Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties

Improvement of gait and balance function in chronic post-stroke patients induced by Lower Extremity - Constraint Induced Movement Therapy: a randomized controlled clinical trial

OBJECTIVE

To evaluate the effects of Lower Extremity - Constraint Induced Movement Therapy on gait function and balance in chronic hemiparetic patients.

METHODS

Randomized, controlled, single-blinded study. We recruited chronic post stroke patients and allocated them to Lower Extremity - Constraint Induced Movement Tharapy (LE-CIMT) or Control Group. The LE-CIMT group received this protocol 2.5 hour/day for 15 followed days, including: 1) intensive supervised training, 2) use of shaping as a strategy for motor training, and 3) application of a transfer package. The control group received conventional physiotherapy for 2.5 hours/day for 15 followed days. Outcomes were assessed at baseline, after the interventions, and after 6 months, through 6-minute walk test and Mini-Balance Evaluation Systems Test; 10-meter walk test, Timed Up and Go, 3-D gait analysis, and Lower Extremity - Motor Activity Log.

RESULTS

LE-CIMT was superior on the Assistance and confidence subscale of Lower Extremity - Motor Activity Log, Mini-BESTest and 6-minute walk test. The effect size for all outcomes was small when comparing both groups. LE-CIMT showed clinically significant differences in daily activities, balance, and gait capacity, with no clinically significant difference for spatiotemporal parameters.

CONCLUSION

The LE-CIMT protocol had positive outcomes on balance, performance, and confidence perception.

Validity of the two-minute walk test to assess exercise capacity and estimate cardiorespiratory fitness in individuals after stroke: a cross-sectional study

OBJECTIVES

The purpose of this study was to investigate the construct validity of the 2-minute walk test (2MWT) to assess the exercise capacity and the criterion-concurrent validity of the 2MWT and the 6-minute walk test (6MWT) to estimate the cardiorespiratory fitness of ambulatory individuals with chronic stroke. In addition, to provide an equation to predict the distance covered in the 6MWT and another to predict the peak oxygen consumption (VO2peak) for these individuals.

METHODS

This is a cross-sectional and prospective study. A convenience sample with 57 individuals with chronic stroke was recruited. The 2MWT, the 6MWT and the cardiopulmonary exercise test (CPET) were performed in a laboratory. The Spearman's correlation coefficient was used to investigate the validity. To develop the equations, stepwise multiple linear regression analysis was used.

RESULTS

A significant correlation of very high magnitude between the distance covered in the 2MWT and the 6MWT was found (rs = 0.93; p < 0.001). A significant correlation of moderate magnitude between the distance covered in the 2MWT and the VO2peak (rs = 0.53; p < 0.001) similar to the correlation between the 6MWT and the VO2peak (rs = 0.55; p < 0,001) were found. Furthermore, an equation was developed to predict the VO2peak (R2 = 0.690; p < 0.001; VO2peak = 13.532 + 0.078*distance walked in the 2MWT +4.509*sex-0.172*age), and another to predict the distance covered in the 6MWT (R2 = 0.827; p < 0.001; MWT = -1.867 + 3.008*distance walked in the 2MWT).

CONCLUSION

2MWT showed adequate construct and concurrent validity. Furthermore, it is possible to use the prediction equations developed to estimate the VO2peak or the distance covered in the 6MWT.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review

Background

Use of standardized tools to assess balance and mobility limitations is a recommended practice in stroke rehabilitation. The extent to which clinical practice guidelines (CPGs) for stroke rehabilitation recommend specific tools and provide resources to support their implementation is unknown.

Purpose

To identify and describe standardized, performance-based tools for assessing balance and/or mobility and describe postural control components challenged, the approach used to select tools, and resources provided for clinical implementation, in CPGs for stroke.

Methods

A scoping review was conducted. We included CPGs with recommendations on the delivery of stroke rehabilitation to address balance and mobility limitations. We searched seven electronic databases and grey literature. Pairs of reviewers reviewed abstracts and full texts in duplicate. We abstracted data about CPGs, standardized assessment tools, the approach for tool selection, and resources. Experts identified postural control components challenged by each tool.

Results

Of the 19 CPGs included in the review, 7 (37%) and 12 (63%) were from middle- and high-income countries, respectively. Ten CPGs (53%) recommended or suggested 27 unique tools. Across 10 CPGs, the most commonly cited tools were the Berg Balance Scale (BBS) (90%), 6-Minute Walk Test (6MWT) (80%), Timed Up and Go Test (80%) and 10-Meter Walk Test (70%). The tool most frequently cited in middle- and high-income countries was the BBS (3/3 CPGs), and 6MWT (7/7 CPGs), respectively. Across 27 tools, the three components of postural control most frequently challenged were underlying motor systems (100%), anticipatory postural control (96%), and dynamic stability (85%). Five CPGs provided information in varying detail on how tools were selected; only 1 CPG provided a level of recommendation. Seven CPGs provided resources to support clinical implementation; one CPG from a middle-income country included a resource available in a CPG from a high-income country.

Conclusion

CPGs for stroke rehabilitation do not consistently provide recommendations for standardized tools to assess balance and mobility or resources to facilitate clinical application. Reporting of processes for tool selection and recommendation is inadequate. Review findings can be used to inform global efforts to develop and translate recommendations and resources for using standardized tools to assess balance and mobility post-stroke.

Systematic Review Registration

https://osf.io/, identifier: 10.17605/OSF.IO/6RBDV.

Informing the development of an outcome set and banks of items to measure mobility among individuals with acquired brain injury using natural language processing

BACKGROUND

The sheer number of measures evaluating mobility and inconsistencies in terminology make it challenging to extract potential core domains and items. Automating a portion of the data synthesis would allow us to cover a much larger volume of studies and databases in a smaller fraction of the time compared to the usual process. Thus, the objective of this study was to identify a comprehensive outcome set and develop preliminary banks of items of mobility among individuals with acquired brain injury (ABI) using Natural Language Processing (NLP).

METHODS

An umbrella review of 47 reviews evaluating the content of mobility measures among individuals with ABI was conducted. A search was performed on 5 databases between 2000 and 2020. Two independent reviewers retrieved copies of the measures and extracted mobility domains and items. A pre-trained BERT model (state-of-the-art model for NLP) provided vector representations for each sentence. Using the International Classification of Functioning, Disability, and Health Framework (ICF) ontology as a guide for clustering, a k-means algorithm was used to retrieve clusters of similar sentences from their embeddings. The resulting embedding clusters were evaluated using the Silhouette score and fine-tuned according to expert input.

RESULTS

The study identified 246 mobility measures, including 474 domains and 2109 items. Encoding the clusters using the ICF ontology and expert knowledge helped in regrouping the items in a way that is more closely related to mobility terminology. Our best results identified banks of items that were used to create a 24 comprehensive outcome sets of mobility, including Upper Extremity Mobility, Emotional Function, Balance, Motor Control, Self-care, Social Life and Relationships, Cognition, Walking, Postural Transition, Recreation, and Leisure Activities, Activities of Daily Living, Physical Functioning, Communication, Work/Study, Climbing, Sensory Functions, General Health, Fatigue, Functional Independence, Pain, Alcohol and Drugs Use, Transportation, Sleeping, and Finances.

CONCLUSION

The banks of items of mobility domains represent a first step toward establishing a comprehensive outcome set and a common language of mobility to develop the ontology. It enables researchers and healthcare professionals to begin exposing the content of mobility measures as a way to assess mobility comprehensively.

An Equation With Clinical Applicability and Adequate Validity to Predict the Maximum Oxygen Consumption of Individuals Post-stroke

OBJECTIVE

To develop an equation with clinical applicability and adequate validity to predict the maximum oxygen consumption (V̇o_2max) of individuals post-stroke.

DESIGN

A cross-sectional study.

SETTING

A university laboratory.

PARTICIPANTS

Individuals post-stroke in the chronic phase (at least 6 months post-stroke). Step-1 (equation development): n=50, aged 55±12 years; Step-2 (validity investigation): n=20, aged 58±8 years (N=50 [step 1], N=20 [step 2]).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Step-1 (equation development): multiple linear regression analysis was performed.

DEPENDENT VARIABLE

V̇o_2max (mL/kg^/min) in the cardiopulmonary exercise test.

INDEPENDENT VARIABLES

age (years), sex (1-women, 2-men), body mass index (BMI) (kg/m²), and distance (meters) in the Six-Minute Walk Test (6MWT) (6MWT-Equation) or in the Incremental Shuttle Walk Test (ISWT) (ISWT-Equation). Step-2 (validity investigation): agreement between the V̇o_2max measured and predicted was evaluated with the intraclass correlation coefficient (ICC) with 95% confidence interval (CI) and the Bland-Altman method (α=5%).

RESULTS

In step-1 (equation development), the 4 independent variables for each equation were retained (6MWT-Equation: R²=0.68, P<.001; ISWT-Equation: R²=0.58, P<.001). In step-2 (validity investigation), the 6MWT-Equation showed an ICC of 0.73 (95% CI=0.30, 0.89; P=.004) and a mean bias of 0.003 mL/kg/min; and the ISWT-Equation showed an imprecise ICC of 0.55 (95% CI=-0.12, 0.82; P=.045) and a mean bias of 0.971 mL/kg/min. 6MWT-Equation (V̇o_2max=22.239+0.02 × distance in the 6MWT+4.039 × sex-0.157 × age-0.265 × BMI) showed adequate validity.

CONCLUSIONS

An equation with clinical applicability and adequate validity in the investigated sample was developed to predict the V̇o_2max of individuals post-stroke in the chronic phase (6MWT-Equation). Future studies with larger sample should investigate its external validity.

Assessment of Walking Speed and Distance Post-Stroke Increases After Providing a Theory-Based Toolkit

BACKGROUND AND PURPOSE

While underutilized, poststroke administration of the 10-m walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice. We aimed to evaluate provision of a toolkit designed to increase use of these tests by physical therapists (PTs).

METHODS

In a before-and-after study, 54 PTs and professional leaders in 9 hospitals were provided a toolkit and access to a clinical expert over a 5-month period. The toolkit comprised a guide, smartphone app, and video, and described how to set up walkways, implement learning sessions, administer walk tests, and interpret and apply test results clinically. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models.

RESULTS

Data from 347 and 375 pre- and postintervention hospital visits, respectively, were analyzed. Compared with preintervention, the odds of implementing the 10mWT were 12 times greater (odds ratio [OR] = 12.4, 95% confidence interval [CI] 5.8, 26.3), and of implementing the 6MWT were approximately 4 times greater (OR = 3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively).

DISCUSSION AND CONCLUSIONS

Providing a comprehensive toolkit to hospitals with professional leaders likely contributed to increasing 10mWT and 6MWT administration during inpatient and outpatient stroke rehabilitation.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A390 ).

A 6-Month Home-Based Functional Electrical Stimulation Program for Foot Drop in a Post-Stroke Patient: Considerations on a Time Course Analysis of Walking Performance

Foot drop is a common disability in post-stroke patients and represents a challenge for the clinician. To date, ankle foot orthosis (AFO) combined with conventional rehabilitation is the gold standard of rehabilitation management. AFO has a palliative mechanical action without actively restoring the associated neural function. Functional electrical stimulation (FES), consisting of stimulation of the peroneal nerve pathway, represents an alternative approach. By providing an FES device (Bioness L-300, BIONESS, Valencia, CA, USA) for 6 months to a post-stroke 22-year-old woman with a foot drop, our goal was to quantify its potential benefit on walking capacity. The gait parameters and the temporal evolution of the speed were collected with a specific connected sole device (Feet Me^®) during the 10-m walking, the time up and go, and the 6-minute walking tests with AFO, FES, or without any device (NO). As a result, the walking speed changes on 10-m were clinically significant with an increase from the baseline to 6 months in AFO (+0.14 m.s⁻¹), FES (+0.36 m.s⁻¹) and NO (+0.32 m.s⁻¹) conditions. In addition, the speed decreased at about 4-min in the 6-minute walking test in NO and AFO conditions, while the speed increased in the FES conditions at baseline and after 1, 3, and 6 months. In addition to the walking performance improvement, monitoring the gait speed in an endurance test after an ecological rehabilitation training program helps to examine the walking performance in post-stroke patients and to propose a specific rehabilitation program.

Community-based exercise programs incorporating healthcare-community partnerships to improve function post-stroke: feasibility of a 2-group randomized controlled trial

Background

Despite the potential for community-based exercise programs supported through healthcare-community partnerships (CBEP-HCPs) to improve function post-stroke, insufficient trial evidence limits widespread program implementation and funding. We evaluated the feasibility and acceptability of a CBEP-HCP compared to a waitlist control group to improve everyday function among people post-stroke.

Methods

We conducted a 3-site, pilot randomized trial with blinded follow-up evaluations at 3, 6, and 10 months. Community-dwelling adults able to walk 10 m were stratified by site and gait speed and randomized (1:1) to a CBEP-HCP or waitlist control group. The CBEP-HCP involved a 1-h, group exercise class, with repetitive and progressive practice of functional balance and mobility tasks, twice a week for 12 weeks. We offered the exercise program to the waitlist group at 10 months. We interviewed 13 participants and 9 caregivers post-intervention and triangulated quantitative and qualitative results. Study outcomes included feasibility of recruitment, interventions, retention, and data collection, and potential effect on everyday function.

Results

Thirty-three people with stroke were randomized to the intervention (n = 16) or waitlist group (n = 17). We recruited 1–2 participants/month at each site. Participants preferred being recruited by a familiar healthcare professional. Participants described a 10- or 12-month wait in the control group as too long. The exercise program was implemented per protocol across sites. Five participants (31%) in the intervention group attended fewer than 50% of classes for health reasons. In the intervention and waitlist group, retention was 88% and 82%, respectively, and attendance at 10-month evaluations was 63% and 71%, respectively. Participants described inclement weather, availability of transportation, and long commutes as barriers to attending exercise classes and evaluations. Among participants in the CBEP-HCP who attended ≥ 50% of classes, quantitative and qualitative results suggested an immediate effect of the intervention on balance, balance self-efficacy, lower limb strength, everyday function, and overall health.

Conclusion

The CBEP-HCP appears feasible and potentially beneficial. Findings will inform protocol revisions to optimize recruitment, and program and evaluation attendance in a future trial.

Trial registration

ClinicalTrials.gov, NCT03122626. Registered April 21, 2017 — retrospectively registered.

Quality of mobility measures among individuals with acquired brain injury: an umbrella review

Background and objective

While several mobility measures exist, there is large variability across measures in how mobility is conceptualized, the source of information and the measurement properties making it challenging to select relevant mobility measures for individuals with acquired brain injury (ABI). Therefore, the objective was to conduct a comprehensive synthesis of existing evidence on the measurement properties, the interpretability and the feasibility of mobility measures from various sources of information (patients, clinicians, technology) using an umbrella review of published systematic reviews among individuals with ABI.

Methods

Ovid MEDLINE, CINHAL, Cochrane Library and EMBASE electronic databases were searched from 2000 to March 2020. Two independent reviewers appraised the methodological quality of the systematic reviews using the Joanna Briggs Institute critical appraisal checklist. Measurement properties and quality of evidence were applied according to COnsensus-based Standards for the Selection of Health Measurement Instrument (COSMIN) guidelines. Mobility measures were categorized using international standards with the international classification of functioning, disability and health (ICF).

Results

Thirty-five systematic reviews were included covering 147 mobility measures, of which 85% were mapped to the ICF Activity and Participation component. Results showed an acceptable overall "sufficient" rating for reliability, construct validity and responsiveness for 132 (90%), 127 (86%) and 76 (52%) of the measures, respectively; however, among these measures, ≤ 25% of the methods for evaluating these properties were rated as ‘high’ quality of evidence. Also, there was limited information that supports measure feasibility and scoring interpretability.

Conclusions

Future systematic reviews should report measures’ content validity to support the use of the measure in clinical care and research. More evaluations of the minimal important difference and floor and ceiling effects are needed to help guide clinical interpretation.

Registration information

International Prospective Register of Systematic Reviews (PROSPERO); ID: CRD42018100068.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-022-03103-4.

Inter-rater reliability and agreement of 6 Minute Walk Test and 10 Meter Walk Test at comfortable walk speed in patients with acute stroke

PURPOSE

Remediation of gait problems is a key feature of neurological physiotherapy We aimed to investigate the inter-rater reliability and agreement of the Six Minute Walk Test (6MWT) and Ten Meter Walk Test (10MWT), at comfortable walking speed, in hospitalized acute ischemic stroke patients.

METHOD

Forty acute first-time patients with brain stem or hemispheric ischemic stroke aged 67.4 ± 12.5 (SD), able to walk with or without an assistive device, were tested by one of three physiotherapists. Test-retest reliability was evaluated using a one-way random effects single measures model (1,1) absolute agreement-type Interclass Correlation Coefficient (ICC). Agreement was evaluated using the Standard Error of Measurement (SEM) and Smallest Detectable Change (SDC).

RESULTS

Both tests demonstrated good reliability; ICC_1,1 0.83 (CI 95% 0.70-0.90) (6MWT) and 0.76 (CI 95% 0.59-0.87) (10MWT). The 6MWT-SEM was 27.2 m (m) and the SDC was 75.4 m. The 10MWT-SEM was 0.36 meters per second (m/s) and the SDC was 1.0 m/s.

CONCLUSION

Both tests demonstrated good inter-rater reliability, confirming their discriminative ability on a group of hospitalized first-time acute ischemic stroke patients. However, the measurement error was large for both tests, which is likely due to spontaneous neurological recovery and stress in the acute phase severely affecting the individual-level agreement estimate.

Can telerehabilitation services combined with caregiver-mediated exercises improve early supported discharge services poststroke? A study protocol for a multicentre, observer-blinded, randomized controlled trial

BACKGROUND

Recovery of walking ability is an important goal for patients poststroke, and a basic level of mobility is critical for an early discharge home. Caregiver-mediated exercises could be a resource-efficient strategy to augment exercise therapy and improve mobility in the first months poststroke. A combination of telerehabilitation and face-to-face support, blended care, may empower patient-caregiver dyads and smoothen the transition from professional support to self-management. The Armed4Stroke study aims to investigate the effects of a caregiver-mediated exercise program using a blended care approach in addition to usual care, on recovery of mobility in the first 6 months poststroke.

METHODS

A multicentre, observer-blinded randomized clinical trial in which 74 patient-caregiver dyads will be enrolled in the first 3 months poststroke. Dyads are randomly allocated to a caregiver-mediated exercises intervention or to a control group. The primary endpoint is the self-reported mobility domain of the Stroke Impact Scale. Secondary endpoints include care transition preparedness and psychological functioning of dyads, length of inpatient stay, gait-related measures and extended ADL of patients, and caregiver burden. Outcomes are assessed at enrolment, end of treatment and 6 months follow-up.

RESULTS

During 8 weeks, caregivers are trained to become an exercise coach using a blended care approach. Dyads will receive a tailor-made, progressive training program containing task-specific exercises focusing on gait, balance, physical activity and outdoor activities. Dyads are asked to perform the training program a minimum of 5 times a week for 30 min per session, supported by a web-based telerehabilitation system with instruction videos and a messaging environment to communicate with their physiotherapist.

CONCLUSIONS

We hypothesize that the Armed4Stroke program will increase self-reported mobility and independence in ADL, facilitating an early discharge poststroke. In addition, we hypothesize that active involvement of caregivers and providing support using blended care, will improve the care transition when professional support tapers off. Therefore, the Armed4Stroke program may complement early supported discharge services.

TRIAL REGISTRATION

Netherlands Trial Register, NL7422 . Registered 11 December 2018.

Experiences of Physical Therapists and Professional Leaders With Implementing a Toolkit to Advance Walking Assessment Poststroke: A Realist Evaluation

OBJECTIVE

The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings.

METHODS

A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice.

RESULTS

Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m.

CONCLUSION

Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings.

IMPACT

This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use.

Best Quantitative Tools for Assessing Static and Dynamic Standing Balance after Stroke: A Systematic Review

Purpose: Our objective was to examine the psychometric qualities (reliability and validity) and clinical utility of quantitative tools in measuring the static and dynamic standing balance of individuals after stroke. Method: We searched four databases (PubMed/MEDLINE, PEDro, Embase, and CINAHL) for studies published from January 2018 through September 2019 and included those that assessed the psychometric properties of standing balance tests with an adult stroke population. We evaluated the quality of the studies using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist and assessed each test on a utility assessment scale. Results: A total of 22 studies met the inclusion criteria, and 18 quantitative tools for assessing static or dynamic standing balance of individuals with stroke were analyzed. Findings support good or excellent reliability for all tests, whereas correlations for validity ranged from weak to strong. Study quality was variable. Dynamic balance tests had better clinical utility scores than static ones. Five tests had complete psychometric analyses: quiet standing on a force platform, five-step test, sideways step, step length, and turn tests.

Effects of lower extremity constraint-induced movement therapy on gait and balance of chronic hemiparetic patients after stroke: description of a study protocol for a randomized controlled clinical trial

BACKGROUND

Protocols involving intensive practice have shown positive outcomes. Constraint induced movement therapy (CIT) appears to be one of the best options for better outcomes in upper limb rehabilitation, but we still have little data about lower extremity constraint-induced movement therapy (LE-CIT) and its effects on gait and balance.

OBJECTIVE

To evaluate the effects of an LE-CIT protocol on gait functionality and balance in chronic hemiparetic patients following a stroke.

METHODS

The study adopts a randomized, controlled, single-blinded study design. Forty-two patients, who suffered a stroke, who were in the chronic phase of recovery (>6 months), with gait disability (no community gait), and who were able to walk at least 10 m with or without the advice or support of 1 person, will be randomly allocated to 2 groups: the LE-CIT group or the control group (intensive conventional therapy). People will be excluded if they have speech deficits that render them unable to understand and/or answer properly to evaluation scales and exercises selected for the protocol and/or if they have suffered any clinical event between the screening and the beginning of the protocol. Outcome will be assessed at baseline (T0), immediately after the intervention (T1), and after 6 months (T2). The outcome measures chosen for this trial are as follows: 6-min walk test (6minWT), 10-m walk test (10mWT), timed up and go (TUG), 3-D gait analysis (3DGA), Mini Balance Evaluation Systems Test (Mini-BESTest), and as a secondary measure, Lower Extremity Motor Activity Log will be evaluated (LE-MAL). The participants in both groups will receive 15 consecutive days of daily exercise. The participants in the LE-CIT group will be submitted to this protocol 2.5 h/day for 15 consecutive days. It will include (1) intensive supervised training, (2) use of shaping as strategy for motor training, and (3) application of a transfer package (plus 30 min). The control group will receive conventional physiotherapy for 2.5 h/day over 15 consecutive days (the same period as the CIT intervention). Repeated measures analyses will be made to compare differences and define clinically relevant changes between groups.

RESULTS

Data collection is currently on-going and results are expected in 2021.

DISCUSSION

LE-CIT seems to be a good protocol for inclusion into stroke survivors' rehabilitation as it has all the components needed for positive results, as well as intensity and transference of gains to daily life activities.

TRIAL REGISTRATION

www.ensaiosclinicos.gov.br RBR-467cv6 . Registered on 10 October 2017. "Effects of Lower Extremities - Constraint Induced Therapy on gait and balance function in chronic hemipretic post-stroke patients".

The Distance Covered in Field Tests is more Explained by Walking Capacity than by Cardiorespiratory Fitness after Stroke

OBJECTIVES

To investigate if the distance covered in the Six-Minute Walk Test (6MWT) and in the Incremental Shuttle Walk Test (ISWT) is most strongly explained by walking capacity or cardiorespiratory fitness (CRF) measures in individuals after chronic stroke.

MATERIALS AND METHODS

This is a cross-sectional study. Individuals after chronic stroke aged at least 20 years old and able to walk at least 10 minutes independently were included. The distance covered (meters) in the 6 MWT and ISWT (dependent variables), comfortable and fast gait speed obtained by the 10 m walk test (10 mWT) (walking capacity measures; independent variables) and peak oxygen consumption (VO_2peak; CRF measure; independent variable) (ml.kg^-1.min^-1) obtained by the cardiopulmonary exercise test (CPET) were obtained. Linear regression analyses were performed (α = 5%).

RESULTS

Fifty individuals (mean age of 55±12 years and mean time after stroke of 67±74 months) were included. Comfortable and fast gait speeds were the variables that most strongly explained the distance covered in the field tests: 6MWT (R² = 0.614, β = 0.784, p < 0.001 and R² = 0.615, β = 0.778, p < 0.001, respectively) and ISWT (R² = 0.450, β = 0.671, p < 0.001 and R² = 0.456, β = 0.746, p < 0.001, respectively). On the other hand, for the VO_2peak, the following models were generated: 6MWT (R² = 0.280, β = 0.530, p < 0.001) and ISWT (R² = 0.154, β = 0.393, p = 0.005)_. CONCLUSIONS: The distance covered in the field tests (6MWT and ISWT) is more suitable to support inferences about the walking capacity than about the CRF of individuals after chronic stroke.

The role of theory to develop and evaluate a toolkit to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke

PURPOSE

The iWalk study showed that 10-meter walk test (10mWT) and 6-minute walk test (6MWT) administration post-stroke increased among physical therapists (PTs) following introduction of a toolkit comprising an educational guide, mobile app, and video. We describe the use of theory guiding toolkit development and a process evaluation.

MATERIALS AND METHODS

We used the knowledge-to-action framework to identify research steps; and a guideline implementability framework, self-efficacy theory, and the transtheoretical model to design and evaluate the toolkit and implementation process (three learning sessions). In a before-and-after study, 37 of the 49 participating PTs completed online questionnaires to evaluate engagement with learning sessions, and rate self-efficacy to perform recommended practices pre- and post-intervention. Thirty-three PTs and 7 professional leaders participated in post-intervention focus groups and interviews, respectively.

RESULTS

All sites conducted learning sessions; attendance was 50-78%. Self-efficacy ratings for recommended practices increased and were significant for the 10mWT (p ≤ 0.004). Qualitative findings highlighted that theory-based toolkit features and implementation strategies likely facilitated engagement with toolkit components, contributing to observed improvements in PTs' knowledge, attitudes, skill, self-efficacy, and clinical practice.

CONCLUSIONS

The approach may help to inform toolkit development to advance other rehabilitation practices of similar complexity.Implications for RehabilitationToolkits are an emerging knowledge translation intervention used to support widespread implementation of clinical practice guideline recommendations.Although experts recommend using theory to inform the development of knowledge translation interventions, there is little guidance on a suitable approach.This study describes an approach to using theories, models and frameworks to design a toolkit and implementation strategy, and a process evaluation of toolkit implementation.Theory-based features of the toolkit and implementation strategy may have facilitated toolkit implementation and practice change to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke.

Distance-limited walk tests post-stroke: A systematic review of measurement properties

BACKGROUND

Improving walking capacity is a key objective of post-stroke rehabilitation. Evidence describing the quality and protocols of standardized tools for assessing walking capacity can facilitate their implementation.

OBJECTIVE

To synthesize existing literature describing test protocols and measurement properties of distance-limited walk tests in people post-stroke.

METHODS

Electronic database searches were completed in 2017. Records were screened and appraised for quality.

RESULTS

Data were extracted from 43 eligible articles. Among the 12 walk tests identified, the 10-metre walk test (10mWT) at a comfortable pace was most commonly evaluated. Sixty-three unique protocols at comfortable and fast paces were identified. Walking pace and walkway surface, but not walkway length, influenced walking speed. Intraclass correlation coefficients for test-retest reliability ranged from 0.80-0.99 across walk tests. Measurement error values ranged from 0.04-0.40 and 0.06 to 0.20 for the 10mWT at comfortable and fast and paces, respectively. Across walk tests, performance was most frequently correlated with measures of strength, balance, and physical activity (r = 0.26-0.8, p < 0.05).

CONCLUSIONS

The 10mWT has the most evidence of reliability and validity. Findings indicate that studies that include people with severe walking deficits, in acute and subacute phases of recovery, with improved quality of reporting, are needed.

Reliability and validity of the incremental shuttle walking test in individuals after stroke

BACKGROUND

There are limitations to perform the cardiopulmonary exercise test (CPET) and the six-minute walking test (6MWT) in clinical settings. The incremental shuttle walking test (ISWT) might be an alternative assessment of exercise capacity and an estimation of cardiopulmonary fitness after stroke.

OBJECTIVES

To investigate the test-retest and inter-rater reliabilities, the standard error of measurement (SEM) and the minimal detectable change (MDC) of the ISWT, its construct validity to assess exercise capacity and its concurrent validity to estimate cardiopulmonary fitness after stroke.

METHODS

Prospective diagnostic accuracy study. Fifty-one individuals (54 ± 11 years) at the chronic phase (65 ± 73 months after stroke) were included. The distance walked, in meters, during the 12-stage-ISWT and the 6MWT and the peak oxygen uptake (VO_2peak, ml.kg^-1.min^-1) in the CPET (gold standard) were assessed.

RESULTS

Significant and high to very high magnitude test-retest and inter-rater reliabilities (0.88≤ICC≤0.93) of the ISWT was found. The SEM for both reliabilities was small (-23.35 m≤ SEM≤41.47 m). The MDC for test-retest and inter-rater reliabilities were 114.63 m and 64.53 m, respectively. For construct validity, a significant and high magnitude correlation between the ISWT and the 6MWT was found (ICC = 0.82). For the concurrent validity, a significant, but low magnitude correlation was found between the ISWT and the VO_2peak (rho = 0.42).

CONCLUSIONS

The ISWT demonstrated adequate reliabilities and construct validity for exercise capacity assessment. However, the concurrent validity of the ISWT as an estimation of cardiopulmonary fitness still requires further research.

Identifying Instruments to Assess Care Quality for Individuals With Custom Ankle Foot Orthoses: A Scoping Review

OBJECTIVES

We conducted 2 complementary scoping reviews to identify instruments that assess the experience and outcomes of custom ankle-foot orthosis (AFO) care in individuals with neurologic and traumatic conditions and to determine to what extent they might be psychometrically sound for AFO users. A stakeholder advisory committee considered to what extent the identified and psychometrically sound instruments might be feasible for use in developing quality measures for custom AFO users.

DATA SOURCES

Both scoping reviews were conducted using PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, and Cochrane Systematic Reviews. The following were used for the first scoping review only: Cochrane Central Register of Controlled Trials and the Physiotherapy Evidence Database.

STUDY SELECTION

The initial scoping review yielded 79 articles with 82 instruments, 16 of which were used in 4 or more studies. The second scoping review yielded 57 articles reporting psychometric properties.

DATA EXTRACTION

Psychometric properties for populations who use AFOs were summarized for 15 of the 16 instruments. The advisory committee eliminated 2 insrtruments, noted overlap between 4 instruments in terms of the constructs measured, and suggested 6 potential contemporary substitutes.

DATA SYNTHESIS

Most instruments assessed activity (specifically mobility) and pertained to the National Quality Forum domain of "Health-Related Quality of Life." The 10-meter walk test, 6-minute walk test, Berg Balance Scale, Timed Up and Go, and Rivermead Mobility Index were reported to have adequate reliability and validity, and were considered feasible for administration in a clinical setting.

CONCLUSIONS

Complementary scoping reviews demonstrated that some instruments with reasonable psychometric properties are available that are feasible to use in developing quality measures for custom AFO care. However, experience of care instruments suitable for this population were not identified but are needed for a comprehensive evaluation of care quality for AFO users.

Noninvasive investigation of the cardiodynamic response to 6MWT in people after stroke using impedance cardiography

This is a cross-section observational study that investigated the cardiodynamic response to a 6-minute walk test (6MWT) in patients after stroke using impedance cardiography (ICG). Patients diagnosed with stroke were invited to participate in a 6MWT on consecutive days. Heart rate (HR), cardiac output (CO), stroke volume (SV) and cardiac index (CI) were measured by ICG using the PhysioFlow^® PF07 Enduro^TM at 1-second intervals for 10 minutes prior to, during and for 10 minutes after each 6MWT. Oxygen saturation, perceived exertion score (modified Borg scale) and the distance covered at the end of each 6MWT were recorded. Twenty-nine patients (mean age 55.6±10.9 years) completed the study. The mean duration of stroke after diagnosis was 14.4±19.1 months. There were no differences in the measured data between the first and second 6MWT (mean intraclass correlation coefficient (ICC) range: 0.87–0.95). The 6 minute walk distance (6WMD) covered in the two 6MWTs was 246±126 and 255±130m respectively (p>0.05). Mean measured data for each subject at rest, and at the end of the better performed 6MWT were, respectively: HR 78±11 and 100±18 bpm; CO 5.5±1.2 and 8.9±2.6 l/min, SV 71.3±16 and 89.3±18.6 ml/beat and CI 3.0±0.6 and 4.9±1.3 l/min/m². After commencement of the 6MWT, the increase in SV took 30 sec before the rise approaching a plateau, whereas HR, CO and CI continued to rise steeply for 90 sec before leveling off to a steady rise. After completion of the 6MWT, all parameters had returned to baseline by a mean of 3.5 min. Sub-group analysis showed that the increase in cardiac output was predominantly contributed by an increase in heart rate in participants diagnosed with stroke for less than 1 year, whereas both stroke volume and heart rate contributed similarly to the increase in cardiac output in participants with diagnosis of stroke for longer than 1 year. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) both returned to baseline within 2 minutes post 6MWT. HR recorded at the end of the 6MWT was 60.8±10.6% of the predicted maximal heart rate and perceived exertion score was 5±2. Correlations between 6MWD and HR, and between 6MWD and SV were weak, with correlation coefficients Spearman’s rho (r_s) =0.46, and 0.42, respectively (p<0.05). Correlation between 6MWD and CO and CI were higher (r_s= 0.66 and 0.63, respectively (p<0.01)). This is the first study to report cardiac responses during a 6MWT in stroke patients. ICG is a reliable, non-invasive, repeatable method of measuring cardiodynamic data in stroke patients.

Distance-Induced Changes in Walking Speed After Stroke: Relationship to Community Walking Activity

BACKGROUND AND PURPOSE

Physical inactivity is a major contributing factor to reduced health and quality of life. The total distance walked during the 6-Minute Walk Test is a strong indicator of real-world walking activity after stroke. The purpose of this study was to determine whether measurement of distance-induced changes in walking speed during the 6-Minute Walk Test improves the test's ability to predict community walking activity.

METHODS

For 40 individuals poststroke, community walking activity (steps/d), the total distance walked during the 6-Minute Walk Test (6MWTtotal), and the difference between the distances walked during the final and first minutes of the test (Δ6MWTmin6-min1) were analyzed using moderated regression. Self-efficacy, assessed using the Activities-specific Balance Confidence scale, was also included in the model.

RESULTS

Alone, 6MWTtotal explained 41% of the variance in steps/d. The addition of Δ6MWTmin6-min1 increased explanatory power by 29% (ΔR = 0.29, P < 0.001). The final model accounted for 71% of steps/d variance (F4,32 = 19.52, P < 0.001). Examination of a significant 6MWTtotal × Δ6MWTmin6-min1 interaction revealed a positive relationship between 6MWTtotal and steps/d, with individuals whose distances declined from minute 1 to minute 6 by 0.10 m/s or more presenting with substantially fewer steps/d than those whose distances did not decline.

DISCUSSION AND CONCLUSIONS

Coassessment of distance-induced changes in walking speed during the 6-Minute Walk Test and the total distance walked substantially improves the prediction of real-world walking activity after stroke. This study provides new insight into how walking ability after stroke can be characterized to reduce heterogeneity and advance personalized treatments.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

A Core Set of Outcome Measures for Adults With Neurologic Conditions Undergoing Rehabilitation: A CLINICAL PRACTICE GUIDELINE

Supplemental Digital Content is Available in the Text.

Background:

Use of outcome measures (OMs) in adult neurologic physical therapy is essential for monitoring changes in a patient's status over time, quantifying observations and patient-reported function, enhancing communication, and increasing the efficiency of patient care. OMs also provide a mechanism to compare patient and organizational outcomes, examine intervention effectiveness, and generate new knowledge. This clinical practice guideline (CPG) examined the literature related to OMs of balance, gait, transfers, and patient-stated goals to identify a core set of OMs for use across adults with neurologic conditions and practice settings.

Methods:

To determine the scope of this CPG, surveys were conducted to assess the needs and priorities of consumers and physical therapists. OMs were identified through recommendations of the Academy of Neurologic Physical Therapy's Evidence Database to Guide Effectiveness task forces. A systematic review of the literature on the OMs was conducted and additional OMs were identified; the literature search was repeated on these measures. Articles meeting the inclusion criteria were critically appraised by 2 reviewers using a modified version of the COnsensus-based Standards for the selection of health Measurement INstruments. (COSMIN) checklist. Methodological quality and the strength of statistical results were determined. To be recommended for the core set, the OMs needed to demonstrate excellent psychometric properties in high-quality studies across neurologic conditions.

Results/Discussion:

Based on survey results, the CPG focuses on OMs that have acceptable clinical utility and can be used to assess change over time in a patient's balance, gait, transfers, and patient-stated goals. Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance and the Activities-specific Balance Confidence Scale to assess changes in balance confidence. Strong to moderate evidence supports the use of the Functional Gait Assessment to assess changes in dynamic balance while walking, the 10 meter Walk Test to assess changes in gait speed, and the 6-Minute Walk Test to assess changes in walking distance. Best practice evidence supports the use of the 5 Times Sit-to-Stand to assess sit to standing transfers. Evidence was insufficient to support use of a specific OM to assess patient-stated goals across adult neurologic conditions. Physical therapists should discuss the OM results with patients and collaboratively decide how the results should inform the plan of care.

Disclaimer:

The recommendations included in this CPG are intended as a guide for clinicians, patients, educators, and researchers to improve rehabilitation care and its impact on adults with neurologic conditions. The contents of this CPG were developed with support from the APTA and the Academy of Neurologic Physical Therapy (ANPT). The Guideline Development Group (GDG) used a rigorous review process and was able to freely express its findings and recommendations without influence from the APTA or the ANPT. The authors declare no competing interest.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A214.

Walking endurance in multiple sclerosis: Meta-analysis of six-minute walk test performance

BACKGROUND

The 6-minute walk (6 MW) is the most commonly applied measure of endurance walking capacity in persons with multiple sclerosis (MS); however, we are not aware of a quantitative synthesis of 6 MW performance in MS.

RESEARCH QUESTION

We undertook a meta-analysis quantifying the overall magnitude of difference in 6 MW performance between MS and healthy controls (HCs), and then within MS as a function of disability status. We further examined possible moderator variables of 6 MW performance.

METHODS

The systematic search was conducted for articles that included the 6 MW in persons with MS and involved comparison groups (i.e., HCs or MS disability subgroups (i.e., mild vs moderate-to-severe disability status)). The mean and standard deviation of the distance traveled during the 6 MW as well as sample sizes were entered into Comprehensive Meta-Analysis software and we estimated the overall effect size (Cohen's d) using a random effects model and examined categorical variables as possible moderators (e.g., instruction protocol, provision of encouragement, method of distance measurement, and course description).

RESULTS

Thirty-four studies met inclusion criteria with a total sample size of 3204 persons (MS: 2683; HC: 521) yielding 42 total comparisons. Persons with MS walked a shorter distance than HCs (mean difference = -177.2 ± 19.1 m) with a large effect size (d = - 1.87). Persons with mild disability walked further than those with moderate-to-severe disability (mean difference = 185.19 ± 9.2 m) with a large effect (d = 1.83). The categorical variables of provision of encouragement and course layout moderated the effect of MS and course layout moderated the effect of disability status on 6 MW performance.

SIGNIFICANCE

This meta-analysis of 6 MW performance defines mean difference in 6 MW performance in MS compared with HCs and provides an estimate of the disease-related effect of MS on endurance walking capacity for application within clinical research and practice.

The Neurological Exercise Training (NExT) program: A pilot study of a community exercise program for survivors of stroke

BACKGROUND

Many survivors of stroke face chronic disability and increased risk for recurrent stroke. Regular physical activity can reduce these risk factors and improve cardiovascular fitness. Most survivors of stroke face barriers to exercise, including lack of access to programs; as a result, most are sedentary.

OBJECTIVE

Pilot the Neurological Exercise Training (NExT) program or survivors of stroke for attendance, safety, and effectiveness.

METHODS

The NExT program was designed to promote self-directed exercise in a safe, accessible environment. Six participants attended as desired during open gym hours over two exercise periods per week totalling 19 weeks. After, participants were encouraged to continue exercise away from the gym for 20 weeks. Practicability of the program was assessed through safety, attendance, exercise intensity, and perception of the program. Pilot effectiveness measures were performed at five time points and effect sizes were generated.

RESULTS

Attendance averaged 76% (SD12%) of possible sessions with an average duration of 62 (SD 11.3) minutes. Effectiveness measures had positive effect sizes after 19 weeks of the NExT program, but these benefits were lost after 20-weeks (cohen's d, mobility = 0.67 to -0.22, balance = 0.57 to -1.22, strength = 0.41 to -0.30, endurance = 0.09 to -0.19 and fatigue = 1.02 to -0.57).

CONCLUSION

Results demonstrate that a community-based gym that is accessible for survivors of stroke will be well attended and perceived as beneficial. Pilot data suggests positive changes in multiple health domains regardless of the type of exercise self-selected by participants. Offering the gym on a continual basis may maintain gains.

Promoting Independent Mobility-related Physical ACTivity (IMPACT) in an inpatient stroke rehabilitation unit: a proof-of-concept evaluation of self-management intervention

Purpose: To establish proof-of-concept of a novel rehabilitation self-management program that aims to optimize walking recovery after stroke through engaging patients in independent walking-related practice outside of supervised physiotherapy sessions.Materials and Methods: The Independent Mobility-related Physical ACTivity (IMPACT) Program is a coach-supported intervention that uses self-management strategies to empower patients to engage in additional autonomous walking-related activities after stroke during and after inpatient rehabilitation. The aim of this study was to assess whether implementation of this intervention would be associated with targeted patient behaviors; goal setting, negotiation and completion of a walking-related practice plan outside of formal therapy sessions. Using a pre-intervention/post-intervention design, the Independent Mobility-related Physical Activity program was implemented with a convenience sample of 10 adults (mean age 62.3; SD 11.7 years) within an inpatient stroke rehabilitation unit (mean stroke onset 25.3 [SD 10.5] days).Results: All participants were able to set a personal goal, negotiate an autonomous walking-related activity practice plan, and partially or completely adhere to that plan. Patients completed an average of 36 min/day of practice outside of supervised physiotherapy, practicing on weekdays and weekend days. All patients indicated that the Independent Mobility-related Physical Activity program helped them increase their activity, and indicated they would continue to practice walking-related activities beyond the coaching period.Implications for rehabilitationThe IMPACT program is a feasible self-management strategy to facilitate walking-related practice outside of supervised therapy time during inpatient stroke rehabilitation.Patients were able to engage in goal-setting and practice plan development with support of a therapist-coach.Patients who are able to stand and walk with minimal assist were able to practice walking-related activities outside of formal therapy sessions.Therapists may benefit from specific training and support to adopt self-management strategies into practice.

One-Quarter of People Leave Inpatient Stroke Rehabilitation with Physical Capacity for Community Ambulation

BACKGROUND AND PURPOSE

Ability to walk in the community is important for independence and participation in life roles, but is difficult for many people following stroke. The purpose of this study was to determine the proportion of people with stroke with the physical capacity to be independent community ambulators at discharge from a publicly funded inpatient rehabilitation setting.

METHOD

Consecutive medical records were audited to collate walking outcome at discharge, and to clarify if people with stroke had potential to walk independently in the community as defined by 4 criteria: independence with stairs; ability to traverse slopes and inclines; walking speed of .8m/s or more; and walking distance 367 m or higher on 6-Minute Walk Test.

RESULTS

While 80% of the 124 persons with stroke could walk indoors, only 27% could perform 4 essential skills needed to walk independently in the community at discharge from hospital. The proportion that met each criterion was 52% for stairs, 39% for slopes and inclines, 58% for speed, and 40% for distance. For the overall sample, mean (standard deviation) walking speed was .90 (.33) m/s, and distance for 6-Minute Walk Test was 349.6 (146.5) m.

DISCUSSION AND CONCLUSION

A retrospective review found that three quarters of stroke survivors lacked physical capacity for 4 skills required to walk independently in the community at the time of discharge from a public inpatient rehabilitation. Our findings recommend that people with stroke have access to outpatient physical rehabilitation to optimize walking outcome.

Framework of care: communicating the structure and processes of care

AIM

This article attempts to present a 'macro view' of the role and nature of an organization's Framework of Care (FrOC). This 'view' arises from a critical reflection on the available literature and the combined professional experience of the authors, who have worked in a variety of healthcare systems and settings in Australia, North America, United Kingdom, and the Middle East.

BACKGROUND

FrOC can be defined as the systems and processes within an organization that structure the delivery of care. These systems and processes are made evident in a series of documents, such as the Mission and Vision statement, Policies and Procedures, Standards of Care, Clinical Practice Guidelines, Clinical Pathways, and Protocols. These frameworks can provide structure for important organizational activities such as clinical audits, quality management and clinical information system (CIS) 'decision support', thereby supporting clinicians in their efforts to deliver high-quality, evidence-based care. How a healthcare organization structures its systems and processes of care directly impacts the patient and caregiver experience - made evident in patient and staff satisfaction with the services provided.

RECOMMENDATIONS

Mapping out and understanding an organization's FrOC is a critical first step for interprofessional teams attempting to implement evidence into practice and/or accreditation teams and expert consultants critiquing the performance of an organization.

How does wearable robotic exoskeleton affect overground walking performance measured with the 10-m and six-minute walk tests after a basic locomotor training in healthy individuals?

It is still unknown to what extent overground walking with a WRE is equivalent to natural overground walking without a WRE. Hence, the interpretability of the 10-m (10MWT) and six-minute (6MWT) walk tests during overground walking with a WRE against reference values collected during natural overground walking without a WRE is challenging. This study aimed to 1) compare walking performance across three different overground walking conditions: natural walking without a WRE, walking with a WRE providing minimal assistance (active walking), and walking with a WRE proving complete assistance (passive walking) and 2) assess the association and the agreement between the 10MWT and the 6MWT during passive and active walking with a WRE. Seventeen healthy individuals who underwent basic locomotor training with a WRE performed the 10MWT (preferred and maximal speeds) and the 6MWT under the three conditions. For the 10MWT, the speed progressively and significantly decreased from natural walking without a WRE (preferred: 1.40±0.18m/s; maximal: 2.16±0.19m/s), to active walking with a WRE (preferred: 0.48±0.10m/s; maximal: 0.61±0.14m/s), and to passive walking with a WRE (preferred: 0.38±0.09m/s; maximal: 0.42±0.10m/s). For the 6MWT, total distances decreased from walking without a WRE (609±53.9m), to active walking with a WRE (196.6±42.6m), and to passive walking with a WRE (144.3±33.3m). The 10MWT and 6MWT provide distinct information and can't be used interchangeably to document speed only during active walking with the WRE. Speed and distance drastically decrease during active and, even more so, passive walking with the WRE in comparison to walking without a WRE. Selection of walking tests should depend on the level of assistance provided by the WRE.