A Network of Sites and Upskilled Therapists to Deliver Best-Practice Stroke Rehabilitation of the Arm: Protocol for a Knowledge Translation Study.

Implementation of evidence-informed rehabilitation of the upper limb is variable, and outcomes for stroke survivors are often suboptimal. We established a national partnership of clinicians, survivors of stroke, researchers, healthcare organizations, and policy makers to facilitate change. The objectives of this study are to increase access to best-evidence rehabilitation of the upper limb and improve outcomes for stroke survivors. This prospective pragmatic, knowledge translation study involves four new specialist therapy centers to deliver best-evidence upper-limb sensory rehabilitation (known as SENSe therapy) for survivors of stroke in the community. A knowledge-transfer intervention will be used to upskill therapists and guide implementation. Specialist centers will deliver SENSe therapy, an effective and recommended therapy, to stroke survivors in the community. Outcomes include number of successful deliveries of SENSe therapy by credentialled therapists; improved somatosensory function for stroke survivors; improved performance in self-selected activities, arm use, and quality of life; treatment fidelity and confidence to deliver therapy; and for future implementation, expert therapist effect and cost-effectiveness. In summary, we will determine the effect of a national partnership to increase access to evidence-based upper-limb sensory rehabilitation following stroke. If effective, this knowledge-transfer intervention could be used to optimize the delivery of other complex, evidence-based rehabilitation interventions.

Effects of Upper Limb Exercise or Training on Hand Dexterity and Function in People With Parkinson Disease: A Systematic Review and Meta-analysis.

OBJECTIVE: This systematic review investigated the effects of exercise and training on hand dexterity and function outcomes in people with Parkinson disease (PD). DATA SOURCES: We searched 5 databases (MEDLINE Ovid, CINAHL, PEDro, PubMed, Cochrane Database) from inception to October 2022. STUDY SELECTION: Included studies were randomized controlled trials delivering upper limb exercise or training interventions to people with PD and evaluating 1 or more upper limb activity outcomes. Two independent reviewers screened 668 articles for inclusion. DATA EXTRACTION: Two reviewers independently extracted data relating to study participants, intervention characteristics, and key outcomes. Cochrane Risk of Bias and GRADE tools assessed methodological quality of included studies, and strength of evidence for 3 outcomes: hand dexterity, self-reported hand function, and handwriting performance. Meta-analyses synthesized results for within-hand dexterity and self-reported function. RESULTS: Eighteen randomized controlled trials (n=704) with low to unclear risk of bias were identified. Experimental interventions varied considerably in their approach and treatment dose, and 3 studies focused on training handwriting. Meta-analysis showed moderate quality evidence of a small positive effect on within-hand dexterity (SMD=0.26; 95% CI 0.07, 0.44). Very low-quality evidence pointed toward a nonsignificant effect on self-reported hand function (SMD=0.67; 95% CI -0.40, 1.75). A narrative review of handwriting interventions showed low quality evidence for improved performance after training. CONCLUSIONS: There is moderate certainty of evidence supporting the use of exercise and training to address dexterity problems, but evidence remains unclear for self-reported hand function and handwriting. Our findings suggest that training could employ task-related approaches. Future research should interrogate aspects of clinical practice such as optimal dose and key ingredients for effective interventions.

Evaluating Feasibility of a Secondary Stroke Prevention Program.

Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information (referrals, uptake, participant demographics and costs), and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre-post scores on standardized clinical tests (e.g., waist circumference and 6-Minute Walk (6MWT)). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for 'relevance' (100%), 'felt safe to exercise' (96%) and 'intend to continue' (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors (diet, exercise, smoking and alcohol). Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m, p < 0.001) and waist circumference (MD -2.1 cm, 95%CI -3.9 cm to -1.4 cm, p < 0.001). The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention.

Is telehealth an effective and feasible option for improving falls-related outcomes in community-dwelling adults with neurological conditions? A systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of telehealth interventions in reducing community falls risk or rates compared to equivalent in-person interventions in adults with neurological conditions. DATA SOURCES: Eight electronic databases, trial registries and search engines were searched for the concepts 'falls', 'neurological conditions', and 'telehealth', limited to English language, from inception until August 2022. REVIEW METHODS: Search for original research where the intervention was delivered via synchronous videoconferencing with the aim of reducing falls and falls-related outcomes. Screening and risk of bias assessment were completed by two independent researchers. Outcome data included falls rates, falls-related outcomes, safety, feasibility, and acceptability. Risk of bias was assessed using the ROB-2 and ROBINS-I tools. Quality of evidence was rated with the grading of recommendations, assessment, development and evaluation (GRADE) approach. RESULTS: Seventeen studies with 581 participants were included; six were randomised controlled trials. Risk of bias ranged from low to high. Only one study (n = 76) reported falls and did not find differences between telehealth and in-person physiotherapy. There was low-quality evidence that telehealth interventions improve balance outcomes more than face-to-face interventions (pooled between-group mean difference 2.48 Berg Balance Scale units, 95%CI 0.77 to 4.20). Fear of falling was not different between intervention delivery modes. CONCLUSION: Findings suggest that telehealth delivered falls prevention interventions are safe, feasible and acceptable in community-dwelling adults with neurological conditions, however, data related to effectiveness in reducing falls is limited. Low-quality evidence suggests that telehealth may deliver similar or better outcomes for standing balance in this population.PROSPERO Registration: (CRD42021240167).

Stroke survivors' perceptions of the factors that influence engagement in activity outside dedicated therapy sessions in a rehabilitation unit: A qualitative study.

OBJECTIVE: To investigate stroke survivors' perceptions of factors influencing their engagement in activity outside of dedicated therapy sessions during inpatient rehabilitation. DESIGN: Qualitative study. SETTING: Four metropolitan rehabilitation units in Australia. PARTICIPANTS: People undertaking inpatient rehabilitation after stroke. METHODS: Semi-structured interviews conducted in person by a speech pathologist A stepped iterative process of inductive analysis was employed until data saturation was achieved with themes then applied against the three domains of the Theory of Planned Behaviour (perceived behavioural control, social norms and attitude). RESULTS: Interviews of 33 stroke survivors (60% female, median age of 73 years) revealed five themes (i) uncertainty about how to navigate and what was available for use in the rehabilitation unit restricts activity and (ii) post-stroke mobility, fatigue and pre- and post-stroke communication impairments restrict activity (perceived behavioural control); (iii) unit set up, rules (perceived and actual) and staff expectations influence activity and (iv) visiting family and friends are strong facilitators of activity (social norms), and (v) personal preferences and mood influence level of activity (attitude). CONCLUSION: At the individual level, stroke survivors perceived that their ability to be active outside of dedicated therapy sessions was influenced by their impairments, including mood, and their attitude towards and preference for activity. At the ward level, stroke survivors perceived that their ability to be active was influenced by ward set-up, rules and staff expectations. Visitors were perceived to be important facilitators of activity outside of therapy sessions.

Impairments, and physical design and culture of a rehabilitation unit influence stroke survivor activity: qualitative analysis of rehabilitation staff perceptions.

PURPOSE: This study aimed to investigate rehabilitation staff perceptions of factors influencing stroke survivor activity outside of dedicated therapy time for the purpose of supporting successful translation of activity promoting interventions in a rehabilitation unit. MATERIALS AND METHODS: Purposive sampling of multi-disciplinary teams from four rehabilitation units was performed, and semi-structured interviews were conducted by telephone, digitally audio-recorded and then transcribed verbatim. A stepped iterative process of thematic analysis was employed until data saturation was reached. RESULTS: All but one of the 22 participants were female, the majority were either physiotherapists or occupational therapists, with a median of 4 years (interquartile range, 2-10) working at their respective rehabilitation units. Analysis of the data revealed three themes: (i) stroke survivor characteristics influence their activity outside therapy, (ii) the rehabilitation environment influences physical, cognitive, and social activity, and (iii) institutional priorities, staff culture, and attitude can be barriers to activity. Rehabilitation units were perceived to be unstimulating, and visitors considered enablers of activity when resources were perceived to be scarce. CONCLUSIONS: Our results suggest careful consideration of the involvement of visitors, an individual's needs and preferences, and the institution's priorities and staff attitude may result in greater stroke survivor activity during rehabilitation.Implications for rehabilitationStaff should consider stroke survivor impairments and a rehabilitation unit's institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity.The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity.Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity.Discussion within the rehabilitation team concerning "ownership" of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same.

The stroke exercise preference inventory is feasible to use in a community rehabilitation setting.

Exploring exercise preferences may help people to adhere to exercise programs by promoting customized programs to suit the person's choices and concerns. We investigated if the Stroke Exercise Preference Inventory, a questionnaire designed to explore stroke survivors' preferences for exercise and potential barriers, was feasible to use, and whether it assisted physiotherapists to design ongoing exercise programs in a mixed diagnostic convenience sample attending community rehabilitation. Physiotherapy staff interviewed 42 participants, and sought feedback about the questionnaire. Participant responses for exercise preferences and perceived barriers were then summarized. The questionnaire was quick to administer, readily understood, and considered relevant to consider when discussing options for exercise. Clinicians reported the questionnaire was useful for 48% (20/42) of participants, as it engaged the participant, clarified their preferences and allowed problem solving of potential barriers to exercise. Participants expressed strong preferences to be challenged, and to receive supervision and support. Preferences regarding environmental and social context of exercise varied widely. Difficulty getting started was the most common barrier reported. The Stroke Exercise Preference Inventory was feasible to use with a mixed diagnostic group during community rehabilitation, and provides structure to explore preferences and barriers to exercise. It remains to be tested whether use of the questionnaire promotes adherence to exercise programs.

Altering the rehabilitation environment to improve stroke survivor activity: A Phase II trial.

BACKGROUND: Environmental enrichment involves organization of the environment and provision of equipment to facilitate engagement in physical, cognitive, and social activities. In animals with stroke, it promotes brain plasticity and recovery. AIMS: To assess the feasibility and safety of a patient-driven model of environmental enrichment incorporating access to communal and individual environmental enrichment. METHODS: A nonrandomized cluster trial with blinded measurement involving people with stroke (n = 193) in four rehabilitation units was carried out. Feasibility was operationalized as activity 10 days after admission to rehabilitation and availability of environmental enrichment. Safety was measured as falls and serious adverse events. Benefit was measured as clinical outcomes at three months, by an assessor blinded to group. RESULTS: The experimental group (n = 91) spent 7% (95% CI -14 to 0) less time inactive, 9% (95% CI 0-19) more time physically, and 6% (95% CI 2-10) more time socially active than the control group (n = 102). Communal environmental enrichment was available 100% of the time, but individual environmental enrichment was rarely within reach (24%) or sight (39%). There were no between-group differences in serious adverse events or falls at discharge or three months or in clinical outcomes at three months. CONCLUSIONS: This patient-driven model of environmental enrichment was feasible and safe. However, the very modest increase in activity by people with stroke, and the lack of benefit in clinical outcomes three months after stroke do not provide justification for an efficacy trial.

Implementation of the StandingTall programme to prevent falls in older people: a process evaluation protocol.

INTRODUCTION: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. METHODS AND ANALYSIS: This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. TRIAL REGISTRATION NUMBER: ACTRN12619001329156.

Experiences of Upper Limb Somatosensory Retraining in Persons With Stroke: An Interpretative Phenomenological Analysis.

PURPOSE: The aim of this study was to explore experiences of upper limb somatosensory discrimination retraining in persons with stroke. METHODS: A qualitative methodology was used within the context of a randomized control trial of somatosensory retraining: the CoNNECT trial. Participants in the CoNNECT trial completed a treatment program, known as SENSe therapy, to retrain upper limb somatosensory discrimination and recognition skills, and use of these skills in personally valued activities. Eight participants were interviewed on their experience of this therapy. Data were analyzed using Interpretative Phenomenological Analysis (IPA). RESULTS: Five themes represented participants' experiences of upper limb somatosensory retraining after stroke: (1) loss of sensation and desire to reclaim normality; (2) harnessing positivity in the therapeutic relationship and specialized therapy; (3) facing cognitive and emotional challenges; (4) distinct awareness of gains and differences in bodily sensations; and (5) improved functioning: control and choice in daily performance. Persons with stroke experienced somatosensory retraining as a valuable treatment that provided them with sensory and functional gains. CONCLUSION: Upper limb somatosensory retraining is a treatment that persons with stroke perceived as challenging and rewarding. People who have experienced stroke believed that somatosensory retraining therapy assisted them to improve their sensation, functional arm use, as well as daily performance and participation in life.

The effectiveness of somatosensory retraining for improving sensory function in the arm following stroke: a systematic review.

OBJECTIVE: The aim of this study was to evaluate if somatosensory retraining programmes assist people to improve somatosensory discrimination skills and arm functioning after stroke. DATA SOURCES: Nine databases were systematically searched: Medline, Cumulative Index to Nursing and Allied Health Literature, PsychInfo, Embase, Amed, Web of Science, Physiotherapy Evidence Database, OT seeker, and Cochrane Library. REVIEW METHODS: Studies were included for review if they involved (1) adult participants who had somatosensory impairment in the arm after stroke, (2) a programme targeted at retraining somatosensation, (3) a primary measure of somatosensory discrimination skills in the arm, and (4) an intervention study design (e.g. randomized or non-randomized control designs). RESULTS: A total of 6779 articles were screened. Five group trials and five single case experimental designs were included ( N = 199 stroke survivors). Six studies focused exclusively on retraining somatosensation and four studies focused on somatosensation and motor retraining. Standardized somatosensory measures were typically used for tactile, proprioception, and haptic object recognition modalities. Sensory intervention effect sizes ranged from 0.3 to 2.2, with an average effect size of 0.85 across somatosensory modalities. A majority of effect sizes for proprioception and tactile somatosensory domains were greater than 0.5, and all but one of the intervention effect sizes were larger than the control effect sizes, at least as point estimates. Six studies measured motor and/or functional arm outcomes ( n = 89 participants), with narrative analysis suggesting a trend towards improvement in arm use after somatosensory retraining. CONCLUSION: Somatosensory retraining may assist people to regain somatosensory discrimination skills in the arm after stroke.

Initial severity of somatosensory impairment influences response to upper limb sensory retraining post-stroke.

BACKGROUND: Somatosensory loss occurs often following stroke. A proportional recovery model is proposed for spontaneous motor recovery, with implication for treatment planning. It is currently unknown if initial severity of sensory impairment influences stroke survivors' response to treatment to improve sensation. OBJECTIVE: To examine if initial (pre-treatment) severity of upper limb somatosensory impairment is related to sensation outcomes following treatment. METHODS: Regression analysis was used to investigate the relationship between initial and post-treatment sensation performance. Data were pooled from two randomized controlled trials of somatosensory discrimination retraining (N = 80). Upper limb somatosensation was measured using standardized tests of sensory discrimination: Fabric Matching Test, Wrist Position Sense Test, and functional Tactile Object Recognition Test. RESULTS: Post-treatment somatosensory improvement patterns were proportional to the extent of initial pre-treatment somatosensory impairment (Texture discrimination: B = 0.74, 95% CIs [0.52, 0.96]; Proprioception: B = 0.35, 95% CIs [0.24, 0.47]; Object recognition: B = 0.85, 95% CIs [0.75, 0.95]). CONCLUSIONS: The effect of somatosensory retraining on post-treatment sensation was proportional to the extent of upper limb initial somatosensory impairment. Findings suggest sensory retraining can benefit stroke survivors of varying severity of sensory impairment, including those with more severe somatosensory loss.

One-Quarter of People Leave Inpatient Stroke Rehabilitation with Physical Capacity for Community Ambulation.

BACKGROUND AND PURPOSE: Ability to walk in the community is important for independence and participation in life roles, but is difficult for many people following stroke. The purpose of this study was to determine the proportion of people with stroke with the physical capacity to be independent community ambulators at discharge from a publicly funded inpatient rehabilitation setting. METHOD: Consecutive medical records were audited to collate walking outcome at discharge, and to clarify if people with stroke had potential to walk independently in the community as defined by 4 criteria: independence with stairs; ability to traverse slopes and inclines; walking speed of .8m/s or more; and walking distance 367 m or higher on 6-Minute Walk Test. RESULTS: While 80% of the 124 persons with stroke could walk indoors, only 27% could perform 4 essential skills needed to walk independently in the community at discharge from hospital. The proportion that met each criterion was 52% for stairs, 39% for slopes and inclines, 58% for speed, and 40% for distance. For the overall sample, mean (standard deviation) walking speed was .90 (.33) m/s, and distance for 6-Minute Walk Test was 349.6 (146.5) m. DISCUSSION AND CONCLUSION: A retrospective review found that three quarters of stroke survivors lacked physical capacity for 4 skills required to walk independently in the community at the time of discharge from a public inpatient rehabilitation. Our findings recommend that people with stroke have access to outpatient physical rehabilitation to optimize walking outcome.

Behavioral Mapping of Patient Activity to Explore the Built Environment During Rehabilitation.

AIM: To explore the use of a rehabilitation-focused behavioral mapping method to identify changes in patient physical activity, location, and social interaction following the relocation of a rehabilitation ward. BACKGROUND: Rehabilitation wards are unique healthcare environments where patient activity is encouraged to improve recovery. Little is known about the impact of building design on patient behavior within a rehabilitation setting. We examined this issue when a rehabilitation ward was relocated without altering other aspects of the healthcare service. METHOD: The setting was a publicly funded inpatient general rehabilitation ward with a separate therapy area. Before and after ward relocation, patient behavior (location, physical, and social activities) was observed at 10-min intervals between 8:00 a.m. and 5:00 p.m. Patients and staff performed their usual activities during data collection. RESULTS: Twenty-three patients participated in the old ward and 24 in the new ward, resulting in 1,150 and 1,200 observation time points, respectively. Patient location and behaviors were similar between wards ( p > .05). Participants were in bedrooms for more than half of the observations (67% old ward, 58% new ward), sitting down (62.8% old ward, 59.0% new ward), and alone (42.0% old ward, 38.0% new ward). Design features, such as separation of the therapy area and ward, may have impacted on patient behavior. CONCLUSIONS: The rehabilitation-focused behavioral mapping method provided a rich description of relevant patient behaviors, indicating that it is a feasible and useful method for exploring the impact of the built environment in rehabilitation settings.

Change in Functional Arm Use Is Associated With Somatosensory Skills After Sensory Retraining Poststroke.

OBJECTIVE: We investigated changes in functional arm use after retraining for stroke-related somatosensory loss and identified whether such changes are associated with somatosensory discrimination skills. METHOD: Data were pooled (N = 80) from two randomized controlled trials of somatosensory retraining. We used the Motor Activity Log to measure perceived amount of arm use in daily activities and the Action Research Arm Test to measure performance capacity. Somatosensory discrimination skills were measured using standardized modality-specific measures. RESULTS: Participants' arm use improved after somatosensory retraining (z = -6.80, p < .01). Change in arm use was weakly associated with somatosensation (tactile, ß = 0.31, p < .01; proprioception, ß = -0.17, p > .05; object recognition, ß = 0.13, p < .05). CONCLUSION: Change in daily arm use was related to a small amount of variance in somatosensory outcomes. Stroke survivors' functional arm use can increase after somatosensory retraining, with change varying among survivors.

Preparing patients at high risk of falls for discharge home after rehabilitation: Do we meet the guidelines?

AIM: To determine whether rehabilitation inpatients at high risk of falls receive adequate falls risk assessment, management and handover on discharge as per Australian Best Practice Guidelines. METHODS: Medical records of 121 people who received inpatient rehabilitation were retrospectively screened; records of 50 people discharged home and at high falls risk (fall in last 12 months, fall preceding/during admission) were audited. Data extracted included falls risk identification during rehabilitation and in discharge documentation; falls risk factors assessed; and fall prevention strategies implemented. RESULTS: Discharge documentation correctly identified falls risk for just nine of the 50 people. Patients at high falls risk had a median of 8.0 (interquartile range 6-10) of 17 risk factors. There was limited evidence of assessment for osteoporosis (n = 8), footwear (n = 4) and visual assessment in the previous 2 years (n = 1). Patients received a median of 6.5 (interquartile range 5-9) out of 16 possible strategies. Common strategies were mobility (n = 48), strength (n = 44) and Personal Activity of Daily Living training (n = 43). For 12 risk factors, if the factor was present, there was evidence of a strategy in more than 80% of records. CONCLUSIONS: There was little evidence that people at high risk of falls received systematic falls risk assessment during rehabilitation. When a risk was identified, generally a strategy was implemented. However, failure to assess some risk factors might have limited fall prevention strategies offered. Failure to adequately address risks during hospitalization could contribute to falls post-discharge. Geriatr Gerontol Int 2016; 16: 570-576.

A Phase 1 exercise dose escalation study for stroke survivors with impaired walking.

BACKGROUND: Targeted exercise and increased practice can improve the mobility of stroke survivors. However, many stroke survivors continue to have reduced physical work capacity and impaired walking, and experience frequent falls after participating in physical rehabilitation programs. AIM: In this Phase 1 study, we used a dose escalation method, common in pharmaceutical trials, to determine the maximum tolerable dose of multimodal exercise in community-dwelling stroke survivors with mobility impairment. METHODS: Stroke survivors 14-59 months poststroke participated in a 12-week (36 sessions) multimodal exercise program implemented using a cumulative 3 + 3 dose escalation design (featuring increasing doses in successive cohorts of three participants), with set dose-limiting tolerance criteria. The exercise intervention included challenging balance activities, strength, and endurance training. The program was individualized and focused on task-specific requirements for walking in the community. RESULTS: Six survivors participated before escalation was ceased. Four participants were able to tolerate up to 10·5 h/week of exercise, which included 283 min of endurance, 182 min of task practice, 138 min of strengthening, and 28 min resting. The program led to increased walking distance (Six-Minute Walk Test) and faster mobility (4 Square Step Test, Timed Up and Go Test), with pre-postimprovements averaging 23-41%. CONCLUSIONS: This is the first multimodal exercise dose escalation study in stroke. The maximal dose of exercise identified was dramatically higher than the dose typically delivered to stroke survivors in current trials. We now plan to confirm safety and feasibility of this program in a larger Phase II trial.

Over-ground walking on level and sloped surfaces in people with stroke compared to healthy matched adults.

PURPOSE: To investigate the basic spatio-temporal gait characteristics of people with stroke whilst walking on sloped and level terrain, and to compare this performance to healthy matched adults. METHOD: Fifteen community dwelling people with stroke who walked with a hemiplegic gait and a reference group of 15 adults without impairments matched for sex, age and height participated in this descriptive, observational study. Basic gait spatio-temporal measures were recorded at self-selected speed across a GAITRite mat placed on level, uphill and downhill (ramp gradient 1:14 or 4.1°) surfaces. Measures recorded were gait speed, cadence, step length, support base, single and double limb support duration and step length symmetry. Group and walking condition effects were assessed by two separate 2-way (group × slope) repeated measures multivariate analysis of variance. RESULTS: The stroke group walked slower (p < 0.001) than the reference group for all conditions. Within-group analyses found the stroke group decreased their speed and step length when walking downhill compared to level and uphill walking (p < 0.001). In contrast, the reference group maintained speed across all walking conditions. CONCLUSIONS: The findings suggest that walking on slopes affects gait speed in people with stroke and this may have implications when walking in the community. IMPLICATIONS FOR REHABILITATION: • Although a high percentage of people achieve walking independence following a stroke, few achieve independent community mobility. • Walking on slopes is an important aspect of community mobility. • When walking down a standard gradient ramp, people with stroke reduced their speed and step length, relative to level over-ground and uphill walking. • It is recommended that attention be directed to assessment and treatment of walking on slopes as part of stroke rehabilitation, as this may have implications when walking in the community.

Changes in balance and walking from stroke rehabilitation to the community: a follow-up observational study.

OBJECTIVES: To investigate (1) whether clinical test scores at discharge predict falls or limited community mobility after discharge from inpatient stroke rehabilitation; and (2) how walking and dynamic standing balance change after discharge. DESIGN: Follow-up observational study between 6 and 36 months after discharge. SETTING: Rehabilitation setting. PARTICIPANTS: Community-dwelling stroke survivors (N=30) who could walk unassisted when discharged from inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Six-minute walk test (6MWT), Four Square Step Test (FSST), Step Test (ST), Environmental Analysis of Mobility Questionnaire (EAMQ), Falls Efficacy Scale-International (FES-I), and self-reported falls. RESULTS: Follow-up occurred at a median of 14.5 months postdischarge. Significant improvements occurred between discharge and follow-up for the 6MWT (mean difference [MD]=110.1m; 95% confidence interval [CI], 70.8-149.4; P<.001), ST (MD=1.8 steps; 95% CI, 0.3-3.4; P=.03), and FSST (MD=4.3s; 95% CI, -10.3 to 1.6; P=.05). Despite this, 40% of participants reported falling. The group who fell had lower clinical test scores at discharge and follow-up than nonfallers. Specific cutoff scores for the clinical tests accurately classified falls history in 70% to 78% of participants. The cutoff scores were <250m for the 6MWT, <10 steps on the ST, and a failure or ≥15 seconds to complete the FSST. Participants performing under the cutoff scores reported lower levels of community mobility (EAMQ, P<.04). Concern about falling was only higher for those classified at risk by the FSST (FES-I, P=.008). CONCLUSIONS: The FSST, ST, and 6MWT scores at discharge had good falls prediction. People classified at risk of falls avoided more tasks in their home and community than those not classified at risk.

The test-retest reliability and responsiveness to change for the Hand Function Survey during stroke rehabilitation.

BACKGROUND/AIM: The Hand Function Survey (HFS) is a questionnaire designed to measure self-reported ability to use the affected hand during 13 everyday tasks in people with stroke. The HFS appears practical for clinical use and has established psychometric properties. This study aimed to investigate test-retest reliability and responsiveness to change for the HFS during stroke rehabilitation. METHODS: Twenty-two people with a first episode stroke, and without severe cognitive and language difficulties, participated. Participants were assessed on three occasions: baseline, 48 hours later and at follow-up (four to six weeks later) using two tests of upper extremity function, the HFS and the Action Research Arm Test (ARAT). Test-retest reliability of the HFS between baseline and 48 hours was examined using tests of agreement (Lin's Concordance and Cohen's Kappa). Responsive to change for the HFS was investigated by comparing the difference between baseline and follow-up scores. The level of agreement between the change observed for the ARAT and HFS was analysed. RESULTS: Strong agreement (Rho_c = 0.99; Κ(w) =0.97) was observed between the test-retest HFS scores. Significant improvement between baseline and follow-up occurred for both the HFS and ARAT. A moderate agreement was found between change observed for the HFS and ARAT (Rho_c=0.62; Κ(w) =0.65). CONCLUSION: The HFS was found to be a reliable and responsive self-report test of hand function during stroke rehabilitation. The HFS could be used in conjunction with other clinical tests of hand function during the rehabilitation of people with stroke without severe cognitive and language difficulties.