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Handelzalts S, Soroker N, Melzer I. Characteristics of unsuccessful reactive responses to lateral loss of balance in people with stroke. Neurol Res 2024:1-10. [PMID: 39168452 DOI: 10.1080/01616412.2024.2394327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 08/14/2024] [Indexed: 08/23/2024]
Abstract
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.
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Affiliation(s)
- Shirley Handelzalts
- Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Physical Therapy, Loewenstein Rehabilitation Medical Center, Ra'anana, Israel
| | - Nachum Soroker
- Neurological Rehabilitation Department, Loewenstein Rehabilitation Medical Center, Ra'anana, Israel
- Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Itshak Melzer
- Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Walking-adaptability therapy after stroke: results of a randomized controlled trial. Trials 2021; 22:923. [PMID: 34911566 PMCID: PMC8672482 DOI: 10.1186/s13063-021-05742-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ability to adapt walking to environmental properties and hazards, a prerequisite for safe ambulation, is often impaired in persons after stroke. RESEARCH QUESTION The aim of this study was to compare the efficacy of two walking-adaptability interventions: a novel treadmill-based C-Mill therapy (using gait-dependent augmented reality) and the standard overground FALLS program (using physical context). We expected sustained improvements for both treatment groups combined but hypothesized better outcomes for C-Mill therapy than the FALLS program due to its expected greater amount of walking practice. METHODS In this pre-registered single-centre parallel group randomized controlled trial, forty persons after stroke (≥ 3 months ago) with walking and/or balance deficits were randomly allocated to either 5 weeks of C-Mill therapy or the FALLS program. The primary outcome measure was the standard walking speed as determined with the 10-meter walking test (10MWT). Additionally, context-specific walking speed was assessed in environments enriched with either stationary physical context (10MWT context) or suddenly appearing visual images (Interactive Walkway obstacles). The walking-adaptability scores of those enriched walking tests served as secondary outcome measures. Furthermore, a cognitive task was added to all three assessments to evaluate dual-task performance in this context. Finally, the participants' experience and amount of walking practice were scored. The outcome measures were assessed at four test moments: pre-intervention (T0), post-intervention (T1), 5-week post-intervention retention (T2), and 1-year post-intervention follow-up (T3). RESULTS No significant group differences were found between the interventions for the primary outcome measure standard walking speed, but we found a greater improvement in context-specific walking speed with stationary physical context of the C-Mill therapy compared to the FALLS program at the post-intervention test, which was no longer significant at retention. Both interventions were well received, but C-Mill therapy scored better on perceived increased fitness than the FALLS program. C-Mill therapy resulted in twice as many steps per session of equal duration than the FALLS program. The "change-over-time" analyses for participants of both interventions combined showed no significant improvements in the standard walking speed; however, significant improvements were found for context-specific walking speed, walking adaptability, and cognitive dual-task performance. SIGNIFICANCE This study showed no between-group differences between the novel treadmill-based C-Mill therapy and the standard overground FALLS program with respect to the primary outcome measure standard walking speed. However, the greater amount of walking practice observed for the C-Mill group, an essential aspect of effective intervention programs after stroke, may underlie the reported increased perceived fitness and observed increased context-specific walking speed for the C-Mill group directly after the intervention. Although the "change-over-time" results for all participants combined showed no improvement in the standard walking speed, context-specific walking speed and walking adaptability showed sustained improvements after the interventions, underscoring the importance of including walking-adaptability training and assessment in rehabilitation post stroke. TRIAL REGISTRATION The Netherlands Trial Register NTR4030 . Registered 11 June 2013.
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Mansfield A, Aqui A, Danells CJ, Knorr S, Centen A, DePaul VG, Schinkel-Ivy A, Brooks D, Inness EL, Mochizuki G. Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial. BMJ Open 2018; 8:e021510. [PMID: 30121600 PMCID: PMC6104758 DOI: 10.1136/bmjopen-2018-021510] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/06/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES No intervention has been shown to prevent falls poststroke. We aimed to determine if perturbation-based balance training (PBT) can reduce falls in daily life among individuals with chronic stroke. DESIGN Assessor-blinded randomised controlled trial. SETTING Two academic hospitals in an urban area. INTERVENTIONS Participants were allocated using stratified blocked randomisation to either 'traditional' balance training (control) or PBT. PBT focused on improving responses to instability, whereas traditional balance training focused on maintaining stability during functional tasks. Training sessions were 1 hour twice/week for 6 weeks. Participants were also invited to complete 2 'booster' training sessions during the follow-up. PARTICIPANTS Eighty-eight participants with chronic stroke (>6 months poststroke) were recruited and randomly allocated one of the two interventions. Five participants withdrew; 42 (control) and 41 (PBT group) were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was rate of falls in the 12 months post-training. Negative binomial regression was used to compare fall rates between groups. Secondary outcomes were measures of balance, mobility, balance confidence, physical activity and social integration. RESULTS PBT participants reported 53 falls (1.45 falls/person-year) and control participants reported 64 falls (1.72 falls/person-year; rate ratio: 0.85(0.42 to 1.69); p=0.63). Per-protocol analysis included 32 PBT and 34 control participants who completed at least 10/12 initial training sessions and 1 booster session. Within this subset, PBT participants reported 32 falls (1.07 falls/person-year) and control participants reported 57 falls (1.75 falls/person-year; rate ratio: 0.62(0.29 to 1.30); p=0.20). PBT participants had greater improvement in reactive balance control than the control group, and these improvements were sustained 12 months post-training. There were no intervention-related serious adverse effects. CONCLUSIONS The results are inconclusive. PBT may help to prevent falls in daily life poststroke, but ongoing training may be required to maintain the benefits. TRIAL REGISTRATION NUMBER ISRCTN05434601; Results.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Svetlana Knorr
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew Centen
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Vincent G DePaul
- School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
| | - Alison Schinkel-Ivy
- Schulich School of Education – School of Physical and Health Education, Nipissing University, North Bay, Ontario, Canada
| | - Dina Brooks
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Timmermans C, Roerdink M, van Ooijen MW, Meskers CG, Janssen TW, Beek PJ. Walking adaptability therapy after stroke: study protocol for a randomized controlled trial. Trials 2016; 17:425. [PMID: 27565425 PMCID: PMC5002097 DOI: 10.1186/s13063-016-1527-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/25/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Walking in everyday life requires the ability to adapt walking to the environment. This adaptability is often impaired after stroke, and this might contribute to the increased fall risk after stroke. To improve safe community ambulation, walking adaptability training might be beneficial after stroke. This study is designed to compare the effects of two interventions for improving walking speed and walking adaptability: treadmill-based C-Mill therapy (therapy with augmented reality) and the overground FALLS program (a conventional therapy program). We hypothesize that C-Mill therapy will result in better outcomes than the FALLS program, owing to its expected greater amount of walking practice. METHODS This is a single-center parallel group randomized controlled trial with pre-intervention, post-intervention, retention, and follow-up tests. Forty persons after stroke (≥3 months) with deficits in walking or balance will be included. Participants will be randomly allocated to either C-Mill therapy or the overground FALLS program for 5 weeks. Both interventions will incorporate practice of walking adaptability and will be matched in terms of frequency, duration, and therapist attention. Walking speed, as determined by the 10 Meter Walking Test, will be the primary outcome measure. Secondary outcome measures will pertain to walking adaptability (10 Meter Walking Test with context or cognitive dual-task and Interactive Walkway assessments). Furthermore, commonly used clinical measures to determine walking ability (Timed Up-and-Go test), walking independence (Functional Ambulation Category), balance (Berg Balance Scale), and balance confidence (Activities-specific Balance Confidence scale) will be used, as well as a complementary set of walking-related assessments. The amount of walking practice (the number of steps taken per session) will be registered using the treadmill's inbuilt step counter (C-Mill therapy) and video recordings (FALLS program). This process measure will be compared between the two interventions. DISCUSSION This study will assess the effects of treadmill-based C-Mill therapy compared with the overground FALLS program and thereby the relative importance of the amount of walking practice as a key aspect of effective intervention programs directed at improving walking speed and walking adaptability after stroke. TRIAL REGISTRATION Netherlands Trial Register NTR4030 . Registered on 11 June 2013, amendment filed on 17 June 2016.
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Affiliation(s)
- Celine Timmermans
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, Amsterdam, 1081 BT, The Netherlands. .,Amsterdam Rehabilitation Research Center, Reade, Overtoom 283, Amsterdam, 1054 HW, The Netherlands.
| | - Melvyn Roerdink
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, Amsterdam, 1081 BT, The Netherlands
| | - Marielle W van Ooijen
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, Amsterdam, 1081 BT, The Netherlands.,Amsterdam Rehabilitation Research Center, Reade, Overtoom 283, Amsterdam, 1054 HW, The Netherlands
| | - Carel G Meskers
- VU Medical Centre, Department of Rehabilitation Medicine, De Boelelaan 1118, Amsterdam, 1081 HZ, The Netherlands
| | - Thomas W Janssen
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, Amsterdam, 1081 BT, The Netherlands.,Amsterdam Rehabilitation Research Center, Reade, Overtoom 283, Amsterdam, 1054 HW, The Netherlands
| | - Peter J Beek
- MOVE Research Institute Amsterdam, Department of Human Movement Sciences, Vrije Universiteit Amsterdam, Van der Boechorststraat 9, Amsterdam, 1081 BT, The Netherlands
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Mansfield A, Aqui A, Centen A, Danells CJ, DePaul VG, Knorr S, Schinkel-Ivy A, Brooks D, Inness EL, McIlroy WE, Mochizuki G. Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. BMC Neurol 2015; 15:87. [PMID: 26048054 PMCID: PMC4456796 DOI: 10.1186/s12883-015-0347-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 05/29/2015] [Indexed: 11/10/2022] Open
Abstract
Background Falls are one of the most common medical complications post-stroke. Physical exercise, particularly exercise that challenges balance, reduces the risk of falls among healthy and frail older adults. However, exercise has not proven effective for preventing falls post-stroke. Falls ultimately occur when an individual fails to recover from a loss of balance. Thus, training to specifically improve reactive balance control could prevent falls. Perturbation training aims to improve reactive balance control by repeatedly exposing participants to postural perturbations. There is emerging evidence that perturbation training reduces fall rates among individuals with neurological conditions, such as Parkinson disease. The primary aim of this work is to determine if perturbation-based balance training can reduce occurrence of falls in daily life among individuals with chronic stroke. Secondary objectives are to determine the effect of perturbation training on balance confidence and activity restriction, and functional balance and mobility. Methods/design Individuals with chronic stroke will be recruited. Participants will be randomly assigned to one of two groups: 1) perturbation training, or 2) ‘traditional’ balance training. Perturbation training will involve both manual perturbations (e.g., a push or pull from a physiotherapist), and rapid voluntary movements to cause a loss of balance. Training will occur twice per week for 6 weeks. Participants will record falls and activity for 12 months following completion of the training program. Standardized clinical tools will be used to assess functional balance and mobility, and balance confidence before and after training. Discussion Falls are a significant problem for those with stroke. Despite the large body of work demonstrating effective interventions, such as exercise, for preventing falls in other populations, there is little evidence for interventions that prevent falls post-stroke. The proposed study will investigate a novel and promising intervention: perturbation training. If effective, this training has the potential to not only prevent falls, but to also improve safe independent mobility and engagement in daily activities for those with stroke. Trial registration Current Controlled Trials: ISRCTN05434601.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
| | - Andrew Centen
- Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Vincent G DePaul
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada. .,St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
| | - Svetlana Knorr
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
| | - Alison Schinkel-Ivy
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
| | - Dina Brooks
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
| | - William E McIlroy
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada. .,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
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