Abnormal sensory integration affects balance control in hemiparetic patients within the first year after stroke

The effect of a motor relearning on balance and postural control in patients after stroke: An open-label randomized controlled trial

INTRODUCTION

Balance and postural control impairments are common in stroke patients, increasing fall risk and limiting their daily and social activities. Current research lacks comprehensive studies evaluating the efficacy and long-term effects of task-specific training on balance and postural control among stroke patients, especially when considering biomechanical and posturographic assessments.

PATIENTS AND METHODS

A randomized controlled trial included 63 subacute stroke patients recruited from the outpatient rehabilitation department. Participants were randomly assigned to the MRP group (n=32), receiving task-specific training based on MRP, or the CPT group (n=31), receiving conventional physical therapy. Both groups completed an 8-week intervention (3 sessions/week; 1 h./session). Balance and postural control were assessed at baseline, post-intervention, and 3-month follow-up using the Berg Balance Scale (BBS) and posturography.

RESULTS

The MRP group exhibited significantly larger improvements than the CPT group in both BBS scores (p=0.001, d=2.98, 95% CI [2.25, 3.70]) and Balance Index scores (p=0.001, d=2.83, 95% CI [2.12, 3.53]) after the intervention. These improvements were sustained at 3-month follow-up.

DISCUSSION

The findings suggest that task-specific training based on MRP is more effective than CPT for improving balance and postural control. The MRP intervention may enhance the motor learning and neural plasticity of the patients, leading to better functional outcomes. However, the study's open-label design represents a limitation, and further research with adequate blinding is needed.

CONCLUSION

Task-specific training based on MRP was superior to CPT for improving balance and postural control in subacute stroke patients. Participants undergoing MRP exhibited significant and clinically relevant improvements that were sustained at follow-up.

Wii Fit-Based Biofeedback Rehabilitation Among Post-Stroke Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

BACKGROUND

Stroke is one of the most widespread reasons for acquired adult disability. Recent experimental studies have reported the beneficial influence of Wii Fit-based feedback on improving overall balance and gait for stroke survivors.

METHODS

We conducted a systematic review of the literature using the following keywords to retrieve the data: feedback, biofeedback, stroke, visual, auditory, tactile, virtual reality, videogame rehabilitation, Nintendo Wii stroke, videogame stroke, exergame stroke, Nintendo Wii rehabilitation, balance, and gait. A review and meta-analysis of RCTs regarding Wii Fit-based rehabilitation accompanied by conventional therapy effects on Berg Balance Scale (BBS), Timed Up and Go (TUG), functional reach test, and gait (speed) in stroke survivors was conducted.

OBJECTIVE

To determine the impacts of Wii Fit-based feedback combined with traditional therapy on balance and gait in stroke survivors.

RESULTS

22 studies were included. The meta-analysis results revealed statistically significant improvements in functional ambulation measured using TUG (p < 0.0001), balance measured using BBS (p = 0.0001), and functional reach test (p = 0.01), but not in gait speed (p = 0.32) following Wii Fit-based feedback. Regarding the types of feedback, significant differences were found in BBS scores when mixed visual and auditory feedback was used.

CONCLUSION

Wii Fit-based feedback has desired effects on improving balance in stroke patients, making it a suitable adjunct to physical therapy.

Insufficiencies in sensory systems reweighting is associated with walking impairment severity in chronic stroke: an observational cohort study

Background

Walking and balance impairment are common sequelae of stroke and significantly impact functional independence, morbidity, and mortality. Adequate postural stability is needed for walking, which requires sufficient integration of sensory information between the visual, somatosensory, and vestibular centers. "Sensory reweighting" describes the normal physiologic response needed to maintain postural stability in the absence of sufficient visual or somatosensory information and is believed to play a critical role in preserving postural stability after stroke. However, the extent to which sensory reweighting successfully maintains postural stability in the chronic stages of stroke and its potential impact on walking function remains understudied.

Methods

In this cross-sectional study, fifty-eight community-dwelling ambulatory chronic stroke survivors underwent baseline postural stability testing during quiet stance using the modified Clinical test of Sensory Interaction in Balance (mCTSIB) and assessment of spatiotemporal gait parameters.

Results

Seventy-six percent (45/58) of participants showed sufficient sensory reweighting with visual and somatosensory deprivation for maintaining postural stability, albeit with greater postural sway velocity indices than normative data. In contrast, survivors with insufficient reweighting demonstrated markedly slower overground walking speeds, greater spatiotemporal asymmetry, and limited acceleration potential.

Conclusion

Adequate sensory system reweighting is essential for chronic stroke survivors' postural stability and walking independence. Greater emphasis should be placed on rehabilitation strategies incorporating multisensory system integration testing and strengthening as part of walking rehabilitation protocols. Given its potential impact on outcomes, walking rehabilitation trials may benefit from incorporating formal postural stability testing in design and group stratification.

Treatment of balance with Computerised Dynamic Posturography therapy in chronic hemiplegic patients

Background

As patients with hemiplegia have a high risk of falling, it is important to develop a fall rehabilitation plan and/or apply personalised treatment when necessary.

Objectives

We aimed to evaluate the effects of individualised treatment with Computerised Dynamic Posturography (CDP) on balance in patients with and without a history of chronic hemiplegic falls.

Method

Forty patients with hemiplegia (time post-stroke: 8-18 months) between 40 and 70 years of age in the Istanbul Yeniyüzyıl University, Gaziosmanpaşa Hospital participated in our study. The patients were divided into two groups: Group 1, falling history (n = 20) and Group 2, no falling history (n = 20). The patients in both groups were included in a traditional rehabilitation programme for 5 weeks, 5 days a week, for 1 h. The group with a history of falls also received individualised CDP treatment for 20 min, 3 days a week, for 5 weeks. Patients were evaluated with a Sensory Organisation Test (SOT) and a Berg Balance Scale (BBS).

Results

In Group 1, a significant improvement was determined in the after-treatment SOT 5 values compared with the before treatment SOT 5 values (p = 0.022). Significant improvement was found in BBS (p = 0.003) and SOT 6 (p = 0.022) values in Group 2. There was no statistically significant difference in improvement between the two groups (p ≥ 0.05).

Conclusion

Larger samples and longer duration of individualised CDP therapy studies may be required to improve balance with chronic hemiplegia and a history of falls.

Clinical Implications

In addition to traditional therapy, individualised CDP treatment may be beneficial for patients with a history of post-stroke falls.

Effect of a visual dual task on postural stability-A comparative study using linear and nonlinear methods

Background and Aims

The dual-task experimental paradigm is used to study the attentional demands of postural control. Postural control is impaired in poststroke patients, and dual-task balance studies address the visual needs of postural control in stroke patients. A nonlinear approach can help us understand the overall behavior of the dynamic system.

Methods

A total of 20 chronic stroke patients and 20 healthy subjects with similar age, height, and weight participated in this study. The stability and complexity of postural control were assessed using linear and nonlinear methods. All data and parameters (center of pressure [COP] velocity, anteroposterior and mediolateral directions displacement, length of COP path, and phase plane) were analyzed using the Kolmogorov-Smirnov test.

Results

When postural control was examined based on linear analysis, the results showed that the main effect of the group was not significant, but the main impact of position was significant for all parameters of the COP variation (p < 0.05). Examination of postural control based on nonlinear analysis also showed that the main effect of the group was not significant, and the main effect of status was significant only for the parameters of approximate entropy in both directions and short-term Lyapunov view in the anterior-posterior direction (p < 0.05).

Conclusion

According to the results of this study, the assessment of postural control and gait performance in poststroke patients, as well as the dual tasks they have to perform in daily life, is crucial for their independence in activities of daily living.

The Effects of Vestibular Rehabilitation on Poststroke Fatigue: A Randomized Controlled Trial Study

Background. A major complication caused by stroke is poststroke fatigue (PSF), and by causing limitations in doing activities of daily living (ADL), it can lower the quality of life. Objective. The present study is an attempt to examine the effects of vestibular rehabilitation on BADL (Basic Activities of Daily Living), fatigue, depression, and Lawton Instrumental Activities of Daily Living (IADL) in patients with stroke. Method. Patients with a history of stroke took part voluntarily in a single-blind clinical trial. The participants were allocated to control and experimental groups randomly. The experimental group attended 24 sessions of vestibular rehabilitation protocol, while the control group received the standard rehabilitation (including three sessions per week each for around 60 min). To measure fatigue, the Fatigue Impact Scale (FIS) and the Fatigue Assessment Scale (FAS) were used. Depression, BADL, and IADL were measured using the Beck Depression Inventory-II (BDI-II), Barthel Index (BI), and Lawton Instrumental Activities of Daily Living, respectively. All changes were measured from the baseline after the intervention. Results. Significant improvement was found in the experimental group compared to the control group ( $p<0.05$ ) in FIS (physical, cognition, and social subscales), FAS, BDI-II, BADL, and IADL. Moreover, the results showed small to medium and large effect sizes for the physical subscale of FIS and FAS scores based on Cohen’s $d$ , respectively; however, no significant difference was found in terms of cognition and social subscales of FIS, BDI-II, BADL, and IADL scores. Conclusion. It is possible to improve fatigue, depression, and independence in BADL and IADL using vestibular rehabilitation. Thus, it is an effective intervention in case of stroke, which is also well tolerated.

Receiver Operating Characteristic Curve Analysis of the Somatosensory Organization Test, Berg Balance Scale, and Fall Efficacy Scale–International for Predicting Falls in Discharged Stroke Patients

Background: Although fall prevention in patients after stroke is crucial, the clinical validity of fall risk assessment tools is underresearched in this population. The study aim was to determine the cut-off scores and clinical validity of the Sensory Organization Test (SOT), the Berg Balance Scale (BBS), and the Fall Efficacy Scale–International (FES-I) in patients after stroke. Methods: In this prospective cross-sectional study, we analyzed data for patients admitted to a rehabilitation unit after stroke from 2018 through 2021. Participants underwent SOT, BBS, and FES-I pre-discharge, and the fall incidence was recorded for 6 months. We used an area under the receiver operating characteristic curve (AUC) to calculate predictive values. Results: Of 84 included patients (median age 68.5 (interquartile range 67–71) years), 32 (38.1%) suffered a fall. All three tests were significantly predictive of fall risk. Optimal cut-off scores were 60 points for SOT (AUC 0.686), 35 and 42 points for BBS (AUC 0.661 and 0.618, respectively), and 27 and 29 points for FES-I (AUC 0.685 and 0.677, respectively). Conclusions: Optimal cut-off scores for SOT, BBS, and FES-I were determined for patients at risk for falls after a stroke, which all three tools classified with a good discriminatory ability.

Stroke Patients Showed Improvements in Balance in Response to Visual Restriction Exercise

OBJECTIVE

Several strategies have been designed to improve balance after stroke. Although recent studies have suggested that the balance training in stroke should include exercises that are performed in different sensory conflict conditions, little attention has been paid to manipulation of visual input. This study aimed to compare effects of balance training on an unstable surface with balance training under visual deprivation conditions in persons with stroke.

METHOD

Forty-five stroke patients were randomized into three groups: the visual deprivation- stable based training (VD-SBT); unstable based training (UBT); and control (C) groups. Subjects of the VD-SBT group performed balance training on a stable surface with closed eyes. The UBT group performed balance training on an unstable surface with open eyes. Patients were assessed before and after interventions for Timed Up and Go (TUG), Four Square Step (FSS) and Five Times Sit to Stand (FTSS) tests.

RESULT

There was a significant difference in pre- post intervention time of TUG, FSS and FTSS tests in all three groups. In a comparison of three groups, the UBT and VD-SBT groups had a significant improvement in time of all tests but significant improvement in time of all tests was observed in the VD-SBT group in comparison with the UBT group. In the field of balance training, the manipulation of visual input was more effective than the manipulation of standing surface to reweighting the sensory information.

CONCLUSION

We recommended balance rehabilitation programs after stroke performed under conditions to stimulate the use of underused sensory input.

The Effectiveness of Additional Core Stability Exercises in Improving Dynamic Sitting Balance, Gait and Functional Rehabilitation for Subacute Stroke Patients (CORE-Trial): Study Protocol for a Randomized Controlled Trial

Background: Trunk impairment produces disorders of motor control, balance and gait. Core stability exercises (CSE) are a good strategy to improve local strength of trunk, balance and gait. Methods and analysis: This is a single-blind multicenter randomized controlled trial. Two parallel groups are compared, and both perform the same type of therapy. A control group (CG) (n = 110) performs conventional physiotherapy (CP) (1 h per session) focused on improving balance. An experimental group (EG) (n = 110) performs CSE (30 min) in addition to CP (30 min) (1 h/session in total). EG is divided in two subgroups, in which only half of patients (n = 55) perform CSE plus transcutaneous electrical nerve stimulation (TENS). Primary outcome measures are dynamic sitting, assessed by a Spanish version of Trunk Impairment Scale and stepping, assessed by Brunel Balance Assessment. Secondary outcomes are postural control, assessed by Postural Assessment Scale for Stroke patients; standing balance and risk of fall assessed by Berg Balance Scale; gait speed by BTS G-Walk (accelerometer); rate of falls, lower-limb spasticity by Modified Ashworth Scale; activities of daily living by Barthel Index; and quality of life by EQ-5D-5L. These are evaluated at baseline (T0), at three weeks (T1), at five weeks (end of the intervention) (T2), at 17 weeks (T3) and at 29 weeks (T4). Study duration per patient is 29 weeks (a five-week intervention, followed by a 24-week post-intervention).

The Effects of Electrical Stimulation of Lower Extremity Muscles on Balance in Stroke Patients: A Systematic Review of Literatures

OBJECTIVE

Stroke is one of the main causes of disability and the second common cause of mortality in the world. Stroke causes relatively permanent motor defects, including balance disorder, and thus affects an individual's functional capacity and independence. Many clinical types of research have been conducted to evaluate the effect of functional electrical stimulation (FES) on balance in post-stroke patients. The objective of this study was to systematically review the effect of functional electrical stimulation (FES) on balance as compared to conventional therapy alone in post-stroke.

METHODS

The databases of Google Scholar, PubMed, Scopus, ScienceDirect and ProQuest were searched using selected keywords. The randomized controlled trials were searched for published original articles before February 2019 in English language and included if they assessed the effect of FES on balance ability compared to conventional therapy alone in adult post-stroke. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality.

RESULTS

Nine papers were included in this review (median PEDro scale =7/11). The total number of participants in this review study was 255. The age of participants ranged from 20 to 80 years. Stroke patients were in chronic phase (n = 5) and in subacute phase (n = 4). various parameters, including the target muscles, the treatment time per session (20 min-2 h), number of treatment sessions (12-48) and FES frequency (25-40 Hz), were assessed. Among the studies, significant between-group improvement favoring FES in combination with conventional therapy was found on the Berg Balance Scale (n = 7) and Timed Up and Go Scale (n = 4) when compared to conventional therapy alone. There was no adverse effect reported by any studies.

CONCLUSION

FES was reported to be more beneficial in balance improvement among stroke patients when combined with conventional balance therapy. The studies were limited by low-powered, small sample sizes ranging from 9 to 48, and lack of blinding, and reporting of missing data.

Effects of Virtual Reality-Based Therapy on Quality of Life of Patients with Subacute Stroke: A Three-Month Follow-Up Randomized Controlled Trial

Objective: To evaluate the influence of conventional rehabilitation combined with virtual reality on improving quality of life related to post-stroke health. Design: Randomized controlled trial. Setting: Rehabilitation and neurology departments of a general hospital (Talavera de la Reina, Spain). Subjects: A total of 43 participants with subacute stroke. Intervention: Participants were randomized into experimental group (conventional treatment + virtual reality) and control (conventional treatment). Main measures: Health-related quality of life as measured by the EuroQoL-5 dimensions instrument (EQ-5D-5L) and EuroQoL visual analog scale (EQ-VAS). Results: A total of 23 patients in the experimental group (62.6 ± 13.5 years) and 20 in the control (63.6 ± 12.2 years) completed the study. In the experimental group, EQ-VAS score was 29.1 ± 12.8 at baseline, 86.5 ± 7.1 post-intervention, and 78.3 ± 10.3 at the three-month follow-up. The control group obtained scores of 25.5 ± 5.1, 57.0 ± 4.7, and 58.5 ± 5.9, respectively. We identified significant differences at the post-intervention and follow-up timepoints (p = 0.000) and a partial η² of 0.647. In EQ-5D-5L, the severity of issues decreased after intervention in the experimental group, while pain and anxiety dimensions increased between post-intervention and follow-up. Conclusions: The conventional rehabilitative approach combined with virtual reality appears to be more effective for improving the perceived health-related quality of life in stroke survivors.

Sensory integration training improves balance in older individuals

With the massive growth of the aging population worldwide, of utmost importance is reducing falls. Critical to reducing fall risk is one's ability to weight incoming sensory information towards maintaining balance. The purpose of this research was to investigate if simple, targeted sensory training on aging individuals (50 - 80 years old), including twelve healthy and eight individuals with chronic stroke, could improve their balance. Repeated sensory training targeted visual (via eyesopen/closed) and somatosensory inputs (via light touch to the fingertip as well as hard, soft foam, and hard foam support surfaces to the feet) during standing and dynamic base-ofsupport (BOS) exercises. Study participants underwent six weeks of training. Prior to and post training, standing balance was assessed via a simple, clinical measure: the balance error scoring system (BESS). Following several weeks of training, participants showed significant improvements in BESS errors: healthy participants for small BOS with limited somatosensory information (i.e., tandem and single-leg standing on foam) and participants with stroke in all conditions.Clinical Relevance- This research study demonstrated that simple, accessible exercises, can positively impact balance in the aging population, a pressing need.

Slip-Fall Predictors in Community-Dwelling, Ambulatory Stroke Survivors: A Cross-sectional Study

BACKGROUND AND PURPOSE

Considering the multifactorial nature and the often-grave consequences of falls in people with chronic stroke (PwCS), determining measurements that best predict fall risk is essential for identifying those who are at high risk. We aimed to determine measures from the domains of the International Classification of Functioning, Disability and Health (ICF) that can predict laboratory-induced slip-related fall risk among PwCS.

METHODS

Fifty-six PwCS participated in the experiment in which they were subjected to an unannounced slip of the paretic leg while walking on an overground walkway. Prior to the slip, they were given a battery of tests to assess fall risk factors. Balance was assessed using performance-based tests and instrumented measures. Other fall risk factors assessed were severity of sensorimotor impairment, muscle strength, physical activity level, and psychosocial factors. Logistic regression analysis was performed for all variables. The accuracy of each measure was examined based on its sensitivity and specificity for fall risk prediction.

RESULTS

Of the 56 participants, 24 (43%) fell upon slipping while 32 (57%) recovered their balance. The multivariate logistic regression analysis model identified dynamic gait stability, hip extensor strength, and the Timed Up and Go (TUG) score as significant laboratory-induced slip-fall predictors with a combined sensitivity of 75%, a specificity of 79.2%, and an overall accuracy of 77.3%.

DISCUSSION AND CONCLUSIONS

The results indicate that fall risk measures within the ICF domains-body, structure, and function (dynamic gait stability and hip extensor strength) and activity limitation (TUG)-could provide a sensitive laboratory-induced slip-fall prediction model in PwCS.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A323).

Standing Balance Strategies and Dual-Task Interference Are Differentially Modulated Across Various Sensory Contexts and Cognitive Tests in Individuals With Chronic Stroke

BACKGROUND AND PURPOSE

Mental tracking and verbal fluency tests have been linked to poor mobility and falls; however, no studies have examined the influence of imposing these tests on standing balance post-stroke. The purpose of this study was to investigate standing balance and cognitive performance across sensory conditions and cognitive tests post-stroke.

METHODS

Ninety-two participants with chronic stroke stood on dual-force platforms while performing various sensory conditions (eyes open/fixed surface, eyes closed/fixed surface, eyes open/sway-referenced surface, and eyes closed/sway-referenced surface) and cognitive tests (no cognitive test, serial subtractions, and verbal fluency). Equilibrium scores were computed based on the anterior-posterior sway angle. The number of correct verbal responses was recorded.

RESULTS

Performing serial subtractions during eyes closed/sway-referenced surface revealed the highest equilibrium score (64.0 ± 13.5), followed by the same sensory condition with added verbal fluency test (59.6 ± 15.1), followed by the single-task condition with no cognitive test (52.6 ± 20.9). The number of correct serial subtractions between seated (7.7 ± 3.7) and standing (7.2 ± 3.5) conditions was similar. A trend for more correct verbal fluency responses emerged when seated (8.1 ± 2.9) than the eyes open/sway-referenced surface condition (7.5 ± 2.8). Greater correct verbal fluency responses emerged when seated (8.6 ± 3.1) than the eyes closed/sway-referenced surface condition (7.8 ± 2.7).

DISCUSSION AND CONCLUSIONS

Standing balance enhancement (higher equilibrium score/better balance) depends on the neuropsychological process targeted and the sensory input available post-stroke. Cognitive dual-task interference emerged for the verbal fluency test during the most attention demanding sensory condition. Cognitive tests that enhance standing balance should be considered in assessments and interventions to evaluate and improve dual-tasking post-stroke.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A321).

Influence of back support shape in wheelchairs offering pelvic support on asymmetrical sitting posture and pressure points during reaching tasks in stroke patients

Many poststroke hemiplegic patients have an asymmetrical wheelchair-sitting posture. This study aimed to investigate the impact of different back support shapes on asymmetrical sitting posture and pressure points among poststroke hemiplegic patients during an activities of daily living–related reaching task. This study included 23 poststroke hemiplegic patients who performed tasks that involved the movement of objects using the unaffected upper limb to the affected side while sitting in a conventional wheelchair (C-WC) with a flat back support or a wheelchair providing pelvic and thoracic support (P-WC). Body alignment angles from video images and pressure distribution on supporting surfaces were measured using a two-dimensional motion analysis software (Dartfish) and a pressure mapping system (FSA). Regarding movement performance, although postural asymmetry increased in both wheelchair types, the degree of postural variation was smaller with P-WC use than C-WC use (p < 0.05), with partly reduced postural asymmetry. With P-WC, one-sided ischial asymmetrical pressure was significantly less after the movement (p < 0.05). In conclusion, P-WC’s back support shape contributed to a decrease in postural asymmetry for pelvic girdle support both at rest and during movement. This highlights the importance of a wheelchair back support shape and may help to increase the quality of activities of daily living movement in poststroke hemiplegic patients in wheelchairs.

Effects of Video-Game Based Therapy on Balance, Postural Control, Functionality, and Quality of Life of Patients with Subacute Stroke: A Randomized Controlled Trial

Purpose

To determine the effects of a structured protocol using commercial video games on balance, postural control, functionality, quality of life, and level of motivation in patients with subacute stroke.

Methods

A randomized controlled trial was conducted. A control group (n = 25) received eight weeks of conventional rehabilitation consisting of five weekly sessions based on an approach for task-oriented motor training. The experimental group (n = 25) received eight weeks of conventional rehabilitation consisting of five weekly sessions based on an approach for task-oriented motor training. The experimental group (

Results

In the between-group comparison, statistically significant differences were observed in the Modified Rankin scores (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (

Conclusion

A protocol of semi-immersive video-game based therapy, combined with conventional therapy, may be effective for improving balance, functionality, quality of life, and motivation in patients with subacute stroke. This trial is registered with NCT03528395.

Evaluation of Postural Stability and Transverse Abdominal Muscle Activity in Overweight Post-Stroke Patients: A Prospective, Observational Study

PURPOSE

Post-stroke hemiparesis has a significant impact on postural stability. The transversus abdominis (TrA) muscle contributes to the stability of the spine. The aim was to assess both the postural stability and the activity of the TrA muscle in overweight post-stroke patients.

METHODS

A group of 56 participants (61.12 ± 11.5 years) was divided into the study group (n=28 post-stroke patients, 63.7 ± 10.9 years) and control group (n= 23 healthy participants (58.5 ± 12.2 years). The Berg Balance Scale (BBS) and the Timed Up and Go Test (TUG) were used to evaluate postural stability and risk of falls. The Pressure Bio-Feedback Stabilizer (PBFS) device was used to assess functional stability.

RESULTS

Stroke had a significantly negative effect on the BBS (p < 0.001) and TUG (p = 0.001). The older age negatively affected the BBS (p = 0.001), TUG (p = 0.017), and the TrA muscle activity (p = 0.017). Higher values of body mass index (BMI) negatively affected the BBS (p = 0.028), however there were no changes of TUG results (p = 0.141), and the TrA muscle activity (p = 0.808). Also, BBS and TUG results were not associated with TrA muscle activity (p = 0.541 and p = 0.411, respectively). The results of the BBS, TUG, and PBFS did not differ according to gender (p < 0.05). Time from stroke negatively affected the TUG (p = 0.001), but had no effect on the TrA muscle activity (p < 0.05). The side of hemiparesis did not affect the postural stability (p < 0.05).

CONCLUSION

The consequences of a stroke have an essential negative effect on postural stability. Factors such as age, gender, time from stroke, and the side of the hemiparesis have not negatively affected postural stability in overweight post-stroke patients.

Effects of diagonally aligned sitting training with a tilted surface on sitting balance for low sitting performance in the early phase after stroke: a randomised controlled trial

PURPOSE

To clarify the effects of diagonally aligned sitting training using a tilted surface on sitting balance for patients with low sitting performance in the early phase after stroke.

MATERIALS AND METHODS

This was an assessor-blinded randomised controlled trial. The experimental group used a surface tilted 10° backward and down toward the most affected side; the control group trained on a horizontal surface. Both groups were asked to move their trunk diagonally forward toward the least affected side. Participants performed the activity 40 times/session for seven sessions over 8 days. Sitting performances were assessed using the function in sitting test (FIST), subjective postural vertical (SPV) on the diagonal plane, and trunk impairment scale (TIS).

RESULTS

Thirty-three stroke patients were randomly allocated into two groups. Treatment effects differed significantly: mean differences between groups for FIST (total score, static, dynamic, scooting, and reactive) were 8.96, 2.35, 3.01, 1.27, and 1.72 points, for the mean SPV value was 1.82°, and for the TIS (total score and static) were 1.87 and 1.58 points, respectively. These results were more favourable in the experimental group.

CONCLUSIONS

Diagonally aligned sitting training on a tilted surface improves sitting balance and modulates the SPV compared with a horizontal surface.

Standing postural stability during galvanic vestibular stimulation is associated with the motor function of the hemiplegic lower extremity post-stroke

Background: The vestibular system is profoundly involved in standing postural stability. Patients with post-stroke hemiparesis have poor postural control function; nevertheless, it is unclear as to how the vestibular system affects postural control after stroke.Objectives: The purpose of this study was to quantitatively evaluate the relationship between galvanic whole-body sway responses and motor function of the hemiplegic lower extremity post-stroke.Methods: Thirty stroke patients and 49 healthy controls underwent standing body sway tests to examine postural control function during vestibular stimulation. Postural stabilization was measured using a C7-mounted accelerometer during galvanic vestibular stimulation. Postural stability was assessed during stimulation while quietly standing with eyes closed. For the stroke group, lower extremity function was measured using the Fugl-Meyer Assessment scale (FMA-LE).Results: The standing body sway test scores during stimulation were lower in the stroke group than the control group (p = .010). In the stroke group, correlation analysis demonstrated that the standing body sway response score was significantly associated with the FMA-LE (r = 0.374, p = .021).Conclusions: Motor dysfunction directly causes standing postural instability during vestibular stimulation, even though sensory information suggests normal peripheral vestibular function. Therefore, motor dysfunction of the hemiplegic lower extremity might lead to inhibition of normal standing postural stability.

Clinical application of backward walking training to improve walking function, balance, and fall-risk in acute stroke: a case series

Background: With limited inpatient rehabilitation (IR) length of stays for patients post-stroke, it is critical to maximize the effectiveness of interventions to address their balance and gait speed deficits. Backward walking (BW) is an emerging training approach; however, its application to patient populations consistent with those in IR is limited. Objectives: To describe the effects of an additional BW training program to standard IR care on balance, walking ability and fall-risk in a heterogenic caseload of adults <2 weeks post-stroke with a broad range of lesion locations and physical sequelae. Methods: Eight patients with first-time stroke (5 male; average age 66.5 ± 11.7 years; average stroke onset 7.6 ± 1.6 days; 6 right hemiparesis) participated in 10-daily sessions that included 20 min of over ground BW training for each session, in addition to standard IR. Standard outcome measures were used to assess balance, walking ability and fall-risk at admission and post-intervention. Results: All eight patients demonstrated improvements in all outcomes with a clinically meaningful increase in forward walking speed, as measured by 10MWT. Four participants exceeded fall-risk cut-off scores for all balance-related outcome measures. Conclusions: In a diverse patient population early after stroke, individuals successfully participated in an additional BW training program. Despite the patients' acuity and severe impairments in walking, significant gains in balance and walking function were noted. This program may be useful in improving outcomes with patient characteristics commonly seen in IR.

Lower Extremity Position Test: A new clinical quantitative assessment tool of proprioception post stroke

OBJECTIVE

To develop a quantitative, inexpensive and easy to use tool, for assessing proprioception of the lower extremity of individuals post-stroke, and examine its test-retest reliability and known-groups validity.

METHODS

The Lower Extremity Position Test was developed. Testing procedure: seated subjects were asked to reproduce 12 cm or 22 cm distances on a plastic surface, by verbally stopping passive movement of the foot produced by the tester. The deviation from the target point was measured as the mismatch score. Fifty one subjects post-stroke (n = 51) participated in prospective test-retest assessment. The tests were performed one week apart by a single assessor, in physical therapy out-patient clinics. The t-test, ICC and Bland-Altman tests were used to determine known-groups validity by determining leg differences and test-retest reliability.

RESULTS

Post-stroke involved foot demonstrated significantly higher mismatch scores then the uninvolved foot did (p < 0.0001). Good test-retest reliability was demonstrated for the involved leg for both 12 cm and 22 cm distances (ICC = 0.79 and 0.85, respectively). The 95% repeatability ranges were leg related.

CONCLUSIONS

The Lower Extremity Position Test (LEPT) is a newly-developed testing tool with good clinical utility, reliable in post-stroke population and has known-group validity (involved versus uninvolved foot).

Centre of pressure displacements produced in sitting during virtual reality training in younger and older adults and patients who have had a stroke

Purpose: Poor sitting balance is common after stroke and makes leaning and reaching while sitting difficult and dangerous. Virtual reality training (VRT) uses computer hardware and software to track a person's movements and allow him or her to interact with a virtual environment. VRT games are available to train sitting balance after stroke; however, it is unknown how challenging they are. The objectives of this study were to characterize the centre of pressure displacements generated during the performance of VRT in stroke patients (ST) and compare their performance to that of young (YA) and older adults (OA).Materials and Methods: Eight ST participants who could stand for at least four minutes were recruited from an inpatient stroke rehabilitation unit for this cross-sectional, observational pilot study. Eight YA and eight OA were recruited from the community. Participants sat on a pressure mat and played 17 VRT game/difficulty combinations. The area, range and average velocity of centre of pressure displacement were determined for each game/difficulty.Results: Virtually manoeuvring a motorcycle around barriers and leaning to move a ball down a maze produced the greatest displacement of the centre of pressure, particularly in the mediolateral direction. OA moved further and faster in the mediolateral direction than YA. ST's performance was more variable.Conclusions: Some VRT games were more likely to push participants to challenge their limits of stability. Others required less displacement but more trunk stability. These results can guide which VRT games are used for the rehabilitation of sitting balance after stroke.Implications for rehabilitationSome virtual reality training games produce greater displacements of the centre of pressure in sitting than others, suggesting that careful matching between game challenge and desired therapeutic outcome is necessary when selecting games.Virtual reality training performed in sitting with feet on the floor challenges sitting balance in the frontal plane more so than in the sagittal plane.Older adults tend to lean more than younger adults while individuals with stroke move more or less than others, depending on the game.

Impairments in Multisensory Integration after Stroke

The integration of information from multiple senses leads to a plethora of behavioral benefits, most predominantly to faster and better detection, localization, and identification of events in the environment. Although previous studies of multisensory integration (MSI) in humans have provided insights into the neural underpinnings of MSI, studies of MSI at a behavioral level in individuals with brain damage are scarce. Here, a well-known psychophysical paradigm (the redundant target paradigm) was employed to quantify MSI in a group of stroke patients. The relation between MSI and lesion location was analyzed using lesion subtraction analysis. Twenty-one patients with ischemic infarctions and 14 healthy control participants responded to auditory, visual, and audiovisual targets in the left and right visual hemifield. Responses to audiovisual targets were faster than to unisensory targets. This could be due to MSI or statistical facilitation. Comparing the audiovisual RTs to the winner of a race between unisensory signals allowed us to determine whether participants could integrate auditory and visual information. The results indicated that (1) 33% of the patients showed an impairment in MSI; (2) patients with MSI impairment had left hemisphere and brainstem/cerebellar lesions; and (3) the left caudate, left pallidum, left putamen, left thalamus, left insula, left postcentral and precentral gyrus, left central opercular cortex, left amygdala, and left OFC were more often damaged in patients with MSI impairments. These results are the first to demonstrate the impact of brain damage on MSI in stroke patients using a well-established psychophysical paradigm.

Time-course investigation of postural sway variability: Does anxiety exacerbate the sensory reweighting impairment in chronic stroke survivors?

Although anxiety is one of the most prevalent psychological disorders in stroke survivors, its effect on sensory reweighting has not yet been fully studied. The aim of this work was to investigate how anticipation of collision avoidance events affects sensory reweighting in chronic stroke survivors with low and high levels of anxiety (LA-stroke and HA-stroke, respectively), as compared with healthy controls (HC), under the condition of perturbed proprioception. Eighteen LA-stroke and 18 HA-stroke survivors, as well as 18 gender- and age-matched HC, participated in this study. Postural sway variability (i.e. Root Mean Square (RMS) of the COP velocity) was measured for a duration of 180 s under two conditions: quiet standing and standing while predicting random virtual spheres to be avoided. Proprioceptive perturbation was simulated using bilateral Achilles tendon vibration at mid duration (60 s) for both conditions. The results showed that the HC were able to timely use visual anticipation to reduce the postural sway variability induced by tendon vibration. However, marked delay in using such anticipation was observed in stroke participants, especially in the HA-stroke group, as indicated by a significant decrease in the RMS of the COP velocity late in the vibration phase. This is the first study to consider the effect of anxiety while comparing sensory reweighting between stroke and healthy participants. The results indicated that chronic stroke survivors, particularly those with HA, could not efficiently use sensory reweighting to maintain balance in sensory conflicting conditions, which may subject them to loosing balance and/or falling. These findings are critical for future assessment and planning of rehabilitation interventions and balance in chronic stroke survivors.

Right in Comparison to Left Cerebral Hemisphere Damage by Stroke Induces Poorer Muscular Responses to Stance Perturbation Regardless of Visual Information

OBJECTIVE

Fast and scaled muscular activation is required to recover body balance following an external perturbation. An issue open to investigation is the extent to which the cerebral hemisphere lesioned by stroke leads to asymmetric deficits in postural reactive responses. In this experiment, we aimed to compare muscular responses to unanticipated stance perturbations between individuals who suffered unilateral stroke either to the right or to the left cerebral hemisphere.

METHODS

Stance perturbations were produced by releasing a load attached to the participant's trunk, inducing fast forward body oscillation. Electromyography was recorded from the gastrocnemius medialis and biceps femoris muscles. Muscular activation from age-matched healthy individuals was taken as reference.

RESULTS

Analysis indicated that damage to the right hemisphere induced delayed activation onset, and lower rate and magnitude of activation of the proximal and distal muscles of the paretic leg. Those deficits were associated with stronger activation of the nonparetic leg. Comparisons between left hemisphere damage and controls showed deficits limited to activation of the biceps femoris of the paretic leg. Manipulation of visual information led to no significant effects on muscular responses.

CONCLUSIONS

These results suggest that right cerebral hemisphere damage by stroke leads to more severe deficits in the generation of reactive muscular responses to stance perturbation than damage to the left cerebral hemisphere regardless of visual information.

Effects of Tai Chi Yunshou exercise on community-based stroke patients: a cluster randomized controlled trial

Backgroud

Tai Chi Chuan was used for stroke survivors with balance impairments. However, even a short-form of Tai Chi Chuan includes forms that make the exercise challenging for the stroke survivors. Tai Chi Yunshou (wave hands in the cloud) is the “mother” form and the fundamental form of all Tai Chi Chuan styles, which is considered more suitable and feasible for stroke survivors with balance impairments. So this study was designed to evaluate the effects of Tai Chi Yunshou exercise on community-based stroke patients with balance dysfunctions.

Methods

A total of 250 participants from 10 community health centers (5 per arm) were selected and randomly allocated into Tai Chi Yunshou exercise group (TC group) or a balance rehabilitation training group (control group) in an equal ratio. Participants in the TC group were received Tai Chi Yunshou exercise training five times per week for 12 weeks and those in control group were received balance rehabilitation training five times per week for 12 weeks. Outcome assessments including Berg Balance Scale (BBS), Time up to go test (TUGT), Modified Barthel Index (MBI) were measured at baseline, 4 weeks, 8 weeks, 12 weeks and followed-up 6 weeks (18 weeks), 12 weeks (24 weeks). Intention-to-treat analysis was performed. Analysis of variance of repeated measures was used to assess between-group differences.

Results

A total of 244 participants, 120 in the TC group and 124 in the rehabilitation group, were included in final analysis. There was no siginificant difference in Tai Chi Yunshou and balance rehabilitation training on the improvement of balance ability and mobility (P = 0.531 and P = 0.839, respectively) after adjustment for baseline. However, there was significant difference between two groups on improvement of motor funtion (P = 0.022), fear of falling (P < 0.001) and depression (P = 0.035) for the post stroke patients. No adverse events were reported during the study.

Conclusion

Tai Chi Yunshou and balance rehabilitation training led to improved balance ability and functional mobility, and both are suitable community-based programs that may benefit for stroke recovery and community reintegration. Our data demonstrated that a 12-week Tai Chi Yunshou intervention was more effective in motor function, fear of falling and depression than balance rehabilitation training. Future studies examining the effectiveness of Tai Chi Yunahou as a balance ability improvement strategy for community-dwelling survivors of stroke are recommended.

Trial registration

Chinese Clinical Trail Registry: ChiCRT-TRC-13003641. Registration date: 22 August, 2013.

Learning Effects and the Sensory Organization Test: Influence of a Unilateral Peripheral Vestibular Impairment

PURPOSE

Healthy young controls exhibit a learning effect after undergoing repeated administrations of the sensory organization test (SOT). The primary objective of the present experiment was to determine if an SOT learning effect is present in individuals with a unilateral vestibular impairment (UVI), and if so, whether it is different from healthy controls. The secondary objective was to determine if the learning effect is dependent on the time frame of repeated SOT assessments.

METHOD

Eleven individuals diagnosed with a UVI and 11 controls underwent 6 repetitions of the SOT over 2 visits (3 per visit all within 1 week). A second control group underwent 3 SOT repetitions, with each repetition separated by 1 week, to evaluate the time course of the SOT learning effect.

RESULTS

No statistically significant differences were found between the UVI group and the control group. In addition, the magnitude of the learning effect was found to be similar regardless of the length of time that separated the repetitions.

CONCLUSIONS

If the SOT is to be used as a measure of improvement, the learning effect should be exhausted (which typically occurs following the third administration) prior to the introduction of therapy. Future research should further investigate the results from those with other vestibular pathologies.

Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial

OBJECTIVE

To determine the effects of inclusion of deep dry needling into a treatment session following the Bobath concept on spasticity, motor function and postural control after a stroke.

METHODS

26 patients who had suffered a stroke were randomly assigned to one of two treatment groups: Bobath only, or Bobath plus dry needling. Both groups received a session including strengthening, stretching and reconditioning exercises following the principles of the Bobath concept. Patients in the Bobath plus dry needling group also received a single session of ultrasound-guided dry needling of the tibialis posterior. Spasticity (Modified Modified Ashworth Scale), function (Fugl-Meyer Scale) and stability limits (computerised dynamic posturography using the SMART EquiTest System) were collected before and 10 min after treatment by a blinded assessor. The parameters of the stability limits included movement velocity (MVL), maximum excursion (MXE), end-point excursion (EPE) and directional control (DCL).

RESULTS

A greater number of individuals receiving Bobath plus dry needling exhibited a decrease in spasticity after treatment (P<0.001). Analysis of covariance (ANCOVA) showed that patients receiving Bobath plus dry needling exhibited greater improvements in the balance (0.8, 95% CI 0.2 to 1.4), sensory (1.7, 95% CI 0.7 to 2.7) and range of motion (3.2, 95% CI 2.0 to 4.4) domains of the Fugl-Meyer Scale than those receiving Bobath only. ANCOVA also found that subjects receiving dry needling showed a greater increase in MVL non-affected forward direction, EPE non-affected direction, MXE backward and MXE affected/non-affected, DCL backward and DCL affected backward direction, than those who did not receive it.

CONCLUSIONS

The inclusion of deep dry needling into a treatment session following the Bobath concept was effective at decreasing spasticity and improving balance, range of motion and the accuracy of maintaining stability in patients who had experienced a stroke.

TRIAL REGISTRATION NUMBER

NCT02579291.

Effects of Excitatory Repetitive Transcranial Magnetic Stimulation of the P3 Point in Chronic Stroke Patients—Case Reports

Objective: To evaluate the effects of excitatory repetitive transcranial magnetic stimulation (rTMS) of the international 10–20 system P3 point (intraparietal sulcus region) in chronic patients with a frontal lesion and parietal sparing due to stroke on the impaired upper (UL) and lower limb (LL) as measured by the Fugl-Meyer Assessment (FMA). Methods: Three patients (C1: 49.83/2.75, C2: 53.17/3.83, C3: 63.33/3.08-years-old at stroke/years post-stroke, respectively) received two weeks (five days/week) of rTMS at 10 Hz of P3. A patient was treated in similar conditions with a sham coil (S1: 56.58/4.33). Patients were evaluated before, after, and two months post-treatment (A1, A2, and A3, respectively). Results: For LL, the scores of the motor function subsection of C1 and C3 as well as the sensory function of C2 increased by A2 and remained by A3. For UL, the score of the motor function of C2 and C3 also increased, but the score of C3 decreased by A3. The score of the range of motion subsection of C3 increased by the two follow-up evaluations. Conclusion: This study suggests excitatory rTMS over P3 may be of use for some chronic stroke patients, but these findings need to be verified in a future clinical trial.

A Backward Walking Training Program to Improve Balance and Mobility in Acute Stroke: A Pilot Randomized Controlled Trial

BACKGROUND AND PURPOSE

Strategies to address gait and balance deficits early poststroke are minimal. The postural and motor control requirements of Backward Walking Training (BWT) may provide benefits to improve balance and walking speed in this population. This pilot study (1) determined the feasibility of administering BWT during inpatient rehabilitation and (2) compared the effectiveness of BWT to Standing Balance Training (SBT) on walking speed, balance, and balance-related efficacy in acute stroke.

METHODS

Eighteen individuals 1-week poststroke were randomized to eight, 30-minute sessions of BWT or SBT in addition to scheduled therapy. Five-Meter Walk Test, 3-Meter Backward Walk Test, Activities-Specific Balance Confidence Scale, Berg Balance Scale, Sensory Organization Test, and Function Independence Measure-Mobility were assessed pre- and postintervention and at 3 months poststroke.

RESULTS

Forward gait speed change (BWT: 0.75 m/s; SBT: 0.41 m/s), assessed by the 5-Meter Walk Test, and backward gait speed change (BWT: 0.53 m/s; SBT: 0.23 m/s), assessed by the 3-Meter Backward Walk Test, preintervention to 1-month retention were greater for BWT than for SBT (P < 0.05). Group difference effect size from preintervention to 1-month retention was large for Activities-Specific Balance Confidence Scale, moderate for Berg Balance Scale and Function Independence Measure-Mobility, and small for Sensory Organization Test.

DISCUSSION AND CONCLUSIONS

Individuals 1-week poststroke tolerated 30 min/d of additional therapy. At 1-month postintervention, BWT resulted in greater improvements in both forward and backward walking speed than SBT. Backward walking training is a feasible important addition to acute stroke rehabilitation. Future areas of inquiry should examine BWT as a preventative modality for future fall incidence.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A193).

A wearable vibrotactile biofeedback system improves balance control of healthy young adults following perturbations from quiet stance

Maintaining postural equilibrium requires fast reactions and constant adjustments of the center of mass (CoM) position to prevent falls, especially when there is a sudden perturbation of the support surface. During this study, a newly developed wearable feedback system provided immediate vibrotactile clues to users based on plantar force measurement, in an attempt to reduce reaction time and CoM displacement in response to a perturbation of the floor. Ten healthy young adults participated in this study. They stood on a support surface, which suddenly moved in one of four horizontal directions (forward, backward, left and right), with the biofeedback system turned on or off. The testing sequence of the four perturbation directions and the two system conditions (turned on or off) was randomized. The resulting reaction time and CoM displacement were analysed. Results showed that the vibrotactile feedback system significantly improved balance control during translational perturbations. The positive results of this preliminary study highlight the potential of a plantar force measurement based biofeedback system in improving balance under perturbations of the support surface. Future system optimizations could facilitate its application in fall prevention in real life conditions, such as standing in buses or trains that suddenly decelerate or accelerate.

Validation and reliability of the Spanish version of the Function in Sitting Test (S-FIST) to assess sitting balance in subacute post-stroke adult patients

BACKGROUND

Function in Sitting Test (FIST) is a clinical functional assessment of sitting balance validated in adults with stroke. For a major use of this, the test is recommended to be translated in Spanish-speaking countries.

OBJECTIVES

Translate to Spanish the FIST and determine its intra-rater and inter-rater reliabilities and concurrent validity as a measure of sitting balance in adult individuals with stroke.

METHODS

The original version was translated into Spanish and was agreed by a team of experts. A back-translation into English was subsequently performed and sent to the original author, who approved this version named from now Spanish version of Function in Sitting Test (S-FIST). Sixty post-stroke patients' performance was recorded on a videotape. These videos were then used to carry out four measurements to assess the intra-rater and inter-rater reliabilities; two of these were performed by the same rater and the third and fourth by a second and third rater.

RESULTS

The S-FIST meets the following requirements: good construct validity and high correlation with Spanish version of Trunk Impairment Scale 2.0 (S-TIS 2.0) scores (r = 0.791) Spearman's rank, high internal consistency (Cronbach's α-coefficient = 0.97), and high intra-rater and inter-rater reliabilities for the summed scores assessed by intra-class correlation coefficient were 0.999 and 0.997, respectively.

CONCLUSIONS

The S-FIST is valid and reliable and can be recommended for use in the evaluation of dynamic and sitting balance and trunk control in future research and clinical practice on post-stroke patients. Guidelines for treatment and level of quality of trunk activity can be derived from its use.

Treatment of Spinocerebellar Ataxia With Mesenchymal Stem Cells: A Phase I/IIa Clinical Study

Ataxia is one of the most devastating symptoms of many neurodegenerative disorders. As of today, there is not any effective treatment to retard its progression. Mesenchymal stem cells (MSCs) have shown promise in treating neurodegenerative diseases. We hereby report the results of a phase I/IIa clinical study conducted in Taiwan to primarily evaluate the safety, tolerability, and, secondarily, the possible efficacy of intravenous administration of allogeneic adipose tissue-derived MSCs from healthy donors. Six patients with spinocerebellar ataxia type 3 and one with multiple system atrophy-cerebellar type were included in this open-label study with intravenous administration of 106 cells/kg body weight. The subjects were closely monitored for 1 year for safety (vital signs, complete blood counts, serum biochemical profiles, and urinalysis) and possible efficacy (scale for assessment and rating of ataxia and sensory organization testing scores, metabolite ratios on the brain magnetic resonance spectroscopy, and brain glucose metabolism of 18-fluorodeoxyglucose using positron emission tomography). No adverse events related to the injection of MSCs during the 1-year follow-up were observed. The intravenous administration of allogeneic MSCs seemed well tolerated. Upon study completion, all patients wished to continue treatment with the allogeneic MSCs. We conclude that allogeneic MSCs given by intravenous injection seems to be safe and tolerable in patients with spinocerebellar ataxia type 3, thus supporting advancement of the clinical development of allogeneic MSCs for the treatment of spinocerebellar ataxias (SCAs) in a randomized, double-blind, placebo-controlled phase II trials.

Balance evaluation techniques and physical therapy in post-stroke patients: A literature review

A stroke (cerebrovascular accident - CVA) is a significant social-economic issue. Approximately 15-30% of all patients develop life-long disability, 20% require over 3 months of specialized care in healthcare institutions, and the majority of the patients never recover the ability to maintain a proper vertical position. Such CVA sequelae as balance disturbances not only negatively affect patients' daily physical activity, but also result in social isolation. A number of standardized clinical scales, tests, and instrumental examination techniques have been proposed for evaluating not only post-CVA balance function, but also any changes in this function following various interventions. Even though scientific literature lists numerous methods and instruments for the improvement of balance after a CVA, not all of them are equally effective, and there have been rather controversial evaluations of some techniques. Nevertheless, the application of the majority of the techniques as complementary or alternative measures to traditional physical therapy (PT) frequently yields better results.

Impact of sensory integration training on balance among stroke patients: sensory integration training on balance among stroke patients

This study attempts to investigate the impact that the sensory integration training has on the recovery of balance among patients with stroke by examining the muscle activity and limit of stability (LOS). A total of 28 subjects participated. The subjects were randomly allocated by the computer program to one of two groups: control (CON) group (n=15), sensory integration training (SIT) group (n=13). The research subjects received intervention five days a week for a total of four weeks. The CON group additionally received 30-minute general balance training, while the SIT group additionally received 30-minute sensory integration training. In the muscle activity, the improvement of Erector spinae (ES) and Gluteus medius (GM) was more significant in the SIT group than in the CON group. In the LOS, the improvement of affected side and forward side was significantly higher in the SIT group compared to the CON group. Sensory integration training can improve balance ability of patients with stroke by increasing muscle activity of stance limb muscles such as GM and trunk extensor such as ES along with enhancement of the limit of stability.

Comparison of upright balance in stroke, Parkinson and multiple sclerosis

OBJECTIVE

Multiple sclerosis (MS), Parkinson's disease (PD) and stroke (ST) subjects show balance impairments due to damage of the balance control system. The objective of the study was to assess the impact of MS, PD and ST on upright posture in eyes open condition and when visual and/or proprioceptive inputs are altered.

MATERIALS AND METHODS

A total of 188 subjects with MS (n = 80), PD (n = 58) and ST (n = 50), mean age (SD), 57.9 (14.6) years, and 32 healthy subjects (HS) aged 53.7 (15.7) years were assessed by a stabilometric platform in a cross-sectional study.

RESULTS

Compared to HS, MS showed large deviations from normal performances with respect to magnitude (P < 0.001) and regularity (P < 0.05) of body sway irrespective of the altered sensory information. Similarly to MS, PD showed large and abnormal levels of body sway (P < 0.001) and postural tremor (P < 0.05), while ST was the least impaired except for an asymmetrical distribution of body weight between legs (P < 0.001). Finally, the MS group compared to PD and ST showed the largest body instability after eye closure (P < 0.05) and when visual and proprioceptive inputs were removed (P < 0.05). PD showed instability mainly after the alteration of proprioceptive inputs (P < 0.05), while ST showed the smallest increase of body instability when sensory inputs were reduced.

DISCUSSION

Objective assessment revealed pathology-specific balance disorders and showed the differential impact of MS, PD and ST on the ability to use sensory information for balance control.

Verticality Perceptions Associate with Postural Control and Functionality in Stroke Patients

Deficits of postural control and perceptions of verticality are disabling problems observed in stroke patients that have been recently correlated to each other. However, there is no evidence in the literature confirming this relationship with quantitative posturography analysis. Therefore, the objectives of the present study were to analyze the relationship between Subjective Postural Vertical (SPV) and Haptic Vertical (HV) with posturography and functionality in stroke patients. We included 45 stroke patients. The study protocol was composed by clinical interview, evaluation of SPV and HV in roll and pitch planes and posturography. Posturography was measured in the sitting and standing positions under the conditions: eyes open, stable surface (EOSS); eyes closed, stable surface (ECSS); eyes open, unstable surface (EOUS); and eyes closed, unstable surface (ECUS). The median PV in roll plane was 0.34° (-1.44° to 2.54°) and in pitch plane 0.36° (-2.72° to 2.45°). The median of HV in roll and pitch planes were -0.94° (-5.86° to 3.84°) and 3.56° (-0.68° to 8.36°), respectively. SPV in the roll plane was correlated with all posturagraphy parameters in sitting position in all conditions (r = 0.35 to 0.47; p < 0.006). There were moderate correlations with the verticality perceptions and all the functional scales. Linear regression model showed association between speed and SPV in the roll plane in the condition EOSS (R2 of 0.37; p = 0.005), in the condition ECSS (R2 of 0.13; p = 0.04) and in the condition EOUS (R2 of 0.22; p = 0.03). These results suggest that verticality perception is a relevant component of postural control and should be systematically evaluated, particularly in patients with abnormal postural control.

Optic flow improves adaptability of spatiotemporal characteristics during split-belt locomotor adaptation with tactile stimulation

Human locomotor adaptation requires feedback and feed-forward control processes to maintain an appropriate walking pattern. Adaptation may require the use of visual and proprioceptive input to decode altered movement dynamics and generate an appropriate response. After a person transfers from an extreme sensory environment and back, as astronauts do when they return from spaceflight, the prolonged period required for re-adaptation can pose a significant burden. In our previous paper, we showed that plantar tactile vibration during a split-belt adaptation task did not interfere with the treadmill adaptation however, larger overground transfer effects with a slower decay resulted. Such effects, in the absence of visual feedback (of motion) and perturbation of tactile feedback, are believed to be due to a higher proprioceptive gain because, in the absence of relevant external dynamic cues such as optic flow, reliance on body-based cues is enhanced during gait tasks through multisensory integration. In this study, we therefore investigated the effect of optic flow on tactile-stimulated split-belt adaptation as a paradigm to facilitate the sensorimotor adaptation process. Twenty healthy young adults, separated into two matched groups, participated in the study. All participants performed an overground walking trial followed by a split-belt treadmill adaptation protocol. The tactile group (TC) received vibratory plantar tactile stimulation only, whereas the virtual reality and tactile group (VRT) received an additional concurrent visual stimulation: a moving virtual corridor, inducing perceived self-motion. A post-treadmill overground trial was performed to determine adaptation transfer. Interlimb coordination of spatiotemporal and kinetic variables was quantified using symmetry indices and analyzed using repeated-measures ANOVA. Marked changes of step length characteristics were observed in both groups during split-belt adaptation. Stance and swing time symmetries were similar in the two groups, suggesting that temporal parameters are not modified by optic flow. However, whereas the TC group displayed significant stance time asymmetries during the post-treadmill session, such aftereffects were absent in the VRT group. The results indicated that the enhanced transfer resulting from exposure to plantar cutaneous vibration during adaptation was alleviated by optic flow information. The presence of visual self-motion information may have reduced proprioceptive gain during learning. Thus, during overground walking, the learned proprioceptive split-belt pattern is more rapidly overridden by visual input due to its increased relative gain. The results suggest that when visual stimulation is provided during adaptive training, the system acquires the novel movement dynamics while maintaining the ability to flexibly adapt to different environments.

The effect of additional core stability exercises on improving dynamic sitting balance and trunk control for subacute stroke patients: a randomized controlled trial

OBJECTIVE

To examine the effect of core stability exercises on trunk control, dynamic sitting and standing balance, gait, and activities of daily living in subacute stroke patients.

DESIGN

A randomized controlled trial.

SETTING

Inpatient rehabilitation hospital in two centres.

SUBJECTS

Eighty patients (mean of 23.25 (±16.7) days post-stroke) were randomly assigned to an experimental group and a control group.

INTERVENTIONS

Both groups underwent conventional therapy for five days/week for five weeks and the experimental group performed core stability exercises for 15 min/day. The patients were assessed before and after intervention.

MAIN MEASURES

The Trunk Impairment Scale (Spanish-Version) and Function in Sitting Test were used to measure the primary outcome of dynamic sitting balance. Secondary outcome measures were standing balance and gait as evaluated via Berg Balance Scale, Tinetti Test, Brunel Balance Assessment, Postural Assessment Scale for Stroke (Spanish-Version), and activities of daily living using Barthel Index.

RESULTS

The experimental group showed statistically significant differences for all of the total scale scores (P<0.05), except for the sitting section of the Brunel Balance Assessment. The mean (SD) difference between groups in Trunk Impairment Scale total score was 3.40 (±4.12) points, and its subscale dynamic sitting balance was 2.28 (±3.29). The Berg Balance Scale was 14.54 (±18.19) points, and the Barthel Index was 13.17 (±25.27) points. Collectively, these results were in favour of the experimental group.

CONCLUSIONS

Core stability exercises in addition to conventional therapy improves trunk control, dynamic sitting balance, standing balance, gait and activities of daily living in subacute post-stroke patients.

Sex Differences in Neuroanatomy of the Human Mirror Neuron System: Impact on Functional Recovery of Ischemic Hemiparetic Patients

Background:

Considering the higher activity of mirror neuron system in females, they frequently have better performance in empathy, interpersonal sensitivity, and emotional recognition compared to males.

Objectives:

The purpose of this study was to assess whether gender difference in neuroanatomy of the human mirror neuron system has any impact on functional recovery of ischemic hemiparetic patients.

Patients and Methods:

This single-blind clinical trial was conducted on 24 patients with cerebrovascular accident (CVA) in the age range of 45 - 60 years, referring at a rehabilitation center in Tehran, Iran, during 2013 - 2014. Sampling method was stratified random sampling. The subjects were assigned to 2 groups of 12 males and 12 females. Then, each group was randomly divided into 2 groups (totally 4 groups, n = 6 for each group): women watching functional movies, control women, men watching functional movies, and control men. Movies were shown to patients and then, they were evaluated by Timed Up and Go (TUG), Six-minute walk test (SMW), Barthel index (BI), and Berg balance scale (BBS).

Results:

Comparison of all variables related to functional activities of all groups before and after watching movies revealed significant differences. The highest percentage of change and improvement was observed in groups 1 and 3 watching the functional movies (P = 0.0001). Percentage of improvement in women of groups 1 and 2 was higher than men in groups 3 and 4 (P = 0.0003). The changes in group of females watching the functional movies (group 1) were significantly greater than in other groups (P < 0.0001).

Conclusions:

The Sex differences in the neuroanatomy of the human mirror neuron system affect functional recovery of patients with hemiparesis. The improvement in studied women was found to be significantly greater than studied men. The results indicate a higher chance of recovery among hemiparetic women, especially those watching functional movies.

Does correcting position and increasing sensorial input of the foot and ankle with Kinesio Taping improve balance in stroke patients?

BACKGROUND

We thought that the application of Kinesio Tape (KT) on the foot and ankle in stroke patients may improve the quality of somatosensory information and may activate ankle muscles which have an important role in postural control and that ultimately balance could be improved in stroke patients.

OBJECTIVE

The purpose of this study was to evaluate the effects of KT on balance in stroke patients.

METHODS

Nineteen stroke patients and 16 healthy controls were included in the study. The study group was evaluated with and without KT. Balance of the all subjects was evaluated Sensory Organization Tests (SOT) by using the Computerized Dynamic Posturography. Equilibrium, Strategy Analysis and Composite Equilibrium Scores were investigated in SOT.

RESULTS

Statistically significant differences were observed in all of the SOT parameters between stroke patients and healthy controls (p <  0.05). When the results with and without KT application were compared, the Equilibrium Scores in the conditions 3, 4, 6, Strategy Analysis Score in the conditions 2, 4, 6 and the Composite Equilibrium Score of the SOT were found to be improved in stroke patents (p <  0.05).

CONCLUSIONS

The results obtained from KT application are promising in improving balance in stroke patients.

Reliability of muscle strength assessment in chronic post-stroke hemiparesis: a systematic review and meta-analysis

BACKGROUND

Muscle weakness is the main cause of motor impairment among stroke survivors and is associated with reduced peak muscle torque.

OBJECTIVE

To systematically investigate and organize the evidence of the reliability of muscle strength evaluation measures in post-stroke survivors with chronic hemiparesis.

DATA SOURCES

Two assessors independently searched four electronic databases in January 2014 (Medline, Scielo, CINAHL, Embase).

STUDY SELECTION

Inclusion criteria comprised studies on reliability on muscle strength assessment in adult post-stroke patients with chronic hemiparesis.

DATA EXTRACTION

We extracted outcomes from included studies about reliability data, measured by intraclass correlation coefficient (ICC) and/or similar. The meta-analyses were conducted only with isokinetic data.

RESULTS

Of 450 articles, eight articles were included for this review. After quality analysis, two studies were considered of high quality. Five different joints were analyzed within the included studies (knee, hip, ankle, shoulder, and elbow). Their reliability results varying from low to very high reliability (ICCs from 0.48 to 0.99). Results of meta-analysis for knee extension varying from high to very high reliability (pooled ICCs from 0.89 to 0.97), for knee flexion varying from high to very high reliability (pooled ICCs from 0.84 to 0.91) and for ankle plantar flexion showed high reliability (pooled ICC = 0.85).

CONCLUSION

Objective muscle strength assessment can be reliably used in lower and upper extremities in post-stroke patients with chronic hemiparesis.

Virtual Reality-Based Training to Improve Obstacle-Crossing Performance and Dynamic Balance in Patients With Parkinson's Disease

BACKGROUND

Obstacle crossing is a balance-challenging task and can cause falls in people with Parkinson's disease (PD). However, programs for people with PD that effectively target obstacle crossing and dynamic balance have not been established.

OBJECTIVE

To examine the effects of virtual reality-based exercise on obstacle crossing performance and dynamic balance in participants with PD.

METHODS

Thirty-six participants with a diagnosis of PD (Hoehn and Yahr score ranging 1 to 3) were randomly assigned to one of three groups. In the exercise groups, participants received virtual reality-based Wii Fit exercise (VRWii group) or traditional exercise (TE group) for 45 minutes, followed by 15 minutes of treadmill training in each session for a total of 12 sessions over 6 weeks. Participants in the control group received no structured exercise program. Primary outcomes included obstacle crossing performance (crossing velocity, stride length, and vertical toe obstacle clearance) and dynamic balance (maximal excursion, movement velocity, and directional control measured by the limits-of-stability test). Secondary outcomes included sensory organization test (SOT), Parkinson's Disease Questionnaire (PDQ39), fall efficacy scale (FES-I), and timed up and go test (TUG). All outcomes were assessed at baseline, after training, and at 1-month follow-up.

RESULTS

The VRWii group showed greater improvement in obstacle crossing velocity, crossing stride length, dynamic balance, SOT, TUG, FES-I, and PDQ39 than the control group. VRWii training also resulted in greater improvement in movement velocity of limits-of-stability test than TE training.

CONCLUSIONS

VRWii training significantly improved obstacle crossing performance and dynamic balance, supporting implementation of VRWii training in participants with PD.

Does motor training of the nonparetic side influences balance and function in chronic stroke? A pilot RCT

Background. Balance and functional abilities are controlled by both sides of the body. The role of nonparetic side has never been explored for such skills. Objective. The objective of the present study was to examine the effect of a motor therapy program primarily involving the nonparetic side on balance and function in chronic stroke. Method. A randomized controlled, double blinded trial was conducted on 39 poststroke hemiparetic subjects (21, men; mean age, 42 years; mean poststroke duration, 13 months). They were randomly divided into the experimental group (n = 20) and control group (n = 19). The participants received either motor therapy focusing on the nonparetic side along with the conventional program or conventional program alone for 8 weeks (3 session/week, 60 minutes each). The balance ability was assessed using Berg Balance Scale (BBS) and Functional Reach Test (FRT) while the functional performance was measured by Barthel Index (BI). Result. After intervention, the experimental group exhibited significant (P < 0.05) change on BBS (5.65 versus 2.52) and BI (12.75 versus 2.16) scores in comparison to the control group. Conclusion. The motor therapy program incorporating the nonparetic side along with the affected side was found to be effective in enhancing balance and function in stroke.

Role of proprioceptive information to control balance during gait in healthy and hemiparetic individuals

Proprioceptive information is important for balance control yet little is known about how it is used during gait or how a stroke affects its use. The aim of this study was to evaluate the role of proprioception in controlling balance during gait in healthy participants and after stroke. Twelve healthy and 9 hemiparetic participants walked on an instrumented treadmill in a fully lit room, while whole-body, three-dimensional kinematics were quantified. Vibration was applied continuously or during the stance phase only, on the posterior neck muscles and triceps surae tendon on the non-dominant/paretic side. Difficulty in maintaining dynamic and postural balance was evaluated using stabilizing and destabilizing forces, respectively. Continuous and stance phase vibration of the triceps surae reduced the difficulty in maintaining both dynamic and postural balance in healthy participants (p<.05), with a greater distance between the center of pressure and the limit of the potential base of support, a more backward body position, and no change in spatio-temporal gait parameters. No effect of neck muscle vibration was observed on balance (p=.63 and above). None of the vibration conditions affected balance or gait parameters among stroke participants. The results confirmed that proprioceptive information was not used to control balance during gait in stroke participants. The importance of proprioceptive information may depend on other factors such as walking and visual conditions. Changes in sensory integration ability likely explain the results after stroke. Further study is needed to understand the integration of proprioceptive and visual information to control balance during gait after stroke.

Progression of posturographic findings after acquired brain injury

OBJECTIVE

To study the characteristics of balance performance in a sample of patients with increasing postural instability after acquired brain injury (ABI) and to establish the clinical utility of a new computerized posturographic system (NedSVE/IBV).

METHODS

This study included 108 patients with ABI divided into five groups from minimal to severe postural impairment. All patients were assessed with the NedSVE/IBV system and with traditional balance measures. Posturographic analyses included the modified clinical test of sensory interaction on balance, the limits of stability and the weight-shifting test. Sensitivity to detect changes and reproducibility were evaluated in 63 patients who were followed-up for 6 months and in 20 patients who were evaluated on two separate occasions during the same week, respectively.

RESULTS

The patients showed reduced stability limits, abnormal postural responses and an increased reliance on visual input with differences in intensity directly related to their degree of balance impairment. Posturographic study showed excellent convergent validity, reproducibility and sensitivity to detect changes.

CONCLUSION

The data suggests that, regardless of the intensity of postural instability, there is a common mechanism of sensory processing to maintain balance after ABI. The NedSVE-IBV system is a valid tool to quantify balance after ABI.

Factors influencing obstacle crossing performance in patients with Parkinson's disease

BACKGROUND

Tripping over obstacles is the major cause of falls in community-dwelling patients with Parkinson's disease (PD). Understanding the factors associated with the obstacle crossing behavior may help to develop possible training programs for crossing performance. This study aimed to identify the relationships and important factors determining obstacle crossing performance in patients with PD.

METHODS

Forty-two idiopathic patients with PD (Hoehn and Yahr stages I to III) participated in this study. Obstacle crossing performance was recorded by the Liberty system, a three-dimensional motion capture device. Maximal isometric strength of the lower extremity was measured by a handheld dynamometer. Dynamic balance and sensory integration ability were assessed using the Balance Master system. Movement velocity (MV), maximal excursion (ME), and directional control (DC) were obtained during the limits of stability test to quantify dynamic balance. The sum of sensory organization test (SOT) scores was used to quantify sensory organization ability.

RESULTS

Both crossing stride length and stride velocity correlated significantly with lower extremity muscle strength, dynamic balance control (forward and sideward), and sum of SOT scores. From the regression model, forward DC and ankle dorsiflexor strength were identified as two major determinants for crossing performance (R(2) = .37 to.41 for the crossing stride length, R(2) = .43 to.44 for the crossing stride velocity).

CONCLUSIONS

Lower extremity muscle strength, dynamic balance control and sensory integration ability significantly influence obstacle crossing performance. We suggest an emphasis on muscle strengthening exercises (especially ankle dorsiflexors), balance training (especially forward DC), and sensory integration training to improve obstacle crossing performance in patients with PD.