Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers

How do individuals with subacute stroke nearly fall during forward walking?

BACKGROUND

Clarifying how falls have occurred in individuals with stroke is difficult because most falls are unwitnessed. We regularly measured gait using a 3D motion analysis system; thus, falling motion was recorded kinematically, allowing analysis of the relationship between near-fall timing and direction.

RESEARCH QUESTION

When and in what direction an individual with stroke nearly falls?

METHODS

Sixty-seven individuals with stroke who experienced near falls (67 trials) were selected from 2,494 participants (40,602 trials). Near-fall timing was classified into the loading response phase (LR), single stance phase (SS), pre-swing phase (PS), and swing phase (SW) groups of the paretic limb. Near-fall direction was classified into forward, backward, paretic, and nonparetic side. Differences in frequencies of near-fall timing and direction were examined using Fisher's exact test.

RESULTS

Regarding the relationship between near-fall timing and direction analyzed using adjusted residuals, two participants of the LR group (2 participants) fell in the paretic side direction, 12 participants of the SS group (22 participants) fell backward, and 9 participants of the SW group (13 participants) fell forward (p < 0.01). PS group (30 participants) showed no specific near-fall direction.

CONCLUSIONS

We clarified the specific near-fall timing and direction in individuals with stroke; finding they tended to fall during the backwards in the single stance phase and forwards during the swing phase. Providing caregivers with information and instructions regarding when and in what direction participants are likely to fall may contribute to fall prevention in patients with subacute 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.

Enhancing safety monitoring in post-stroke rehabilitation through wearable technologies

ObjectiveCurrent clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Technology enables monitoring of exercise and therapy intensity, but safety concerns could also be addressed. This study explores functional mobility in post-stroke individuals using wearable technology to quantify movement smoothness-an indicator of safe mobility.DesignObservational cohort study.SettingA movement analysis and rehabilitation laboratory.ParticipantsA total of 56 chronic post-stroke individuals and 51 healthy controls.InterventionParticipants performed the mobility test while wearing an inertial measurement unit attached to their waist. Thirty-two healthy participants also engaged in a steady-state walking task.Main measuresFunctional mobility smoothness by examining angular velocities in the yaw, pitch, and roll axes, employing the spectral arc length metrics.ResultsOur findings reveal that post-stroke individuals extend the duration of the timed-up-and-go test (≈9 s and 23 s longer compared to the controls) to ensure safe mobility-greater mobility smoothness (p < 0.001). Notably, for mild and severe impairments, post-stroke mobility demonstrated ≈8% and ≈11% greater smoothness in pitch movements, respectively (p = 0.025 and p = 0.002). In the roll direction, mobility was ≈12% smoother in cases of severe strokes (p = 0.006).ConclusionThis study addresses a crucial gap in the understanding of mobility smoothness in chronic stroke survivors using wearable technology. Our study suggests the potential utility of spectral arc length to predict challenging mobility situations in real-world situations. We highlight the potential for automated monitoring of safety offering promising avenues for real-time, real-life monitoring.

Studying turn performance, trunk control, and mobility in acute stroke subjects: a cross-sectional study

Background

Stroke leads to various impairments like motor deficits, impaired trunk control and restricted mobility. However, rehabilitation professionals often underestimate the fundamental function of turning, which is essential for daily living activities like walking, cooking, or performing household chores. Impaired turning can be attributed to motor deficits post-stroke, resulting in restricted mobility and impaired trunk movement. Therefore, the present study aimed to determine the relationship between turn performance, trunk control, and mobility in stroke patients.

Materials and Methods

A total of 63 first-time supratentorial stroke (i.e., anterior circulation stroke) patients aged 18-90 years were recruited for the study. Turn performance was assessed by asking patients to walk for 10 feet comfortably, then take a 180° turn and return to the starting position. In addition, the duration and number of steps were recorded. Following this, the Trunk Impairment Scale (TIS) and Stroke Rehabilitation Assessment of Movement (STREAM) were used to assess trunk impairment and mobility, respectively. The group turn performance was analyzed using the Kruskal-Wallis test with a post hoc Mann-Whitney U test for between-group comparisons. The turn duration and turn steps were correlated with age, trunk control, and mobility using Spearman's rank correlation. A regression analysis was performed to determine the association of turn performance with age, trunk control, and mobility among stroke patients.

Results

Thirty stroke patients had turning difficulty, and 33 did not. Hence, they were categorized into the turning difficulty (TD) and non-turning difficulty (NTD) groups. When correlated with turn duration and the number of steps taken by the stroke patients while turning, the STREAM and TIS scores revealed a significant negative correlation (p < 0.001). The subjects' age showed a significant positive correlation with the turn duration and number of steps taken by stroke patients while turning (p < 0.001). A significant association was also found between turn performance and age and trunk control. However, there was no significant association between turn performance and mobility.

Conclusion

The observed associations highlight the complexity of turning ability and trunk control necessary to complete a turn safely. Additionally, with advancing age, turn performance and turning movement are compromised in stroke patients. This indicates that turning difficulty is more pronounced in older individuals with stroke.

Adapting spatiotemporal gait symmetry to functional electrical stimulation during treadmill walking

Individuals with neurological impairments often exhibit asymmetrical gait patterns. This study explored the potential of using functional electrical stimulation (FES) as a perturbation method during treadmill walking to promote gait symmetry adaptation by investigating whether the FES perturbation could induce gait adaptation concerning spatial and temporal gait symmetry in healthy subjects. In the FES perturbation, both legs received electrical pulses at the same period as the subjects' initial stride duration, and the temporal gap between the two pulses for each leg was manipulated over a 7-min period. Following this, subjects continued to walk for another 5 minutes without FES. Subjects participated in two trials: implicit and explicit. In the implicit trial, they walked comfortably during FES perturbation without consciously adjusting their gait. In the explicit trial, they voluntarily synchronized their toe-off phase to the stimulation timing. To examine the effects of the FES perturbation, we measured step length and stance time and then analyzed changes in step length and stance time symmetries alongside their subsequent aftereffects. During the explicit trial, subjects adapted their gait patterns to the electrical pulses, resulting in a directional change in stance time (temporal) symmetry, with the left stance becoming shorter than the right. The stance time asymmetry induced by FES perturbation showed a slight residual effect. In the implicit trial, the directional change trend was slightly observed but not statistically significant. No consistent trend in step length (spatial) symmetry changes was observed in either condition, indicating that subjects may adapt their spatial gait patterns independently of their temporal patterns. Our findings suggest that the applied FES perturbation strategy under explicit condition can induce adaptations in subjects' temporal gait asymmetry, particularly in stance. The implicit condition showed a similar slight trend but was not statistically significant. Further experiments would provide deeper understanding into the mechanism behind subjects' response to FES perturbations, as well as the long-term effects of these perturbations on the spatial and temporal aspects of gait symmetry.

Inverted U-shaped relationship between Barthel Index Score and falls in Chinese non-bedridden patients: a cross-sectional study

BACKGROUND

Performing activities of daily living comprise an important risk factor for falls among non-bedridden stroke inpatients in rehabilitation departments.

OBJECTIVES

To explore the correlation between Barthel Index score and the occurrence of falls in non-bedridden stroke rehabilitation inpatients.

METHODS

In this cross-sectional study, information of patients grouped as non-bedridden patients by the Longshi Scale was collected.

RESULTS

A total of 3097 patients were included in this study, with a fall incidence of 10.43%. After adjusting covariates, the total score of Barthel Index and falls in non-bedridden inpatients after stroke presented an inverted U-shaped curve relationship, in which inflection point was 60. The effect sizes on the left and right sides of infection point were 1.02 (95%CI 1.00-1.04) and 0.97 (95%CI 0.96-0.99), respectively.

CONCLUSIONS

Non-bedridden stroke patients with moderate activities of daily living (ADL) capacity may be at particularly increased risk of falls in rehabilitation departments.

Impaired Balance Predicts Cardiovascular Disease in 70-Year-Old Individuals-An Observational Study From the Healthy Aging Initiative

BACKGROUND

Limited research has explored balance problems as a prospective risk factor for cardiovascular disease (CVD). This study aimed to characterize the association between balance measures and the risk of incident CVD in a population of 70-year-olds.

METHODS AND RESULTS

From 2012 to 2022 a cohort of 4927 older individuals who were CVD free underwent balance assessments using a balance board. Measurements included lateral and anterior-posterior sway, along with a safety limit of stability in a subcohort (N=2782). Time to first hospitalization for CVD, encompassing stroke, myocardial infarction, or angina pectoris was the primary outcome. Multivariable regression models assessed associations between balance parameters and CVD risk. Over a mean follow-up of 4.9 years, 320 individuals were hospitalized for CVD. In a balance test with eyes open, increased lateral sway at baseline was associated with a higher risk of CVD (hazard ratio [HR], 1.014 [95% CI, 1.004-1.025], P=0.005, per mm increased sway), after adjustment for traditional risk factors for CVD. Similarly, individuals with CVD during follow-up exhibited higher lateral sway with eyes closed at baseline (HR, 1.015 [95% CI, 1.005-1.025], P=0.002, per mm increased sway), after multivariable adjustment. The 4 strongest independent predictors of CVD included lateral sway and were associated with a population attributable fraction of 61% (95% CI, 54-68).

CONCLUSIONS

In community-dwelling 70-year-olds, impaired lateral balance was an independent predictor of later CVD, after adjustment for traditional risk factors. This may suggest that position balance could be used as an early risk marker for underlying atherosclerotic disease.

Modeling the Heterogeneity of Post-Stroke Gait Control in Free-Living Environments Using a Personalized Causal Network

Post-stroke gait control is a complex, often fail to account for the heterogeneity and continuity of gait in existing gait models. Precisely evaluating gait speed adjustability and gait instability in free-living environments is important to understand how individuals with post-stroke gait dysfunction approach diverse environments and contexts. This study aimed to explore individual causal interactions in the free-living gait control of persons with stroke. To this end, fifty persons with stroke wore an accelerometer on the fifth lumbar vertebra (L5) for 24 h in a free-living environment. Individually directed acyclic graphs (DAGs) were generated based on the spatiotemporal gait parameters at contemporaneous and temporal points calculated from the acceleration data. Spectral clustering and Bayesian model comparison were used to characterize the DAGs. Finally, the DAG patterns were interpreted via Bayesian logistic analysis. Spectral clustering identified three optimal clusters from the DAGs. Cluster 1 included persons with moderate stroke who showed high gait asymmetry and gait instability and primarily adjusted gait speed based on cadence. Cluster 2 included individuals with mild stroke who primarily adjusted their gait speed based on step length. Cluster 3 comprised individuals with mild stroke who primarily adjusted their gait speed based on both step length and cadence. These three clusters could be accurately classified based on four variables: Ashman's D for step velocity, Fugl-Meyer Assessment, step time asymmetry, and step length. The diverse DAG patterns of gait control identified suggest the heterogeneity of gait patterns and the functional diversity of persons with stroke. Understanding the theoretical interactions between gait functions will provide a foundation for highly tailored rehabilitation.

Effect of fear of falling on turning performance among patients with chronic stroke

BACKGROUND

Turning difficulties have been reported in stroke persons, but studies have indicated that fall history might not significantly affect turning performance. Fear of falling (FOF) is common after a fall, although it can occur in individuals without a fall history.

RESEARCH QUESTION

Could FOF have an impact on turning performance among chronic stroke patients?

METHODS

This cross-sectional study recruited 97 stroke persons. They were instructed to perform 180° and 360° turns, and their performance was represented by angular velocity. FOF was evaluated using the Falls Efficacy Scale-International (FES-I). Falls that occurred 12 months prior to the study assessment were recorded.

RESULTS

A higher FES-I score was significantly correlated with a decline in angular velocity in all turning tasks after adjustment for demographic data. The correlation remained significant after controlling for falls history. Participants with a high level of FOF exhibited significantly slower angular velocities during all turning tasks compared with those with a low level of FOF. Participants with a moderate level of FOF had a significantly slower angular velocity than did those with a low level of FOF during the 360° turn to the paretic side only.

SIGNIFICANCE

A higher level of FOF, regardless of fall history, was significantly associated with a reduced angular velocity during turning. A high level of FOF affected turning performance in all tasks. Turning performance may not be affected by fall experience. Anxiety about falling may have a greater effect on turning performance than does fall history.

Cautious Gait during Navigational Tasks in People with Hemiparesis: An Observational Study

Locomotor and balance disorders are major limitations for subjects with hemiparesis. The Timed Up and Go (TUG) test is a complex navigational task involving oriented walking and obstacle circumvention. We hypothesized that subjects with hemiparesis adopt a cautious gait during complex locomotor tasks. The primary aim was to compare spatio-temporal gait parameters, indicators of cautious gait, between the locomotor subtasks of the TUG (Go, Turn, Return) and a Straight-line walk in people with hemiparesis. Our secondary aim was to analyze the relationships between TUG performance and balance measures, compare spatio-temporal gait parameters between fallers and non-fallers, and identify the biomechanical determinants of TUG performance. Biomechanical parameters during the TUG and Straight-line walk were analyzed using a motion capture system. A repeated measures ANOVA and two stepwise ascending multiple regressions (with performance variables and biomechanical variables) were conducted. Gait speed, step length, and % single support phase (SSP) of the 29 participants were reduced during Turn compared to Go and Return and the Straight-line walk, and step width and % double support phase were increased. TUG performance was related to several balance measures. Turn performance (R2 = 63%) and Turn trajectory deviation followed by % SSP on the paretic side and the vertical center of mass velocity during Go (R2 = 71%) determined TUG performance time. People with hemiparesis adopt a cautious gait during complex navigation at the expense of performance.

Dorsiflexion Specific Ankle Robotics to Enhance Motor Learning After Stroke: A Preliminary Report

Background

Robotics has emerged as a promising avenue for gait retraining of persons with chronic hemiparetic gait and footdrop, yet there is a gap regarding the biomechanical adaptations that occur with locomotor learning. We developed an ankle exoskeleton (AMBLE) enabling dorsiflexion assist-as-needed across gait cycle sub-events to train and study the biomechanics of motor learning stroke. This single-armed, non-controlled study investigates effects of nine hours (9 weeks × 2 sessions/week) locomotor task-specific ankle robotics training on gait biomechanics and functional mobility in persons with chronic hemiparetic gait and foot drop. Subjects include N = 16 participants (8 male, 8 female) age 53 ± 12 years with mean 11 ± 8 years since stroke. All baseline and post-training outcomes including optical motion capture for 3-D gait biomechanics are conducted during unassisted (no robot) over-ground walking conditions.

Findings

Robotics training with AMBLE produced significant kinematic improvements in ankle peak dorsiflexion angular velocity (°/s, + 44 [49%], p < 0.05), heel-first foot strikes (%steps, + 14 [15%], p < 0.01) toe-off angle (°, + 83[162%], p < 0.05), and paretic knee flexion (°, + 20 [30%], p < 0.05). Improvements in gait temporal-spatial parameters include increased paretic step length (cm, + 12 [20%], p< 0.05), reduced paretic swing duration (%GC, -3[6%], p < 0.05), and trend toward improved step length symmetry (-16 [11%], p = 0.08). Functional improvements include 10-meter comfortable (m/s, + 13 [16%], p < 0.01) and fastest (m/s, + 13 [15%], p<0.01) walking velocities, 6-minute timed walk distance (m, + 16 [19%], p < 0.01) and Dynamic Gait Index scores (+15 [15%], p < 0.01). Subjects' perceived improvements surpassed the minimal clinically important difference on the Stroke Impact Scale (SIS) mobility subscale (+11 [19%], p < 0.05).

Conclusions

AMBLE training improves paretic ankle neuromotor control, paretic knee flexion, and gait temporal-distance parameters during unassisted over-ground walking in persons with chronic stroke and foot drop. This locomotor learning indexed by an increase in volitional autonomous (non-robotic) control of paretic ankle across training translated to improvements in functional mobility outcomes. Larger randomized clinical trials are needed to investigate the effectiveness of task-specific ankle robotics, and precise training characteristics to durably improve gait, balance, and home and community-based functional mobility for persons with hemiparetic gait and foot drop.

Clinical trial identifier

NCT04594837.

Transcranial Direct Current Stimulation to Ameliorate Post-Stroke Cognitive Impairment

Post-stroke cognitive impairment is a common and disabling condition with few effective therapeutic options. After stroke, neural reorganization and other neuroplastic processes occur in response to ischemic injury, which can result in clinical improvement through spontaneous recovery. Neuromodulation through transcranial direct current stimulation (tDCS) is a promising intervention to augment underlying neuroplasticity in order to improve cognitive function. This form of neuromodulation leverages mechanisms of neuroplasticity post-stroke to optimize neural reorganization and improve function. In this review, we summarize the current state of cognitive neurorehabilitation post-stroke, the practical features of tDCS, its uses in stroke-related cognitive impairment across cognitive domains, and special considerations for the use of tDCS in the post-stroke patient population.

Three-phase Enriched Environment Improves Post-stroke Gait Dysfunction via Facilitating Neuronal Plasticity in the Bilateral Sensorimotor Cortex: A Multimodal MRI/PET Analysis in Rats

The three-phase Enriched Environment (EE) paradigm has been shown to promote post-stroke functional improvement, but the neuronal mechanisms are still unclear. In this study, we applied a multimodal neuroimaging protocol combining magnetic resonance imaging (MRI) and positron emission tomography (PET) to examine the effects of post-ischemic EE treatment on structural and functional neuroplasticity in the bilateral sensorimotor cortex. Rats were subjected to permanent middle cerebral artery occlusion. The motor function of the rats was examined using the DigiGait test. MRI was applied to investigate the EE-induced structural modifications of the bilateral sensorimotor cortex. [18F]-fluorodeoxyglucose PET was used to detect glucose metabolism. Blood oxygen level-dependent (BOLD)-functional MRI (fMRI) was used to identify the regional brain activity and functional connectivity (FC). In addition, the expression of neuroplasticity-related signaling pathways including neurotrophic factors (BDNF/CREB), axonal guidance proteins (Robo1/Slit2), and axonal growth-inhibitory proteins (NogoA/NgR) as well as downstream proteins (RhoA/ROCK) in the bilateral sensorimotor cortex were measured by Western blots. Our results showed the three-phase EE improved the walking ability. Structural T2 mapping imaging and diffusion tensor imaging demonstrated that EE benefited structure integrity in the bilateral sensorimotor cortex. PET-MRI fused images showed improved glucose metabolism in the corresponding regions after EE intervention. Specifically, the BOLD-based amplitude of low-frequency fluctuations showed that EE increased spontaneous activity in the bilateral motor cortex and ipsilateral sensory cortex. In addition, FC results showed increased sensorimotor connectivity in the ipsilateral hemisphere and increased interhemispheric motor cortical connectivity and motor cortical-thalamic connectivity following EE intervention. In addition, a strong correlation was found between increased functional connectivity and improved motor performance of limbs. Specifically, EE regulated the expression of neuroplasticity-related signaling, involving BDNF/CREB, Slit2/Robo1, as well as the axonal growth-inhibitory pathways Nogo-A/Nogo receptor and RhoA/ROCK in the bilateral sensorimotor cortex. Our results indicated that the three-phase enriched environment paradigm enhances neuronal plasticity of the bilateral sensorimotor cortex and consequently ameliorates post-stroke gait deficits. These findings might provide some new clues for the development of EE and thus facilitate the clinical translation of EE.

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.

Functional electrical stimulation to enhance reactive balance among people with hemiparetic stroke

BACKGROUND

Individuals with stroke demonstrate a twofold higher fall incidence compared to healthy counterparts, potentially associated with deficits in reactive balance control, which is crucial for regaining balance from unpredictable perturbations to the body. Moreover, people with higher stroke-related motor impairment exhibit greater falls and cannot recover balance during higher perturbation intensities. Thus, they might need supplemental agents for fall prevention or even to be included in a perturbation-based protocol. Functional electrical stimulation is a widely used clinical modality for improving gait performance; however, it remains unknown whether it can enhance or interfere with reactive balance control.

METHODS

We recruited twelve ambulatory participants with hemiparetic stroke (61.48 ± 6.77 years) and moderate-to-high motor impairment (Chedoke-McMaster Stroke Leg Assessment ≤ 4/7). Each participant experienced 4 unpredicted paretic gait-slips, with and without functional electrical stimulation (provided 50-500 ms after perturbation) in random order. The paretic quadriceps muscle group was chosen to receive electrical stimulation, considering the role of support limb knee extensors for preventing limb-collapse. Outcomes including primary (laboratory falls), secondary (reactive stability, vertical limb support) and tertiary (compensatory step length, step initiation, execution time) measures were compared between the two conditions.

RESULTS

Participants demonstrated fewer falls, higher reactive stability, and higher vertical limb support (p < 0.05) following gait-slips with functional electrical stimulation compared to those without. This was accompanied by reduced step initiation time and a longer compensatory step (p < 0.05).

CONCLUSION

The application of functional electrical stimulation to paretic quadriceps following gait-slips reduced laboratory fall incidence with enhanced reactive balance outcomes among people with higher stroke-related motor impairment. Our results lay the preliminary groundwork for understanding the instantaneous neuromodulatory effect of functional electrical stimulation in preventing gait-slip falls, future studies could test its therapeutic effect on reactive balance. Clinical registry number: NCT04957355.

Relationships between mediolateral step modulation and clinical balance measures in people with chronic stroke

BACKGROUND

Many people with chronic stroke (PwCS) exhibit walking balance deficits linked to increased fall risk and decreased balance confidence. One potential contributor to these balance deficits is a decreased ability to modulate mediolateral stepping behavior based on pelvis motion. This behavior, hereby termed mediolateral step modulation, is thought to be an important balance strategy but can be disrupted in PwCS.

RESEARCH QUESTION

Are biomechanical metrics of mediolateral step modulation related to common clinical balance measures among PwCS?

METHODS

In this cross-sectional study, 93 PwCS walked on a treadmill at their self-selected speed for 3-minutes. We quantified mediolateral step modulation for both paretic and non-paretic steps by calculating partial correlations between mediolateral pelvis displacement at the start of each step and step width (ρSW), mediolateral foot placement relative to the pelvis (ρFP), and final mediolateral location of the pelvis (ρPD) at the end of the step. We also assessed several common clinical balance measures (Functional Gait Assessment [FGA], Activities-specific Balance Confidence scale [ABC], self-reported fear of falling and fall history). We performed Spearman correlations to relate each biomechanical metric of step modulation to FGA and ABC scores. We performed Wilcoxon rank sum tests to compare each biomechanical metric between individuals with and without a fear of falling and a history of falls.

RESULTS

Only ρFP for paretic steps was significantly related to all four clinical balance measures; higher paretic ρFP values tended to be observed in participants with higher FGA scores, with higher ABC scores, without a fear of falling and without a history of falls. However, the strength of each of these relationships was only weak to moderate.

SIGNIFICANCE

While the present results do not provide insight into causality, they justify future work investigating whether interventions designed to increase ρFP can improve clinical measures of post-stroke balance in parallel.

Quantifying Turning Tasks With Wearable Sensors: A Reliability Assessment

OBJECTIVE

The aim of this study was to establish the test-retest reliability of metrics obtained from wearable inertial sensors that reflect turning performance during tasks designed to imitate various turns in daily activity.

METHODS

Seventy-one adults who were healthy completed 3 turning tasks: a 1-minute walk along a 6-m walkway, a modified Illinois Agility Test (mIAT), and a complex turning course (CTC). Peak axial turning and rotational velocity (yaw angular velocity) were extracted from wearable inertial sensors on the head, trunk, and lumbar spine. Intraclass correlation coefficients (ICCs) were established to assess the test-retest reliability of average peak turning speed for each task. Lap time was collected for reliability analysis as well.

RESULTS

Turning speed across all tasks demonstrated good to excellent reliability, with the highest reliability noted for the CTC (45-degree turns: ICC = 0.73-0.81; 90-degree turns: ICC = 0.71-0.83; and 135-degree turns: ICC = 0.72-0.80). The reliability of turning speed during 180-degree turns from the 1-minute walk was consistent across all body segments (ICC = 0.74-0.76). mIAT reliability ranged from fair to excellent (end turns: ICC = 0.52-0.72; mid turns: ICC = 0.50-0.56; and slalom turns: ICC = 0.66-0.84). The CTC average lap time demonstrated good test-retest reliability (ICC = 0.69), and the mIAT average lap time test-retest reliability was excellent (ICC = 0.91).

CONCLUSION

Turning speed measured by inertial sensors is a reliable outcome across a variety of ecologically valid turning tasks that can be easily tested in a clinical environment.

IMPACT

Turning performance is a reliable and important measure that should be included in clinical assessments and clinical trials.

Effectiveness of mid thoracic spine mobilization on postural balance and gait ability in subacute stroke patients: A randomized clinical trial

BACKGROUND

Although mulligan sustained natural apophyseal glides (SNAG) and maitland mobilization (MM) are common interventions for musculoskeletal disease, no study has directly compared the effectiveness of mid-thoracic spine mobilization in subacute stroke patients.

OBJECTIVE

To investigate the effects of mid-thoracic spine mobilization (SNAG vs. MM) on postural balance and gait ability in subacute stroke patients.

METHODS

Fifty subacute stroke patients were randomly allocated to the SNAG (n= 17), MM (n= 16), and control (n= 17) groups, each receiving a neuro-developmental therapy program for four successive weeks. The SNAG and MM groups additionally received mid-thoracic spine mobilization (T4∼8). The primary outcome measure was postural sway, and secondary outcome measures included the five times sit-to-stand test (FTSST), functional reach test (FRT), 10-m walk test (10MWT), 6-minute walk test (6MWT) and global rating of change (GRC).

RESULTS

Participants reported no adverse events, and there was no loss to follow-up. The SNAG and MM group patients demonstrated significant improvements (p< 0.05) in postural sway, FTSST, FRT, 10MWT, and 6MWT compared with those in the control group, with no between-group differences.

CONCLUSIONS

Mid-thoracic spine mobilization allows significant improvements in postural balance and gait ability in subacute stroke patients, with no differences between the SNAG and MM techniques.

Characteristics of muscle synergy extracted using an autoencoder in patients with stroke during the curved walking in comparison with healthy controls

BACKGROUND AND OBJECTIVE

This study investigated the spatial and temporal features of muscle synergy during two types of curved walking (CW), according to whether the analyzed legs were located on the outside (OCW) or inside (ICW) on the basis of the curve direction during CW, in patients with stroke.

METHODS

Thirteen patients with stroke and seven age-matched healthy controls participated in this study. Using the autoencoder technique, four muscle synergies were extracted from eight muscles of the paretic legs in patients with stroke and the dominant legs in healthy controls. Walking speed, variance accounted for (VAF) of the four synergies, and each synergy with the same number were compared. Pearson's correlation and activation peak timing calculation were used to identify spatial and temporal features, respectively.

RESULTS

Regarding walking speed in patients with stroke, ICW was significantly faster than OCW (P = 0.027). Regarding spatial features, muscle weighting values of patients with stroke in synergy 3 that were mainly involved in the early swing phase had the lowest similarity [r = 0.30] during OCW, and synergy 4 that was mainly involved in the late swing phase had the lowest similarity [r = 0.39] during ICW compared to the healthy group. Meanwhile, in terms of temporal features, activation peak timings of patients with stroke in synergy 1, which was mainly involved in the early stance phase, and synergy 2, which was mainly involved in the mid-late stance phase, were significantly delayed during OCW (P < .001, P = 0.003), while peak timings of synergy 1 and synergy 3 were delayed during ICW (P = .004, P = .002).

SIGNIFICANCE

Based on distinctive features of spatial synergy during the swing phase of CW and temporal synergy during the swing-stance transition phase of CW in patients with stroke in gait rehabilitation, specific approaches need to be considered depending on the curve direction and each gait phase.

Image Findings as Predictors of Fall Risk in Patients with Cerebrovascular Disease

This study examined computed tomography findings in patients with cerebrovascular disease and determined predictors for falls. Images of the head were divided into 13 regions, and the relationships between computed tomography findings and the presence or absence of falls were investigated. A total of 138 patients with cerebrovascular disease (66% men, aged 73.8 ± 9.6 years) were included. A comparison between the fall and non-fall groups revealed a significant difference in the total functional independence measure scores and imaging findings at admission. Logistic regression analysis showed that the thalamus (p < 0.001), periventricular lucency (p < 0.001), lateral hemisphere room enlargement (p < 0.05), and age (p < 0.05) were related to the presence or absence of falls. For the 42 patients with cerebral hemorrhage, the thalamus (p < 0.01), periventricular lucency (p < 0.05), lateral ventricle vicinity (p < 0.05), and posterior limb of the internal capsule (p < 0.05) were extracted as factors related to the presence or absence of falls. For the 96 patients with cerebral infarction, the thalamus (p < 0.001), periventricular lucency (p < 0.01), and anterior limb of the internal capsule (p < 0.05) were extracted as factors related to the presence or absence of falls. This study found a relationship between the thalamus, lateral ventricle enlargement, periventricular lucency, and falls. Fall prognosis can potentially be predicted from computed tomography findings at admission.

Treadmill Handrail-Use Increases the Anteroposterior Margin of Stability in Individuals' Post-Stroke

Treadmills are important rehabilitation tools used with or without handrails. The handrails could be used to attain balance, prevent falls, and improve the walking biomechanics of stroke survivors, but it is yet unclear how the treadmill handrails impact their stability margins. Here, we investigated how 3 treadmill handrail-use conditions (no-hold, self-selected support, and light touch) impact stroke survivors' margins of stability (MoS). The anteroposterior MoS significantly increased for both legs with self-selected support while the mediolateral MoS of the unaffected leg decreased significantly when the participants walked with self-selected support in comparison to no-hold in both cases. We concluded that the contextual use of the handrail should guide its prescription for fall prevention or balance training in rehabilitation programs.

Ankle stiffness asymmetry is associated with balance function in individuals with chronic stroke

Ankle joint is one of important contributors on balance in stroke survivors. This study aimed to investigate the relationships of ankle stiffness symmetry ratios along the talocrural and subtalar axes with clinical balance measures and weight distribution during quiet standing in ambulatory chronic post-stroke survivors. The clinical trials involved 15 ambulatory elderly with chronic post-stroke hemiparesis and 15 healthy controls. Ankle stiffness was evaluated during non-weight-bearing isokinetic passive biaxial ankle movements, and ankle stiffness symmetry ratios between paretic and non-paretic ankle stiffness (SR: Inversion/Eversion SRIE & Dorsi-/Plantarflexion SRDP) were measured. A certified physiotherapist evaluated the Berg Balance Scale (BBS) and weight-distribution ratio (WDR) on bilateral force plates during quiet standing. Correlation coefficients, the factor analysis, and Pearson linear multiple regression were assessed with measured parameters. Correlation coefficients showed significances in-betweens; BBS and SRDP (r = -0.543, p = 0.022), WDR and SRIE (r = -0.667, p = 0.004), SRIE and SRDP (r = -0.604, p = 0.011). The exploratory factor analysis suggested four extracted factors; (1) Balance & Gait, (2) Stroke, (3) Symmetry and (4) Dimension. The first and second factors include general and pathological characteristics in stoke participants respectively. The third factor is associated with symmetrical characteristics explaining up to 99.9% of the variance. Multiple regression analysis showed ankle stiffness ratios predict BBS up to 60% of variance. The biaxial ankle stiffness ratio is a useful clinical variable that assesses balance function, in ambulatory chronic stroke survivors.

Motor adaptation and immediate retention to overground gait-slip perturbation training in people with chronic stroke: an experimental trial with a comparison group

Background

Perturbation-based training has shown to be effective in reducing fall-risk in people with chronic stroke (PwCS). However, most evidence comes from treadmill-based stance studies, with a lack of research focusing on training overground perturbed walking and exploring the relative contributions of the paretic and non-paretic limbs. This study thus examined whether PwCS could acquire motor adaptation and demonstrate immediate retention of fall-resisting skills following bilateral overground gait-slip perturbation training.

Methods

65 PwCS were randomly assigned to either (i) a training group, that received blocks of eight non-paretic (NP-S1 to NP-S8) and paretic (P-S1 to P-S8) overground slips during walking followed by a mixed block (seven non-paretic and paretic slips each interspersed with unperturbed walking trials) (NP-S9/P-S9 to NP-S15/P-S15) or (ii) a control group, that received a single non-paretic and paretic slip in random order. The assessor and training personnel were not blinded. Immediate retention was tested for the training group after a 30-minute rest break. Primary outcomes included laboratory-induced slip outcomes (falls and balance loss) and center of mass (CoM) state stability. Secondary outcomes to understand kinematic contributors to stability included recovery strategies, limb kinematics, slipping kinematics, and recovery stride length.

Results

PwCS within the training group showed reduced falls (p < 0.01) and improved post-slip stability (p < 0.01) from the first trial to the last trial of both paretic and non-paretic slip blocks (S1 vs. S8). During the mixed block training, there was no further improvement in stability and slipping kinematics (S9 vs. S15) (p > 0.01). On comparing the first and last training trial (S1 vs. S15), post-slip stability improved on both non-paretic and paretic slips, however, pre-slip stability improved only on the non-paretic slip (p < 0.01). On the retention trials, the training group had fewer falls and greater post-slip stability than the control group on both non-paretic and paretic slips (p < 0.01). Post-slip stability on the paretic slip was lower than that on the non-paretic slip for both groups on retention trials (p < 0.01).

Conclusion

PwCS can reduce laboratory-induced slip falls and backward balance loss outcomes by adapting their post-slip CoM state stability after bilateral overground gait-slip perturbation training. Such reactive adaptations were better acquired and retained post-training in PwCS especially on the non-paretic slips than paretic slips, suggesting a need for higher dosage for paretic slips.

Clinical registry number

NCT03205527.

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.

Comparative Analysis of Fall Risk Assessment Features in Community-Elderly and Stroke Survivors: Insights from Sensor-Based Data

Fall-risk assessment studies generally focus on identifying characteristics that affect postural balance in a specific group of subjects. However, falls affect a multitude of individuals. Among the groups with the most recurrent fallers are the community-dwelling elderly and stroke survivors. Thus, this study focuses on identifying a set of features that can explain fall risk for these two groups of subjects. Sixty-five community dwelling elderly (forty-nine female, sixteen male) and thirty-five stroke-survivors (twenty-two male, thirteen male) participated in our study. With the use of an inertial sensor, some features are extracted from the acceleration data of a Timed Up and Go (TUG) test performed by both groups of individuals. A short-form berg balance scale (SFBBS) score and the TUG test score were used for labeling the data. With the use of a 100-fold cross-validation approach, Relief-F and Extra Trees Classifier algorithms were used to extract sets of the top 5, 10, 15, 20, 25, and 30 features. Random Forest classifiers were trained for each set of features. The best models were selected, and the repeated features for each group of subjects were analyzed and discussed. The results show that only the stand duration was an important feature for the prediction of fall risk across all clinical tests and both groups of individuals.

Effect of physical exercise on fear of falling in patients with stroke: A systematic review and meta-analysis

OBJECTIVE

To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke.

DATA SOURCES

PubMed, CINAHL, Cochrane Database and MEDLINE.

METHODS

An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis.

RESULTS

Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70).

CONCLUSION

Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

Training for walking through an opening improves collision avoidance behavior in subacute patients with stroke: a randomized controlled trial

PURPOSE

Paretic side collisions frequently occur in stroke patients, especially while walking through narrow spaces. We determined whether training for walking through an opening (T-WTO) while entering from the paretic side would improve collision avoidance behavior and prevent falls after 6 months.

MATERIALS AND METHODS

Thirty-eight adults with moderate-to-mild hemiparetic gait after stroke who were hospitalized in a rehabilitation setting were randomly allocated to the T-WTO (n = 20) or regular rehabilitation (R-Control; n = 18) program. Both groups received five sessions of 40 min per week, for three weeks total. T-WTO included walking through openings of various widths while rotating with the paretic side in front, and R-Control involved normal walking without body rotation. Obstacle avoidance ability, 10-m walking test, timed Up and Go test, Berg Balance Scale, Activities-specific Balance Confidence, the perceptual judgment of passability, and fall incidence were assessed.

RESULTS

Collision rate and time to passage of the opening in obstacle avoidance task significantly improved in the T-WTO group compared with those in the R-Control group. Contrast, T-WTO did not lead to significant improvements in other outcomes.

CONCLUSIONS

T-WTO improved efficiency and safety in managing subacute stroke patients. Such training could improve patient outcomes/safety because of the paretic body side during walking.

CLINICAL TRIAL REGISTRATION NO.

R000038375 UMIN000033926.

Effects of Tai Chi Yunshou on upper-limb function and balance in stroke survivors: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

Physical rehabilitation plays an important role in the recovery of motor function after a stroke. This study aimed to evaluate the effects of Tai Chi Yunshou (TCY), a form of physical therapy, on upper-limb function and balance in stroke survivors.

METHODS

MEDLINE, Embase, CENTRAL and five Chinese databases were retrieved from inception to July 1, 2020 (updated on March 31, 2022). Randomized controlled trials of TCY versus no-treatment for stroke were included. The RoB-2 was used to evaluate the quality of included studies. Upper-limb motor impairment, balance, and activities of daily living (ADLs) were measured by Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE), Berg Balance Scale (BBS), and Barthel Index (BI), respectively. Data synthesis was performed using RevMan (v5.3), and expressed as mean difference (MD) with 95% confidence intervals (CI).

RESULTS

Seven studies with 529 participants were included. Compared with no-treatment, TCY improved FMA-UE (MD = 7.31, 95% CI: 5.86-8.77, minimal clinically important difference [MCID]: 9-10), BBS (MD = 4.68, 95% CI: 0.28-9.07, MCID: 4), and BI (MD = 4.12, 95% CI: 3.28-4.96, MCID: 1.85) in stroke survivors.

CONCLUSION

TCY may benefit balance and ADLs in rehabilitation after a stroke, but it may not improve upper-limb function clinically.

Sensor based assessment of turning during instrumented Timed Up and Go Test for quantifying mobility in chronic stroke patients

BACKGROUND

Turning may be particularly challenging for stroke patients leading to decreased mobility and increased functional restriction. Timed up and go instrumentation using a simple technology in the clinical context could allow for the collection of both traditional and potentially more discriminatory variables in turning ability.

AIM

Determine whether the speed turning metrics obtained by a single inertial sensor are suitable for differentiating between stroke patients with varying levels of mobility and disability.

DESIGN

Cross-sectional study.

SETTING

Outpatients setting.

POPULATION

Chronic stroke patients.

METHODS

A total of 48 chronic stroke patients and 23 healthy controls were included. Stroke patients were divided in two groups based on the total iTUG score: an impaired mobility (> 20 seconds) and an available mobility (<20 seconds) group. All subjects performed an instrumented Timed Up and Go (iTUG) wearing a single IMU sensor on the lower back. Time of subcomponents of the timed up and go test and kinematic parameters of turning were quantified. Other clinical outcomes were: 10 meters walk test, Functional Ambulation Categories Scale (FAC), the Rivermead Mobility Index (RMI), Modified Rankin Scale and the Saltin-Grimby Physical Activity Level Scale (SGPALS).

RESULTS

There were significant differences (P<0.01) in iTUG phases and turning speeds among groups. Low to strong significant correlations were found between measures derived from the turning speeds and clinical measures. The area under the curve (AUC) of Receiver Operating Characteristic (ROC) turning speeds was demonstrated to be able to discriminate (AUC: 0.742-0.912) from available to impaired stroke patients.

CONCLUSIONS

This study provides evidence that turning speeds during timed up and go test are accurate measures of mobility and capable of discriminating stroke patients with impaired mobility from those with normal mobility.

CLINICAL REHABILITATION IMPACT

The turning metrics are related to impairment and mobility in chronic stroke patients; hence they are important to include during clinical evaluation and may assist in creating a customized strategy, assess potential treatments, and effectively organize recovery.

Fallers after stroke: a retrospective study to investigate the combination of postural sway measures and clinical information in faller's identification

Background

Falls can have devastating effects on quality of life. No clear relationships have been identified between clinical and stabilometric postural measures and falling in persons after stroke.

Objective

This cross-sectional study investigates the value of including stabilometric measures of sway with clinical measures of balance in models for identification of faller chronic stroke survivors, and the relations between variables.

Methods

Clinical and stabilometric data were collected from a convenience sample of 49 persons with stroke in hospital care. They were categorized as fallers (N = 21) or non-fallers (N = 28) based on the occurrence of falls in the previous 6 months. Logistic regression (model 1) was performed with clinical measures, including the Berg Balance scale (BBS), Barthel Index (BI), and Dynamic Gait Index (DGI). A second model (model 2) was run with stabilometric measures, including mediolateral (SwayML) and anterior-posterior sway (SwayAP), velocity of antero-posterior (VelAP) and medio-lateral sway (VelML), and absolute position of center of pressure (CopX abs). A third stepwise regression model was run including all variables, resulting in a model with SwayML, BBS, and BI (model 3). Finally, correlations between independent variables were analyzed.

Results

The area under the curve (AUC) for model 1 was 0.68 (95%CI: 0.53-0.83, sensitivity = 95%, specificity = 39%) with prediction accuracy of 63.3%. Model 2 resulted in an AUC of 0.68 (95%CI: 0.53-0.84, sensitivity = 76%, specificity = 57%) with prediction accuracy of 65.3%. The AUC of stepwise model 3 was 0.74 (95%CI: 0.60-0.88, sensitivity = 57%, specificity = 81%) with prediction accuracy of 67.4%. Finally, statistically significant correlations were found between clinical variables (p < 0.05), only velocity parameters were correlated with balance performance (p < 0.05).

Conclusion

A model combining BBS, BI, and SwayML was best at identifying faller status in persons in the chronic phase post stroke. When balance performance is poor, a high SwayML may be part of a strategy protecting from falls.

Concurrent locomotor adaptation and retention to visual and split-belt perturbations

Gait asymmetry is a common symptom in groups with neurological disorders and significantly reduces gait efficiency. To develop efficient training for gait rehabilitation, we propose a novel gait rehabilitation paradigm that combines two distinct perturbation strategies: visual feedback distortion (VFD) and split-belt treadmill (SBT) walking. In SBT walking, spatiotemporal gait adaptation can be readily achieved, but it quickly fades after training. Gait adaptation to implicit VFD in an unconscious manner tends to persist longer, potentially due to a greater engagement of implicit learning during training. Thus, we investigated whether the combined strategies would lead to more effective changes in symmetric gait patterns with longer retention periods. We compared the retention of the preserved asymmetric pattern acquired by "implicit VFD+SBT walking" with "SBT-only walking" and with "SBT walking with conscious correction". In the implicit VFD+SBT walking, the speed of the two belts was gradually changed, the visual representation of gait symmetry was implicitly distorted, and no instructions were given to subjects except to watch the visual feedback. In the SBT walking with conscious correction, subjects were instructed to consciously correct their steps with the help of visual feedback while SBT walking. The SBT-only walking consisted of SBT walking with no visual feedback. After the 7-minute adaptation period, we removed the visual feedback and the split-belt perturbations, and we assessed the retention of the preserved asymmetric pattern while subjects continued walking for the 15-minute post-adaptation period. In a group of subjects who spontaneously showed visuomotor adaptation in response to the implicit VFD (16 out of 27 subjects), we found a greater retention rate during the implicit VFD+SBT walking trial than the SBT-only walking or the SBT walking with conscious correction trials. The implicit visual distortion paradigm delivered in an attention-independent (unconscious) manner can be utilized and integrated into SBT walking to improve the efficacy of symmetric gait adaptation by producing longer-lasting effects on the retention of a newly learned motor pattern.

Evidence-based improvement of gait in post-stroke patients following robot-assisted training: A systematic review

BACKGROUND

The recovery of walking after stroke is a priority goal for recovering autonomy. In the last years robotic systems employed for Robotic Assisted Gait Training (RAGT) were developed. However, literature and clinical practice did not offer standardized RAGT protocol or pattern of evaluation scales.

OBJECTIVE

This systematic review aimed to summarize the available evidence on the use of RAGT in post-stroke, following the CICERONE Consensus indications.

METHODS

The literature search was conducted on PubMed, Cochrane Library and PEDro, including studies with the following criteria: 1) adult post-stroke survivors with gait disability in acute/subacute/chronic phase; 2) RAGT as intervention; 3) any comparators; 4) outcome regarding impairment, activity, and participation; 5) both primary studies and reviews.

RESULTS

Sixty-one articles were selected. Data about characteristics of patients, level of disability, robotic devices used, RAGT protocols, outcome measures, and level of evidence were extracted.

CONCLUSION

It is possible to identify robotic devices that are more suitable for specific phase disease and level of disability, but we identified significant variability in dose and protocols. RAGT as an add-on treatment seemed to be prevalent. Further studies are needed to investigate the outcomes achieved as a function of RAGT doses delivered.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects and Adaptation of Visual-Motor Illusion Using Different Visual Stimuli on Improving Ankle Joint Paralysis of Stroke Survivors—A Randomized Crossover Controlled Trial

Visual-motor illusion (VMI) is an intervention to induce kinesthetic sensation from visual stimuli. We aimed to compare the effects of VMI of different visual stimuli on the paralyzed side ankle joint of stroke hemiplegic patients (hemiplegic patients) and to clarify their indication. We applied two types of VMI images of ankle dorsiflexion: ankle dorsiflexion without resistance (standard VMI (S-VMI)) and maximum effort dorsiflexion with resistance (power VMI (P-VMI)). Twenty-two hemiplegic patients were divided into two groups: Group A, which received S-VMI first and P-VMI one week later (n = 11), and Group B, which received P-VMI first and S-VMI one week later (n = 11). Immediate effects were evaluated. Outcomes were the dorsiflexion angle and angular velocity, degree of sense of agency (SoA), and sense of ownership. Patient’s characteristics of cognitive flexibility were assessed using the Trail making test-B (TMT-B). Fugl-Meyer assessment and the Composite-Spasticity-Scale were also assessed. P-VMI was significantly higher than S-VMI in SoA and dorsiflexion angular velocity. Additionally, the degree of improvement in dorsiflexion function with P-VMI was related to TMT-B and degree of muscle tone. Therefore, P-VMI improves ankle function in hemiplegic patients more than S-VMI but should be performed with cognitive flexibility and degree of muscle tone in mind.

Gait Kinematics and Asymmetries Affecting Fall Risk in People with Chronic Stroke: A Retrospective Study

Stroke survivors are at a relatively higher risk of falling than their healthy counterparts. To identify the key gait characteristics affecting fall risk in this population, this study analyzed the gait kinematics and gait asymmetries for 36 community-dwelling people with chronic stroke (PwCS). According to their fall history in the last 12 months, they were divided into a fall group (n = 21) and non-fall group (n = 15), and then the gait kinematics (step length, stride length, stance time, swing time, trunk angle, and segment angles for lower limbs) and their asymmetries (symmetry ratio and symmetry index) were compared between these two groups. To investigate the relationship between fall types and gait characteristics, these variables were also compared between 11 slip-fallers and non-fallers, as well as between 7 trip-fallers and non-fallers. Our results indicated that the fallers showed smaller trunk and thigh angle, larger shank angle, and higher gait asymmetries (trunk and foot). Such changes in gait pattern could also be found in the trip-fallers, except the trunk angle. Additionally, the trip-fallers also showed a shorter step length, shorter stride length, shorter swing time, larger foot angle on the paretic side, and higher asymmetries in shank angle and step length, while the slip-fallers only showed changes in trunk angle and thigh angle and higher asymmetries in step length and foot angle compared to the non-fall group. Our results indicated that improper or pathological gait patterns (i.e., smaller thigh angle or higher foot asymmetry) increases the risk of falling in PwCS, and different fall types are associated with different gait characteristics. Our findings would be helpful for the development of fall risk assessment methods that are based on kinematic gait measurements. Implementation of objective fall risk assessments in PwCS has the potential to reduce fall-related injuries, leading to a reduction in associated hospital costs.

Increased temporal stride variability contributes to impaired gait coordination after stroke

Heightened motor variability is a prominent impairment after stroke. During walking, stroke survivors show increased spatial and temporal variability; however, the functional implications of increased gait variability are not well understood. Here, we determine the effect of gait variability on the coordination between lower limbs during overground walking in stroke survivors. Ambulatory stroke survivors and controls walked at a preferred pace. We measured stride length and stride time variability, and accuracy and consistency of anti-phase gait coordination with phase coordination index (PCI). Stroke survivors showed increased stride length variability, stride time variability, and PCI compared with controls. Stride time variability but not stride length variability predicted 43% of the variance in PCI in the stroke group. Stride time variability emerged as a significant predictor of error and consistency of phase. Despite impaired spatial and temporal gait variability following stroke, increased temporal variability contributes to disrupted accuracy and consistency of gait coordination. We provide novel evidence that decline in gait coordination after stroke is associated with exacerbated stride time variability, but not stride length variability. Temporal gait variability may be a robust indicator of the decline in locomotor function and an ideal target for motor interventions that promote stable walking after stroke.

Exploring the effects of peripheral sensibility on visuospatial and postural capacities during goal-directed movements in long-term Tai Chi practitioners

Background

Falls are directly related to visuospatial ability and postural stability. Perturbations of upper body movements pose a challenge to older adults and may cause falls. This study investigated visuospatial ability and postural stability during goal-directed upper body movements between the Tai Chi and control groups and tried to connect them with their sensations.

Materials and methods

Thirty-seven older adults were recruited to perform the touch (TT) and blind touch (BTT) tasks. The target positioning error (TPE), ankle proprioception, tactile sensation, time to stabilization (TTS), and maximum displacement (D_max) of the center of pressure trajectory were compared between the groups during the tasks. The relationships of visuospatial ability and postural stability to proprioception and tactile sensation were investigated.

Results

D_max in the mediolateral (D_maxML) direction decreased during BTT compared to TT among the Tai Chi group but not the control group. Compared to the control group, less D_max in the anterio-posterior (D_maxAP) direction, and shorter TTS in AP/ML (TTS_AP/TTS_ML) directions were observed among the Tai Chi group. Compared to TT, D_maxAP decreased during the BTT. The Tai Chi group had less TPE in the vertical (TPE_V) direction and in three-dimensional space. Among the Tai Chi group, TPE_V, TTS_ML, and D_maxAP were correlated to their proprioception during plantarflexion; TTS_AP was correlated to tactile sensation at the great toe during the TT and BTT; D_maxAP was correlated to tactile sensation at the great toe during the TT. Among the control group, TTS_ML was correlated to ankle proprioception during dorsiflexion and plantarflexion during the BTT.

Conclusion

Long-term Tai Chi practitioners exhibited superior visuospatial ability and postural stability during goal-directed upper body movements, which was associated with sensitive proprioception and tactile sensation.

Association Between Turning Mobility and Cognitive Function in Chronic Poststroke

Turning difficulties are common in patients with stroke. The detrimental effects of dual tasks on turning indicate a correlation between turning and cognition. Cognitive impairment is prevalent after stroke, and stroke patients with mild cognitive impairment had a poorer turning performance than did stroke patients with intact cognitive abilities. Therefore, we investigated the association between turning mobility and cognitive function in patients with chronic poststroke. Ninety patients with chronic stroke (>6 months post-stroke) were recruited. Angular velocity was assessed using wearable sensors during 180° walking turns and 360° turning on the spot from both sides. Global cognition and distinct cognitive domains were assessed using the Mini-Mental State Examination. In patients with stroke, turning mobility was significantly associated with global cognitive function and distinct cognitive domains, such as visuospatial ability and language. The balance function and lower limbs strength were mediators of the association between cognition and turning. The association highlights the complexity of the turning movement and dynamic motor and cognitive coordination necessary to safely complete a turn. However, our findings should be regarded as preliminary, and a thorough neuropsychological assessment to provide a valid description of distinct cognitive domains is required.

Can prior exposure to repeated non-paretic slips improve reactive responses on novel paretic slips among people with chronic stroke?

This study examined if people with chronic stroke (PwCS) could adapt following non-paretic overground gait-slips and whether such prior exposure to non-paretic slips could improve reactive responses on novel paretic slip. Forty-nine PwCS were randomly assigned to either adaptation group, which received eight unexpected, overground, nonparetic-side gait-slips followed by two paretic-side slips or a control group, which received two paretic-side slips. Slip outcome, recovery strategies, center of mass (CoM) state stability, post-slip stride length and slipping kinematics were analyzed. The adaptation group demonstrated fall-reduction from first to eighth non-paretic slips, along with improved stability, stride length and slipping kinematics (p < 0.05). Within the adaptation group, on comparing novel slips, paretic-side demonstrated comparable pre-slip stability (p > 0.05); however, lower post-slip stability, increased slip velocity and falls was noted (p < 0.05). There was no difference in any variables between the novel paretic slips of adaptation and control group (p > 0.01). However, there was a rapid improvement on the 2nd slip such that adaptation group demonstrated improved performance from the first to second paretic slip compared to that in the control group (p < 0.01). PwCS demonstrated immediate proactive and reactive adaptation with overground, nonparetic-side gait-slips. However, PwCS did not demonstrate any inter-limb performance gain on the paretic-side after prior nonparetic-side adaptation when exposed to a novel paretic-side slip; but they did show significant positive gains with single slip priming on the paretic-side compared to controls without prior adaptation.Clinical registry number: NCT03205527.

Trunk Muscle Activation Patterns During Standing Turns in Patients With Stroke: An Electromyographic Analysis

Recent evidence indicates that turning difficulty may correlate with trunk control; however, surface electromyography has not been used to explore trunk muscle activity during turning after stroke. This study investigated trunk muscle activation patterns during standing turns in healthy controls (HCs) and patients with stroke with turning difficulty (TD) and no TD (NTD). The participants with stroke were divided into two groups according to the 180° turning duration and number of steps to determine the presence of TD. The activation patterns of the bilateral external oblique and erector spinae muscles of all the participants were recorded during 90° standing turns. A total of 14 HCs, 14 patients with TD, and 14 patients with NTD were recruited. The duration and number of steps in the turning of the TD group were greater than those of the HCs, independent of the turning direction. However, the NTD group had a significantly longer turning duration than did the HC group only toward the paretic side. Their performance was similar when turning toward the non-paretic side; this result is consistent with electromyographic findings. Both TD and NTD groups demonstrated increased amplitudes of trunk muscles compared with the HC groups. Their trunk muscles failed to maintain consistent amplitudes during the entire movement of standing turns in the direction that they required more time or steps to turn toward (i.e., turning in either direction for the TD group and turning toward the paretic side for the NTD group). Patients with stroke had augmented activation of trunk muscles during turning. When patients with TD turned toward either direction and when patients with NTD turned toward the paretic side, the flexible adaptations and selective actions of trunk muscles observed in the HCs were absent. Such distinct activation patterns during turning may contribute to poor turning performance and elevate the risk of falling. Our findings provide insights into the contribution and importance of trunk muscles during turning and the association with TD after stroke. These findings may help guide the development of more effective rehabilitation therapies that target specific muscles for those with TD.

Dance-based exergaming on postural stability and kinematics in people with chronic stroke - A preliminary study

INTRODUCTION

The study evaluated the feasibility, and compliance of a dance-based exergaming (DBExG) on postural stability (PS) and lower extremity (LE) kinematics, along with post-intervention changes in gait function and falls self-efficacy in people with chronic stroke (PwCS).

METHODS

Fifteen PwCS underwent DBExG for six weeks using Kinect "Just Dance 3." Pre- to post- changes were recorded during DBExG assessment on a fast-paced song (130 bpm) using an 8-camera motion capture system to assess PS (center of mass [CoM] excursions [EXs] in the anterior-posterior [AP] and mediolateral [ML] directions) and LE kinematics (hip, knee, and ankle joint angle EXs). Gait function was also assessed with gait parameters, such as gait speed, cadence, and gait symmetry on an electronic walkway. Falls self-efficacy was recorded with Falls Efficacy Scale (FES).

RESULTS

The AP and ML CoM EXs and paretic joint angle EXs significantly increased pre- to post- DBExG assessment (p < .05). Gait parameters, and falls self-efficacy measures significantly changed pre- to post- DBExG (p < .05).

CONCLUSIONS

Results exhibited the feasibility of the proposed DBExG for positively impacting postural stability, and kinematics, along with increasing gait function and falls self-efficacy among PwCS.

A Pilot Study Quantifying Center of Mass Trajectory during Dynamic Balance Tasks Using an HTC Vive Tracker Fixed to the Pelvis

Fall rates are increasing among the aging population and even higher falls rates have been reported in populations with neurological impairments. The Berg Balance Scale is often used to assess balance in older adults and has been validated for use in people with stroke, traumatic brain injury, and Parkinson’s disease. While the Berg Balance Scale (BBS) has been found to be predictive of the length of rehabilitation stay following stroke, a recent review concluded the BBS lacked predictive validity for fall risk. Conversely, sophisticated measures assessing center of mass (COM) displacement have shown to be predictive of falls risk. However, calculating COM displacement is difficult to measure outside a laboratory. Accordingly, we sought to validate COM displacement measurements derived from an HTC Vive tracker secured to the pelvis by comparing it to COM derived from ‘gold’ standard laboratory-based full-body motion capture. Results showed that RMS between the COM calculated from HTC Vive tracker and full body motion capture agree with an average error rate of 2.1 ± 2.6 cm. Therefore, we conclude measurement of COM displacement using an HTC Vive tracker placed on the pelvis is reasonably representative of laboratory-based measurement of COM displacement.

Post-stroke deficits in mediolateral foot placement accuracy depend on the prescribed walking task

People with chronic stroke (PwCS) are susceptible to mediolateral losses of balance while walking, possibly due in part to inaccurate control of mediolateral paretic foot placement. We hypothesized that mediolateral foot placement errors when stepping to stationary or shifting visual targets would be larger for paretic steps than for steps taken by neurologically-intact individuals, hereby referred to as controls. Secondarily, we hypothesized that paretic foot placement errors would be correlated with previously identified deficits in isolated paretic hip abduction accuracy. 34 PwCS and 12 controls walked overground on an instrumented mat used to quantify foot placement location relative to parallel lines separated by various widths (10, 20, 30 cm). With stationary step width targets, foot placement errors were larger for paretic steps than for either non-paretic or control steps, most notably for the narrowest prescribed step width (mean absolute errors of 3.9, 2.3, and 1.9 cm, respectively). However, no differences in foot placement accuracy were observed immediately following visual target shifts, as all groups required multiple steps to achieve the new prescribed step width. Paretic hip abduction accuracy was moderately correlated with mediolateral foot placement accuracy when stepping to stationary targets (r = 0.49), but not shifting targets (r = 0.16). The present results suggest that a reduced ability to accurately abduct the paretic leg contributes to inaccurate paretic foot placement. However, the need to ensure mediolateral walking balance through mechanically-appropriate foot placement may often override the prescribed goal of stepping to visual targets, a concern of particular importance for narrow steps.

Effects of Robot-Aided Rehabilitation on the Ankle Joint Properties and Balance Function in Stroke Survivors: A Randomized Controlled Trial

Background: Stroke survivors with impaired control of the ankle due to stiff plantarflexors often experience abnormal posture control, which affects balance and locomotion. Forceful stretching may decrease ankle stiffness and improve balance. Recently, a robot-aided stretching device was developed to decrease ankle stiffness of patient post-stroke, however, their benefits compared to manual stretching exercises have not been done in a randomized controlled trial, and the correlations between the ankle joint biomechanical properties and balance are unclear.

Objective: To compare the effects of robot-aided to manual ankle stretching training in stroke survivors with the spastic ankle on the ankle joint properties and balance function post-stroke, and further explore the correlations between the ankle stiffness and balance.

Methods: Twenty inpatients post-stroke with ankle spasticity received 20 minutes of stretching training daily over two weeks. The experimental group used a robot-aided stretching device, and the control group received manual stretching. Outcome measures were evaluated before and after training. The primary outcome measure was ankle stiffness. The secondary outcome measures were passive dorsiflexion ranges of motion, dorsiflexor muscle strength, Modified Ashworth Scale (MAS), Fugl-Meyer Motor Assessment of Lower Extremity (FMA-LE), Berg Balance Scale (BBS), Modified Barthel Index (MBI), and the Pro-Kin balance test.

Results: After training, two groups showed significantly within-group improvements in dorsiflexor muscle strength, FMA-LE, BBS, MBI (P < 0.05). The between-group comparison showed no significant differences in all outcome measures (P > 0.0025). The experimental group significantly improved in the stiffness and passive range of motion of dorsiflexion, MAS. In the Pro-Kin test, the experimental group improved significantly with eyes closed and open (P < 0.05), but significant improvements were found in the control group only with eyes open (P < 0.05). Dorsiflexion stiffness was positively correlated with the Pro-Kin test results with eyes open and the MAS (P < 0.05).

Conclusions: The robot-aided and manual ankle stretching training provided similar significant improvements in the ankle properties and balance post-stroke. However, only the robot-aided stretching training improved spasticity and stiffness of dorsiflexion significantly. Ankle dorsiflexion stiffness was correlated with balance function.

Clinical Trial Registration:www.chictr.org.cn ChiCTR2000030108.

Discriminative Mobility Characteristics between Neurotypical Young, Middle-Aged, and Older Adults Using Wireless Inertial Sensors

Age-related mobility research often highlights significant mobility differences comparing neurotypical young and older adults, while neglecting to report mobility outcomes for middle-aged adults. Moreover, these analyses regularly do not determine which measures of mobility can discriminate groups into their age brackets. Thus, the current study aimed to provide a comprehensive analysis for commonly performed aspects of mobility (walking, turning, sit-to-stand, and balance) to determine which variables were significantly different and furthermore, able to discriminate between neurotypical young adults (YAs), middle-aged adults (MAAs), and older adults (OAs). This study recruited 20 YAs, 20 MAAs, and 20 OAs. Participants came into the laboratory and completed mobility testing while wearing wireless inertial sensors. Mobility tests assessed included three distinct two-minute walks, 360° turns, five times sit-to-stands, and a clinical balance test, capturing 99 distinct mobility metrics. Of the various mobility tests assessed, only 360° turning measures demonstrated significance between YAs and MAAs, although the capacity to discriminate between groups was achieved for gait and turning measures. A variety of mobility measures demonstrated significance between MAAs and OAs, and furthermore discrimination was achieved for each mobility test. These results indicate greater mobility differences between MAAs and OAs, although discrimination is achievable for both group comparisons.

Walking with robot-generated haptic forces in a virtual environment: a new approach to analyze lower limb coordination

Background

Walking with a haptic tensile force applied to the hand in a virtual environment (VE) can induce adaptation effects in both chronic stroke and non-stroke individuals. These effects are reflected in spatiotemporal outcomes such as gait speed. However, the concurrent kinematic changes occurring in bilateral lower limb coordination have yet to be explored.

Methods

Chronic stroke participants were stratified based on overground gait speed into lower functioning (LF < 0.8 m/s, N = 7) and higher functioning (HF ≥ 0.8 m/s, N = 7) subgroups. These subgroups and an age-matched control group (N = 14, CG) walked on a self-paced treadmill in a VE with either robot-generated haptic leash forces delivered to the hand and then released or with an instrumented cane. Walking in both leash (10 and 15 N) and cane conditions were compared to pre-force baseline values to evaluate changes in lower limb coordination outcomes.

Results

All groups showed some kinematic changes in thigh, leg and foot segments when gait speed increased during force and post-force leash as well as cane walking. These changes were also reflected in intersegmental coordination and 3D phase diagrams, which illustrated increased intersegmental trajectory areas (p < 0.05) and angular velocity. These increases could also be observed when the paretic leg transitions from stance to swing phases while walking with the haptic leash. The Sobolev norm values accounted for both angular position and angular velocity, providing a single value for potentially quantifying bilateral (i.e. non-paretic vs paretic) coordination during walking. These values tended to increase (p < 0.05) proportionally for both limbs during force and post-force epochs as gait speed tended to increase.

Conclusions

Individuals with chronic stroke who increased their gait speed when walking with tensile haptic forces and immediately after force removal, also displayed moderate concurrent changes in lower limb intersegmental coordination patterns in terms of angular displacement and velocity. Similar results were also seen with cane walking. Although symmetry was less affected, these findings appear favourable to the functional recovery of gait. Both the use of 3D phase diagrams and assigning Sobolev norm values are potentially effective for detecting and quantifying these coordination changes.

Gait alterations induced by unloaded body weight in individuals with stroke while walking on moveable and fixed surfaces

This study examined the effects of the support surface (i.e., treadmill or ground) and the quantity of body weight unloading provided by a partial body weight support (PBWS) system on the spatiotemporal gait characteristics of individuals with stroke. Fifteen individuals, aged 57.2 ± 9.8 years, with chronic stroke walked on a treadmill and on the ground with 0%, 10%, and 20% of PBWS. Inertial sensors placed on the participants' feet registered 3-D acceleration and 3-D angular velocity during walking, and some gait parameters were calculated. Overall, individuals with stroke walked with shorter and slower strides and spent more time in contact with the support surface when walking on the treadmill compared to when walking on the ground. The duration of double limb support decreased when the percentage of PBWS increased. Stride length and speed were more variable in the paretic limb than in the non-paretic limb. Treadmill walking was more consistent and less similar to ordinary walking than walking on the ground. The gait pattern of individuals with stroke was modulated according to the support surface on which walking was performed, and the use of a PBWS system seems suitable to develop walking proficiencies on a daily basis.

Young adults recruit similar motor modules across walking, turning, and chair transfers

Moving about in the world during daily life requires executing and successfully shifting between a variety of functional tasks, such as rising from a chair or bed, walking, turning, and navigating stairs. Moreover, moving about during daily life requires not only navigating between different functional tasks, but also performing these tasks in the presence of mental distractions. However, little is known about underlying neuromuscular control for executing and shifting between these different tasks. In this study, we investigated muscle coordination across walking, turning, and chair transfers by applying motor module (a.k.a. muscle synergy) analysis to the Timed-Up-and-Go (TUG) test with and without a secondary cognitive dual task. We found that healthy young adults recruit a small set of common motor modules across the subtasks of the TUG test and that their composition is robust to cognitive distraction. Instead, cognitive distraction impacted motor module activation timings such that they became more consistent. This work is the first to demonstrate motor module generalization across multiple tasks that are both functionally different and crucial for healthy mobility. Overall, our results suggest that the central nervous system may draw from a "library" of modular control strategies to navigate the variety of movements and cognitive demands required of daily life.

An evaluation of the reliability of the foot-tapping test in a healthy sample

The foot-tapping test (FTT) can be used to assess upper motor neuron dysfunction in clinical populations. However, relatively little is known regarding the reliability or normative values of the FTT in either healthy or clinical populations. Although several different FTT methods have been used, no study to date has demonstrated the reliability or validity of FTT by comparing it across several different counting methods in healthy persons. This unfortunately limits its usefulness in medicine and research.

OBJECTIVE

This study sought to examine the reliability and validity of the FTT in healthy individuals to determine its usefulness and to make recommendations for its implementation in clinical populations. Furthermore, the concurrent validity and reliability of using a force plate as an objective measure of foot-taps was considered.

DESIGN

Thirty-eight healthy individuals had their foot-tapping assessed using Live, Force Plate, and Video Counting methods over four separate visits.

METHODS

Participants were seated as per previous FTT recommendations and asked to tap their foot in 10-second intervals while the number of taps was counted via Live, Video, and Force Plate counters. This was done with both legs, with shoes ON and OFF, and repeated over four separate visits.

RESULTS

Despite significant differences between repeat trials for Force Plate and Video Counts (∼2 foot-taps, p < 0.01), test-retest reliability was high for all three methods (Pearson's R > 0.90). Dominant foot trials were higher (∼2 foot-taps, p < 0.05) than Non-dominant for all three counts. When performed with shoes ON, counts were higher (∼2 foot-taps, p < 0.05) than OFF for the Live and Force Plate counts. Reliability between visits was high (ICC > 0.80) and only the Video count was significantly lower for Visit 1 (p < 0.01).

CONCLUSIONS

Given findings, the authors suggest using a Force Plate counting method and have compiled a list of suggestions for future implementation of the FTT.