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Legasto-Mulvale JM, Inness EL, Thompson AN, Chandran N, Mathur S, Salbach NM. Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review. J Neurol Phys Ther 2024; 48:27-37. [PMID: 37184472 DOI: 10.1097/npt.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
BACKGROUND AND PURPOSE Concern for adverse cardiovascular events and limited guidance regarding how to conduct aerobic exercise (AEx) testing for individuals poststroke are key barriers to implementation by physical therapists in stroke rehabilitation. This study aimed to describe the nature and safety of submaximal AEx testing protocols for people with subacute stroke (PwSS) and the nature of comorbidity of PwSS who underwent submaximal AEx testing. METHODS We conducted a scoping review and searched MEDLINE, EMBASE, PsycINFO, CINAHL, and SPORTDiscus from inception to October 29, 2020. Studies involving submaximal AEx testing with PwSS, reporting on participant comorbidity and on adverse events during testing, were eligible. Two reviewers independently conducted title and abstract and full-text screening. One reviewer extracted data; a second reviewer verified data. RESULTS Thirteen studies involving 452 participants and 19 submaximal AEx testing protocols (10 field test, 7 incremental, and 2 constant load) were included. Hypertension (41%), diabetes (31%), and dyslipidemia (27%) were the most common comorbidities reported. No protocols resulted in a serious adverse event. The most common test termination criterion was a heart rate (HR) limit (9 protocols); a limit of 85% age-predicted maximal HR (APM-HR) most frequently reported. Average APM-HR achieved, computed using mean age and mean peak HR, ranged from 59% to 88% across 13 protocols. DISCUSSION AND CONCLUSION Diverse submaximal AEx testing protocols with conservative test termination criteria can be safely implemented with PwSS. Results can inform clinical practice guidelines and address physical therapists' concerns with the occurrence of serious adverse events during submaximal AEx testing.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A430 ).
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Affiliation(s)
- Jean Michelle Legasto-Mulvale
- Rehabilitation Sciences Institute (J.M.L.M., E.L.I., A.N.T., N.C., S.M., N.M.S.) and Department of Physical Therapy (J.M.L.M., E.L.I., S.M., N.M.S), Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; The KITE Research Institute, Toronto Rehabilitation Institute (E.L.I., N.M.S), University Health Network, Toronto, Ontario, Canada; and School of Rehabilitation Therapy (S.M.), Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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Comper P, Foster E, Chandra T, Langer L, Wiseman-Hakes C, Mochizuki G, Ruttan L, Lawrence DW, Inness EL, Gladstone J, Saverino C, Tam A, Kam A, Al-Rawi F, Bayley MT. The Toronto Concussion Study: a prospective investigation of characteristics in a cohort of adults from the general population seeking care following acute concussion, 2016-2020. Front Neurol 2023; 14:1152504. [PMID: 37662043 PMCID: PMC10471513 DOI: 10.3389/fneur.2023.1152504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 07/20/2023] [Indexed: 09/05/2023] Open
Abstract
Purpose There is limited research regarding the characteristics of those from the general population who seek care following acute concussion. Methods To address this gap, a large cohort of 473 adults diagnosed with an acute concussion (female participants = 287; male participants = 186) was followed using objective measures prospectively over 16 weeks beginning at a mean of 5.1 days post-injury. Results Falls were the most common mechanism of injury (MOI) (n = 137, 29.0%), followed by sports-related recreation (n = 119, 25.2%). Male participants were more likely to be injured playing recreational sports or in a violence-related incident; female participants were more likely to be injured by falling. Post-traumatic amnesia (PTA) was reported by 80 participants (16.9 %), and loss of consciousness (LOC) was reported by 110 (23.3%). In total, 54 participants (11.4%) reported both PTA and LOC. Male participants had significantly higher rates of PTA and LOC after their injury compared to their female counterparts. Higher initial symptom burden was associated with a longer duration of recovery for both male and female participants. Female participants had more symptoms and higher severity of symptoms at presentation compared to male participants. Female participants were identified to have a longer recovery duration, with a mean survival time of 6.50 weeks compared to 5.45 weeks in male participants (p < 0.0001). A relatively high proportion of female and male participants in this study reported premorbid diagnoses of depression and anxiety compared to general population characteristics. Conclusion Although premorbid diagnoses of depression and/or anxiety were associated with higher symptom burden at the initial visit, the duration of symptoms was not directly associated with a pre-injury history of psychological/psychiatric disturbance. This cohort of adults, from the general population, seeking care for their acute concussion attained clinical and functional recovery over a period of 4-12 weeks.
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Affiliation(s)
- Paul Comper
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Laura Langer
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Catherine Wiseman-Hakes
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- School of Kinesiology and Health Science, York University, Toronto, ON, Canada
| | - Lesley Ruttan
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, ON, Canada
| | - David W. Lawrence
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Jonathan Gladstone
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Division of Neurology, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada
- Gladstone Headache Clinic, Toronto, ON, Canada
| | - Cristina Saverino
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Alan Tam
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Division of Physiatry, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Alice Kam
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Division of Physiatry, Department of Medicine, University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
| | - Firas Al-Rawi
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Toronto General Hospital, University Health Network, Toronto, ON, Canada
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mark Theodore Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Division of Physiatry, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Sakakibara BM, Wiley E, Barclay R, Bayley M, Davis JC, Eng JJ, Harris A, Inness EL, MacKay-Lyons M, Monaghan J, Pollock C, Pooyania S, Schneeberg A, Teasell R, Yao J, Tang A. TeleRehabilitation with Aims to Improve Lower extremity recovery in community-dwelling individuals who have had a stroke: protocol for a multisite, parallel group, assessor-blinded, randomised attention-controlled trial. BMJ Open 2023; 13:e076723. [PMID: 37474180 PMCID: PMC10357752 DOI: 10.1136/bmjopen-2023-076723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Telerehabilitation is an accessible service delivery model that may support innovative lower extremity rehabilitation programmes that extend the stroke recovery continuum into the community. Unfortunately, there is limited evidence on the provision of exercises for lower extremity recovery after stroke delivered using telerehabilitation. In response, we developed the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke (TRAIL) programme, a 4-week progressive exercise and self-management intervention delivered synchronously using video-conferencing technology. Our primary hypothesis is that individual within 1-year poststroke who participate in TRAIL will experience significantly greater improvements in functional mobility than individuals in an attention-controlled education programme (EDUCATION). METHODS AND ANALYSIS In this multisite, parallel group, assessor-blinded randomised attention-controlled trial, 96 community-living stroke survivors within 1-year poststroke will be recruited from five sites (Vancouver, Winnipeg, Toronto, London and Halifax, Canada) from the CanStroke Recovery Trials Platform which is a network of Canadian hospital sites that are affiliated with academic institutions to facilitate participant recruitment and quality trial practices. Participants will be randomised on a 1:1 basis to TRAIL or EDUCATION. Participants randomised to TRAIL will receive eight telerehabilitation sessions where they will perform exercises and receive self-management support to improve lower extremity recovery from a TRAIL physical therapist. The primary outcome will be measured using the Timed Up and Go. Secondary outcomes include lower extremity muscle strength, functional balance, motor impairment, balance self-efficacy, health-related quality of life and health service use for our economic evaluation. Measurements will be taken at baseline, immediately after the intervention, 3-month and 6-month postintervention. ETHICS AND DISSEMINATION Ethics approval for this research has been obtained by all participating sites. All study participants will provide their informed consent prior to enrolling them in the study. Findings from this trial will be disseminated in peer-reviewed journals and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT04908241.
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Affiliation(s)
- Brodie M Sakakibara
- Department of Occupational Science and Occupational Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Chronic Disease Prevention and Management, The University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Elise Wiley
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ruth Barclay
- College of Rehabilitation Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mark Bayley
- Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer C Davis
- Faculty of Management, The University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Janice J Eng
- Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
- GF Strong Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Anne Harris
- GF Strong Rehabilitation Centre, Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Elizabeth L Inness
- Mobility Innovations Centre, Toronto Rehabiltiation Institute, Toronto, Ontario, Canada
| | | | - Jennifer Monaghan
- Centre for Chronic Disease Prevention and Management, The University of British Columbia Okanagan, Kelowna, British Columbia, Canada
| | - Courtney Pollock
- Department of Physical Therapy, The University of British Columbia, Vancouver, British Columbia, Canada
- GF Strong Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Sepideh Pooyania
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amy Schneeberg
- Consultant, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Teasell
- Lawson Health Research Unit, Parkwood Hospital, London, Ontario, Canada
- Physical Medicine and Rehabiliation, University of Western Ontario, London, Ontario, Canada
| | - Jennifer Yao
- GF Strong Rehabilitation Centre, Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Ada Tang
- School of Rehabilitation Sciences, McMaster University, Hamilton, Ontario, Canada
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Benn NL, Jervis-Rademeyer H, Benson K, Chan K, Lee JW, Inness EL, Wolfe DL, Alizadeh-Meghrazi M, Masani K, Musselman KE. Identifying priorities for balance interventions through a participatory co-design approach with end-users. BMC Neurol 2023; 23:266. [PMID: 37442947 DOI: 10.1186/s12883-023-03312-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Most individuals living with spinal cord injuries/diseases (SCI/D) or stroke experience at least one fall each year; hence, the development of interventions and technologies that target balance control is needed. The purpose of this study was to identify and explore the priorities for balance-focused interventions and technologies from the perspectives of end-users to assist with the design of an intervention that combines functional electrical stimulation (FES) with visual feedback training for standing balance. METHODS Two individuals with SCI/D, one individual with stroke, two physical therapists (PT) and one hospital administrator were recruited. Participants attended three focus group meetings that followed a participatory co-design approach. A semi-structured interview guide, developed from the FAME (Feasibility, Appropriateness, Meaningfulness, Effectiveness, Economic Evidence) framework, was used to lead the discussion, querying participants' experiences with balance deficits and interventions, and FES. Meetings were audio-recorded and transcribed verbatim. An iterative and reflexive inductive thematic analysis was applied to the transcripts by three researchers. RESULTS Four themes were identified: (1) Balance is meaningful for daily life and rehabilitation. Participants acknowledged various factors influencing balance control and how balance deficits interfered with participation in activities. End-users stressed the importance of continuing to work on one's balance after discharge from hospital-based rehabilitation. (2) Desired characteristics of balance interventions. Participants explained that balance interventions should be tailored to an individual's unique needs and goals, relevant to their lives, balance their safety and risk, and be engaging. (3) Prior experiences with FES to inform future therapeutic use. Participants with stroke or SCI/D described initial apprehension with FES, but experienced numerous benefits that motivated them to continue with FES. Challenges with FES were mentioned, including wires, cost, and time of set up. (4) Potential role of FES in balance interventions. Participants felt that FES would complement balance interventions; however, they had not experienced this combination of therapies previously. CONCLUSIONS End-users described how their experiences with balance deficits, rehabilitation, and FES informed their priorities for balance interventions. The findings inform the design and implementation of future balance interventions for individuals with SCI/D or stroke, including an intervention involving FES and visual feedback training.
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Affiliation(s)
- Natasha L Benn
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Hope Jervis-Rademeyer
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Kayla Benson
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Katherine Chan
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Jae W Lee
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Elizabeth L Inness
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Dalton L Wolfe
- Parkwood Institute, Lawson Health Research Institute, London, Canada
| | | | - Kei Masani
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | - Kristin E Musselman
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.
- KITE Research Institute-Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.
- Department of Physical Therapy, University of Toronto, Toronto, Canada.
- SCI Mobility Lab, KITE-Toronto Rehabilitation Institute, UHN, 520 Sutherland Drive, Toronto, M4G 3V9, Canada.
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Munce S, Andreoli A, Bayley M, Guo M, Inness EL, Kua A, McIntyre M. Clinicians' Experiences of Implementing a Telerehabilitation Toolkit During the COVID-19 Pandemic: Qualitative Descriptive Study. JMIR Rehabil Assist Technol 2023; 10:e44591. [PMID: 36897634 PMCID: PMC10039414 DOI: 10.2196/44591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 02/01/2023] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Although the COVID-19 pandemic resulted in a rapid implementation and scale-up of telehealth for patients in need of rehabilitation, an overall slower scaling up to telerehabilitation has been documented. OBJECTIVE The purpose of this study was to understand experiences of implementing telerehabilitation during the COVID-19 pandemic as well as using the Toronto Rehab Telerehab Toolkit from the perspective of rehabilitation professionals across Canada and internationally. METHODS The study adopted a qualitative descriptive approach that consisted of telephone- or videoconference-supported interviews and focus groups. Participants included rehabilitation providers as well as health care leaders who had used the Toronto Rehab Telerehab Toolkit. Each participant took part in a semi-structured interview or focus group, lasting approximately 30-40 minutes. Thematic analysis was used to understand the barriers and enablers of providing telerehabilitation and implementing the Toronto Rehab Telerehab Toolkit. Three members of the research team independently analyzed a set of the same transcripts and met after each set to discuss their analysis. RESULTS A total of 22 participants participated, and 7 interviews and 4 focus groups were included. The data of participants were collected from both Canadian (Alberta, New Brunswick, and Ontario) and international sites (Australia, Greece, and South Korea). A total of 11 sites were represented, 5 of which focused on neurological rehabilitation. Participants included health care providers (ie, physicians, occupational therapists, physical therapists, speech language pathologists, and social workers), managers and system leaders, as well as research and education professionals. Overall, 4 themes were identified including (1) implementation considerations for telerehabilitation, encompassing 2 subthemes of "infrastructure, equipment, and space" and "leadership and organizational support"; (2) innovations developed as a result of telerehabilitation; (3) the toolkit as a catalyst for implementing telerehabilitation; and (4) recommendations for improving the toolkit. CONCLUSIONS Findings from this qualitative study confirm some of the previously identified experiences with implementing telerehabilitation, but from the perspective of Canadian and international rehabilitation providers and leaders. These findings include the importance of adequate infrastructure, equipment, and space; the key role of organizational or leadership support in adopting telerehabilitation; and availing resources to implement it. Importantly, participants in our study described the toolkit as an important resource to broker networking opportunities and highlighted the need to pivot to telerehabilitation, especially early in the pandemic. Findings from this study will be used to improve the next iteration of the toolkit (Toolkit 2.0) to promote safe, accessible, and effective telerehabilitation to those patients in need in the future.
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Affiliation(s)
- Sarah Munce
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Angie Andreoli
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Mark Bayley
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Meiqi Guo
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth L Inness
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Ailene Kua
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - McKyla McIntyre
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Jagroop D, Houvardas S, Danells CJ, Kochanowski J, French E, Salbach NM, Musselman K, Inness EL, Mansfield A. Rehabilitation clinicians' perspectives of reactive balance training. Disabil Rehabil 2022; 44:7967-7973. [PMID: 34812700 DOI: 10.1080/09638288.2021.2004246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE Reactive balance training (RBT) aims to improve reactive balance control. However, because RBT involves clients losing balance, clinicians may view that it is unsafe or not feasible for some clients. We aimed to explore how clinicians implement RBT to treat balance and mobility issues. MATERIALS AND METHODS Physiotherapists and kinesiologists across Canada who reported that they include RBT in their practices were invited to complete telephone interviews about their experiences with RBT. Interviews were transcribed verbatim, and analysed using a deductive thematic analysis. RESULTS Ten participants completed telephone interviews, which lasted between 30-60 min. Participants primarily worked in a hospital setting (inpatient rehabilitation (n = 3); outpatient rehabilitation (n = 2)), and were treated clients with neurological conditions (n = 5). Four main themes were identified: 1) there is variability in RBT approaches; 2) knowledge can be a barrier and facilitator to RBT; 3) reactive balance control is viewed as an advanced skill; and 4) RBT experience builds confidence. CONCLUSIONS Our findings suggest a need for resources to make clinical implementation of RBT more feasible.Implications for rehabilitationTrust between the therapist and client improves self-efficacy and feelings of apprehension/fear when conducting reactive balance training.Being creative and improvising with equipment that is readily available in clinics enables reactive balance training, without the need for high-tech equipment.Clinicians should consider using standardized tools with reactive balance control components, such as the Balance Evaluation Systems Test or Performance Oriented Mobility Assessment, to assess balance control.
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Affiliation(s)
- David Jagroop
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | | | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
| | | | - Esmé French
- Northwestern Ontario Regional Stroke Network, Thunder Bay, Canada
| | - Nancy M Salbach
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Kristin Musselman
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Faculty of Kinesiology, University of Toronto, Toronto, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Canada.,Evaluative Clinical Sciences, Hurvtiz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Canada
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Inness EL, Jagroop D, Andreoli A, Bayley M, Biasin L, Danells C, Hall J, Mansfield A, McDonald A, Nishri D, Salbach NM, Taylor D, Wong K, Tang A. Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study. Phys Ther 2022; 102:6534400. [PMID: 35194641 DOI: 10.1093/ptj/pzac014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 10/14/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting. METHODS A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework and Consolidated Framework for Implementation Research informed content analysis for clinician and manager perspectives, respectively. RESULTS Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources. CONCLUSION Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills, the provision of clinical decision-making tools, access to expert consultation, the roles and social influence of the interprofessional team and formal and informal leaders, and supportive processes adapted to the local context. IMPACT Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.
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Affiliation(s)
- Elizabeth L Inness
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - David Jagroop
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Angie Andreoli
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Mark Bayley
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Division of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louis Biasin
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Cynthia Danells
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Jayne Hall
- Regional Rehabilitation Outpatient Services, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Avril Mansfield
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Evaluative Clinical Sciences, Hurvtiz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Alison McDonald
- Nova Scotia Rehabilitation & Arthritis Centre, Halifax, NS, Canada
| | - Diane Nishri
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Nancy M Salbach
- KITE-Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Denise Taylor
- St Joseph's Care Group, Thunder Bay, ON, Canada.,Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Karl Wong
- Brain and Spinal Cord Rehabilitation Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Ada Tang
- McMaster University, School of Rehabilitation, Hamilton ON, Canada
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8
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Langer LK, Comper P, Ruttan L, Saverino C, Alavinia SM, Inness EL, Kam A, Lawrence DW, Tam A, Chandra T, Foster E, Bayley MT. Can Sport Concussion Assessment Tool (SCAT) Symptom Scores Be Converted to Rivermead Post-concussion Symptoms Questionnaire (RPQ) Scores and Vice Versa? Findings From the Toronto Concussion Study. Front Sports Act Living 2021; 3:737402. [PMID: 34778758 PMCID: PMC8583872 DOI: 10.3389/fspor.2021.737402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and the Sports Concussion Assessment Tool (SCAT) are widely used self-report tools assessing the type, number, and severity of concussion symptoms. There are overlapping symptoms and domains, though they are scored differently. The SCAT consists of 22 questions with a 7-point Likert scale for a total possible score 132. The RPQ has 16 questions and a 5-point Likert scale for a total of 64 possible points. Being able to convert between the two scores would facilitate comparison of results in the concussion literature. Objectives: To develop equations to convert scores on the SCAT to the RPQ and vice versa. Methods: Adults (17–85 years) diagnosed with a concussion at a referring emergency department were seen in the Hull-Ellis Concussion and Research Clinic, a rapid access concussion clinic at Toronto Rehab–University Health Network (UHN) Toronto Canada, within 7 days of injury. The RPQ and SCAT symptom checklists as well as demographic questionnaires were administered to all participants at Weeks 1, 2, 3, 4, 5, 6, 7, 8, 12, 16. Results: 215 participants had 1,168 matched RPQ and SCAT assessments. Total scores of the RPQ and the SCAT had a rho = 0.91 (p < 0.001); correlations were lower for sub-scores of specific symptom domains (range 0.74–0.87, p < 0.001 for all domain comparisons). An equation was derived to calculate SCAT scores using the number and severity of symptoms on the RPQ. Estimated scores were within 3 points of the observed total score on the SCAT. A second equation was derived to calculate the RPQ from the proportion weighted total score of the SCAT. This equation estimated corresponding scores within 3 points of the observed score on the RPQ. Conclusions: The RPQ and SCAT symptom checklists total scores are highly correlated and can be used to estimate the total score on the corresponding assessment. The symptom subdomains are also strongly correlated between the 2 scales however not as strongly correlated as the total score. The equations will enable researchers and clinicians to quickly convert between the scales and to directly compare concussion research findings.
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Affiliation(s)
- Laura Kathleen Langer
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada
| | - Paul Comper
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Lesley Ruttan
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada.,Graduate Department of Psychological Clinical Science, University of Toronto Scarborough, Toronto, ON, Canada
| | - Cristina Saverino
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Seyed Mohammad Alavinia
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada.,Division of Physical Medicine and Rehab, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Elizabeth L Inness
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Alice Kam
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - David W Lawrence
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Alan Tam
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Tharshini Chandra
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Evan Foster
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Mark T Bayley
- KITE Toronto Rehabilitation Institute, University Health Network Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Division of Physical Medicine and Rehab, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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9
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Sharpe A, Boyes V, Lee C, Murtha C, Mah J, Yoshida K, Marzolini S, Inness EL. Cardiopulmonary Exercise Testing in Stroke Rehabilitation: Benefits and Clinical Utility Perceived by Physiotherapists and Individuals with Stroke. Physiother Can 2021; 73:110-117. [PMID: 34456420 DOI: 10.3138/ptc-2019-0070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Purpose: The purpose of this study was to understand the perceived benefits and clinical utility of cardiopulmonary exercise testing (CPET) from the perspectives of physiotherapists and patients and to explore the factors that influence adopting CPET in a stroke rehabilitation setting. Method: A qualitative descriptive study was conducted. Physiotherapists (n = 6) participated in a focus group to discuss the use of CPET in practice. Patients (n = 8) who had completed CPET during stroke rehabilitation participated in a semi-structured interview to explore their experiences. Thematic analysis was performed. Results: CPET increased the physiotherapists' confidence in prescribing exercise, especially for medically complex patients. Ongoing medical management early post-stroke was a barrier to referral. Physiotherapists expressed decreased confidence in interpreting test results. Consultation with local experts facilitated the use of CPET. Patients described how CPET increased their confidence to participate in exercise. They desired more information before and after CPET to better understand the purpose and results and their relation to their rehabilitation goals. Conclusions: Both physiotherapists and patients described the benefit of having CPET available to support them as they participated in exercise in a stroke rehabilitation setting. Physiotherapists would benefit from having educational tools to support their interpretation and application of test results, and patients would benefit from improved communication and education to support their understanding of the relevance of CPET to their rehabilitation goals. Future research should explore these findings in other stroke rehabilitation settings.
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Affiliation(s)
| | - Valerie Boyes
- Department of Physical Therapy, University of Toronto
| | - Calvin Lee
- Department of Physical Therapy, University of Toronto
| | | | - Justin Mah
- Department of Physical Therapy, University of Toronto
| | - Karen Yoshida
- Department of Physical Therapy, University of Toronto
| | - Susan Marzolini
- Department of Physical Therapy, University of Toronto.,Cardiovascular Prevention and Rehabilitation Program.,The KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ont
| | - Elizabeth L Inness
- Department of Physical Therapy, University of Toronto.,Brain & Spinal Cord Rehabilitation Program.,The KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Ont
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10
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Sweeny M, Habib Perez O, Inness EL, Danells C, Chandra T, Foster E, Comper P, Bayley M, Mochizuki G. The Toronto concussion study: a cross-sectional analysis of balance deficits following acute concussion in community-dwelling adults. Brain Inj 2021; 35:587-595. [PMID: 33734923 DOI: 10.1080/02699052.2021.1891288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: To characterize balance deficits in community-dwelling adults following acute concussion.Design: Cross-sectional observational study.Methods: Individuals with acute concussion (n=100) and healthy controls (n=20) completed the BESS (Balance Error Scoring System) and quiet standing trials on forceplates with the eyes open, closed, or during a cognitive dual task. BESS score and centre-of-pressure root mean square and high-frequency power (0.4-3Hz) were used to characterize group differences. In a secondary analysis, participants were subdivided based on self-reported symptoms of balance problems and dizziness using the SCAT-3 (Sport Concussion Assessment Tool - Third Edition) Symptom Checklist.Results: In comparing individuals with concussion and controls, BESS score (16.0 ± 6.0 vs 12.6 ± 3.8; F(1,116) = 5.814, p = .017) and anteroposterior [F(1.78, 204.2) = 11.93, p < .001] and mediolateral [F(1, 114) = 10.05, p = .002] high-frequency power revealed significant group differences. Dividing individuals based on self-reported symptoms revealed significant differences in mediolateral high frequency power, such that participants reporting balance and dizziness problems as well as those participants not reporting balance or dizziness symptoms following concussion were less stable than controls.Conclusions: Deficits in clinical and posturographic measures of balance occur in community-dwelling adults with concussion. These measures do not align with self-reported balance symptoms. Future research and clinical practice aimed at careful selection of optimized balance assessment is recommended.
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Affiliation(s)
- Michelle Sweeny
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Olinda Habib Perez
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Cynthia Danells
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada
| | - Paul Comper
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada.,Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Canada
| | - Mark Bayley
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute -University Centre, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute,Faculty of Medicine, University of Toronto, Toronto, Canada.,School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Canada
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11
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Mansfield A, Inness EL, Danells CJ, Jagroop D, Bhatt T, Huntley AH. Determining the optimal dose of reactive balance training after stroke: study protocol for a pilot randomised controlled trial. BMJ Open 2020; 10:e038073. [PMID: 32847916 PMCID: PMC7451480 DOI: 10.1136/bmjopen-2020-038073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/30/2020] [Accepted: 07/20/2020] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Falls risk poststroke is highest soon after discharge from rehabilitation. Reactive balance training (RBT) aims to improve control of reactions to prevent falling after a loss of balance. In healthy older adults, a single RBT session can lead to lasting improvements in reactive balance control and prevent falls in daily life. While increasing the dose of RBT does not appear to lead to additional benefit for healthy older adults, stroke survivors, who have more severely impaired balance control, may benefit from a higher RBT dose. Our long-term goal is to determine the optimal dose of RBT in people with subacute stroke. This assessor-blinded pilot randomised controlled trial aims to inform the design of a larger trial to address this long-term goal. METHODS AND ANALYSIS Participants (n=36) will be attending out-patient stroke rehabilitation, and will be randomly allocated to one of three groups: one, three or six RBT sessions. RBT will replace a portion of participants' regular physiotherapy so that the total physical rehabilitation time will be the same for the three groups. Balance and balance confidence will be assessed at: (1) study enrolment; (2) out-patient rehabilitation discharge; and (3) 6 months postdischarge. Participants will report falls and physical activity for 6 months postdischarge. Pilot data will be used to plan the larger trial (ie, sample size estimate using fall rates, and which groups should be included based on between-group trends in pre-to-post training effect sizes for reactive balance control measures). Pilot data will also be used to assess the feasibility of the larger trial (ie, based on the accrual rate, outcome completion rate and feasibility of prescribing specific training doses). ETHICS AND DISSEMINATION Institutional research ethics approval has been received. Study participants will receive a lay summary of results. We will also publish our findings in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04219696; Pre results.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - David Jagroop
- Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
| | - Tanvi Bhatt
- Department of Physical Therapy, University of Illinois, Chicago, Illinois, USA
| | - Andrew H Huntley
- Toronto Rehabilitation Institute - University Health Network, Toronto, Ontario, Canada
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12
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Sweeny M, Inness EL, Singer J, Habib Perez O, Danells C, Chandra T, Foster E, Comper P, Bayley M, Mochizuki G. The Toronto Concussion Study: a longitudinal analysis of balance deficits following concussion in community-dwelling adults. Brain Inj 2020; 34:1384-1394. [DOI: 10.1080/02699052.2020.1802665] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Michelle Sweeny
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan Singer
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, MB, Canada
| | - Olinda Habib Perez
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tharshini Chandra
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Paul Comper
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
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13
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Inness EL, Aqui A, Foster E, Fraser J, Danells CJ, Biasin L, Brunton K, Howe JA, Poon V, Tang A, Mansfield A, Marzolini S, Oh P, Bayley M. Determining Safe Participation in Aerobic Exercise Early After Stroke Through a Graded Submaximal Exercise Test. Phys Ther 2020; 100:1434-1443. [PMID: 32494824 PMCID: PMC7462052 DOI: 10.1093/ptj/pzaa103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 03/01/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The benefits of aerobic exercise early after stroke are well known, but concerns about cardiovascular risk are a barrier to clinical implementation. Symptom-limited exercise testing with electrocardiography (ECG) is recommended but not always feasible. The purpose of this study was to determine the frequency of and corresponding exercise intensities at which ECG abnormalities occurred during submaximal exercise testing that would limit safe exercise prescription beyond those intensities. METHODS This study was a retrospective analysis of ECGs from 195 patients who completed submaximal exercise testing during stroke rehabilitation. A graded submaximal exercise test was conducted with a 5- or 12-lead ECG and was terminated on the basis of predetermined endpoint criteria (heart rate, perceived exertion, signs, or symptoms). ECGs were retrospectively reviewed for exercise-induced abnormalities and their associated heart rates. RESULTS The peak heart rate achieved was 65.4% (SD = 10.5%) of the predicted maximum heart rate or 29.1% (SD = 15.5%) of the heart rate reserve (adjusted for beta-blocker medications). The test was terminated more often because of perceived exertion (93/195) than because of heart rate limits (60/195). Four patients (2.1%) exhibited exercise-induced horizontal or downsloping ST segment depression of ≥1 mm. Except for 1 patient, the heart rate at test termination was comparable with the heart rate associated with the onset of the ECG abnormality. CONCLUSION A graded submaximal exercise test without ECG but with symptom monitoring and conservative heart rate and perceived exertion endpoints may facilitate safe exercise intensities early after stroke. Symptom-limited exercise testing with ECG is still recommended when progressing to higher intensity exercise. IMPACT Concerns about cardiovascular risk are a barrier to physical therapists implementing aerobic exercise in stroke rehabilitation. This study showed that, in the absence of access to exercise testing with ECG, submaximal testing with conservative heart rate and perceived exertion endpoints and symptom monitoring can support physical therapists in the safe prescription of aerobic exercise early after stroke. LAY SUMMARY It is recommended that people with stroke participate in aerobic exercise as early as possible during their rehabilitation. A submaximal exercise test with monitoring of heart rate, perceived exertion, blood pressure, and symptoms can support physical therapists in safely prescribing that exercise.
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Affiliation(s)
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute
| | - Evan Foster
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute
| | - Julia Fraser
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute; and Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Louis Biasin
- Toronto Rehabilitation Institute, University Health Network–Brain and Spinal Cord Rehab Program; and Department of Physical Therapy, University of Toronto
| | - Karen Brunton
- Toronto Rehabilitation Institute, University Health Network–Education; and Department of Physical Therapy, University of Toronto
| | - Jo-Anne Howe
- Toronto Rehabilitation Institute, University Health Network–Education
| | - Vivien Poon
- Toronto Rehabilitation Institute, University Health Network–Brain and Spinal Cord Rehab Program; and Department of Physical Therapy, University of Toronto
| | - Ada Tang
- School of Rehabilitation Science, Institute of Applied Health Science, McMaster University, Hamilton, Ontario, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute; Department of Physical Therapy, University of Toronto; and Sunnybrook Research Institute–Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Toronto, Ontario, Canada
| | - Susan Marzolini
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute and Cardiovascular Prevention and Rehabilitation Program; and Department of Exercise Sciences, Faculty of Kinesiology and Physical Education, University of Toronto
| | - Paul Oh
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute and Cardiovascular Prevention and Rehabilitation Program
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network–KITE Research Institute; and Faculty of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto
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14
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Barzideh A, Marzolini S, Danells C, Jagroop D, Huntley AH, Inness EL, Mathur S, Mochizuki G, Oh P, Mansfield A. Effect of reactive balance training on physical fitness poststroke: study protocol for a randomised non-inferiority trial. BMJ Open 2020; 10:e035740. [PMID: 32606059 PMCID: PMC7328813 DOI: 10.1136/bmjopen-2019-035740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Regular exercise is essential in the chronic phase of stroke recovery for improving or maintaining function, and reducing the risk of a second stroke. To achieve these goals, multiple components of fitness should be targeted with poststroke exercise, including aerobic capacity, strength and balance. However, following the recommended frequency and duration of each component separately can take a long time and lead to fatigue in people with stroke. Therefore, finding types of exercise that target multiple components of fitness all together is valuable.Reactive balance training (RBT) is a novel type of exercise where individuals repeatedly lose their balance in order to practise balance reactions. When people do RBT, they increase their heart rate and exert forces with their leg muscles which could improve aerobic fitness and muscle strength, respectively. This means that RBT could have the potential to improve multiple components of fitness, simultaneously. METHODS AND ANALYSIS This is a randomised controlled non-inferiority trial with internal pilot study. Participants with chronic stroke will be randomly assigned to one of two groups: (1) RBT or (2) aerobic and strength training (AST). Participants in both groups will complete 1 hour of exercise, three times/week for 12 weeks. The primary objective is to determine the effect of RBT on aerobic capacity and knee muscles' strength. The secondary objective is to determine the effects of RBT and AST on balance control and balance confidence. We expect to find that RBT is superior to AST in terms of improving balance control and balance confidence, yet not inferior to AST in terms of its effects on aerobic capacity and strength. ETHICS AND DISSEMINATION Research ethics approval has been received. Results will be disseminated directly to study participants at the end of the trial, and to other stakeholders via publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04042961.
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Affiliation(s)
- Azadeh Barzideh
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Susan Marzolini
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Cynthia Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - David Jagroop
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew H Huntley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Sunita Mathur
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | | | - Paul Oh
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Evaulative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
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15
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Schinkel-Ivy A, Huntley AH, Danells CJ, Inness EL, Mansfield A. Improvements in balance reaction impairments following reactive balance training in individuals with sub-acute stroke: A prospective cohort study with historical control. Top Stroke Rehabil 2019; 27:262-271. [PMID: 31742486 DOI: 10.1080/10749357.2019.1690795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Reactive balance training (RBT) has been previously found to reduce fall risk in individuals with sub-acute stroke; however, our understanding of the effects of RBT on specific balance impairments is lacking.Objective: To quantify changes in common balance reaction impairments in individuals with sub-acute stroke resulting from RBT, relative to traditional balance training, using a prospective cohort study design with a historical control group.Methods: Individuals with sub-acute stroke completed either RBT or traditional balance training as part of their routine care during physiotherapy in inpatient rehabilitation. Reactive balance control was assessed using lean-and-release perturbations pre-intervention, post-intervention, and 6-months post-intervention (follow-up). Individuals with impaired balance reactions (delayed foot-off times, slide steps, and/or a preference for stepping with the preferred limb) at the pre-intervention assessment were identified using video and force plate data. Outcome measures (foot-off times, frequency of trials with slide steps, and stepping with the preferred limb) from the RBT participants with impaired reactions were compared for each of the three assessments to the mean values for the participants with impaired reactions in the historical control group.Results: Improvements were observed in all outcome measures for the RBT participants between pre-intervention and post-intervention, and/or between post-intervention and follow-up. These improvements were generally equivalent to, if not better than, the improvements demonstrated by the historical control group.Conclusions: Findings further support the use of RBT for post-stroke inpatient rehabilitation, and provide insight into specific balance reaction impairments that are improved by RBT.
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Affiliation(s)
- Alison Schinkel-Ivy
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew H Huntley
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
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16
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Mansfield A, Danells CJ, Inness EL, Musselman K, Salbach NM. A survey of Canadian healthcare professionals' practices regarding reactive balance training. Physiother Theory Pract 2019; 37:787-800. [PMID: 31402743 DOI: 10.1080/09593985.2019.1650856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Perturbation-based balance training (PBT) is a relatively new type of balance training that aims to improve control of reactions to a loss of balance. This study aimed to determine the prevalence of use of PBT in clinical practice, and the most significant barriers and facilitators to implementing PBT in practice.Methods: Health-care professionals across Canada (primarily physiotherapists and kinesiologists) who provide balance training to individuals with balance impairments and/or increased fall risk completed a questionnaire that asked about knowledge and use of PBT in practice.Results: Overall, 76.3% of participants (299/392) reported that they had used PBT in their practices, with 22.4% (88/392) reporting regular PBT use. Lack of knowledge of PBT appeared to be the most significant barrier for those not currently using PBT in their practices, whereas individuals who were familiar with PBT and open to using it in practice experienced barriers related to training, knowledge, human resources, client characteristics, and the practice setting. More than 90% of respondents were interested in learning more about almost all aspects of PBT.Conclusions: These findings could be used to inform development of future educational strategies to increase uptake of PBT in rehabilitation practice.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kristin Musselman
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Nancy M Salbach
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada.,Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.,St. John's Rehab-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Borrelli JR, Junod CA, Inness EL, Jones S, Mansfield A, Maki BE. Clinical assessment of reactive balance control in acquired brain injury: A comparison of manual and cable release-from-lean assessment methods. Physiother Res Int 2019; 24:e1787. [PMID: 31209998 DOI: 10.1002/pri.1787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 02/15/2019] [Accepted: 04/07/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Perturbation-evoked stepping reactions are infrequently assessed directly in clinical settings even though stepping reactions in response to a sudden loss-of-balance perturbation ultimately determine whether a fall occurs. Individuals with acquired brain injury (ABI) due to stroke who are ambulatory and awaiting hospital discharge have been found to exhibit delayed stepping reactions but are typically discharged without assessment of perturbation-evoked stepping. Tests that specifically target the capacity to perform perturbation-evoked stepping reactions are important to identify those at risk for falls and to direct intervention strategies. The aim of this study was to evaluate agreement and reliability of two assessment methods used to assess rapid stepping reactions, specifically in individuals with ABI due to stroke or other causes. A secondary aim was to compare perturbation-triggered biomechanics of the two assessment methods. METHODS Thirty-five participants who were less than 4 months post-ABI were evaluated in an inpatient unit at the Toronto Rehabilitation Institute. Stepping reactions were assessed using manual release-from-lean and cable release-from-lean perturbation-based assessment methods. RESULTS There was moderate agreement between the assessment scores resulting from the two assessment methods (κ = 0.55) and substantial test-retest reliability (κ's > 0.61) for both assessment methods. There was no evidence that the assessment score was affected by assessment method, test-retest, or assessment order. However, the cable release from lean resulted in a more rapid release of the lean support force (2 ms vs. 125 ms) and earlier foot-off times (340 ms vs. 401 ms) compared with the manual release from lean. CONCLUSION Delays in foot-off time associated with the manual release-from-lean perturbation raise concerns that the manual assessment method may not provide a perturbation that is sufficiently challenging to reveal a patient's balance-recovery capacity and associated fall risk. However, the manual assessment requires no equipment and the assessment score may provide a useful indication of gross reactive balance control.
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Affiliation(s)
- James R Borrelli
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Christiane A Junod
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Simon Jones
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Brian E Maki
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
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18
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Faure C, Inness EL, Lamontagne ME, Sirois G, Edwards G, McFadyen BJ, Zabjek K. The perspective of rehabilitation health care professionals regarding the clinical utility of a body-environment proximity measurement device. Cogent Medicine 2019. [DOI: 10.1080/2331205x.2019.1605722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Affiliation(s)
- Céline Faure
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, QC, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Marie-Eve Lamontagne
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, QC, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Geneviève Sirois
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, QC, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, QC, Canada
- Centre intégré universitaire de santé et de services sociaux de la Capitale-Nationale, Institut de réadaptation en déficience physique de Québec, Québec, QC, Canada
| | - Geoffrey Edwards
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, QC, Canada
| | - Bradford J. McFadyen
- Centre interdisciplinaire de recherche en réadaptation et intégration sociale (CIRRIS), Québec, QC, Canada
- Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Karl Zabjek
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
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19
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Rozanski GM, Wong JS, Inness EL, Patterson KK, Mansfield A. Longitudinal change in spatiotemporal gait symmetry after discharge from inpatient stroke rehabilitation. Disabil Rehabil 2019; 42:705-711. [DOI: 10.1080/09638288.2018.1508508] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Gabriela M. Rozanski
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Jennifer S. Wong
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kara K. Patterson
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
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Mansfield A, Aqui A, Danells CJ, Knorr S, Centen A, DePaul VG, Schinkel-Ivy A, Brooks D, Inness EL, Mochizuki G. Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial. BMJ Open 2018; 8:e021510. [PMID: 30121600 PMCID: PMC6104758 DOI: 10.1136/bmjopen-2018-021510] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 06/06/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES No intervention has been shown to prevent falls poststroke. We aimed to determine if perturbation-based balance training (PBT) can reduce falls in daily life among individuals with chronic stroke. DESIGN Assessor-blinded randomised controlled trial. SETTING Two academic hospitals in an urban area. INTERVENTIONS Participants were allocated using stratified blocked randomisation to either 'traditional' balance training (control) or PBT. PBT focused on improving responses to instability, whereas traditional balance training focused on maintaining stability during functional tasks. Training sessions were 1 hour twice/week for 6 weeks. Participants were also invited to complete 2 'booster' training sessions during the follow-up. PARTICIPANTS Eighty-eight participants with chronic stroke (>6 months poststroke) were recruited and randomly allocated one of the two interventions. Five participants withdrew; 42 (control) and 41 (PBT group) were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was rate of falls in the 12 months post-training. Negative binomial regression was used to compare fall rates between groups. Secondary outcomes were measures of balance, mobility, balance confidence, physical activity and social integration. RESULTS PBT participants reported 53 falls (1.45 falls/person-year) and control participants reported 64 falls (1.72 falls/person-year; rate ratio: 0.85(0.42 to 1.69); p=0.63). Per-protocol analysis included 32 PBT and 34 control participants who completed at least 10/12 initial training sessions and 1 booster session. Within this subset, PBT participants reported 32 falls (1.07 falls/person-year) and control participants reported 57 falls (1.75 falls/person-year; rate ratio: 0.62(0.29 to 1.30); p=0.20). PBT participants had greater improvement in reactive balance control than the control group, and these improvements were sustained 12 months post-training. There were no intervention-related serious adverse effects. CONCLUSIONS The results are inconclusive. PBT may help to prevent falls in daily life poststroke, but ongoing training may be required to maintain the benefits. TRIAL REGISTRATION NUMBER ISRCTN05434601; Results.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Svetlana Knorr
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew Centen
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Vincent G DePaul
- School of Rehabilitation Therapy, Queen’s University, Kingston, Ontario, Canada
| | - Alison Schinkel-Ivy
- Schulich School of Education – School of Physical and Health Education, Nipissing University, North Bay, Ontario, Canada
| | - Dina Brooks
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Abstract
Stroke, or cerebrovascular accident, involves injury to the central nervous system as a result of a vascular cause, and is a leading cause of disability worldwide. People with stroke often experience sensory, cognitive, and motor sequelae that can lead to difficulty walking, controlling balance in standing and voluntary tasks, and reacting to prevent a fall following an unexpected postural perturbation. This chapter discusses the interrelationships between stroke-related impairments, problems with control of balance and gait, fall risk, fear of falling, and participation in daily physical activity. Rehabilitation can improve balance and walking function, and consequently independence and quality of life, for those with stroke. This chapter also describes effective interventions for improving balance and walking function poststroke, and identifies some areas for further research in poststroke rehabilitation.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network and Department of Physical Therapy, University of Toronto, Toronto, ON, Canada.
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network and Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - William E Mcilroy
- Department of Kinesiology, University of Waterloo and Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Waterloo, ON, Canada
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Inness EL, Bayley M, Biasin L, Brunton K, Danells CJ, Mansfield A, McIlroy WE, Poon V, Salbach NM, Zee J. La promotion de partenariats en recherche clinique pour faire évoluer la pratique de la physiothérapie : le rôle d'une clinique de neuroréadaptation novatrice. Physiother Can 2017. [DOI: 10.3138/ptc.69.3.gef] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network
- Institute of Medical Science
| | - Louis Biasin
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
| | - Karen Brunton
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
| | - Cynthia J. Danells
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
- Sciences évaluatives cliniques, Hurvitz Brain Sciences Program, Sunnybrook Research Institute
| | - William E. McIlroy
- Toronto Rehabilitation Institute, University Health Network
- Rehabilitation Sciences Institute
- Institute of Health Policy, Management and Evaluation, université de Toronto
- département de kinésiologie, université de Waterloo, Waterloo (Ontario)
| | - Vivien Poon
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
| | - Nancy M. Salbach
- Toronto Rehabilitation Institute, University Health Network
- département de physiothérapie
- Rehabilitation Sciences Institute
- St. John's Rehab – Sunnybrook Health Sciences Centre, Toronto
| | - Joanne Zee
- Toronto Rehabilitation Institute, University Health Network
- Institute of Health Policy, Management and Evaluation, université de Toronto
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Mansfield A, Brooks D, Tang A, Taylor D, Inness EL, Kiss A, Middleton L, Biasin L, Fleck R, French E, LeBlanc K, Aqui A, Danells C. Promoting Optimal Physical Exercise for Life (PROPEL): aerobic exercise and self-management early after stroke to increase daily physical activity-study protocol for a stepped-wedge randomised trial. BMJ Open 2017; 7:e015843. [PMID: 28667222 PMCID: PMC5726051 DOI: 10.1136/bmjopen-2017-015843] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/07/2017] [Accepted: 04/25/2017] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Physical exercise after stroke is essential for improving recovery and general health, and reducing future stroke risk. However, people with stroke are not sufficiently active on return to the community after rehabilitation. We developed the Promoting Optimal Physical Exercise for Life (PROPEL) programme, which combines exercise with self-management strategies within rehabilitation to promote ongoing physical activity in the community after rehabilitation. This study aims to evaluate the effect of PROPEL on long-term participation in exercise after discharge from stroke rehabilitation. We hypothesise that individuals who complete PROPEL will be more likely to meet recommended frequency, duration and intensity of exercise compared with individuals who do not complete the programme up to 6 months post discharge from stroke rehabilitation. METHODS AND ANALYSIS Individuals undergoing outpatient stroke rehabilitation at one of six hospitals will be recruited (target n=192 total). A stepped-wedge design will be employed; that is, the PROPEL intervention (group exercise plus self-management) will be 'rolled out' to each site at a random time within the study period. Prior to roll-out of the PROPEL intervention, sites will complete the control intervention (group aerobic exercise only). Participation in physical activity for 6 months post discharge will be measured via activity and heart rate monitors, and standardised physical activity questionnaire. Adherence to exercise guidelines will be evaluated by (1) number of 'active minutes' per week (from the activity monitor), (2) amount of time per week when heart rate is within a target range (ie, 55%-80% of age-predicted maximum) and (3) amount of time per week completing 'moderate' or 'strenuous' physical activities (from the questionnaire). We will compare the proportion of active and inactive individuals at 6 months post intervention using mixed-model logistic regression, with fixed effects of time and phase and random effect of cluster (site). ETHICS AND DISSEMINATION To date, research ethics approval has been received from five of the six sites, with conditional approval granted by the sixth site. Results will be disseminated directly to study participants at the end of the trial, and to other stake holders via publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02951338; Pre-results.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Dina Brooks
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- West Park Healthcare Centre, Toronto, Ontario, Canada
| | - Ada Tang
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Denise Taylor
- St Joseph’s Care Group, Thunder Bay, Ontario, Canada
- Northern Ontario School of Medicine, West Campus, Thunder Bay, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Alex Kiss
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Laura Middleton
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada
| | - Louis Biasin
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Rebecca Fleck
- Regional Rehabilitation Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Esmé French
- Northwestern Ontario Regional Stroke Network, Thunder Bay, Ontario, Canada
| | - Kathryn LeBlanc
- Regional Rehabilitation Program, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Anthony Aqui
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
| | - Cynthia Danells
- Toronto Rehabilitation Institute, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Mansfield A, Schinkel-Ivy A, Danells CJ, Aqui A, Aryan R, Biasin L, DePaul VG, Inness EL. Does Perturbation Training Prevent Falls after Discharge from Stroke Rehabilitation? A Prospective Cohort Study with Historical Control. J Stroke Cerebrovasc Dis 2017; 26:2174-2180. [PMID: 28579506 DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 04/29/2017] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Individuals with stroke fall frequently, and no exercise intervention has been shown to prevent falls post stroke. Perturbation-based balance training (PBT), which involves practicing reactions to instability, shows promise for preventing falls in older adults and individuals with Parkinson's disease. This study aimed to determine if PBT during inpatient stroke rehabilitation can prevent falls after discharge into the community. METHODS Individuals with subacute stroke completed PBT as part of routine inpatient rehabilitation (n = 31). Participants reported falls experienced in daily life for up to 6 months post discharge. Fall rates were compared to a matched historical control group (HIS) who did not complete PBT during inpatient rehabilitation. RESULTS Five of 31 PBT participants, compared to 15 of 31 HIS participants, reported at least 1 fall. PBT participants reported 10 falls (.84 falls per person per year) whereas HIS participants reported 31 falls (2.0 falls per person per year). When controlled for follow-up duration and motor impairment, fall rates were lower in the PBT group than the HIS group (rate ratio: .36 [.15, .79]; P = .016). CONCLUSIONS These findings suggest that PBT is promising for reducing falls post stroke. While this was not a randomized controlled trial, this study may provide sufficient evidence for implementing PBT in stroke rehabilitation practice.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada.
| | - Alison Schinkel-Ivy
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; School of Physical and Health Education, Nipissing University, North Bay, Ontario, Canada
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
| | - Raabeae Aryan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Louis Biasin
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Vincent G DePaul
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
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Rajachandrakumar R, Fraser JE, Schinkel-Ivy A, Inness EL, Biasin L, Brunton K, McIlroy WE, Mansfield A. Atypical anticipatory postural adjustments during gait initiation among individuals with sub-acute stroke. Gait Posture 2017; 52:325-331. [PMID: 28038342 PMCID: PMC5218837 DOI: 10.1016/j.gaitpost.2016.12.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/14/2016] [Accepted: 12/18/2016] [Indexed: 02/02/2023]
Abstract
Anticipatory postural adjustments, executed prior to gait initiation, help preserve lateral stability when stepping. Atypical patterns of anticipatory activity prior to gait initiation may occur in individuals with unilateral impairment (e.g., stroke). This study aimed to determine the prevalence, correlates, and consequences of atypical anticipatory postural adjustment patterns prior to gait initiation in a sub-acute stroke population. Forty independently-ambulatory individuals with sub-acute stroke stood on two force plates and initiated gait at a self-selected speed. Medio-lateral centre of pressure displacement was calculated and used to define anticipatory postural adjustments (shift in medio-lateral centre of pressure >10mm from baseline). Stroke severity, motor recovery, and functional balance and mobility status were also obtained. Three patterns were identified: single (typical), absent (atypical), and multiple (atypical) anticipatory postural adjustments. Thirty-five percent of trials had atypical anticipatory postural adjustments (absent and multiple). Frequency of absent anticipatory postural adjustments was negatively correlated with walking speed. Multiple anticipatory postural adjustments were more prevalent when leading with the non-paretic than the paretic limb. Trials with multiple anticipatory postural adjustments had longer duration of anticipatory postural adjustment and time to foot-off, and shorter unloading time than trials with single anticipatory postural adjustments. A high prevalence of atypical anticipatory control prior to gait initiation was found in individuals with stroke. Temporal differences were identified with multiple anticipatory postural adjustments, indicating altered gait initiation. These findings provide insight into postural control during gait initiation in individuals with sub-acute stroke, and may inform interventions to improve ambulation in this population.
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Affiliation(s)
- Roshanth Rajachandrakumar
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Julia E Fraser
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada
| | - Alison Schinkel-Ivy
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Lou Biasin
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - Karen Brunton
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - William E McIlroy
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada; Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada; University of Waterloo, Waterloo, ON, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute -University Health Network, Toronto, ON, Canada; Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, ON, Canada; Sunnybrook Research Institute, Toronto, ON, Canada.
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Inness EL, Bayley M, Biasin L, Brunton K, Danells CJ, Mansfield A, McIlroy WE, Poon V, Salbach NM, Zee J. Fostering Clinical-Research Partnerships to Advance Physiotherapy Practice: The Role of an Innovative Neuro-Rehabilitation Clinic. Physiother Can 2017; 69:187-192. [PMID: 30275633 PMCID: PMC5963559 DOI: 10.3138/ptc.69.3.gee] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network
- Institute of Medical Science
| | - Louis Biasin
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
| | - Karen Brunton
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
| | - Cynthia J. Danells
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute
| | - William E. McIlroy
- Toronto Rehabilitation Institute, University Health Network
- Rehabilitation Sciences Institute
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Department of Kinesiology, University of Waterloo, Waterloo, Ont
| | - Vivien Poon
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
| | - Nancy M. Salbach
- Toronto Rehabilitation Institute, University Health Network
- Department of Physical Therapy
- Rehabilitation Sciences Institute
- St. John's Rehab – Sunnybrook Health Sciences Centre, Toronto
| | - Joanne Zee
- Toronto Rehabilitation Institute, University Health Network
- Institute of Health Policy, Management and Evaluation, University of Toronto
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Schinkel-Ivy A, Huntley AH, Inness EL, Mansfield A. Timing of reactive stepping among individuals with sub-acute stroke: effects of 'single-task' and 'dual-task' conditions. Heliyon 2016; 2:e00186. [PMID: 27861645 PMCID: PMC5103078 DOI: 10.1016/j.heliyon.2016.e00186] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 09/23/2016] [Accepted: 10/21/2016] [Indexed: 10/26/2022] Open
Abstract
Performance decrements in balance tasks are often observed when a secondary cognitive task is performed simultaneously. This study aimed to determine whether increased cognitive load resulted in altered reactive stepping in individuals with sub-acute stroke, compared to a reactive stepping trial with no secondary task. The secondary purpose was to determine whether differences existed between the first usual-response trial, subsequent usual-response trials, and the dual-task condition. Individuals with sub-acute stroke were exposed to external perturbations to elicit reactive steps. Perturbations were performed under a usual-response (single-task) and dual-task condition. Measures of step timing and number of steps were based on force plate and video data, respectively; these measures were compared between the usual-response and dual-task trials, and between the first usual-response trial, later usual-response trials (trials 2-5) and a dual-task trial. A longer time of unloading onset and greater number of steps were identified for the first usual-response trial compared to later usual-response trials. No significant differences were identified between usual-response and dual-task trials. Although improvements were observed from the first to subsequent usual-response lean-and-release trials, performance then tended to decrease with the introduction of the dual-task condition. These findings suggest that when introduced after usual-response trials, the dual-task trial may represent the first trial of a new condition, which may be beneficial in reducing the potential for adaptation that may occur after multiple repetitions of a reactive stepping task. Therefore, these findings may lend support to the introduction of a new condition (i.e. a dual-task trial) in addition to usual-response trials when assessing reactive balance in individuals with stroke.
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Affiliation(s)
- Alison Schinkel-Ivy
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, Ontario M5G 2A2, Canada; School of Physical and Health Education, Nipissing University, 100 College Drive, Box 5002, North Bay, Ontario P1B 8L7, Canada
| | - Andrew H Huntley
- Human Health and Nutritional Sciences, University of Guelph, 50 Stone Road East, Guelph, Ontario N1G 2W1, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, Ontario M5G 2A2, Canada; Department of Physical Therapy, University of Toronto, 500 University Ave, Toronto, Ontario M5G 1V7, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute-University Health Network, 550 University Ave, Toronto, Ontario M5G 2A2, Canada; Department of Physical Therapy, University of Toronto, 500 University Ave, Toronto, Ontario M5G 1V7, Canada; Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario M4N 3M5, Canada
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Howe JA, Inness EL, Venturini A, Williams JI, Verrier MC. The Community Balance and Mobility Scale-a balance measure for individuals with traumatic brain injury. Clin Rehabil 2016; 20:885-95. [PMID: 17008340 DOI: 10.1177/0269215506072183] [Citation(s) in RCA: 120] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To provide evidence for the validity and reliability of a new outcome measure of balance, the Community Balance and Mobility Scale, developed for the ambulatory individual with traumatic brain injury. Design: A validity and reliability study. Setting: Acute care, in- and outpatient rehabilitation and day hospital settings. Subjects: Two convenience samples ( n=36, 32) of ambulatory patients with traumatic brain injury. Main measures: The content and construct validity, test-retest, inter- and intra-rater reliability and internal consistency of the Community Balance and Mobility Scale. Results: Content validity was demonstrated by the involvement of patients with traumatic brain injury ( n=7) and clinicians ( n=17) in the process of item generation and by physical therapists’ ratings of item relevance. Further support is the correlation of the Community Balance and Mobility Scale scores with physical therapists’ global balance ratings of the patient ( r=0.62). Construct validity was supported by the ability of the measure to differentiate between patients along the continuum of care and also by comparisons with maximal walking velocity ( r=0.64). Patients who scored greater than or less than 50 on the balance measure demonstrated significantly different Community Integration Questionnaire scores ( P=0.004). The Community Balance and Mobility Scale demonstrated intraclass correlation coefficients (ICCs) of 0.977, 0.977, 0.975 and Cronbach’s alpha of 0.96 for intra-, inter-, test-retest reliability and internal consistency, respectively. Conclusion: The Community Balance and Mobility Scale is a valid and reliable outcome measure for the ambulatory individual with traumatic brain injury.
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Affiliation(s)
- J A Howe
- Toronto Rehabilitation Institute and Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada.
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Wong JS, Brooks D, Inness EL, Mansfield A. The Impact of Falls on Motor and Cognitive Recovery after Discharge from In-Patient Stroke Rehabilitation. J Stroke Cerebrovasc Dis 2016; 25:1613-1621. [PMID: 27062418 DOI: 10.1016/j.jstrokecerebrovasdis.2016.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/27/2016] [Accepted: 03/12/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Falls are common among community-dwelling stroke survivors. The aims of this study were (1) to compare motor and cognitive outcomes between individuals who fell in the 6 months' postdischarge from in-patient stroke rehabilitation and those who did not fall, and (2) to explore potential mechanisms underlying the relationship between falls and recovery of motor and cognitive function. METHODS Secondary analysis of a prospective cohort study of individuals discharged home from in-patient rehabilitation was conducted. Participants were recruited at discharge and completed a 6-month falls monitoring period using postcards with follow-up. Nonfallers and fallers were compared at the 6-month follow-up assessment on the Berg Balance Scale (BBS), the Chedoke-McMaster Stroke Assessment (CMSA), gait speed, and the Montreal Cognitive Assessment (MoCA). Measures of balance confidence and physical activity were also assessed. RESULTS Twenty-three fallers were matched to 23 nonfallers on age and functional balance scores at discharge. A total of 43 falls were reported during the study period (8 participants fell more than once). At follow-up, BBS scores (P = .0066) and CMSA foot scores (P = .0033) were significantly lower for fallers than for nonfallers. The 2 groups did not differ on CMSA leg scores (P = .049), gait speed (P = .47), or MoCA score (P = .23). There was no significant association between change in balance confidence scores and change in physical activity levels among all participants from the first and third questionnaire (r = .27, P = .08). CONCLUSIONS Performance in balance and motor recovery of the foot were compromised in fallers when compared to nonfallers at 6 months post discharge from in-patient stroke rehabilitation.
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Affiliation(s)
- Jennifer S Wong
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Dina Brooks
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada; Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada; Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.
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Abstract
OBJECTIVES Stroke rehabilitation best practices recommend interventions to address individual deficits, guided by a comprehensive assessment to identify specific impairments. The relationship of motor impairments to balance has been well investigated, but the role of impaired plantar cutaneous sensation is less understood, despite the fact that 41% of individuals post-stroke have this deficit. The study objectives were to (1) characterize the relationship between plantar sensation and measures of standing balance control and (2) determine the threshold of sensory impairment related to balance impairment post-stroke. METHODS Monofilament test scores, force plate measures of standing balance control and Berg Balance Scale (BBS) scores were extracted from 52 inpatient rehabilitation charts. Spearman correlations were conducted between sensation and balance measures. Receiver operator characteristic (ROC) analysis was completed to determine the monofilament score that best discriminates between individuals with impaired and unimpaired balance (as defined by variability of center of pressure [COP] in the mediolateral direction). RESULTS Plantar sensation of the affected foot was correlated with anteroposterior COP variability in standing with eyes closed and BBS scores. ROC analysis determined that a monofilament cut-off of 4.31 log(mg) discriminated individuals with impaired balance with 73% sensitivity and 70% specificity. DISCUSSION The present results suggest that plantar cutaneous sensation deficits contribute to balance impairment post-stroke. The monofilament cutoff score may help clinicians determine whether impaired plantar cutaneous sensation is a contributing factor to a patient's balance deficits.
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Affiliation(s)
- Stephen L Parsons
- a Health and Rehabilitation Sciences , Western University , London , Canada.,b Department of Research , Toronto Rehab, University Health Network , Toronto , Canada
| | - Avril Mansfield
- b Department of Research , Toronto Rehab, University Health Network , Toronto , Canada.,c Clinical Evaluative Sciences , Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute , Toronto , Canada.,d Department of Physical Therapy , University of Toronto , Toronto , Canada
| | - Elizabeth L Inness
- b Department of Research , Toronto Rehab, University Health Network , Toronto , Canada.,d Department of Physical Therapy , University of Toronto , Toronto , Canada
| | - Kara K Patterson
- a Health and Rehabilitation Sciences , Western University , London , Canada.,b Department of Research , Toronto Rehab, University Health Network , Toronto , Canada.,d Department of Physical Therapy , University of Toronto , Toronto , Canada
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Schinkel-Ivy A, Singer JC, Inness EL, Mansfield A. Do quiet standing centre of pressure measures within specific frequencies differ based on ability to recover balance in individuals with stroke? Clin Neurophysiol 2016; 127:2463-71. [PMID: 27178866 DOI: 10.1016/j.clinph.2016.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/24/2015] [Accepted: 02/24/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine whether quiet standing measures at specific frequency levels (representative of reactive control) differed between individuals with stroke based on their ability to recover balance (Failed or Successful Responses to external perturbations). METHODS Individuals with stroke completed a clinical assessment, including 30 s of quiet standing and lean-and-release postural perturbations, at admission to in-patient rehabilitation. Quiet standing centre of pressure (COP) signals were calculated and discrete wavelet decomposition was performed. Net COP amplitude, between-limb synchronization, and ratios of individual-limb COP were determined for each frequency level of interest, and for the non-decomposed signal (all frequency levels). Outcome measures were compared between individuals who exhibited Failed and Successful Responses during (a) unconstrained and (b) encouraged-use lean-and-release trials. RESULTS Individuals with Failed Responses during the unconstrained lean-and-release trials displayed greater net COP amplitude than those with Successful Responses, specifically within a frequency range of 0.40-3.20Hz. CONCLUSIONS Reduced ability to recover balance among individuals with stroke may be reflected in impaired reactive control of quiet standing. SIGNIFICANCE These results provide insight into the mechanism by which reactive control of quiet standing is impaired in individuals with stroke, and may inform assessment and rehabilitation strategies for post-stroke reactive balance control.
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Affiliation(s)
- Alison Schinkel-Ivy
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON M5G 2A2, Canada.
| | - Jonathan C Singer
- Faculty of Kinesiology and Recreation Management, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB R3T 2N2, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON M5G 2A2, Canada; Department of Physical Therapy, University of Toronto, 500 University Ave, Toronto, ON M5G 1V7, Canada
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave, Toronto, ON M5G 2A2, Canada; Department of Physical Therapy, University of Toronto, 500 University Ave, Toronto, ON M5G 1V7, Canada; Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, ON M4N 3M5, Canada
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Schinkel-Ivy A, Inness EL, Mansfield A. Relationships between fear of falling, balance confidence, and control of balance, gait, and reactive stepping in individuals with sub-acute stroke. Gait Posture 2016; 43:154-9. [PMID: 26482234 PMCID: PMC5045898 DOI: 10.1016/j.gaitpost.2015.09.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 09/16/2015] [Accepted: 09/18/2015] [Indexed: 02/02/2023]
Abstract
Fear of falling is common in individuals with stroke; however, the associations between fear of falling, balance confidence, and the control of balance and gait are not well understood for this population. This study aimed to determine whether, at the time of admission to in-patient rehabilitation, specific features of balance and gait differed between individuals with stroke who did and did not report fear of falling, and whether these features were related to balance confidence. Individuals with stroke entering in-patient rehabilitation were asked if they were afraid of falling, and completed the Activities-Specific Balance Confidence Scale. Participants performed quiet standing, gait, and reactive stepping tasks, and specific measures were extracted for each (quiet standing: centre of pressure amplitude, between-limb synchronization, and Romberg quotients; gait: walking velocity, double support time, and variability measures; reactive stepping: number of steps, frequency of grasp reactions, and frequency of assists). No significant differences were identified between individuals with and without fear of falling. Balance confidence was negatively related to centre of pressure amplitude, double support time, and step time variability, and positively related to walking velocity. Low balance confidence was related to poor quiet standing balance control and cautious behavior when walking in individuals with sub-acute stroke. While the causal relationship between balance confidence and the control of balance and gait is unclear from the current work, these findings suggest there may be a role for interventions to increase balance confidence among individuals with stroke, in order to improve functional mobility.
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Affiliation(s)
- Alison Schinkel-Ivy
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave., Toronto, ON, Canada M5G 2A2,Corresponding author. Tel.: +1 416 597 3422x7820.
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave., Toronto, ON, Canada M5G 2A2,University of Toronto, 500 University Ave., Toronto, ON, Canada M5G 1V7
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, 550 University Ave., Toronto, ON, Canada M5G 2A2,University of Toronto, 500 University Ave., Toronto, ON, Canada M5G 1V7,Evaluative Clinical Sciences, Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, 2075 Bayview Ave., Toronto, ON, Canada M4 N 3M5 1
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Mansfield A, Inness EL. Force Plate Assessment of Quiet Standing Balance Control: Perspectives on Clinical Application within Stroke Rehabilitation. Rehabil Process Outcome 2015. [DOI: 10.4137/rpo.s20363] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Assessment of balance control is essential to guide physical rehabilitation poststroke. However, current observational assessment tools available to physiotherapists provide limited information about underlying dyscontrol. This paper describes a force plate-based assessment of quiet standing balance control that we have implemented for individuals attending inpatient stroke rehabilitation. The assessment uses two force plates to measure location of ground reaction forces to maintain stability in quiet standing in five conditions (eyes open, eyes closed, standing symmetrically, and maximal loading on the less-affected and more-affected limbs). Measures of interest are variability of the centers of pressure under each foot and both feet combined, weight-bearing asymmetry, and correlation of center of pressure fluctuations between limbs. We present representative values for the above-mentioned measures and case examples to illustrate how the assessment can reveal patient-specific balance control problems and direct treatment. We identify limitations to our current assessment and recommendations for future research.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Canadian Partnership for Stroke Recovery, Ottawa, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
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Mansfield A, Aqui A, Centen A, Danells CJ, DePaul VG, Knorr S, Schinkel-Ivy A, Brooks D, Inness EL, McIlroy WE, Mochizuki G. Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. BMC Neurol 2015; 15:87. [PMID: 26048054 PMCID: PMC4456796 DOI: 10.1186/s12883-015-0347-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 05/29/2015] [Indexed: 11/10/2022] Open
Abstract
Background Falls are one of the most common medical complications post-stroke. Physical exercise, particularly exercise that challenges balance, reduces the risk of falls among healthy and frail older adults. However, exercise has not proven effective for preventing falls post-stroke. Falls ultimately occur when an individual fails to recover from a loss of balance. Thus, training to specifically improve reactive balance control could prevent falls. Perturbation training aims to improve reactive balance control by repeatedly exposing participants to postural perturbations. There is emerging evidence that perturbation training reduces fall rates among individuals with neurological conditions, such as Parkinson disease. The primary aim of this work is to determine if perturbation-based balance training can reduce occurrence of falls in daily life among individuals with chronic stroke. Secondary objectives are to determine the effect of perturbation training on balance confidence and activity restriction, and functional balance and mobility. Methods/design Individuals with chronic stroke will be recruited. Participants will be randomly assigned to one of two groups: 1) perturbation training, or 2) ‘traditional’ balance training. Perturbation training will involve both manual perturbations (e.g., a push or pull from a physiotherapist), and rapid voluntary movements to cause a loss of balance. Training will occur twice per week for 6 weeks. Participants will record falls and activity for 12 months following completion of the training program. Standardized clinical tools will be used to assess functional balance and mobility, and balance confidence before and after training. Discussion Falls are a significant problem for those with stroke. Despite the large body of work demonstrating effective interventions, such as exercise, for preventing falls in other populations, there is little evidence for interventions that prevent falls post-stroke. The proposed study will investigate a novel and promising intervention: perturbation training. If effective, this training has the potential to not only prevent falls, but to also improve safe independent mobility and engagement in daily activities for those with stroke. Trial registration Current Controlled Trials: ISRCTN05434601.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Anthony Aqui
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
| | - Andrew Centen
- Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Cynthia J Danells
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
| | - Vincent G DePaul
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada. .,St Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
| | - Svetlana Knorr
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
| | - Alison Schinkel-Ivy
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada.
| | - Dina Brooks
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada.
| | - William E McIlroy
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada. .,Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.
| | - George Mochizuki
- Toronto Rehabilitation Institute, University Health Network, Room 11-117, 550 University Avenue, Toronto, ON, M5G 2A2, Canada. .,Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada. .,Department of Physical Therapy and Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada. .,Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada.
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Pak P, Jawed H, Tirone C, Lamb B, Cott C, Brunton K, Mansfield A, Inness EL. Incorporating research technology into the clinical assessment of balance and mobility: perspectives of physiotherapists and people with stroke. Physiother Can 2015; 67:1-8. [PMID: 25931648 DOI: 10.3138/ptc.2013-63] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe the perspectives of people with stroke and their physiotherapists on the use of biomechanics technology to assess balance and mobility. METHODS This qualitative study used semi-structured interviews with patients with stroke and a focus group with their physiotherapists. Coding of interview and focus-group data used a line-by-line inductive approach, with qualitative software to develop codes into themes. RESULTS The quantitative data from the assessment were seen as beneficial to providing patients with insight into balance and mobility problems. Physiotherapists found that the assessment confirmed clinical reasoning and aided in precise evaluation of progress but expressed mixed opinions as to whether treatment choice was influenced. Patients would have liked more communication regarding the purpose of the assessment. Patients also stated that trust in their physiotherapists helped them overcome anxieties and that confidence was gained through exposure to more challenging balance assessments. Physiotherapists advocated for the use of a harness system to safely incorporate reactive balance control assessment and training into practice. CONCLUSION Both patients and therapists saw value in the quantitative data provided by the assessment. Regardless of the technology used, patients value a strong physiotherapist-patient relationship. Ongoing collaboration between clinicians and researchers should guide the evolution of technology into clinically useful tools.
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Affiliation(s)
| | | | | | | | - Cheryl Cott
- Department of Physical Therapy ; Graduate Department of Rehabilitation Sciences, University of Toronto ; Toronto Rehabilitation Institute ; Toronto Western Research Institute, University Health Network
| | - Karen Brunton
- Department of Physical Therapy ; Toronto Rehabilitation Institute
| | - Avril Mansfield
- Department of Physical Therapy ; Graduate Department of Rehabilitation Sciences, University of Toronto ; Toronto Rehabilitation Institute ; Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto
| | - Elizabeth L Inness
- Department of Physical Therapy ; Graduate Department of Rehabilitation Sciences, University of Toronto ; Toronto Rehabilitation Institute
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Inness EL, Mansfield A, Biasin L, Brunton K, Bayley M, McIlroy WE. Clinical implementation of a reactive balance control assessment in a sub-acute stroke patient population using a 'lean-and-release' methodology. Gait Posture 2015; 41:529-34. [PMID: 25596621 DOI: 10.1016/j.gaitpost.2014.12.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Revised: 12/02/2014] [Accepted: 12/03/2014] [Indexed: 02/02/2023]
Abstract
Reactive balance control, specifically performance of rapid stepping responses, is associated with falls, but not routinely assessed in clinical practice. Challenges to clinical assessment may include a lack of available methods that are safe, standardized and able to quantify the balance responses. We implemented a reactive balance control assessment, using lean-and-release methodology, in an inpatient stroke rehabilitation program. Through retrospective chart review of all admissions (n=183) over a 1-year period, we evaluated the clinical uptake and patient-specific factors associated with its use. Seventy-seven of 183 (42%) patients were administered the assessment, on average, 16.2 (SD 13.1) days post-admission. Patients who received the assessment were younger, at an earlier time post-stroke, with a shorter rehabilitation length of stay, with less lower-limb impairment, higher levels of functional balance, less motor and cognitive impairment, greater recovery of functional mobility, and were more likely to have the capacity to walk (all measures p<0.0001), compared to those who did not receive the assessment. This study demonstrates the potential for clinical uptake of the lean-and-release assessment among patients with stroke, who are progressing in their functional and mobility status over the course of their inpatient rehabilitation. However, the results suggest limitations in application to patients with greater disability or who demonstrate slower recovery of functional mobility. Ongoing research is required to develop clinical approaches to reactive balance control assessment that are effective, efficient and relevant to clinical populations and feasible for clinical practice.
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Affiliation(s)
- Elizabeth L Inness
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada.
| | - Avril Mansfield
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada; Heart & Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - Louis Biasin
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Karen Brunton
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Mark Bayley
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Heart & Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada
| | - William E McIlroy
- Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada; Department of Physical Therapy, University of Toronto, Toronto, ON, Canada; Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada; Heart & Stroke Foundation, Canadian Partnership for Stroke Recovery, Ottawa, ON, Canada; Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
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Mansfield A, Wong JS, Bryce J, Brunton K, Inness EL, Knorr S, Jones S, Taati B, McIlroy WE. Use of Accelerometer-Based Feedback of Walking Activity for Appraising Progress With Walking-Related Goals in Inpatient Stroke Rehabilitation: A Randomized Controlled Trial. Neurorehabil Neural Repair 2015; 29:847-57. [PMID: 25605632 DOI: 10.1177/1545968314567968] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Regaining independent ambulation is important to those with stroke. Increased walking practice during "down time" in rehabilitation could improve walking function for individuals with stroke. OBJECTIVE To determine the effect of providing physiotherapists with accelerometer-based feedback on patient activity and walking-related goals during inpatient stroke rehabilitation. METHODS Participants with stroke wore accelerometers around both ankles every weekday during inpatient rehabilitation. Participants were randomly assigned to receive daily feedback about walking activity via their physiotherapists (n = 29) or to receive no feedback (n = 28). Changes in measures of daily walking (walking time, number of steps, average cadence, longest bout duration, and number of "long" walking bouts) and changes in gait control and function assessed in-laboratory were compared between groups. RESULTS There was no significant increase in walking time, number of steps, longest bout duration, or number of long walking bouts for the feedback group compared with the control group (P values > .20). However, individuals who received feedback significantly increased cadence of daily walking more than the control group (P = .013). From the in-laboratory gait assessment, individuals who received feedback had a greater increase in walking speed and decrease in step time variability than the control group (P values < .030). CONCLUSION Feedback did not increase the amount of walking completed by individuals with stroke. However, there was a significant increase in cadence, indicating that intensity of daily walking was greater for those who received feedback than the control group. Additionally, more intense daily walking activity appeared to translate to greater improvements in walking speed.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Jennifer S Wong
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada
| | - Jessica Bryce
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - Karen Brunton
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada
| | - Svetlana Knorr
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - Simon Jones
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada
| | - Babak Taati
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada
| | - William E McIlroy
- Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Toronto, Ontario, Canada University of Toronto, Toronto, Ontario, Canada Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada University of Waterloo, Waterloo, Ontario, Canada
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Brown C, Fraser JE, Inness EL, Wong JS, Middleton LE, Poon V, McIlroy WE, Mansfield A. Does Participation in Standardized Aerobic Fitness Training During Inpatient Stroke Rehabilitation Promote Engagement in Aerobic Exercise After Discharge? A Cohort Study. Top Stroke Rehabil 2015; 21 Suppl 1:S42-51. [DOI: 10.1310/tsr21s1-s42] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chisholm AE, Makepeace S, Inness EL, Perry SD, McIlroy WE, Mansfield A. Spatial-Temporal Gait Variability Poststroke: Variations in Measurement and Implications for Measuring Change. Arch Phys Med Rehabil 2014; 95:1335-41. [DOI: 10.1016/j.apmr.2014.02.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 11/26/2022]
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Patterson KK, Mansfield A, Biasin L, Brunton K, Inness EL, McIlroy WE. Longitudinal Changes in Poststroke Spatiotemporal Gait Asymmetry Over Inpatient Rehabilitation. Neurorehabil Neural Repair 2014; 29:153-62. [DOI: 10.1177/1545968314533614] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. Little information exists about longitudinal changes in spatiotemporal gait asymmetry during rehabilitation, despite it being a common goal. Objectives. To describe longitudinal changes in spatiotemporal gait asymmetry over rehabilitation and examine relationships with changes in other poststroke impairments. Methods. Retrospective chart reviews were conducted for 71 stroke rehabilitation inpatients. Admission and discharge measures of spatiotemporal symmetry, velocity, motor impairment, mobility and balance were extracted and change scores were calculated. Relationships between changes in spatiotemporal symmetry and other change scores were investigated with Spearman correlations. Individuals were divided into four groups (worse, no change-symmetric, no change-asymmetric, improved) based on (1) symmetry/asymmetry at admission and (2) symmetry change scores >minimal detectable change. Differences in change scores between groups were investigated with analyses of covariance using the admission value as a covariate. Results. At admission, 59% and 49% of individuals were asymmetric in swing time and step length, respectively. Of these individuals, 21% and 14% improved swing symmetry or step symmetry, respectively. In contrast, 30% improved gait velocity, 62% improved functional balance and 73% improved functional mobility. Associations between change in swing symmetry and change in paretic limb weight bearing in standing and change in step symmetry and change in velocity were significant. There were no significant differences in change scores between the symmetry groups. Conclusions. The majority of asymmetric stroke patients did not improve spatiotemporal asymmetry during rehabilitation despite the fact that velocity, balance and functional mobility improved. Future work should investigate other factors associated with improved spatiotemporal symmetry and interventions to specifically improve it.
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Affiliation(s)
- Kara K. Patterson
- University of Toronto, Toronto, Ontario, Canada
- Toronto Rehab, University Health Network, Toronto, Ontario, Canada
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Avril Mansfield
- University of Toronto, Toronto, Ontario, Canada
- Toronto Rehab, University Health Network, Toronto, Ontario, Canada
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Louis Biasin
- Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Karen Brunton
- University of Toronto, Toronto, Ontario, Canada
- Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Elizabeth L. Inness
- University of Toronto, Toronto, Ontario, Canada
- Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - William E. McIlroy
- Toronto Rehab, University Health Network, Toronto, Ontario, Canada
- Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- University of Waterloo, Waterloo, Ontario, Canada
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Wong JS, Jasani H, Poon V, Inness EL, McIlroy WE, Mansfield A. Inter- and intra-rater reliability of the GAITRite system among individuals with sub-acute stroke. Gait Posture 2014; 40:259-61. [PMID: 24630463 DOI: 10.1016/j.gaitpost.2014.02.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/03/2014] [Accepted: 02/09/2014] [Indexed: 02/02/2023]
Abstract
Technology-based assessment tools with semi-automated processing, such as pressure-sensitive mats used for gait assessment, may be considered to be objective; therefore it may be assumed that rater reliability is not a concern. However, user input is often required and rater reliability must be determined. The purpose of this study was to assess the inter- and intra-rater reliability of spatial and temporal characteristics of gait in stroke patients using the GAITRite system. Forty-six individuals with stroke attending in-patient rehabilitation walked across the pressure-sensitive mat 2-4 times at preferred walking speeds, with or without a gait aid. Five raters independently processed gait data. Three raters re-processed the data after a delay of at least one month. The intraclass correlation coefficients (ICC) and 95% confidence intervals of the ICC were determined for velocity, step time, step length, and step width. Inter-rater reliability for velocity, step time, and step length were high (ICC>0.90). Intra-rater reliability was generally greater than inter-rater reliability (from 0.81 to >0.99 for inter-rater versus 0.77 to >0.99 for intra-rater reliability). Overall, this study suggests that GAITRite is a reliable assessment tool; however, there still remains subjectivity in processing the data, resulting in no patients with perfect agreement between raters. Additional logic checking within the processing software or standardization of training could help to reduce potential errors in processing.
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Affiliation(s)
- Jennifer S Wong
- University of Toronto, Toronto, ON, Canada; Toronto Rehabilitation Institute - UHN, Toronto, ON, Canada
| | - Hardika Jasani
- Toronto Rehabilitation Institute - UHN, Toronto, ON, Canada; University of Waterloo, Waterloo, ON, Canada
| | - Vivien Poon
- University of Toronto, Toronto, ON, Canada; Toronto Rehabilitation Institute - UHN, Toronto, ON, Canada
| | - Elizabeth L Inness
- University of Toronto, Toronto, ON, Canada; Toronto Rehabilitation Institute - UHN, Toronto, ON, Canada
| | - William E McIlroy
- University of Toronto, Toronto, ON, Canada; Toronto Rehabilitation Institute - UHN, Toronto, ON, Canada; University of Waterloo, Waterloo, ON, Canada; Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, ON, Canada
| | - Avril Mansfield
- University of Toronto, Toronto, ON, Canada; Toronto Rehabilitation Institute - UHN, Toronto, ON, Canada; Heart and Stroke Foundation Canadian Partnership for Stroke Recovery, ON, Canada.
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Hendrickson J, Patterson KK, Inness EL, McIlroy WE, Mansfield A. Relationship between asymmetry of quiet standing balance control and walking post-stroke. Gait Posture 2014; 39:177-81. [PMID: 23877032 DOI: 10.1016/j.gaitpost.2013.06.022] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 04/29/2013] [Accepted: 06/28/2013] [Indexed: 02/02/2023]
Abstract
Spatial and temporal gait asymmetry is common after stroke. Such asymmetric gait is inefficient, can contribute to instability and may lead to musculoskeletal injury. However, understanding of the determinants of such gait asymmetry remains incomplete. The current study is focused on revealing if there is a link between asymmetry during the control of standing balance and asymmetry during walking. This study involved review of data from 94 individuals with stroke referred to a gait and balance clinic. Participants completed three tests: (1) walking at their usual pace; (2) quiet standing; and (3) standing with maximal loading of the paretic side. A pressure sensitive mat recorded placement and timing of each footfall during walking. Standing tests were completed on two force plates to evaluate symmetry of weight bearing and contribution of each limb to balance control. Multiple regression was conducted to determine the relationships between symmetry during standing and swing time, stance time, and step length symmetry during walking. Symmetry of antero-posterior balance control and weight bearing were related to swing time and step length symmetry during walking. Weight-bearing symmetry, weight-bearing capacity, and symmetry of antero-posterior balance control were related to stance time symmetry. These associations were independent of underlying lower limb impairment. The results support the hypothesis that impaired ability of the paretic limb to control balance may contribute to gait asymmetry post-stroke. Such work suggests that rehabilitation strategies that increase the contribution of the paretic limb to standing balance control may increase symmetry of walking post-stroke.
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Affiliation(s)
- Janna Hendrickson
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada; Mobility Team, Toronto Rehabilitation Institute, Toronto, ON, Canada
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Sibley KM, Inness EL, Straus SE, Salbach NM, Jaglal SB. Clinical assessment of reactive postural control among physiotherapists in Ontario, Canada. Gait Posture 2013; 38:1026-31. [PMID: 23810087 DOI: 10.1016/j.gaitpost.2013.05.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 05/15/2013] [Accepted: 05/22/2013] [Indexed: 02/02/2023]
Abstract
Reactive postural control, the ability to recover from an external perturbation to stability, ultimately determines whether an individual will fall following a loss of balance and should be routinely incorporated in balance assessment. The purpose of this study was to identify (1) methods used to assess reactive postural control in clinical practice and (2) factors associated with regular assessment of reactive postural control. A cross-sectional survey was conducted. Three hundred and fifty-seven physiotherapists in Ontario, Canada who treated adults with balance impairments answered questions about the components of balance they assess and how they assess reactive control in their practice. Of the 273 respondents who assessed reactive postural control at least some of the time, 15.4% used a standardized measure, 79.1% used a non-standardized approach, and 5.5% used both. Forty-five methods of assessing reactive control were reported. The most common methods used were non-standardized perturbations (43.5%; 104/239 respondents) and movement observation (18.8%; 45/239). The remaining 43 methods were each used by less than 8% of respondents. Practice area had the strongest association with regular assessment of reactive postural control (>60% of the time), and respondents working with neurological disorders were more likely to regularly evaluate reactive control than those working with people with orthopedic conditions. Despite the availability of valid standardized measures to evaluate reactive postural control, respondents relied primarily on non-standardized approaches and observational assessment. Future work should examine the factors influencing choice of reactive control assessment tools and awareness of standardized measures for reactive postural control.
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Affiliation(s)
- K M Sibley
- Toronto Rehabilitation Institute, University Health Network, Canada; Department of Physical Therapy, University of Toronto, Canada
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44
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Mansfield A, Wong JS, Bayley M, Biasin L, Brooks D, Brunton K, Howe JA, Inness EL, Jones S, Lymburner J, Mileris R, McIlroy WE. Using wireless technology in clinical practice: does feedback of daily walking activity improve walking outcomes of individuals receiving rehabilitation post-stroke? Study protocol for a randomized controlled trial. BMC Neurol 2013; 13:93. [PMID: 23865593 PMCID: PMC3723815 DOI: 10.1186/1471-2377-13-93] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 07/16/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Regaining independent ambulation is the top priority for individuals recovering from stroke. Thus, physical rehabilitation post-stroke should focus on improving walking function and endurance. However, the amount of walking completed by individuals with stroke attending rehabilitation is far below that required for independent community ambulation. There has been increased interest in accelerometer-based monitoring of walking post-stroke. Walking monitoring could be integrated within the goal-setting process for those with ambulation goals in rehabilitation. The feedback from these devices can be downloaded to a computer to produce reports. The purpose of this study is to determine the effect of accelerometer-based feedback of daily walking activity during rehabilitation on the frequency and duration of walking post-stroke. METHODS Participants will be randomly assigned to one of two groups: feedback or no feedback. Participants will wear accelerometers daily during in- and out-patient rehabilitation and, for participants in the feedback group, the participants' treating physiotherapist will receive regular reports of walking activity. The primary outcome measures are the amount of daily walking completed, as measured using the accelerometers, and spatio-temporal characteristics of walking (e.g. walking speed). We will also examine goal attainment, satisfaction with progress towards goals, stroke self-efficacy, and community-integration. DISCUSSION Increased walking activity during rehabilitation is expected to improve walking function and community re-integration following discharge. In addition, a focus on altering walking behaviour within the rehabilitation setting may lead to altered behaviour and increased activity patterns after discharge. TRIAL REGISTRATION ClinicalTrials.gov NCT01521234.
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Affiliation(s)
- Avril Mansfield
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Heart and Stroke Foundation Centre for Stroke Recovery, Toronto Rehabilitation Institute and Sunnybrook Health Sciences Centre sites, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada
| | - Jennifer S Wong
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Mark Bayley
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Heart and Stroke Foundation Centre for Stroke Recovery, Toronto Rehabilitation Institute and Sunnybrook Health Sciences Centre sites, Toronto, ON, Canada
| | - Lou Biasin
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Dina Brooks
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada
| | - Karen Brunton
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Jo-Anne Howe
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Elizabeth L Inness
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada
| | - Simon Jones
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Jackie Lymburner
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Ramona Mileris
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - William E McIlroy
- Balance Mobility and Falls Clinic and Mobility Research Team, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Heart and Stroke Foundation Centre for Stroke Recovery, Toronto Rehabilitation Institute and Sunnybrook Health Sciences Centre sites, Toronto, ON, Canada
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
- Graduate Department of Rehabilitation Science, University of Toronto, Toronto, ON, Canada
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
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Sibley KM, Straus SE, Inness EL, Salbach NM, Jaglal SB. Clinical balance assessment: perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada. Implement Sci 2013; 8:33. [PMID: 23510277 PMCID: PMC3606836 DOI: 10.1186/1748-5908-8-33] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Accepted: 03/13/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Balance impairment is common in multiple clinical populations, and comprehensive assessment is important for identifying impairments, planning individualized treatment programs, and evaluating change over time. However, little information is available regarding whether clinicians who treat balance are satisfied with existing assessment tools. In 2010 we conducted a cross-sectional survey of balance assessment practices among physiotherapists in Ontario, Canada, and reported on the use of standardized balance measures (Sibley et al. 2011 Physical Therapy; 91: 1583-91). The purpose of this study was to analyse additional survey data and i) evaluate satisfaction with current balance assessment practices and standardized measures among physiotherapists who treat adult or geriatric populations with balance impairment, and ii) identify factors associated with satisfaction. METHODS The questionnaire was distributed to 1000 practicing physiotherapists. This analysis focuses on questions in which respondents were asked to rate their general perceptions about balance assessment, the perceived utility of individual standardized balance measures, whether they wanted to improve balance assessment practices, and why. Data were summarized with descriptive statistics and utility of individual measures was compared across clinical practice areas (orthopaedic, neurological, geriatric or general rehabilitation). RESULTS The questionnaire was completed by 369 respondents, of which 43.4% of respondents agreed that existing standardized measures of balance meet their needs. In ratings of individual measures, the Single Leg Stance test and Berg Balance Scale were perceived as useful for clinical decision-making and evaluating change over time by over 70% of respondents, and the Timed Up-and-Go test was perceived as useful for decision-making by 56.9% of respondents and useful for evaluating change over time by 62.9% of respondents, but there were significant differences across practice groups. Seventy-nine percent of respondents wanted to improve their assessments, identifying individual, environmental and measure-specific barriers. The most common barriers were lack of time and knowledge. CONCLUSIONS This study offers new information on issues affecting the evaluation of balance in clinical settings from a broad sample of physiotherapists. Continued work to address barriers by specific practice area will be critical for the success of any intervention attempting to implement optimal balance assessment practices in the clinical setting.
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Affiliation(s)
- Kathryn M Sibley
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Sharon E Straus
- Li-Ka-Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada
- Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Elizabeth L Inness
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada
- Graduate Department of Rehabilitation Sciences, University of Toronto, Toronto, Canada
| | - Nancy M Salbach
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
| | - Susan B Jaglal
- Toronto Rehabilitation Institute- University Health Network, Toronto, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Canada
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Mansfield A, Inness EL, Wong JS, Fraser JE, McIlroy WE. Is Impaired Control of Reactive Stepping Related to Falls During Inpatient Stroke Rehabilitation? Neurorehabil Neural Repair 2013; 27:526-33. [DOI: 10.1177/1545968313478486] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Individuals with stroke fall more often than age-matched controls. Although many focus on the multifactorial nature of falls, the fundamental problem is likely the ability for an individual to generate reactions to recover from a loss of balance. Stepping reactions to recover balance are particularly important to balance recovery, and individuals with stroke have difficulty executing these responses to prevent a fall following a loss of balance. Objective. The purpose of this study is to determine if characteristics of balance recovery steps are related to falls during inpatient stroke rehabilitation. Methods. We conducted a retrospective review of individuals with stroke attending inpatient rehabilitation (n = 136). Details of falls experienced during inpatient rehabilitation were obtained from incident reports, nursing notes, and patient interviews. Stepping reactions were evoked using a “release-from-lean” postural perturbation. Poisson regression was used to determine characteristics of stepping reactions that were related to increased fall frequency relative to length of stay. Results. In all, 20 individuals experienced 29 falls during inpatient rehabilitation. The characteristics of stepping reactions significantly related to increased fall rates were increased frequency of external assistance to prevent a fall to the floor, increased frequency of no-step responses, increased frequency of step responses with inadequate foot clearance, and delayed time to initiate stepping responses. Conclusions. Impaired control of balance recovery steps is related to increased fall rates during inpatient stroke rehabilitation. This study informs the specific features of stepping reactions that can be targeted with physiotherapy intervention during inpatient rehabilitation to improve dynamic stability control and potentially prevent falls.
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Affiliation(s)
- Avril Mansfield
- Toronto Rehabilitation Institute–UHN, Toronto, ON, Canada
- Heart and Stroke Foundation Centre for Stroke Recovery, ON, Canada
| | - Elizabeth L. Inness
- Toronto Rehabilitation Institute–UHN, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | | - Julia E. Fraser
- Toronto Rehabilitation Institute–UHN, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - William E. McIlroy
- Toronto Rehabilitation Institute–UHN, Toronto, ON, Canada
- Heart and Stroke Foundation Centre for Stroke Recovery, ON, Canada
- University of Toronto, Toronto, ON, Canada
- University of Waterloo, Waterloo, ON, Canada
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Mansfield A, Inness EL, Lakhani B, McIlroy WE. Determinants of limb preference for initiating compensatory stepping poststroke. Arch Phys Med Rehabil 2012; 93:1179-84. [PMID: 22480548 DOI: 10.1016/j.apmr.2012.02.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 01/16/2012] [Accepted: 02/08/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the determinants of limb preference for initiating compensatory stepping poststroke. DESIGN Retrospective chart review. SETTING Inpatient rehabilitation. PARTICIPANTS Convenience sample of individuals admitted to inpatient rehabilitation with poststroke hemiparesis. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Compensatory stepping responses were evoked using a lean-and-release postural perturbation. The limb used to initiate compensatory stepping was determined. The relationships between stepping with the paretic limb and premorbid limb dominance, weight bearing on the paretic limb in quiet standing, ability to bear weight on the paretic limb, preperturbation weight bearing on the paretic limb, and lower-limb motor recovery scores were determined. RESULTS The majority (59.1%) of responses were steps initiated with the nonparetic limb. Increased lower-limb motor recovery scores and preperturbation weight bearing on the nonparetic limb were significantly related to increased frequency of stepping with the paretic limb. When the preferred limb was physically blocked, an inappropriate response was initiated in 21% of trials (ie, nonstep responses or an attempt to step with the blocked limb). CONCLUSIONS This study reveals the challenges that individuals with poststroke hemiparesis face when executing compensatory stepping responses to prevent a fall after a postural perturbation. The inability or challenges to executing a compensatory step with the paretic limb may increase the risk for falls poststroke.
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Affiliation(s)
- Avril Mansfield
- Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON, Canada.
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Mansfield A, Mochizuki G, Inness EL, McIlroy WE. Clinical correlates of between-limb synchronization of standing balance control and falls during inpatient stroke rehabilitation. Neurorehabil Neural Repair 2012; 26:627-35. [PMID: 22275158 DOI: 10.1177/1545968311429688] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stroke-related sensorimotor impairment potentially contributes to impaired balance. Balance measures that reveal underlying limb-specific control problems, such as a measure of the synchronization of both lower limbs to maintain standing balance, may be uniquely informative about poststroke balance control. OBJECTIVE This study aimed to determine the relationships between clinical measures of sensorimotor control, functional balance, and fall risk and between-limb synchronization of balance control. METHODS The authors conducted a retrospective chart review of 100 individuals with stroke admitted to inpatient rehabilitation. Force plate-based measures were obtained while standing on 2 force plates, including postural sway (root mean square of anteroposterior and mediolateral center of pressure [COP]), stance load asymmetry (percentage of body weight borne on the less-loaded limb), and between-limb synchronization (cross-correlation of the COP recordings under each foot). Clinical measures obtained were motor impairment (Chedoke-McMaster Stroke Assessment), plantar cutaneous sensation, functional balance (Berg Balance Scale), and falls experienced in rehabilitation. RESULTS Synchronization was significantly related to motor impairment and prospective falls, even when controlling for other force plate-based measures of standing balance control (ie, postural sway and stance load symmetry). CONCLUSIONS Between-limb COP synchronization for standing balance appears to be a uniquely important index of balance control, independent of postural sway and load symmetry during stance.
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Affiliation(s)
- Avril Mansfield
- Heart and Stroke Foundation Centre for Stroke Recovery, Toronto, ON, Canada.
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49
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Inness EL, Howe JA, Niechwiej-Szwedo E, Jaglal SB, McIlroy WE, Verrier MC. Measuring Balance and Mobility after Traumatic Brain Injury: Validation of the Community Balance and Mobility Scale (CB&M). Physiother Can 2011; 63:199-208. [PMID: 22379260 DOI: 10.3138/ptc.2009-45] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To further investigate the construct validity of the Community Balance and Mobility Scale (CB&M), developed for ambulatory individuals with traumatic brain injury (TBI). METHODS A convenience sample of 35 patients with TBI (13 in-patients, 22 outpatients) was recruited. Analyses included a comparison of CB&M and Berg Balance Scale (BBS) admission and change scores and associations between the CB&M and measures of postural sway, gait, and dynamic stability; the Community Integration Questionnaire (CIQ); and the Activities-specific Balance Confidence (ABC) Scale. RESULTS Mean admission scores on the BBS and the CB&M were 53.6/56 (SD=4.3) and 57.8/96 (SD=23.3) respectively. Significant correlations were demonstrated between the CB&M and spatiotemporal measures of gait, including walking velocity, step length, step width, and step time; measures of dynamic stability, including variability in step length and step time; and the ABC (p<0.05). Significant correlations between the CB&M and CIQ were revealed with a larger data set (n=47 outpatients) combined from previous phases of research. CONCLUSIONS In patients with TBI, the CB&M is less susceptible to a ceiling effect than the BBS. The construct validity of the CB&M was supported, demonstrating associations with laboratory measures of dynamic stability, measures of community integration, and balance confidence.
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Affiliation(s)
- Elizabeth L Inness
- Elizabeth L. Inness, BScPT, MSc: Toronto Rehabilitation Institute, Toronto, Ontario; Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Ontario
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50
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Lakhani B, Mansfield A, Inness EL, McIlroy WE. Characterizing the determinants of limb preference for compensatory stepping in healthy young adults. Gait Posture 2011; 33:200-4. [PMID: 21159510 DOI: 10.1016/j.gaitpost.2010.11.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 09/27/2010] [Accepted: 11/08/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND Compensatory stepping responses are frequently observed following postural perturbations. Compensatory steps require extremely rapid onset timing while maintaining sophisticated control of limb placement. However, the influence of asymmetric limb loading on compensatory stepping limb preference and step characteristics is unknown. The purpose of this study was to gain an understanding of the factors that influence limb preference for compensatory stepping under symmetric and asymmetric loading. METHODS Ten healthy young individuals (mean age 24±3 years) experienced postural perturbations delivered using a lean-and-release system. Perturbations were delivered during three different loading conditions: (1) symmetric stance, (2) asymmetric stance with 30-70% body weight over the preferred limb and, (3) asymmetric stance with the unloaded (30% body weight) limb constrained. Kinematic and kinetic data were collected from three force plates mounted in the platform and a three-dimensional motion analysis system. RESULTS As stance loading on the preferred limb increased, step frequency with the preferred limb decreased. Forced stepping with the preferred limb loaded at 70% body weight resulted in shorter (p=0.005) and more laterally displaced (p<0.001) steps as well as non-significant trends towards faster swing time (p=0.057) and shorter time to foot-off (p=0.081) compared to steps taken from symmetric stance. DISCUSSION Healthy young adults prefer to step with the more unloaded limb. However, when forced to step with an asymmetrically vertically loaded limb, individuals demonstrate a number of spatio-temporal characteristics that may indicate increased instability.
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Affiliation(s)
- Bimal Lakhani
- Graduate Department of Rehabilitation Sciences, University of Toronto, Toronto, ON, Canada.
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