Noninvasive spinal stimulation improves walking in chronic stroke survivors: a proof-of-concept case series.

BACKGROUND: After stroke, restoring safe, independent, and efficient walking is a top rehabilitation priority. However, in nearly 70% of stroke survivors asymmetrical walking patterns and reduced walking speed persist. This case series study aims to investigate the effectiveness of transcutaneous spinal cord stimulation (tSCS) in enhancing walking ability of persons with chronic stroke. METHODS: Eight participants with hemiparesis after a single, chronic stroke were enrolled. Each participant was assigned to either the Stim group (N = 4, gait training + tSCS) or Control group (N = 4, gait training alone). Each participant in the Stim group was matched to a participant in the Control group based on age, time since stroke, and self-selected gait speed. For the Stim group, tSCS was delivered during gait training via electrodes placed on the skin between the spinous processes of C5-C6, T11-T12, and L1-L2. Both groups received 24 sessions of gait training over 8 weeks with a physical therapist providing verbal cueing for improved gait symmetry. Gait speed (measured from 10 m walk test), endurance (measured from 6 min walk test), spatiotemporal gait symmetries (step length and swing time), as well as the neurophysiological outcomes (muscle synergy, resting motor thresholds via spinal motor evoked responses) were collected without tSCS at baseline, completion, and 3 month follow-up. RESULTS: All four Stim participants sustained spatiotemporal symmetry improvements at the 3 month follow-up (step length: 17.7%, swing time: 10.1%) compared to the Control group (step length: 1.1%, swing time 3.6%). Additionally, 3 of 4 Stim participants showed increased number of muscle synergies and/or lowered resting motor thresholds compared to the Control group. CONCLUSIONS: This study provides promising preliminary evidence that using tSCS as a therapeutic catalyst to gait training may increase the efficacy of gait rehabilitation in individuals with chronic stroke. Trial registration NCT03714282 (clinicaltrials.gov), registration date: 2018-10-18.

Perspectives on factors influencing quality of life in persons with long-term spinal cord injury: a qualitative study.

STUDY DESIGN: Qualitative Cohort Study. OBJECTIVES: Many people with long-term spinal cord injury (SCI) develop adaptation strategies to succeed. Understanding the factors that support their capacity to adapt and develop is important to enhance quality of life of others with SCI. This study aims to learn how these factors influence how people with SCI attain and maintain optimal quality of life as time since injury grows. SETTING: IL, USA. METHODS: A qualitative approach using one-on-one structured interviews with 16 individuals with long-term SCI was used to elicit perspectives of topics of importance. Analysis of these topics was done for the entire group, and for subgroups based on injury duration, i.e., 1-5 years, 5-15 years, and 15+ years post-injury. Deductive and inductive analyses of transcripts were performed. RESULTS: Five important themes emerged: 1. Injury, Medical Care, and Rehabilitation; 2. Built Environment and Accessibility; 3. Relationships and Support Systems; 4. Intrapersonal Thoughts and Emotions; and 5. Handling Challenges and Adversity. Topics of importance evolved over time. Most important were: 1-5 years: injury and recovery process; 5-15 years: navigating the community and how to handle difficult situations; and 15+ years: self-reflection and understanding how to handle challenges positively. CONCLUSIONS: Recognition of the factors (e.g. resilience, self-acceptance, built environment) that contribute to quality of life in people with SCI, and their prevalence over time, enables development of strategies to facilitate personal fulfillment and favorable adaptation at each stage. TRIAL REGISTRATION: This trial was posted on clinicaltrials.gov under NCT04544761.

Overground walking with a constraint force on the nonparetic leg during swing improves weight shift toward the paretic side in people after stroke.

Targeting enhancing the use of the paretic leg during locomotor practice might improve motor function of the paretic leg. The purpose of this study was to determine whether application of constraint force to the nonparetic leg in the posterior direction during overground walking would enhance the use of the paretic leg in people with chronic stroke. Fifteen individuals after stroke participated in two experimental conditions, i.e., overground walking with a constraint force applied to the nonparetic leg and overground walking only. Each participant was tested in the following procedures that consisted of overground walking with either constraint force or no constraint force, instrumented split-belt treadmill walking, and pressure-sensitive gait mat walking before and after the overground walking. Overground walking practice with constraint force resulted in greater enhancement in lateral weight shift toward the paretic side (P < 0.01), muscle activity of the paretic hip abductors (P = 0.04), and propulsion force of the paretic leg (P = 0.05) compared with the results of the no-constraint condition. Overground walking practice with constraint force tended to induce greater increase in self-selected overground walking speed (P = 0.06) compared with the effect of the no-constraint condition. The increase in propulsion force from the paretic leg was positively correlated with the increase in self-selected walking speed (r = 0.6, P = 0.03). Overground walking with constraint force applied to the nonparetic leg during swing phase of gait may enhance use of the paretic leg, improve weight shifting toward the paretic side and propulsion of the paretic leg, and consequently increase walking speed.NEW & NOTEWORTHY Application of constraint force to the nonparetic leg during overground walking induced improved lateral weight shifts toward the paretic leg and enhanced muscle activity of the paretic leg during walking. In addition, one session of overground walking with constraint force might induce an increase in propulsive force of the paretic leg and an increase in self-selected overground walking speed, which might be partially due to the improvement in motor control of the paretic leg.

Enhanced phasic sensory afferents paired with controlled constraint force improve weight shift toward the paretic side in individuals post-stroke.

PURPOSE: The goal of this study was to determine whether enhanced phasic sensory afferent input paired with the application of controlled constraint force during walking would improve weight shift toward the paretic side and enhance use of the paretic leg. METHODS: Fourteen stroke survivors participated in two experimental conditions, sessions that consisted of 1 min treadmill walking without force and stimulation (baseline), 7 min walking with either "constraint force and sensory stimulation (constraint+stim)" or "constraint force only (constraint)" (adaptation), and then 2 min walking without force and stimulation (post-adaptation). Kinematics of the pelvis and legs, and muscle activity of the paretic leg were recorded. RESULTS: Participants showed greater increases in hip abductor (p < 0.001) and adductor (p = 0.04) muscle activities, weight shift toward the paretic side (p = 0.002), and step length symmetry (p < 0.01) during the late post-adaptation period in the "constraint+stim" condition, compared with the effect of the "constraint" condition. In addition, changes in overground walking speed from baseline to 10 min post treadmill walking was significantly greater for the "constraint force and stimulation" condition than for the "constraint force only" condition (p = 0.04). CONCLUSION: Enhanced targeted sensory afferent input during locomotor training may facilitate recruitment of targeted muscles of the paretic leg and facilitate use-dependent motor learning of locomotor tasks, which might retain longer and partially transfer from treadmill to overground walking, in stroke survivors.

Repeated adaptation and de-adaptation to the pelvis resistance force facilitate retention of motor learning in stroke survivors.

Locomotor adaptation to novel walking patterns induced by external perturbation has been tested to enhance motor learning for improving gait parameters in individuals poststroke. However, little is known regarding whether repeated adaptation and de-adaptation to the externally perturbed walking pattern may facilitate or degrade the retention of locomotor learning. In this study, we examined whether the intermittent adaptation to novel walking patterns elicited by external perturbation induces greater retention of the adapted locomotion in stroke survivors, compared with effects of the continuous adaptation. Fifteen individuals poststroke participated in two experimental conditions consisting of 1) treadmill walking with intermittent (i.e., interspersed 2 intervals of no perturbation) or continuous (no interval) adaptation to externally perturbed walking patterns and 2) overground walking before, immediately, and 10 min after treadmill walking. During the treadmill walking, we applied a laterally pulling force to the pelvis toward the nonparetic side during the stance phase of the paretic leg to disturb weight shifts toward the paretic side. Participants showed improved weight shift toward the paretic side and enhanced muscle activation of hip abductor/adductors immediately after the removal of the pelvis perturbation for both intermittent and continuous conditions (P < 0.05) and showed longer retention of the improved weight shift and enhanced muscle activation for the intermittent condition, which transferred from treadmill to overground walking (P < 0.05). In conclusion, repeated motor adaptation and de-adaptation to the pelvis resistance force during walking may promote the retention of error-based motor learning for improving weight shift toward the paretic side in individuals poststroke.NEW & NOTEWORTHY We examined whether the intermittent versus the continuous adaptation to external perturbation induces greater retention of the adapted locomotion in stroke survivors. We found that participants showed longer retention of the improved weight shift and enhanced muscle activation for the intermittent versus the continuous conditions, suggesting that repeated motor adaptation and de-adaptation to the pelvis perturbation may promote the retention of error-based motor learning for improving weight shift toward the paretic side in individuals poststroke.

The Value of Rehabilitation Interventions-Integrating Evidence, Clinical Expertise, Critical Assessment, and Patient Needs: A Conference Report.

To understand issues related to the value, outcomes, and cost-effectiveness of rehabilitation interventions, and to explore how scientific evidence, clinical expertise, and patient needs can be integrated, the Rehabilitation Research and Training Center on Developing Optimal Strategies in Exercise and Survival Skills to Increase Health and Function held a State of the Science Symposium on "The Value of Rehabilitation Interventions" at Shirley Ryan AbilityLab in Chicago in 2017. During this conference, 35 invited experts, including individuals with disabilities, professionals, and consumers, explored the topic of the "value" of rehabilitation interventions and discussed their perspectives on the means to integrate best scientific evidence with clinical expertise and patient preferences. This symposium also resulted in the production of several multifaceted articles providing perspectives on the topic of value and how to use evidence to best determine and demonstrate it. These articles comprise this supplement. The present article introduces the key concepts of value, evidence, and knowledge translation in an effort to provide a context for the articles that follow in the supplement.

Clinical Performance Measures for Stroke Rehabilitation: Performance Measures From the American Heart Association/American Stroke Association.

The American Heart Association/American Stroke Association released the adult stroke rehabilitation and recovery guidelines in 2016. A working group of stroke rehabilitation experts reviewed these guidelines and identified a subset of recommendations that were deemed suitable for creating performance measures. These 13 performance measures are reported here and contain inclusion and exclusion criteria to allow calculation of rates of compliance in a variety of settings ranging from acute hospital care to postacute care and care in the home and outpatient setting.

Increased motor variability facilitates motor learning in weight shift toward the paretic side during walking in individuals post-stroke.

The purpose of this study was to determine whether applying "varied" versus constant pelvis assistance force mediolaterally toward the paretic side of stroke survivors during walking would result in short-term improvement in weight shift toward the paretic side. Twelve individuals post-stroke (60.4 ± 6.2 years; gait speed: 0.53 ± 0.19 m/s) were tested under two conditions (varied vs. constant). Each condition was conducted in a single separate session, which consisted of (a) treadmill walking with no assistance force for 1 min (baseline), pelvis assistance toward the paretic side for 9 min (adaptation), and then no force for additional 1 min (post-adaptation), and (b) overground walking. In the "varied" condition, the magnitude of force was randomly changed across steps between 30% and 100% of the predetermined amount. In the abrupt condition, the magnitude of force was kept constant at 100% of the predetermined amount. Participants exhibited greater improvements in weight shift toward the paretic side (p < 0.01) and in muscle activity of plantar flexors and hip adductors of the paretic leg (p = 0.02) from baseline to late post-adaptation period for the varied condition than for the constant condition. Motor variability of the peak pelvis displacement at baseline was correlated with improvement in weight shift toward the paretic side after training for the varied (R2  = 0.64, p = 0.01) and the constant condition (R2  = 0.39, p = 0.03). These findings suggest that increased motor variability, induced by applying the varied pelvis assistance, may facilitate motor learning in weight shift and gait symmetry during walking in individuals post-stroke.

Gradual adaptation to pelvis perturbation during walking reinforces motor learning of weight shift toward the paretic side in individuals post-stroke.

The purpose of this study was to determine whether the gradual versus abrupt adaptation to lateral pelvis assistance force improves weight shift toward the paretic side and enhance forced use of the paretic leg during walking. Sixteen individuals who had sustained a hemispheric stroke participated in two experimental sessions, which consisted of (1) treadmill walking with the application of lateral pelvis assistance force (gradual vs. abrupt condition) and (2) overground walking. In the "gradual" condition, during treadmill walking, the assistance force was gradually increased from 0 to 100% of the predetermined force step by step. In the abrupt condition, the force was applied at 100% of the predetermined force throughout treadmill walking. Participants exhibited significant improvements in hip abductor and adductor, ankle dorsiflexor, and knee extensor muscle activities, weight shift toward the paretic side, and overground walking speed in the gradual condition (P < 0.05), but showed no significant changes in the abrupt condition (P > 0.20). Changes in weight shift toward the paretic side were statistically different between conditions (P < 0.001), although changes in muscle activities were not (P > 0.11). In the gradual condition, the error amplitude was proportional to the improvement in weight shift during the late post-adaptation (R2 = 0.32, P = 0.03), but not in the abrupt condition (R2 = 0.001, P = 0.93). In conclusion, the "gradual adaptation" inducing "small errors" during constraint-induced walking may improve weight shift and enhance forced use of the paretic leg in individuals post-stroke. Applying gradual pelvis assistance force during walking may be used as an intervention strategy to improve walking in individuals post-stroke.

Enhanced error facilitates motor learning in weight shift and increases use of the paretic leg during walking at chronic stage after stroke.

The purpose of this study was to determine whether the application of lateral pelvis pulling force toward the non-paretic side during the stance phase of the paretic leg would enhance forced use of the paretic leg and increase weight shift toward the paretic side in stroke survivors. Eleven chronic stroke survivors participated in two experimental sessions, which consisted of (1) treadmill walking with the application of "pelvis resistance" or "pelvis assistance" and (2) overground walking. During the treadmill walking, the laterally pulling force was applied during the stance phase of the paretic leg toward the non-paretic side for the "pelvis resistance" condition or toward the paretic side for the "pelvis assistance" condition during the stance phase of the paretic leg. After force release, the "pelvis resistance" condition exhibited greater enhancement in muscle activation of hip ABD, ADD, and SOL and greater improvement in lateral weight shift toward the paretic side, compared with the effect of the "pelvis assistance" condition (P < 0.03). This improved lateral weight shift was associated with the enhanced muscle activation of hip ABD and ADD (R2 = 0.67, P = 0.01). The pelvis resistance condition also improved overground walking speed and stance phase symmetry when measured 10 min after the treadmill walking (P = 0.004). In conclusion, applying pelvis resistance forces to increase error signals may facilitate motor learning of weight shift toward the paretic side and enhance use of the paretic leg in chronic stroke survivors. Results from this study may be utilized to develop an intervention approach to improve walking in stroke survivors.

Stepwise Regression and Latent Profile Analyses of Locomotor Outcomes Poststroke.

BACKGROUND AND PURPOSE: Previous data suggest patient demographics and clinical presentation are primary predictors of motor recovery poststroke, with minimal contributions of physical interventions. Other studies indicate consistent associations between the amount and intensity of stepping practice with locomotor outcomes. The goal of this study was to determine the relative contributions of these combined variables to locomotor outcomes poststroke across a range of patient demographics and baseline function. METHODS: Data were pooled from 3 separate trials evaluating the efficacy of high-intensity training, low-intensity training, and conventional interventions. Demographics, clinical characteristics, and training activities from 144 participants >1-month poststroke were included in stepwise regression analyses to determine their relative contributions to locomotor outcomes. Subsequent latent profile analyses evaluated differences in classes of participants based on their responses to interventions. RESULTS: Stepwise regressions indicate primary contributions of stepping activity on locomotor outcomes, with additional influences of age, duration poststroke, and baseline function. Latent profile analyses revealed 2 main classes of outcomes, with the largest gains in those who received high-intensity training and achieved the greatest amounts of stepping practice. Regression and latent profile analyses of only high-intensity training participants indicated age, baseline function, and training activities were primary determinants of locomotor gains. Participants with the smallest gains were older (≈60 years), presented with slower gait speeds (<0.40 m/s), and performed 600 to 1000 less steps/session. CONCLUSIONS: Regression and cluster analyses reveal primary contributions of training interventions on mobility outcomes in patients >1-month poststroke. Age, duration poststroke, and baseline impairments were secondary predictors. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466 and NCT01789853.

Survivors of Chronic Stroke Experience Continued Impairment of Dexterity But Not Strength in the Nonparetic Upper Limb.

OBJECTIVE: To investigate the performance of the less affected upper limb in people with stroke compared with normative values. To examine less affected upper limb function in those whose prestroke dominant limb became paretic and those whose prestroke nondominant limb became paretic. DESIGN: Cohort study of survivors of chronic stroke (7.2±6.7y post incident). SETTING: The study was performed at a freestanding academic rehabilitation hospital. PARTICIPANTS: Survivors of chronic stroke (N=40) with severe hand impairment (Chedoke-McMaster Stroke Assessment rating of 2-3 on Stage of Hand) participated in the study. In 20 participants the prestroke dominant hand (DH) was tested (nondominant hand [NH] affected by stroke), and in 20 participants the prestroke NH was tested (DH affected by stroke). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Jebsen-Taylor Hand Function Test. Data from survivors of stroke were compared with normative age- and sex-matched data from neurologically intact individuals. RESULTS: When combined, DH and NH groups performed significantly worse on fine motor tasks with their nonparetic hand relative to normative data (P<.007 for all measures). Even the participants who continued to use their prestroke DH as their primary hand after the stroke demonstrated reduced fine motor skills compared with normative data. In contrast, grip strength was not significantly affected in either group of survivors of stroke (P>.140). CONCLUSIONS: Survivors of stroke with severe impairment of the paretic limb continue to present significant upper extremity impairment in their nominally nonparetic limb even years after stroke. This phenomenon was observed regardless of whether the DH or NH hand was primarily affected. Because this group of survivors of stroke is especially dependent on the nonparetic limb for performing functional tasks, our results suggest that the nonparetic upper limb should be targeted for rehabilitation.

Contributions of Stepping Intensity and Variability to Mobility in Individuals Poststroke.

Background and Purpose- The amount of task-specific stepping practice provided during rehabilitation poststroke can influence locomotor recovery and reflects one aspect of exercise dose that can affect the efficacy of specific interventions. Emerging data suggest that markedly increasing the intensity and variability of stepping practice may also be critical, although such strategies are discouraged during traditional rehabilitation. The goal of this study was to determine the individual and combined contributions of intensity and variability of stepping practice to improving walking speed and distance in individuals poststroke. Methods- This phase 2, randomized, blinded assessor clinical trial was performed between May 2015 and November 2018. Individuals between 18 and 85 years old with hemiparesis poststroke of >6 months duration were recruited. Of the 152 individuals screened, 97 were randomly assigned to 1 of 3 training groups, with 90 completing >10 sessions. Interventions consisted of either high-intensity stepping (70%-80% heart rate reserve) of variable, difficult stepping tasks (high variable), high-intensity stepping performing only forward walking (high forward), and low-intensity stepping in variable contexts at 30% to 40% heart rate reserve (low variable). Participants received up to 30 sessions over 2 months, with testing at baseline, post-training, and a 3-month follow-up. Primary outcomes included walking speeds and timed distance, with secondary measures of dynamic balance, transfers, spatiotemporal kinematics, and metabolic measures. Results- All walking gains were significantly greater following either high-intensity group versus low-variable training (all P<0.001) with significant correlations with stepping amount and rate (r=0.48-60; P<0.01). Additional gains in spatiotemporal symmetry were observed with high-intensity training, and balance confidence increased only following high-variable training in individuals with severe impairments. Conclusions- High-intensity stepping training resulted in greater improvements in walking ability and gait symmetry than low-intensity training in individuals with chronic stroke, with potential greater improvements in balance confidence. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT02507466.

Development of the TBI-QOL Headache Pain Item Bank and Short Form.

OBJECTIVE: To develop, calibrate, and evaluate the test-retest reliability of a new patient-reported outcome measure of headache pain relevant for individuals with traumatic brain injury (TBI). SETTING: Six TBI Model Systems rehabilitation centers in the United States. PARTICIPANTS: Adults with medically confirmed documentation of TBI. DESIGN: Cross-sectional calibration field testing and test-retest reliability analyses. MAIN MEASURES: Traumatic Brain Injury-Quality of Life Headache Pain item bank. RESULTS: Thirteen headache pain items were calibrated as a unidimensional measure using data from 590 participants. The new measure was reliable (α = .98; item-total correlation range: 0.71-0.91). Item parameter estimates were estimated using Samejima's Graded Response Model and a 10-item calibrated short form was created. Simulation testing confirmed that both the computer-adaptive test and the short-form administrations were equivalent to the full item bank. One- to-2-week test-retest reliability of the computer-adaptive test was high (Pearson r and intraclass correlation coefficients = 0.81). Approximately two-thirds of the sample reported at least 1 headache symptom. CONCLUSION: The Traumatic Brain Injury-Quality of Life Headache Pain item bank and short form provide researchers and clinicians with reliable measures of the subjective experience of headache symptoms for individuals with a history of TBI.

Walking and balance outcomes for stroke survivors: a randomized clinical trial comparing body-weight-supported treadmill training with versus without challenging mobility skills.

BACKGROUND: Treadmill training, with or without body-weight support (BWSTT), typically involves high step count, faster walking speed, and higher heart-rate intensity than overground walking training. The addition of challenging mobility skill practice may offer increased opportunities to improve walking and balance skills. Here we compare walking and balance outcomes of chronic stroke survivors performing BWSTT with BWSTT including challenging mobility skills. METHODS: Single-blind randomized clinical trial comparing two BWSTT interventions performed in a rehabilitation research laboratory facility over 6 weeks. Participants were 18+ years of age with chronic (≥5 months) poststroke hemiparesis due to a cortical or subcortical ischemic or hemorrhagic stroke and walking speeds < 1.1 m/s at baseline. A hands-free group (HF; n = 15) performed BWSTT without assistance from handrails or assistive devices, and a hands-free plus challenge group (HF + C; n = 14) performed the same protocol while additionally practicing challenging mobility skills. The primary outcome was change in comfortable walking speed (CWS), with secondary outcomes of fast walk speed (FWS), six-minute walk distance, Berg Balance Scale (BBS) scores, and Activities Specific Balance Confidence (ABC) scores. RESULTS: Significant pre-post improvement of CWS (Z = - 4.2, p ≤ 0.0001) from a median of 0.35 m/s (range 0.10 to 1.09) to a median of 0.54 m/s (range 0.1 to 1.17), but no difference observed between groups (U = 96.0, p = 0.69). Pre-post improvements across all participants resulted in reclassified baseline ambulation status from sixteen to ten household ambulators, three to seven limited community ambulators, and ten to twelve community ambulators. Secondary outcomes showed similar pre-post improvements with no between-group differences. CONCLUSIONS: The addition of challenging mobility skills to a hands-free BWSTT protocol did not lead to greater improvements in CWS following 6 weeks of training. One reason for lack of group differences may be that both groups were adequately challenged by walking in an active, self-driven treadmill environment without use of handrails or assistive devices. TRIAL REGISTRATION: NCT02787759 Falls-based Training for Walking Post-Stroke (FBT); retrospectively registered June 1st, 2016.

Risk Factors for Institutionalization After Traumatic Brain Injury Inpatient Rehabilitation.

OBJECTIVE: To create a profile of individuals with traumatic brain injury (TBI) who received inpatient rehabilitation and were discharged to an institutional setting using characteristics measured at rehabilitation discharge. METHODS: The Traumatic Brain Injury Model Systems National Database is a prospective, multicenter, longitudinal database for people with moderate to severe TBI. We analyzed data for participants enrolled from January 2002 to June 2012 who had lived in a private residence before TBI. This cross-sectional study used logistic regression analyses to identify sociodemographic factors, lengths of stay, and cognitive and physical functioning levels that differentiated patients discharged to institutional versus private settings. RESULTS: Older age, living alone before TBI, and lower levels of function at rehabilitation discharge (independence in locomotion, bladder management, comprehension, and social interaction) were significantly associated with higher institutionalization rates and provided the best models identifying factors associated with institutionalization. Institutionalization was also associated with decreased independence in bed-chair-wheelchair transfers and increased duration of posttraumatic amnesia. CONCLUSIONS: Individuals institutionalized after inpatient rehabilitation for TBI were older, lived alone before injury, had longer posttraumatic amnesia durations, and were less independent in specific functional characteristics. Research evaluating the effect of increasing postdischarge support and improving treatment effectiveness in these functional areas is recommended.

Influence of skill and exercise training parameters on locomotor recovery during stroke rehabilitation.

PURPOSE OF REVIEW: Research findings from the fields of motor learning and exercise physiology suggest specific training parameters that can be manipulated during physical rehabilitation profoundly influence skilled task performance. This review details the rationale for some of these training variables and their application in selected intervention studies focused on improving walking function in patients poststroke. RECENT FINDINGS: Basic and applied studies have shown that the amount, intensity, and variability of specific task practice applied during rehabilitation interventions can affect recovery of walking poststroke. Many studies detailing the effects of conventional, therapist, and mechanically assisted interventions may incorporate some of these training parameters but minimize others, and their relative contributions may influence walking outcomes. Specific patient factors, such as the stroke acuity and degree of impairments, appear to influence the relative contributions of these training variables, and different patient subgroups may benefit from greater emphasis on specific parameters. SUMMARY: The present findings suggest these training parameters should be considered when evaluating or implementing physical interventions directed toward improving locomotor function poststroke. More work is needed to understand their optimal combinations to maximize walking outcomes in patients with different levels of impairment poststroke.

Alterations in Aerobic Exercise Performance and Gait Economy Following High-Intensity Dynamic Stepping Training in Persons With Subacute Stroke.

BACKGROUND AND PURPOSE: Impairments in metabolic capacity and economy (O2cost) are hallmark characteristics of locomotor dysfunction following stroke. High-intensity (aerobic) training has been shown to improve peak oxygen consumption in this population, with fewer reports of changes in O2cost. However, particularly in persons with subacute stroke, inconsistent gains in walking function are observed with minimal associations with gains in metabolic parameters. The purpose of this study was to evaluate changes in aerobic exercise performance in participants with subacute stroke following high-intensity variable stepping training as compared with conventional therapy. METHODS: A secondary analysis was performed on data from a randomized controlled trial comparing high-intensity training with conventional interventions, and from the pilot study that formed the basis for the randomized controlled trial. Participants 1 to 6 months poststroke received 40 or fewer sessions of high-intensity variable stepping training (n = 21) or conventional interventions (n = 12). Assessments were performed at baseline (BSL), posttraining, and 2- to 3-month follow-up and included changes in submaximal (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2submax) and O2cost at fastest possible treadmill speeds and peak speeds at BSL testing. RESULTS: Significant improvements were observed in (Equation is included in full-text article.)O2submax with less consistent improvements in O2cost, although individual responses varied substantially. Combined changes in both (Equation is included in full-text article.)O2submax and (Equation is included in full-text article.)O2 at matched peak BSL speeds revealed stronger correlations to improvements in walking function as compared with either measure alone. DISCUSSION AND CONCLUSIONS: High-intensity stepping training may elicit significant improvements in (Equation is included in full-text article.)O2submax, whereas changes in both peak capacity and economy better reflect gains in walking function. Providing high-intensity training to improve locomotor and aerobic exercise performance may increase the efficiency of rehabilitation sessions.Video Abstract available for more insights from the authors (see Supplemental Digital Content, http://links.lww.com/JNPT/A142).

Safety and efficacy of medically performed tongue piercing in people with tetraplegia for use with tongue-operated assistive technology.

BACKGROUND: Individuals with high-level spinal cord injuries need effective ways to perform activities. OBJECTIVES: To develop and test a medically supervised tongue-piercing protocol and the wearing of a magnet-containing tongue barbell for use with the Tongue Drive System (TDS) in persons with tetraplegia. METHODS: Volunteers with tetraplegia underwent initial screening sessions using a magnet glued on the tongue to activate and use the TDS. This was followed by tongue piercing, insertion of a standard barbell, a 4-week healing period, and an exchange of the standard barbell for a magnet-containing barbell. This was then used twice weekly for 6 to 8 weeks to perform computer tasks, drive a powered wheelchair, accomplish in-chair weight shifts, and dial a phone. Symptoms of intraoral dysfunction, change in tongue size following piercing, and subjective assessment of receiving and wearing a magnet-containing tongue barbell and its usability with the TDS were evaluated. RESULTS: Twenty-one volunteers underwent initial trial sessions. Thirteen had their tongues pierced. One individual's barbell dislodged during healing resulting in tongue-tract closure. Twelve had the barbell exchanged for a magnet-containing barbell. One subject withdrew for unrelated issues. Eleven completed the TDS testing sessions and were able to complete the assigned tasks. No serious adverse events occurred related to wearing or using a tongue barbell to operate the TDS. CONCLUSIONS: Using careful selection criteria and a medically supervised piercing protocol, no excess risk was associated with tongue piercing and wearing a tongue barbell in people with tetraplegia. Participants were able to operate the TDS.

Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

PURPOSE: This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. METHODS: Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. RESULTS: Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. CONCLUSIONS: The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.