People with stroke who fail an obstacle crossing task have a higher incidence of falls and utilize different gait patterns compared with people who pass the task

Effects of gait adaptation training on augmented reality treadmill for patients with stroke in community ambulation

Gait adaptability is essential for stroke survivors to achieve efficient and safe community ambulation. However, conventional treadmill rehabilitation is only a repetitive practice of leg movement. This study compared the effects of augmented reality treadmill-based gait adaptation training with regular treadmill programs for patients with stroke. Forty patients with stroke (n = 40) were randomly assigned to the gait adaptation training {n = 20, age: 49.85 [standard deviation (SD) 8.44] years; onset of stroke: 107.80 (SD 48.31) days} and regular training [n = 20, age: 50.75 (SD 8.05) years, onset of stroke: 111.60 (SD 49.62) days] groups. Both groups completed three sessions of training per week for 5 weeks (15 sessions). The primary outcomes were the 10-m walk test and success rate of obstacle avoidance, while secondary outcomes included the Berg balance scale, component timed-up-and-go, and fall rate in a 6-month follow-up period. Assessments were performed before and after the intervention. The paired t-test was applied to compare the differences within groups and independent sample t-test was performed to compare the differences between groups. The 10-m walk test, success rate of obstacle avoidance, Berg balance scale, and component timed-up-and-go all significantly improved in the both groups (P < .001). The success rate of obstacle avoidance [P = .02, 95% confidence interval (CI): -21.07, -1.64], Berg Balance Scale (P = .02, 95% CI: -8.03, -0.67), 'turning around time' (P = .04, 95% CI: 0.08, 2.81), 'stand-to-sit' (P = .03, 95% CI: 0.16, 2.41) and 'total time' (P = .048, 95% CI: 0.04, 10.32) improved significantly in gait adaptation training group after intervention, while the 10-m walk test (P = .09, 95% CI: -0.17, 0.01), timed 'sit-to-stand' (P = .09, 95% CI: -0.14, 2.04), and 'linear walking' (P = .09, 95% CI: -0.27, 3.25) in gait adaptation training group did not show statistical difference compared to the regular training group. Total fall rate during the follow-up period was statistically decreased in the gait adaptation training group (P = .045). Both interventions improved mobility outcomes, with augmented reality treadmill-based gait adaptation indicating greater improvement in obstacle avoidance, balance, turning, and stand-to-sit. Augmented reality treadmill-based gait adaptation training emerges as an effective and promising intervention for patients with stroke in early rehabilitation.

Reliability, Concurrent Validity, and Minimal Detectable Change of Timed Up and Go Obstacle Test in People With Stroke

OBJECTIVE

The aims of this study were to investigate the psychometric property of the timed Up and Go Obstacle (TUGO) test in people with stroke.

DESIGN

Cross-sectional design.

SETTING

University based neurorehabilitation laboratory.

PARTICIPANTS

Twenty-eight people with stroke and 30 healthy older adults.

INTERVENTION

Not Applicable.

OUTCOME MEASURES

The TUGO (obstacle heights: 0, 5, 17 cm) test completion times, Fugl-Meyer Assessment (FMA) score, ankle dorsiflexor and plantarflexor muscle strength, Berg Balance Scale (BBS) score, Narrow Corridor Walking Test (NCWT) completion time, timed Up and Go (TUG) test completion time, and Community Integrated Measure.

RESULTS

Excellent inter-rater (intraclass correlation coefficient [ICC]=0.999-1.000) and test-retest reliabilities (ICC=0.917-0.975) were found for TUGO test completion times for all obstacle heights. The TUGO test completion times for all obstacle heights were significantly correlated with NCWT and TUG test completion times (r=0.817-0.912). Only TUGO test completion times for 0 and 5 cm obstacle heights showed significant correlations with BBS scores (r=-0.518 to -0.534), while the TUGO test completion time for the 17 cm obstacle height correlated significantly with FMA scores. The minimal detectable change and optimal cut-off values for TUGO test completion times for the 0, 5, and 17 cm obstacle heights were 2.54, 3.60, and 3.07 s, and 14.69, 14.76, and 16.10 s, respectively.

CONCLUSION

The TUGO test is a reliable, valid, and easy-to-administer clinical measure to discriminate between people with stroke and healthy older adults.

Pathophysiological and motor factors associated with collision avoidance behavior in individuals with stroke

BACKGROUND

High collision rates and frequency of entering the opening from non-paretic sides are associated with collision in individuals with stroke.

OBJECTIVE

To identify factors associated with collision avoidance behavior when individuals with stroke walked through narrow openings.

METHODS

Participants with subacute or chronic stroke walked through a narrow opening and had to avoid colliding with obstacles. Multiple regression analyses were conducted with pathophysiology, motor function, and judgment ability as predictor variables; collision rate and frequency of entering the opening from non-paretic sides were outcome variables.

RESULTS

Sixty-one eligible individuals with stroke aged 63±12 years were enrolled. Thirty participants collided twice or more and 37 entered the opening from the non-paretic side. Higher collision occurrence was associated with slower Timed Up and Go tests and left-right sway (odds ratios, 1.2 and 5.6; 95% confidence intervals, 1.1-1.3 and 1.3-28.2; p = .008 and.025, respectively). Entering from non-paretic sides was associated with lesions in the thalamus, left-sided hemiplegia, and Brunnstrom stage 3 or lower (odds ratios, 6.6, 8.7, and 6.7; 95% confidence intervals, 1.3-52.5, 2.5-36.5, and 1.2-57.5; and p = .038,.001, and.048, respectively).

CONCLUSION

Walking ability is associated with avoiding obstacle collision, while pathophysiological characteristics and degree of paralysis are associated with a preference for which side of the body enters an opening first. Interventions to improve walking ability may improve collision avoidance. Avoidance behavior during intervention varies depending on the lesion position.

Brief composite mobility index predicts post-stroke fallers after hospital discharge

Introduction

Community-dwelling, ambulatory stroke survivors fall at very high rates in the first 3-6 months. Current inpatient clinical assessments for fall risk have inadequate predictive accuracy. We found that a pre-discharge obstacle-crossing test has excellent specificity (83%) but lacks acceptable sensitivity (67%) for identifying would-be fallers and non-fallers post discharge.

Hypothesis

We assessed the hypothesis that combining the obstacle-crossing test with other highly discriminatory fall risk factors would compensate for the obstacle test's fair sensitivity and yield an instrument with superior prediction accuracy.

Methods

45 ambulatory stroke survivors (60 ± 11 years old, 15 ± 11 days post stroke) being discharged home completed a battery of physical performance-based and self-reported measures 1-5 days prior to discharge. After discharge, participants were prospectively followed and classified as fallers (≥1 fall) or non-fallers at 3 months. Pre-discharge measures with the largest effect sizes for differentiating fallers and non-fallers were combined into a composite index. Several variations of the composite index were examined to optimize accuracy.

Results

A 4-item discharge composite index significantly predicted fall status at 3-months. The goodness of fit of the regression model was significantly better than the obstacle-crossing test alone, χ ²(1) = 6.036, p = 0.014. Furthermore, whereas the obstacle-crossing test had acceptable overall accuracy (AUC 0.78, 95% CI, 0.60-0.90), the composite index had excellent accuracy (AUC 0.85, 95% CI, 0.74-0.96). Combining the obstacle-crossing test with only the step test produced a model of equivalent accuracy (AUC 0.85, 95% CI, 0.73-0.96) and with better symmetry between sensitivity and specificity (0.71, 0.83) than the 4-item composite index (0.86, 0.67). This 2-item index was validated in an independent sample of n = 30 and with bootstrapping 1,000 samples from the pooled cohorts. The 4-item index was internally validated with bootstrapping 1,000 samples from the derivation cohort plus n = 9 additional participants.

Conclusion

This study provides convincing proof-of-concept that strategic aggregation of performance-based and self-reported mobility measures, including a novel and demanding obstacle-crossing test, can predict post-discharge fallers with excellent accuracy. Further instrument development is warranted to construct a brief aggregate tool that will be pragmatic for inpatient use and improve identification of future post-stroke fallers before the first fall.

Recovery of balance control in bilateral medial knee osteoarthritis after total knee arthroplasty during level walking

Older adults are at higher risk of falling following total knee arthroplasty (TKA). However, it remains unclear how long a full recovery of the balance control during gait post-TKA will take. The current study aimed to bridge this knowledge gap via long-term follow-up gait analyses. Twelve older adults with severe bilateral medial knee osteoarthritis (OA) before, 3 and 12 months after TKA, and twelve healthy controls were evaluated for their balance control during level walking, in terms of the inclination angle (IA) of the center of pressure to center of mass vector, and the rate of change of IA (RCIA). The patients before TKA showed significantly increased sagittal IA but decreased RCIA throughout the gait cycle (p < 0.04) compared to controls, suggesting a compromised balance control. Three months post-TKA, deviations in IA remained, although those in RCIA were improved to normal. One-year post-TKA, no significant differences were found in any of the IA- and RCIA-related variables between patient and Control groups. The results show that TKA surgery was effective in reducing the deviations in the center of mass-center of pressure control in patients with severe bilateral knee OA, and full recovery of balance control can be expected 1 year after surgery.

Utility of an obstacle-crossing test to classify future fallers and non-fallers at hospital discharge after stroke: A pilot study

BACKGROUND

Existing clinical assessments of balance and functional mobility have poor predictive accuracy for prospectively identifying post-stroke fallers, which may be due to a lack of ecological complexity that is typical of community-based fall incidents.

RESEARCH QUESTION

Does an obstacle-crossing test at hospital discharge predict fall status of ambulatory stroke survivors 3 months after discharge?

METHODS

Ambulatory stroke survivors being discharged home completed an obstacle-crossing test at hospital discharge. Falls were tracked prospectively for 3 months after discharge. Logistic regression examined the relationship between obstacle-crossing at discharge (pass/fail) and fall status (faller/non-faller) at 3 months post discharge.

RESULTS

45 participants had discharge obstacle test and 3-month fall data. 21 (47 %) participants experienced at least one fall during follow-up, with 52 % of the falls occurring within the first month after discharge. Of the 21 fallers, 14 failed the obstacle-crossing test (67 % sensitivity). Among the 24 non-fallers, 20 passed the obstacle-crossing test (83 % specificity). The area under the receiver operating characteristic curve was 0.75 (95 % CI 0.60-0.90). Individuals who failed the obstacle-crossing test were 10.00 (95 % CI: 2.45-40.78) times more likely to fall in the first 3 months after discharge. The unadjusted logistic regression model correctly classified 76 % of the subjects. After adjusting for age, sex, days post stroke, and post-stroke disability, the odds ratio remained significant at 6.93 (95 % CI: 1.01-47.52) and correctly classified 79.5% of the participants.

SIGNIFICANCE

The obstacle-crossing test may be a useful discharge assessment to identify ambulatory stroke survivors being discharged home who are likely to fall in the first 3 months post discharge. Modifications to improve the obstacle-crossing test sensitivity should be explored further.

Avascular Necrosis of the Hip Compromises Gait Balance Control in Female Juveniles With Unilateral Developmental Dysplasia Treated in Toddlerhood

Avascular necrosis of the hip (AVN) is one of the most severe complications of surgical reduction when treating developmental dysplasia of the hip (DDH). The current study identified the differences in the balance control during walking in terms of the inclination angle (IA) of the center of pressure (COP) to the center of mass (COM), and the rate of change of IA (RCIA) between female juveniles with and without secondary AVN at the hip who were treated for unilateral DDH during toddlerhood as compared to their healthy peers. When compared to female healthy controls, the non-AVN group showed bilaterally similar compromised balance control with significantly decreased IA (p < 0.05) but increased RCIA (p < 0.04) in the sagittal plane during single-limb support (SLS) of the unaffected side, and in the frontal plane during terminal double-limb support (DLS) of the affected side. In contrast, the AVN increased between-side differences in the sagittal IA (p = 0.01), and sagittal and frontal RCIA during DLS (p < 0.04), leading to bilaterally asymmetrical balance control. Secondary AVN significantly reduced IA and RCIA in the sagittal plane (p < 0.05), and reduced range of RCIA in the frontal plane during initial DLS (p < 0.05). The trend reversed during terminal DLS, indicating a conservative COM-COP control in the sagittal plane and a compromised control in the frontal plane during body weight acceptance, with a compromised COM-COP control in the frontal plane during weight release. The current results suggest that increased between-side differences in the sagittal IA, and sagittal and frontal RCIA during DLS are a sign of AVN secondary to treated unilateral DDH in female juveniles, and should be monitored regularly for early identification of the disease.

Does the Environment Cause Changes in Hemiparetic Lower Limb Muscle Activity and Gait Velocity During Walking in Stroke Survivors?

Stroke survivors often face difficulty in community ambulation though they attain steady-state walking in clinical setups. Compliance and unpredictability of the environment may alter the muscle activity and challenge the individual's gait. Successful reintegration into the community requires gait assessment and training in a real-life challenging environment. Little is known about the assessment and training of gait in the community environment under challenging mobility dimensions. Hence, we aimed to study the changes that real-life environmental dimensions have on the activity of selected muscles in hemiparetic lower limb and gait velocity in stroke survivors.

METHODS

An observational cross-sectional study was conducted on 16 ambulatory stroke survivors to assess the hemiparetic lower limb muscle activity during walking in real-life environmental dimensions. Participants were made to walk in the community on a walkway consisting of even surface, ramp, stairs, uneven terrain and obstacles. They were also made to manoeuvre through traffic and pick a load while walking for a distance in the walkway. Muscle activity of Rectus Femoris, Biceps Femoris, Gastrocnemius Medialis and Tibialis Anterior of the paretic lower limb were continuously recorded while walking using wireless surface electromyography. Gait velocity for the entire walkway and level of perceived difficulty while walking in different dimensions were also measured. Paired t-test was used to compare the percentage Maximum Voluntary Contraction (%MVC) of lower limb muscles between even surface and real-life environment dimensions while walking. One sample t-test was used to compare the gait velocity in real-life dimensions versus gait velocity in even surface measured in an earlier study.

RESULTS

There was a significant reduction (p < 0.01) in the activity of all four hemiparetic lower limb muscles while walking under the influence of real-life environmental dimensions compared to even surface. Gait velocity (0.33 ± 0.17 m/s) was significantly lower than that is essential to be a community ambulator. The level of perceived difficulty across all dimensions was reported qualitatively with the highest difficulty reported during stair and obstacle clearance.

CONCLUSION

Real-life environmental dimensions lead to the reduction of paretic lower limb muscle activities and gait velocity during walking in community-dwelling stroke survivors. Stroke survivors perceived more difficulty while walking in real-life environment dimensions particularly while negotiating stairs and obstacles.

SIGNIFICANCE

Knowledge about the influence of real-life environmental dimensions will help the clinicians to target rehabilitation methods to improve walking adaptability.

Short-Step Adjustment and Proximal Compensatory Strategies Adopted by Stroke Survivors With Knee Extensor Spasticity for Obstacle Crossing

Stroke survivors adopt cautious or compensatory strategies for safe and successful obstacle crossing. Although knee extensor spasticity is a common independent secondary sensorimotor disorder post-stroke, few studies have examined the step adjustment and compensatory strategies used by stroke survivors with knee extensor spasticity during obstacle crossing. This study aimed to compare the differences in the kinematics and kinetics during obstacle crossing between stroke survivors with and without knee extensor spasticity, and to identify knee extensor spasticity-related differences in step adjustment and compensatory strategies. Twenty stroke subjects were divided into a spasticity group [n = 11, modified Ashworth scale (MAS) ≥ 1] and a non-spasticity group (n = 9, MAS = 0), based on the MAS score of the knee extensor. Subjects were instructed to walk at a self-selected speed on a 10-m walkway and step over a 15 cm obstacle. A ten-camera 3D motion analysis system and two force plates were used to collect the kinematic and kinetic data. During the pre-obstacle phase, stroke survivors with knee extensor spasticity adopted a short-step strategy to approach the obstacle, while the subjects without spasticity used long-step strategy. During the affected limb swing phase, the spasticity group exhibited increased values that were significantly higher than those seen in the non-spasticity group for the following measurements: pelvic lateral tilt angle, trunk lateral tilt angle, medio-lateral distance between the ankle and ipsilateral hip joint, hip work contributions, the inclination angles between center of mass and center of pressure in anterior–posterior and medio-lateral directions. These results indicate that the combined movement of the pelvic, trunk lateral tilt, and hip abduction is an important compensatory strategy for successful obstacle crossing, but it sacrifices some balance in the sideways direction. During the post-obstacle phase, short-step and increase step width strategy were adopted to reestablish the walking pattern and balance control. These results reveal the step adjustment and compensatory strategies for obstacle crossing and also provide insight into the design of rehabilitation interventions for fall prevention in stroke survivors with knee extensor spasticity.

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

BACKGROUND

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

RESEARCH QUESTION

How do stroke patients approach and cross elevated surfaces?

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Identify the Alteration of Balance Control and Risk of Falling in Stroke Survivors During Obstacle Crossing Based on Kinematic Analysis

This study aims to compare the differences in the kinematic characteristics of crossing obstacles of different heights between stroke survivors and age-matched healthy controls and to identify the changes of balance control strategy and risk of falling. Twelve stroke survivors and twelve aged-matched healthy controls were recruited. A three-dimensional motion analysis system and two force plates were used to measure the kinematic and kinetic data during crossing obstacles with heights of 10, 20, and 30% leg length. The results showed that during leading and trailing limb clearance, (AP) center of mass (COM) velocities of the stroke group were smaller than those of the healthy controls for all heights. The decreased distances between COM and center of pressure (COP) in the AP direction during the both trailing and leading limb support period were also found between stroke survivors and healthy controls for all heights. The COM velocity and COM-COP distance significantly correlated with the lower limb muscle strength. In addition, stroke survivors showed greater lateral pelvic tilt, greater hip abduction, and larger peak velocity in the medio-lateral (ML) direction. There was a positive correlation between the COM-COP distance in the AP direction and the clinical scales. These results might identify that the stroke survivors used a conservative strategy to negotiate the obstacles and control balance due to a lack of muscle strength. However, the abnormal patterns during obstacle crossing might increase the risk of falling. The findings could be used to design specific rehabilitation training programs to enhance body stability, reduce energy cost, and improve motion efficiency.

Dynamic balance during walking adaptability tasks in individuals post-stroke

Maintaining dynamic balance during community ambulation is a major challenge post-stroke. Community ambulation requires performance of steady-state level walking as well as tasks that require walking adaptability. Prior studies on balance control post-stroke have mainly focused on steady-state walking, but walking adaptability tasks have received little attention. The purpose of this study was to quantify and compare dynamic balance requirements during common walking adaptability tasks post-stroke and in healthy adults and identify differences in underlying mechanisms used for maintaining dynamic balance. Kinematic data were collected from fifteen individuals with post-stroke hemiparesis during steady-state forward and backward walking, obstacle negotiation, and step-up tasks. In addition, data from ten healthy adults provided the basis for comparison. Dynamic balance was quantified using the peak-to-peak range of whole-body angular-momentum in each anatomical plane during the paretic, nonparetic and healthy control single-leg-stance phase of the gait cycle. To understand differences in some of the key underlying mechanisms for maintaining dynamic balance, foot placement and plantarflexor muscle activation were examined. Individuals post-stroke had significant dynamic balance deficits in the frontal plane across most tasks, particularly during the paretic single-leg-stance. Frontal plane balance deficits were associated with wider paretic foot placement, elevated body center-of-mass, and lower soleus activity. Further, the obstacle negotiation task imposed a higher balance requirement, particularly during the trailing leg single-stance. Thus, improving paretic foot placement and ankle plantarflexor activity, particularly during obstacle negotiation, may be important rehabilitation targets to enhance dynamic balance during post-stroke community ambulation.

Virtual obstacle crossing: Reliability and differences in stroke survivors who prospectively experienced falls or no falls

INTRODUCTION

Stroke survivors often fall during walking. To reduce fall risk, gait testing and training with avoidance of virtual obstacles is gaining popularity. However, it is unknown whether and how virtual obstacle crossing is associated with fall risk.

AIM

The present study assessed whether obstacle crossing characteristics are reliable and assessed differences in stroke survivors who prospectively experienced falls or no falls.

METHOD

We recruited twenty-nine community dwelling chronic stroke survivors. Participants crossed five virtual obstacles with increasing lengths. After a break, the test was repeated to assess test-retest reliability. For each obstacle length and trial, we determined; success rate, leading limb preference, pre and post obstacle distance, margins of stability, toe clearance, and crossing step length and speed. Subsequently, fall incidence was monitored using a fall calendar and monthly phone calls over a six-month period.

RESULTS

Test-retest reliability was poor, but improved with increasing obstacle-length. Twelve participants reported at least one fall. No association of fall incidence with any of the obstacle crossing characteristics was found.

DISCUSSION

Given the absence of height of the virtual obstacles, obstacle avoidance may have been relatively easy, allowing participants to cross obstacles in multiple ways, increasing variability of crossing characteristics and reducing the association with fall risk.

CONCLUSION

These finding cast some doubt on current protocols for testing and training of obstacle avoidance in stroke rehabilitation.

Key function for obstacle crossing in hemiplegic persons with varied degrees of spasticity

[Purpose] To evaluate various key functions related to obstacle crossing motions in hemiplegic people based on the paralysis degree. [Subjects and Methods] Thirty-seven patients with maintenance-stage hemiplegia who could independently ambulate outdoors were included. Subjects’ crossing movements were measured using obstacles with heights of 10%, 20%, and 30% of the trochanter length. The relationship among maximal crossing height and isometric knee extension muscle strength, one leg standing time, Trunk Impairment Scale score, disease duration, and subject age was examined, as was the target variable of maximum crossing height and the top four measurement items, to determine the explanatory variables. The participants were grouped based on Brunnstrom Recovery Stages III–IV (severe spasticity) and V–VI (mild spasticity). [Results] The explanatory variables were the Trunk Impairment Scale in the severe spasticity group and unaffected side-knee extension muscle strength in the mild spasticity group (contribution rates: 75.6% and 21.0%, respectively). [Conclusion] Trunk function in the severe spasticity group majorly contributed to crossing obstacles. Furthermore, knee extension muscle strength on the unaffected side in the mild spasticity group moderately contributed to crossing obstacles. Selecting and implementing a physical therapy routine that is aimed at improving function, depending on the severity of paralysis, is necessary.

Risk Factors for Falls in Community Stroke Survivors: A Systematic Review and Meta-Analysis

OBJECTIVE

To identify the risk factors for falls in community stroke survivors.

DATA SOURCES

A comprehensive search for articles indexed in MEDLINE, Embase, CINAHL, PsycINFO, Cochrane Library, and Web of Science databases was conducted.

STUDY SELECTION

Prospective studies investigating fall risk factors in community stroke survivors were included. Reviewers in pair independently screened the articles and determined inclusion through consensus. Studies meeting acceptable quality rating using the Q-Coh tool were included in the meta-analysis.

DATA EXTRACTION

Data extraction was done in duplicate by 4 reviewers using a standardized data extraction sheet and confirmed by another independent reviewer for completeness and accuracy.

DATA SYNTHESIS

Twenty-one articles met the minimum criteria for inclusion; risk factors investigated by ≥3 studies (n=16) were included in the meta-analysis. The following risk factors had a strong association with all fallers: impaired mobility (odds ratio [OR], 4.36; 95% confidence interval [CI], 2.68-7.10); reduced balance (OR, 3.87; 95% CI, 2.39-6.26); use of sedative or psychotropic medications (OR, 3.19; 95% CI, 1.36-7.48); disability in self-care (OR, 2.30; 95% CI, 1.51-3.49); depression (OR, 2.11; 95% CI, 1.18-3.75); cognitive impairment (OR, 1.75; 95% CI, 1.02-2.99); and history of fall (OR, 1.67; 95% CI, 1.03-2.72). A history of fall (OR, 4.19; 95% CI, 2.05-7.01) had a stronger association with recurrent fallers.

CONCLUSIONS

This study confirms that balance and mobility problems, assisted self-care, taking sedative or psychotropic medications, cognitive impairment, depression, and history of falling are associated with falls in community stroke survivors. We recommend that any future research into fall prevention programs should consider addressing these modifiable risk factors. Because the risk factors for falls in community stroke survivors are multifactorial, interventions should be multidimensional.

Canadian stroke best practice recommendations: Stroke rehabilitation practice guidelines, update 2015

Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of the Canadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelines is a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.

Reliability and Validity of Dual-Task Mobility Assessments in People with Chronic Stroke

Background

The ability to perform a cognitive task while walking simultaneously (dual-tasking) is important in real life. However, the psychometric properties of dual-task walking tests have not been well established in stroke.

Objective

To assess the test-retest reliability, concurrent and known-groups validity of various dual-task walking tests in people with chronic stroke.

Design

Observational measurement study with a test-retest design.

Methods

Eighty-eight individuals with chronic stroke participated. The testing protocol involved four walking tasks (walking forward at self-selected and maximal speed, walking backward at self-selected speed, and crossing over obstacles) performed simultaneously with each of the three attention-demanding tasks (verbal fluency, serial 3 subtractions or carrying a cup of water). For each dual-task condition, the time taken to complete the walking task, the correct response rate (CRR) of the cognitive task, and the dual-task effect (DTE) for the walking time and CRR were calculated. Forty-six of the participants were tested twice within 3–4 days to establish test-retest reliability.

Results

The walking time in various dual-task assessments demonstrated good to excellent reliability [Intraclass correlation coefficient (ICC_2,1) = 0.70–0.93; relative minimal detectable change at 95% confidence level (MDC₉₅%) = 29%-45%]. The reliability of the CRR (ICC_2,1 = 0.58–0.81) and the DTE in walking time (ICC_2,1 = 0.11–0.80) was more varied. The reliability of the DTE in CRR (ICC_2,1 = -0.31–0.40) was poor to fair. The walking time and CRR obtained in various dual-task walking tests were moderately to strongly correlated with those of the dual-task Timed-up-and-Go test, thus demonstrating good concurrent validity. None of the tests could discriminate fallers (those who had sustained at least one fall in the past year) from non-fallers.

Limitation

The results are generalizable to community-dwelling individuals with chronic stroke only.

Conclusions

The walking time derived from the various dual-task assessments generally demonstrated good to excellent reliability, making them potentially useful in clinical practice and future research endeavors. However, the usefulness of these measurements in predicting falls needs to be further explored. Relatively low reliability was shown in the cognitive outcomes and DTE, which may not be preferred measurements for assessing dual-task performance.

Comparison of kinetic strategies for avoidance of an obstacle with either the paretic or non-paretic as leading limb in persons post stroke

The task of stepping over obstacles is known to be particularly risky for persons post stroke. A kinetic analysis informing on the movement strategies used to ensure clearance of the leading limb over an obstacle is, however, lacking. We examined obstacle avoidance strategies in six community dwelling stroke survivors comparing the use of paretic and non-paretic limb as the leading limb for clearance over obstacles measuring 7.5% and 15% of their total leg length. Subjects were able to increase foot clearance height in both limbs in order to avoid the two obstacles. Obstacle clearance with the non-paretic limb leading was associated with positive knee flexor work that increased when stepping over each obstacle, thus showing a normal knee strategy that flexes both the knee and the hip for foot clearance. There was also slightly increased hip flexor contribution for non-paretic obstacle clearance that was the same for both obstacle heights. When the paretic limb led during obstacle clearance, there was also evidence of an increased knee flexor moment, suggesting a residual knee strategy, but it was less pronounced than for the non-paretic limb and was assisted by greater vertical hip elevation and additional positive hip flexor work that both gained greater importance with increased obstacle height. These findings suggest that rehabilitation should explore the ability to improve the residual, but less powerful, knee flexor strategy in the paretic limb in specific patients, with further promotion of a hip flexor and limb elevation strategy depending on patient deficits and obstacle height.

Stroke rehabilitation: clinical picture, assessment, and therapeutic challenge

This chapter reviews the evolution of stroke rehabilitation in the last 20 years. It begins by describing the different types of stroke that can occur in adults, their potential consequences on a person's capacity to function in daily life and statistics on the number of strokes and their burden on families and the economy. The assessment of stroke severity, recovery of function over time, and the impact of initial stroke severity and age on potential recovery are then addressed as well as the concept of rehabilitation to enhance recovery. Fueled by the synthesis of an ever-increasing research knowledge base and the creation of stroke rehabilitation recommendations for optimal delivery of rehabilitation services and of therapeutic interventions, stroke rehabilitation has changed dramatically. Examples of improvements in stroke rehabilitation in Canada are given with emphasis on the "best practices" inspired stroke rehabilitation continuum recently recommended for the Province of Quebec. The need for an improved community-based rehabilitation approach that includes regular follow-ups and community-based programs promoting reintegration is emphasized. The importance of knowledge translation strategies to promote the uptake of best-practice recommendations is illustrated by describing the activities of the Sensorimotor Rehabilitation Research Team. Over the past 3 years, the researchers of this team and clinicians in three rehabilitation centers, two in Montreal and one in Quebec City, have collaborated to adopt standardized assessment tools, create a common stroke registry, a best-practice recommended approach to interventions and the participation of clinicians in the research process.

The capacity to restore steady gait after a step modification is reduced in people with poststroke foot drop using an ankle-foot orthosis

BACKGROUND

A reduced capacity to modify gait to the environment may contribute to the risk of falls in people with poststroke foot drop using an ankle-foot orthosis.

OBJECTIVE

This study aimed to quantify their capacity to restore steady gait after a step modification.

DESIGN

This was a cross-sectional, observational study.

METHODS

Nineteen people in the chronic phase (>6 months) after stroke (mean age=55.0 years, SD=10.1) and 20 people of similar age (mean age=54.6 years, SD=12.0) who were able-bodied were included. Participants were instructed to avoid obstacles that were suddenly released in front of the paretic leg (stroke group) or left leg (control group) while walking on a treadmill. Outcomes were success rates of obstacle avoidance as well as post-crossing step length, step duration, hip flexion angle at foot-strike, and peak hip extension of the steps measured within 10 seconds following obstacle release.

RESULTS

Success rates of obstacle avoidance were lower for people poststroke. Moreover, their first post-crossing step length and duration (ie, the nonparetic step) deviated more from steady gait than those of people in the control group (ie, the right step), with lower values for people poststroke. Similar deviations were observed for post-crossing hip flexion and extension excursions.

LIMITATIONS

People poststroke were relatively mildly impaired and used an ankle-foot orthosis, which may limit the generalizability of the results to other populations poststroke.

CONCLUSIONS

People with poststroke foot drop using an ankle-foot orthosis had reduced gait adaptability, as evidenced by lower success rates of obstacle avoidance as well as an impaired capacity to restore steady gait after crossing an obstacle. The latter finding unveils their difficulty in incorporating step modifications in ongoing gait.

The effect of obstacle training in water on static balance of chronic stroke patients

[Purpose] This study evaluated the effects of water and land-based obstacle training on static balance of chronic stroke patients. [Subjects] The subjects were randomly allocated to an aqua group (n=15) and a land group (n=15). [Methods] Both groups trained for 40 minutes, 3 times a week for 12 weeks. Static balance was assessed by measuring the mean velocities of mediolateral (ML) and anteroposterior (AP), and sway area with the eyes closed. [Results] Following the intervention, both groups showed significant changes in ML velocity, AP velocity, and sway area. The static balance of the aqua group was significantly better than the land group. [Conclusion] The results of this study suggest the feasibility and suitability of obstacle training in water for stroke patients.

Effects of overweight and obese body mass on motor planning and motor skills during obstacle crossing in children

Little is known about how obesity relates to motor planning and skills during functional tasks. We collected 3-D kinematics and kinetics as normal weight (n=10) and overweight/obese (n=12) children walked on flat ground and as they crossed low, medium, and high obstacles. We investigated if motor planning and motor skill impairments were evident during obstacle crossing. Baseline conditions showed no group differences (all ps>.05). Increased toe clearance was found on low obstacles (p=.01) for the overweight/obese group and on high obstacles (p=.01) for the normal weight group. With the crossing leg, the overweight/obese group had larger hip abduction angles (p=.01) and medial ground reaction forces (p=.006) on high obstacles and high anterior ground reaction forces on low obstacles (p=.001). With the trailing leg, overweight/obese children had higher vertical ground reaction forces on high obstacles (p=.005) and higher knee angles (p=.01) and anterior acceleration in the center of mass (p=.01) on low obstacles. These findings suggest that differences in motor planning and skills in overweight/obese children may be more apparent during functional activities.

Obstacle crossing following stroke improves over one month when the unaffected limb leads, but not when the affected limb leads

While it is well established that obstacle crossing is impaired following stroke, it is not known whether obstacle crossing improves as gait improves following stroke. The purpose of this study was to determine whether obstacle crossing changed over a one month time period in people with a recent stroke. Twenty participants receiving rehabilitation following a recent stroke were tested on two occasions one month apart. Participants received usual care rehabilitation, including physiotherapy, between the tests. The main outcome measure was obstacle crossing speed as participants stepped over a 4-cm high obstacle. Secondary measures were spatiotemporal variables. Data were collected via a three dimensional motion analysis system. When leading with the affected limb no changes in obstacle crossing speed or spatiotemporal variables were observed over the one month period. When leading with the unaffected limb, crossing speed significantly increased (p=.002), and affected trail limb swing time (p=.03) and crossing step double support time reduced (p=.016). While not significant, the lead and trail limb pre-obstacle distance increased (p=.08), and lead swing time (p=.052) reduced. Change in obstacle crossing speed did not correlate with change in level gait speed. Obstacle crossing does not necessarily improve over a one month time period in people receiving rehabilitation following stroke. These findings suggest that there may be a need for more targeted training of obstacle crossing, particularly when leading with the affected limb.