Falls after stroke

Management Approaches to Spastic Gait Disorders

Spastic gait presents clinically as the net mechanical consequence of neurological impairments of spasticity, weakness, and abnormal synergies and their interactions with the ground reaction force in patients with upper motor neuron syndromes and with some neuromuscular diseases. It is critical to differentiate whether the primary problem is weakness or spasticity, thus better understanding different phenotypes of spastic gait disorders. Pelvic girdle abnormality plays a pivotal role in determining the clinical presentation of gait disorders, since it determines the body vector and compensatory kinetic chain reactions in the knee and ankle joints. Knee joint abnormality can be a mechanical compensation for hip and/or ankle and foot abnormality. Diagnostic nerve blocks and instrumented gait analysis may be needed for diagnosing the underlying problems and developing an individualized plan of care. A wide spectrum of treatment options has been used to manage spastic gait disorders. Some are in early and investigational stages, such as neuromodulation modalities, while others are well-developed, such as therapeutic exercise, ankle-foot orthoses, botulinum toxin treatment, and surgical interventions. Physicians and other healthcare providers who manage spastic gait disorders should be familiar with these treatment options and should employ appropriate interventions concurrently rather than serially. The most effective treatments can be selected based on careful evaluation, inputs from patients, family, and therapists, along with appropriate goal setting. Treatment plans need to be re-evaluated for effectiveness, relevance, and in concordance with disease progress. This is particularly important for patients with progressive neuromuscular diseases such as amyotrophic lateral sclerosis.

The impact of ankle-foot orthoses on mobility of dual-task walking in stroke patients? A cross-sectional two-factor factorial design clinical trial

ABSTRACTTo assess the impact of ankle-foot orthoses (AFOs) on mobility and gait during dual-task walking in post-stroke survivors. In this cross-sectional, factorial design trial, stroke survivors performed four randomized tasks: (1) dual-task walking with AFOs, (2) single-task walking with AFOs, (3) dual-task walking without AFOs, and (4) single-task walking without AFOs. Primary outcome was the Timed Up and Go (TUG) test, with secondary outcomes including gait metrics, Tinetti scores, and auditory N-back tests. In the results, 48 subjects (38 males and 10 females; 19-65 years) completed the trial. Patients had a greater TUG score with AFOs compared with non-AFOs conditions (95% CI: 7.22-14.41, P < 0.001) in single-task and dual-task conditions. Secondary outcomes showed marked enhancement with AFOs during dual-task walking, with significant interaction effects in gait metrics, balance, and cognitive function (P < 0.05). Although not statistically significant, dual-task effects of TUG and walking speed were more pronounced during dual-task walking. In conclusion, AFOs enhance mobility and gait during both single and dual-task walking in post-stroke survivors.

Gait spatio-temporal characteristics during obstacle crossing as predictors of fall risk in stroke patients

BACKGROUND

Spatio-temporal parameters provide reference information for the gait variations of stroke patients during obstacle crossing. Analyzing these gait spatio-temporal characteristics of patients during obstacle crossing can assist in assessing the risk of falls. The aim of this study was to analyze the variances in gait spatio-temporal characteristics during obstacle crossing between stroke patients with and without a history of falls, to explore spatio-temporal parameters for assessing fall risk, and to construct a regression model for predicting patients' fall risk.

METHODS

Thirty-three patients with unilateral brain injury from stroke who were discharged from rehabilitation were included. These patients were categorized into a falls group (with a history of falls) and a non-falls group (without a history of falls) based on whether they had experienced a fall in the previous six months. A Qualisys motion capture system was used to record the marker positions when crossing an obstacle 4 cm in height with the affected leg as the leading limb, and gait spatio-temporal parameters were calculated and obtained. Univariate analysis and logistic regression models were used to compare the gait spatio-temporal parameters of the two groups.

RESULTS

17 participants were categorised into the falls group and 16 into the non-falls group. The single support phase of leading limb, post-obstacle swing phase of trailing limb, obstacle-heel distance of leading limb, and obstacle-heel distance of trailing limb were significantly smaller in the fall group compared to the non-fall group (P < 0.05). The gait spatio-temporal parameter ultimately included in the fall risk prediction model was the obstacle-heel distance of leading limb (OR = 0.819, 95%CI = 0.688-0.973, P = 0.023). The overall correct classification rate from this model was 69.7%, and the area under the curve (AUC) was 0.750 (P = 0.014).

CONCLUSION

Abnormalities in gait spatio-temporal parameters during obstacle crossing in stroke patients can contribute to an increased risk of falls. The fall risk prediction model developed in this study demonstrated excellent predictive performance, indicating its potential utility in clinical settings.

Clinical implications of fracture severity risk with pioglitazone: a systematic review and meta-analysis of clinical randomized trials

Introduction

Pioglitazone, a thiazolidinedione, effectively reduces stroke and cardiovascular events in individuals with type 2 diabetes, insulin resistance, and/or stroke. However, its potential to increase fracture risk, particularly among women and those with pre-existing skeletal conditions, has not yet been completely understood. This meta-analysis aims to clarify fracture risk associated with pioglitazone, thereby focusing on individuals with a history of stroke.

Methods

A systematic review was performed for clinical trials conducted up to March 2024, focusing on trials comparing pioglitazone to placebo or other antihyperglycemic drugs that reported fracture outcomes.

Results

From 860 trials identified, 78 satisfied the inclusion criteria: 34 with a high risk of bias, 8 with unclear risk, and 36 with low risk. The meta-analysis revealed an association between pioglitazone and a significant increase in fracture risk (risk ratio [RR] 1.21; 95% CI 1.01-1.45; P = 0.04), including non-serious (RR 1.25; 95% CI 1.03-1.51; P = 0.02) and serious fractures (RR 1.48; 95% CI 1.10-1.98; P = 0.01). Notably, the risk was exacerbated for low-energy fractures, particularly resulting from falls (RR 1.49; 95% CI 1.20-1.87; P = 0.0004), in insulin resistance individuals (RR 0.87; 95% CI 0.43-1.76; P = 0.69), and stroke survivors (RR 1.41; 95% CI 1.09-1.83; P = 0.008). Fractures were most frequently observed in lower extremities (RR 1.85; 95% CI 1.33-2.56; P = 0.0002), with women at a greater risk (RR 1.56; 95% CI 1.20-2.02; P = 0.0008). When compared with other antihyperglycemic drugs, no significant difference in fracture risk was noted (RR 1.08; 95% CI 0.73-1.59; P = 0.70), except rosiglitazone, which showed higher fracture risk (RR 1.42; 95% CI 1.23-1.64; P < 0.00001). Fracture risk was significant in the fixed-effect model but not in the random-effects model.

Discussion

Though pioglitazone offers several cardiovascular benefits, its association with increased fracture risk, especially among women and non-diabetic individuals post-stroke, warrants careful consideration. Individualized treatment interventions balancing cardiovascular and skeletal outcomes are essential, and further research is needed to optimize therapeutic strategies in this population.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42016038242, identifier CRD42016038242.

Injurious Falls before, during, and after Stroke Diagnosis: A Population-based Study

OBJECTIVES

We aimed to examine changes in the incidence of injurious falls before, during, and after stroke, and to identify risk factors of injurious falls before and after stroke diagnosis.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

Within the Swedish Twin Registry, 4431 participants (aged 66.5 ± 10.3 years) with incident stroke and 4431 stroke-free controls (aged 66.5 ± 10.3 years) were identified and matched with cases according to birth year and sex. Cases and controls were retrospectively and prospectively followed for a total of 21 years.

METHODS

Information on the onset of stroke and injurious falls was ascertained from medical records in the National Patient Registry. Data were analyzed using conditional Poisson regression and generalized estimating equation models.

RESULTS

During the 4 to 10 year pre-stroke period, the standardized incidence rates of injurious falls were 4.29-7.53 per 1000 person-years in stroke and 3.97-7.47 per 1000 person-years in control groups. The incidence of injurious falls among participants with stroke was significantly higher compared with non-stroke controls beginning 3 years before stroke [incidence rate ratio (IRR), 1.27; 95% confidence interval (CI), 1.02-1.59], peaked during the year of stroke diagnosis (IRR, 2.55; 95% CI, 2.17-3.01), and declined 4 years after stroke (IRR, 1.42; 95% CI, 1.14-1.77) until reaching a similar level as the controls (IRRs around 1.11-1.56). Former/current smoking, heavy drinking, and overweight were associated with increased falls during the pre-stroke period, and being single and heart disease with falls during the post-stroke period.

CONCLUSIONS AND IMPLICATIONS

Among people with stroke, incidence of injurious falls is significantly elevated already 3 years before stroke diagnosis and lasting until 4 years post-stroke. Risk factors for falls differ pre-stroke and post-stroke. Taking preventive measures may be beneficial in managing both stroke and fall-related risks.

Comparison of psychometric properties of the dual-task timed up-and-go test (cognitive) and the 3-m walk backward test in community-dwelling stroke patients

BACKGROUND

There is a need for practical, easy-to-use and accurately assessing balance tools in stroke patients.

OBJECTIVES

This study aimed to compare the psychometric properties of the dual-task Timed Up-and-Go test (cognitive) (DTUG) and the 3-m walk backward test (3MBWT) in stroke patients.

METHODS

This study evaluated the practicality, validity, and reliability of the DTUG and the 3MBWT. The test-retest method was used for reliability. The Modified Four Square Step Test (MFSST), the Timed Up-and-Go (TUG), and Berg Balance Scale (BBS) were administered for concurrent validity. A cutoff value was calculated to discriminate between fallers and non-fallers.

RESULTS

The mean practicality times of the tests were 63.58 ± 47.32 sec for DTUG and 37.42 ± 24.036 sec for 3MBWT. Intraclass correlation coefficient of the DTUG and 3MBWT were 0.977, 0.964, respectively which showed excellent test - retest reliability. The DTUG demonstrated strong/very strong correlations with the MFSST (r = 0.724, p < 0.001), TUG (r = 0.909, p < 0.001), and BBS (r = -0.740, p < 0.001). The 3MBWT showed strong correlations with the MFSST (r = 0.835, p < 0.001), the TUG (r = 0.799, p < 0.001), and the BBS (r = -0.740, p < 0.001). The cutoff point was 36.945 s for DTUG and 14.605 s for 3MBWT.

CONCLUSIONS

The 3MBWT was a more practical test than the DTUG; however, the DTUG was more discriminative than the 3MBWT in identifying fallers after stroke.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05211349.

URL

https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000BRKZ&selectaction=Edit&uid=U0005GRO&ts=2&cx=z21bhg.

Motor control complexity estimation using gait measures in individuals post-stroke

Motor control impairments post-stroke significantly limit walking ability, with residual gait impairments often persisting despite rehabilitation efforts. Integrating motor control-based assessments in post-stroke gait evaluations is essential for monitoring the underlying causes of the limited functionality and enhancing recovery outcomes. This study aimed to develop motor control-based post-stroke gait evaluation techniques using common gait measures to inform and guide rehabilitation decisions. Subject-specific, forward-dynamic simulations of eight individuals with post-stroke gait undergoing a 12-weeks FastFES gait retraining program were created pre- and post-treatment to determine muscle activation patterns for muscle module analysis. The motor control complexity index was defined by the variance not accounted for by one module (VNAF1) as a summary measure of the analysis. Twenty-eight gait measures were investigated, and the relevant measures were selected using feature selection methods and fed into a multiple linear regression model to estimate the motor control complexity index. The motor control complexity of 182 gait cycles were quantified (0.164 ± 0.047). No strong relationship (quantified using Pearson correlation coefficients) was found between gait measures and the motor control complexity index. However, a combination of four gait measures from the paretic side (maximum hip abduction and knee flexion angle during swing, knee range of motion, and maximum paretic ankle power) explained most of the variation (R2 = 0.66) in motor control complexity.

Dynamic Nomogram for Predicting the Fall Risk of Stroke Patients: An Observational Study

Background

Common fall risk assessment scales are not ideal for the prediction of falls in stroke patients. The study aimed to develop and verify a dynamic nomogram model for predicting the falls risk in stroke patients during rehabilitation.

Methods

An observational study design was adopted, 488 stroke patients were treated in a tertiary hospital from March to September 2022 were investigated for fall risk factors and related functional tests. We followed up by telephone within 2 months after that to understand the occurrence of falls. Forward stepwise regression was used to analyze the data, and a dynamic nomogram model was developed.

Results

During follow-up, three patients died, and 16 failed the follow-up, with a failure rate of 3.89%. Among 469 patients, 115 experienced falls, with a fall incidence rate of 24.4% and a cumulative of 163 falls. The fall risk was higher among patients aged 60-69, and ≥80 years than among patients aged <60 years. Patients with a fall history within the last 3 months, or a Berg balance scale (BBS) score of <40, or combined with anxiety had a higher fall risk. The differentiation of the dynamic nomogram model was evaluated. The area under the receiver operating characteristics curve (AUC-ROC), sensitivity, specificity of the model was 0.756, 66.09% and 73.16%, respectively. The AUC-ROC of the model was 0.761 by using the Bootstrap test, and the calibration curve coincided with the diagonal dashed line with a slope of one. The Hosmer-Lemeshow good of fit test value was χ²=2.040, and the decision curve analysis showed that the net benefit was higher than that of the two extreme curves.

Conclusion

Independent fall risk factors in stroke patients are age, had a fall history within the last 3 months, anxiety, and with the BBS score below 40 during rehabilitation. The dynamic nomogram prediction model for stroke patients during rehabilitation has good differentiation, calibration, and clinical utility. The prediction model is simple and practical.

Typical Changes in Gait Biomechanics in Patients with Subacute Ischemic Stroke

Background/Objectives: Gait dysfunction occurs in 80% of stroke survivors. It increases the risk of falls, reduces functional independence, and thus affects the quality of life. Therefore, it is very important to restore the gait function in post-stroke survivors. The purpose of this study was to investigate the functional changes of gait biomechanics in patients with hemiplegia in the subacute stage of ischemic stroke based on spatiotemporal, kinematic, and EMG parameters. Methods: Initial biomechanical gait analyses of 31 patients and 34 controls were selected. The obtained parameters were assessed and compared within and across the study groups (post-stroke hemiparetic patients and healthy controls) to determine the pathognomonic features of the hemiplegic gait. Results: The gait function asymmetry was characterized by reciprocal changes, i.e., harmonic sequences of gait cycles. The most significant changes were in the kinematics of the knee joint and the EMG activity in the anterior tibialis, gastrocnemius, and hamstring muscles on the paretic side. The movements in the lower extremity joints ranged from a typical amplitude decrease to an almost complete lack of movement or involuntary excessive movement, as can occur in the ankle joint. The knee joint showed two distinct patterns: a slight flexion throughout the entire gait cycle and knee hyperextension during the middle stance phase. Conclusions: The gait function asymmetry is characterized by reciprocal changes (in temporal gait parameters). The most significant changes included decreased amplitude in the knee joint and decreased amplitude of EMG of all muscles under study, except for the m. quadriceps femoris.

Physiotherapy management focusing on proprioceptive impairment in a patient with gait and balance impairments following stroke: A case report

BACKGROUND

Proprioceptive impairment contributes to gait and balance impairments in patients with stroke. Diagnosis functional impairments and evaluation treatment efficacy require quantitative proprioception assessment. However, proprioception assessment has remained limited to ordinal scale measurement, with a lack of ratio scale measurements.

PURPOSE

This case report describes a physiotherapy management program focusing on proprioceptive impairment in patients with stroke using quantitative tests such as Threshold to Detect Passive Motion (TDPM) and Joint Position Sense (JPS).

CASE DESCRIPTION

A63-year-old male patient with an acute pontine lacunar infarction was admitted to our hospital. His muscle strength, selective movement, and trunk activity were preserved. However, the Berg Balance Scale (BBS) and Gait Assessment andIntervention Tool (GAIT) score were 42 and 9 points, observing balance impairment and the buckling knee pattern with hip ataxia during gait. Based on these, TDPM and JPS using image capture were performed. In physiotherapeuticdiagnosis, proprioceptive impairments in the hip and knee joints were the primary functional impairments related to balance and gait. To address these proprioceptive impairments, a 13-day treatment protocol incorporating transcutaneous electrical nerve stimulation (intensity: sensory threshold, frequency: 100 Hz) targeting the quadriceps femoris was performed.

OUTCOMES

The patient was discharged after achieving independent ambulation and improvement in BBS (56 points) and GAIT (2 points) scores, exceeding the minimum clinically important difference. Recovery of proprioceptive impairment corresponded withimproved balance and gait ability.

CONCLUSION

Quantitatively evaluating proprioceptive impairments may provide novel rehabilitation for patients with stroke who have proprioceptive impairments and contribute to clinical decision-making.

Interacting with virtual characters, objects and environments: investigating immersive virtual reality in rehabilitation

PURPOSE

This pilot study aimed to (a) investigate opportunities for immersive Virtual Reality (VR) technology in communication, physical, and visual rehabilitation by examining the interaction of people without disabilities in a range of structured virtual environments; and (b) validate research protocols that might be used to evaluate the physical, visual, and verbal interaction of users in virtual worlds, and their safety while using the technology.

METHODS

Thirteen adults identifying as people without disability were exposed to VR via a head-mounted display. A video-review method was used to qualitatively code and analyse each participant's communication, movement, orientation, and support needs.

RESULTS

All participants oriented to their virtual environments sufficiently to use applications. Their spoken language was effective for interaction, although unconventional social behaviours were also observed. Two participants reported minor adverse reactions consistent with mild cybersickness.

CONCLUSION

The results provide insight into the types of environments and characters that support the greatest communicative, physical, and visual interaction in immersive VR. The tested protocols are useful to assess safety when using VR, and to observe communicative, physical, and visual interaction with virtual environments and characters. Implications for future research and use of VR with people with communication, physical and visual disability are discussed.

Protocol for a single-blind randomized controlled clinical trial to investigate the feasibility and safety of in-bed self-exercises based on electromyography sensor feedback in patients with subacute stroke

BACKGROUND

The dosage and intensity of physical therapy are crucial factors influencing the motor recovery of the hemiplegic lower limb in patients with subacute stroke. Biofeedback using wearable sensors may provide opportunities for patients with stroke to effectively guide self-exercises with monitoring of muscular activities in hemiplegic lower limbs. This study aims to explore the feasibility and safety of in-bed self-exercises based on electromyography sensor feedback in patients with subacute stroke.

METHODS

This is a pilot randomized controlled trial comparing conventional physical therapy with additional in-bed self-exercises based on electromyography sensor feedback and conventional physical therapy alone. The interventions will be adjusted according to the muscle strength and Brunnstrom recovery stage in the hemiplegic lower limbs. The primary outcome measure is the Pittsburgh Rehabilitation Participation Scale. The secondary outcome measures include the number and percentage of participating sessions, number and percentage of effortful sessions, number and percentage of successful sessions, mean amplitude of muscle contractions in a session, duration and percentage of participating sessions during self-exercises, Rivermead Motor Assessment, Manual Muscle Test, Brunnstrom recovery stage, Fugl-Meyer assessment, Berg Balance Scale, Functional Ambulation Category, modified Rankin scale, and Short-Form Health Survey 36 version 2.

RESULTS

The results will be described in future studies.

CONCLUSION

This clinical trial will estimate the feasibility and safety of in-bed self-exercises based on electromyography sensor feedback in patients with subacute stroke. If the expected results are achieved in this study, stroke rehabilitation methods will be enriched.

TRIAL REGISTRATION

clinicialtrials.gov, NCT05820815.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"We don't look too much into the communication disability": clinicians' views and experiences on the effect of communication disability on falls in hospital patients with stroke

PURPOSE

Difficulty with communicating basic needs and attracting the attention of health professionals may contribute to falls for patients with communication disability after stroke. The aim of this study was to explore the views of hospital-based health professionals on: (a) the effect of communication disability on falls in patients with stroke; (b) falls prevention strategies for patients with communication disability following stroke; and (c) the roles of speech pathologists in the assessment, management, and prevention of falls in this population.

MATERIALS AND METHODS

Online focus groups were conducted and analysed using content thematic analysis.

RESULTS

In total, 11 health professionals participated in four focus groups. Clinicians viewed that: (a) the effects of falls in patients with communication disability are far-reaching; (b) communication disability complicates falls risk assessment and falls management; (c) current falls prevention strategies do not meet the needs of patients with communication disability; and (d) strong relationships have a central role in decreasing falls in this population.

CONCLUSIONS

Health professionals articulate concerning gaps in falls prevention strategies for patients with communication disability. Further research should investigate strategies enabling falls prevention and management to be more inclusive of patients with communication disability following stroke and consider ways in which speech pathologists could contribute to this field.

Increased stride time variability is associated with a higher risk of falls in patients with ataxia after stroke

INTRODUCTION

Patients presenting with ataxia are at high risk of falling, however, there are limited studies evaluating fall factors restricted to patients presenting with ataxia due to stroke.

PURPOSE

This study aimed to examine the characteristics of patients with ataxia after stroke based on their motor function to identify variables associated with fall occurrence.

METHODS

We divided 33 participants who presented with ataxia after stroke into fall and non-fall groups. Data on motor function, cognitive function, and daily functionality were extracted from their admission records. Walking ability was measured as comfortable walking speed and Stride Time Variability (STV). Independent sample t-tests, Mann - Whitney U tests, and multiple logistic regression analysis were performed.

RESULTS

There were significant differences between fallers and non-fallers in the STV (p < .001), Mini-Balance Evaluations Systems Test score (p < .014) and Scale for Assessment and Rating of Ataxia score assessment (p < .028). In the multiple logistic regression analysis, only STV was associated with an increased risk of falls (p < .02). The area under the receiver operating characteristic curve was 0.839; the cutoff value of gait cycle variability for falls was 6.345% (sensitivity, 80.0%; specificity, 74.0%).

CONCLUSION

Increased stride time variability is a useful indicator that sensitively captures fall risk in patients with ataxia after stroke.

Efficacy of acupuncture in reducing accidental injury risk in stroke patients: A national-scale cohort study

Background

Falls among stroke patients pose a significant health concern, leading to injuries, reduced mobility, and functional limitations. Recent research has suggested the potential benefits of acupuncture in enhancing balance and motor function in stroke patients. However, large-scale, long-term studies on acupuncture's role in reducing the risk of accidental injuries are scarce. This study aimed to evaluate acupuncture's effectiveness in decreasing the risk of accidental injuries in stroke patients.

Materials and methods

This study employed a large-scale cohort design, utilizing data from the 2000 Longitudinal Generation Tracking Database (LGTD 2000) in Taiwan, covering two million individuals. The cohort comprised stroke patients hospitalized between 2001 and 2012, with follow-up periods of at least six years to estimate accidental injury incidence and risk. Acupuncture treatments during both inpatient and outpatient phases after stroke diagnosis were included. Accidental injury data, including vehicular accidents and falls, were extracted from specialized hospitalization records. Hazard ratios were calculated, adjusting for variables like comorbidities, hypnotic medication usage, and demographic factors.

Result

A total of 108,196 newly diagnosed stroke patients were included in the final cohort, with 42,083 receiving acupuncture treatment and 66,113 not receiving acupuncture. The acupuncture group exhibited a significantly lower incidence rate of accidental injuries (10.2 per 1,000 person-years) compared to the non-acupuncture group (15.8 per 1,000 person-years). After adjusting for various covariates, the acupuncture group had a reduced risk of accidental injuries with an adjusted hazard ratio (aHR) of 0.74 (95 % CI: 0.51-0.92). Subgroup analyses revealed consistent protective effects of acupuncture across different patient profiles and treatment characteristics, including age, sex, comorbidities, and hypnotic medication usage.

Conclusion

This study provides evidence supporting the potential of acupuncture as an adjunctive therapy to reduce the risk of accidental injuries among stroke patients. Regardless of stroke subtype, age, or comorbidity burden, acupuncture was associated with a lower risk of accidental injuries.

Neuromuscular Mechanisms of Motor Adaptation to Repeated Treadmill-Slip Perturbations During Stance in Healthy Young Adults

Treadmill-based repeated perturbation training (PBT) induces motor adaptation in reactive balance responses, thus lowering the risk of slip-induced falls. However, little evidence exists regarding intervention-induced changes in neuromuscular control underlying motor adaptation. Examining neuromuscular changes could be an important step in identifying key elements of adaptation and evaluating treadmill training protocols for fall prevention. Moreover, identifying the muscle synergies contributing to motor adaptation in young adults could lay the groundwork for comparison with high fall-risk populations. Thus, we aimed to investigate neuromuscular changes in reactive balance responses during stance slip-PBT. Lower limb electromyography (EMG) signals (4/leg) were recorded during ten repeated forward stance (slip-like) perturbations in twenty-six young adults. Muscle synergies were compared between early-training (slips 1-2) and late-training (slips 9-10) stages. Results showed that 5 different modes of synergies (named on dominant muscles: WTA, W , W , W , and W were recruited in both stages. 3 out of 5 synergies (WTA, W , and W showed a high similarity (r >0.97) in structure and activation between stages, whereas W and W showed a lower similarity (r <0.83) between the two stages, and the area of activation in WTA, the peak value of activation in W and the activation onset in W showed a reduction from early- to late-training stage (p <0.05). These results suggest that a block of stance slip-PBT resulted in modest changes in muscle synergies in young adults, which might explain the smaller changes seen in biomechanical variables. Future studies should examine neuromuscular changes in people at high risk of falls.

Is lateral external perturbation training more beneficial for protective stepping responses than voluntary stepping training in stroke? A pilot randomized control study

The study examined whether lateral perturbation training could improve stepping performance and balance in individuals post-stroke. Thirty-one participants with hemiparesis were randomly allocated to PERT (external perturbation) or VOL (voluntary stepping) step training. The PERT and VOL group consisted of 80 step trials predominantly in the lateral direction, with a small proportion of steps in the anterior/posterior direction. Outcome measures based on step type (medial and lateral) included step initiation time, step length, step clearance, step velocity during an induced waist pull perturbation and voluntary step, and clinical balance assessments. The PERT group initiated a lateral step faster with the non-paretic leg during the induced waist pull perturbation step (P = 0.044) than the VOL group after training. Both groups improved the non-paretic step length and step velocity during lateral steps. During the voluntary steps, the PERT group significantly initiated a voluntary step faster. No significant changes were observed in the paretic leg. Both groups significantly improved on the Community Balance & Mobility Scale and Activities Specific Balance Confidence Scale. Overall, we demonstrated that an exercise to improve stepping performance with external perturbations might provide more benefits in protective stepping responses than training with voluntary steps for individuals with a stroke.

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

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

Early screening of post-stroke fall risk: A simultaneous multimodal fNIRs-EMG study

BACKGROUND

Stroke is the third-leading cause of death and disability, and poststroke falls (PSF) are common at all stages after stroke and could even lead to injuries or death. Brain information from functional near-infrared spectroscopy (fNIRs) may precede conventional imaging and clinical symptoms but has not been systematically considered in PSF risk prediction. This study investigated the difference in brain activation between stroke patients and healthy subjects, and this study was aimed to explore fNIRs biomarkers for early screening of PSF risk by comparing the brain activation in patients at and not at PSF risk.

METHODS

In this study, we explored the differences in brain activation and connectivity between stroke and healthy subjects by synchronizing the detection of fNIRs and EMG tests during simple (usual sit-to-stand) and difficult tasks (sit-to-stand based on EMG feedback). Thereby further screened for neuroimaging biomarkers for early prediction of PSF risk by comparing brain activation variability in poststroke patients at and not at fall risk during simple and difficult tasks. The area under the ROC curve (AUROC), sensitivity, and specificity were used to compare the diagnostic effect.

RESULTS

A total of 40 patients (22 not at and 18 at PSF risk) and 38 healthy subjects were enrolled. As the difficulty of standing task increased, stroke patients compared with healthy subjects further increased the activation of the unaffected side of supplementary motor area (H-SMA) and dorsolateral prefrontal cortex-Brodmann area 46 (H-DLFC-BA46) but were unable to increase functional connectivity (Group*Task: p < 0.05). More importantly, the novel finding showed that hyperactivation of the H-SMA during a simple standing task was a valid fNIRs predictor of PSF risk [AUROC 0.74, p = 0.010, sensitivity 77.8%, specificity 63.6%].

CONCLUSIONS

This study provided novel evidence that fNIR-derived biomarkers could early predict PSF risk that can facilitate the widespread use of real-time assessment tools in early screening and rehabilitation. Meanwhile, this study demonstrated that the higher brain activation and inability to increase the brain functional connectivity in stroke patients during difficult task indicated the inefficient use of brain resources.

Effects of carbon versus plastic ankle foot orthoses on gait outcomes and energy cost in patients with chronic stroke

OBJECTIVE

To compare the walking performances of hemiplegic subjects with chronic stroke under 3 conditions: with a new standard carbon fibre ankle foot orthosis (C-AFO), with a personal custom-made plastic AFO (P-AFO), and without any orthosis (No-AFO).

DESIGN

Randomized, controlled crossover design.

PATIENTS

Fifteen chronic patients with stroke (3 women  and 12 men, 59 [10] years, 13 [15] years since injury).

METHODS

Patients performed 3 randomized sessions (with C-AFO, P-AFO, no-AFO), consisting of a 6-min walk test (6MWT) with VO2 measurement and a clinical gait analysis. Energy cost (Cw), walking speed, spatio-temporal, kinetic, and kinematic variables were measured.

RESULTS

No significant differences were found between the C-AFO and P-AFO conditions. Distance and walking speed in the 6MWT increased by 12% and 10% (p < 0.001) and stride width decreased by -8.7% and -13% (p < 0.0001) with P-AFO and C-AFO compared with the No-AFO condition. Cw decreased by 15% (p < 0.002), stride length increased by 10% (p < 0.01), step length on affected leg increased by 8% (p < 0.01), step length on contralateral leg by 13% (p < 0.01), and swing time on the contralateral leg increased by 6% (p < 0.01) with both AFO compared with the No-AFO condition.

CONCLUSION

The use of an off-the-shelf composite AFO (after a short habituation period) in patients with chronic stroke immediately improved energy cost and gait outcomes to the same extent as their usual custom-made AFO.

The effects of gaze stability exercises on balance, gait ability, and fall efficacy in patients with chronic stroke: A 2-week follow-up from a randomized controlled trial

BACKGROUND

This study aimed to examine the effect of gaze stability exercises on balance, gait ability, and fall efficacy in patients with chronic stroke, as well as to investigate whether any observed effects were maintained 2 weeks later.

METHODS

In this experiment, 30 chronic stroke patients were selected. The patients were randomly divided into 3 groups (10 patients in each group). All patients in the 3 groups performed basic neurodevelopmental treatment. Group 1 performed balance exercises accompanied by gaze stability exercises. Group 2 performed gaze stability exercises, and group 3 performed balance exercises. Each exercise program for 40 minutes 3 times a week for 4 weeks. After the intervention period, the patient's balance, gait ability, and fall efficacy were measured again. In order to know whether the training effect is maintained, a 2-week follow-up test was conducted after the training.

RESULTS

The results of this study showed that there was a significant improve in balance (overall stability index, limit of stability test, and Berg Balance Scale), gait ability (gait velocity, cadence, step time and step length, Timed Up and Go [TUG] test), and fall efficacy over the different time within the 3 groups. The effect was observed to be maintained in follow-up tests after 2 weeks. In the comparison among 3 groups, the overall stability index, limit of stability test in the balance test and the gait velocity, cadence, step time, step length and Timed Up and Go test in the gait test all showed statistically significant differences, and the other items did not have significant differences. In most of the assessments, group 1 that used balance exercise combined with gaze stability exercise showed a better improvement than the other 2 groups.

CONCLUSION

As a result, for stroke patients, gaze stability exercise is an effective arbitration method to improve balance and gait ability and fall efficacy. With balance exercise combined with gaze stability exercise, a greater effect can be seen than with gaze stability exercise or balance exercise alone. Thus, this combination exercise program can be recommended as effective.

Multimorbidity patterns and the risk of falls among older adults: a community-based study in China

BACKGROUND

Due to the high prevalence of multimorbidity and realistic health service demands for fall prevention, there is growing interest in the association between multimorbidity and falls. Our study aimed to identify multimorbidity patterns among Chinese older adults and explore the association between multimorbidity patterns and falls.

METHODS

Data from 4,579 Chinese community-dwelling older adults was included in this analysis. Information regarding falls and 10 chronic conditions was collected. An exploratory factor analysis was performed to determine multimorbidity patterns. Regression models were fitted to explore the associations of individual chronic disease or multimorbidity patterns with falls.

RESULTS

Among 4,579 participants, 368 (8.0%) were defined as fallers, including 92 (2.0%) frequent fallers, and multimorbidity affected 2,503 (54.7%) participants. Older adults with multimorbidity were more likely to be fallers [odds ratio (OR) = 1.3, P = 0.02] and frequent fallers (OR = 1.7, P = 0.04). Three multimorbidity patterns were identified (i.e., cardiovascular-metabolic diseases, psycho-cognitive diseases and organic diseases), and the associations between psycho-cognitive diseases/organic diseases and prevalent falls or frequent falls were found to be significant.

CONCLUSIONS

The psycho-cognitive disease pattern and organic disease pattern are significantly associated with falls. Therefore, more attention should be paid to patients with psycho-cognitive diseases and timely, targeted diagnostic and treatment services should be provided in fall prevention.

Reduced trunk muscle mass in patients with stroke is associated with reduced balance function recovery

BACKGROUND & AIMS

Skeletal muscles are essential for postural retention and balance function. However, the relationship between trunk muscle mass (TMM) and balance function has not yet been clarified. This study aimed to examine the impact of TMM on the change in balance function in patients with stroke from admission to a rehabilitation hospital to discharge.

METHODS

This retrospective observational study included patients aged ≥65 years with cerebral infarction admitted to our rehabilitation hospital from May 2018 to July 2022. The trunk muscle mass index (TMI) was calculated at admission and discharge using bioelectrical impedance analysis. Patients were divided into low and high TMI groups according to the median TMI at admission. The primary outcome was the change in the Berg Balance Scale (BBS) score (BBS score at discharge - BBS score at admission).

RESULTS

A total of 315 patients (mean age, 78.9 ± 8.0 years; 172 men and 143 women) were included. The median TMI was 7.31 kg/m2 in men and 6.30 kg/m2 in women. Among male patients, the high TMI group had higher BBS scores at admission (31.2 ± 18.2 vs. 23.4 ± 17.7, P = 0.005) and discharge (43.0 ± 15.3 vs. 33.4 ± 19.0, P < 0.001) than those in the low TMI group. After adjusting for confounding factors, TMI at admission was independently associated with the change in BBS score (β = 0.587, P = 0.002).

CONCLUSIONS

Reduced TMM negatively influences balance function recovery in patients after stroke. A strategy aimed at increasing TMM could have beneficial effects on balance function.

Physiotherapists' decision-making about transition to independent walking in hospital after stroke: a qualitative study

PURPOSE

Physiotherapists working in hospitals have a key role in decisions about when a person with stroke is safe to walk independently. The aim of this study was to explore the factors influencing decision-making of physiotherapists in this situation.

METHODS

A qualitative design with semi-structured interviews and reflexive thematic analysis was used. Fifteen physiotherapists with recent experience working in inpatient stroke rehabilitation participated.

RESULTS

Multiple factors influence decision-making about walking independence after stroke in hospitals. Four themes were identified: (1) Assessment of walking safety involves observation of walking function and consideration of complex individual factors; (2) Perspectives on risk vary, and influence whether a person is considered safe to walk; (3) Institutional culture involves background pressures that may influence decision-making; and (4) Physiotherapists adopt a structured, individualised mobility progression to manage risk. Physiotherapists consistently use observation of walking and understanding of attention and perception in this decision-making. There can sometimes be a conflict between goals of independence and of risk avoidance, and decisions are made by personal judgements.

CONCLUSIONS

Decision-making about independent walking for people in a hospital after a stroke is complex. Improved guidance about clinical assessment of capacity and determining acceptable risk may enable physiotherapists to engage more in shared decision-making.IMPLICATIONS FOR REHABILITATIONRegaining independence in walking after a stroke comes with the potential risk of falls.Assessment of walking safety should be specific to the complexity of the situation and consider perception and cognition.Benefits of activity and autonomy, and the risk of falls need to be considered in decisions about walking independence.Patients with the capacity to understand consequences and accept risk can be active participants in determining what is sufficiently safe.

Enhancing fall risk assessment: instrumenting vision with deep learning during walks

BACKGROUND

Falls are common in a range of clinical cohorts, where routine risk assessment often comprises subjective visual observation only. Typically, observational assessment involves evaluation of an individual's gait during scripted walking protocols within a lab to identify deficits that potentially increase fall risk, but subtle deficits may not be (readily) observable. Therefore, objective approaches (e.g., inertial measurement units, IMUs) are useful for quantifying high resolution gait characteristics, enabling more informed fall risk assessment by capturing subtle deficits. However, IMU-based gait instrumentation alone is limited, failing to consider participant behaviour and details within the environment (e.g., obstacles). Video-based eye-tracking glasses may provide additional insight to fall risk, clarifying how people traverse environments based on head and eye movements. Recording head and eye movements can provide insights into how the allocation of visual attention to environmental stimuli influences successful navigation around obstacles. Yet, manual review of video data to evaluate head and eye movements is time-consuming and subjective. An automated approach is needed but none currently exists. This paper proposes a deep learning-based object detection algorithm (VARFA) to instrument vision and video data during walks, complementing instrumented gait.

METHOD

The approach automatically labels video data captured in a gait lab to assess visual attention and details of the environment. The proposed algorithm uses a YoloV8 model trained on with a novel lab-based dataset.

RESULTS

VARFA achieved excellent evaluation metrics (0.93 mAP50), identifying, and localizing static objects (e.g., obstacles in the walking path) with an average accuracy of 93%. Similarly, a U-NET based track/path segmentation model achieved good metrics (IoU 0.82), suggesting that the predicted tracks (i.e., walking paths) align closely with the actual track, with an overlap of 82%. Notably, both models achieved these metrics while processing at real-time speeds, demonstrating efficiency and effectiveness for pragmatic applications.

CONCLUSION

The instrumented approach improves the efficiency and accuracy of fall risk assessment by evaluating the visual allocation of attention (i.e., information about when and where a person is attending) during navigation, improving the breadth of instrumentation in this area. Use of VARFA to instrument vision could be used to better inform fall risk assessment by providing behaviour and context data to complement instrumented e.g., IMU data during gait tasks. That may have notable (e.g., personalized) rehabilitation implications across a wide range of clinical cohorts where poor gait and increased fall risk are common.

Cognitive-motor exergame training on a labile surface in stroke inpatients: study protocol for a randomized controlled trial

Background

Cognitive-motor training in form of exergames has been found to be feasible and effective for the improvement of motor and cognitive functioning in older adults and several patient populations. Exergame training under unstable conditions might increase the proprioceptive resources needed and thus might be a superior training approach compared to exergame training on stable ground for stroke patients, who often have proprioceptive deficits.

Objective

Aim of this study is to assess the feasibility and effects of exergame-based cognitive-motor training on a labile platform on physical and cognitive functioning in stroke inpatients.

Methods

This is two-armed pilot randomized controlled trial taking place in an inpatient neurologic rehabilitation clinic. A total of 30 persons that are undergoing inpatient rehabilitation due to a stroke will be randomly assigned to either the intervention group (IG) or the control group (CG). Participants of the IG will receive exergame-based motor-cognitive training on a labile surface, whereas participants of the CG will train on a stable surface. Primary outcome is feasibility comprising measures of adherence, attrition, safety and usability. Secondary outcomes will be measures of cognitive (psychomotor speed, inhibition, selective attention, cognitive flexibility, brain activity) and motor (functional mobility, gait speed, balance, proprioception) functioning.

Results

Data collection started in February 2024 and is expected to be completed by August 2024.

Conclusion

This is the first study looking into exergame training on labile surface in stroke patients. It will give valuable insights into the feasibility and potential added value of this type of training and thus inform further implementation efforts in the context of inpatient rehabilitation.

Clinical trial registration

ClinicalTrials.gov, NCT06296069.

The Neuropsychological Assessment of Unilateral Spatial Neglect Through Computerized and Virtual Reality Tools: A Scoping Review

Unilateral Spatial Neglect is a disabling neuropsychological deficit. Patients with spatial neglect fail to detect and report events, and to perform actions in the side of space contralateral to a hemispheric cerebral lesion. Neglect is assessed by evaluating the patients' abilities in daily life activities and by psychometric tests. Computer-based, portable and Virtual Reality technologies may provide more and precise data, and be more sensitive and informative, compared to current paper-and-pencil procedures. Studies since 2010, in which such technologies have been used, are reviewed. Forty-two articles meeting inclusion criteria are categorized according to their technological approaches (computer-, graphics tablet or tablet-, virtual reality-based assessment, and other). The results are promising. However, a definite golden standard, technologically based procedure cannot be still established. Developing technologically based tests is a laborious process, which requires technical and user experience improvements as well as normative data, to increase the evidence of efficacy for clinical evaluation of at least some of the tests considered in this review.

Patterns and assessment of spastic hemiplegic gait

Hemiparetic gait disorders are common in stroke survivors. A circumductory gait is often considered the typical hemiparetic gait. In clinical practice, a wide spectrum of abnormal gait patterns is observed, depending on the severity of weakness and spasticity, and the anatomical distribution of spasticity. Muscle strength is the key determinant of gait disorders in hemiparetic stroke survivors. Spasticity and its associated involuntary activation of synergistic spastic muscles often alter posture of involved joint(s) and subsequently the alignment of hip, knee, and ankle joints, resulting in abnormal gait patterns. Due to combinations of various levels of muscle weakness and spasticity and their interactions with ground reaction force, presentations of gait disorders are variable. From a neuromechanical perspective, a stepwise visual gait analysis approach is proposed to identify primary underlying causes. In this approach, the pelvic and hip joint movement is examined first. The pelvic girdle constitutes three kinematic determinants. Its abnormality determines the body vector and compensatory kinetic chain reactions in the knee and ankle joints. The second step is to assess the ankle and foot complex abnormality. The last step is to examine abnormality of the knee joint. Assessment of muscle strength and spasticity of hip, knee, and ankle/foot joints needs to be performed before these steps. Lidocaine nerve blocks can be a useful diagnostic tool. Recognizing different patterns and identifying the primary causes are critical to developing clinical interventions to improve gait functions.

Role of virtual reality in examining the effect of fear of falling (FOF) on postural stability in individuals without and with Parkinson's disease in Egypt: a mixed-methods feasibility study protocol

BACKGROUND

Falls are common in older people and individuals with neurological conditions. Parkinson's disease (PD) is known for postural instability causing mobility disabilities, falls and reduced quality of life. The fear of falling (FOF), a natural response to unstable balance, can worsen postural control problems. Evaluating FOF relies largely on affected persons' subjective accounts due to limited objective assessment methods available. The aim of this mixed-methods feasibility study is to develop an assessment method for FOF while in motion and walking within virtual environments. This study will assess a range of FOF-related responses, including cognitive factors, neuromuscular response and postural stability.

METHODS AND ANALYSIS

This feasibility study will consist of four phases: the first two phases will include people without PD, while the other two will include people diagnosed with PD. Participants will be assessed for direct and indirect responses to real life, as well as virtual environment walking scenarios that may induce FOF. Data from questionnaires, different neurophysiological assessments, movement and gait parameters, alongside evaluations of usability and acceptability, will be collected. Semistructured interviews involving both participants and research assistants shall take place to elicit their experiences throughout different phases of the assessments undertaken. Demographic data, the scores of assessment scales, as well as feasibility, usability and acceptability of the measurement methods, will be illustrated via descriptive statistics. Movement and gait outcomes, together with neurophysiological data, will be extracted and calculated. Exploring relationships between different factors in the study will be achieved using a regression model. Thematic analysis will be the approach used to manage qualitative data.

ETHICS AND DISSEMINATION

This feasibility study was approved by the Ethics Committee of the Faculty of Physical Therapy, Kafr El Sheikh University, Egypt (number: P.T/NEUR/3/2023/46). The results of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05931692).

Spatiotemporal variability after stroke reflects more than just slow walking velocity

BACKGROUND

Increased spatiotemporal gait variability is considered a clinical biomarker of ageing and pathology, and a predictor of future falls. Nevertheless, it is unclear whether the increased spatiotemporal variability observed in persons with stroke is directly related to the pathology or simply reflects their choice of walking velocity.

RESEARCH QUESTION

Does increased spatiotemporal gait variability directly relate to motor coordination deficits after stroke?

METHODS

Forty persons with stroke participated in this cross-sectional study. Participants performed the lower-extremity motor coordination test (LEMOCOT) on an electronic mat equipped with force sensors. Then, participants walked for 120 s on a computerized treadmill at their comfortable walking velocity. For the LEMOCOT we used the traditional score of in-target touch count and computed the absolute and variable error around the targets. For gait variability, we extracted the standard deviation of step time, step length, step velocity, and step width. Using linear modeling, we tested the correlations of gait variability with the outcome measures from the LEMOCOT, after controlling for walking velocity.

RESULTS

The variability in step time, step length and step width correlated with walking velocity, while the variability in step velocity did not. After controlling for walking velocity, we observed that the LEMOCOT score correlated with the variance in step time, and the variable error in the LEMOCOT correlated with the variance in step length, in step width, and in step velocity. No significant correlation with any of the velocity-controlled step parameters was found for the absolute error in the LEMOCOT.

SIGNIFICANCE

Decreased performance in the LEMOCOT was associated with increased spatiotemporal variability in persons with stroke, regardless of their walking velocity. Our results demonstrate the connection between lower-extremity coordination impairments and deficits in gait function.

Outcomes of importance to people with multiple sclerosis, Parkinson's disease and stroke following a falls prevention intervention: a qualitative study to inform a core outcome set

Purpose: Falls are a major issue for people with neurological conditions, and the evaluation of falls prevention interventions is of high priority. To date, the views of patient groups regarding outcomes of importance have been largely overlooked. The purpose of this study was to explore outcomes of interest among people with Multiple Sclerosis (MS), Parkinson's disease (PD) and stroke upon completion of falls prevention interventions to inform the development of a core outcome set (COS).Materials and methods: Five online focus groups and one semi-structured interview were conducted among people with PD (n = 10), MS (n = 7), and post-stroke (n = 3), one of whom also had PD. Transcripts were analysed using reflexive thematic analysis.Results: Four themes were developed; (1) Fall events are not homogeneous, (2) Exercise-based programmes are beneficial but falls services are not meeting user needs, (3) Programme success beyond the reduction in falls, and (4) Acquisition of skills to self-manage falls beyond the life of the programme.Conclusions: This study presents new perspectives across patient groups regarding important outcomes upon completion of falls prevention interventions. Taken together with the findings of a literature review, this data will inform the development of a COS.Implications for rehabilitationPeople with multiple sclerosis, Parkinson's disease and stroke consider the success of a falls prevention intervention to be dependent on improvements across a wide range of outcomes.The design and implementation of falls prevention interventions should align with patient preferences.Clinicians and researchers should consider the use of multidomain interventions to facilitate improvements in the desired outcomes of patients.

Effect of Qigong exercise on motor function in stroke patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Motor impairment is one of the most common defects after stroke, which could seriously affect the life quality of stroke patients. Exercise intervention gradually becomes a popular alternative rehabilitation therapy because of its safety and applicability.

OBJECTIVES

To systematically assess the effect of Qigong exercise on motor function in stroke patients.

METHODS

Randomized controlled trials that evaluated the effect of Qigong on motor function of stroke patients were obtained from PubMed and Chinese National Knowledge Infrastructure through May 2022. Mean values and standard deviations of the post-intervention score in both experimental group and control group were collected to calculate the mean difference (MD) and corresponkding 95% confidence interval (95% CI) of each study, which were quantificationally summarized using the Review Manager 5.3 software.

RESULTS

Nineteen randomized controlled trials enrolling 1487 stroke patients were included. Pooled results indicated that Qigong exercise had beneficial effect on balance function (Berg Balance Scale [MD: 7.56, 95% CI: 4.09-11.02]), limb motor function (Fugl-Meyer Assessment [total score: MD: 7.54, 95% CI: 6.38-8.69; upper limb: MD: 3.57, 95% CI: 0.71-6.43; lower limb: MD: 2.44, 95% CI: 0.59-4.29]) and walking function (6-min walking test [MD: 62.21, 95% CI: 11.70-112.73]) of stroke patients. It was also found to be associated with an improvement in trunk function as indicated by the Trunk Impairment Scale.

CONCLUSIONS

Available evidence supported potential benefits of Qigong exercise for improving motor functions of stroke patients. As a safe and widely applicable exercise, Qigong is worthy of further promotion in the rehabilitation of stroke patients.

Hearing loss, gait and balance impairments and falls among individuals with sub-acute stroke: A comparative cross-sectional study

Background

The impact of hearing loss in stroke is less explored. This study aimed to compare hearing loss in patients with sub-acute stroke with healthy controls and evaluate its association with gait and balance impairments and falls.

Methods

This study involved 78 ambulant sub-acute stroke patients and 78 age-sex-matched controls. Hearing loss was assessed with pure tone average, while gait and balance impairments were assessed with the Timed Up and Go test, Berg Balance Scale, Functional Gait Assessment and 10-m walk test (gait speed). Fall occurrence was evaluated by a self-report questionnaire.

Results

The prevalence of hearing loss (pure tone average of >25 dB) was higher in stroke patients than in controls (64.1% vs. 35.9%; p < 0.001). The mean pure tone average of stroke patients showed a significant positive correlation with Timed Up and Go test (r = 0.357; p = 0.001) and fall occurrence (r = 0.253; p = 0.025), and a significant negative correlation with Berg Balance Scale (r = -0.299; p = 0.008) and Functional Gait Assessment (r = -0.452; p < 0.001). There was a non-significant negative correlation with gait speed (r = -0.166; p = 0.147). Multiple regression showed that mean pure tone average was associated with Timed Up and Go test (B = 0.096; 95%CI: 0.010, 0.183) and Functional Gait Assessment (B = -0.087; 95%CI: -0.157, -0.017), but not with gait speed (B = -0.003; 95%CI: -0.007, 0.001) and Berg Balance Scale (B = -0.058; 95%CI: -0.165, 0.049).

Conclusion

Hearing loss is more prevalent among patients with sub-acute stroke compared with age-sex-matched controls. Hearing loss is also associated with gait and balance impairments and falls among sub-acute stroke patients. We recommend that hearing screening and rehabilitation be incorporated into post-stroke rehabilitation programmes as part of strategies to improve balance and gait and reduce or prevent falls.

Action observation with motor simulation improves reactive stepping responses following strong backward balance perturbations in healthy young individuals

BACKGROUND AND OBJECTIVE

Adequate reactive steps are critical for preventing falls following balance perturbations. Perturbation-based balance training was shown to improve reactive stepping in various clinical populations, but its delivery is labor-intensive and generally uses expensive equipment. Action observation of reactive steps with either motor imagery (AOMI) or motor simulation (AOMS) are potential alternative training modalities. We here aimed to study their effects on reactive stepping performance.

METHODS

Sixty healthy young subjects were subjected to forward platform translations that elicited backward reactive steps. The AOMI group (n = 20) was tested after AOMI of an actor's reactive steps, while the AOMS group (n = 20) additionally stepped along with the actor. The control group (n = 20) was tested without any prior observation. Our primary outcome was the step quality of the first trial response, as this best represents a real-life loss-of-balance. Step quality was quantified as the leg angle with respect to the vertical at stepping-foot contact. We also studied single step success rates and reactive step quality across repeated trials.

RESULTS

Reactive step quality was significantly better in the AOMI and AOMS groups than in the control group, which differences coincided with a twofold higher single step success rate. Reactive step quality improved upon repeated trials in all groups, yet the AOMS group needed the fewest repetitions to reach plateau performance.

SIGNIFICANCE

The present results demonstrate that both AOMI and AOMS improved first and repeated trial reactive stepping performance. These findings point at the potential applicability of these concepts for home-based reactive balance training, for instance in serious games, with overt movements (AOMS) possibly having some benefits over mental imaginations (AOMI). Whether similar beneficial effects also emerge in the target populations of balance-impaired individuals remains to be investigated.

Correlation between trunk function improvement and recovery of activities of daily living after stroke in older adult patients

OBJECTIVES

To examine the impact of improved trunk function on activities of daily living in stroke patients using the Functional Independence Measure (FIM).

METHODS

This retrospective observational study was conducted on patients aged ≥ 65 years who had cerebral infarction. Patients were divided into a group with improved trunk function and a group without trunk function improvement based on the difference between the calculated Functional Assessment for Control of Trunk (FACT) gain at discharge and admission.

RESULTS

Of the 218 patients (mean age, 79.5 ± 7.9 years; 56.9% were men) included, 110 patients had improved FACT scores. Multiple linear regression analysis revealed that the group with improved FACT scores had higher FIM gain (coefficient = 7.562, 95% confidence interval = 3.870-11.253, P < 0.001). Multivariate logistic regression showed that the factors associated with FACT score improvement were the Mini Nutritional Assessment Short-Form score at admission, National Institutes of Health Stroke Scale score at admission, FACT score at admission, length of hospital stay, and period of rehabilitation.

DISCUSSIONS

Improvement in trunk function suggests a positive correlation with the recovery of activities of daily living in patients with cerebral infarction. This relationship should be further validated through prospective observational studies.

One-year retention of gait speed improvement in stroke survivors after treatment with a wearable home-use gait device

Background

Gait impairments after stroke are associated with numerous physical and psychological consequences. Treatment with the iStride® gait device has been shown to facilitate improvements to gait function, including gait speed, for chronic stroke survivors with hemiparesis. This study examines the long-term gait speed changes up to 12 months after treatment with the gait device.

Methods

Eighteen individuals at least one-year post-stroke completed a target of 12, 30-minute treatment sessions with the gait device in their home environment. Gait speed was measured at baseline and five follow-up sessions after the treatment period: one  week, one  month, three months, six months, and 12 months. Gait speed changes were analyzed using repeated-measures ANOVA from baseline to each follow-up time frame. Additional analysis included comparison to the minimal clinically important difference (MCID), evaluation of gait speed classification changes, and review of subjective questionnaires.

Results

Participants retained an average gait speed improvement >0.21 m/s compared to baseline at all post-treatment time frames. Additionally, 94% of participants improved their gait speed beyond the MCID during one or more post-treatment measurements, and 88% subjectively reported a gait speed improvement.

Conclusion

Treatment with the gait device may result in meaningful, long-term gait speed improvement for chronic stroke survivors with hemiparetic gait impairments.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03649217, identifier NCT03649217.

Assessment of functional fitness impacted by hospital rehabilitation in post-stroke patients who additionally contracted COVID-19

Background

The aim of the study was to assess the effects of rehabilitation in post-stroke patients, or post-stroke patients with simultaneous COVID-19 infection, in relation to: improved locomotion efficiency, improved balance, reduced risk of falling as well as the patients' more effective performance in everyday activities.

Methods

The study involved 60 patients in the early period (2-3 months) after a stroke. Group I consisted of 18 patients (30.0%) who, in addition to a stroke, also contracted COVID-19. Group II consisted of 42 patients (70%) post-stroke, with no SARS-CoV2 infection. The effects were assessed on the basis of: Tinetti test, Timed Up & Go test and Barthel scale.

Results

Both groups achieved a statistically significant improvement in their Barthel score after therapy (p < 0.001). The Tinetti test, assessing gait and balance, showed that participants in Group I improved their score by an average of 4.22 points. ±4.35, and in Group II, on average, by 3.48 points ± 3.45 points. In the Timed Up & Go test over a distance of 3 m, significant improvement was achieved in both groups, as well but the effect was higher in Group I (p < 0.001).

Conclusions

Hospital rehabilitation in the early period after stroke improved locomotion efficiency and balance, and reduced the risk of falls in post-stroke patients, both with and without COVID-19 infection.

Identifying best fall-related balance factors and robotic-assisted gait training attributes in 105 post-stroke patients using clinical machine learning models

BACKGROUND

Despite the promising effects of robot-assisted gait training (RAGT) on balance and gait in post-stroke rehabilitation, the optimal predictors of fall-related balance and effective RAGT attributes remain unclear in post-stroke patients at a high risk of fall.

OBJECTIVE

We aimed to determine the most accurate clinical machine learning (ML) algorithm for predicting fall-related balance factors and identifying RAGT attributes.

METHODS

We applied five ML algorithms- logistic regression, random forest, decision tree, support vector machine (SVM), and extreme gradient boosting (XGboost)- to a dataset of 105 post-stroke patients undergoing RAGT. The variables included the Berg Balance Scale score, walking speed, steps, hip and knee active torques, functional ambulation categories, Fugl- Meyer assessment (FMA), the Korean version of the Modified Barthel Index, and fall history.

RESULTS

The random forest algorithm excelled (receiver operating characteristic area under the curve; AUC = 0.91) in predicting balance improvement, outperforming the SVM (AUC = 0.76) and XGboost (AUC = 0.71). Key determinants identified were knee active torque, age, step count, number of RAGT sessions, FMA, and hip torque.

CONCLUSION

The random forest algorithm was the best prediction model for identifying fall-related balance and RAGT determinants, highlighting the importance of key factors for successful RAGT outcome performance in fall-related balance improvement.

Risk Factors Associated with Falls in Hospitalized Older Adults Patients

Background: Given the complexity of existing assessment methods and the scarcity of specialized geriatric healthcare professionals in China, this study aimed to investigate the risk factors for falls in hospitalized older adults patients. Methods: From July 2018 to July 2020, 112 older adults patients hospitalized in the Department of Geriatrics of our hospital were enrolled and grouped into the low-(n = 12), medium-(n = 58), and high-(n = 42) (fall) risk groups according to the Johns Hopkins Fall Risk Assessment. The patient's clinical characteristics, smoking, alcohol consumption, disease, falling history, osteoporosis medication, mobility, Barthel index, MMSE, and JHFRAT score were compared between groups. Results: The high-risk group had the oldest age, and the lowest weight, BMI, as well as highest rate of stroke history and sarcopenia among the three groups. Multivariate linear regression analysis revealed that stroke history (B = 2.66, 95% CI = [0.43, 4.89]; p = .020) and gait speed (B = -4.78, 95% CI = [-8.74, -0.76]; p = .020) were the significant factors associated with fall risk in hospitalized older adults patients. Conclusions: The results suggested that hospitalized older adults patients with stroke history and low gait speed had higher fall risk. These findings may be helpful for fall prevention in hospitalized older adults patients.

Is a portable pressure plate an alternative to force plates for measuring postural stability and interlimb coordination of quiet standing balance control?

Introduction

Center-of-pressure (COP) synchronization and symmetry can inform adaptations in balance control following one-sided sensorimotor impairments (e.g., stroke). As established force plates are impossible to transport, we aimed to criterion validate a portable pressure plate for obtaining reliable COP synchronization and symmetry measures, next to conventional postural stability measures.

Methods

Twenty healthy adults participated. In a single session, three 40-s eyes-open and eyes-closed quiet stance trials were performed per plate-type, randomly ordered. Individual-limb COPs were measured to calculate between-limb synchronization (BLS) and dynamic control asymmetry (DCA). Net COP (i.e., limbs combined) area, amplitude, and velocity were used to describe anteroposterior (AP) and mediolateral (ML) postural stability. Criterion validity was evaluated using Spearman correlations (r) and Bland-Altman plots. Test-retest reliability was tested using intraclass correlation coefficients (ICC).

Results

Strong correlations (r > 0.75) and acceptable reliability (ICC > 0.80) were found regarding individual-limb COP velocity and DCA, net COP ML amplitude and AP and ML velocities. Bland-Altman plots yielded possible proportional bias; the pressure plate systematically underestimated COP scores by force plates and a larger error associated with a larger measurement.

Conclusions

Despite correlations between instruments and sufficient reliability for measuring postural stability and DCA, this technical note strongly suggests, due to a systematic deviation, using the same plate-type to accurately assess performance change within subjects longitudinally over time.

Mild Stroke, Serious Problems: Limitations in Balance and Gait Capacity and the Impact on Fall Rate, and Physical Activity

BACKGROUND

After mild stroke persistent balance limitations may occur, creating a risk factor for fear of falling, falls, and reduced activity levels. Objective. To investigate whether individuals in the chronic phase after mild stroke show balance and gait limitations, elevated fall risk, reduced balance confidence, and physical activity levels compared to healthy controls.

METHODS

An observational case-control study was performed. Main outcomes included the Mini-Balance Evaluation Systems Test (mini-BEST), Timed Up and Go (TUG), 10-m Walking Test (10-MWT), and 6-item version Activity-specific Balance Confidence (6-ABC) scale which were measured in 1 session. Objectively measured daily physical activity was measured for 7 consecutive days. Fall rate in daily life was recorded for 12 months. Individuals after a mild stroke were considered eligible when they: (1) sustained a transient ischemic attack or stroke longer than 6 months ago, resulting in motor and/or sensory loss in the contralesional leg at the time of stroke, (2) showed (near-) complete motor function, that is, ≥24 points on the Fugl-Meyer Assessment-Lower Extremity (range: 0-28).

RESULTS

Forty-seven healthy controls and 70 participants after mild stroke were included. Participants with stroke fell more than twice as often as healthy controls, had a 2 point lower median score on the mini-BEST, were 1.7 second slower on TUG, 0.6 km/h slower on the 10-MWT, and had a 12% lower 6-ABC score. Intensity for both total activity (8%) as well as walking activity (6%) was lower in the participants with stroke, while no differences were found in terms of duration.

CONCLUSIONS

Individuals in the chronic phase after a mild stroke demonstrate persistent balance limitations and have an increased fall risk. Our results point at an unmet clinical need in this population.

Built Environments to Support Rehabilitation for People With Stroke From the Hospital to the Home (B-Sure): Protocol for a Mixed Method Participatory Co-Design Study

BACKGROUND

A global trend is to move rehabilitation closer to people's neighborhoods and homes. Still, little attention has been given to how the built environment outside the hospital setting might impact rehabilitation and recovery for stroke survivors.

OBJECTIVE

The overarching objective of this project is to develop conceptual models of built environments that support stroke rehabilitation and recovery outside the hospital setting. Specifically, the project will explore factors and characteristics of the built environment that support people with stroke and their families and identify innovative built environments that can be designed for local health care. The project will examine facilitators and obstacles for implementing built environmental solutions and evaluate the potential benefits, feasibility, and acceptability.

METHODS

The project uses a mixed methods design approach with 3 phases. In phase 1, factors and characteristics of the built environment for rehabilitation will be identified. Based on the results from phase 1, phase 2 will involve co-designing prototypes of environments to support the rehabilitation process for people with stroke. Finally, the prototypes will be evaluated in phase 3. Qualitative and quantitative methods will include a literature review, a concept mapping (CM) study, stakeholder interviews, prototype development, and testing. The project will use multidimensional scaling, hierarchical cluster analysis, descriptive statistics for quantitative data, and content analysis for qualitative data. Location analysis will rely on the location-allocation model for network problems, and the rule-based analysis will be based on geographic information systems data.

RESULTS

As of the submission of this protocol, ethical approval for the CM study and the interview study has been obtained. Data collection is planned to start in September 2023 and the workshops later in the same year. The scoping review is ongoing from January 2023. The CM study is ongoing and will be finalized in the spring of 2024. We expect to finish the data analysis in the second half of 2024. The project is a 3-year project and will continue until December 2025.

CONCLUSIONS

We aim to determine how new environments could better support a person's control over their day, environment, goals, and ultimately control over their recovery and rehabilitation activities. This "taking charge" approach would have the greatest chance of transferring the care closer to the patient's home. By co-designing with multiple stakeholders, we aim to create solutions with the potential for rapid implementation. The project's outcomes may target other people with frail health after a hospital stay or older persons in Sweden and anywhere else. The impact and social benefits include collaboration between important stakeholders to explore how new environments can support the transition to local health care, co-design, and test of new conceptual models of environments that can promote health and well-being for people post stroke.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52489.

Floor-to-Stand Performance Among People Following Stroke

OBJECTIVES

Studies have examined floor-to-stand performance in varied adult populations both quantitatively and qualitatively. Despite an elevated risk of falls and inability to independently return to stand after a fall, few have examined the ability to stand from the floor in patients recovering from stroke. There were 2 objectives of the study: to identify the relationships between floor-to-stand performance using a timed supine-to-stand test (TSS) and physical performance measures of gait, balance, and balance confidence among persons in the subacute phase after stroke; and to analyze descriptive strategies used in the completion of the TSS.

METHODS

A cross-sectional design was implemented. Fifty-eight adults (mean age = 59.2 [standard deviation (SD) = 13.9] years; 34 [58.6%] men) who were in the subacute phase after ischemic or hemorrhagic stroke and who could stand from the floor with no more than supervision completed the TSS and physical performance assessments.

RESULTS

The median time to complete the TSS in our sample was 13.0 (interquartile range = 15.5) seconds. TSS time was significantly correlated with physical performance tests, including the Timed "Up & Go" Test (ρ = 0.70), gait speed (ρ = -0.67), Dynamic Gait Index (ρ = -0.52), and Activities-Specific Balance Confidence Scale (ρ = -0.43). Thirty-two percent of the variance in TSS time was attributed to Timed "Up & Go" Test time and the use of the quadruped position to transition to standing. Participants who used a gait device were more likely to use a chair during rise to stand.

CONCLUSION

The TSS demonstrates concurrent validity with physical performance measures.

IMPACT

Findings serve to improve functional mobility examination after stroke and to formulate effective treatment interventions to improve floor-to-stand performance.

Feasibility and outcomes of supplemental gait training by robotic and conventional means in acute stroke rehabilitation

INTRODUCTION

Practicality of implementation and dosing of supplemental gait training in an acute stroke inpatient rehabilitation setting are not well studied but can have positive impact on outcomes.

OBJECTIVES

To determine the feasibility of early, intense supplemental gait training in inpatient stroke rehabilitation, compare functional outcomes and the specific mode of delivery.

DESIGN AND SETTING

Assessor blinded, randomized controlled trial in a tertiary Inpatient Rehabilitation Facility.

PARTICIPANTS

Thirty acute post-stroke patients with unilateral hemiparesis (≥ 18 years of age with a lower limb MAS ≤ 3).

INTERVENTION

Lokomat® or conventional gait training (CGT) in addition to standard mandated therapy time.

MAIN OUTCOME MEASURES

Number of therapy sessions; adverse events; functional independence measure (FIM motor); functional ambulation category (FAC); passive range of motion (PROM); modified Ashworth scale (MAS); 5 times sit-to-stand (5x-STS); 10-m walk test (10MWT); 2-min walk test (2MWT) were assessed before (pre) and after training (post).

RESULTS

The desired supplemental therapy was implemented during normal care delivery hours and the patients generally tolerated the sessions well. Both groups improved markedly on several measures; the CGT group obtained nearly 45% more supplemental sessions (12.8) than the Lokomat® group (8.9). Both groups showed greater FIM improvement scores (discharge - admission) than those from a reference group receiving no supplemental therapy. An overarching statistical comparison between methods was skewed towards a differential benefit (but not significant) in the Lokomat® group with medium effect sizes. By observation, the robotic group completed a greater number of steps, on average. These results provide some evidence for Lokomat® being a more efficient tool for gait retraining by providing a more optimal therapy "dose".

CONCLUSIONS

With careful planning, supplemental therapy was possible with minimal intrusion to schedules and was well tolerated. Participants showed meaningful functional improvement with relatively little supplemental therapy over a relatively short time in study.

A survey to assess perspectives of people with chronic stroke about customized safety harnesses for dance-based exergaming in home settings

BACKGROUND

Early dance-based exergaming (DBExG) trials in people with chronic stroke (PwCS) have shown promising results, but there remains a lack of knowledge if PwCS are interested in receiving such training in their homes and the applicability of a fall-protection safety harness in the home environment.

OBJECTIVE

To survey people with chronic stroke to understand the perspectives and preferences of various customized safety harnesses for home-based harness assisted dance-based exergaming rehabilitation.

METHODS

Participants were included in this survey study if they had a stroke, lived in the community, and understood English. Participants completed a study-specific safety harness survey via mail, in-person, or online. Descriptive statistics were used to characterize the sample and survey responses.

RESULTS

One hundred two survey responses were returned. The majority of participants voted for a door mountable harness (51%), side-release style buckle (58%), and preferred to receive a manual to explain how to use the harness (51%). Seventy-eight percent of the participants required permission to install or use a harness system in their homes. More than half of the participants preferred exhibiting independence by strapping the harness themselves (68%), along with choosing to live independently (the ability to live in one's own home and community safely, independently, comfortably, and able also perform their activities of daily living, regardless of physical ability level) (89%).

CONCLUSIONS

PwCS opted to use ShA-DBExG in their homes. The current survey serves as a guideline to develop, customize, and prescribe home-based ShA-DBExG rehabilitation.

Using Quality Indicator Codes to Identify Patients' Fall Risk in Inpatient Rehabilitation Facilities

OBJECTIVE

To discover if quality indicator (QI) codes are associated with patient falls in inpatient rehabilitation facilities (IRFs).

DESIGN

This retrospective cohort study explored differences between patients who fell and those who did not fall. We analyzed potential associations between QI codes and falls using univariable and multivariable logistic regression models.

SETTING

We collected data from electronic medical records at 4 IRFs.

PARTICIPANTS

In 2020, our 4 data collection sites admitted and discharged a total of 1742 patients older than 14 years . We only excluded patients (N=43) from statistical analysis if they were discharged before admission data had been assigned.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Using a data extraction report, we collected age, sex, race and ethnicity, diagnosis, falls, and QI codes for communication, self-care, and mobility performance. Staff documented communication codes on a 1-4 scale and self-care and mobility codes on a 1-6 scale, with higher codes representing greater independence.

RESULTS

Ninety-seven patients (5.71%) fell in the 4 IRFs over a 12-month period. The group who fell had lower QI codes for communication, self-care, and mobility. When adjusting for bed mobility, transfer, and stair-climbing ability, low performance with understanding, walking 10 feet, and toileting were significantly associated with falls. Patients with admission QI codes below 4 for understanding had 78% higher odds of falling. If they were assigned admission QI codes below 3 for walking 10 feet or toileting, they had 2 times greater odds of falling. We did not find a significant association between falls and patients' diagnosis, age, sex, or race and ethnicity in our sample.

CONCLUSIONS

Communication, self-care, and mobility QI codes appear to be significantly associated with falls. Future research should explore how to use these required codes to better identify patients likely to fall in IRFs.

Footwear characteristics and foot problems in community dwelling people with stroke: a cross-sectional observational study

PURPOSE

To explore footwear characteristics and foot problems in community dwelling people with stroke as most research to date focused on the general elderly population.

METHODS

Thirty people with mild to moderate stroke (nine men, mean age 68, mean time since onset 67 months) attended a single session to assess footwear and foot problems using established podiatry foot (wear) and ankle assessments.

RESULTS

Most participants wore slippers indoors (n = 17, 57%) and walking shoes outdoors (n = 11, 37%). Over half wore unsupportive ill-fitting shoes indoors and 47% of outdoor shoes fitted badly. All participants had foot problems (mean 6.5 (3.1), 95% CI: 5.4-7.7), including impaired single limb heel raise (93%), reduced range of movement (77%), sensation (47%), and muscle strength (43%). Many had foot-pain, hallux valgus (both 50%), or swollen feet (40%). Foot problems were associated with reduced balance confidence, activity, and community participation (all p < 0.05). A greater proportion of fallers (13/16) than non-fallers (4/14) reported foot problems (p = 0.029).

CONCLUSIONS

Many community-dwelling people with stroke wore poorly fitting shoes; all had foot problems. Foot problems were linked to reduced mobility. Finding more effective pathways to support people with stroke to select supportive, well-fitting indoor and outdoor footwear is indicated.Implications for rehabilitationPeople with stroke often wear unsupportive ill-fitting shoes and experience foot problems.Assessment of foot problems and footwear advice should be considered during stroke rehabilitation particularly when interventions target fall prevention or improvements in balance and mobility.Information on appropriate footwear and signposting that new shoe purchases should include measuring feet to ensure a good fit is recommended.

Recovery of Quiet Standing Balance and Lower Limb Motor Impairment Early Poststroke: How Are They Related?

BACKGROUND

Recovery of quiet standing balance early poststroke has been poorly investigated using repeated measurements.

OBJECTIVE

To investigate (1) the time course of steady-state balance in terms of postural stability and inter-limb symmetry, and (2) longitudinal associations with lower limb motor recovery in the first 3 months poststroke.

METHODS

Forty-eight hemiparetic subjects (age: 58.9 ± 16.1 years) were evaluated at weeks 3, 5, 8, and 12 poststroke. Motor impairments concerned the Fugl-Meyer assessment (FM-LE) and Motricity Index total score (MI-LE) or ankle item separately (MI-ankle). Postural stability during quiet 2-legged stance was calculated as the net center-of-pressure area (COPArea) and direction-dependent velocities (COPVel-ML and COPVel-AP). Dynamic control asymmetry (DCA) and weight-bearing asymmetry (WBA) estimated inter-limb symmetries in balance control and loading. Linear mixed models determined (1) time-dependent change and (2) the between- and within-subject associations between motor impairments and postural stability or inter-limb symmetry.

RESULTS

Time-dependent improvements were significant for FM-LE, MI-LE, MI-ankle, COPArea, COPVel-ML, and COPVel-AP, and tended to plateau by week 8. DCA and WBA did not exhibit significant change. Between-subject analyses yielded significant regression coefficients for FM-LE, MI-LE, and MI-ankle scores with COPArea, COPVel-ML, and COPVel-AP up until week 8, and with WBA until week 12. Within-subject regression coefficients of motor recovery with change in COPArea, COPVel-ML, COPVel-AP, DCA, or WBA were generally non-significant.

CONCLUSIONS

Postural stability improved significantly in the first 8 weeks poststroke, independent of lower limb motor recovery at the most affected side within subjects. Our findings suggest that subjects preferred to compensate with their less affected side, making metrics reflecting inter-limb asymmetries in balance invariant for change early poststroke.Clinical Trial Registration: Clinicaltrials.gov. unique identifier NCT03728036.