Psychological Contributions to Symptom Provocation Testing After Concussion.

OBJECTIVE: Following concussion, symptoms such as headache, dizziness, and fatigue may transiently worsen or reemerge with increased exertion or activity. Standardized tests have been developed to assess symptom increases following aerobic, cognitive, or vestibular/oculomotor challenge. Although neurophysiological mechanisms are proposed to underlie symptom increases following exertion, psychological factors such as anxiety and misinterpretation of normal bodily sensations may also play a role. In this study, we examined the contribution of psychological factors to symptom provocation testing outcomes. SETTING: Two outpatient concussion clinics in British Columbia, Canada. PARTICIPANTS: Adults with persistent symptoms following concussion ( N = 79; 62% women). DESIGN: In a single session, participants completed self-report questionnaires measuring the psychological factors of interest and underwent symptom provocation testing including aerobic (Buffalo Concussion Bike Test; BCBT), cognitive (National Institutes of Health Toolbox-Cognition Battery; NIHTB-CB), and vestibular/oculomotor (Vestibular/Ocular Motor Screening for Concussion; VOMS) challenge. MAIN MEASURES: Psychological factors of interest included premorbid and current anxiety (Generalized Anxiety Disorder-7; GAD-7), catastrophizing (Pain Catastrophizing Scale-Adapted; PCS-A), fear avoidance behavior (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and somatization (Patient Health Questionnaire-15; PHQ-15). Our primary outcome variables were self-reported symptom change during each symptom provocation test. RESULTS: We found that current anxiety ( B = 0.034; 95% CI = 0.003, 0.065), symptom catastrophizing ( B = 0.013; 95% CI = 0.000, 0.026), fear avoidance behavior ( B = 0.029; 95% CI = 0.008, 0.050), and somatization ( B = 0.041; 95% CI = 0.007, 0.075) were associated with increased symptoms during the VOMS in univariate models adjusted for time postinjury but not in a multivariable model that included all covariates. The psychological variables of interest were not significantly related to symptom change during the BCBT or NIHTB-CB. CONCLUSION: Our findings suggest that symptom provocation test failure should be interpreted with caution because it might indicate psychological maladjustment rather than lingering brain injury or incomplete neurophysiological recovery.

Patients' and therapists' experience and perception of exoskeleton-based physiotherapy during subacute stroke rehabilitation: a qualitative analysis.

PURPOSE: To explore the experience and acceptability of an exoskeleton-based physiotherapy program for non-ambulatory patients during subacute stroke rehabilitation from the perspective of patients and therapists. MATERIALS AND METHODS: This was a qualitative descriptive study using semi-structured interviews and thematic analysis. Fourteen patients with stroke who participated in the experimental arm of a randomized controlled trial investigating the efficacy of exoskeleton-based physiotherapy were recruited. Six physiotherapists who provided the intervention were also recruited. RESULTS: Three themes were identified relating to the experience and acceptability of an exoskeleton-based physiotherapy program: (1) A matter of getting into the swing of things depicted the initial and ongoing learning process of using an exoskeleton; (2) More of a positive experience than anything else described the participants' mostly favorable attitude toward exoskeleton-based gait training; and (3) The best step forward captured participant-identified recommendations and considerations for the future integration of exoskeleton training into stroke rehabilitation. CONCLUSIONS: Patients with stroke were even more optimistic than therapists toward the experience and benefits of exoskeleton-based gait training during subacute stroke rehabilitation. Future clinical practice should consider the balance between actual and perceived benefits, as well as the potential barriers to integrating an exoskeleton into stroke rehabilitation.IMPLICATIONS FOR REHABILITATIONPowered robotic exoskeletons can be used to provide higher duration and more repetitious walking practice for non-ambulatory patients with stroke.Patients with stroke view exoskeleton-based physiotherapy highly favorably, attributing greater opportunity and benefit to using the device during subacute rehabilitation.Physiotherapists should consider learning challenges, patient characteristics, and implementation barriers when integrating exoskeleton-based training within a treatment program.

Prevalence of Walking Limitation After Acute Stroke and Its Impact on Discharge to Home.

OBJECTIVE: The purpose of this study was to provide contemporary estimates of the prevalence of lower extremity motor impairment and walking limitation after first-ever stroke and to characterize the predictive nature of early walking ability for being discharged home after acute hospitalization. METHODS: In this cohort study, data were collected from a metropolitan acute care hospital in Canada at admission for 487 adults with first-ever acute ischemic or hemorrhagic stroke. Lower extremity motor impairment and walking limitation were measured using the National Institutes of Health Stroke Scale and AlphaFIM, respectively. Parallel multivariable logistic regression models were built to predict discharge home after acute hospitalization compared with further hospitalization. RESULTS: For patients surviving a first-ever stroke, 44.1% presented with some degree of lower extremity motor impairment and 46.0% were unable to walk. In a multivariable model built around a binary classification of walking (Nagelkerke R2 = 0.41), those with any ability to walk at admission (with or without therapist assistance) had 9.48 times greater odds of being discharged home (odds ratio = 9.48, 95% CI = 6.11-14.92) than those who were unable. In a parallel multivariable model built around an ordinal classification of walking (Nagelkerke R2 = 0.49), patients had 2.07 times greater odds (odds ratio = 2.07, 95% CI = 1.82-2.38) of being discharged home for each increment on a 6-point walking scale (total dependence to complete independence) assessed at acute admission. CONCLUSION: Approximately one-half of patients with first-ever stroke present with lower extremity weakness and walking limitation. Early walking ability is a significant predictor of returning home after acute hospitalization, independent of stroke severity. Discharge planning may be facilitated early after stroke with the familiar assessment of walking ability. IMPACT: An early assessment of walking function within days of stroke admission can help to streamline discharge planning. LAY SUMMARY: Nearly one-half of all individuals who experience a first-time stroke have walking difficulty when they arrive at the hospital. The severity of the walking limitation can predict whether a patient will eventually be discharged home or go on to further hospitalization.

Efficacy of an exoskeleton-based physical therapy program for non-ambulatory patients during subacute stroke rehabilitation: a randomized controlled trial.

BACKGROUND: Individuals requiring greater physical assistance to practice walking complete fewer steps in physical therapy during subacute stroke rehabilitation. Powered exoskeletons have been developed to allow repetitious overground gait training for individuals with lower limb weakness. The objective of this study was to determine the efficacy of exoskeleton-based physical therapy training during subacute rehabilitation for walking recovery in non-ambulatory patients with stroke. METHODS: An assessor-blinded randomized controlled trial was conducted at 3 inpatient rehabilitation hospitals. Patients with subacute stroke (< 3 months) who were unable to walk without substantial assistance (Functional Ambulation Category rating of 0 or 1) were randomly assigned to receive exoskeleton-based or standard physical therapy during rehabilitation, until discharge or a maximum of 8 weeks. The experimental protocol replaced 75% of standard physical therapy sessions with individualized exoskeleton-based sessions to increase standing and stepping repetition, with the possibility of weaning off the device. The primary outcome was walking ability, measured using the Functional Ambulation Category. Secondary outcomes were gait speed, distance walked on the 6-Minute Walk Test, days to achieve unassisted gait, lower extremity motor function (Fugl-Meyer Assessment), Berg Balance Scale, Patient Health Questionnaire, Montreal Cognitive Assessment, and 36-Item Short Form Survey, measured post-intervention and after 6 months. RESULTS: Thirty-six patients with stroke (mean 39 days post-stroke) were randomized (Exoskeleton = 19, Usual Care = 17). On intention-to-treat analysis, no significant between-group differences were found in the primary or secondary outcomes at post-intervention or after 6 months. Five participants randomized to the Exoskeleton group did not receive the protocol as planned and thus exploratory as-treated and per-protocol analyses were undertaken. The as-treated analysis found that those adhering to exoskeleton-based physical therapy regained independent walking earlier (p = 0.03) and had greater gait speed (p = 0.04) and 6MWT (p = 0.03) at 6 months; however, these differences were not significant in the per-protocol analysis. No serious adverse events were reported. CONCLUSIONS: This study found that exoskeleton-based physical therapy does not result in greater improvements in walking independence than standard care but can be safely administered at no detriment to patient outcomes. Clinical Trial Registration The Exoskeleton for post-Stroke Recovery of Ambulation (ExStRA) trial was registered at ClinicalTrials.gov (NCT02995265, first registered: December 16, 2016).

Mirror Therapy for Lower-Extremity Hemiparesis: A Knowledge Translation Study Using an Educational Module to Change Physiotherapists' Perceptions.

Purpose: Despite growing evidence that mirror therapy (MT) is effective for improving lower-extremity (LE) function in patients with stroke, it is not commonly used by physiotherapists. The purpose of this study was to determine whether change would occur in physiotherapists' knowledge of, confidence in performing, and willingness to use MT for LE stroke rehabilitation after participating in a 1-hour educational module. Method: A convenience sample of physiotherapists working in neurorehabilitation was recruited for a single-group quasi-experimental pre-post study. Participants attended a 1-hour educational module on MT. Therapists' perceptions of the use of MT were assessed by questionnaire before and after they participated in the module. A follow-up telephone survey was conducted after 3 months to determine how many participants had actually used MT in their practice. Results: Nine physiotherapists participated in this study. Statistically significant increases were found in their perceived knowledge of, confidence in, and willingness to use MT. At the 3-month follow-up, three participants had used MT with patients with LE hemiparesis. Conclusions: Therapists' knowledge of and attitudes toward MT for LE stroke rehabilitation changed favourably after participating in a 1-hour educational module. The module also led some therapists to make a change in practice at 3 months.

Objectif : malgré les données croissantes démontrant l'efficacité de la thérapie du miroir (TM) pour améliorer la fonction des extrémités inférieures (EL) chez les patients victimes d'un accident vasculaire cérébral (AVC), cette thérapie n'est pas d'usage courant chez les physiothérapeutes. La présente étude visait à établir si les physiothérapeutes accroissaient leurs connaissances de la TM pour la réadaptation des EI après un AVC ainsi que leur confiance et leur volonté à utiliser cette thérapie après avoir participé à un module de formation d'une heure. Méthodologie : les chercheurs ont recruté un échantillon de commodité de physiothérapeutes en neuroréadaptation en vue d'une étude avant-après quasi expérimentale d'un groupe unique. Les participants ont suivi un module de formation d'une heure sur la TM. Les chercheurs ont évalué la perception qu'avaient les physiothérapeutes de l'utilisation de la TM par questionnaire avant et après leur participation au module. Ils ont réalisé un sondage téléphonique trois mois plus tard pour déterminer le nombre de participants qui avaient vraiment intégré la TM à leur pratique. Résultats : neuf physiothérapeutes ont participé à la présente étude. Les chercheurs ont constaté des augmentations statistiquement significatives de la perception des connaissances, de la confiance et de la volonté d'utiliser la TM. Au bout de trois mois, trois participants avaient utilisé la TM chez des patients présentant une hémiparésie des EI. Conclusion : Les connaissances et les attitudes des thérapeutes relativement à la TM pour la réadaptation des EI après un AVC ont augmenté après un module de formation d'une heure. Ce module a également incité certains thérapeutes à apporter certains changements au bout de trois mois.

Brain activity during real-time walking and with walking interventions after stroke: a systematic review.

Investigations of real-time brain activations during walking have become increasingly important to aid in recovery of walking after a stroke. Individual brain activation patterns can be a valuable biomarker of neuroplasticity during the rehabilitation process and can result in improved personalized medicine for rehabilitation. The purpose of this systematic review is to explore the brain activation characteristics during walking post-stroke by determining: (1) if different components of gait (i.e., initiation/acceleration, steady-state, complex) result in different brain activations, (2) whether brain activations differ from healthy individuals. Six databases were searched resulting in 22 studies. Initiation/acceleration showed bilateral activation in frontal areas; steady-state and complex walking showed broad activations with the majority exploring and finding increases in frontal regions and some studies also showing increases in parietal activation. Asymmetrical activations were often related to performance asymmetry and were more common in studies with slower gait speed. Hyperactivations and asymmetrical activations commonly decreased with walking interventions and as walking performance improved. Hyperactivations often persisted in individuals who had experienced severe strokes. Only a third of the studies included comparisons to a healthy group: individuals post-stroke employed greater brain activation compared to young adults, while comparisons to older adults were less clear and limited. Current literature suggests some indicators of walking recovery however future studies investigating more brain regions and comparisons with healthy age-matched adults are needed to further understand the effect of stroke on walking-related brain activation.

Passive, yet not inactive: robotic exoskeleton walking increases cortical activation dependent on task.

BACKGROUND: Experimental designs using surrogate gait-like movements, such as in functional magnetic resonance imaging (MRI), cannot fully capture the cortical activation associated with overground gait. Overground gait in a robotic exoskeleton may be an ideal tool to generate controlled sensorimotor stimulation of gait conditions like 'active' (i.e. user moves with the device) and 'passive' (i.e. user is moved by the device) gait. To truly understand these neural mechanisms, functional near-infrared spectroscopy (fNIRS) would yield greater ecological validity. Thus, the aim of this experiment was to use fNIRS to delineate brain activation differences between 'Active' and 'Passive' overground gait in a robotic exoskeleton. METHODS: Fourteen healthy adults performed 10 walking trials in a robotic exoskeleton for Passive and Active conditions, with fNIRS over bilateral frontal and parietal lobes, and electromyography (EMG) over bilateral thigh muscles. Digitization of optode locations and individual T1 MRI scans were used to demarcate the brain regions fNIRS recorded from. RESULTS: Increased oxyhemoglobin in the right frontal cortex was found for Passive compared with Active conditions. For deoxyhemoglobin, increased activation during Passive was found in the left frontal cortex and bilateral parietal cortices compared with Active; one channel in the left parietal cortex decreased during Active when compared with Passive. Normalized EMG mean amplitude was higher in the Active compared with Passive conditions for all four muscles (p ≤ 0.044), confirming participants produced the conditions asked of them. CONCLUSIONS: The parietal cortex is active during passive robotic exoskeleton gait, a novel finding as research to date has not recorded posterior to the primary somatosensory cortex. Increased activation of the parietal cortex may be related to the planning of limb coordination while maintaining postural control. Future neurorehabilitation research could use fNIRS to examine whether exoskeletal gait training can increase gait-related brain activation with individuals unable to walk independently.

Perspectives on the prospective development of stroke-specific lower extremity wearable monitoring technology: a qualitative focus group study with physical therapists and individuals with stroke.

BACKGROUND: Wearable activity monitors that track step count can increase the wearer's physical activity and motivation but are infrequently designed for the slower gait speed and compensatory patterns after stroke. New and available technology may allow for the design of stroke-specific wearable monitoring devices, capable of detecting more than just step counts, which may enhance how rehabilitation is delivered. The objective of this study was to identify important considerations in the development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke. METHODS: A qualitative research design with focus groups was used to collect data. Five focus groups were conducted, audio recorded, and transcribed verbatim. Data were analyzed using content analysis to generate overarching categories representing the stakeholder considerations for the development of stroke-specific wearable monitor technology for the lower extremity. RESULTS: A total of 17 physical therapists took part in four focus group discussions and three individuals with stroke participated in the fifth focus group. Our analysis identified four main categories for consideration: 1) 'Variability' described the heterogeneity of patient presentation, therapy approaches, and therapeutic goals that are taken into account for stroke rehabilitation; 2) 'Context of use' described the different settings and purposes for which stakeholders could foresee employing stroke-specific wearable technology; 3) 'Crucial design features' identified the measures, functions, and device characteristics that should be considered for incorporation into prospective technology to enhance uptake; and 4) 'Barriers to adopting technology' highlighted challenges, including personal attitudes and design flaws, that may limit the integration of current and future wearable monitoring technology into clinical practice. CONCLUSIONS: The findings from this qualitative study suggest that the development of stroke-specific lower extremity wearable monitoring technology is viewed positively by physical therapists and individuals with stroke. While a single, specific device or function may not accommodate all the variable needs of therapists and their clients, it was agreed that wearable monitoring technology could enhance how physical therapists assess and treat their clients. Future wearable devices should be developed in consideration of the highlighted design features and potential barriers for uptake.

A Systematic Review of Pelvic Floor Muscle Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research.

BACKGROUND: Erectile dysfunction is one potential complication after radical prostatectomy; often pelvic floor muscle training is offered as an intervention to improve quality of life and erectile function post-operatively. AIM: To provide a summary of current evidence regarding the effectiveness of pelvic floor muscle training in the management of erectile dysfunction after radical prostatectomy and provide recommendations for future research. METHODS: An electronic search was conducted for relevant research studies using PubMed, EMBASE, CINAHL, Medline, and PEDro. Quality of selected trials was assessed by 2 independent reviewers using the Modified Downs and Black Checklist; disagreements were resolved by consensus. MAIN OUTCOME MEASURE: The main outcome measure is the International Index of Erectile function (IIEF-5). RESULTS: 9 studies of various study design were included in this review. Most studies demonstrated improvements in erectile dysfunction with pelvic floor muscle training; however, lack of methodological rigor for several studies and variability among training protocols limited interpretation of results. CLINICAL IMPLICATIONS: Further well powered and rigorously designed randomized controlled trials are needed to investigate the effect of pelvic floor muscle training on erectile dysfunction after radical prostatectomy. STRENGTHS & LIMITATIONS: This review employed a systematic method of appraising the available evidence for pelvic floor muscle training for erectile dysfunction after radical prostatectomy. Limited high-quality articles were identified and few conclusions could be drawn from the existing evidence. CONCLUSION: Future high-quality randomized controlled trials should include strategies to improve adherence to exercise, clearly describe exercise protocols, and integrate new evidence for verbal cues and biofeedback for muscles involved in erection. Wong C, Louie DR, Beach C. A Systematic Review of Pelvic Floor Muscle Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research. J Sex Med 2020;17:737-748.

Exoskeleton for post-stroke recovery of ambulation (ExStRA): study protocol for a mixed-methods study investigating the efficacy and acceptance of an exoskeleton-based physical therapy program during stroke inpatient rehabilitation.

BACKGROUND: The ability to walk is commonly reported as a top rehabilitation priority for individuals after a stroke. However, not all individuals with stroke are able to practice walking, especially those who require more assistance from their therapist to do so. Powered robotic exoskeletons are a new generation of robotic-assisted gait training devices, designed to assist lower extremity movement to allow repetitious overground walking practice. To date, minimal research has been conducted on the use of an exoskeleton for gait rehabilitation after stroke. The following research protocol aims to evaluate the efficacy and acceptability, and thus adoptability, of an exoskeleton-based gait rehabilitation program for individuals with stroke. METHODS: This research protocol describes a prospective, multi-center, mixed-methods study comprised of a randomized controlled trial and a nested qualitative study. Forty adults with subacute stroke will be recruited from three inpatient rehabilitation hospitals and randomized to receive either the exoskeleton-based gait rehabilitation program or usual physical therapy care. The primary outcome measure is the Functional Ambulation Category at post-intervention, and secondary outcomes include motor recovery, functional mobility, cognitive, and quality-of-life measures. Outcome data will be collected at baseline, post-intervention, and at 6 months. The qualitative component will explore the experience and acceptability of using a powered robotic exoskeleton for stroke rehabilitation from the point of view of individuals with stroke and physical therapists. Semi-structured interviews will be conducted with participants who receive the exoskeleton intervention, and with the therapists who provide the intervention. Qualitative data will be analyzed using interpretive description. DISCUSSION: This study will be the first mixed-methods study examining the adoptability of exoskeleton-based rehabilitation for individuals with stroke. It will provide valuable information regarding the efficacy of exoskeleton-based training for walking recovery and will shed light on how physical therapists and patients with stroke perceive the device. The findings will help guide the integration of robotic exoskeletons into clinical practice. TRIAL REGISTRATION: NCT02995265 (clinicaltrials.gov), Registered 16 December 2016.

The Efficacy of Lower Extremity Mirror Therapy for Improving Balance, Gait, and Motor Function Poststroke: A Systematic Review and Meta-Analysis.

BACKGROUND: Mirror therapy is less commonly used to target the lower extremity after stroke to improve outcomes but is simple to perform. This review and meta-analysis aimed to evaluate the efficacy of lower extremity mirror therapy in improving balance, gait, and motor function for individuals with stroke. METHODS: PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Physiotherapy Evidence Database, and PsychINFO were searched from inception to May 2018 for randomized controlled trials (RCTs) comparing lower extremity mirror therapy to a control intervention for people with stroke. Pooled effects were determined by separate meta-analyses of gait speed, mobility, balance, and motor recovery. RESULTS: Seventeen RCTs involving 633 participants were included. Thirteen studies reported a significant between-group difference favoring mirror therapy in at least one lower extremity outcome. In a meta-analysis of 6 trials that reported change in gait speed, a large beneficial effect was observed following mirror therapy training (standardized mean differences [SMD] = 1.04 [95% confidence interval [CI] = .43, 1.66], I2 = 73%, and P < .001). Lower extremity mirror therapy also had a positive effect on mobility (5 studies, SMD = .46 [95% CI = .01, .90], I2 = 43%, and P = .05) and motor recovery (7 studies, SMD = .47 [95% CI = .21, .74], I2 = 0%, and P < .001). A significant pooled effect was not found for balance capacity. CONCLUSIONS: Mirror therapy for the lower extremity has a large effect for gait speed improvement. This review also found a small positive effect of mirror therapy for mobility and lower extremity motor recovery after stroke.

Suicide Prevention From the Perspectives of Gay, Bisexual, and Two-Spirit Men.

Although gay, bisexual, and two-spirit men (GBTSM) experience high rates of suicidality, there have been few empirical studies of prevention initiatives and policies that could address or reverse this major social problem. This article reports on a photovoice study of 29 GBTSM who had a history of suicidality or lost a fellow GBTSM to suicide. We focused our analysis on participants' perspectives on suicide prevention. Participants described four key considerations for GBTSM suicide prevention: (a) recognizing and addressing enduring homophobia, biphobia, and mental illness stigma; (b) provision of low-barrier, long-term, and GBTSM-affirming counseling; (c) de-isolation through peer support and community connection; and (d) fostering creativity and cultural resilience. By engaging GBTSM affected by suicide through photographs that depict their experiences and points of view, in this study, we offer concrete recommendations to reduce suicidality among GBTSM.

Berg Balance Scale score at admission can predict walking suitable for community ambulation at discharge from inpatient stroke rehabilitation.

OBJECTIVE: This retrospective cohort study identified inpatient rehabilitation admission variables that predict walking ability at discharge and established Berg Balance Scale cut-off scores to predict the extent of improvement in walking. METHODS: Participants (n=123) were assessed for various cognitive and physical outcomes at admission to inpatient stroke rehabilitation. Multivariate logistic regression identified admission predictors of regaining community ambulation (gait speed ≥0.8 m/s) or unassisted ambulation (no physical assistance) after 4 weeks. Receiver operating characteristic curve analysis identified cut-off admission Berg Balance Scale scores. RESULTS: Mini-Mental State Examination (odds ratio (OR) 1.60, 95% confidence interval (95% CI) 1.19-2.14) was a significant predictor when coupled with admission walking speed for regaining community ambulation speed; stroke type (haemorrhagic/ischaemic) was a significant predictor (OR=0.19, 95% CI 0.05-0.77) when coupled with Berg Balance Scale (OR 1.14, 95% CI 1.09-1.20). Only Berg Balance Scale was a significant predictor of regaining unassisted ambulation (OR 1.11, 95% CI 1.05-1.17). A cut-off Berg Balance Scale score of 29 on admission predicts that an individual will go on to achieve community walking speed (n=123, area under the curve (AUC)=0.88, 95% CI 0.81-0.95); a cut-off score of 12 predicts a non-ambulator to regain unassisted ambulation (n=84, AUC 0.73, 95% CI 0.62-0.84). CONCLUSION: The Berg Balance Scale can be used at rehabilitation admission to predict the degree of improvement in walking for patients with stroke.

Powered robotic exoskeletons in post-stroke rehabilitation of gait: a scoping review.

Powered robotic exoskeletons are a potential intervention for gait rehabilitation in stroke to enable repetitive walking practice to maximize neural recovery. As this is a relatively new technology for stroke, a scoping review can help guide current research and propose recommendations for advancing the research development. The aim of this scoping review was to map the current literature surrounding the use of robotic exoskeletons for gait rehabilitation in adults post-stroke. Five databases (Pubmed, OVID MEDLINE, CINAHL, Embase, Cochrane Central Register of Clinical Trials) were searched for articles from inception to October 2015. Reference lists of included articles were reviewed to identify additional studies. Articles were included if they utilized a robotic exoskeleton as a gait training intervention for adult stroke survivors and reported walking outcome measures. Of 441 records identified, 11 studies, all published within the last five years, involving 216 participants met the inclusion criteria. The study designs ranged from pre-post clinical studies (n = 7) to controlled trials (n = 4); five of the studies utilized a robotic exoskeleton device unilaterally, while six used a bilateral design. Participants ranged from sub-acute (<7 weeks) to chronic (>6 months) stroke. Training periods ranged from single-session to 8-week interventions. Main walking outcome measures were gait speed, Timed Up and Go, 6-min Walk Test, and the Functional Ambulation Category. Meaningful improvement with exoskeleton-based gait training was more apparent in sub-acute stroke compared to chronic stroke. Two of the four controlled trials showed no greater improvement in any walking outcomes compared to a control group in chronic stroke. In conclusion, clinical trials demonstrate that powered robotic exoskeletons can be used safely as a gait training intervention for stroke. Preliminary findings suggest that exoskeletal gait training is equivalent to traditional therapy for chronic stroke patients, while sub-acute patients may experience added benefit from exoskeletal gait training. Efforts should be invested in designing rigorous, appropriately powered controlled trials before powered exoskeletons can be translated into a clinical tool for gait rehabilitation post-stroke.

"Stepping Up" Activity Poststroke: Ankle-Positioned Accelerometer Can Accurately Record Steps During Slow Walking.

BACKGROUND: As physical activity in people poststroke is low, devices that monitor and provide feedback of walking activity provide motivation to engage in exercise and may assist rehabilitation professionals in auditing walking activity. However, most feedback devices are not accurate at slow walking speeds. OBJECTIVE: This study assessed the accuracy of one accelerometer to measure walking steps of community-dwelling individuals poststroke. DESIGN: This was a cross-sectional study. METHODS: Two accelerometers were positioned on the nonparetic waist and ankle of participants (N=43), and walking steps from these devices were recorded at 7 speeds (0.3-0.9 m/s) and compared with video recordings (gold standard). RESULTS: When positioned at the waist, the accelerometer had more than 10% error at all speeds, except 0.8 and 0.9 m/s, and numerous participants recorded zero steps at 0.3 to 0.5 m/s. The device had 10% or less error when positioned at the ankle for all speeds between 0.4 and 0.9 m/s. LIMITATIONS: Some participants were unable to complete the faster walking speeds due to their walking impairments and inability to maintain the requested walking speed. CONCLUSIONS: Although not recommended by the manufacturer, positioning the accelerometer at the ankle (compared with the waist) may fill a long-standing need for a readily available device that provides accurate feedback for the altered and slow walking patterns that occur with stroke.

Gait speed using powered robotic exoskeletons after spinal cord injury: a systematic review and correlational study.

Powered robotic exoskeletons are an emerging technology of wearable orthoses that can be used as an assistive device to enable non-ambulatory individuals with spinal cord injury (SCI) to walk, or as a rehabilitation tool to improve walking ability in ambulatory individuals with SCI. No studies to date have systematically reviewed the literature on the efficacy of powered exoskeletons on restoring walking function. Our objective was to systematically review the literature to determine the gait speed attained by individuals with SCI when using a powered exoskeleton to walk, factors influencing this speed, and characteristics of studies involving a powered exoskeleton (e.g. inclusion criteria, screening, and training processes). A systematic search in computerized databases was conducted to identify articles that reported on walking outcomes when using a powered exoskeleton. Individual gait speed data from each study was extracted. Pearson correlations were performed between gait speed and 1) age, 2) years post-injury, 3) injury level, and 4) number of training sessions. Fifteen articles met inclusion criteria, 14 of which investigated the powered exoskeleton as an assistive device for non-ambulatory individuals and one which used it as a training intervention for ambulatory individuals with SCI. The mean gait speed attained by non-ambulatory participants (n = 84) while wearing a powered exoskeleton was 0.26 m/s, with the majority having a thoracic-level motor-complete injury. Twelve articles reported individual data for the non-ambulatory participants, from which a positive correlation was found between gait speed and 1) age (r = 0.27, 95 % CI 0.02-0.48, p = 0.03, 63 participants), 2) injury level (r = 0.27, 95 % CI 0.02-0.48, p = 0.03, 63 participants), and 3) training sessions (r = 0.41, 95 % CI 0.16-0.61, p = 0.002, 55 participants). In conclusion, powered exoskeletons can provide non-ambulatory individuals with thoracic-level motor-complete SCI the ability to walk at modest speeds. This speed is related to level of injury as well as training time.

Capturing step counts at slow walking speeds in older adults: comparison of ankle and waist placement of measuring device.

OBJECTIVE: It is important for older adults to be physically active, but many older adults walk slowly. This study examined the accuracy of a commercially available step-count device (Fitbit One) at slow speeds and compared the accuracy of the device when worn at the ankle and waist in older adults. METHODS: The Fitbit One was placed at the ankle and waist of participants (n=42; mean age 73 years) while they performed walking trials at 7 different speeds (0.3-0.9 m/s). Step counts obtained from video recordings were used as the gold standard comparison to determine the accuracy of the device. RESULTS: The ankle-worn device had significantly less error than the waist-worn device at all speeds. The percentage error of the ankle-worn device was less than 10% at speeds of 0.4-0.9 m/s and did not record zero steps at any speed. The percentage error of the waist-worn device was below 10% at only the 2 fastest speeds (0.8 and 0.9 m/s) and recorded zero steps for numerous participants at speeds of 0.3-0.5 m/s. CONCLUSION: The Fitbit One can accurately capture steps at slow speeds when placed at the ankle and thus may be appropriate for capturing physical activity in slow-walking older adults.