Falls and injury prevention should be part of every stroke rehabilitation plan

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

RESEARCH QUESTION

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

The Influence of Interval Training Combined with Occlusion and Cooling on Selected Indicators of Blood, Muscle Metabolism and Oxidative Stress

There is increasing evidence to support the use of interval training and/or low-impact blood flow restriction exercises in musculoskeletal rehabilitation. The aim of the study was to assess the effect of interval training combined with occlusion and cooling in terms of changes in selected blood parameters affecting the development and progression of atherosclerosis of the lower limbs, as well as selected parameters of muscle metabolism and oxidative stress affecting the growth of muscle mass and regeneration after training.

MATERIAL AND METHODS

The study included 30 young, healthy and untrained people. The VASPER (Vascular Performance) training system was used-High-Intensity Interval Training with the simultaneous use of occlusion and local cryotherapy. Blood from the project participants was collected six times (2 weeks before the start of training, on the day of training, after the first training, after the 10th training, after the 20th training and two weeks after the end of training). The subjects were randomly divided into three groups: exercises only (controlled), with occlusion and with occlusion and local cryotherapy.

RESULTS

Statistical analysis of changes in the average values of indicators in all study groups showed a significant change increase due to the time of testing IGF-1 (F = 2.37, p = 0.04), XOD (F = 14.26, p = 0.00), D-Dimer (F = 2.90, p = 0.02), and decrease in MDA (F = 7.14, p = 0.00), T-AOC (F = 11.17, p = 0.00), PT Quick (F = 26.37, p = 0.00), INR (F = 8.79, p = 0.00), TT (F = 3.81, p = 0.00). The most pronounced changes were observed in the occlusion and cooling group.

CONCLUSIONS

Both interval training without and with the modifications used in the study influences coagulation and oxidative stress parameters and, to a small extent, muscle metabolism. It seems reasonable to use occlusion and local cryotherapy in combination with occlusion.

Floor-to-Stand Performance Among People Following Stroke

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

The TSS demonstrates concurrent validity with physical performance measures.

IMPACT

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

[Incidence, circumstances and consequences of falls in subjects with stroke: One year of follow-up]

INTRODUCTION

Falls are among the most frequent complications following stroke (CVA), and have a negative impact on rehabilitation.

OBJECTIVES

To study the incidence, circumstances, and consequences of falls in stroke patients up to 12months after starting outpatient kinetic treatment.

MATERIALS AND METHODS

Prospective design, case series. Consecutive sampling. Patients admitted to the day hospital between June 2019 and May 2020. Included: adults with a diagnosis of first supratentorial stroke and functional ambulatory category score ≥3.

EXCLUSION CRITERIA

other condition affecting locomotion.

MAIN VARIABLES

number of falls, circumstances, and consequences. Clinical, demographic, and functional characteristics were measured.

RESULTS

Twenty-one subjects were included, 13 suffered at least one fall. The subjects reported 41 falls: 15 were to the most affected side, 35 inside the home, 28 without the indicated equipment, they were alone when the event occurred on 29 occasions, and in two situations medical assistance was required. There were statistically significant differences (P<.05) in functional performance (balance, gait velocity) between those who fell and those who did not. No significant differences were found between gait endurance and falls.

CONCLUSION

More than half suffered a fall, alone, to the weaker side, and without the appropriate equipment. With this information the incidence could be reduced by preventive measures.

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

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

Effect of gait distance during robot training on walking independence after acute brain injury

This study aimed to determine whether the distance of gait training using a hybrid assistive limb (HAL) is related to the improvement of walking independence in patients with acute brain injury. This was an exploratory, observational study. Thirty patients having hemiplegia (functional ambulation category, FAC score ≤2) with acute stroke or after brain tumor surgery were included. Patients performed 4 sessions of gait training using HAL (60 min/session), 1-3 sessions/week, combined with conventional physical therapy. The gait distance achieved in the four training sessions using HAL was measured. FAC score was measured before and after intervention. Patients were divided into groups A, B, and C, for FAC score improvements of 0, 1, and ≥2, respectively. Gait distance was compared among groups using one-way analysis of variance. Gait distance in group C was significantly longer than that ingroup A [mean (standard deviation): 2527 (1725) m vs. 608 (542) m]. This study suggested that the gait distance achieved during training using the HAL may be a clinical indicator of the effectiveness of the HAL on gait training in patients with acute brain injury.Clinical trial registration number: UMIN000012764 R000014756.

Effectiveness of the Pelvic Clock and Static Bicycle Exercises on Wisconsin Gait Scale and Trunk Impairment Scale in Chronic Ambulatory Hemiplegic Patients: A Single Group Pre-Post Design

BACKGROUND

Most Hemiplegic patients achieve ambulatory function during the sub-acute stage of stroke. Though ambulatory, they still perform an unpleasant awkward gait with remarkable compensations requiring more energy expenditure. Fatigue arises at an early duration as a result of increased energy expenditure. The walking pattern becomes circumduction, featured by asymmetry with an extensor synergy of the lower limb. Each step is rotated away from the body then towards the body, forming a semicircle. This leads to changes in various parameters of gait (spatiotemporal, kinematic, and kinetic) in hemiparetic patients.

PURPOSE

Many studies reveal the effectiveness of various therapeutic techniques in managing hemiplegic circumduction gait. Pelvic clock exercises aid in improving pelvic rotation components and cause dissociation in impaired pelvic mobility due to spasticity. A static bicycle helps in enhancing proper control between the hamstrings and quadriceps. It also helps in improving knee flexion range. As the patient places the foot in the cycle's petals, it helps to enhance dorsiflexion and eversion functions as well. As the lower body is exercised, there could be relative changes in the upper body, i.e., the trunk. Thus, this study aimed to determine the changes in gait functions and trunk performance of chronic ambulatory hemiplegic patients in response to the above therapies for four weeks.

METHOD

Twenty-five subjects (post-stroke duration (2.8 ± 0.6) years) who could walk 10 m independently without assistance or support of aid participated in a pelvic clock and static bicycle exercise intervention. The session duration was 30 min a day, and therapy was delivered six days a week and continued for four weeks. The entire program was carried out in an outpatient neurorehabilitation center.

RESULTS

After the intervention with pelvic clock and static bicycle exercises, there was a remarkable change in gait and trunk functions in chronic hemiplegic patients.

CONCLUSION

The exercises comprising pelvic clock and static bicycle showed positive differences in gait and trunk functions in chronic stage hemiplegic patients. Later, randomized controlled studies involving larger sample sizes, advanced activation techniques, and increased intervention duration will explore in-depth information on their effectiveness and clinical significance.

Brief composite mobility index predicts post-stroke fallers after hospital discharge

Introduction

Community-dwelling, ambulatory stroke survivors fall at very high rates in the first 3-6 months. Current inpatient clinical assessments for fall risk have inadequate predictive accuracy. We found that a pre-discharge obstacle-crossing test has excellent specificity (83%) but lacks acceptable sensitivity (67%) for identifying would-be fallers and non-fallers post discharge.

Hypothesis

We assessed the hypothesis that combining the obstacle-crossing test with other highly discriminatory fall risk factors would compensate for the obstacle test's fair sensitivity and yield an instrument with superior prediction accuracy.

Methods

45 ambulatory stroke survivors (60 ± 11 years old, 15 ± 11 days post stroke) being discharged home completed a battery of physical performance-based and self-reported measures 1-5 days prior to discharge. After discharge, participants were prospectively followed and classified as fallers (≥1 fall) or non-fallers at 3 months. Pre-discharge measures with the largest effect sizes for differentiating fallers and non-fallers were combined into a composite index. Several variations of the composite index were examined to optimize accuracy.

Results

A 4-item discharge composite index significantly predicted fall status at 3-months. The goodness of fit of the regression model was significantly better than the obstacle-crossing test alone, χ ²(1) = 6.036, p = 0.014. Furthermore, whereas the obstacle-crossing test had acceptable overall accuracy (AUC 0.78, 95% CI, 0.60-0.90), the composite index had excellent accuracy (AUC 0.85, 95% CI, 0.74-0.96). Combining the obstacle-crossing test with only the step test produced a model of equivalent accuracy (AUC 0.85, 95% CI, 0.73-0.96) and with better symmetry between sensitivity and specificity (0.71, 0.83) than the 4-item composite index (0.86, 0.67). This 2-item index was validated in an independent sample of n = 30 and with bootstrapping 1,000 samples from the pooled cohorts. The 4-item index was internally validated with bootstrapping 1,000 samples from the derivation cohort plus n = 9 additional participants.

Conclusion

This study provides convincing proof-of-concept that strategic aggregation of performance-based and self-reported mobility measures, including a novel and demanding obstacle-crossing test, can predict post-discharge fallers with excellent accuracy. Further instrument development is warranted to construct a brief aggregate tool that will be pragmatic for inpatient use and improve identification of future post-stroke fallers before the first fall.

Using Deep Learning to Predict Minimum Foot-Ground Clearance Event from Toe-Off Kinematics

Efficient, adaptive, locomotor function is critically important for maintaining our health and independence, but falls-related injuries when walking are a significant risk factor, particularly for more vulnerable populations such as older people and post-stroke individuals. Tripping is the leading cause of falls, and the swing-phase event Minimum Foot Clearance (MFC) is recognised as the key biomechanical determinant of tripping probability. MFC is defined as the minimum swing foot clearance, which is seen approximately mid-swing, and it is routinely measured in gait biomechanics laboratories using precise, high-speed, camera-based 3D motion capture systems. For practical intervention strategies designed to predict, and possibly assist, swing foot trajectory to prevent tripping, identification of the MFC event is essential; however, no technique is currently available to determine MFC timing in real-life settings outside the laboratory. One strategy has been to use wearable sensors, such as Inertial Measurement Units (IMUs), but these data are limited to primarily providing only tri-axial linear acceleration and angular velocity. The aim of this study was to develop Machine Learning (ML) algorithms to predict MFC timing based on the preceding toe-off gait event. The ML algorithms were trained using 13 young adults' foot trajectory data recorded from an Optotrak 3D motion capture system. A Deep Learning configuration was developed based on a Recurrent Neural Network with a Long Short-Term Memory (LSTM) architecture and Huber loss-functions to minimise MFC-timing prediction error. We succeeded in predicting MFC timing from toe-off characteristics with a mean absolute error of 0.07 s. Although further algorithm training using population-specific inputs are needed. The ML algorithms designed here can be used for real-time actuation of wearable active devices to increase foot clearance at critical MFC and reduce devastating tripping falls. Further developments in ML-guided actuation for active exoskeletons could prove highly effective in developing technologies to reduce tripping-related falls across a range of gait impaired populations.

A cohort study on longitudinal changes in postural balance during the first year after stroke

INTRODUCTION

Many patients with strokes report increased incidence of fall that can be due to impaired postural balance. The recovery of balance in patients with varying degrees of impairments and activity limitations is less studied, and whether individuals with mild paresis can recover their balance faster is unclear. Better knowledge about factors influencing the recovery of postural balance can be used to guide clinical management after stroke to provide the right rehabilitation to the right person at the right time, and thus to avoid potential fall incidences.

OBJECTIVE

This study aims to examine longitudinal changes in postural balance during the first year after stroke.

METHODS

Postural balance was assessed using the Berg Balance Scale (BBS) within 5 days, 1, 2, and 3 months and 1-year post-stroke. Stroke severity was stratified using a cluster analysis by including multidimensional baseline measures. A longitudinal mixed-effect model was constructed to analyze changes in proportional balance impairment by stroke severity over time. Individuals with a cut-off of BBS below 45 scores were identified through a classification algorithm using baseline predictors.

RESULTS

A total of 135 patients were stratified to mild stroke (77 [57%] patients) or moderate stroke (58 [43%] patients). Ninety-three patients were included in the longitudinal analysis. Significant recovery was found at 1-year for moderate stroke (48% recovery from the initial impaired postural balance, adjusted P < 0.001), but not for mild stroke, after adjusting for age and cognition. Both stroke severities had a maximal recovery in postural balance at 3 months post-stroke, but the moderate stroke group deteriorated after that. Patients with higher age and worse cognition had more severe balance impairments. The classification model achieved a sensitivity of 0.95 (95% confidence interval [CI]: 0.91-0.98) and a specificity of 0.99 (95% CI: 0.98-1.0) for classifying individuals with BBS below 45 points.

CONCLUSIONS

This study indicates that continuous improvements in postural balance ends at 3 months regardless for mild or moderate stroke groups, and patients with moderate stroke significantly deteriorate in postural balance after 3 months.

Increased temporal stride variability contributes to impaired gait coordination after stroke

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

The association between fatigue severity and risk of falls among middle-aged and older Australian stroke survivors

Background

Fatigue is a common and often debilitating symptom experienced by many stroke survivors. Significant post stroke fatigue may predispose individuals to other health complications, such as falls, which can lead to fractures and soft tissue injuries. Only limited research has examined the association between fatigue and falls in stroke survivors.

Methods

Data were obtained from the Sax Institute’s 45 and Up Study, from a subset of individuals who had experienced a stroke. The Modified Fatigue Impact Scale—5-item version (MFIS-5) was used to measure the level of fatigue. A logistic regression model, adjusted for stroke characteristics and comorbidities, was used to determine the magnitude of association between change in fatigue score and odds of having had a fall.

Results

A total of 576 participants completed the questionnaire. A total of 214 (37.2%) participants reported having had a fall in the previous 12 months. There was a statistically significant association between fatigue scores and fall status (p < 0.001). Specifically, for every 1-point increase in the fatigue score (MFIS-5) (i.e. higher level of fatigue), the odds of a person having a fall is 1.10 times greater (AOR = 1.10; 95% CI 1.05, 1.15; p < 0.001).

Conclusion

This study revealed an association between an increasing risk of falls with increasing severity of post stroke fatigue. Accurate detection and management of fatigue may help reduce the risk of falls and should be the focus of future research.

Impairments and Compensations of Static Balance and Plantar Load Distribution in Patients With Chronic Stroke: An Observational Study

OBJECTIVES

The purpose of this study was to explore impairment and compensation characteristics of static balance and plantar load distribution in patients with chronic stroke.

METHODS

We recruited 68 patients who had chronic stroke who could stand independently (stroke group) and 30 healthy individuals (control group) with the Zebris FDM platform. Static balance parameters, including center of pressure (COP) ellipse sway area, COP path length, and angle-θ between y and major axis, were compared between 2 groups under standard standing posture. In the stroke group, balance parameters were re-tested under their preferring standing posture. Plantar load distribution was also assessed. Another 8 patients with chronic stroke who could not stand independently and had to rely on a crutch were enrolled to analyze the characteristics of balance compensation.

RESULTS

In the stroke group, the ellipse sway area, COP path length, and angle-θ were significantly larger than those of the control group. Sixty-one (89.7%) patients preferred standing with the affected foot outward-forward supporting, and their preferring standing balance was better than that of standard standing. All patients who could not stand independently tended to compensate for balance with a crutch supporting laterally and also preferred standing with a typical posture- the affected foot was outward-forward.

CONCLUSIONS

In patients post stroke, static balance is impaired mainly at the lateral direction, and patients commonly locate the crutch laterally for compensation of lateral balance. Patients preferred standing with the affected foot outward-forward supporting, and their preferring standing balance was better than that of standard standing, which challenged the necessity of training standing symmetrically.

Assessing the risk for falls among Portuguese community-dwelling stroke survivors. Are we using the better tools? Observational study

This study assesses the estimation of the risk for falls among community-dwelling stroke survivors referred for ambulatory physiotherapy and explores factors that affect the risk.

Water-based therapeutic exercise in stroke: a scoping review

PURPOSE

To (1) describe the state of the literature on water-based therapeutic exercise (WBTE) for people living with stroke, (2) describe the content and structure of interventions, (3) summarize the effects of interventions described in the literature, and (4) identify gaps in the literature limiting application and implementation.

MATERIALS AND METHODS

Scoping review methodology described by Arksey and O'Malley (2005) and Levac et al. (2010). Electronic databases were searched for articles with eligibility criteria including: (1) adult stroke survivors (18 years or older) of any type (ischemic/hemorrhagic) or stage (acute/chronic) in any setting, and (2) the study intervention involved WBTE to address a post-stroke deficit.

RESULTS

40 articles were included in this review. Five trials had a treatment control, 20 had an active comparison. Calculated intervention effect sizes demonstrated a strong effect of WBTE on balance and gait related outcomes in 80% of controlled and comparison trials.

CONCLUSIONS

This scoping review highlights common parameters of WBTE interventions and provides an inventory of the differences in the treatment approaches utilized in this population. Opportunities for future work include the development of a standardized treatment protocol, qualitative or mixed methodology research, and greater inclusion of more individuals with more severe stroke-related impairments. IMPLICATIONS FOR REHABILITATIONWater-based therapeutic exercise is an approach that may allow stroke survivors to carry out challenging activities in a safe and accessible environment.Water-based interventions for stroke survivors appear to have a beneficial impact on walking and balance.Given that an aquatic environment offers an opportunity for individuals with more significant physical impairments to carry out early practice of walking and balance related tasks, clinicians should explore the feasibility and effectiveness for this subset of stroke survivors.

Biomechanical Correlates of Falls Risk in Gait Impaired Stroke Survivors

Increased falls risk is prevalent among stroke survivors with gait impairments. Tripping is the leading cause of falls and it is highly associated with mid-swing Minimum Foot Clearance (MFC), when the foot’s vertical margin from the walking surface is minimal. The current study investigated MFC characteristics of post-stroke individuals (n = 40) and healthy senior controls (n = 21) during preferred speed treadmill walking, using an Optotrak 3D motion capture system to record foot-ground clearance. In addition to MFC, bi-lateral spatio-temporal gait parameters, including step length, step width and double support time, were obtained for the post-stroke group’s Unaffected and Affected limb and the control group’s Dominant and Non-dominant limbs. Statistical analysis of MFC included central tendency (mean, median), step-to-step variability (standard deviation and interquartile range) and distribution (skewness and kurtosis). In addition, the first percentile, that is the lowest 1% of MFC values (MFC 1%) were computed to identify very high-risk foot trajectory control. Spatio-temporal parameters were described using the mean and standard deviation with a 2 × 2 (Group × Limb) Multivariate Analysis of Variance applied to determine significant Group and Limb effects. Pearson’s correlations were used to reveal any interdependence between gait variables and MFC control. The main finding of the current research was that post-stroke group’s affected limb demonstrated lower MFC 1% with higher variability and lower kurtosis. Post-stroke gait was also characterised by shorter step length, larger step width and increased double support time. Gait retraining methods, such as using real-time biofeedback, would, therefore, be recommended for post-stroke individuals, allowing them to acquire optimum swing foot control and reduce their tripping risk by elevating the swing foot and improving step-to-step consistency in gait control.

Association between fall risk and assessments of single-task and dual-task walking among community-dwelling individuals with chronic stroke: A prospective cohort study

BACKGROUND

Falling and fall-related injuries are common among community-dwelling individuals with chronic stroke. Falls often occur during dual-task walking scenarios. Accurate fall prediction is critical for formulating effective fall prevention strategies.

RESEARCH QUESTIONS

Can dual-task walking tests and corresponding single-task tests predict falls among individuals with chronic stroke? Are dual-task walking tests involving visuospatial cognition more effective in predicting falls than those involving other cognitive domains?

METHODS

Ninety-three individuals with stroke (age: 62.4 ± 6.7 years; stroke duration: 5.6 ± 4.5 years) participated in this prospective cohort study. Two mobility tasks (level-ground walking and obstacle-crossing) were performed with and without two cognitive tasks (auditory clock test and auditory Stroop test). Demographic information and clinical measures of depression, motor function, walking speed and balance were collected. Monthly telephone interviews were conducted to collect data on fall incidence, related circumstances and injuries incurred during a 12-month follow-up period. Multivariate logistic regression analysis was performed to identify predictive factors associated with future risk of falls.

RESULTS

Thirty-six participants (39%) reported one or more falls during the follow-up period. The regression model including reaction time during the auditory clock task performance while negotiating obstacles correctly classified the fall status of 80% of the participants (72% future fallers and 84% non-fallers). Performance did not differ between fallers and non-fallers on any other measures tested.

SIGNIFICANCE

Dual-task assessment combining an auditory clock task with an obstacle-crossing task has potential clinical utility for identifying future fall risk among people with chronic stroke.

Determinants of falls after stroke based on data on 5065 patients from the Swedish Väststroke and Riksstroke Registers

We aimed to identify determinants in acute stroke that are associated with falls during the stroke unit stay. In order to enable individualized preventive actions, this knowledge is fundamental. Based on local and national quality register data on an unselected sample of 5065 stroke patients admitted to a stroke unit at a Swedish university hospital, univariable and multivariable logistic regression analyses were performed. The dependent variable was any fall during stroke unit stay. The independent variables related to function, activity, personal factors, time to assessment, comorbidities and treatments. Determinants of falls were: being male (odds ratio (OR) 2.25, 95% confidence interval (95% CI) 1.79–2.84), haemorrhagic stroke (OR 1.39, 95% CI 1.05–1.86), moderate stroke symptoms according to the National Institutes of Health Stroke Scale (NIHSS score 2–5 vs. NIHSS score 0–1) (OR 1.43, 95% CI 1.08–1.90), smoking (OR 1.70, 95% CI 1.29–2.25), impaired postural control in walking (OR 4.61, 95% CI 3.29–6.46), impaired postural control in standing (OR 1.60, 95% CI 1.25–2.05), stroke-related arm- and hand problems, OR 1.45, 95% CI 1.11–1.91), impaired cognition (OR 1.43, 95% CI 1.04–1.95), and urinary tract infection (OR 1.91, 95% CI 1.43–2.56). The findings from this study are useful in clinical practice and might help to improve patient safety after stroke.

Measures of Bipedal Toe-Ground Clearance Asymmetry to Characterize Gait in Stroke Survivors

Post-stroke hemiparesis often impairs gait and increases the risks of falls. Low and variable Minimum Toe Clearance (MTC) from the ground during the swing phase of the gait cycle has been identified as a major cause of such falls. In this paper, we study MTC characteristics in 30 chronic stroke patients, extracted from gait patterns during treadmill walking, using infrared sensors and motion analysis camera units. We propose objective measures to quantify MTC asymmetry between the paretic and non-paretic limbs using Poincaré analysis. We show that these subject independent Gait Asymmetry Indices (GAIs) represent temporal variations of relative MTC differences between the two limbs and can distinguish between healthy and stroke participants. Compared to traditional measures of cross-correlation between the MTC of the two limbs, these measures are better suited to automate gait monitoring during stroke rehabilitation. Further, we explore possible clusters within the stroke data by analysing temporal dispersion of MTC features, which reveals that the proposed GAIs can also be potentially used to quantify the severity of lower limb hemiparesis in chronic stroke.

Stroke Rehabilitation for Falls and Risk of Falls in Southeast Asia: A Scoping Review With Stakeholders' Consultation

Background: Research on rehabilitation for falls after stroke is warranted. However, published evidence on fall interventions with stroke survivors is limited and these are mainly international studies that may be less relevant for Southeast Asia. Objective: This review aims to systematically identify literature related to stroke rehabilitation for falls and risk of falls in Southeast Asia. Methods: A scoping review with stakeholders' consultation was implemented. An electronic search was conducted up to December 2020 on 4 databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only original studies conducted in Southeast Asia were selected. Results: The initial search yielded 3,112 articles, however, only 26 were selected in the final analysis. Most of the articles focused on physical rehabilitation and implemented conventional therapies. While the literature may reflect practice in Southeast Asia, stakeholders perceived that the literature was inadequate to show true practice, was not informative and missed several aspects such as functional, cognitive, and psychological interventions in managing falls. Individual-centric interventions dominated the review while community-based and environmental-focused studies were limited. Majority of the articles were written by physiotherapists while others were from physicians, occupational therapists, and an engineer but few from other healthcare practitioners (i.e., speech therapists, psychologists) or disciplines interested in falls. Conclusions: Falls prevention among stroke survivors has received a lack of attention and is perceived as an indirect goal in stroke rehabilitation in Southeast Asia. More innovative research adopted from falls research with older people is needed to advance falls prevention and intervention practice with stroke survivors.

Effects of Targeted Assistance and Perturbations on the Relationship Between Pelvis Motion and Step Width in People With Chronic Stroke

During walking in neurologically-intact controls, larger mediolateral pelvis displacements or velocities away from the stance foot are accompanied by wider steps. This relationship contributes to gait stabilization, as modulating step width based on pelvis motion (hereby termed a “mechanically-appropriate” step width) reduces the risk of lateral losses of balance. The relationship between pelvis displacement and step width is often weakened among people with chronic stroke (PwCS) for steps with the paretic leg. Our objective was to investigate the effects of a single exposure to a novel force-field on the modulation of paretic step width. This modulation was quantified as the partial correlation between paretic step width and pelvis displacement at the step’s start (step start paretic ρ_disp). Following 3-minutes of normal walking, participants were exposed to 5-minutes of either force-field assistance (n = 10; pushing the swing leg toward mechanically-appropriate step widths) or perturbations (n = 10: pushing the swing leg away from mechanically-appropriatestep widths). This period of assistance or perturbations was followed by a 1-minute catch period to identify after-effects, a sign of altered sensorimotor control. The effects of assistance were equivocal, without a significant direct effect or after-effect on step start paretic ρ_disp. In contrast, perturbations directly reduced step start paretic ρ_disp (p = 0.004), but were followed by a positive after-effect (p = 0.02). These results suggest that PwCS can strengthen the link between pelvis motion and paretic step width if exposed to a novel mechanical environment. Future work is needed to determine whether this effect is extended with repeated perturbation exposure.

Characteristics of upper-extremity reactions to sudden lateral loss of balance in persons with stroke

BACKGROUND

Upper-extremity reactions are part of a whole-body response to counterweight the falling center of mass after unexpected balance loss. Impairments in upper-extremity reactions due to unilateral hemiparesis may contribute to stroke survivors propensity for falling. We aimed to characterize upper-extremity (paretic and non-paretic sides) reactive movements in response to lateral balance perturbations in Persons with Stroke vs. healthy controls.

METHODS

Twenty-six subacute persons with stroke and 15 healthy controls were exposed to multidirectional sudden unannounced surface translations in stance. Spatiotemporal parameters of upper- and lower-extremity balance responses to lateral perturbations were analyzed.

FINDINGS

In both groups reactive upper-extremity movement initiation preceded reactive step initiation. In response to a loss of balance toward the paretic side, persons with stroke demonstrated delayed movement initiation of both upper- and lower-extremity compared with healthy controls (In persons with stroke: 234.7 ± 60.0 msec and 227.1 ± 39.6 msec for upper extremities vs. 272.1 ± 59.1 msec for lower-extremity; and in controls: 180.1 ± 39.9 msec and 197.8 ± 61.3 msec for upper-extremities vs. 219.3 ± 40.8 msec for lower-extremity; p = 0.001, Cohen's d's: 0.59-1.03) and a greater abduction excursion in the ipsilateral upper-extremity compared with the contralateral upper-extremity (In persons with stroke: 39.3 ± 23.6 cm vs. 24.9 ± 10.1 cm, respectively; In Controls: 42.6 ± 21.8 cm vs. 29.3 ± 17.3 cm, respectively).

INTERPRETATION

The faster upper-extremity reactive movement reactions compared to reactive step initiation in both persons with stroke and healthy controls suggests that balance recovery is an automatic "reflex-like" response. Delayed upper-extremity reactive reactions in conditions of surface translation toward the non-paretic side in persons with stroke may increase the risk of falls in the direction of the paretic side.

Feasibility of Using Foot-Ground Clearance Biofeedback Training in Treadmill Walking for Post-Stroke Gait Rehabilitation

Hemiplegic stroke often impairs gait and increases falls risk during rehabilitation. Tripping is the leading cause of falls, but the risk can be reduced by increasing vertical swing foot clearance, particularly at the mid-swing phase event, minimum foot clearance (MFC). Based on previous reports, real-time biofeedback training may increase MFC. Six post-stroke individuals undertook eight biofeedback training sessions over a month, in which an infrared marker attached to the front part of the shoe was tracked in real-time, showing vertical swing foot motion on a monitor installed in front of the subject during treadmill walking. A target increased MFC range was determined, and participants were instructed to control their MFC within the safe range. Gait assessment was conducted three times: Baseline, Post-training and one month from the final biofeedback training session. In addition to MFC, step length, step width, double support time and foot contact angle were measured. After biofeedback training, increased MFC with a trend of reduced step-to-step variability was observed. Correlation analysis revealed that MFC height of the unaffected limb had interlinks with step length and ankle angle. In contrast, for the affected limb, step width variability and MFC height were positively correlated. The current pilot-study suggested that biofeedback gait training may reduce tripping falls for post-stroke individuals.

Validity and Reliability of The 3-Meter Backward Walk Test in Individuals with Stroke

OBJECTIVES

The 3-m backward walk test (3MBWT) is used to evaluate neuromuscular control, proprioception, protective reflexes, fall risk and balance. The aim of our study was to reveal the test-retest reliability and validity of the 3MBWT in stroke patients.

MATERIALS AND METHODS

This study included a total of 41 stroke patients [age 59 (35-78) years]. 3MBWT, Berg Balance Scale (BBS), Timed Up and Go test (TUG) were applied to the patients. The second evaluation (retest) was carried out by the same physiotherapist two days following the first evaluation (test) in order to measure test-retest reliability.

RESULTS

Cronbach's alpha coefficient was found to be 0.974 (excellent). For intra-rater agreement, the ICC values in the individual test were 0.985. The SEM value was 1.11 sec, the MDC value was found to be 1.57 sec. A moderate correlation was revealed between the 3 m-backward walking speed and BBS (r: -0.691, p: 0.001) and TUG (r: 0.849, p: 0.001).

CONCLUSIONS

The 3MBWT was observed to be valid and reliable in stroke individuals. It is an effecive and reliable tool for measuring dynamic balance and falls in stroke.

Identification of risk factors for falls in postmenopausal women: a systematic review and meta-analysis

The purpose of this study was to identify risk factors for falls in postmenopausal women and provide evidence for the primary prevention of falls in postmenopausal women. The protocol for this meta-analysis is registered with PROSPERO (CRD42020170927). We searched PubMed, the Cochrane Library and EMBASE for observational studies on the risk factors for falls in postmenopausal women. Review Manager 5.3 was used to calculate the relative risk (RR) or weighted mean difference (WMD) of potential risk factors related to falls. STATA 14.0 was used for the quantitative evaluation of publication bias. Eleven studies with 42,429 patients from 7 countries were included. The main risk factors for falls in postmenopausal women were patient sociodemographic risk factors (age: WMD = 0.37, 95% CI 0.07 to 0.68; body weight: WMD = 0.88, 95% CI 0.56 to 1.12; BMI: WMD = 0.34, 95% CI 0.21 to 0.46; exercise: RR = 0.97, 95% CI 0.94 to 0.99; and FES-I: WMD = 6.60, 95% CI 0.72 to 12.47) and medical risk factors (dietary calcium intake: WMD = - 16.91, 95% CI - 25.80 to - 8.01; previous fracture history: RR = 1.21, 95% CI 1.13 to 1.29; previous falls: RR = 2.02, 95% CI 1.91 to 2.14; number of diseases, ˃ 2: RR = 1.17, 95% CI 1.11 to 1.23; and number of reported chronic health disorders: WMD = 0.30, 95% CI 0.10 to 0.49). Knowledge of the many risk factors associated with falls in postmenopausal women can aid in fall prevention. However, we cannot rule out some additional potential risk factors (age at the onset of menopause, years since last menstruation, hormone therapy and BMD) that need further clinical research.

Predicting Falls Using the Stroke Assessment of Fall Risk Tool

BACKGROUND

Falls in the inpatient stroke population are common, resulting in increased morbidity and slow rehabilitation progress. Falls may result from stroke-specific neurologic deficits; however, assessment of these deficits is lacking in many fall screening tools.

OBJECTIVE

To compare the ability to predict falls of the Stroke Assessment of Fall Risk (SAFR) tool, which includes items related to stroke-specific neurologic deficits, and the commonly used Morse Fall Scale, which does not include these items.

DESIGN

Prospective cohort study.

SETTING

Inpatient tertiary stroke rehabilitation unit.

PARTICIPANTS

Patients (N = 220) with acute stroke.

MAIN OUTCOME MEASURES

Falls were captured by the medical records from January 2017 to September 2018. Logistic regression analysis evaluated both screening tools for predicting falls by calculating sensitivity, specificity, area under the receiver operating characteristic (AUC-ROC) curve, and odds ratio (OR). We compared SAFR and Morse mean scores between fallers and non-fallers using t-tests.

RESULTS

Forty-eight (21.8%) patients experienced ≥1 fall. SAFR, but not Morse, scores showed a statistically significant difference between fallers and non-fallers (P = .001 vs P = .24, respectively). Higher SAFR score was associated with higher odds of falls (OR 1.36, 95% CI [1.12, 1.64]), whereas Morse was not (OR 1.04, 95% CI [0.97, 1.12]). SAFR showed a statistically significant difference in hemi-neglect between fallers and non-fallers (P = .03). Sensitivity and specificity of SAFR were 47.9% and 76.7%, vs 45.8% and 68.0% for Morse, respectively. SAFR positive predictive value and negative predictive value were 36.5% and 84.1%, respectively, similar to Morse (28.6% and 81.8%). The AUC-ROC was 0.65 for SAFR and 0.56 for Morse.

CONCLUSIONS

SAFR was significantly associated with fall risk and had better discrimination between fallers and non-fallers than Morse. The neurologic-specific hemi-neglect component of SAFR, a component not present on the Morse, was a fall risk factor. Further research evaluating the predictive value of fall scales that include neurologic deficits is needed.

A structural equation model of falls at home in individuals with chronic stroke, based on the international classification of function, disability, and health

PURPOSE

To use structural equation model (SEM) to explain falls at home in individuals with chronic stroke, based on the International Classification of Functioning, Disability and Health (ICF).

MATERIALS AND METHODS

A cross sectional observation study was conducted in home-dwelling individuals with chronic stroke (N = 236; 148 non-fallers, 88 fallers). Participants were assessed; structural impairments using Modified Ashworth Scale, Fugl-Meyer Assessment upper (FMA-UE), lower (FMA-LE), and sensory function, ankle plantarflexor strength; activity limitations using Timed Up and Go Test, Step Test, Berg Balance Scale, Barthel Index (BI); participation restrictions using Stroke Impact Scale-participation (SIS-P); and contextual factors using home hazard environments, home safety surroundings, risk behaviors, and Fall-related Self Efficacy. The measurement model was analyzed by confirmatory factor analysis. The SEM was conducted to analyze a structural model of falls at home.

RESULTS

FMA-UE was significantly (p<0.01) associated with FMA-LE, combining as one variable in the structural impairments. In the measurement model, variables were fit to their domains, except variables of contextual factors, but the ICF domains did not correspond to disability. A structural model of falls at home demonstrated a significant (p<0.01) direct path of contextual factors and activity limitations with falls at home. The structural impairments showed a significant (p<0.01) direct path with activity limitations. All variables, except BI, SIS-P and risk behaviors, related to their domains in the structural model.

CONCLUSIONS

A structural model of falls at home proposes contextual factors being the strongest association with falls at home that home hazard environments seem the most influence in its domain. The activity limitations presented by balance ability are directed to falls at home. The structural impairments are associated with falls at home through activity limitations. Home assessment to decrease home hazard environments is suggested to prevent falls at home for individuals with chronic stroke.

Fear of Falling among Older Patients Admitted to Hospital after Falls in Vietnam: Prevalence, Associated Factors and Correlation with Impaired Health-Related Quality of Life

Fear of falling (FOF) diminishes older people’s independence in daily activities, as well as causes serious health and economic consequences. This study examined the prevalence of FOF in older patients hospitalized due to fall-injuries, its effect on health-related quality of life (HRQOL), and its associated factors. We conducted a cross-sectional study in seven hospitals in Thai Binh, Vietnam. FOF was assessed using a single close-ended question. HRQOL was evaluated by the EQ-5D-5L instrument. Multilevel logistic regression and Tobit regression models were utilized. The prevalence of FOF in 405 older patients admitted to hospitals after fall injuries was 88.2%, with a mean EQ-5D index and EQ-VAS of 0.34 (SD = 0.38) and 61.6 (SD = 15.2), respectively. Factors associated with FOF included living alone (OR = 0.13, 95%CI = 0.04; 0.50.,), history of eye diseases (OR = 4.12; 95%CI = 1.91; 8.89), and experiencing psychological distress (OR= 3.56, 95% CI = 1.05; 12.00). After adjusting for confounders, the EQ-5D index in the FOF group reduced by 0.15 points (Coef. = −0.15; 95%CI= −0.24; −0.05) compared to that of non-FOF group. Our study shows that FOF had an independent negative relationship with HRQOL of patients. Improving knowledge about fall prevention in patients and caregivers could reduce the burden of falls in older people.

Experienced complaints, activity limitations and loss of motor capacities in patients with pure hereditary spastic paraplegia: a web-based survey in the Netherlands

Background

Hereditary spastic paraplegia (HSP) is a group of inherited disorders characterized by progressive spastic paresis of the lower limbs. Treatment is often focused on reducing spasticity and its physical consequences. To better address individual patients’ needs, we investigated a broad range of experienced complaints, activity limitations, and loss of motor capacities in pure HSP. In addition, we aimed to identify patient characteristics that are associated with increased fall risk and/or reduced walking capacity.

Methods

We developed and distributed an HSP-specific online questionnaire in the Netherlands. A total of 109 out of 166 questionnaires returned by participants with pure HSP were analyzed.

Results

Participants experienced the greatest burden from muscle stiffness and limited standing and walking activities, while 72% reported leg and/or back pain. Thirty-five and 46% reported to use walking aids (e.g. crutches) indoors and outdoors, respectively; 57% reported a fall incidence of at least twice a year (‘fallers’); in 51% a fall had led to an injury at least once; and 73% reported fear of falling. Duration of spasticity and incapacity to rise from the floor were positively associated with being a ‘faller’, whereas non-neurological comorbidity and wheelchair use were negatively associated. Higher age, experienced gait problems, not being able to stand for 10 min, and incapacity to open a heavy door showed a negative association with being a ‘walker without aids’ (> 500 m).

Conclusions

Our results emphasize the large impact of spastic paraparesis on the lives of people with pure HSP and contribute to a better understanding of possible targets for rehabilitation.

Do orthopaedic and neurosciences inpatients who are at risk of falls have best practice fall prevention strategies implemented during their acute inpatient hospitalization?

OBJECTIVE

To determine whether inpatients identified as being at high risk for falls received fall prevention interventions as recommended in the Best Practice Guidelines for Australian Hospitals.

METHODS

This cross-sectional study examined medical record data from a convenience sample of inpatients admitted to orthopaedic and neurosciences wards (N = 100). Data were compared to the fall prevention recommendations. Percentages were used to describe compliance and independent samples t-tests to assess difference in adherence.

RESULTS

Data revealed that 45% and 62% of recommendations were implemented amongst inpatients on orthopaedic and neurosciences ward, respectively (P < 0.001). There was a significant positive correlation between orthopaedic inpatients at higher risk of falls and those with a greater length of stay [r(39) = .46, P = 0.003]. When analysed together, patients who were admitted following a fall had a lower percentage of fall prevention strategies implemented (P < 0.001).

CONCLUSION

Implementation of fall prevention strategies is essential to target in the inpatient setting.

Impaired Motor Function in the Affected Arm Predicts Impaired Postural Balance After Stroke: A Cross Sectional Study

Background: Impaired postural balance is a common symptom after stroke and a common cause of falling. Most common daily tasks use arm and hand movements. Impairment in an upper extremity is a common stroke symptom, affecting 50–80% in the acute phase after stroke, and 40–50% in the sub-acute phase. The impact of leg function on postural balance has been investigated in several studies, but few have stressed the importance of arm function on postural balance.

Objective: To explore whether there is any association between arm function and postural balance after stroke.

Method: A cross sectional study where 121 adults (mean age: 70 ± 12.3 years, 72 men) from two different data sources, Gothenburg Very Early Supported Discharge (GOTVED), and a study by Carvalho et al. were merged. Time for assessments ranged from 1 to 13 years when the patients were in the chronic phase. The dependent variables were Berg Balance scale (BBS) and Time Up and Go (TUG) both dichotomized to “impaired postural balance” and “not impaired postural balance.” As independent variables, the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) scale was used. The FMA-UE was presented with the total score.

Results: The motor function in the arm affected after stroke onset correlated with postural balance both measured with the BBS (0.321, p < 0.001) and the TUG (−0.315, p = 0.001). Having impaired motor function in the arm was significantly associated with impaired postural balance assessed with the BBS with OR = 0.879 (CI 0.826–0.934, p < 0.001). Regression analysis with the TUG showed the same result, OR = 0.868 (CI 0.813–0.927, p < 0.001) for FM-UE.

Conclusion: The motor function of the affected arm was significantly associated with impaired postural balance post stroke, as assessed by BBS or TUG. It could be of clinical importance to be aware of the fact that not only lower extremity impairment, but also arm function can have an impact on postural balance in a late stage after stroke.

Trial Registration: VGFOUGSB-669501.

Effect of Scapular Stabilization Exercise during Standing on Upper Limb Function and Gait Ability of Stroke Patients

Background

The purpose of this study was to determine the effect of scapular stabilization exercise during standing on a paretic side on upper limb function and gait ability of stroke patients.

Methods

This study was a hospital-based, randomized controlled trial with a blinded assessor. A total of 17 patients with hemiplegic diagnosis after stroke were divided into two groups (9 patients in a study group and 8 patients in a control group). The study group received physical therapy and scapular stabilization exercise on a paretic side. Participants were subjected to initial evaluation before the treatment. Subjects were subsequently re-evaluated 4 and 8 weeks later to compare the changes. Measurements of hand function and gait ability were performed.

Results

Based on multivariate analysis of variance for repeated-measures, there was a significant time effect for Timed Up and Go test (TUG) (F = 13.816, P = 0.000), Functional Gait Assessment (FGA) (F = 18.613, P = 0.000), and manual function test (MFT) (F = 16.777, P = 0.000). The group × time interaction effect was also significant for FGA (F = 4.966, P = 0.024) and MFT (F = 6.946, P = 0.003), but not for TUG test (F = 3.343, P = 0.069).

Conclusion

Results of the present study indicated that scapular stabilization exercise during standing on a paretic side for 8 weeks had an effect on hand function and gait ability of hemiplegic patients after stroke. Further studies are needed to find the most proper exercise for stroke patients who have gait disability and upper limb dysfunction.

Insufficient Balance Recovery Following Unannounced External Perturbations in Persons With Stroke

Background. Persons with stroke (PwS) are at increased risk of falls, especially toward the paretic side, increasing the probability of a hip fracture. The ability to recover from unexpected loss of balance is a critical factor in fall prevention. Objectives. We aimed to compare reactive balance capacity and step kinematics between PwS and healthy controls. Methods. Thirty subacute PwS and 15 healthy controls were exposed to forward, backward, right, and left unannounced surface translations in 6 increasing intensities while standing. Single step threshold, multiple step threshold, and fall threshold (ie, perturbation intensity leading to a fall into harness system) were recorded as well as reactive step initiation time, step length, and step velocity. Results. Twenty-five PwS fell into harness system during the experiment while healthy controls did not fall. Fourteen out of 31 falls occurred in response to surface translations toward the nonparetic side, that is, falling toward the paretic side. Compared with healthy controls, PwS demonstrated significantly lower fall threshold and multiple step threshold in response to forward, backward, and lateral surface translations. Impairments were more pronounced in response to forward surface translation and toward the nonparetic side (ie, loss of balance toward the paretic side). A trend toward significant shorter step length in response to lateral surface translations was found in PwS compared with healthy controls. Conclusions. Findings highlight the importance of assessing reactive balance capacity in response to perturbations in different directions and intensities in addition to the routine assessment in PwS.

Real-time foot clearance biofeedback to assist gait rehabilitation following stroke: a randomized controlled trial protocol

Background

The risk of falling is significantly higher in people with chronic stroke and it is, therefore, important to design interventions to improve mobility and decrease falls risk. Minimum toe clearance (MTC) is the key gait cycle event for predicting tripping-falls because it occurs mid-swing during the walking cycle where forward velocity of the foot is maximum.

High forward velocity coupled with low MTC increases the probability of unanticipated foot-ground contacts. Training procedures to increase toe-ground clearance (MTC) have potential, therefore, as a falls-prevention intervention. The aim of this project is to determine whether augmented sensory information via real-time visual biofeedback during gait training can increase MTC.

Methods

Participants will be aged > 18 years, have sustained a single stroke (ischemic or hemorrhagic) at least six months previously, able to walk 50 m independently, and capable of informed consent. Using a secure web-based application (REDCap), 150 participants will be randomly assigned to either no-feedback (Control) or feedback (Experimental) groups; all will receive 10 sessions of treadmill training for up to 10 min at a self-selected speed over 5–6 weeks. The intervention group will receive real-time, visual biofeedback of MTC during training and will be asked to modify their gait pattern to match a required “target” criterion. Biofeedback is continuous for the first six sessions then progressively reduced (faded) across the remaining four sessions. Control participants will walk on the treadmill without biofeedback. Gait assessments are conducted at baseline, immediately following the final training session and then during follow-up, at one, three, and six months. The primary outcome measure is MTC. Monthly falls calendars will also be collected for 12 months from enrolment.

Discussion

The project will contribute to understanding how stroke-related changes to sensory and motor processes influence gait biomechanics and associated tripping risk. The research findings will guide our work in gait rehabilitation following stroke and may reduce falls rates. Treadmill training procedures incorporating continuous real-time feedback may need to be modified to accommodate stroke patients who have greater difficulties with treadmill walking.

Trial registration

Australia New Zealand Clinical Trials Registry, ACTRN12617000250336. Registered on 17 February 2017.

Content Reporting in Post-Stroke Therapeutic Circuit-Class Exercise Programs in randomized control trials

BACKGROUND

Therapeutic exercise in the form of group circuit-class training can improve mobility and gait while being cost-effective among patients who survived a stroke. Accurate clinical replication of interventions, especially when they are effective, is needed to advance research and treatment. However, replication is difficult when reporting is not detailed.

OBJECTIVE

The objective of this study was to assess the quality of reporting of interventions within the selected studies using three different scales and to assess the criterion validity between the scales.

METHODS

Two independent assessors used the CERT, the CONTENT scale, and TIDieR checklist to review the quality of reporting of 16 randomized controlled trials (RCTs) from a recent Cochrane Review. Assessments were done independently before a consensus was reached with an experienced third reviewer mediating any disagreements. Criterion validity between the three quality reporting tools was measured using weighted Cohen's kappa coefficients.

RESULTS

The mean (±SD) for the CERT was 9.31 (±1.66) out of 19 points; the TIDieR checklist was 8.81 (±1.33) out of 12 points; and the CONTENT was 4.82 (±1.22) out of 9 points for the 16 included RCTs. The CERT and CONTENT scale had a fair agreement (k = 0.455, p = 0.064), while both CERT and CONTENT had only slight agreement with TIDieR (k = 0.143, p = 0.267; k = 0.200, p = 0.182, respectively).

CONCLUSIONS

The results of this study indicate a lack of reporting from the 16 RCTs on post-stroke therapeutic circuit-class exercise programs. This presents a major barrier to knowledge translation and clinical implementation of effective exercise programs for stroke rehabilitation.

The differences in sagittal plane whole-body angular momentum during gait between patients with hemiparesis and healthy people

Regulation of whole-body angular momentum (WBAM) is essential for maintaining dynamic balance during gait. Patients with hemiparesis frequently fall toward the anterior direction; however, whether this is due to impaired WBAM control in the sagittal plane during gait remains unknown. The present study aimed to investigate the differences in WBAM in the sagittal plane during gait between patients with hemiparesis and healthy individuals. Thirty-three chronic stroke patients with hemiparesis and twenty-two age- and gender-matched healthy controls walked along a 7-m walkway while gait data were recorded using a motion analysis system and force plates. WBAM and joint moment were calculated in the sagittal plane during each gait cycle. The range of WBAM in the sagittal plane in the second half of the paretic gait cycle was significantly larger than that in the first and second halves of the right gait cycle in the controls (P = 0.015 and P = 0.011). Furthermore, multiple regression analysis revealed the slower walking speed (P < 0.001) and larger knee extension moment on the non-paretic side (P = 0.003) contributed to the larger range of WBAM in the sagittal plane in the second half of the paretic gait cycle. Our findings suggest that dynamic stability in the sagittal plane is impaired in the second half of the paretic gait cycle. In addition, the large knee extension moment on the non-paretic side might play a role in the dynamic instability in the sagittal plane during gait in patients with hemiparesis.

Effects of Perturbation-Based Balance Training in Subacute Persons With Stroke: A Randomized Controlled Trial

BACKGROUND

Reactive balance responses are critical for fall prevention. Perturbation-based balance training (PBBT) has shown a positive effect in reducing the risk of falls among older adults and persons with Parkinson's disease.

OBJECTIVE

To explore the effect of a short-term PBBT on reactive balance responses, performance-based measures of balance and gait and balance confidence.

METHODS

Thirty-four moderate-high functioning, subacute persons with stroke (PwS) (lower extremity Fugl-Meyer score 29.2 ± 4.3; Berg Balance Scale [BBS] score 43.8 ± 9.5, 42.0 ± 18.7 days after stroke onset) hospitalized in a rehabilitation setting were randomly allocated to PBBT (n = 18) and weight shifting and gait training (WS&GT) (n = 16). Both groups received 12 training sessions, 30 minutes each, for a period of 2.5 weeks. PBBT included unexpected balance perturbations during standing and treadmill walking, WS&GT included weight shifting in standing and treadmill walking without perturbations. The main outcome measures, that is, multiple step-threshold and fall-threshold were examined at baseline, immediately postintervention, and about 5 weeks postintervention. The secondary outcome measures, that is, BBS, 6-minute walk test (6MWT), 10-meter walk test (10MWT), and Activity-specific Balance Confidence (ABC) scale were examined at baseline and immediately postintervention.

RESULTS

Compared with the WS&GT group, immediately postintervention participants in the PBBT group showed higher multiple-step thresholds in response to forward and backward surface translations (effect size [ES] = 1.07 and ES = 1.10, respectively) and moderate ES in the ABC scale (ES = 0.74). No significant differences were found in fall-threshold, BBS, 6MWT, and 10MWT between the groups.

CONCLUSIONS

Inclusion of perturbation training during rehabilitation of PwS improved reactive balance and balance confidence.

Incidence and circumstances of falls among community-dwelling ambulatory stroke survivors: A prospective study

AIM

To elucidate the incidences and circumstances of falls and fall-related injuries, and to explore the physical characteristics of community-dwelling ambulatory stroke survivors who experienced falls.

METHODS

A total of 144 community-dwelling ambulatory survivors of hemiparetic stroke (mean age 68.0 years [SD 10.4 years]) who were undergoing rehabilitation in an adult daycare center participated in this prospective study. The mean duration from stroke onset was 5.21 years (SD 3.15 years). The occurrence of falls was collected for 1 year with a fall diary. The incidence rates of falls and fall-related injuries, and the detailed circumstances of falls were descriptively analyzed. The characteristics of fallers were explored by comparing background information, motor impairments and results of physical function tests, including the 10-m walk test, Timed Up and Go test and five-times-sit-to-stand test, between fallers and non-fallers.

RESULTS

The incidence rates of falls and fall-related fractures were 0.88 per person-year and 2.8 per 100 person-years, respectively. Falls occurred more frequently during daytime and in winter. Falls were caused most often by losing balance while walking indoors, especially on the way to the toilet. After falling, 34.1% of individuals who fell could not stand up by themselves. The time of the five-times-sit-to-stand test was significantly longer in fallers than in non-fallers (P < 0.05).

CONCLUSIONS

The incidence rate of falls was high among community-dwelling ambulatory survivors of hemiparetic stroke. Appropriate approaches, including mastering the skills to cope with falling, are required, especially for individuals with reduced lower limb muscle strength. Geriatr Gerontol Int 2019; 19: 240-244.

Early prediction of falls after stroke: a 12-month follow-up of 490 patients in The Fall Study of Gothenburg (FallsGOT)

OBJECTIVE:

To identify the incidence of falls and factors present shortly after stroke, which are associated with the occurrence of falls over the first 12 months after stroke onset, following discharge from inpatient rehabilitation.

DESIGN:

Prospective follow-up study.

SETTING:

Stroke unit and outpatient department.

SUBJECTS:

A total of 490 individuals with acute stroke.

METHODS:

Postural control was assessed using the Swedish modified version of the Postural Assessment Scale for Stroke Patients. Data on self-reported falls were collected using a standardized questionnaire at three months after discharge and six and 12 months after stroke onset. Associations between characteristics during the acute phase after a stroke and falls after six and 12 months were investigated using univariable and multivariable regression analyses.

MAIN MEASURES:

The endpoint was a self-reported fall.

RESULTS:

Within three months after discharge, 38 of 165 respondents (23%) had experienced at least one fall. Within six and 12 months after stroke onset, respectively, 108 of 376 (29%) and 140 of 348 (40%) of the respondents had experienced at least one fall. Poor postural control (odds ratio 3.92, 95% confidence interval 2.07-7.45, P < 0.0001) and using a walking aid (odds ratio 2.84, 95% confidence interval 1.71-4.72, P < 0.0001) were predictors of falls after discharge within 12 months after stroke onset. The same variables were independent predictors of falls within six months.

CONCLUSION:

Poor postural control and using a walking aid in the acute phase after a stroke are associated with falls after discharge from a stroke unit within 12 months after stroke onset.

The impact of implementing a fall prevention educational session for community-dwelling physical therapy patients

AIM

The aim of this study was to evaluate the impact of a fall prevention educational session on fall risk knowledge, use of fall prevention interventions and the number of falls in community-dwelling older persons attending physical therapy.

DESIGN

This pilot study used a mixed method design consisting of a quantitative pretest-posttest quasi-experimental design followed by a qualitative interview.

METHOD

An educational intervention was given with pre- and posttest questionnaires to determine the outcome measures of: (a) fall risk knowledge; (b) number of participants implementing fall prevention techniques; and (c) the number of falls sustained for 60 days post the educational sessions. The Health Belief Model served as the theoretical underpinnings for development and presentation of two educational sessions.

RESULTS

Eight of 20 participants completed the fall prevention educational sessions and subsequent evaluation. An increase in fall risk knowledge (p = 0.031) and implementation of fall prevention techniques was noted. One fall was sustained 60 days after therapy discharge.

Identifying trippers and non-trippers based on knee kinematics during obstacle-free walking

Trips are a major cause of falls. Sagittal-plane kinematics affect clearance between the foot and obstacles, however, it is unclear which kinematic measures during obstacle-free walking are associated with avoiding a trip when encountering an obstacle. The purpose of this study was to determine kinematic factors during obstacle-free walking that are related to obstacle avoidance ability. It was expected that successful obstacle avoidance would be associated with greater peak flexion/dorsiflexion and range of motion (ROM), and differences in timing of peak flexion/dorsiflexion during swing of obstacle-free walking for the hip, knee and ankle. Three-dimensional kinematics were recorded as 35 participants (young adults age 18-45 (N = 10), older adults age 65+ without a history of falls (N = 10), older adults age 65+ who had fallen in the last six months (N = 10), and individuals who had experienced a stroke more than six months earlier (N = 5)) walked on a treadmill, under obstacle-free walking conditions with kinematic features calculated for each stride. A separate obstacle avoidance task identified trippers (multiple obstacle contact) and non-trippers. Linear discriminant analysis with sequential feature selection classified trippers and non-trippers based on kinematics during obstacle-free walking. Differences in classification performance and selected features (knee ROM and timing of peak knee flexion during swing) were evaluated between trippers and non-trippers. Non-trippers had greater knee ROM (P = .001). There was no significant difference in classification performance (P = .193). Individuals with reduced knee ROM during obstacle-free walking may have greater difficulty avoiding obstacles.

Differences in Fracture Incidence According to Caregiver Type in Stroke Survivors

BACKGROUND

To assess whether the type of primary caregiver is a risk factor of the incidence of fracture among older adults who have survived a stroke.

METHODS

Data from 4282 stroke survivors in the National Health Insurance Service-Senior Cohort (2002-2013) were used in this study. We categorized type of primary caregiver as none, spouse/family caregiver, and formal caregiver. The incidence of fracture within the year postdischarge was used as the outcome variable. These data were subjected to a survival analysis using the Cox proportional hazard model.

RESULTS

Of the 4282 stroke survivors, 308 (7.2%) experienced a fracture during the 1-year follow-up period. According to type of primary caregiver, the adjusted hazard ratio (HR) of fracture was lower among those whose caregiver was a spouse (HR = .68, 95% confidence interval [CI], .48-.96] and those with a formal caregiver (HR = .59, 95% CI, .36-.97) compared to stroke survivors with no caregiver. In particular, those with a family or formal caregiver who were being cared for in nursing facilities were less likely to be associated with fracture than those with no caregiver.

CONCLUSIONS

The adjusted HR of fracture among stroke survivors was lower among those with primary caregivers compared to those without them. Thus, the government should monitor and allocate the appropriate attention to stroke survivors after discharge in order to ensure that they obtain the needed health care, especially for stroke survivors who are without a primary caregiver.

Neural Constraints Affect the Ability to Generate Hip Abduction Torques When Combined With Hip Extension or Ankle Plantarflexion in Chronic Hemiparetic Stroke

Stroke lesions interrupt descending corticofugal fibers that provide the volitional control of the upper and lower extremities. Despite the evident manifestation of movement impairments post-stroke during standing and gait, neural constraints in the ability to generate joint torque combinations in the lower extremities are not yet well determined. Twelve chronic hemiparetic participants and 8 age-matched control individuals participated in the present study. In an isometric setup, participants were instructed to combine submaximal hip extension or ankle plantarflexion torques with maximal hip abduction torques. Statistical analyses were run using linear mixed effects models. Results for the protocol combining hip extension and abduction indicate that participants post-stroke have severe limitations in the amount of hip abduction torque they can generate, dependent upon hip extension torque magnitude. These effects are manifested in the paretic extremity by the appearance of hip adduction torques instead of hip abduction at higher levels of hip extension. In the non-paretic extremity, significant reductions of hip abduction were also observed. In contrast, healthy control individuals were capable of combining varied levels of hip extension with maximal hip abduction. When combining ankle plantarflexion and hip abduction, only the paretic extremity showed reductions in the ability to generate hip abduction torques at increased levels of ankle plantarflexion. Our results provide insight into the neural mechanisms controlling the lower extremity post-stroke, supporting previously hypothesized increased reliance on postural brainstem motor pathways. These pathways have a greater dominance in the control of proximal joints (hip) compared to distal joints (ankle) and lead to synergistic activation of musculature due to their diffuse, bilateral connections at multiple spinal cord levels. We measured, for the first time, bilateral constraints in hip extension/abduction coupling in hemiparetic stroke, again in agreement with the expected increased reliance on bilateral brainstem motor pathways. Understanding of these neural constraints in the post-stroke lower extremities is key in the development of more effective rehabilitation interventions that target abnormal joint torque coupling patterns.

Development of the Modified Four Square Step Test and its reliability and validity in people with stroke

Adults with stroke have difficulty avoiding obstacles when walking, especially when a time constraint is imposed. The Four Square Step Test (FSST) evaluates dynamic balance by requiring individuals to step over canes in multiple directions while being timed, but many people with stroke are unable to complete it. The purposes of this study were to (1) modify the FSST by replacing the canes with tape so that more persons with stroke could successfully complete the test and (2) examine the reliability and validity of the modified version. Fifty-five subjects completed the Modified FSST (mFSST) by stepping over tape in all four directions while being timed. The mFSST resulted in significantly greater numbers of subjects completing the test than the FSST (39/55 [71%] and 33/55 [60%], respectively) (p < 0.04). The test-retest, intrarater, and interrater reliability of the mFSST were excellent (intraclass correlation coefficient ranges: 0.81-0.99). Construct and concurrent validity of the mFSST were also established. The minimal detectable change was 6.73 s. The mFSST, an ideal measure of dynamic balance, can identify progress in people with stroke in varied settings and can be completed by a wide range of people with stroke in approximately 5 min with the use of minimal equipment (tape, stop watch).

Functional Reach, Depression Scores, and Number of Medications Are Associated With Number of Falls in People With Chronic Stroke

BACKGROUND

Falls are a common adverse event among people with stroke. Previous studies investigating risk of falls after stroke have relied primarily on retrospective fall history ranging from 6-12 months recall, with inconsistent findings.

OBJECTIVES

To identify factors and balance assessment tools that are associated with number of falls in individuals with chronic stroke.

DESIGN

Secondary analysis of a randomized clinical trial.

SETTING

Multisite academic and clinical institutions.

PARTICIPANTS

Data from 181 participants with stroke (age 60.67 ± 11.77 years, post stroke 4.51 ± 4.78 years) were included.

METHODS

Study participants completed baseline testing and were prospectively asked about falls. A multivariate negative binomial regression was used to identify baseline predictive factors predicting falls: age, endurance (6 minute walk test), number of medications, motor control (Fugl-Meyer lower extremity score), depression (Patient Health Questionnaire-9), physical activity (number of steps per week), and cognition (Mini Mental Status Exam score). A second negative binomial regression analysis was used to identify baseline balance assessment scores predicting falls: gait velocity (comfortable 10 Meter Walk), Berg Balance Scale (BBS), Timed Up and Go (TUG), and Functional Reach Test (FRT). Receiver operating characteristic (ROC) and area under the curve (AUC) were used to determine the cutoff scores for significant predictors of recurrent falls.

MAIN OUTCOME MEASUREMENT

The number of falls during the 42-week follow-up period.

RESULTS

Baseline measures that significantly predicted the number of falls included increased number of medications, higher depression scores, and decreased FRT. Cutoff scores for the number of medications were 8.5 with an AUC of 0.68. Depression scores differentiated recurrent fallers at a threshold of 2.5 scores with an AUC of 0.62. FRT differentiated recurrent fallers at a threshold of 18.15 cm with an AUC of 0.66.

CONCLUSIONS

Number of medications, depression scores, and decreased FRT distance at baseline were associated with increased number of falls. Increased medications might indicate multiple comorbidities or polypharmacy effect; increased depression scores may indicate psychological status; and decreased functional reach distance could indicate dynamic balance impairments.

LEVEL OF EVIDENCE

II.

Developing a falls prevention program for community-dwelling stroke survivors in Singapore: client and caregiver perspectives

PURPOSE

Drawing on the perspectives of stroke survivors, family members and domestic helpers, this study explores participants' experiences of self-perceived fall risk factors after stroke, common fall prevention strategies used, and challenges to community participation after a fall.

METHODS

Semi-structured interviews were conducted in Singapore with community-dwelling stroke survivors with a previous fall (n = 9), family caregivers (n = 4), and domestic helpers (n = 4) who have cared for a stroke survivor with a previous fall. Purposive sampling was used for recruitment; all interviews were audio-recorded with permission and transcribed. Thematic analysis was conducted using NVivo (v10) software.

RESULTS

All participants shared their self-perceived intrinsic and extrinsic fall risk factors and main challenges after a fall. For stroke participants and family caregivers, motivational factors in developing safety strategies after a previous fall(s) include social connectedness, independent living and community participation. For family caregivers and domestic helpers, the stroke survivor's safety is their top priority, however this can also lead to over-protective behavior outside of the rehabilitation process.

CONCLUSIONS

Reducing the risk of falls in community-dwelling stroke survivors seems to be more important than promoting community participation among caregivers. The study findings highlight that a structured and client-centered fall prevention program targeting stroke survivors and caregivers is needed in Singapore. Implications for rehabilitation Falls after stroke can lead to functional decline in gait and mobility and restricted self-care activities. Community-dwelling stroke survivors develop adaptive safety strategies after a fall and want to be socially connected. However, caregivers see the safety of the stroke survivors as their top priority and demonstrate over-protective behaviors. Fall prevention programs for community-dwelling stroke survivors should target both stroke survivors and their caregivers. A structured and client-centered fall prevention program targeting at multiple risk factors post-stroke is needed for community-living stroke survivors.

Manipulating post-stroke gait: Exploiting aberrant kinematics

Post-stroke individuals often exhibit abnormal kinematics, including increased pelvic obliquity and hip abduction coupled with reduced knee flexion. Prior examinations suggest these behaviors are expressions of abnormal cross-planar coupling of muscle activity. However, few studies have detailed the impact of gait-retraining paradigms on three-dimensional joint kinematics. In this study, a cross-tilt walking surface was examined as a novel gait-retraining construct. We hypothesized that relative to baseline walking kinematics, exposure to cross-tilt would generate significant changes in subsequent flat-walking joint kinematics during affected limb swing. Twelve post-stroke participants walked on a motorized treadmill platform during a flat-walking condition and during a 10-degree cross-tilt with affected limb up-slope, increasing toe clearance demand. Individuals completed 15 min of cross-tilt walking with intermittent flat-walking catch trials and a final washout period (5 min). For flat-walking conditions, we examined changes in pelvic obliquity, hip abduction/adduction and knee flexion kinematics at the spatiotemporal events of swing initiation and toe-off, and the kinematic event of maximum angle during swing. Pelvic obliquity significantly reduced at swing initiation and maximum obliquity in the final catch trial and late washout. Knee flexion significantly increased at swing initiation, toe-off, and maximum flexion across catch trials and late washout. Hip abduction/adduction was not significantly influenced following cross-tilt walking. Significant decrease in the rectus femoris and medial hamstrings muscle activity across catch trials and late washout was observed. Exploiting the abnormal features of post-stroke gait during retraining yielded desirable changes in muscular and kinematic patterns post-training.