Locomotor Training Improves Daily Stepping Activity and Gait Efficiency in Individuals Poststroke Who Have Reached a “Plateau” in Recovery

High-intensity locomotor training during inpatient rehabilitation improves the discharge ambulation function of patients with stroke. A systematic review with meta-analysis

OBJECTIVE

To evaluate the evidence of high-intensity locomotor training on outcomes related to gait and balance for patients with stroke in inpatient rehabilitation.

METHODS

Four databases were searched (PubMed, CINAHL, Web of Science, and MedLINE) for articles published prior to 13 June 2023. Studies of adults (>18 years old) with a diagnosis of stroke who received a high-intensity locomotor intervention while admitted to an inpatient rehabilitation facility were included. A functional outcome in the domain of gait speed, gait endurance, or balance must have been reported. Following the screening of 1052 studies, 43 were selected for full-text review. Studies were assessed for risk of bias using the tool appropriate to the study type. Gait speed, gait endurance, and balance outcome data were extracted for further analysis.

RESULTS

Eight studies were selected with risk of bias ratings as moderate (4), high (2), and low (2). Six studies were analyzed in the meta-analysis (N = 635). A random-effects model analyzed between-group differences. Standard mean differences demonstrated that high-intensity locomotor training produces a moderate effect on gait endurance (0.50) and gait speed (0.41) and a negligible effect on balance (0.08) compared with usual care.

CONCLUSIONS

The meta-analysis supports the use of high-intensity locomotor training over usual care for improving gait speed and gait endurance during inpatient post-stroke. Future studies should investigate dose-response relationships of high-intensity locomotor training in this setting.

PROSPERO REGISTRATION

#CRD42022341329.

Quantifying the effects of sleep on sensor-derived variables from upper limb accelerometry in people with and without upper limb impairment

BACKGROUND

Despite the promise of wearable sensors for both rehabilitation research and clinical care, these technologies pose significant burden on data collectors and analysts. Investigations of factors that may influence the wearable sensor data processing pipeline are needed to support continued use of these technologies in rehabilitation research and integration into clinical care settings. The purpose of this study was to investigate the effect of one such factor, sleep, on sensor-derived variables from upper limb accelerometry in people with and without upper limb impairment and across a two-day wearing period.

METHODS

This was a secondary analysis of data collected during a prospective, longitudinal cohort study (n = 127 individuals, 62 with upper limb impairment and 65 without). Participants wore a wearable sensor on each wrist for 48 h. Five upper limb sensor variables were calculated over the full wear period (sleep included) and with sleep time removed (sleep excluded): preferred time, non-preferred time, use ratio, non-preferred magnitude and its standard deviation. Linear mixed effects regression was used to quantify the effect of sleep on each sensor variable and determine if the effect differed between people with and without upper limb impairment and across a two-day wearing period.

RESULTS

There were significant differences between sleep included and excluded for the variables preferred time (p < 0.001), non-preferred time (p < 0.001), and non-preferred magnitude standard deviation (p = 0.001). The effect of sleep was significantly different between people with and without upper limb impairment for one variable, non-preferred magnitude (p = 0.02). The effect of sleep was not substantially different across wearing days for any of the variables.

CONCLUSIONS

Overall, the effects of sleep on sensor-derived variables of upper limb accelerometry are small, similar between people with and without upper limb impairment and across a two-day wearing period, and can likely be ignored in most contexts. Ignoring the effect of sleep would simplify the data processing pipeline, facilitating the use of wearable sensors in both research and clinical practice.

Comparative Efficacy of High-Intensity Training Versus Conventional Training in Individuals With Chronic Traumatic Brain Injury: A Pilot Randomized Controlled Study

Numerous studies have evaluated the efficacy of interventions to improve locomotion after acute-onset brain injury, although most focus on patients with stroke, with less attention toward traumatic brain injury (TBI). For example, a number of studies in patients post-stroke have evaluated the effects of high-intensity training (HIT) attempting to maximize stepping practice, while no studies have attempted this intervention in patients with TBI. The purpose of this blinded-assessor randomized trial was to evaluate the effects of HIT focused on stepping practice versus conventional training on walking and secondary outcomes in individuals with TBI. Using a crossover design, ambulatory participants with TBI >6-months duration performed HIT focused on stepping in variable contexts (overground, treadmill, stairs) or conventional training for up to 15 sessions over five weeks, with interventions alternated >4 weeks later. HIT focused on maximizing stepping practice while trying to achieve higher cardiovascular intensities (>70% heart rate reserve), while conventional training focused on impairment-based and functional exercises with no restrictions on intensities achieved. Greater increases in 6-min walk test and peak treadmill speed during graded exercise testing were observed after HIT versus conventional training, with moderate associations between differences in stepping practice and outcomes. Greater gains were also observed in estimates of aerobic capacity and efficiency after HIT, with additional improvements in selected cognitive assessments. The present study suggests that the amount and intensity of stepping practice may be important determinants of improved locomotor outcomes in patients with chronic TBI, with possible secondary benefits on aerobic capacity/efficiency and cognition. Clinical Trial Registration-URL: https://clinicaltrials.gov/; Unique Identifier: NCT04503473.

Moderate to Vigorous Intensity Locomotor Training After Stroke: A Systematic Review and Meta-analysis of Mean Effects and Response Variability

BACKGROUND AND PURPOSE

This meta-analysis quantified mean effects of moderate to vigorous intensity locomotor training (LT mv ) on walking outcomes in subacute and chronic stroke, and the magnitude of variability in LT mv response.

METHODS

Databases were searched for randomized trials comparing LT mv with no intervention, nongait intervention, or low-intensity gait training. Comfortable gait speed (CGS), fastest gait speed (FGS), 6-minute walk test (6MWT), walking activity (steps per day), and adverse effect/event (AE) data were extracted. Pooled estimates were calculated for mean changes, AE relative risks, and the standard deviation of response (SD response ) to LT mv versus control groups, stratified by study chronicity where possible.

RESULTS

There were 19 eligible studies (total N = 1096): 14 in chronic stroke (N = 839) and 5 in subacute stroke (N = 257). Compared with control interventions, LT mv yielded significantly greater increases in CGS (chronic, +0.06 m/s [95% confidence interval (CI), 0.01-0.10]; subacute, +0.16 [0.12-0.19]; subacute vs chronic, P = 0.03), FGS (chronic, +0.07 m/s [0.02-0.13]; subacute, +0.21 [0.01, 0.41]; P = 0.04), and 6MWT (chronic, +33 m [24-42]; subacute, +51 [26-77]; P = 0.054) but not steps/day (+260 [-1159 to 1679]). There were no treatment-related serious AEs among 398 LT mv participants in 14 AE-reporting studies. SD response estimates indicated substantial response variability: CGS, 0.11 m/s [0.00-0.15]; FGS, 0.14 m/s [-0.00 to 0.20]; and 6MWT, 41 m [27-51].

DISCUSSION AND CONCLUSIONS

LT mv improves mean walking capacity outcomes in subacute and chronic stroke and does not appear to have high risk of serious harm. Response magnitude varies within and between chronicity subgroups, and few studies have tested effects on daily walking activity or non-serious AEs.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A452 ).

Impact of Active Physiotherapy on Physical Activity Level in Stroke Survivors: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke survivors are frequently physically inactive. However, evidence of the effectiveness of active physiotherapy on physical activity level in stroke survivors is scarce.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, covering electronic searches from inception to March 16, 2022. Participants: Stroke survivors living in the community. Intervention: Any active physiotherapy, that is, involving exercises that require voluntary effort. Outcome measure: Objective and subjective physical activity level.

RESULTS

Of 5590 identified references, 25 randomized controlled trials were eligible, and 21 had available data. The random-effects meta-analysis resulted in a small, significant effect size in favor of active physiotherapy measured using objective or subjective tools (21 studies, 1834 participants, standardized mean difference, 0.22 [95% CI, 0.04-0.40]; heterogeneity I2=65%), and a medium significant effect when objective tools were used (9 studies, 424 participants, standardized mean differences, 0.48 [95% CI, 0.03-0.92]; I2=73%). Meta-regression showed that 35% of the variance in trial outcome was explained by the measurement tool (objective or subjective) and 23% by age. None of the variances were associated with a specific dosage in terms of frequency, time, exercise duration, or the severity of the disability.

CONCLUSIONS

Active physiotherapy seems to increase objective physical activity in community-dwelling stroke survivors. However, the evidence is of very low certainty.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022315639.

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.

The Effects of Stroke and Stroke Gait Rehabilitation on Behavioral and Neurophysiological Outcomes:: Challenges and Opportunities for Future Research

Stroke continues to be a leading cause of adult disability, contributing to immense healthcare costs. Even after discharge from rehabilitation, post-stroke individuals continue to have persistent gait impairments, which in turn adversely affect functional mobility and quality of life. Multiple factors, including biomechanics, energy cost, psychosocial variables, as well as the physiological function of corticospinal neural pathways influence stroke gait function and training-induced gait improvements. As a step toward addressing this challenge, the objective of the current perspective paper is to outline knowledge gaps pertinent to the measurement and retraining of stroke gait dysfunction. The paper also has recommendations for future research directions to address important knowledge gaps, especially related to the measurement and rehabilitation-induced modulation of biomechanical and neural processes underlying stroke gait dysfunction. We posit that there is a need for leveraging emerging technologies to develop innovative, comprehensive, methods to measure gait patterns quantitatively, to provide clinicians with objective measure of gait quality that can supplement conventional clinical outcomes of walking function. Additionally, we posit that there is a need for more research on how the stroke lesion affects multiple parts of the nervous system, and to understand the neuroplasticity correlates of gait training and gait recovery. Multi-modal clinical research studies that can combine clinical, biomechanical, neural, and computational modeling data provide promise for gaining new information about stroke gait dysfunction as well as the multitude of factors affecting recovery and treatment response in people with post-stroke hemiparesis.

Feasibility of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability: a randomized controlled trial

Background

Treadmill training shows advantages in the specificity, amount, and intensity of gait and balance practice for the rehabilitation of stroke patients.

Objective

To investigate the feasibility and effectiveness of challenging treadmill speed-dependent gait and perturbation-induced balance training in chronic stroke patients with low ambulation ability.

Methods

For this randomized controlled trial (Chinese Clinical Trials.gov registration number ChiCTR-IOR-16009536) with blinded testers, we recruited 33 ambulatory stroke participants with restricted community ambulation capacity and randomly assigned them into two groups: the experimental group with 2 week treadmill speed-dependent gait training combined with 2 week treadmill perturbation-induced balance training (EXP) or the control group with traditional gait and balance training (CON). Various variables were recorded during EXP training, including the rating of perceived exertion, heart rate, causes of pauses, treadmill speed, and perturbation intensity. Outcome measures were examined before training and at 2 and 4 weeks after training. They included gait velocity during five-meter walk test at comfortable and fast speed and reactive balance ability in the compensatory stepping test as primary outcome measures, as well as dynamic balance ability (timed up-and-go test and 5 times sit-to-stand test) and balance confidence as secondary outcome measures.

Results

All participants completed the study. The treadmill speed and perturbation intensity significantly increased across training sessions in the EXP group, and no adverse effects occurred. The normal and fast gait velocities showed significant time and group interaction effects. They significantly increased after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05). Likewise, dynamic balance ability measured using the timed up-and-go test at a fast speed significantly improved after 2 and 4 weeks of training in the EXP group (p < 0.05) but not in the CON group (p > 0.05), although without a significant time and group interaction effect. Surprisingly, the reactive balance ability did not show improvement after treatment in the EXP group (p > 0.05).

Conclusion

Challenging treadmill speed-dependent gait and treadmill perturbation-induced balance training is feasible and effective to improve ambulation function in chronic stroke patients with low ambulation ability.

Optimal Intensity and Duration of Walking Rehabilitation in Patients With Chronic Stroke: A Randomized Clinical Trial

Importance

For walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization.

Objective

To assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke.

Design, Setting, and Participants

This multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled.

Interventions

Participants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated.

Main Outcomes and Measures

The main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training.

Results

Of 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, -9 to 33 m]; mean difference, 15 m [95% CI, -13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue.

Conclusions and Relevance

These findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains.

Trial Registration

ClinicalTrials.gov Identifier: NCT03760016.

The effect of exercise on walking economy in patients with chronic neurological conditions: A systematic review and meta-analysis

Introduction

To investigate the effect of exercise on the walking economy (WE) of patients with chronic neurological conditions (CNCs) and to determine the type of physical activity that best improves the WE of patients with CNCs.

Methods

Four electronic databases were searched until December 2022 (Web of Science, PubMed, Cochrane, and CINAHL). Studies were screened using the following inclusion criteria: 1. randomized controlled or non-randomized controlled trials; 2. exercise interventions >4 weeks in duration; 3. patients aged ≥18 years with a diagnosis of CNCs. 4. walking economy of patients measured before and after the intervention. The PEDro scale was used to assess the methodological quality of the included studies.

Results and discussion

Twenty-two studies met the inclusion criteria. Meta-analysis results showed that exercise significantly improved WE (g = -0.352, 95% CI, -0.625 to -0.078, P = 0.012). Subgroup analysis revealed that patients who received exercise showed better WE compared with those who underwent no control intervention (g = -0.474, 95% CI, -0.636 to -0.311, P < 0.001). However, exercise therapy did not show a significant improvement of WE compared with control groups (g = -0.192, 95% CI, -0.451 to 0.067, P = 0.146). In addition, we found that endurance combined with resistance, high-intensity intermittent, and other training modalities resulted in better WE compared with the pre-intervention. Of these, interval training has the greatest effect on improving WE. In conclusion, exercise can improve WE in patients with CNCs. More randomized controlled trials are necessary for the future.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022361455, identifier: CRD42022361455.

G-Exos: A wearable gait exoskeleton for walk assistance

Stroke is the second leading cause of death and one of the leading causes of disability in the world. According to the World Health Organization, 11 million people suffer a stroke yearly. The cost of the disease is exorbitant, and the most widely used treatment is conventional physiotherapy. Therefore, assistive technology emerges to optimize rehabilitation and functional capabilities, but cost, robustness, usability, and long-term results still restrict the technology selection. This work aimed to develop a low-cost ankle orthosis, the G-Exos, a wearable exoskeleton to increase motor capability by assisting dorsiflexion, plantarflexion, and ankle stability. A hybrid system provided near-natural gait movements using active, motor, and passive assistance, elastic band. The system was validated with 10 volunteers with foot drop: seven with stroke, two with incomplete spinal cord injury (SCI), and one with acute inflammatory transverse myelitis (ATM). The G-Exos showed assistive functionality for gait movement. A Friedman test showed a significant difference in dorsiflexion amplitude with the use of the G-Exos compared to gait without the use of the G-Exos [x²₍₃₎ = 98.56, p < 0.001]. In addition, there was also a significant difference in ankle eversion and inversion comparing walking with and without the G-Exos [x²₍₃₎ = 36.12, p < 0.001]. The G-Exos is a robust, lightweight, and flexible assistive technology device to detect the gait phase accurately and provide better human-machine interaction. G-Exos training improved capability to deal with gait disorders, usability, and motor and functional recovery. Wearable assistive technologies lead to a better quality of life and contribute using in activities of daily living.

Beyond steps per day: other measures of real-world walking after stroke related to cardiovascular risk

Background

Significant variability exists in how real-world walking has been measured in prior studies in individuals with stroke and it is unknown which measures are most important for cardiovascular risk. It is also unknown whether real-world monitoring is more informative than laboratory-based measures of walking capacity in the context of cardiovascular risk. The purpose of this study was to determine a subset of real-world walking activity measures most strongly associated with systolic blood pressure (SBP), a measure of cardiovascular risk, in people with stroke and if these measures are associated with SBP after accounting for laboratory-based measures of walking capacity.

Methods

This was a cross-sectional analysis of 276 individuals with chronic (≥ 6 months) stroke. Participants wore an activity monitor for ≥ 3 days. Measures of activity volume, activity frequency, activity intensity, and sedentary behavior were calculated. Best subset selection and lasso regression were used to determine which activity measures were most strongly associated with systolic blood pressure. Sequential linear regression was used to determine if these activity measures were associated with systolic blood pressure after accounting for walking capacity (6-Minute Walk Test).

Results

Average bout cadence (i.e., the average steps/minute across all bouts of walking) and the number of long (≥ 30 min) sedentary bouts were most strongly associated with systolic blood pressure. After accounting for covariates (ΔR² = 0.089, p < 0.001) and walking capacity (ΔR² = 0.002, p = 0.48), these activity measures were significantly associated with systolic blood pressure (ΔR² = 0.027, p = 0.02). Higher systolic blood pressure was associated with older age (β = 0.219, p < 0.001), male gender (β = − 0.121, p = 0.046), black race (β = 0.165, p = 0.008), and a slower average bout cadence (β = − 0.159, p = 0.022).

Conclusions

Measures of activity intensity and sedentary behavior may be superior to commonly used measures, such as steps/day, when the outcome of interest is cardiovascular risk. The relationship between walking activity and cardiovascular risk cannot be inferred through laboratory-based assessments of walking capacity.

"Magic" Number of Treadmill Sessions Needed to Achieve Meaningful Change in Gait Speed After Stroke: A Systematic Review

ABSTRACT

The purpose of this systematic review was to determine the number of treadmill training sessions needed to make a meaningful change in gait speed for chronic stroke survivors. Relevant databases were searched up through February 2020. Articles were included if they fit the following criteria: stroke onset more than 5 mos, intention to treat with traditional treadmill training, and gait speed included as an outcome. Change in gait speed after intervention was used to classify treadmill groups as responders (at least 0.1 m/sec change) or nonresponders (less than 0.1 m/sec change). Seventeen articles met our criteria, resulting in a total of 19 intervention groups. Ten groups were classified as responders and completed a mean of 30.5 sessions within 6 wks, whereas nonresponders completed 20.4 sessions within 10 wks, indicating that at least 30 treadmill sessions (preferably in a period of 10 wks and at least 40 mins per session) is necessary to reach a meaningful change in gait speed. Although these trends were noted between the responder and nonresponder groups, no firm conclusions can be drawn regarding the "magic" number of sessions chronic stroke survivors should perform given the low correlation between number of sessions and change in gait speed.

Gains in Daily Stepping Activity in People With Chronic Stroke After High-Intensity Gait Training in Variable Contexts

OBJECTIVE

Many physical therapist interventions provided to individuals with chronic stroke can lead to gains in gait speed or endurance (eg, 6-Minute Walk Test [6MWT]), although changes in objective measures of participation are not often observed. The goal of this study was to determine the influence of different walking interventions on daily stepping (steps per day) and the contributions of demographic, training, and clinical measures to these changes.

METHODS

In this secondary analysis of a randomized clinical trial, steps per day at baseline and changes in steps per day following 1 of 3 locomotor interventions were evaluated in individuals who were ambulatory and >6 months after stroke. Data were collected on 58 individuals who received ≤30 sessions of high-intensity training (HIT) in variable contexts (eg, tasks and environments; n = 19), HIT focused on forward walking (n = 19), or low-intensity variable training (n = 20). Primary outcomes were steps per day at baseline, at post-training, and at a 3-month follow-up, and secondary outcomes were gait speed, 6MWT, balance, and balance confidence. Correlation and regression analyses identified demographic and clinical variables associated with steps per day.

RESULTS

Gains in steps per day were observed across all groups combined, with no between-group differences; post hoc within-group analyses revealed significant gains only following HIT in variable contexts. Both HIT groups showed gains in endurance (6MWT), with increases in balance confidence only following HIT in variable contexts. Changes in steps per day were associated primarily with gains in 6MWT, with additional associations with baseline 6MWT, lower-extremity Fugl-Meyer scores, and changes in balance confidence.

CONCLUSION

HIT in variable contexts elicited gains in daily stepping, with changes primarily associated with gains in gait endurance.

IMPACT

Providing HIT in variable contexts appears to improve measures of participation (eg, daily stepping) that may be associated with clinical measures of function. Gains in multiple measures of mobility and participation with HIT in variable contexts may improve the efficiency and value of physical therapy services.

Feasibility of virtual reality and treadmill training in traumatic brain injury: a randomized controlled pilot trial

OBJECTIVE

To evaluate the safety and efficacy of treadmill training with virtual reality compared to treadmill training alone and standard of care balance and mobility treatment in chronic traumatic brain injury (TBI).

PARTICIPANTS AND DESIGN

Thirty-one individuals with chronic TBI with self-reported and objective balance deficits participated in a 4-week 12 session intervention of treadmill training with virtual reality, treadmill training alone, or standard of care overground therapy.

OUTCOME MEASURES

Primary measures included recruitment and enrollment rates, retention, tolerance to intervention, completeness of outcome measures, and adverse events. Secondary measures included the Community Balance and Mobility Scale, 10 Meter Walk Test, 6 Minute Walk Test, and Timed Up and Go.

RESULTS

No serious adverse events were reported. All participants completed all training sessions and assessments at all time points. Recruitment, enrollment, and retention rates were high. All groups showed a trend toward improvement in all balance and mobility measures following treatment.

CONCLUSION

Virtual reality and treadmill training are safe and feasibile for individuals with TBI. Participants show improvements on balance and mobility measures following a 4-week intervention. Future research is needed to evaluate the efficacy of this intervention compared to other modes of balance and mobility training.

Predicting Discharge Walking Function With High-Intensity Stepping Training During Inpatient Rehabilitation in Nonambulatory Patients Poststroke

OBJECTIVE

This cohort investigation identified primary predictors of discharge walking function of nonambulatory individuals poststroke with high-intensity training (HIT) during inpatient rehabilitation.

DESIGN

Observational cohort investigation.

SETTING

Inpatient rehabilitation.

PARTICIPANTS

Data were collected from individuals (N=257) <6 months poststroke who required assistance to walk at admission.

INTERVENTION

Clinical physical therapy interventions attempted to maximize stepping practice at higher intensities.

MAIN OUTCOME MEASURES

Primary outcomes included the discharge level of assistance required during walking (minimal or no assistance) and attainment of specific gait speed thresholds (0.4 and 0.8 m/s) during the 10-m walk test. Independent predictors were demographics, training interventions (including steps/day), baseline Berg Balance Scale (BBS), and paretic leg strength.

RESULTS

Participants performed a median (interquartile range) of 1270 (533-2297) steps per day throughout inpatient rehabilitation, with significant differences between those who walked with versus without assistance at discharge. Logistic regressions indicate steps per day was a primary predictor of unassisted walking recovery; removal of steps per day resulted in primary predictors of baseline BBS and strength. Receiver operating characteristic (ROC) analyses indicate significant areas under the curve for BBS and relatively low cutoff scores of 5.5 points at admission to walk without assistance at any speed. ROC analyses performed using 1-week outcomes indicate BBS scores of 5-17 points were needed to achieve locomotor thresholds.

CONCLUSION

Stepping activity, BBS, and paretic leg strength were primary predictors of walking outcomes in patients performing HIT, and ROC analyses indicated recovery of independent walking could be achieved in low functioning patients early poststroke.

Stance Phase Gait Training Post Stroke Using Simultaneous Transcranial Direct Current Stimulation and Motor Learning-Based Virtual Reality-Assisted Therapy: Protocol Development and Initial Testing

Gait deficits are often persistent after stroke, and current rehabilitation methods do not restore normal gait for everyone. Targeted methods of focused gait therapy that meet the individual needs of each stroke survivor are needed. Our objective was to develop and test a combination protocol of simultaneous brain stimulation and focused stance phase training for people with chronic stroke (>6 months). We combined Transcranial Direct Current Stimulation (tDCS) with targeted stance phase therapy using Virtual Reality (VR)-assisted treadmill training and overground practice. The training was guided by motor learning principles. Five users (>6 months post-stroke with stance phase gait deficits) completed 10 treatment sessions. Each session began with 30 min of VR-assisted treadmill training designed to apply motor learning (ML)-based stance phase targeted practice. During the first 15 min of the treadmill training, bihemispheric tDCS was simultaneously delivered. Immediately after, users completed 30 min of overground (ML)-based gait training. The outcomes included the feasibility of protocol administration, gait speed, Timed Up and Go (TUG), Functional Gait Assessment (FGA), paretic limb stance phase control capability, and the Fugl−Meyer for lower extremity coordination (FMLE). The changes in the outcome measures (except the assessments of stance phase control capability) were calculated as the difference from baseline. Statistically and clinically significant improvements were observed after 10 treatment sessions in gait speed (0.25 ± 0.11 m/s) and FGA (4.55 ± 3.08 points). Statistically significant improvements were observed in TUG (2.36 ± 3.81 s) and FMLE (4.08 ± 1.82 points). A 10-session intervention combining tDCS and ML-based task-specific gait rehabilitation was feasible and produced clinically meaningful improvements in lower limb function in people with chronic gait deficits after stroke. Because only five users tested the new protocol, the results cannot be generalized to the whole population. As a contribution to the field, we developed and tested a protocol combining brain stimulation and ML-based stance phase training for individuals with chronic stance phase deficits after stroke. The protocol was feasible to administer; statistically and/or clinically significant improvements in gait function across an array of gait performance measures were observed with this relatively short treatment protocol.

Brain Network Organization Following Post-Stroke Neurorehabilitation

Brain network analysis can offer useful information to guide the rehabilitation of post-stroke patients. We applied functional network connection models based on multiplex-multilayer network analysis (MMN) to explore functional network connectivity changes induced by robot-aided gait training (RAGT) using the Ekso, a wearable exoskeleton, and compared it to conventional overground gait training (COGT) in chronic stroke patients. We extracted the coreness of individual nodes at multiple locations in the brain from EEG recordings obtained before and after gait training in a resting state. We found that patients provided with RAGT achieved a greater motor function recovery than those receiving COGT. This difference in clinical outcome was paralleled by greater changes in connectivity patterns among different brain areas central to motor programming and execution, as well as a recruitment of other areas beyond the sensorimotor cortices and at multiple frequency ranges, contemporarily. The magnitude of these changes correlated with motor function recovery chances. Our data suggest that the use of RAGT as an add-on treatment to COGT may provide post-stroke patients with a greater modification of the functional brain network impairment following a stroke. This might have potential clinical implications if confirmed in large clinical trials.

Preliminary Outcomes of Combined Treadmill and Overground High-Intensity Interval Training in Ambulatory Chronic Stroke

Purpose

Locomotor high-intensity interval training (HIIT) is a promising intervention for stroke rehabilitation. However, overground translation of treadmill speed gains has been somewhat limited, some important outcomes have not been tested and baseline response predictors are poorly understood. This pilot study aimed to guide future research by assessing preliminary outcomes of combined overground and treadmill HIIT.

Materials and Methods

Ten participants >6 months post-stroke were assessed before and after a 4-week no-intervention control phase and a 4-week treatment phase involving 12 sessions of overground and treadmill HIIT.

Results

Overground and treadmill gait function both improved during the treatment phase relative to the control phase, with overground speed changes averaging 61% of treadmill speed changes (95% CI: 33–89%). Moderate or larger effect sizes were observed for measures of gait performance, balance, fitness, cognition, fatigue, perceived change and brain volume. Participants with baseline comfortable gait speed <0.4 m/s had less absolute improvement in walking capacity but similar proportional and perceived changes.

Conclusions

These findings reinforce the potential of locomotor HIIT research for stroke rehabilitation and provide guidance for more definitive studies. Based on the current results, future locomotor HIIT studies should consider including: (1) both overground and treadmill training; (2) measures of cognition, fatigue and brain volume, to complement typical motor and fitness assessment; and (3) baseline gait speed as a covariate.

A Subject-Tailored Variability-Based Platform for Overcoming the Plateau Effect in Sports Training: A Narrative Review

The plateau effect in training is a significant obstacle for professional athletes and average subjects. It evolves from both the muscle-nerve-axis-associated performance and various cardiorespiratory parameters. Compensatory adaptation mechanisms contribute to a lack of continuous improvement with most exercise regimens. Attempts to overcome this plateau in exercise have been only partially successful, and it remains a significant unmet need in both healthy subjects and those suffering from chronic neuromuscular, cardiopulmonary, and metabolic diseases. Variability patterns characterize many biological processes, from cellular to organ levels. The present review discusses the significant obstacles in overcoming the plateau in training and establishes a platform to implement subject-tailored variability patterns to prevent and overcome this plateau in muscle and cardiorespiratory performance.

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.

Step Monitor Accuracy During PostStroke Physical Therapy and Simulated Activities

Introduction/Purpose

The amount of stepping activity during rehabilitation post-stroke can predict walking outcomes, although the most accurate methods to evaluate stepping activity are uncertain with conflicting findings on available stepping monitors during walking assessments. Rehabilitation sessions also include non-stepping activities and the ability of activity monitors to differentiate these activities from stepping is unclear. The objective of this study was to examine the accuracy of different activity monitors worn by individuals post-stroke with variable walking speeds during clinical physical therapy (PT) and research interventions focused on walking.

Methods

In Part I, 28 participants post-stroke wore a StepWatch, ActiGraph with and without a Low Frequency Extension (LFE) filter, and Fitbit on paretic and non-paretic distal shanks at or above the ankle during clinical PT or research interventions with steps simultaneously hand counted. Mean absolute percent errors were compared between limbs and tasks performed. In Part II, 12 healthy adults completed 8 walking and 9 non-walking tasks observed during clinical PT or research. Data were descriptively analyzed and used to assist interpretation of Part I results.

Results

Part I results indicate most devices did not demonstrate an optimal limb configuration during research sessions focused on walking, with larger errors during clinical PT on the non-paretic limb. Using the limb that minimized errors for each device, the StepWatch had smaller errors than the ActiGraph and Fitbit (p<0.01), particularly in those who walked < 0.8 m/s. Conversely, errors from the ActiGraph-LFE demonstrated inconsistent differences in step counts between Fitbit and ActiGraph. Part II results indicate that errors observed during different stepping and non-stepping activities were often device-specific, with non-stepping tasks frequently detected as stepping.

Conclusions

The StepWatch and ActiGraph-LFE had smaller errors than the Fitbit or ActiGraph, with greater errors in those walking at slower speeds. Inclusion of non-stepping activities affected step counts and should be considered when measuring stepping activity in individuals post-stroke to predict locomotor outcomes following rehabilitation.

Effects of Interactive Dynamic Scalp Acupuncture on Motor Function and Gait of Lower Limbs after Stroke: A Multicenter, Randomized, Controlled Clinical Trial

OBJECTIVE

To evaluate the effects of interactive dynamic scalp acupuncture (IDSA), simple combination therapy (SCT), and traditional scalp acupuncture (TSA) on motor function and gait of the lower limbs in post-stroke hemiplegia patients.

METHODS

A total of 231 patients with post-stroke hemiplegia was randomly divided into IDSA (78 cases), SCT (78 cases), and TSA (75 cases) groups by a random number table. Scalp acupuncture (SA) and lower-limb robot training (LLRT) were both performed in the IDSA and SCT groups. The patients in the TSA group underwent SA and did not receive LLRT. The treatment was administered once daily and 6 times weekly for 8 continuous weeks, each session lasted for 30 min. The primary outcome measures included Fugl-Meyer assessment of the lower extremity (FMA-LE), berg balance scale (BBS), modified barthel index (MBI), and 6-min walking test (6MWT). The secondary outcome measures included stride frequency (SF), stride length (SL), stride width (SW), affected side foot angle (ASFA), passive range of motion (PROM) of the affected hip (PROM-H), knee (PROM-K) and ankle (PROM-A) joints. The patients were evaluated before treatment, at 1- and 2-month treatment, and 1-, and 2-month follow-up visits, respectively. Adverse events during 2-month treatment were observed.

RESULTS

Nineteen patients withdrew from the trial, with 8 in the IDSA and 5 in the SCT groups, 6 in the TSA group. The FMA-LE, BBS, 6MWT and MBI scores in the IDSA group were significantly increased after 8-week treatment and 2 follow-up visits compared with the SCT and TSA groups (P<0.05 or P<0.01). Compared with pre-treatment, the grade distribution of BBS and MBI scores in the 3 groups were significantly improved at 1, 2-month treatment and 2 follow-up visits (P<0.05 or P<0.01). The SF, PROM-H, PROM-K and PROM-A in the IDSA group was significantly increased compared with the SCT and TSA groups after 8-week of treatment (P<0.05 or P<0.01). Compared with the SCT group, ASFA of the IDSA group was significantly reduced after 8-week of treatment (P<0.05). SF, SL, PROM-K and PROM-A were significantly increased at the 2nd follow-up visit whereas the ASFA was significantly reduced in the IDSA group compared with the SCT groups at 1st follow-up visit (P<0.05 or P<0.01). The SF was significantly increased in the SCT group compared with the TSA group after 8-week treatment (P<0.05). Compared with the TSA group, PROM-K, PROM-A were significantly increased at the 2nd follow-up visit (P<0.05).

CONCLUSIONS

The effects of IDSA on lower-limb motor function and walking ability of post-stroke patients were superior to SCT and TSA. The SCT was comparable to TSA treatment, and appeared to be superior in improving the motion range of the lower extremities. (Registration No. ChiCTR1900027206).

Development and Results of an Implementation Plan for High-Intensity Gait Training

BACKGROUND AND PURPOSE

High-intensity gait training is recommended in stroke rehabilitation to improve gait speed, walking distance, and balance. However, identifying effective and efficient implementation methods is a challenge for rehabilitation providers. This article describes the development of an implementation plan, presents findings of each implementation phase, and identifies the project's impact on clinicians and the health system.

METHODS

Two inpatient rehabilitation facilities, including 9 physical therapists, collaborated with a knowledge translation center to implement this program. We developed an implementation plan using the Knowledge-to-Action Framework and utilized the Consolidated Framework for Implementation Research to identify barriers and select implementation strategies. Using mix-methods research, including surveys and informal discussions, we evaluated current practice, barriers, outcomes, and the sustainability of high-intensity gait training in practice.

RESULTS

A multicomponent implementation plan that targeted barriers was developed. Before implementation, clinicians reported providing several balance, strength training, and gait interventions to improve walking. Barriers to using high-intensity gait training included knowledge, beliefs, adaptability of high-intensity gait training, resources, culture, and others. Twenty-six implementation strategies were selected to target the barriers. Surveys and informal discussions identified significant changes in perceived practice, adoption of high-intensity gait training, and positive impacts on the health system. The 2-year follow-up survey indicated that the new practice was sustained.

DISCUSSION AND CONCLUSIONS

Using a multicomponent implementation plan that targeted barriers, we successfully implemented high-intensity gait training in clinical practice. Contributors to successful implementation may include the implementation methods, usual care interventions, and clinicians' readiness for this change.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A352.).

Effect of robotic-assisted ankle training on gait in stroke participants: A case series study

BACKGROUND

Robotic rehabilitation therapy has grown rapidly during the last two decades allowing researchers and clinicians to deliver high-intensity training to persons with sensorimotor disorders caused by neurological injuries and diseases.

METHODS

This case series reports the effect of robot-assisted, impairment-oriented training for persons recovering from stroke on impairment of the paretic ankle as well as on the kinematic and spatiotemporal parameters of gait. Five persons with chronic stroke (>6 months post-stroke) participated in a 10-week training protocol, receiving three, 30-min sessions per week of a robot-assisted therapy. The robot-assisted intervention cyclically induced dorsiflexion and plantarflexion to the ankle at 5 degrees/s through ±15 degrees while the participants assisted with the imposed movement. Concurrently, participants received visual feedback of their active, assistive torque as well as targeted mechanical vibration of the ankle tendons when lengthened by the applied motion. Walking speed, cadence, step length of the non-paretic leg, percentage of paretic single limb support during the gait cycle, and ankle strength were assessed just before training began (baseline), after the last training session (post-training), and 3 months post-training (follow-up).

DISCUSSION

Robot-assisted training that provided assisted movement, biofeedback, and proprioceptive stimulation reduced ankle impairment and improved kinematic and spatiotemporal gait parameters, suggesting that impairment-oriented therapy applied to the paretic ankle may provide a valuable adjunct to locomotor therapies in persons with chronic gait disorders due to stroke.

Targeting Paretic Propulsion and Walking Speed With a Soft Robotic Exosuit: A Consideration-of-Concept Trial

Background: Soft robotic exosuits can facilitate immediate increases in short- and long-distance walking speeds in people with post-stroke hemiparesis. We sought to assess the feasibility and rehabilitative potential of applying propulsion-augmenting exosuits as part of an individualized and progressive training program to retrain faster walking and the underlying propulsive strategy.

Methods: A 54-yr old male with chronic hemiparesis completed five daily sessions of Robotic Exosuit Augmented Locomotion (REAL) gait training. REAL training consists of high-intensity, task-specific, and progressively challenging walking practice augmented by a soft robotic exosuit and is designed to facilitate faster walking by way of increased paretic propulsion. Repeated baseline assessments of comfortable walking speed over a 2-year period provided a stable baseline from which the effects of REAL training could be elucidated. Additional outcomes included paretic propulsion, maximum walking speed, and 6-minute walk test distance.

Results: Comfortable walking speed was stable at 0.96 m/s prior to training and increased by 0.30 m/s after training. Clinically meaningful increases in maximum walking speed (Δ: 0.30 m/s) and 6-minute walk test distance (Δ: 59 m) were similarly observed. Improvements in paretic peak propulsion (Δ: 2.80 %BW), propulsive power (Δ: 0.41 W/kg), and trailing limb angle (Δ: 6.2 degrees) were observed at comfortable walking speed (p's < 0.05). Likewise, improvements in paretic peak propulsion (Δ: 4.63 %BW) and trailing limb angle (Δ: 4.30 degrees) were observed at maximum walking speed (p's < 0.05).

Conclusions: The REAL training program is feasible to implement after stroke and capable of facilitating rapid and meaningful improvements in paretic propulsion, walking speed, and walking distance.

Cost-Effectiveness of High-intensity Training vs Conventional Therapy for Individuals With Subacute Stroke

OBJECTIVE

This investigation estimated the incremental cost-effectiveness of high-intensity training (HIT) compared with conventional physical therapy in individuals with subacute stroke, based on the additional personnel required to deliver the therapy.

DESIGN

Secondary analysis from a pilot study and subsequent randomized controlled trial.

SETTING

Outpatient laboratory setting.

PARTICIPANTS

Data were collected from individuals with locomotor impairments 1-6 months poststroke (N=44) who participated in HIT (n=27) or conventional physical therapy (n=17).

INTERVENTIONS

Individuals performing HIT practiced walking tasks in variable contexts (stairs, overground, treadmill) while targeting up to 80% maximum heart rate reserve. Individuals performing conventional therapy practiced impairment-based and functional tasks at lower intensities (<40% heart rate reserve).

MAIN OUTCOME MEASURES

Costs were assessed based on personnel use with availability of similar equipment. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves were calculated for quality-adjusted life years (QALYs) derived from the Medical Outcomes Short Form-36 questionnaire and gains in self-selected speeds (SSSs).

RESULTS

Personnel costs were higher after HIT (mean, $1420±234) vs conventional therapy (mean, $1111±219), although between-group differences in QALYs (0.05 QALYs; 95% confidence interval [CI], 0.0-0.10 QALYs) and SSS (0.20 m/s; 95% CI, 0.05-0.35 m/s) favored HIT. ICERs were $6180 (95% CI, -$96,364 to $123,211) per QALY and $155 (95% CI, 38-242) for a 0.1 m/s gain in SSS.

CONCLUSIONS

Additional personnel to support HIT are relatively inexpensive but can add substantial effectiveness to subacute rehabilitation. Future research should evaluate patient factors that increase the likelihood of improvement to maximize the cost-effectiveness of treatment post stroke.

Day-to-Day Variability of Walking Performance Measures in Individuals Poststroke and Individuals With Parkinson Disease

BACKGROUND AND PURPOSE

Improvement of walking performance is a primary goal for individuals poststroke or with Parkinson disease (PD) who receive physical therapy. More data about day-to-day variability of walking performance are critical for determining if changes in performance have occurred.

METHODS

Baseline assessments were utilized from an ongoing, observational, prospective cohort study including 84 individuals poststroke (n = 37) or with PD (n = 47) receiving outpatient physical therapy services to improve mobility. Participants wore step activity monitors for up to 7 days to measure walking performance (steps per day, walking duration, maximum 30-minute output, and peak activity index) in daily life. Correlation analyses evaluated relationships between both capacity and performance measures as well as the relationships between mean performance variables and day-to-day variability. Regression analyses explored factors that contribute to variability in day-to-day performance variables.

RESULTS

Mean steps per day for participants poststroke (5376 ± 2804) and with PD (8149 ± 4490) were consistent with previously reported cohorts. Greater amounts of walking were related to more day-to-day variability, with moderate correlations found between the mean and day-to-day variability of each performance measure, regardless of medical diagnosis or walking speed. Day-to-day variability is large (upwards of 50% of the mean), with the amount of walking performance serving as the primary predictor of day-to-day variability in walking performance.

DISCUSSION AND CONCLUSIONS

The results of this study elucidate the factors that are related to and predict day-to-day variability of performance. Walking performance metrics should be evaluated over multiple days and greater variability should be anticipated with greater amounts of performance.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A319).

Concurrent validity and reliability of an activity monitoring for rehabilitation (AMoR) platform for step counting and sitting/lying time in post-stroke individuals

BACKGROUND

Objective and reliable measurements to investigate daily behavior patterns in people with stroke could help therapeutic interventions after a stroke.

OBJECTIVE

To evaluate whether the Activity Monitoring for Rehabilitation (AMoR) platform has adequate concurrent validity and reliability for step counting and time spent sitting/lying in people post-stroke and to investigate its percentage accuracy for step counting at different walking speeds.

METHODS

Cross-sectional observational study. Fifty chronic post-stroke subjects used the AMoR platform and SAM simultaneously while a Video camera recorded the same activities during clinical trials. Spearman's correlation coefficient, the mean absolute percentage error, the intraclass correlation coefficient and Bland-Altman plot analyses were used to estimate the validity and reliability of the AMoR platform and StepWatch^TM Activity Monitor (SAM). The accuracy percentage was calculated for each device and plotted as a function of the walking speed during the 10-meter walk test (10MWT).

RESULTS

There was a very high correlation for step counting in all tests and a high correlation for time spent sitting/lying. The mean absolute percentage error values remained below 4% for step counting and time sitting/lying. The AMoR platform also showed excellent reliability for step counting and sitting/lying time, with values within the limit of agreement in the Bland-Altman plots. A high percentage of accuracy for step counting in the AMoR platform was observed during the 10MWT.

CONCLUSION

The AMoR platform is valid and reliable for step counting and time spent sitting/lying, with a high percentage of accuracy at different walking speeds in the post-stroke population.

Knowledge Translation in Physical Medicine and Rehabilitation: A Citation Analysis of the Knowledge-to-Action Literature

OBJECTIVES

To (1) provide an overview of the use of the Knowledge-to-Action Cycle (KTA) to guide a clinical implementation project; (2) identify activities performed in each phase of the KTA; and (3) provide suggestions to improve KTA activities in physical medicine and rehabilitation.

DATA SOURCES

Google Scholar and PubMed were searched through December 31, 2019.

STUDY SELECTION

Two reviewers screened titles, abstracts, and full-text articles to identify published studies that used the KTA to implement a project.

DATA EXTRACTION

Two reviewers examined full-text articles. Data extraction included activities performed in each phase of the KTA, including measurements used to evaluate the project's effectiveness.

DATA SYNTHESIS

Commonly performed KTA activities were identified and country of study, area of rehabilitation, and other factors related to the use of the KTA in rehabilitation were described. A total of 46 articles that met the study's inclusion criteria provided an overview of the use of the KTA in rehabilitation. Strengths and weaknesses of the articles are discussed and recommendations for improved KTA use are provided.

CONCLUSIONS

Implementation of evidence-based practice requires focused engineering and efforts. This review provides an overview of the knowledge translation activities occurring in physical medicine and rehabilitation and considerations to improve knowledge translation research and practice.

Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury

BACKGROUND

Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor deficits, as quantified by decreases in gait speed and distance walked over a specific duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative efficacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specific diagnoses.

METHODS

A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specific patient populations, at least 6 months postinjury and with specific outcomes of walking speed and timed distance. For all studies, specific parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specific training paradigm, particularly when another intervention may be available and can provide greater benefit.

RESULTS

Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

DISCUSSION

The collective findings suggest that large amounts of task-specific (ie, locomotor) practice may be critical for improvements in walking function, although only at higher cardiovascular intensities or with augmented feedback to increase patient's engagement. Lower-intensity walking interventions or impairment-based training strategies demonstrated equivocal or limited efficacy.

LIMITATIONS

As walking speed and distance were primary outcomes, the research participants included in the studies walked without substantial physical assistance. This guideline may not apply to patients with limited ambulatory function, where provision of walking training may require substantial physical assistance.

SUMMARY

The guideline suggests that task-specific walking training should be performed to improve walking speed and distance in those with acute-onset CNS injury although only at higher intensities or with augmented feedback. Future studies should clarify the potential utility of specific training parameters that lead to improved walking speed and distance in these populations in both chronic and subacute stages following injury.

DISCLAIMER

These recommendations are intended as a guide for clinicians to optimize rehabilitation outcomes for persons with chronic stroke, incomplete spinal cord injury, and traumatic brain injury to improve walking speed and distance.

The Value of High Intensity Locomotor Training Applied to Patients With Acute-Onset Neurologic Injury

Long-standing research in animal models and humans with stroke or incomplete spinal cord injury (iSCI) indicate that specific physical training variables, such as the specificity and amount of practice, may influence neurologic recovery and locomotor function. More recent data highlight the contributions of exercise intensity, as estimated indirectly by cardiovascular exertion, as potentially more important than previously considered. The effects of exercise intensity are well described in neurologically intact individuals, although confusion regarding the definitions of intensity and safety concerns have limited its implementation during physical rehabilitation of patients with neurologic injury. The purpose of this review is to delineate some of the evidence regarding the effects of exercise intensity during locomotor training in patients with stroke and iSCI. We provide specific definitions of exercise intensity used within the literature, describe methods used to ensure appropriate levels of exertion, and discuss potential adverse events and safety concerns during its application. Further details on the effects of locomotor training intensity on clinical outcomes, and on neuromuscular and cardiovascular function will be addressed as available. Existing literature across multiple studies and meta-analyses reveals that exercise training intensity is likely a major factor that can influence locomotor function after neurologic injury. To extend these findings, we describe previous attempts to implement moderate to high intensity interventions during physical rehabilitation of patients with neurologic injury, including the utility of specific strategies to facilitate implementation, and to navigate potential barriers that may arise during implementation efforts.

Relationships of Linear and Non-linear Measurements of Post-stroke Walking Activity and Their Relationship to Weather

Background: Stroke survivors are more sedentary than the general public. Previous research on stroke activity focuses on linear quantities. Non-linear measures, such as Jensen-Shannon Divergence and Lempel-Ziv Complexity, may help explain when and how stroke survivors move so that interventions to increase activity may be designed more effectively.

Objectives: Our objective was to understand what factors affect a stroke survivor's physical activity, including weather, by characterizing activity by step counts, structure, and complexity.

Methods: A custom MATLAB code was used to analyze clinical trial (NCT02835313, https://clinicaltrials.gov/ct2/show/NCT02835313) data presented as minute by minute step counts. Six days of data were analyzed for 142 participants to determine the regularity of activity structure across days and complexity patterns of varied cadences. The effect of steps on structure and complexity, the season's effect on steps, structure, and complexity, and the presence of precipitation's effect on steps and complexity were all analyzed.

Results: Step counts and regularity were linearly related (p < 0.001). Steps and complexity were quadratically related (r² = 0.70 for mean values, 0.64 for daily values). Season affected complexity between spring and winter (p = 0. 019). Season had no effect on steps or structure. Precipitation had no effect on steps or complexity.

Conclusions: Stroke survivors with high step counts are active at similar times each day and have higher activity complexities as measured through patterns of movement at different intensity levels. Non-linear measures, such as Jensen-Shannon Divergence and Lempel-Ziv Complexity, are valuable in describing a person's activity. Weather affects our activity parameters in terms of complexity between spring and winter.

Implementation of Wearable Sensing Technology for Movement: Pushing Forward into the Routine Physical Rehabilitation Care Field

While the promise of wearable sensor technology to transform physical rehabilitation has been around for a number of years, the reality is that wearable sensor technology for the measurement of human movement has remained largely confined to rehabilitation research labs with limited ventures into clinical practice. The purposes of this paper are to: (1) discuss the major barriers in clinical practice and available wearable sensing technology; (2) propose benchmarks for wearable device systems that would make it feasible to implement them in clinical practice across the world and (3) evaluate a current wearable device system against the benchmarks as an example. If we can overcome the barriers and achieve the benchmarks collectively, the field of rehabilitation will move forward towards better movement interventions that produce improved function not just in the clinic or lab, but out in peoples' homes and communities.

Stepwise Regression and Latent Profile Analyses of Locomotor Outcomes Poststroke

BACKGROUND AND PURPOSE

Previous data suggest patient demographics and clinical presentation are primary predictors of motor recovery poststroke, with minimal contributions of physical interventions. Other studies indicate consistent associations between the amount and intensity of stepping practice with locomotor outcomes. The goal of this study was to determine the relative contributions of these combined variables to locomotor outcomes poststroke across a range of patient demographics and baseline function.

METHODS

Data were pooled from 3 separate trials evaluating the efficacy of high-intensity training, low-intensity training, and conventional interventions. Demographics, clinical characteristics, and training activities from 144 participants >1-month poststroke were included in stepwise regression analyses to determine their relative contributions to locomotor outcomes. Subsequent latent profile analyses evaluated differences in classes of participants based on their responses to interventions.

RESULTS

Stepwise regressions indicate primary contributions of stepping activity on locomotor outcomes, with additional influences of age, duration poststroke, and baseline function. Latent profile analyses revealed 2 main classes of outcomes, with the largest gains in those who received high-intensity training and achieved the greatest amounts of stepping practice. Regression and latent profile analyses of only high-intensity training participants indicated age, baseline function, and training activities were primary determinants of locomotor gains. Participants with the smallest gains were older (≈60 years), presented with slower gait speeds (<0.40 m/s), and performed 600 to 1000 less steps/session.

CONCLUSIONS

Regression and cluster analyses reveal primary contributions of training interventions on mobility outcomes in patients >1-month poststroke. Age, duration poststroke, and baseline impairments were secondary predictors. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466 and NCT01789853.

The retention of fall-resisting behavior derived from treadmill slip-perturbation training in community-dwelling older adults

The purpose of this study was to determine whether and to what extent the immediate generalization of treadmill slip-perturbation training could be retained over 6 months to resist overground slip-induced falls. Four protocols (Tc: treadmill control; Tt: treadmill slip-perturbation training; Oc: overground control; Ot: overground slip-perturbation training) from two randomized controlled trials were compared in which two training protocols were executed with single-session repeated slip-perturbation training on the treadmill or overground context, while two control protocols were executed without repeated training. A total of 152 community-dwelling older adults (≥ 65 years) who were trained by one of the four protocols and tested by an overground slip in the initial session attended a retest session 6 months later. Falls were detected by a load cell. Data collected from motion analysis system and force plates were used to calculate stability. Tt group had no significant change in fall incidence from initial post-training test to retest. Tt group had significantly lower fall incidence (p < 0.05) and higher reactive stability (p < 0.05) than Tc group in retest. Tt group had significantly higher fall incidence (p < 0.05) and lower reactive stability (p < 0.01) than Ot group. The generalization of a single session of treadmill slip-perturbation training to overground slip resulted in inferior outcomes compared with overground slip-perturbation training (absolute retention), although the training generalization could be retained over 6 months (relative retention). Thus, treadmill slip-perturbation training could be more convenient to use if future dose-response studies indicate better or equal efficacy to overground slip-perturbation training.

Locomotor Kinematics and Kinetics Following High-Intensity Stepping Training in Variable Contexts Poststroke

Background and Purpose. Previous studies suggest that individuals poststroke can achieve substantial gains in walking function following high-intensity locomotor training (LT). Recent findings also indicate practice of variable stepping tasks targeting locomotor deficits can mitigate selected impairments underlying reduced walking speeds. The goal of this study was to investigate alterations in locomotor biomechanics following 3 different LT paradigms. Methods. This secondary analysis of a randomized trial recruited individuals 18 to 85 years old and >6 months poststroke. We compared changes in spatiotemporal, joint kinematics, and kinetics following up to 30 sessions of high-intensity (>70% heart rate reserve [HRR]) LT of variable tasks targeting paretic limb and balance impairments (high-variable, HV), high-intensity LT focused only on forward walking (high-forward, HF), or low-intensity LT (<40% HRR) of variable tasks (low-variable, LV). Sagittal spatiotemporal and joint kinematics, and concentric joint powers were compared between groups. Regressions and principal component analyses were conducted to evaluate relative contributions or importance of biomechanical changes to between and within groups. Results. Biomechanical data were available on 50 participants who could walk ≥0.1 m/s on a motorized treadmill. Significant differences in spatiotemporal parameters, kinematic consistency, and kinetics were observed between HV and HF versus LV. Resultant principal component analyses were characterized by paretic powers and kinematic consistency following HV, while HF and LV were characterized by nonparetic powers. Conclusion. High-intensity LT results in greater changes in kinematics and kinetics as compared with lower-intensity interventions. The results may suggest greater paretic-limb contributions with high-intensity variable stepping training that targets specific biomechanical deficits. Clinical Trial Registration. https://clinicaltrials.gov/ Unique Identifier: NCT02507466.

Task-Specific Versus Impairment-Based Training on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study

Background. Many research studies attempting to improve locomotor function following motor incomplete spinal cord injury (iSCI) focus on providing stepping practice. However, observational studies of physical therapy strategies suggest the amount of stepping practice during clinical rehabilitation is limited; rather, many interventions focus on mitigating impairments underlying walking dysfunction. Objective. The purpose of this blinded-assessor randomized trial was to evaluate the effects of task-specific versus impairment-based interventions on walking outcomes in individuals with iSCI. Methods. Using a crossover design, ambulatory participants with iSCI >1-year duration performed either task-specific (upright stepping) or impairment-based training for up to 20 sessions over ≤6 weeks, with interventions alternated after >4 weeks delay. Both strategies focused on achieving higher cardiovascular intensities, with training specificity manipulated by practicing only stepping practice in variable contexts or practicing tasks targeting impairments underlying locomotor dysfunction (strengthening, balance tasks, and recumbent stepping). Results. Significantly greater increases in fastest overground and treadmill walking speeds were observed following task-specific versus impairment-based training, with moderate associations between differences in amount of practice and outcomes. Gains in balance confidence were also observed following task-specific vs impairment-based training, although incidence of falls was also increased with the former protocol. Limited gains were observed with impairment-based training except for peak power during recumbent stepping tests. Conclusion. The present study reinforces work from other patient populations that the specificity of task practice is a critical determinant of locomotor outcomes and suggest impairment-based exercises may not translate to improvements in functional tasks. Clinical Trial Registration URL. https://clinicaltrials.gov/ ; Unique Identifier: NCT02115685.

Task-Specific Versus Impairment-Based Training on Locomotor Performance in Individuals With Chronic Spinal Cord Injury: A Randomized Crossover Study

Background. Many research studies attempting to improve locomotor function following motor incomplete spinal cord injury (iSCI) focus on providing stepping practice. However, observational studies of physical therapy strategies suggest the amount of stepping practice during clinical rehabilitation is limited; rather, many interventions focus on mitigating impairments underlying walking dysfunction. Objective. The purpose of this blinded-assessor randomized trial was to evaluate the effects of task-specific versus impairment-based interventions on walking outcomes in individuals with iSCI. Methods. Using a crossover design, ambulatory participants with iSCI >1-year duration performed either task-specific (upright stepping) or impairment-based training for up to 20 sessions over ≤6 weeks, with interventions alternated after >4 weeks delay. Both strategies focused on achieving higher cardiovascular intensities, with training specificity manipulated by practicing only stepping practice in variable contexts or practicing tasks targeting impairments underlying locomotor dysfunction (strengthening, balance tasks, and recumbent stepping). Results. Significantly greater increases in fastest overground and treadmill walking speeds were observed following task-specific versus impairment-based training, with moderate associations between differences in amount of practice and outcomes. Gains in balance confidence were also observed following task-specific vs impairment-based training, although incidence of falls was also increased with the former protocol. Limited gains were observed with impairment-based training except for peak power during recumbent stepping tests. Conclusion. The present study reinforces work from other patient populations that the specificity of task practice is a critical determinant of locomotor outcomes and suggest impairment-based exercises may not translate to improvements in functional tasks. Clinical Trial Registration URL. https://clinicaltrials.gov/ ; Unique Identifier: NCT02115685.

Minimal Detectable Change for Gait Speed Depends on Baseline Speed in Individuals With Chronic Stroke

BACKGROUND AND PURPOSE

Given the heterogeneity of mobility outcomes after stroke, the purpose of this study was to examine how the minimal detectable change (MDC) for gait speed varies based on an individual's baseline walking speed.

METHODS

Seventy-six participants with chronic stroke and able to walk without therapist assistance participated in 2 visits to record overground self-selected comfortable gait speed (CGS) and fast gait speed (FGS). Based on the CGS at visit 1, participants were assigned to 1 of 3 speed groups: low (<0.4 m/s; n = 32), moderate (0.4-0.8 m/s; n = 29), and high functioning group (>0.8 m/s; n = 15). Participants were then reclassified using updated gait speed cutoffs of 0.49 and 0.93 m/s. For each group, we determined test-retest reliability between visits, and the MDC for CGS and FGS.

RESULTS

Gait speed significantly increased from visit 1 to visit 2 for each group (P < 0.001). The reliability for CGS declined with increasing gait speed, and MDC95 values increased with increasing gait speed (low: 0.10 m/s; moderate: 0.15 m/s; and high: 0.18 m/s). Similar findings were observed for FGS, and when participants were recoded using alternative thresholds.

DISCUSSION AND CONCLUSIONS

Slower walkers demonstrated greater consistency in walking speed from day to day, which contributed to a smaller MDC95 than faster walkers. These data will help researchers and clinicians adjust their expectations and goals when working with individuals with chronic stroke. Expectations for changing gait speed should be based on baseline gait speed, and will allow for more appropriate assessments of intervention outcomes. AVAILABLE: for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A253).

Stepping After Stroke: Walking Characteristics in People With Chronic Stroke Differ on the Basis of Walking Speed, Walking Endurance, and Daily Steps

BACKGROUND

What contributes to free-living walking after stroke is poorly understood. Studying the characteristics of walking may provide further details that guide interventions.

OBJECTIVE

The objectives of this study were to examine how the walking characteristics of bouts per day, median steps per bout, maximum steps per bout, and time spent walking differ in individuals with various walking speeds, walking endurance, and daily steps and to identify cutoffs for differentiating ambulators who were active versus inactive.

DESIGN

This study involved a cross-sectional analysis of data from the Locomotor Experience Applied Post-Stroke trial.

METHODS

Participants were categorized by walking speed, walking endurance (via the 6-minute walk test), and daily steps (via 2 consecutive days of objective activity monitoring). Differences in walking characteristics were assessed. Linear regression determined which characteristics predicted daily step counts. Receiver operating characteristic curves and areas under the curve were used to determine which variable was most accurate in classifying individuals who were active (≥5500 daily steps).

RESULTS

This study included 252 participants with chronic stroke. Regardless of categorization by walking speed, walking endurance, or daily steps, household ambulators had significantly fewer bouts per day, steps per bout, and maximum steps per bout and spent less time walking compared with community ambulators. The areas under the curve for maximum steps per bout and bouts per day were 0.91 (95% confidence interval = 0.88 to 0.95) and 0.83 (95% confidence interval = 0.78 to 0.88), respectively, with cutoffs of 648 steps and 53 bouts being used to differentiate active and inactive ambulation.

LIMITATIONS

Activity monitoring occurred for only 2 days.

CONCLUSIONS

Walking characteristics differed based on walking speed, walking endurance, and daily steps. Differences in daily steps between household and community ambulators were largely due to shorter and fewer walking bouts. Assessing and targeting walking bouts may prove useful for increasing stepping after stroke.

Physical fitness training for stroke patients

BACKGROUND

Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function.

OBJECTIVES

The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function.

SEARCH METHODS

In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses.

MAIN RESULTS

We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons.

AUTHORS' CONCLUSIONS

Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.

Locomotor training intensity after stroke: Effects of interval type and mode

Background and Objectives: High-intensity interval training (HIIT) is a promising strategy for improving gait and fitness after stroke, but optimal parameters remain unknown. We tested the effects of short vs long interval type and over-ground vs treadmill mode on training intensity. Methods: Using a repeated measures design, 10 participants with chronic hemiparesis performed 12 HIIT sessions over 4 weeks, alternating between short and long-interval HIIT sessions. Both protocols included 10 minutes of over-ground HIIT, 20 minutes of treadmill HIIT and another 10 minutes over-ground. Short-interval HIIT involved 30 second bursts at maximum safe speed and 30-60 second rest periods. Long-interval HIIT involved 4-minute bursts at ~90% of peak heart rate (HR_peak) and 3-minute recovery periods at ~70% HR_peak. Results: Compared with long-interval HIIT, short-interval HIIT had significantly faster mean overground speeds (0.75 vs 0.67 m/s) and treadmill speeds (0.90 vs 0.51 m/s), with similar mean treadmill HR (82.9 vs 81.8%HR_peak) and session perceived exertion (16.3 vs 16.3), but lower overground HR (78.4 vs 81.1%HR_peak) and session step counts (1481 vs 1672). For short-interval HIIT, training speeds and HR were significantly higher on the treadmill vs. overground. For long-interval HIIT, the treadmill elicited HR similar to overground training at significantly slower speeds. Conclusions: Both short and long-interval HIIT elicit high intensities but emphasize different dosing parameters. From these preliminary findings and previous studies, we hypothesize that overground and treadmill short-interval HIIT could be optimal for improving gait speed and overground long-interval HIIT could be optimal for improving gait endurance.

Effect of investigator observation on gait parameters in individuals with stroke

Improvements in gait speed following various training paradigms applied to patients post-stroke does not always lead to changes in walking performance, defined as gains in daily stepping activity. We hypothesized that testing conditions, specifically the presence of an observer, influences patient behaviors and resultant outcomes may overestimate their true walking capacity. This potential Hawthorne effect on spatiotemporal and biomechanical measures of locomotor function in individuals post-stroke has not been assessed previously. Fifteen ambulatory individuals with chronic stroke wore instrumented insoles and performed two separate normal-pace walking assessments, including unobserved conditions during which participants were unattended and unaware of data collection, and observed conditions with an investigator present. Gait analysis was conducted outside of a laboratory setting using instrumented insoles equipped with a 3D accelerometer and pressure sensors which captured the spatiotemporal kinematics, vertical ground reaction forces and foot acceleration. Data were compared using paired comparisons, with subsequent correlation and stepwise regression analyses to explore potential associations between Hawthorne-induced changes in walking strategies, gait speed and locomotor performance (daily stepping). Except for cadence, other measures of spatiotemporal parameters and swing kinematics (acceleration) were not significantly different between observed vs unobserved conditions. However, analyses of ground reaction forces revealed significantly greater paretic limb loading (Δ1^st peak = 1.5 ± 1.6 N/kg Δ2^nd peak = 1.4 ± 1.8 N/kg; p < 0.01) and increases in weight bearing symmetry (11-24%, p < 0.01) during observed vs unobserved conditions. This potential Hawthorne effect was greater in those with slower walking speeds and shorter stride lengths but was not related to daily stepping. The present findings suggest that biomechanical parameters of walking function may be related to the presence of an observer and highlight the need to separately measure locomotor capacity (gait speed) and performance (daily stepping).

Energy Cost During the 6-Minute Walk Test and Its Relationship to Real-World Walking After Stroke: A Correlational, Cross-Sectional Pilot Study

BACKGROUND

After experiencing stroke, individuals expend more energy walking than people who are healthy. However, among individuals who have experienced stroke, the correlation between the energy cost of walking, as measured by validated tests (such as the 6-minute walk test), and participation in walking, as measured by more sensitive tools (such as an ambulatory activity monitor), remains unknown.

OBJECTIVE

The main objective of this study was to determine whether the energy cost of walking is correlated with participation in walking.

DESIGN

This study was a correlational, cross-sectional pilot study.

METHODS

Data from 23 participants who had experienced chronic stroke were analyzed. On the first day, data on oxygen uptake were collected using a portable metabolic system while participants walked during the 6-minute walk test. Then, the ambulatory activity monitor was placed on the participants' nonparetic ankle and removed 9 days later. The energy cost of walking was calculated by dividing the mean oxygen uptake recorded during the steady state by the walking speed.

RESULTS

The energy cost of walking was correlated with the following: the number of steps (Spearman rank correlation coefficient [rs] = -0.59); the percentage of time spent in inactivity (rs = 0.48), low cadence (rs = 0.67), medium cadence (rs = -0.56), high cadence (rs = -0.65), and the percentages of steps taken at low cadence (rs = 0.65) and high cadence (rs = -0.64).

LIMITATIONS

Individuals who were physically inactive, convenience sampling, and a small sample size were used in this study.

CONCLUSIONS

Higher energy costs of walking were associated with fewer steps per day and lower cadence in real-world walking in individuals who had experienced stroke.

Clinical non-superiority of technology-assisted gait training with body weight support in patients with subacute stroke: A meta-analysis

BACKGROUND

Technology-assisted gait training (TAGT) with body weight support (BWS) has been designed to provide high numbers of repetitions during stepping practice, but its benefits have been inconclusive.

OBJECTIVE

We evaluated the superiority of TAGT over conventional overground training (COT) to judge the clinical benefits.

METHODS

We searched PubMed, Embase and Web of Science databases from their earliest record to July 1, 2019 and included randomized controlled trials of TAGT with BWS, such as robot-assisted gait training and body weight-supported treadmill training, for treating walking disability in patients within 6months after stroke. We conducted a meta-analysis of the outcomes motor impairment, mobility capacity, walking speed, endurance and fitness, balance, and activities of daily living as well as subgroup analyses of initial ambulatory ability and stroke duration.

RESULTS

Among 14robotics and 10body weight-supported treadmill studies included for review, 23studies involving 1452participants contributed to the meta-analysis. We found no significant standardized mean differences between TAGT and COT (P>0.05) across all outcome categories in the robotics subgroup, the body weight-supported treadmill subgroup, or both subgroups combined, for both the short and long term. Further subgroup analyses also revealed non-significant standardized mean differences (P>0.05) across all outcomes in the subgroups initially ambulatory, non-ambulatory, or stroke duration less than 3 months.

CONCLUSIONS

TAGT with BWS was not superior to COT in improving post-stroke recovery in patients with subacute stroke. Strategies other than simply increasing the repetitions by external assistance may be considered to augment the treatment effects of TAGT.