Faculty publications - Department of Physical Therapy

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Cardiorespiratory exercise and self-management early after stroke to increase daily physical activity: results from a stepped-wedge cluster randomised trial
(2024-11-12) Devasahayam, Augustine J.; Tang, Ada; Taylor, Denise; Inness, Elizabeth L.; Fleck, Rebecca; French, Esmé; Jagroop, David; Danells, Cynthia J.; Mansfield, Avril
Purpose: This study aimed to determine if the Promoting Optimal Physical Exercise for Life (PROPEL) program increases participation in physical activity up to six months post-discharge from stroke rehabilitation, compared to participation in group cardiorespiratory exercise (GCE) alone. Methods: This was a stepped-wedge cluster superiority randomized controlled trial. People with sub-acute stroke participated in the PROPEL (n=107) or GCE (n=65) intervention phases. The primary outcome was adherence to physical activity guidelines over seven days at six months post-discharge from rehabilitation. Secondary outcomes were exercise self-efficacy (Short Self-Efficacy for Exercise scale), exercise-related beliefs and attitudes (Short Outcome Expectation for Exercise scale), and perceived barriers to physical activity (Barriers to Being Active Quiz). Results: Fifty-seven participants (PROPEL, n=29; GCE, n=28) were included in the analysis. At six months post-discharge, 6/17 PROPEL participants and 9/22 GCE participants met the guidelines for intensity and duration of physical activity; the odds of meeting physical activity guidelines did not differ between phases (p>0.84). PROPEL participants reported higher self-efficacy for exercise than GCE participants (p=0.0047). Conclusions: While PROPEL participants reported higher self-efficacy for exercise than those who completed GCE alone, we were unable to find evidence that this translated to increased odds of meeting physical activity guidelines. Trial registration: NCT02951338.
Reliability of unconventional centre of pressure measures of quiet standing balance in people with chronic stroke
(2023-04) Jagroop, David; Aryan, Raabeae; Schinkel-Ivy, Alison; Mansfield, Avril
Background: People with stroke often have asymmetric motor impairment. Investigating asymmetries in, and dynamic properties of, centre of pressure movement during quiet standing can inform how balance is controlled. Research question: What are the test-retest reliabilities of unconventional measures of quiet standing balance control in people with chronic stroke? Methods: Twenty people with chronic stroke (>6 months post-stroke), who were able to stand for at least 30 seconds without support, were recruited. Participants completed two 30-second quiet standing trials in a standardized position. Unconventional measures of quiet standing balance control included: symmetry of variability in centre of pressure displacement and velocity, between-limb synchronization, and sample entropy. Root mean square of centre of pressure displacement and velocity in the antero-posterior and medio-lateral directions were also calculated. Intraclass correlation coefficients (ICCs) were used to determine test-retest reliability, and Bland-Altman plots were created to examine proportional biases. Results: ICC3,2 were between 0.79 and 0.95 for all variables, indicating ‘good’ to ‘excellent’ reliability (>0.75). However, ICC3,1 for symmetry indices and between-limb synchronization were <0.75. Bland-Altman plots revealed possible proportional biases for root mean square of medio-lateral centre of pressure displacement and velocity and between-limb synchronization, with larger between-trial differences for participants with worse values. Significance: These findings suggest that centre of pressure measures extracted from a single 30-second quiet standing trial may have sufficient reliability for some research studies in chronic stroke. However, for clinical applications, the average of at least two trials may be required.
Rehabilitation clinicians' perspectives of reactive balance training
(2022-12) Jagroop, David; Houvardas, Stephanie; Danells, Cynthia J; Kochanowski, Jennifer; French, Esmé; Salbach, Nancy M; Musselman, Kristin; Inness, Elizabeth L; Mansfield, Avril
Purpose: Reactive balance training (RBT) aims to improve reactive balance control. However, because RBT involves clients losing balance, clinicians may view that it is unsafe or not feasible for some clients. We aimed to explore how clinicians implement RBT to treat balance and mobility issues. Materials and methods: Physiotherapists and kinesiologists across Canada who reported that they include RBT in their practices were invited to complete telephone interviews about their experiences with RBT. Interviews were transcribed verbatim, and analysed using a deductive thematic analysis. Results: Ten participants completed telephone interviews, which lasted between 30-60 min. Participants primarily worked in a hospital setting (inpatient rehabilitation (n = 3); outpatient rehabilitation (n = 2)), and were treated clients with neurological conditions (n = 5). Four main themes were identified: 1) there is variability in RBT approaches; 2) knowledge can be a barrier and facilitator to RBT; 3) reactive balance control is viewed as an advanced skill; and 4) RBT experience builds confidence. Conclusions: Our findings suggest a need for resources to make clinical implementation of RBT more feasible.
The Effect of Reactive Balance Training on Falls in Daily Life: An Updated Systematic Review and Meta-Analysis
(2022-11-09) Devasahayam, Augustine Joshua; Farwell, Kyle; Lim, Bohyung; Morton, Abigail; Fleming, Natalie; Jagroop, David; Aryan, Raabeae; Saumur, Tyler Mitchell; Mansfield, Avril
Objective: Reactive balance training is an emerging approach to reduce falls risk in people with balance impairments. The purpose of this study was to determine the effect of reactive balance training on falls in daily life among individuals at increased risk of falls, and to document associated adverse events. Data sources: Databases searched were Ovid MEDLINE (1946-March 2022), Embase Classic and Embase (1947-March 2022), Cochrane Central Register of Controlled Trials (2014-March 2022), Physiotherapy Evidence Database (PEDro; searched on 22 March 2022). Study selection: Randomized controlled trials of reactive balance training were included. The literature search was limited to English language. Records were screened by two investigators separately. Data extraction: Outcome measures were number of participants who reported falls after training, number of falls reported after training, and the nature, frequency, and severity of adverse events. Authors of included studies were contacted to obtain additional information. Data synthesis: Twenty-nine trials were included, of which 17 reported falls and 21 monitored adverse events. Participants assigned to reactive balance training groups were less likely to fall compared to control groups (fall risk ratio: 0.76, 95% confidence interval=[0.63, 0.92]; p=0.005, I2=32%) and reported fewer falls than control groups (rate ratio: 0.61, 95% confidence interval=[0.45, 0.83]; p=0.002, I2=81%). Prevalence of adverse events was higher in reactive balance training (29%) compared to control groups (20%; p=0.016). Conclusion: Reactive balance training reduces the likelihood of falls in daily life for older adults and people with balance impairments. More adverse events were reported for reactive balance training than control groups. Impact: Balance training that evokes balance reactions can reduce falls among people at increased risk of falls.
Spatial-temporal gait variability poststroke: variations in measurement and implications for measuring change
(2014-07) Chisholm, Amanda E; Makepeace, Shelley; Inness, Elizabeth L; Perry, Stephen D; McIlroy, William E; Mansfield, Avril
Objective: This study aims to determine the responsiveness to change of spatial-temporal gait parameters among stroke survivors for three different variability measures: SD, coefficient of variation (CV) and median absolute deviation (MAD). Design: Retrospective chart review. Setting: Clinical laboratory in a Canadian hospital. Interventions: Not applicable. Participants: Seventy-four stroke survivors receiving in-patient rehabilitation. Main Outcome Measures: Spatial-temporal gait variability was calculated for step length, step width, stance time, swing time and double support time. Responsiveness to change was determined by comparing trials: 1) without vs. with the addition of a concurrent cognitive task and 2) admission to discharge from rehabilitation. Results: Variability estimators (SD, CV and MAD) increased with addition of a cognitive task and decreased from admission to discharge of rehabilitation. However, these changes were not statistically significant when change in gait velocity was included as a covariate. The effect size values were similar for all variability estimators with a trend towards a greater SD response to temporal parameters. The CV displayed a larger response to change for step length compared to the SD and MAD. While gait variability decreased between admission and discharge, the effect size was larger for the condition without the cognitive task than the condition with the cognitive task. Conclusion: Our results show that gait variability estimators demonstrate a similar responsiveness to a concurrent cognitive task and improved walking ability with recovery from stroke. Future work may focus on evaluating the clinical utility of these measures in relation to informing therapy and response to gait specific training protocols.
Lower limb muscle activity underlying temporal gait asymmetry post-stroke
(2020-08-01) Rozanski, Gabriela M; Huntley, Andrew H; Crosby, Lucas D; Schinkel-Ivy, Alison; Mansfield, Avril; Patterson, Kara K
Objective: Asymmetric walking after stroke is common, detrimental, and difficult to treat, but current knowledge of underlying physiological mechanisms is limited. This study investigated electromyographic (EMG) features of temporal gait asymmetry (TGA). Methods: Participants post-stroke with or without TGA and control adults (n=27, 8, and 9, respectively) performed self-paced overground gait trials. EMG, force plate, and motion capture data were collected. Lower limb muscle activity was compared across groups and sides (more/less affected). Results: Significant group by side interaction effects were found: more affected plantarflexor stance activity ended early (p=.0006) and less affected dorsiflexor on/off time was delayed (p<.01) in persons with asymmetry compared to symmetric and normative controls. The TGA group exhibited fewer dorsiflexor bursts during swing (p=.0009). Conclusions: Temporal patterns of muscular activation, particularly about the ankle around the stance to-swing transition period, are associated with TGA. The results may reflect specific impairments or compensations that affect locomotor coordination. Significance: Neuromuscular underpinnings of spatiotemporal asymmetry have not been previously characterized. These novel findings may inform targeted therapeutic strategies to improve gait qualityafter stroke.
Test-retest reliability of force plate-derived measures of reactive stepping
(2021) Saumur, Tyler M; Mathur, Sunita; Nestico, Jacqueline; Perry, Stephen D; Mochizuki, George; Mansfield, Avril
Characterizing reactive stepping is important to describe the response's effectiveness. Timing of reactive step initiation, execution, and termination have been frequently reported to characterize reactive balance control. However, the test-retest reliabilities of these measures are unknown. Accordingly, the purpose of this study was to determine the between- and within-session test-retest reliabilities of various force plate-derived measures of reactive stepping. Nineteen young, healthy adults responded to 6 small (~8-10% of body weight) and 6 large perturbations (~13-15% of body weight) using an anterior lean-and-release system. Tests were conducted during two visits separated by at least two days. Participants were instructed to recover balance in as few steps as possible. Step onset, foot-off, swing, and restabilization times were extracted from force plates. Relative test-retest reliability was determined through intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs). Absolute test-retest reliability was assessed using the standard error of the measurement (SEM). Foot-off and swing times had the highest between- and within-session test-retest reliabilities regardless of perturbation size (between-session ICC = 0.898-0.942; within-session ICC = 0.455-0.753). Conversely, step onset and restabilization times had lower ICCs and wider CIs (between-session ICC = 0.495-0.825; within-session ICC = -0.040-0.174). Between-session test-retest reliability was higher (ICC = 0.495-0.942) for all measures than within-session test-retest reliability (ICC = -0.040-0.753). Time to restabilization had the highest SEM, indicating the worst absolute reliability of the measures. These findings suggest multiple baseline sessions are needed for measuring restabilization and step onset times. The minimal detectable changes reported provide an index for measuring meaningful change due to an intervention.
Publication rate and consistency of registered trials of motor-based stroke rehabilitation
(2021-03-30) Aryan, Raabeae; Jagroop, David; Danells, Cynthia J; Rozanski, Gabriela; Unger, Janelle; Huntley, Andrew H; Mansfield, Avril
Objective: To determine the publication rate of motor-rehabilitation trials post-stroke, and the consistency between registry records and their corresponding main publications in terms of trial design, primary objectives and outcomes, eligibility criteria, and sample size. Methods: We searched 18 clinical trial registries to identify randomized controlled trials of motor-based stroke rehabilitation registered after July 2005 and completed before April 2017. Eligible trials included adults with stroke, with at least one outcome measure related to motor function. Information in the registry records were compared with their main publications, if any. Results: 323 trials met our eligibility criteria; we were unable to find a peer-reviewed publication reporting the main findings for 46% (150/323) of these. Of the 169 trials with peer-reviewed papers published in English, 141 (83%) were consistent with the registry record in terms of trial design, 100 (59%) were consistent in primary objectives, 71 (42%) were consistent in primary outcomes, 28 (17%) were consistent in eligibility criteria, and 74 (44%) were consistent in sample size. Conclusions: Approximately half of motor-based stroke rehabilitation trials were not published, even more than three years after the end of the trial. When main publications were found, they substantially deviated from information in the registry record. These findings highlight the importance of trial registries for identifying unpublished stroke rehabilitation trials, and of searching trial registries when conducting systematic reviews and meta-analysis to help ensure that reviews are unbiased.
Does increased gait variability improve stability when faced with an expected balance perturbation during treadmill walking?
(2021-03-08) Nestico, Jacqueline; Novak, Alison; Perry, Stephen D; Mansfield, Avril
Background: Currently, there is uncertainty as to whether movement variability is errorful or exploratory. Research question: This study aimed to determine if gait variability represents exploration to improve stability. We hypothesized that 1) spatiotemporal gait features will be more variable prior to an expected perturbation than during unperturbed walking, and 2) increased spatiotemporal gait variability pre-perturbation will correlate with improved stability post-perturbation. Methods: Sixteen healthy young adults completed 15 treadmill walking trials within a motion simulator under two conditions: unperturbed and expecting a perturbation. Participants were instructed not to expect a perturbation for unperturbed trials, and to expect a single transient medio-lateral balance perturbation for perturbed trials. Kinematic data were collected during the trials. Twenty steps were recorded post-perturbation. Unperturbed and pre-perturbation gait variabilities were defined by the short- and long-term variabilities of step length, width, and time, using 100 steps from pre-perturbation and unperturbed trials. Paired t-tests identified between-condition differences in variabilities. Stability was defined as the number of steps to centre of mass restabilization post-perturbation. Multiple regression analyses determined the effect of pre-perturbation variability on stability. Results: Long-term step width variability was significantly higher pre-perturbation compared to unperturbed walking (mean difference=0.28cm, p=0.0073), with no significant differences between conditions for step length or time variabilities. There was no significant relationship between pre-perturbation variability and post-perturbation restabilization. Significance: Increased pre-perturbation step width variability was neither beneficial nor detrimental to stability. However, the increased variability in medio-lateral foot placement suggests that participants adopted an exploratory strategy in anticipation of a perturbation.
The effects of postural threat induced by a virtual environment on performance of a walking balance task
(2020-12) Boroomand-Tehrani, Amir; Huntley, Andrew H.; Jagroop, David; Campos, Jennifer L.; Patterson, Kara K.; Tremblay, Luc; Mansfield, Avril
Rapid motor learning may occur in situations where individuals perceive a threat if they do not perform a task well. This rapid motor learning may be facilitated by improved motor performance and, consequently, more errorless practice. As a first step towards understanding the role of perceived threat on rapid motor learning, the purpose of this study was to determine how performance of a motor task is affected in situations where perceived threat is high. We hypothesized that perceived threat in a virtual environment would result in improved performance of a walking task (i.e., walking on a narrow beam). Results demonstrated that increased perceived threat did not yield statistically significantly greater balance performance in the high-threat virtual environment (median percentage of successful steps: 78.8%, 48.3%, and 55.2% in the real low-threat, virtual low-threat, and virtual high-threat environments, respectively). These results may be partially attributed to habituation to threat over time and practice. If implemented carefully, virtual reality technology can be an effective tool for investigating walking balance in environments that are perceived as threatening.
Does the margin of stability measure predict medio-lateral stability of gait with a constrained-width base of support?
(2019-10-11) Gill, Lakshdeep; Huntley, Andrew H; Mansfield, Avril
This study aimed to determine the validity of the centre of mass position (COM) position and extrapolated COM (XCOM), relative to the base of support, for predicting medio-lateral stability during a walking task where the base of support width is limited. Nine young healthy participants walked on a narrow beam. Three-dimensional motion capture was used to calculate the COM and XCOM relative to the base of support. Steps were classified as having either the COM or XCOM inside or outside the base of support, and were classified as successful (stable - foot placed on the beam) or failed (unstable - foot stepped off the beam). If the COM or XCOM are valid measures of stability, they should be within the base of support for successful steps and outside the base of support for failed steps. Classifying the COM and XCOM inside or outside the base of support correctly predicted successful or failed steps in 69% and 58% of cases, respectively. When the COM or XCOM were outside the base of support, walking faster seemed to help participants to maintain stability. The further the COM or XCOM were outside the base of support during a successful step, the more likely participants were to fail on a subsequent step. The results of this study suggest that both COM and XCOM are valid measures of stability during a beam walking task, but that classifying COM and XCOM as inside or outside the base of support may be over-simplistic.
Longitudinal change in spatiotemporal gait symmetry after discharge from inpatient stroke rehabilitation
(2020-03) Rozanski, Gabriela M; Wong, Jennifer S; Inness, Elizabeth L; Patterson, Kara K; Mansfield, Avril
Purpose: To describe the change in spatiotemporal gait asymmetry after discharge from stroke rehabilitation and examine the relationship with change in other clinical outcome measures.Methods: Secondary analysis of a prospective cohort study was conducted. Swing time and step length symmetry, balance, mobility, gait speed, and motor impairment were assessed at discharge and 6 months later. Participants (n = 61) were classified by shift in symmetry status (Asymmetric-to-Symmetric, Symmetric-to-Asymmetric, No Shift) and magnitude of difference scores (Improved, Worse, No Difference). Correlations between change in spatiotemporal symmetry and the other clinical measures of physical status were calculated.Results: At discharge, 61% (37/61) and 36% (22/61) of participants were asymmetric in swing time and step length, respectively. Of this subgroup, 43% (16/37) and 50% (11/22) shifted to symmetric gait by follow-up. In contrast, only six individuals significantly improved in swing and/or step symmetry according to minimal detectable change. Change in spatiotemporal symmetry was not significantly correlated with change in the clinical outcome measures.Conclusions: Despite overall gains in physical function and decreased prevalence of asymmetry, most individuals with stroke do not improve in swing or step symmetry following discharge from rehabilitation. Further research is necessary to elucidate factors that affect recovery of gait quality.Implications for rehabilitationAsymmetric gait after stroke is a major concern for patients and their therapists but can be resistant to intervention.Spatiotemporal asymmetry persists for many individuals following discharge from hospital stay despite improvement in other gait-related measures.While the determinants of change remain unclear, gait quality should be specifically monitored and addressed to avoid long-term negative effects.
Improvements in balance reaction impairments following reactive balance training in individuals with sub-acute stroke: A prospective cohort study with historical control
(2019-11-19) Schinkel-Ivy, Alison; Huntley, Andrew H; Danells, Cynthia J; Inness, Elizabeth L; Mansfield, Avril
Background: Reactive balance training (RBT) has been previously found to reduce fall risk in individuals with sub-acute stroke; however, our understanding of the effects of RBT on specific balance impairments is lacking.Objective: To quantify changes in common balance reaction impairments in individuals with sub-acute stroke resulting from RBT, relative to traditional balance training, using a prospective cohort study design with a historical control group.Methods: Individuals with sub-acute stroke completed either RBT or traditional balance training as part of their routine care during physiotherapy in inpatient rehabilitation. Reactive balance control was assessed using lean-and-release perturbations pre-intervention, post-intervention, and 6-months post-intervention (follow-up). Individuals with impaired balance reactions (delayed foot-off times, slide steps, and/or a preference for stepping with the preferred limb) at the pre-intervention assessment were identified using video and force plate data. Outcome measures (foot-off times, frequency of trials with slide steps, and stepping with the preferred limb) from the RBT participants with impaired reactions were compared for each of the three assessments to the mean values for the participants with impaired reactions in the historical control group.Results: Improvements were observed in all outcome measures for the RBT participants between pre-intervention and post-intervention, and/or between post-intervention and follow-up. These improvements were generally equivalent to, if not better than, the improvements demonstrated by the historical control group.Conclusions: Findings further support the use of RBT for post-stroke inpatient rehabilitation, and provide insight into specific balance reaction impairments that are improved by RBT.
A survey of Canadian healthcare professionals’ practices regarding reactive balance training
(2019-08-12) Mansfield, Avril; Danells, Cynthia J.; Inness, Elizabeth L.; Musselman, Kristin; Salbach, Nancy M.
Background: Perturbation-based balance training (PBT) is a relatively new type of balance training that aims to improve control of reactions to a loss of balance. This study aimed to determine the prevalence of use of PBT in clinical practice, and the most significant barriers and facilitators to implementing PBT in practice. Methods: Healthcare professionals across Canada (primarily physiotherapists and kinesiologists) who provide balance training to individuals with balance impairments and/or increased fall risk completed a questionnaire that asked about knowledge and use of PBT in practice. Results: Overall, 76.3% of participants (299/392) reported that they had used PBT in their practices, with 22.4% (88/392) reporting regular PBT use. Lack of knowledge of PBT appeared to be the most significant barrier for those not currently using PBT in their practices, whereas individuals who were familiar with PBT and open to using it in practice experienced barriers related to training, knowledge, human resources, client characteristics, and the practice setting. More than 90% of respondents were interested in learning more about almost all aspects of PBT. Conclusions: These findings could be used to inform development of future educational strategies to increase uptake of PBT in rehabilitation practice.
Postural orientation with conflicting visual and graviceptive cues to ‘upright’ among individuals with and without a history of post-stroke ‘pushing’
(Hippocampus Verlag, 2019-05) Mansfield, Avril; Taati, Babak; Danells, Cynthia J.; Fraser, Lindsey E.; Harris, Laurence R.; Campos, Jennifer L.
Purpose: This study aimed to determine how people with stroke, with and without pushing behaviour, use sensory cues to control postural orientation. Methods: Eight people with chronic stroke (4 with history of pushing behaviour), 5 people with sub-acute stroke (1 with active pushing behaviour) and 8 similarly-aged controls with no history of stroke participated. Participants sat in a motion platform while viewing a 240-degree screen upon which a city street scene was projected. Postural orientation (shoulder and trunk angles) was measured relative to the direction of gravity during 6 trials: visual scene tilted 18-degrees left and right; motion base tilted 18-degrees left and right; and both visual scene and motion base tilted 18-degrees left and right. Results: Participants with stroke did not appear to adjust their posture in response to visual scene tilt to a greater extent than control participants. For most conditions, chronic stroke participants with a history of pushing behaviour oriented their posture more towards the contralesional side than controls. When the motion base was tilted, sub-acute participants with no evidence of pushing behaviour oriented their posture more in the direction of motion base tilt than controls (e.g., when the motion base tilted to their ipsilesional sides, their trunks and shoulders were oriented to the ipsilesional side). Conclusion: This study did not find evidence that people with stroke with and without a history of pushing behaviour rely more on static visual cues to control postural orientation than people without stroke.
Does Perturbation-Based Balance Training Improve Control of Reactive Stepping in Individuals with Chronic Stroke?
(2019-01-07) Schinkel-Ivy, Alison; Huntley, Andrew H; Aqui, Anthony; Mansfield, Avril
Background: Although perturbation-based balance training (PBT) may be effective in improving reactive balance control and/or reducing fall risk in individuals with stroke, the characteristics of reactive balance responses that improve following PBT have not yet been identified. This study aimed to determine if reactive stepping characteristics and timing in response to support-surface perturbations improved to a greater extent following perturbation-based balance training, compared to traditional balance training. Materials and methods: This study represents a sub-study of a multisite randomized controlled trial. Sixteen individuals with chronic stroke were randomly assigned to either perturbation-based or traditional balance training, and underwent 6-weeks of training as a part of the randomized controlled trial. Responses to support-surface perturbation were evaluated pre- and post-training, and 6-months post-training. Reactive stepping characteristics and timing were compared between sessions within each group, and between groups at post-training and 6-months post-training while controlling for each measure at the pre-training session. Results: The frequency of extra steps in response to perturbations decreased from pre-training to post-training for the PBT group, but not for the control group. Conclusions: Improvements in reactive balance control were identified after PBT in individuals with chronic stroke. Findings provide insight into the mechanism by which PBT improves reactive balance control post-stroke, and support the use of PBT in balance rehabilitation programs post-stroke.
Visual feedback of the centre of gravity to optimize standing balance
(2015-02) Lakhani, Bimal; Mansfield, Avril
Force platform biofeedback training, whereby concurrent visual feedback of the centre of pressure (COP) is provided, has previously been used for balance training. Since the goal of balance is to maintain control of the centre of gravity (COG), specific feedback of the COG may be more likely than COP feedback to improve overall balance control. The purpose of this study was to compare the effect of concurrent visual feedback of the COP versus COG on postural control during a novel quiet standing task. Thirty-two young healthy adults (20-35 years old) were recruited. Participants were randomly assigned to receive concurrent visual feedback of either the COP or COG while standing on a foam pad. Training occurred over one session (20-30-second trials). Retention and transfer testing (i.e. without concurrent visual feedback) occurred after ∼24h. Variability of the COG decreased, variability of COP-COG increased, and sample entropy increased with concurrent visual feedback. With practice, variability of COP, COG and COP-COG decreased whereas sample entropy increased. The decrease in variability of COP-COG was greater for those who received COG feedback than those who received COP feedback. Training effects on COP, COG and COP-COG variability were not retained after 24h and removal of visual feedback. However, on retention and transfer testing, sample entropy was significantly higher than on baseline testing, indicating more 'automatic' postural control. These results suggest that concurrent visual feedback of neither the COP nor COG is superior for improving quiet standing balance control.
Does participation in standardized aerobic fitness training during inpatient stroke rehabilitation promote engagement in aerobic exercise after discharge? A cohort study
(2014) Brown, Christiane; Fraser, Julia E; Inness, Elizabeth L; Wong, Jennifer S; Middleton, Laura E; Poon, Vivien; McIlroy, William E; Mansfield, Avril
Objective: To determine if attending an aerobic fitness program during in-patient stroke rehabilitation is associated with increased participation in physical activity after discharge. Design: This was a prospective cohort study. Patients who received in-patient stroke rehabilitation and were discharged into the community (n=61; mean age=65) were recruited. 35 participants attended a standardized aerobic fitness program during in-patient rehabilitation, whereas 26 did not. The Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) and adherence to the American College of Sports Medicine (ACSM) guidelines were assessed up to six months post-discharge. Results: Subjects in the fitness group had similar PASIPD scores and adherence to ACSM guidelines to the non-fitness group up to six months post-discharge. There was no significant correlation between volume of exercise performed during the in-patient program and amount of physical activity post-discharge. Conclusion: Participation in an in-patient fitness program did not increase participation in physical activity post-discharge in individuals with stroke. A new model of care that encourages patients to pursue physical activity post-discharge and reduces the potential barriers to participation should be developed.
Inter- and intra-rater reliability of the GAITRite system among individuals with sub-acute stroke
(2014-05) Wong, Jennifer S; Jasani, Hardika; Poon, Vivien; Inness, Elizabeth L; McIlroy, William E; Mansfield, Avril
Technology-based assessment tools with semi-automated processing, such as pressure-sensitive mats used for gait assessment, may be considered to be objective; therefore it may be assumed that rater reliability is not a concern. However, user input is often required and rater reliability must be determined. The purpose of this study was to assess the inter- and intra-rater reliability of spatial and temporal characteristics of gait in stroke patients using the GAITRite system. Forty-six individuals with stroke attending in-patient rehabilitation walked across the pressure-sensitive mat 2-4 times at preferred walking speeds, with or without a gait aid. Five raters independently processed gait data. Three raters re-processed the data after a delay of at least one month. The intraclass correlation coefficients (ICC) and 95% confidence intervals of the ICC were determined for velocity, step time, step length, and step width. Inter-rater reliability for velocity, step time, and step length were high (ICC>0.90). Intra-rater reliability was generally greater than inter-rater reliability (from 0.81 to >0.99 for inter-rater versus 0.77 to >0.99 for intra-rater reliability). Overall, this study suggests that GAITRite is a reliable assessment tool; however, there still remains subjectivity in processing the data, resulting in no patients with perfect agreement between raters. Additional logic checking within the processing software or standardization of training could help to reduce potential errors in processing.
Relationship between asymmetry of quiet standing balance control and walking post-stroke
(2014-01) Hendrickson, Janna; Patterson, Kara K; Inness, Elizabeth L; McIlroy, William E; Mansfield, Avril
Spatial and temporal gait asymmetry is common after stroke. Such asymmetric gait is inefficient, can contribute to instability and may lead to musculoskeletal injury. However, understanding of the determinants of such gait asymmetry remains incomplete. The current study is focused on revealing if there is a link between asymmetry during the control of standing balance and asymmetry during walking. This study involved review of data from 94 individuals with stroke referred to a gait and balance clinic. Participants completed three tests: (1) walking at their usual pace; (2) quiet standing; and (3) standing with maximal loading of the paretic side. A pressure sensitive mat recorded placement and timing of each footfall during walking. Standing tests were completed on two force plates to evaluate symmetry of weight bearing and contribution of each limb to balance control. Multiple regression was conducted to determine the relationships between symmetry during standing and swing time, stance time, and step length symmetry during walking. Symmetry of antero-posterior balance control and weight bearing were related to swing time and step length symmetry during walking. Weight-bearing symmetry, weight-bearing capacity, and symmetry of antero-posterior balance control were related to stance time symmetry. These associations were independent of underlying lower limb impairment. The results support the hypothesis that impaired ability of the paretic limb to control balance may contribute to gait asymmetry post-stroke. Such work suggests that rehabilitation strategies that increase the contribution of the paretic limb to standing balance control may increase symmetry of walking post-stroke.

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