to adapt common clinical assessments to be administered in virtual formats, but the association between balance self-efficacy and virtually administered clinical tests of balance performance has yet to be established. This study examined the association between the Activities-specific Balance Confidence (ABC) Scale and virtually administered Timed Up and Go (TUG), Tandem Stand, and Functional Reach tests (FRT) in individuals with stroke.

METHODS

This was a secondary analysis of baseline data from two telerehabilitation trials with individuals with stroke. All assessments were administered by trained physical therapists through videoconferencing software. Multivariate regression analyses were used to examine the associations between the ABC scale and TUG test, Tandem Stand test, and FRT, adjusted for age and number of comorbidities.

RESULTS

Data from 51 participants (n = 11 female, median age = 64 [IQR: 18] years, 9.3 ± 4.6 months poststroke) were analyzed. The ABC scores were associated with TUG (R2 = 0.56, F(3,47) = 20.26, p < 0.01), but not Tandem Stand (R2 = 0.18, F(5,45) = 1.93, p = 0.11) or FRT (R2 = 0.14, F(3,47) = 2.55, p = 0.07) tests.

CONCLUSION

We observed associations between the ABC scores and virtual TUG, but not with Tandem Stand or FRT, which may be attributed to the context-specificity of balance self-efficacy. As virtual administration of outcomes assessments becomes part of common practice in stroke rehabilitation, our study supports the use of virtually administered TUG in stroke.

The association of interlimb coordination and temporal symmetry with walking function and motor impairment after stroke

OBJECTIVE

Interlimb coordination during walking is impaired after stroke, with unknown effects on walking function. This cross-sectional study determined associations of interlimb coordination and temporal symmetry with walking function and motor impairment.

DESIGN

During walking, participants wore wireless sensors to detect heel strikes. We calculated interlimb coordination as the phase coordination index and temporal symmetry as the ratio of contralesional (i.e., paretic) to ipsilesional (i.e., non-paretic) stance times. Associations with walking speed (10-meter walk test), walking endurance (6-minute walk test), dynamic balance (Mini Balance Evaluation Systems Test), and motor impairment (Fugl Meyer Lower Extremity assessment) were assessed.

RESULTS

56 individuals with chronic stroke were tested. Worse interlimb coordination was correlated with slower comfortable (R = -0.38, p = 0.004) and maximal (R = -0.36, p = 0.006) walking speed and worse motor function (R = -0.45, p = 0.001). Worse temporal symmetry was correlated with worse motor function (R = 0.39, p = 0.004). Interlimb coordination had stronger associations than temporal symmetry with comfortable (R: -0.38 vs. 0.08) and maximal walking speeds (R: -0.36 vs. 0.12).

CONCLUSION

Poor interlimb coordination was associated with slow walking and motor impairment and had stronger associations with walking speeds than temporal symmetry did. Interlimb coordination may provide unique insights into walking function and a target for walking rehabilitation after stroke.

Contributing factors and interventions for fear of falling in stroke survivors: a systematic review

OBJECTIVES

The purpose of this study was to provide a comprehensive overview of the prevalence, measurement tools, influencing factors, and interventions for fear of falling (FOF) in stroke survivors.

METHODS

A PRISMA-guided systematic literature review was conducted. PubMed, EMBASE, Cochrane, and Web of Science were systematically searched. The search time was up to February 2023. All observational and experimental studies investigating FOF in stroke patients were included. The assessment tool of the Joanna Briggs Institute was used to assess the quality of the included studies and the risk of bias assessment. (PROSPERO: CRD42023412522).

RESULT

A total of 25 observational studies and 10 experimental studies were included. The overall quality of the included studies was "low" to "good." The most common tool used to measure the FOF was the Falls Efficacy Scale-International (FES-I). The prevalence of FOF was 42%- 93.8%. Stroke survivors with physical impairments have the highest prevalence of FOF. The main risk factors for the development of FOF in stroke survivors were female gender, use of assistive devices, balance, limb dysfunction, and functional mobility. The combination of cognitive behavioral and exercise interventions is the most effective strategy.

CONCLUSIONS

This review suggests that the prevalence of FOF in stroke survivors is high and that understanding the factors associated with FOF in stroke patients can help develop multifactorial prevention strategies to reduce FOF and improve quality of life. In addition, a uniform FOF measurement tool should be used to better assess the effectiveness of interventions for stroke survivors.

ETHICS APPROVAL

PROSPERO registration (CRD42023412522).

Effects of Cervical Mobilization on Balance and Gait Parameters in Individuals With Stroke: A Randomized Controlled Trial

Stroke is a significant health problem that may result in long-term functional deficits. Balance and walking problems are among the most common post-stroke deficits, and they may negatively affect quality of life. Our aim in this study was to investigate the effects of cervical mobilization on balance and gait parameters after stroke. Participants were 24 adults (aged 30-65 years), who scored 24 or above on the Standardized Mini-Mental State Exam (MMSE) and no more than 3 on the Modified Rankin scale. Participants were randomly assigned to either an experimental Bobath therapy and cervical mobilization group (n = 12) or a control group who received Bobath therapy and a sham application (n = 12). Both groups received 60 minutes of Bobath therapy three times a week for four weeks; additionally, the experimental group received 15 minutes of cervical mobilization in each session, while the control group received 15 minutes of spinal sham mobilization each session. Pre and post treatment, we assessed all participants' demographic characteristics, gait parameters, balance parameters, and forward head posture values using a clinical data assessment form, spatiotemporal gait analysis (LEGSystm), portable computerized kinesthetic balance device (SportKAT 550), and craniovertebral angle (CVA), respectively. The groups showed no significant differences in their initial demographic and clinical characteristics (age, sex, stroke duration and disability levels.). In comparing changes on variables of interest, we observed significant experimental versus control group improvements in balance parameters except for their left side balance score (right side, left side, forward, backward and total balance scores were significant at p = .003, p = .089, p < .001, p = .022, p < .001, respectively), gait parameters (stride number, stride length, stride time, stride velocity, cadance at p = .007, p = .019, p = .013, p = .005, p = .001, respectively) and CVA (p < .001). Also, there were findings in favor of the experimental group on the modified timed up and go test on walk out, mid turn, walk back and total times (p = .028, p = .001, p = .016, and p = .001, respectively),but not for sit-to-stand time or stand-to-sit time. Clinicians involved in stroke rehabilitation should assess and treat the cervical region to enhance rehabilitation effectiveness.

A comparison of the immediate effects of the Andago over ground body weight support trainer versus over ground walking on selected gait parameters in a post-acute rehabilitation population

BACKGROUND

The Andago is an electromechanical gait trainer providing dynamic body weight support while simultaneously enabling over ground walking. The aim of this study was to compare the effects of the Andago with over ground walking on selected gait parameters, during a single gait reeducation session in a post-acute rehabilitation population.

METHODS

Twenty-seven participants (mean age 78 yrs. (SD = 9.2), female 55.6% (n = 15)) undergoing rehabilitation for neurological (51.8%, n = 14), orthopedic (33.3%, n = 9), and medical conditions (14.8%, n = 4) completed the study. This was a single group, cross sectional, repeated measures study. Participants completed a 10-meter walk test (10MWT) and a 20-minute gait reeducation session under two conditions: i) harnessed in the Andago with body weight support or ii) using their normal walking pattern. Walking speed, steps taken, distance walked, rest breaks, Borg ratings of perceived exertion, and fear of falling were compared over both conditions.

RESULTS

Walking speed was significantly slower with the Andago (10MWT mean difference 0.12 (95% CI 0.03-0.20), eta squared 0.24, p = .008; 20-min gait mean difference 0.04 (95% CI 0.00-0.09), eta squared 0.15, p = .049). During the 20-minute gait reeducation session, step count, distance walked, and duration of walking was similar over both conditions, however participants recorded less rest breaks and fear of falling at minutes 10 and 20 in favor of the Andago.

CONCLUSION

Gait parameters measured during a single gait reeducation session in the Andago, in a mixed cohort of predominately older rehabilitation patients, appear comparable to conventional over ground training, other than walking speed which was reduced.

Relationships between mediolateral step modulation and clinical balance measures in people with chronic stroke

BACKGROUND

Many people with chronic stroke (PwCS) exhibit walking balance deficits linked to increased fall risk and decreased balance confidence. One potential contributor to these balance deficits is a decreased ability to modulate mediolateral stepping behavior based on pelvis motion. This behavior, hereby termed mediolateral step modulation, is thought to be an important balance strategy but can be disrupted in PwCS.

RESEARCH QUESTION

Are biomechanical metrics of mediolateral step modulation related to common clinical balance measures among PwCS?

METHODS

In this cross-sectional study, 93 PwCS walked on a treadmill at their self-selected speed for 3-minutes. We quantified mediolateral step modulation for both paretic and non-paretic steps by calculating partial correlations between mediolateral pelvis displacement at the start of each step and step width (ρSW), mediolateral foot placement relative to the pelvis (ρFP), and final mediolateral location of the pelvis (ρPD) at the end of the step. We also assessed several common clinical balance measures (Functional Gait Assessment [FGA], Activities-specific Balance Confidence scale [ABC], self-reported fear of falling and fall history). We performed Spearman correlations to relate each biomechanical metric of step modulation to FGA and ABC scores. We performed Wilcoxon rank sum tests to compare each biomechanical metric between individuals with and without a fear of falling and a history of falls.

RESULTS

Only ρFP for paretic steps was significantly related to all four clinical balance measures; higher paretic ρFP values tended to be observed in participants with higher FGA scores, with higher ABC scores, without a fear of falling and without a history of falls. However, the strength of each of these relationships was only weak to moderate.

SIGNIFICANCE

While the present results do not provide insight into causality, they justify future work investigating whether interventions designed to increase ρFP can improve clinical measures of post-stroke balance in parallel.

Current Trends in Gait Rehabilitation for Stroke Survivors: A Scoping Review of Randomized Controlled Trials

BACKGROUND

Stroke stands as a significant global health concern, constituting a leading cause of disability worldwide. Rehabilitation interventions are crucial in aiding the recovery of stroke patients, contributing to an overall enhancement in their quality of life. This scoping review seeks to identify current trends in gait rehabilitation for stroke survivors.

METHODS

The review followed the methodological framework suggested by Arksey and O'Malley. Electronic databases, such as CINAHL Complete, MEDLINE Complete, and Nursing & Allied Health Collection, were systematically searched in November 2023. Inclusion criteria comprised papers published in either English or Portuguese from 2013 to 2023.

RESULTS

From the initial search, a total of 837 papers were identified; twenty-one papers were incorporated into this review. Thirteen distinct categories of gait rehabilitation interventions were identified, encompassing diverse approaches. These categories comprise conventional rehabilitation exercises, traditional gait training with integrated technology, and gait training supported by modern technologies.

CONCLUSIONS

Although traditional rehabilitation exercises have historically proven effective in aiding stroke survivors, a recent trend has emerged, emphasizing the development and integration of innovative therapeutic approaches that harness modern technologies.

Frequency-dependent behavior of paretic and non-paretic leg force during standing post stroke

Maintaining upright posture in quiet standing is an important skill that is often disrupted by stroke. Despite extensive study of human standing, current understanding is incomplete regarding the muscle coordination strategies that produce the ground-on-foot force (F) that regulates translational and rotational accelerations of the body. Even less is understood about how stroke disrupts that coordination. Humans produce sagittal plane variations in the location (center of pressure, xCP) and orientation (Fx/Fz) of F that, along with the force of gravity, produce sagittal plane body motions. As F changes during quiet standing there is a strong correlation between the xCP and Fx/Fz time-varying signals within narrow frequency bands. The slope of the correlation varies systematically with frequency in non-disabled populations, is sensitive to changes in both environmental and neuromuscular control factors, and emerges from the interaction of body mechanics and neural control. This study characterized the xCP versus Fx/Fz relationship as frequency-dependent Intersection Point (IP) heights for the paretic and non-paretic legs of individuals with history of a stroke (n = 12) as well as in both legs of non-disabled controls (n = 22) to reveal distinguishing motor coordination patterns. No inter-leg difference of IP height was present in the control group. The paretic leg IP height was lower than the non-paretic, and differences from control legs were in opposite directions. These results quantify disrupted coordination that may characterize the paretic leg balance deficit and non-paretic leg compensatory behavior, providing a means of monitoring balance impairment and a target for therapeutic interventions.

Association between fear of falling and falls following acute and chronic stroke: a systematic review with meta-analysis

OBJECTIVES

To examine the association between falls and fear of falling in people with stroke and to evaluate the differences between patients with acute stroke and those with chronic stroke with regard to any such association.

METHODS

Articles were searched in Medline, CINAHL, AMED, Embase, PsycINFO, Cochrane Library of Reviews and PEDro from inception until March 2023. Experimental, observational or explorative studies investigating the association between fear of falling and falls in people with stroke were included. Articles were screened by 2 independent reviewers. Data were extracted by an independent reviewer.

RESULTS

A total of 26 reports were included in this review (n = 2863). Fear of falling, assessed by a single-question survey, was significantly associated with falls (relative risk = 1.44; 95% confidence interval (95% CI) = 1.22, 1.70; I2 = 0%) in people with acute stroke. Significant mean differences in fear of falling, based on the Falls Efficacy Scale (mean difference = 12.80; 95% CI = 1.81, 23.78; I² = 28%) and Activities-specific Balance Confidence Scale (mean difference = -9.99; 95% CI = -15.36, -4.62; I² = 57%), were also reported between fallers and non-fallers in people with chronic stroke.

CONCLUSION

A small, but significant, association exists between falls and fear of falling in both acute and chronic stroke patients.

Comparison of the immediate effects of plantar vibration of both feet with the plantar vibration of the affected foot on balance in patients with stroke: Preliminary findings

OBJECTIVE

Plantar vibration is one of the strategies to enhance balance in stroke patients. This study compared the effects of the plantar vibration of both feet and the plantar vibration of the most affected side in patients with stroke.

METHODS

This study was a single-blind clinical trial. Post-stroke patients with balance impairment were enrolled in the study and underwent two treatment sessions with a one-week interval. They received both feet's plantar vibration in one session and plantar vibration of the most affected side in the other session (frequency 100 Hz, 5 min). Mini-BESTest, Modified Modified Ashworth Scale (MMAS), and Semmes-Weinstein monofilament examination (SWME) were used to evaluate balance, spasticity, and plantar sensation, before and after the treatment sessions.

RESULTS

Ten patients with a mean age of 52.9 (SD = 5.48) years were enrolled in the study. Mini-BESTest scores of balance and plantar flexor muscle spasticity were significantly improved after both feet plantar vibration and plantar vibration of the more affected side. There was no significant difference between the effectiveness of both sides plantar vibration and the most affected side plantar vibration. There were no significant improvements in SWME sensory scores after plantar vibration of either both sides or the most affected side.

CONCLUSION

Plantar vibration of both sides had no additional benefits in this group of patients with chronic stroke. Plantar vibration of more affected side can be used for improving balance and plantar flexor spasticity post-stroke. The Plantar vibration had no effects on the affected foot sensibility.

Falls, fear of falling, and related factors in patients with diabetic foot disease

BACKGROUND

Falls and fear of falling (FOF) are common in patients with diabetic foot disease (DFD).

PURPOSE

To understand the relationship between falls, FOF, and related factors in patients with DFD.

METHOD

We recruited 70 patients being treated for DFD at two hospitals in Korea. A structured questionnaire was used in investigating fall experience, FOF, and related factors.

RESULTS

Among the participants, 42.8 % fell in the past year, and FOF was reported in 57.1 %. Rates of "no caregiver," "DFD duration (>1 year)," and "burning pain" were higher in fallers than non-fallers. The rates of "older adults (≥65 years of age)," "unemployed," "not using assistive devices," "visual impairment," and "hearing impairment" were higher in patients with FOF than in those without FOF. However, the level of balance confidence was lower in patients with FOF.

CONCLUSIONS

The fall experience of patients with DFD was associated with the presence of their caregiver, disease-related factors, and foot pain symptoms, while FOF was related to age and fall-related factors.

Current Trends in Balance Rehabilitation for Stroke Survivors: A Scoping Review of Experimental Studies

Balance impairment is a common consequence of a stroke, which can significantly hinder individuals' participation in daily activities, social interactions, and leisure pursuits and their ability to return to work. Rehabilitation is vital for minimizing post-stroke sequelae and facilitating the recovery of patients. This review aims to identify current trends in balance rehabilitation of stroke survivors. This Scoping review followed Arksey and O'Malley's methodological framework. The literature search was conducted in electronic databases, including CINAHL Complete, MEDLINE Complete, and Nursing & Allied Health Collection. The search was performed in March 2023, and the inclusion criteria were articles published in English or Portuguese between 2013 and 2023. A total of 446 articles were identified. After selecting and analyzing the reports, fourteen publications were included in this review. Seven distinct categories of balance rehabilitation interventions were identified, covering various approaches. These categories included conventional rehabilitation exercises, gym-based interventions, vibration therapy, rhythmic auditory stimulation training, boxing therapy, dual-task training, and technology-based rehabilitation interventions. Each of these methods presents unique benefits and can significantly impact the recovery of balance in stroke survivors, enhancing their overall well-being and functional capacity.

The effects of Robot-assisted gait training and virtual reality on balance and gait in stroke survivors: A randomized controlled trial

BACKGROUND

Stroke survivors often experience balance and gait problems, which can affect their quality of life and independence in daily living activities. Robot-assisted gait training, such as Lokomat with virtual reality, has been found to be effective in improving gait and balance. However, the specific effects of each virtual reality application on balance and spatiotemporal parameters of gait are not yet established. This study aims to investigate the effects of different virtual reality applications on these parameters.

RESEARCH QUESTION

What are the specific effects of each Lokomat augmented performance feedback application on balance and spatiotemporal parameters of gait in stroke survivors?

METHODS

The study is a randomized controlled trial conducted with four groups: Control Group, Endurance Group, Attention and Motivation Group, and Activity Timing Group. All participants received six weeks of physiotherapy, and Lokomat groups had additional robot-assisted gait training with Lokomat for three days a week. The Endurance group used Lokomat with Faster, Attention and Motivation Group with Gabarello and Smile, and Activity Timing Group with Curve Pursuit, Treasures, and High Flyer applications. Various tests were used to assess walking and balance in the study (gait analysis, 6-minute walk test, 10-meter walk test, Berg Balance Scale, postural stability, and limits of stability).

RESULTS AND SIGNIFICANCE

The study involved 56 male stroke survivors (mean age: 60.02 ± 6.83 years, post-stroke time: 238.88 ± 40.88 days). All groups improved walking speed and distance significantly, but Endurance was better (p < 0.001). Balance improved significantly in all groups, but Attention and Motivation was superior in Berg Balance Scale, postural stability, and limits of stability (p < 0.001). The selection of virtual reality applications during robot-assisted gait training according to rehabilitation goals is important for successful rehabilitation, as these applications may have varying effects on balance and walking.

The effect of telerehabilitation on balance in stroke patients: is it more effective than the traditional rehabilitation model? A meta-analysis of randomized controlled trials published during the COVID-19 pandemic

Objective

Telerehabilitation and telemedicine have gradually gained popularity. In 2019, the outbreak of COVID-19 started in Wuhan and then spread across the world. To date, most countries have opted to coexist with the virus. However, patients, especially those who have suffered a stroke, should take measures to avoid being infected with any disease as much as possible since any infectious disease can lead to adverse events for them. Telerehabilitation can be beneficial to stroke patients as they are less likely to be infected by the virus. In recent years, several studies on telerehabilitation have been conducted globally. This meta-analysis aimed to investigate the effects of telerehabilitation on the balance ability of stroke patients, compare the efficacy of conventional rehabilitation with telerehabilitation, explore the characteristics of telerehabilitation and conventional rehabilitation, and provide recommendations for rehabilitation programs in the context of the global pandemic.

Methods

We searched Pubmed, Embase, the Web of Science, and The Cochrane Library databases from 1 January 2020 to 31 December 2022 for randomized controlled trials published in English that evaluated the improvement of balance function in stroke patients after telerehabilitation and compared the differences between telerehabilitation (TR) and conventional rehabilitation (CR). The random-effects model was utilized to calculate mean differences (MDs) with 95% confidence intervals (CIs) to estimate intervention effects. Statistical heterogeneity was assessed according to the I² values. The risk of bias was measured using the Cochrane risk-of-bias assessment tool.

Results

We included nine studies in the system evaluation, all of which were included in the pooled analysis. All outcomes in the experimental and control groups improved over time. The comparison between groups concluded that people who received the telerehabilitation intervention had a significant improvement in the Berg Balance Scale (MD = 2.80; 95% CI 0.61, 4.98, P < 0.05, I2 = 51.90%) and the Fugl-Meyer Assessment (MD = 8.12; 95% CI 6.35, 9.88, P < 0.05, I2 = 0) compared to controls. The Timed Up and Go test (MD = -4.59; 95% CI -5.93, -.25, P < 0.05, I² = 0) and Tinetti Performance-Oriented Mobility Assessment-Balance (MD = 2.50; 95% CI 0.39, 4.61, P < 0.05) scored better in the control group than in the experimental group. There were no significant differences in other outcomes between the two groups.

Conclusion

Studies on changes in medical conditions during the COVID-19 pandemic also demonstrated that, for stroke patients, telerehabilitation achieves similar effects as the conventional rehabilitation model and can act as a continuation of the conventional rehabilitation model. Owing to the different equipment and intervention programs of telerehabilitation, its curative effect on the static balance and reactive balance of stroke patients may be different. Currently, telerehabilitation may be more conducive to the rehabilitation of patients' static balance abilities, while conventional rehabilitation is more effective for the rehabilitation of patients' reactive balance. Therefore, further studies are needed for investigating the difference in efficacy between varied devices and telerehabilitation programs. Further research is needed on static and reactive balance. In addition, such research should have a large body of literature and a large sample size to support more definitive findings based on the context of the COVID-19 pandemic.

Systematic review registration

CRD42023389456.

Effects of Compression Stockings on Body Balance in Hemiplegic Patients with Subacute Stroke

(1) Background: Stroke patients with hemiplegia have an increased risk of developing deep vein thrombosis (DVT). DVT increases the risk of life-threatening pulmonary embolism and is associated with poor prognosis. The early wearing of compression stockings can help prevent DVT. This study aimed to assess the impact of compression stockings on body balance in stroke patients with unilateral lower extremity muscle weakness; (2) Methods: Hemiplegic stroke patients in the subacute phase who were able to walk with assistance were recruited. The patients were divided into two groups: one group received rehabilitation treatment with compression stockings, and the other received treatment without compression stockings. The rehabilitation treatment involved hospitalization for 4 weeks, the Trunk Control Test (TCT), the Trunk Impairment Scale (TIS), and the Berg Balance Scale (BBS). The patients were evaluated before and 4 weeks after the start of treatment. The differences in BBS, TCT, and TIS before and after treatment between the two groups were compared; (3) Results: Altogether, 236 hemiplegic stroke patients were recruited. There was an improvement in body balance after treatment in both groups, and BBS, TCT, and TIS scores significantly increased in the group that received rehabilitation treatment with compression stockings; (4) Conclusions: In patients with hemiplegic stroke in the subacute period, rehabilitation while wearing compression stockings appears to improve body balance.

Risk factors for fear of falling in stroke patients: a systematic review and meta-analysis

OBJECTIVE

Even though 32%-83% for fear of falling (FoF) in patients with stroke, very little is known about the predictors of the problems. Therefore, we systematically reviewed the literature on risk factors for FoF in patients with stroke.

DESIGN

A systematic review and meta-analysis DATA SOURCES: PubMed, Embase, Cochrane Library database, Web of Science, CINAHL, PsycINFO, Grey literature and other relevant databases for related publications were searched (from inception to 17 July 2021).

RESULTS

Eight studies involving 1597 participants were selected to analyse risk factors for patients with stroke with FoF. The quality of all included studies was assessed and categorised as medium or high quality. Review Manager V.5.3 merged the OR value and 95% CI of the potential risk factors. Meta-regression and Egger's test were performed by Stata V.15.1. The risk factors for FoF in patients with stroke were women (OR=2.13, 95% CI 1.47 to 3.09), impaired balance ability (OR=5.54; 95% CI 3.48 to 8.81), lower mobility (OR=1.12; 95% CI 1.05 to 1.19), history of falls (OR=2.33; 95% CI 1.54 to 3.53) and walking aid (OR=1.98; 95% CI 1.37 to 2.88), anxiety (OR=2.29; 95% CI 1.43 to 3.67), depression (OR=1.80; 95% CI 1.22 to 2.67), poor lower limb motor function (OR=1.14; 95% CI 1.00 to 1.29) and physically inactiveness (OR=2.04; 95% CI 1.01 to 4.12). Measurement of heterogeneity between studies was high for all outcomes (I² =0%-93%), indicating that the substantial interstudy heterogeneity in estimated proportions was not attributed to the sampling error. Sensitivity analysis (leave-one-out method) showed that the pooled estimate was stable.

CONCLUSION

This meta-analysis indicated that female population, impaired balance ability, lower mobility, history of falls and walking aid in patients with stroke might be at greater risk for FoF. Future studies are recommended to determine other risk factors specific to patients with stroke.

Metabolically efficient walking assistance using optimized timed forces at the waist

The metabolic rate of walking can be reduced by applying a constant forward force at the center of mass. It has been shown that the metabolically optimal constant force magnitude minimizes propulsion ground reaction force at the expense of increased braking. This led to the hypothesis that selectively assisting propulsion could lead to greater benefits. We used a robotic waist tether to evaluate the effects of forward forces with different timings and magnitudes. Here, we show that it is possible to reduce the metabolic rate of healthy participants by 48% with a greater efficiency ratio of metabolic cost reduction per unit of net aiding work compared with other assistive robots. This result was obtained using a sinusoidal force profile with peak timing during the middle of the double support. The same timing could also reduce the metabolic rate in patients with peripheral artery disease. A model explains that the optimal force profile accelerates the center of mass into the inverted pendulum movement during single support. Contrary to the hypothesis, the optimal force timing did not entirely coincide with propulsion. Within the field of wearable robotics, there is a trend to use devices to mimic biological torque or force profiles. Such bioinspired actuation can have relevant benefits; however, our results demonstrate that this is not necessarily optimal for reducing metabolic rate.

THE EFFECTS OF TRAINING ON DIFFERENT SURFACES, ON BALANCE AND GAIT PERFORMANCE IN STROKE HEMIPLEGIA

ABSTRACT Although many studies have focused on balance exercises for elderly or stroke patients, no comprehensive studies have investigated the use of training on different surfaces (TDS) with analysis of gait performance in elderly male stroke patients. The active properties of balance and subjective reporting of functional gait ability were used to identify the effects of TDS. Static balance (SB), dynamic balance (DB) and gait analysis was measured in 30 elderly stroke patients. The patients were divided into the TDS group (n=15) and a control group (CG, n=15). Fifteen elderly stroke patients underwent TDS five times a week for 12 weeks. The data was analyzed using repeated measures analysis of variance. Significant differences were observed between the two groups (TDS and Control): SB (p < 0.0001), DB (OSI: p < 0.0001, APSI: p < 0.001, MLSI: p < 0.004) and gait analysis (right: temporal step time: p < 0.0001, temporal cycle time: p < 0.001, temporal double support time: p < 0.0001; left: temporal step time: p < 0.0001, temporal cycle time: p < 0.0001, temporal double support time: p < 0.0001). TDS in elderly male stroke patients suggests that the characteristics of gait performance in these patients may be improved by increasing static balance, dynamic balance and gait velocity. It is hoped that the results of this trial will provide new information on the effects of TDS on balance stability and gait ability in stroke patients, through changes in stability of the lower extremities. Level III, Case-control Study.

Fear of falling and related factors during everyday activities in patients with chronic stroke

The aim of this study was to examine the impact of physical function, anxiety, and depression on the fear of falling associated with everyday activities in patients with stroke. This was a cross-sectional descriptive survey. Convenience sampling was used to select 127 patients with stroke who were undergoing rehabilitative therapy at a single rehabilitation hospital in South Korea. Fear of falling, anxiety, and depression were assessed using structured questionnaires. Physical parameters, including lower extremity function, functional mobility, balance ability, and lower extremity muscle strength, were measured using objective methods. A multiple regression analysis was used to identify the predictors of fear of falling. Female patients had a higher fear of falling associated with walking outdoors compared to male patients. Lower extremity strength was the only significant predictor of fear of falling when adjusting for age, sex, Mini Mental State Examination scores, and fall experience. Lower extremity strength was identified as the most important factor affecting the fear of falling associated with everyday activities in patients with stroke. Preventing muscle weakness in the lower extremities and providing education and support to improve patients' self-efficacy in outdoor activities are strategies that can be used to reduce the fear of falling in patients with stroke.

Increasing the contrast of tread edge highlighters improves stair descent safety in older adults with simulated visual impairment

Falls during stair descent are dangerous and costly. Contrasting tread edge highlighters improve measures of stair safety, however the necessary contrast level of these interventions has not been investigated. Thirteen older adults (67.7 ± 5.5 years) completed stair descent trials under normal (300lx) and low (30lx) lighting conditions, blurred and normal vision, and four different contrast levels (0%, 30%, 50%, 70%) between the tread edge highlighter and the neighbouring tread surface. Cadence and heel clearance decreased for 0% contrast compared to 50% and 70% contrast conditions, but contrast had no effect on foot overhang. Blurred vision was observed to be a greater factor influencing biomechanical measures of fall risk than low ambient lighting. Results suggest higher contrast highlighters improve measures of safety, even more so during simulated vision impairment, and that at least 50% contrast difference provides adequate visual information for safer stair ambulation.

Estimation of Walking Speed and Its Spatiotemporal Determinants Using a Single Inertial Sensor Worn on the Thigh: From Healthy to Hemiparetic Walking

We present the use of a single inertial measurement unit (IMU) worn on the thigh to produce stride-by-stride estimates of walking speed and its spatiotemporal determinants (i.e., stride time and stride length). Ten healthy and eight post-stroke individuals completed a 6-min walk test with an 18-camera motion capture system used for ground truth measurements. Subject-specific estimation models were trained to estimate walking speed using the polar radius extracted from phase portraits produced from the IMU-measured thigh angular position and velocity. Consecutive flexion peaks in the thigh angular position data were used to define each stride and compute stride times. Stride-by-stride estimates of walking speed and stride time were then used to compute stride length. In both the healthy and post-stroke cohorts, low error and high consistency were observed for the IMU estimates of walking speed (MAE < 0.035 m/s; ICC > 0.98), stride time (MAE < 30 ms; ICC > 0.97), and stride length (MAE < 0.037 m; ICC > 0.96). This study advances the use of a single wearable sensor to accurately estimate walking speed and its spatiotemporal determinants during both healthy and hemiparetic walking.

Temporal But Not Spatial Gait Parameters Associated With Lower Balance Capacity in Moderate-High Functioning Persons With Stroke

BACKGROUND AND PURPOSE

Falls are a major health concern after stroke. Spatial and temporal gait asymmetry and variability can contribute to instability and increased fall risk in persons with stroke (PwS). We aimed to quantify gait spatiotemporal symmetry and variability parameters in PwS undergoing rehabilitation in the subacute stage of the disease, by comparison to healthy participants, and to examine the associations between these parameters and patients' reactive and proactive balance capacity.

METHODS

Twenty-two PwS and 12 healthy adults walked over a computerized treadmill system at their self-selected walking speed. Symmetry and variability of gait parameters (step length, swing time, and stance time) as well as upper extremity and lower extremity angular range of motion in the sagittal plane were extracted. In addition, the Berg Balance Scale (BBS) and the fall threshold in response to sudden surface translations at increasing intensities were assessed.

RESULTS

PwS demonstrated significantly higher asymmetry in all gait parameters in comparison to controls. Also, PwS demonstrated increased stance time variability in comparison to healthy controls and increased swing time variability in the paretic lower extremity. Significant negative associations were found between fall threshold and stance time asymmetry in PwS (r = -0.48, P = 0.022), between the BBS and swing time asymmetry (r = -0.50, P = 0.018), and between the BBS and stance time variability of the paretic lower extremity (r = -0.56, P = 0.006).

DISCUSSION AND CONCLUSIONS

Findings highlight the importance of gait temporal symmetry and variability measures for dynamic balance control after stroke. These parameters should be considered when assessing gait recovery and safety in PwS.Video Abstract available for more insight from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A355).

Immediate augmented real-time forefoot weight bearing using visual feedback improves gait symmetry in chronic stroke

BACKGROUND

Symmetry of gait is an important component of rehabilitation in stroke patients. Insufficient weight-bearing causes gait asymmetry.

OBJECTIVE

This study aimed to identify the immediate effects of sufficient weight-bearing on the forefoot during the stance phase using visual feedback.

METHODS

Twenty-seven individuals with stroke enrolled in this study. All patients were evaluated for gait parameters with and without visual feedback. Visual feedback was provided through a smart application and a beam projector screen that showed a weight shift as a change in color. Spatiotemporal gait parameters were evaluated, resulting in values for a calculated symmetry index, in addition to heel % and toe % temporal values.

RESULTS

Velocity and cadence were significantly decreased when visual feedback was provided (p< 0.05). Spatiotemporal parameters, except for bilateral step length, swing time of affected side, and single-limb support of less affected side, showed significant improvement (p< 0.05). The gait pattern of subjects was more symmetrical with visual feedback compared to non-visual feedback (p< 0.05). The toe-on time significantly improved on the affected side with visual feedback (p< 0.05).

CONCLUSION

This study suggests that visual feedback aids in the improvement of gait symmetry, forefoot weight-bearing on the affected side, and spatiotemporal parameters.

Fear of Falling and Related Factors in Older Adults With Spinal Diseases

Fear of falling is common among older adults with spinal diseases. The purpose of the current study was to examine fear of falling and related factors in this population. A total of 138 participants were recruited and completed survey questionnaires along with the Timed Up & Go Test. Participants were 73.7 years old on average, 52% had fall experience, and 56% were taking more than four medications. Multivariate regression analyses revealed that the use of sleeping pills, residence type, pain, activities of daily living, gait ability, and gait efficacy were significant predictors of fear of falling. Findings suggest that a fall prevention intervention for older adults with spinal diseases should include pain management, functional improvement, and gait rehabilitation with a focus on gait performance and gait efficacy. In addition, it is important to improve living environment and sleep hygiene, which are conducive to falls. [Journal of Gerontological Nursing, 47(8), 29-35.].

Short-Term Effect of Kinesio Taping of Lower-Leg Proprioceptive Neuromuscular Facilitation Pattern on Gait Parameter and Dynamic Balance in Chronic Stroke with Foot Drop

The aim of this study is to identify the effectiveness of proprioceptive neuromuscular facilitation (PNF) leg Kinesio taping on gait parameters and dynamic balance in chronic stroke patients with foot drop. A total 22 chronic stroke patients were randomly assigned to experimental (n = 11) and control groups (n = 11). All subjects underwent conventional therapy and gait training for 50 min. The experimental group additionally received KT of tibialis anterior muscle (TA) and hamstring muscles according to the PNF pattern. The control group received KT of only TA. The primary outcome measures that the gait parameter are gait velocity, cadence, step length, and stride length. Dynamic balance was measured by the timed up-and-go test (TUG) time and activity-specific balance confidence scale (ABC) as the secondary outcomes. All of the measurements were performed baseline and 24 h after intervention. Our results showed that the experimental group showed significant improvements in gait velocity, cadence, step length, stride length and TUG, and ABC score compared with the control group. We conclude that the short term effect of application of lower-leg KT according to the PNF pattern increased the gait ability and dynamic balance of chronic stroke patients with foot drop.

The effects of virtual reality augmented robot-assisted gait training on dual-task performance and functional measures in chronic stroke: a randomized controlled single-blind trial

BACKGROUND

Many studies have demonstrated positive effects of virtual reality (VR) and robot-assisted gait training (RAGT) on balance, gait skills, functional capacity, active participation, and motivation in stroke patients, previously. However, the effects of VR augmented RAGT on dual-task performance which requires simultaneous use of motor and cognitive parameters have not been investigated.

AIM

To primarily investigate the effects of virtual reality (VR) augmented robot-assisted gait training (RAGT) on dual-task performance and secondarily, functional measurements in chronic stroke patients.

DESIGN

A randomized, single-blind trial.

SETTING

Inpatient rehabilitation center.

POPULATION

The study included 30 chronic stroke patients aged between 40-65 with the level of ≥3 from Functional Ambulation Classification and ≥24 from the Standardized Mini Mental State Examination.

METHODS

Fifteen patients in the study group received VR augmented RAGT and 15 patients in the control group received only RAGT during 12 sessions (six weeks). All patients received neurodevelopmental therapy in addition to their treatments, simultaneously. To evaluate dual-task performance, motor and cognitive tasks were given in addition to the 10 Meter Walk (first motor task), and durations were recorded in seconds. Functional measures such as Functional Gait Assessment, Rivermead Mobility Index, Berg Balance Scale, Fall Activity Scale International, and the Functional Independence Measure for gait, mobility, balance, fear of falling, and independence in daily living activities were also applied, consecutively.

RESULTS

The mean age of the study population was 57.93±5.91. After the treatment, single and dual-task gait speeds and cognitive dual-task performance increased in the study group (P<0.05), while no change was observed in the control group (P>0.05). No significant difference was detected between the groups in terms of all assessments after the treatment (P>0.05).

CONCLUSIONS

This study demonstrated that VR augmented RAGT improved dual-task gait speeds and dual-task performance of chronic stroke patients; however, there were no difference between the two groups after the treatment. Although functional improvements were determined with VR combined RAGT approach, it was not superior to RAGT only treatment.

CLINICAL REHABILITATION IMPACT

The results of current study suggest the simultaneous use of VR as an adjunct therapy method to the functional training to obtain functional gains in ambulant patients with chronic stroke.

Influence of Multiple Sclerosis on Spatiotemporal Gait Parameters: A Systematic Review and Meta-Regression

OBJECTIVE

To quantify the effect of multiple sclerosis (MS) on spatiotemporal gait characteristics accounting for disability severity and fall classification.

DATA SOURCES

MEDLINE (1946-August 2018), Allied and Complementary Medicine Database (1985-2018 August), and PsycINFO (1806-August 2018) were searched for terms on MS and gait.

STUDY SELECTION

Dual independent screening was conducted to identify observational, cross-sectional studies that compared adults with MS grouped according to Expanded Disability Status Scale (EDSS) level or fall history, reported on spatiotemporal gait characteristics, and were published in English. The search retrieved 5891 results, of which 12 studies satisfied the inclusion criteria.

DATA EXTRACTION

Two authors worked independently to extract and verify data on publication details, study methodology, participant characteristics, gait outcomes, conclusions, and limitations. Risk of bias was assessed using the QualSyst critical appraisal tool. A random-effects meta-regression and meta-analysis were conducted on pooled data.

DATA SYNTHESIS

All studies received quality ratings of very good to excellent and collectively examined 1513 individuals with MS. With every 1-point increase in EDSS, significant changes (P<.05) were observed in gait speed (-0.12 m/s; 95% confidence interval (CI), 0.08-0.15), step length (-0.04 m; 95% CI, 0.03-0.05), step time (+0.04 seconds; 95% CI, 0.02-0.06), step time variability (+0.009 seconds; 95% CI, 0.003-0.016), stride time (+0.08 seconds; 95% CI, 0.03-0.12), cadence (-4.4 steps per minute; 95% CI, 2.3-6.4), stance phase duration (+0.8% gait cycle; 95% CI, 0.1-1.5), and double support time (+3.5% gait cycle; 95% CI, 1.5-5.4). Recent fallers exhibited an 18% (95% CI, 13%-23%) reduction in gait speed compared with nonfallers (P<.001).

CONCLUSIONS

This review provides the most accurate reference values to-date that can be used to assess the effectiveness of MS gait training programs and therapeutic techniques for individuals who differ on disability severity and fall classification. Some gait adaptations could be part of adopting a more cautious gait strategy and should be factored into the design of future interventions.

Role of Spasticity Severity in the Balance of Post-stroke Patients

Background: Lower limb spasticity after stroke is common that can affect the balance, increase the risk of falling, and reduces the quality of life. Objective: First, evaluate the effects of spasticity severity of ankle plantar flexors on balance of patients after stroke. Second, to determine the relationship between the spasticity severity with ankle proprioception, passive ankle dorsiflexion range of motion (ROM), and balance confidence. Methods: Twenty-eight patients with stroke based on the Modified Modified Ashworth Scale (MMAS) were divided into two groups: High Spasticity Group (HSG) (MMAS > 2) (n = 14) or a Low Spasticity Group (LSG) (MMAS ≤ 2) (n = 14). The MMAS scores, Activities-Specific Balance Confidence Questionnaire, postural sway of both affected and non-affected limbs under the eyes open and eyes closed conditions, timed up and go (TUG) test, passive ankle dorsiflexion ROM, and ankle joint proprioception were measured. Results: The ankle joint proprioception was significantly better in the LSG compared to the HSG (p = 0.01). No significant differences were found between the LSG and HSG on all other outcome measures. There were no significant relationships between the spasticity severity and passive ankle dorsiflexion ROM, and balance confidence. Conclusion: The severity of ankle plantar flexor spasticity had no effects on balance of patients with stroke. However, the ankle joint proprioception was better in patients with low spasticity. Our findings suggest that the balance is affected regardless of the severity of the ankle plantar flexor spasticity in this group of participants with stroke.

BALANCE TRAINING: DOES ANTICIPATED BALANCE CONFIDENCE CORRELATE WITH ACTUAL BALANCE CONFIDENCE FOR DIFFERENT UNSTABLE OBJECTS?

Background

Sports rehabilitation professionals often prescribe unstable objects for balance training. Unfortunately, there is a lack of measurement of balance confidence when incorporating these objects. Currently, there is no consensus on the optimal balance confidence measure or proposed progression of unstable objects. Understanding the influence of balance confidence on task performance using unstable objects may help professionals better prescribe a balance training program.

Purpose

The primary purpose of this investigation was to explore the correlation between anticipated and actual balance confidence on different unstable objects during static double leg and single leg stance. The secondary purpose was to explore the correlation between anticipated and actual unstable object difficulty rankings.

Study Design

Repeated measure observational, controlled trial.

Methods

Sixty-five active, healthy adults (M = 35, F = 30) (mean age = 24.38 ± 3.56) underwent two testing sessions. During session one, participants took an online survey, rating their anticipated balance confidence after observing images of different unstable objects. During session two, participants stood on each unstable object under two conditions (static double leg stance and single leg stance) and rated their actual balance confidence. The main outcome measure was an ordinal balance confidence score adapted from the activities-specific balance confidence scale. Statistical analysis included subject demographic calculations and appropriate non-parametric tests.

Results

For the double leg stance and single leg stance conditions, there was a very strong correlation between anticipated and actual balance confidence scores on the stable surface (ρ = 1.0, p = <.001). There was a weak correlation between scores for foam pad, air-filled discs, Bosu® (dome up), Bosu® (dome down), and wobble board for both conditions. For unstable object rankings, there was a very strong correlation between scores (ρ=1.0, p = <.001). The objects were ranked by perceived difficulty as follows: Level 1 (easy)- ground, Level 2- foam pad, Level 3- air-filled discs, Level 4- Bosu®, and Level 5 (difficult)- wobble board.

Conclusion

Study findings suggest that actual measures of balance confidence may provide insight into a patient's confidence level and may help with prescribing and progressing their program. The suggested unstable object difficulty rankings may help professionals better match the objects to their patients to produce optimal outcomes.

Level of Evidence

2c.

Balance confidence and physical activity participation of independently ambulatory youth with cerebral palsy: an exploration of youths' and parents' perspectives

AIM

Youth with cerebral palsy generally participate in less physical activity than typically developing peers. In adults with physical disabilities, balance confidence is a strong predictor of participation and community re-integration. However, balance confidence has not been studied in youth with cerebral palsy.

METHOD

Qualitative descriptive methodology with interviews of eight youth with cerebral palsy (9-17 years old, three girls) in Gross Motor Function Classification System Levels I-III, and eight parents (five mothers) of youth with cerebral palsy (9-17 years old, two girls) in Levels I-III.

RESULTS

Three themes arose: (1) youth in Gross Motor Function Classification System Levels I-II are more concerned about losing their balance during physical activities than those in Level III; (2) when balance is lost, embarrassment and frustration are more common than fear, especially for those in Levels I-II; and (3) social factors can create a favorable participation environment when balance confidence is low, especially for youth in Levels I-II.

CONCLUSION

Balance confidence may have greater influence on physical activity participation for youth in Gross Motor Function Classification System Levels I-II than those in Level III. Youth in Levels I-II may draw greater benefit from interventions targeting balance confidence when addressing physical activity goals.IMPLICATIONS FOR REHABILITATIONBalance confidence may have a greater influence on activity avoidance for youth with cerebral palsy in Gross Motor Function Classification System Levels I and II (who are independently ambulatory without walkers or cane(s)) than for those in Level II (who use walkers or cane(s) to ambulate).Youth who are independently ambulatory without walkers or cane(s) may benefit more from interventions directed at balance confidence (e.g., enactive mastery and verbal persuasion) to address their physical activity participation goals.For youth who are independently ambulatory without walkers or cane(s), addressing factors that could reduce the influence of balance confidence on physical activity participation, such as providing a positive and supportive social environment in which to participate, may be beneficial.

Characteristics of Voluntary-induced Stepping Response in Persons with Stroke compared with those of healthy Young and Older Adults

BACKGROUND

Impairment of protective steps to recover balance from external perturbation is evident after stroke. Voluntary-induced stepping response (VSR) can be used to practice protective steps by instructing an individual to voluntarily lean their whole body forward until they perceive a loss of balance and automatically induce a step. However, to improve protective stepping performance, detailed characteristics of VSR in healthy persons are required.

RESEARCH QUESTION

What is the difference in VSR between healthy and persons with stroke?

METHODS

An observational study was conducted in 30 participants, (10 young, 10 older, and 10 persons with stroke). All participants performed VSR for 10 trials. Step length, step width, step duration, CoM position, CoM velocity, trunk-hip displacement, and strategies of response were recorded using a motion capture system and analysed using Matlab software. Statistical analysis was performed using One-way ANOVA and Chi-square.

RESULTS

On average, participants with stroke had shorter step lengths and step durations than young and older adults. Step width of older adults and participants with stroke was wider than that of young adults (p < 0.05). While multiple steps and losing balance were reported more frequently in participants with stroke than the others, the percentage of trials in which participants grasped the handrails was not significantly different between older adults and participants with stroke. CoM position, CoM velocity, and trunk-hip displacement at foot liftoff were significantly smaller in older adults and participants with stroke than young adults (p < 0.05). Participants with stroke tended to use trunk bending rather than trunk leaning strategies to generate VSR in contrast to healthy participant. The prevalence of the trunk bending strategy was also greater in older adults than young adults.

SIGNIFICANCE

Values obtained from healthy groups can be used as guidelines to set realistic goals during VSR training to improve protective steps in patients with stroke.

Effect of Ankle Plantar Flexor Spasticity Level on Balance in Patients With Stroke: Protocol for a Cross-Sectional Study

BACKGROUND

The lower limb spasticity after stroke can affect the balance and gait of patients with stroke.

OBJECTIVE

The aim of this study is to assess the effects of ankle plantar flexor spasticity level on balance in patients with stroke.

METHODS

Patients with stroke were recruited from neurology and physiotherapy clinics in Tehran, Iran. Based on the level of ankle plantar flexor spasticity according to the Modified Modified Ashworth Scale (MMAS), the eligible patients with stroke were divided into 2 groups: high spasticity (MMAS score≥2) and low spasticity (MMAS score<2). The primary outcome measures were the MMAS scores, Activities-Specific Balance Confidence questionnaire scores, eyes-open and eyes-closed posturography measures, and Timed Up and Go test results. The secondary outcome measures were the ankle passive range of motion and ankle joint proprioception. The t test, mixed model univariate analysis of variance, and Spearman rank correlation were used for statistical analysis.

RESULTS

Data collection and statistical analysis are complete. The interpretation of results is underway. We expect the results to be published in winter 2020.

CONCLUSIONS

We believe that patients with high ankle plantar flexor spasticity after stroke will demonstrate greater balance dysfunction, which will worsen with impaired proprioception, passive range of motion, and eyes closed.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/16045.

Investigating the relationship between spatiotemporal gait variability and falls self-efficacy in individuals with chronic stroke

AIM

To investigate the relationship between spatiotemporal gait variability and falls self-efficacy after chronic stroke while taking into account the effect of some known potential confounders including fall numbers and gait velocity.

METHODS

Participants (n = 62) walked at their preferred speed to calculate gait variability for stride time, stride length, swing time, and double-support percent. The Falls Efficacy Scale-International (FES-I) assessed falls self-efficacy. The linear regression tests were used for statistical analysis. Age, sex, time since stroke, paretic side, motor impairments, fall numbers, and gait velocity were considered as independent variables.

RESULTS

Increased FES-I score was related to higher stride time variability (R² = 0.65, F(8,53) = 15.44, P < .05). Increased FES-I was associated with higher stride length variability (R² = 0.42, F(6,55) = 8.44, P < .05). However, further adjustment on gait velocity and fall numbers made the association non-significant (R² = 0.41, F(8,53) = 6.4, P > .05). No significant relationship was identified between FES-I and swing time (R² = 0.08, F(8,53) = 0.39, P > .05) and FES-I and double-support percent variability (R² = 0.04, F(8,53) = 0.67, P > .05).

CONCLUSION

The results indicate that increased FES-I score may be related to increased stride variability post stroke.

Augmented Reality-Based Rehabilitation of Gait Impairments: Case Report

Background

Gait and balance impairments are common in neurological diseases, including stroke, and negatively affect patients’ quality of life. Improving balance and gait are among the main goals of rehabilitation. Rehabilitation is mainly performed in clinics, which lack context specificity; therefore, training in the patient’s home environment is preferable. In the last decade, developed rehabilitation technologies such as virtual reality and augmented reality (AR) have enabled gait and balance training outside clinics. Here, we propose a new method for gait rehabilitation in persons who have had a stroke in which mobile AR technology and a sensor-based motion capture system are combined to provide fine-grained feedback on gait performance in real time.

Objective

The aims of this study were (1) to investigate manipulation of the gait pattern of persons who have had a stroke based on virtual augmentation during overground walking compared to walking without AR performance feedback and (2) to investigate the usability of the AR system.

Methods

We developed the ARISE (Augmented Reality for gait Impairments after StrokE) system, in which we combined a development version of HoloLens 2 smart glasses (Microsoft Corporation) with a sensor-based motion capture system. One patient with chronic minor gait impairment poststroke completed clinical gait assessments and an AR parkour course with patient-centered performance gait feedback. The movement kinematics during gait as well as the usability and safety of the system were evaluated.

Results

The patient changed his gait pattern during AR parkour compared to the pattern observed during the clinical gait assessments. He recognized the virtual objects and ranked the usability of the ARISE system as excellent. In addition, the patient stated that the system would complement his standard gait therapy. Except for the symptom of exhilaration, no adverse events occurred.

Conclusions

This project provided the first evidence of gait adaptation during overground walking based on real-time feedback through visual and auditory augmentation. The system has potential to provide gait and balance rehabilitation outside the clinic. This initial investigation of AR rehabilitation may aid the development and investigation of new gait and balance therapies.

How does balance during functional tasks change across older adulthood?

BACKGROUND

Aging is associated with declining balance, which may increase fall risk and reduce independence. There is a paucity of work examining functional tasks (e.g., standing from a chair, lifting) related to fall risk. Additionally, many past studies have considered older adults as one age group, rather than viewing aging as a continuum across older adulthood.

RESEARCH QUESTION

How are age and balance measures related in healthy, independently-dwelling older adults during functional tasks?

METHODS

Thirty-eight older (60-89 years old) and 21 younger (18-30 years old) independently-dwelling adults performed quiet standing, sit-stand-sit, sit-stand-gait initiation, and lifting, while ground reaction forces and whole-body motion were measured. Variability of the net center of pressure displacement (root-mean-square; antero-posterior and mediolateral), and minimum margin of stability (anterior, posterior, mediolateral, and/or medial and lateral) were extracted. Regression analyses were used to identify relationships with age for both the full participant sample and the older adult cohort, accounting for sex and task characteristics.

RESULTS

Age was significantly related to balance measures for both participant samples; net center of pressure root-mean-square and minimum margin of stability tended to increase and decrease with age, respectively. For older adults, significant relationships were primarily in the antero-posterior and mediolateral directions for sit-stand-gait initiation and sit-stand-sit, respectively. Relationships did not appear to be simply a function of differences in task performance with age.

SIGNIFICANCE

Some evidence of balance declines during functional tasks was observed across older adulthood, including declines that did not appear in the full participant sample. However, further work with a more diverse older adult cohort will be required to confirm these results. Findings may contribute to the development of strategies for improving balance control and reducing fall risk in older adults, by identifying the balance measures most likely to decline across older adulthood as potential target tasks for interventions.

Factors affecting fear of falls in patients with chronic stroke

Objective: The aim of this study was to find the factors associated with fear of falls in patients having chronic stroke.Methods: Inclusion criterion was subjects with cerebral stroke for more than 3 months. A structured interview of 82 subjects was conducted with a questionnaire with questions regarding personal factors such as gender, side affected, number of comorbidities, and setting of physical therapy sessions. Depression was assessed using Patient Health Questionnaire-9, lower extremity motor function was assessed using Fugl-Meyer scale, and functional mobility was assessed using Timed Up and Go. Chi-square analysis was done on the above factors to find significant factors followed by logistic regression of the factors found significant in Chi square.Results: Lower extremity Fugl-Meyer score was significantly associated with fear of falls (p value 0.047 with Odds ratio of 1.136, 95% CI 1.002-1.287) in patients having chronic stroke while treatment factors, such as setting of physical therapy sessions, and personal factors, such as gender, side affected, number of comorbidities, depression, functional mobility, or use of walking aid, were not found to have significant association.Conclusion: The lower extremity Fugl-Meyer score is associated with fear of falls in patients having chronic stroke.

Improvements in balance reaction impairments following reactive balance training in individuals with sub-acute stroke: A prospective cohort study with historical control

Background: Reactive balance training (RBT) has been previously found to reduce fall risk in individuals with sub-acute stroke; however, our understanding of the effects of RBT on specific balance impairments is lacking.Objective: To quantify changes in common balance reaction impairments in individuals with sub-acute stroke resulting from RBT, relative to traditional balance training, using a prospective cohort study design with a historical control group.Methods: Individuals with sub-acute stroke completed either RBT or traditional balance training as part of their routine care during physiotherapy in inpatient rehabilitation. Reactive balance control was assessed using lean-and-release perturbations pre-intervention, post-intervention, and 6-months post-intervention (follow-up). Individuals with impaired balance reactions (delayed foot-off times, slide steps, and/or a preference for stepping with the preferred limb) at the pre-intervention assessment were identified using video and force plate data. Outcome measures (foot-off times, frequency of trials with slide steps, and stepping with the preferred limb) from the RBT participants with impaired reactions were compared for each of the three assessments to the mean values for the participants with impaired reactions in the historical control group.Results: Improvements were observed in all outcome measures for the RBT participants between pre-intervention and post-intervention, and/or between post-intervention and follow-up. These improvements were generally equivalent to, if not better than, the improvements demonstrated by the historical control group.Conclusions: Findings further support the use of RBT for post-stroke inpatient rehabilitation, and provide insight into specific balance reaction impairments that are improved by RBT.

Body weight support-Tai Chi footwork for balance of stroke survivors with fear of falling: A pilot randomized controlled trial

BACKGROUND AND PURPOSE

Balance impairment is the predominant risk factor for falls in stroke survivors. This study examined the effects of body weight support-Tai Chi (BWS-TC) footwork on balance control among stroke survivors with fear of falling (FOF).

MATERIALS AND METHODS

Twenty-eight stroke survivors with FOF were randomly allocated to either control or BWS-TC groups. Those in BWS-TC underwent Tai Chi training for 12 weeks. Outcomes were assessed in all participants by evaluation of the limits of stability test, modified clinical test of sensory integration of balance, fall risk index, and Fugl-Meyer assessment of lower limbs at baseline and 12 weeks.

RESULTS

The BWS-TC group displayed significant enhancement in dynamic control and vestibular and somatosensory integration.

CONCLUSION

BWS-TC may enhance dynamic control and sensory integration of balance and reduce the risk of fall in stroke survivors with FOF.

Tempo-spatial gait adaptations in stroke patients when approaching and crossing an elevated surface

BACKGROUND

In ambulatory stroke survivors, outdoor walking is important for participation, so adapting to heightened levels (e.g. curbs) is essential. This needs precise step regulation and foot positioning and has to be achieved despite impaired balance and motor regulation.

RESEARCH QUESTION

How do stroke patients approach and cross elevated surfaces?

METHODS

Gait of 12 hemiparetic stroke patients (62.8 ± 10.3 years; Functional Ambulatory Category 3-5) and 13 controls (60.0 ± 12.4 years) was compared using a sensor carpet and 3D motion capturing to collect tempo-spatial parameters and foot trajectories in two conditions: flat walking vs. approaching to and stepping onto an elevated surface (height 15 cm) in a self-selected manner (6 trials each). Tempo-spatial adaptations were normalized to flat walking while trajectory analysis focused on foot clearance and placement. Complementary assessments included the Dynamic-Gait-Index, the Berg-Balance-Test and the Falls Efficacy Scale.

RESULTS

Patients showed significantly worse Dynamic-Gait-Indices, less balance and more fear of falling. During the approach phase, patients slowed down, partly accompanied by shorter steps which controls did not. During crossing, no preference for a specific leading leg was detected. Clearance of the leading leg on average was not reduced but patients landed closer to the edge. Still clearance of the paretic leg was less than that of the non-paretic leg and the minimal clearance across all trials suggested an increased tripping risk, most evident for the trailing leg. In particular slower approaching caused difficulties to ensure sufficient leg clearance and to place the foot safely. Independent from that, better balance correlated with safer clearance.

SIGNIFICANCE

When managing elevated levels, leading with the paretic leg causes more difficulties to safely clear the legs which is considerably dependent upon speed. Therapists should consider that slow walking may not increase safety while faster gait and aspects of postural control potentially facilitate crossing a curb.

Stepping characteristics during externally induced lateral reactive and voluntary steps in chronic stroke

BACKGROUND

Stepping is critical for responding to perturbations, whether externally induced or self-initiated. Falls post-stroke is equally likely to happen from either mechanism. The objective of the study was, to examine lateral stepping performance during waist-pull induced reactive steps and voluntary choice reaction time steps in chronic stroke and controls.

METHODS

In this cross-sectional study participants with chronic stroke (N = 10) and age- and gender-matched controls (N = 10) performed reactive and voluntary lateral steps. Step initiation time, global step length, step clearance, and step velocity were calculated. Other measures for reactive step included, Balance tolerance limit (perturbation magnitude when recovery transitioned from single to multiple steps), and step type. The Community Balance & Mobility Scale, and hip abductor and adductor isokinetic asymmetry torque ratio were assessed.

RESULTS

The paretic and non-paretic leg were combined since step characteristics did not differ. Step (voluntary vs. reactive) by group (stroke vs. controls) was significant for step initiation time. The stroke group took longer initiating a voluntary step (P = 0.004). Reactive and voluntary steps were executed slower (P = 0.041), with a reduced step length (P = 0.028) by the stroke group. The stroke group had a lower balance tolerance limit (P = 0.01) and took reactive medial steps more frequently (P = 0.001). The Community Balance & Mobility Scale (P > 0.001), and hip abductor and adductor asymmetry torque ratio (P > 0.001; P = 0.015) was reduced in the stroke group.

SIGNIFICANCE

Our findings indicate individuals post-stroke are slower initiating and executing reactive and voluntary steps. Though the reactive step timing is less impaired, this may be a method for enhancing faster voluntary movements and training reactive balance.

Effects of Virtual Reality Compared to Conventional Therapy on Balance Poststroke: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to systematically review the effect of virtual reality on balance as compared to conventional therapy alone poststroke.

METHODS

The databases of PubMed, Cochrane, and Ovid were searched using select keywords. The randomized controlled trials published between January 2000 and August 2017 in English language were included if they assessed the effect of virtual reality on balance ability compared to conventional therapy alone in adults' poststroke. The Physiotherapy Evidence Database scale was used to assess the methodological quality.

RESULTS

Fourteen papers were included in this review. The experimental groups largely (n = 13) used virtual reality in combination with conventional therapy. Among the high quality studies, significant between-group improvement favoring virtual reality in combination with conventional therapy was found on Berg Balance Scale (n = 7) and Timed Up and Go Scale (n = 7) when compared to conventional therapy alone. The studies were limited by low powered, small sample sizes ranging from 14 to 40, and lack of blinding, concealed allocation, and reporting of missing data. Thirteen homogenous (n = 348, I² = 37.6%, P = .083) studies were included in the meta-analysis using Berg Balance Scale. Significant improvement was observed in the experimental group compared to control group with a medium effect size of .64, confidence interval of .36-.92.

CONCLUSIONS

The findings of this review indicate that virtual reality when combined with conventional therapy is moderately more effective in improving balance than conventional therapy alone in individuals' poststroke.

Balance Training in Virtual Reality Promotes Performance Improvement but Not Transfer to Postural Control in People with Chronic Stroke

Objective: In people with chronic stroke, we investigated the transfer of gains obtained after balance training with virtual reality (VR) to an untrained task with similar balance demands. Materials and Methods: This study included 29 people with chronic stroke randomized into two groups: experimental (EG, n = 16) and control (CG, n = 13). The EG performed three sessions of balance training with VR using a platform-based videogame (Nintendo Wii Fit system™) for 1 week. The CG received no intervention. Transfer was evaluated through balance tests on the force platform Balance Master™, performed before and after the intervention period, for both groups. Results: The analysis of variance for repeated measures for game performance in the EG showed statistically significant improvement in scores in all five games after training (AT). In contrast, similar analysis for balance tests for the EG and CG showed no significant differences in performance index scores derived from the Balance Master tests after the intervention period for both groups. Conclusion: People with chronic stroke showed performance improvement AT with VR, but there was no transfer of the gains obtained to an untrained task with similar balance demands.