Measurement properties of the Activities-specific Balance Confidence Scale in adults from the general population with concussion: a report from the Toronto Concussion Study.

OBJECTIVE: The aim of this study was to establish the internal consistency and construct validity of the Activities-specific Balance Confidence (ABC) Scale and ABC-6 in adults from the general population with concussion. DESIGN: Prospective analysis. SETTING: Outpatient concussion care clinic. PARTICIPANTS: Adults from the general population with concussion referred to a concussion care clinic within 7 days of injury (n=511). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Balance confidence was assessed with the Activities-specific Balance Confidence Scale (ABC) and the ABC-6. Concussion symptoms were characterized using the Sport Concussion Assessment Tool (SCAT5) symptom checklist. Instrumented measures of balance and gait included centre of pressure (COP) velocity and double support time, respectively. Balance was also assessed using the mBESS (modified Balance Error Scoring System). RESULTS: The ABC and ABC-6 were strongly correlated (ρ=0.980, p<0.001). Cronbach's α for ABC and ABC-6 were 0.966 and 0.940, respectively. Factor analysis verified the existence of 2 components of the ABC, one including all items of the ABC-6 as well as 3 additional items. ABC and ABC-6 were moderately significantly correlated with SCAT5 symptom number, severity, and symptom domain (ρ=-0.350 to -0.604). However, correlations between ABC and ABC-6 with instrumented measures of balance and gait were not statistically significant, except for of double support time during dual task gait with ABC-6 (ρ=-0.218). CONCLUSIONS: In community dwelling adults with concussion, the ABC and ABC-6 have good internal consistency. Convergent validity is stronger for symptom endorsement measures within SCAT5 domains, which has a similar construct (subjectivity) to balance confidence. Both the ABC and ABC-6 are valid measures of balance self-efficacy in adults from the general population with concussion. The ABC-6 may be a useful tool for characterizing the impact of concussion on perceptions of the ability to perform functional tasks that challenge balance and mobility.

Clinical practice recommendations for management of lateropulsion after stroke determined by a Delphi expert panel.

OBJECTIVE: People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel. DESIGN: This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations. PARTICIPANTS: Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion. MAIN MEASURES: The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding 'unsure' responses. RESULTS: Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which 'some agreement' (50%-74% agreement) was achieved and those for which recommendations remain to be clarified were recorded. CONCLUSIONS: These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

Post-stroke lateropulsion terminology: pushing for agreement amongst experts.

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

The Toronto Concussion Study: Reference Data for Balance and Gait Measures in Community-Dwelling Adults With Concussion.

OBJECTIVE: Concussion can cause deficits in balance and gait. Much of what is known about how concussion affects balance and gait has been derived from studies involving youth, high school, and university athletes. However, investigation into the effects of concussion on balance and gait in community-dwelling young, middle-age, and older aged adults is limited. This study aimed to present descriptive reference values for common balance and gait measures in community-dwelling adults between the ages of 20 and 69 years with concussion. METHODS: In this observational study, 318 participants were enrolled from a concussion care clinic at a rehabilitation hospital in an urban center and were assessed within 7 days of injury. Balance measures included the Balance Error Scoring System (BESS), modified BESS, and center-of-pressure root mean square during quiet standing. Gait measures included velocity (absolute and height adjusted), cadence, and step length during self-paced gait. Data were binned by decade-long age range. RESULTS: Mean (SD) per-decade scores for the BESS ranged from 14.8 (5.1) to 21.8 (5.6) errors and 4.0 (3.0) to 9.4 (4.6) errors for the modified BESS. Mean values for center-of-pressure root mean square in the anteroposterior direction ranged from 0.42 (0.18) to 0.52 (0.26) with the eyes open, and from 0.49 (0.19) to 0.62 (0.39) with eyes closed. Mean absolute gait velocity ranged from 98.5 (9.1) to 119.3 (21.3) cm/s. The range of step length values was 58.2 (6.8) to 66.3 (7.3) cm and cadence ranged from 102.1 (9.8) to 108.6 (10.8) steps/min across age groups. CONCLUSION: These data provide insight into the impact of concussion on balance and mobility in community-dwelling adults across the lifespan. IMPACT: Community-dwelling adults can experience concussion across the lifespan. Availability of reference values for commonly used balance and gait measures can help to inform clinical strategies and progression of recovery of balance and mobility after injury.

Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study.

OBJECTIVE: Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting. METHODS: A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework and Consolidated Framework for Implementation Research informed content analysis for clinician and manager perspectives, respectively. RESULTS: Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources. CONCLUSION: Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills, the provision of clinical decision-making tools, access to expert consultation, the roles and social influence of the interprofessional team and formal and informal leaders, and supportive processes adapted to the local context. IMPACT: Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.

Rehabilitation clinicians' perspectives of reactive balance training.

PURPOSE: Reactive balance training (RBT) aims to improve reactive balance control. However, because RBT involves clients losing balance, clinicians may view that it is unsafe or not feasible for some clients. We aimed to explore how clinicians implement RBT to treat balance and mobility issues. MATERIALS AND METHODS: Physiotherapists and kinesiologists across Canada who reported that they include RBT in their practices were invited to complete telephone interviews about their experiences with RBT. Interviews were transcribed verbatim, and analysed using a deductive thematic analysis. RESULTS: Ten participants completed telephone interviews, which lasted between 30-60 min. Participants primarily worked in a hospital setting (inpatient rehabilitation (n = 3); outpatient rehabilitation (n = 2)), and were treated clients with neurological conditions (n = 5). Four main themes were identified: 1) there is variability in RBT approaches; 2) knowledge can be a barrier and facilitator to RBT; 3) reactive balance control is viewed as an advanced skill; and 4) RBT experience builds confidence. CONCLUSIONS: Our findings suggest a need for resources to make clinical implementation of RBT more feasible.Implications for rehabilitationTrust between the therapist and client improves self-efficacy and feelings of apprehension/fear when conducting reactive balance training.Being creative and improvising with equipment that is readily available in clinics enables reactive balance training, without the need for high-tech equipment.Clinicians should consider using standardized tools with reactive balance control components, such as the Balance Evaluation Systems Test or Performance Oriented Mobility Assessment, to assess balance control.

The Toronto concussion study: a cross-sectional analysis of balance deficits following acute concussion in community-dwelling adults.

Objective: To characterize balance deficits in community-dwelling adults following acute concussion.Design: Cross-sectional observational study.Methods: Individuals with acute concussion (n=100) and healthy controls (n=20) completed the BESS (Balance Error Scoring System) and quiet standing trials on forceplates with the eyes open, closed, or during a cognitive dual task. BESS score and centre-of-pressure root mean square and high-frequency power (0.4-3Hz) were used to characterize group differences. In a secondary analysis, participants were subdivided based on self-reported symptoms of balance problems and dizziness using the SCAT-3 (Sport Concussion Assessment Tool - Third Edition) Symptom Checklist.Results: In comparing individuals with concussion and controls, BESS score (16.0 ± 6.0 vs 12.6 ± 3.8; F(1,116) = 5.814, p = .017) and anteroposterior [F(1.78, 204.2) = 11.93, p < .001] and mediolateral [F(1, 114) = 10.05, p = .002] high-frequency power revealed significant group differences. Dividing individuals based on self-reported symptoms revealed significant differences in mediolateral high frequency power, such that participants reporting balance and dizziness problems as well as those participants not reporting balance or dizziness symptoms following concussion were less stable than controls.Conclusions: Deficits in clinical and posturographic measures of balance occur in community-dwelling adults with concussion. These measures do not align with self-reported balance symptoms. Future research and clinical practice aimed at careful selection of optimized balance assessment is recommended.

Publication Rate and Consistency of Registered Trials of Motor-Based Stroke Rehabilitation.

OBJECTIVE: To determine the publication rate of motor-rehabilitation trials poststroke and the consistency between registry records and their corresponding main publications in trial design, primary objectives and outcomes, eligibility criteria, and sample size. METHODS: We searched 18 clinical trial registries to identify randomized controlled trials of motor-based stroke rehabilitation registered after July 2005 and completed before April 2017. Eligible trials included adults with stroke, with at least one outcome measure related to motor function. Information in the registry records was compared with that of their main publications, if any. RESULTS: Three hundred twenty-three trials met our eligibility criteria; we were unable to find a peer-reviewed publication reporting the main findings for 46% (150/323) of these. Of the 169 trials with peer-reviewed articles published in English, 141 (83%) were consistent with the registry record in trial design, 100 (59%) were consistent in primary objectives, 71 (42%) were consistent in primary outcomes, 28 (17%) were consistent in eligibility criteria, and 74 (44%) were consistent in sample size. CONCLUSIONS: Approximately half of motor-based stroke rehabilitation trials were not published, even more than 3 years after the end of the trial. When main publications were found, they substantially deviated from information in the registry record. These findings highlight the importance of trial registries for identifying unpublished stroke rehabilitation trials and of searching trial registries when conducting systematic reviews and meta-analysis to help ensure that reviews are unbiased.

A survey of Canadian healthcare professionals' practices regarding reactive balance training.

Background: Perturbation-based balance training (PBT) is a relatively new type of balance training that aims to improve control of reactions to a loss of balance. This study aimed to determine the prevalence of use of PBT in clinical practice, and the most significant barriers and facilitators to implementing PBT in practice.Methods: Health-care professionals across Canada (primarily physiotherapists and kinesiologists) who provide balance training to individuals with balance impairments and/or increased fall risk completed a questionnaire that asked about knowledge and use of PBT in practice.Results: Overall, 76.3% of participants (299/392) reported that they had used PBT in their practices, with 22.4% (88/392) reporting regular PBT use. Lack of knowledge of PBT appeared to be the most significant barrier for those not currently using PBT in their practices, whereas individuals who were familiar with PBT and open to using it in practice experienced barriers related to training, knowledge, human resources, client characteristics, and the practice setting. More than 90% of respondents were interested in learning more about almost all aspects of PBT.Conclusions: These findings could be used to inform development of future educational strategies to increase uptake of PBT in rehabilitation practice.

Determining the optimal dose of reactive balance training after stroke: study protocol for a pilot randomised controlled trial.

INTRODUCTION: Falls risk poststroke is highest soon after discharge from rehabilitation. Reactive balance training (RBT) aims to improve control of reactions to prevent falling after a loss of balance. In healthy older adults, a single RBT session can lead to lasting improvements in reactive balance control and prevent falls in daily life. While increasing the dose of RBT does not appear to lead to additional benefit for healthy older adults, stroke survivors, who have more severely impaired balance control, may benefit from a higher RBT dose. Our long-term goal is to determine the optimal dose of RBT in people with subacute stroke. This assessor-blinded pilot randomised controlled trial aims to inform the design of a larger trial to address this long-term goal. METHODS AND ANALYSIS: Participants (n=36) will be attending out-patient stroke rehabilitation, and will be randomly allocated to one of three groups: one, three or six RBT sessions. RBT will replace a portion of participants' regular physiotherapy so that the total physical rehabilitation time will be the same for the three groups. Balance and balance confidence will be assessed at: (1) study enrolment; (2) out-patient rehabilitation discharge; and (3) 6 months postdischarge. Participants will report falls and physical activity for 6 months postdischarge. Pilot data will be used to plan the larger trial (ie, sample size estimate using fall rates, and which groups should be included based on between-group trends in pre-to-post training effect sizes for reactive balance control measures). Pilot data will also be used to assess the feasibility of the larger trial (ie, based on the accrual rate, outcome completion rate and feasibility of prescribing specific training doses). ETHICS AND DISSEMINATION: Institutional research ethics approval has been received. Study participants will receive a lay summary of results. We will also publish our findings in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04219696; Pre results.

The Toronto Concussion Study: a longitudinal analysis of balance deficits following concussion in community-dwelling adults.

OBJECTIVE: To characterize recovery of balance deficits in community-dwelling adults with concussion. HYPOTHESIS: Balance measures will improve 2 weeks after injury and persist over 12 weeks. DESIGN: Prospective longitudinal observational study. METHODS: Assessments included the Balance Error Scoring System (BESS) and quiet standing during eyes open, eyes closed, and a cognitive dual task. Recovery was determined using a Hierarchical Growth Curve Model (HGCM) at Week1 (n = 61), Week2 (n = 58), Week4 (n = 53), Week8 (n = 51), and Week12 (n = 39) post-injury. Within-individual follow-up analysis was conducted using the coefficient of variation (quiet standing measures) and a reliable change index (BESS) on 28 individuals with concussion assessed at all 5 time points. RESULTS: Self-reported symptom score recovered between Week 4-8. Anteroposterior COP velocity (eyes closed) was the only variable to show statistically significant (p < .05) recovery in the HGCM. The within-individual analysis identified fewer than 43% (12/28) of participants recovered by Week 12, relative to their own Week 1 assessment. CONCLUSIONS: While recovery of balance deficits was observed in 1 variable over 12 weeks, less than half of the participants included in all assessments demonstrated improvement in balance outcomes. Future research and clinical practice should focus on the unique characteristics of community-dwelling adults with concussion to optimize recovery in this cohort.

Effect of reactive balance training on physical fitness poststroke: study protocol for a randomised non-inferiority trial.

INTRODUCTION: Regular exercise is essential in the chronic phase of stroke recovery for improving or maintaining function, and reducing the risk of a second stroke. To achieve these goals, multiple components of fitness should be targeted with poststroke exercise, including aerobic capacity, strength and balance. However, following the recommended frequency and duration of each component separately can take a long time and lead to fatigue in people with stroke. Therefore, finding types of exercise that target multiple components of fitness all together is valuable.Reactive balance training (RBT) is a novel type of exercise where individuals repeatedly lose their balance in order to practise balance reactions. When people do RBT, they increase their heart rate and exert forces with their leg muscles which could improve aerobic fitness and muscle strength, respectively. This means that RBT could have the potential to improve multiple components of fitness, simultaneously. METHODS AND ANALYSIS: This is a randomised controlled non-inferiority trial with internal pilot study. Participants with chronic stroke will be randomly assigned to one of two groups: (1) RBT or (2) aerobic and strength training (AST). Participants in both groups will complete 1 hour of exercise, three times/week for 12 weeks. The primary objective is to determine the effect of RBT on aerobic capacity and knee muscles' strength. The secondary objective is to determine the effects of RBT and AST on balance control and balance confidence. We expect to find that RBT is superior to AST in terms of improving balance control and balance confidence, yet not inferior to AST in terms of its effects on aerobic capacity and strength. ETHICS AND DISSEMINATION: Research ethics approval has been received. Results will be disseminated directly to study participants at the end of the trial, and to other stakeholders via publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT04042961.

Barriers and Facilitators to Aerobic Exercise Implementation in Stroke Rehabilitation: A Scoping Review.

BACKGROUND AND PURPOSE: Aerobic exercise is a recommended part of stroke best practices; yet, access to aerobic exercise programs within stroke rehabilitation remains limited and inconsistent. The purpose of this scoping review was to describe the nature and extent of barriers and facilitators to aerobic exercise implementation with adults post-stroke as reported by health care professionals. METHODS: MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, and AMED Allied and Complementary Medicine were searched from inception to October 16, 2019. Research studies that examined health care professionals' barriers and facilitators to aerobic exercise implementation in adults post-stroke were included. Two reviewers independently conducted title and abstract screening, full-text evaluation, data extraction, and quality appraisal. The Theoretical Domains Framework was used to map the identified barriers or facilitators and to analyze and interpret the results. RESULTS: Four studies were included in the review. All studies involved surveys conducted among physical therapists and reported barriers related to "environmental context and resources" (eg, lack of equipment, time, staff), insufficient "knowledge" and "skills" (eg, safe aerobic exercise prescription and implementation), "beliefs about capabilities" (eg, uncertainty about exercise intensity and screening tools), and professional role and identity (eg, aerobic exercise not a priority). Access to and continued education in structured aerobic exercise programs and safety monitoring were identified facilitators. DISCUSSION AND CONCLUSIONS: Some of the identified barriers could be overcome with modeling and training in best practice, while others may require interventions targeting organizational environment and leadership. Future knowledge translation interventions should target the identified barriers and facilitators to implementing aerobic exercise.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A312).

Determining Safe Participation in Aerobic Exercise Early After Stroke Through a Graded Submaximal Exercise Test.

OBJECTIVE: The benefits of aerobic exercise early after stroke are well known, but concerns about cardiovascular risk are a barrier to clinical implementation. Symptom-limited exercise testing with electrocardiography (ECG) is recommended but not always feasible. The purpose of this study was to determine the frequency of and corresponding exercise intensities at which ECG abnormalities occurred during submaximal exercise testing that would limit safe exercise prescription beyond those intensities. METHODS: This study was a retrospective analysis of ECGs from 195 patients who completed submaximal exercise testing during stroke rehabilitation. A graded submaximal exercise test was conducted with a 5- or 12-lead ECG and was terminated on the basis of predetermined endpoint criteria (heart rate, perceived exertion, signs, or symptoms). ECGs were retrospectively reviewed for exercise-induced abnormalities and their associated heart rates. RESULTS: The peak heart rate achieved was 65.4% (SD = 10.5%) of the predicted maximum heart rate or 29.1% (SD = 15.5%) of the heart rate reserve (adjusted for beta-blocker medications). The test was terminated more often because of perceived exertion (93/195) than because of heart rate limits (60/195). Four patients (2.1%) exhibited exercise-induced horizontal or downsloping ST segment depression of ≥1 mm. Except for 1 patient, the heart rate at test termination was comparable with the heart rate associated with the onset of the ECG abnormality. CONCLUSION: A graded submaximal exercise test without ECG but with symptom monitoring and conservative heart rate and perceived exertion endpoints may facilitate safe exercise intensities early after stroke. Symptom-limited exercise testing with ECG is still recommended when progressing to higher intensity exercise. IMPACT: Concerns about cardiovascular risk are a barrier to physical therapists implementing aerobic exercise in stroke rehabilitation. This study showed that, in the absence of access to exercise testing with ECG, submaximal testing with conservative heart rate and perceived exertion endpoints and symptom monitoring can support physical therapists in the safe prescription of aerobic exercise early after stroke. LAY SUMMARY: It is recommended that people with stroke participate in aerobic exercise as early as possible during their rehabilitation. A submaximal exercise test with monitoring of heart rate, perceived exertion, blood pressure, and symptoms can support physical therapists in safely prescribing that exercise.

Improvements in balance reaction impairments following reactive balance training in individuals with sub-acute stroke: A prospective cohort study with historical control.

Background: Reactive balance training (RBT) has been previously found to reduce fall risk in individuals with sub-acute stroke; however, our understanding of the effects of RBT on specific balance impairments is lacking.Objective: To quantify changes in common balance reaction impairments in individuals with sub-acute stroke resulting from RBT, relative to traditional balance training, using a prospective cohort study design with a historical control group.Methods: Individuals with sub-acute stroke completed either RBT or traditional balance training as part of their routine care during physiotherapy in inpatient rehabilitation. Reactive balance control was assessed using lean-and-release perturbations pre-intervention, post-intervention, and 6-months post-intervention (follow-up). Individuals with impaired balance reactions (delayed foot-off times, slide steps, and/or a preference for stepping with the preferred limb) at the pre-intervention assessment were identified using video and force plate data. Outcome measures (foot-off times, frequency of trials with slide steps, and stepping with the preferred limb) from the RBT participants with impaired reactions were compared for each of the three assessments to the mean values for the participants with impaired reactions in the historical control group.Results: Improvements were observed in all outcome measures for the RBT participants between pre-intervention and post-intervention, and/or between post-intervention and follow-up. These improvements were generally equivalent to, if not better than, the improvements demonstrated by the historical control group.Conclusions: Findings further support the use of RBT for post-stroke inpatient rehabilitation, and provide insight into specific balance reaction impairments that are improved by RBT.

Self-reported Balance Disturbance and Performance-Based Balance Impairment After Concussion in the General Population.

OBJECTIVE: To characterize the prevalence of, and relationship between, self-reported balance disturbance and performance-based balance impairment in the general population with concussion. SETTING: Rehabilitation hospital outpatient concussion clinic. PARTICIPANTS: One hundred six individuals with concussion (49 males, mean age = 32.4; SD = 11.5 years), mean (SD) = 5 (1.8) days postinjury. DESIGN: Cross-sectional observational study. MAIN MEASURES: SCAT3 Symptoms Subscale, Balance Error Scoring System, modified Balance Error Scoring System, and center-of-pressure root-mean-square amplitude and velocity in eyes open and closed conditions. RESULTS: The majority of participants reported balance or dizziness symptoms (54% and 63%, respectively) and demonstrated balance impairment on the Balance Error Scoring System and modified Balance Error Scoring System (66% and 58%, respectively). The prevalence of balance impairment across center-of-pressure measures varied from 32% to 48%. There was no effect of balance or dizziness symptom severity on any of the balance measures (F2,103 = 1.02; P = .44) and (F2,103 = 1.45; P = .10), respectively. There was poor agreement between self-report of balance/dizziness symptoms and identified balance impairment across all balance measures (all κ ≤ 0.26 and κ ≤ 0.20, respectively). CONCLUSIONS: There was no clear relationship between the subjective experience of balance disturbance and objective measures of balance impairment in the general population. These results have implications for clinical evaluation of postconcussive deficits and determination of recovery.

Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial.

OBJECTIVES: No intervention has been shown to prevent falls poststroke. We aimed to determine if perturbation-based balance training (PBT) can reduce falls in daily life among individuals with chronic stroke. DESIGN: Assessor-blinded randomised controlled trial. SETTING: Two academic hospitals in an urban area. INTERVENTIONS: Participants were allocated using stratified blocked randomisation to either 'traditional' balance training (control) or PBT. PBT focused on improving responses to instability, whereas traditional balance training focused on maintaining stability during functional tasks. Training sessions were 1 hour twice/week for 6 weeks. Participants were also invited to complete 2 'booster' training sessions during the follow-up. PARTICIPANTS: Eighty-eight participants with chronic stroke (>6 months poststroke) were recruited and randomly allocated one of the two interventions. Five participants withdrew; 42 (control) and 41 (PBT group) were included in the analysis. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was rate of falls in the 12 months post-training. Negative binomial regression was used to compare fall rates between groups. Secondary outcomes were measures of balance, mobility, balance confidence, physical activity and social integration. RESULTS: PBT participants reported 53 falls (1.45 falls/person-year) and control participants reported 64 falls (1.72 falls/person-year; rate ratio: 0.85(0.42 to 1.69); p=0.63). Per-protocol analysis included 32 PBT and 34 control participants who completed at least 10/12 initial training sessions and 1 booster session. Within this subset, PBT participants reported 32 falls (1.07 falls/person-year) and control participants reported 57 falls (1.75 falls/person-year; rate ratio: 0.62(0.29 to 1.30); p=0.20). PBT participants had greater improvement in reactive balance control than the control group, and these improvements were sustained 12 months post-training. There were no intervention-related serious adverse effects. CONCLUSIONS: The results are inconclusive. PBT may help to prevent falls in daily life poststroke, but ongoing training may be required to maintain the benefits. TRIAL REGISTRATION NUMBER: ISRCTN05434601; Results.

Characterization of Reactions to Laterally Directed Perturbations in People With Chronic Stroke.

Background: Reactive balance control is often impaired poststroke. Studies addressing responses to laterally directed perturbations in this population are currently lacking. Given that stroke-related motor impairments are unilateral, a better understanding of reactive balance responses to these types of perturbations is critical. Objective: This study aimed to quantify differences in reactive balance control in response to laterally directed perturbations in people with chronic stroke, based on perturbation direction and ability to step with either limb. Design: This study used a cross-sectional design. Methods: Participants with chronic stroke (N = 19) were divided into groups representing their ability to step with either limb, based on performance on a reactive balance task in a baseline assessment. The preferred stepping limb was also identified during this assessment. Each participant then underwent a series of laterally directed perturbations on a motion platform. Behavioral measures were compared between platform direction and group. Results: Trials with extra steps, step initiation with the preferred limb, and crossover steps were more common with platform motion toward the preferred limb compared to the nonpreferred limb; the latter effect was only observed for participants with an impaired ability to step with either limb. Side-step sequences were more common in those able to step with either limb when the platform moved toward the preferred limb. Limitations: The participant sample was likely higher functioning than the general population of stroke survivors due to equipment constraints. Additionally, participants may have developed strategies to use the platform's motion characteristics to aid with balance recovery. Conclusions: These findings provide an indication of responses to laterally directed perturbations in people with chronic stroke and may help inform strategies for improving reactive balance control during stroke rehabilitation.

Promoting Optimal Physical Exercise for Life (PROPEL): aerobic exercise and self-management early after stroke to increase daily physical activity-study protocol for a stepped-wedge randomised trial.

INTRODUCTION: Physical exercise after stroke is essential for improving recovery and general health, and reducing future stroke risk. However, people with stroke are not sufficiently active on return to the community after rehabilitation. We developed the Promoting Optimal Physical Exercise for Life (PROPEL) programme, which combines exercise with self-management strategies within rehabilitation to promote ongoing physical activity in the community after rehabilitation. This study aims to evaluate the effect of PROPEL on long-term participation in exercise after discharge from stroke rehabilitation. We hypothesise that individuals who complete PROPEL will be more likely to meet recommended frequency, duration and intensity of exercise compared with individuals who do not complete the programme up to 6 months post discharge from stroke rehabilitation. METHODS AND ANALYSIS: Individuals undergoing outpatient stroke rehabilitation at one of six hospitals will be recruited (target n=192 total). A stepped-wedge design will be employed; that is, the PROPEL intervention (group exercise plus self-management) will be 'rolled out' to each site at a random time within the study period. Prior to roll-out of the PROPEL intervention, sites will complete the control intervention (group aerobic exercise only). Participation in physical activity for 6 months post discharge will be measured via activity and heart rate monitors, and standardised physical activity questionnaire. Adherence to exercise guidelines will be evaluated by (1) number of 'active minutes' per week (from the activity monitor), (2) amount of time per week when heart rate is within a target range (ie, 55%-80% of age-predicted maximum) and (3) amount of time per week completing 'moderate' or 'strenuous' physical activities (from the questionnaire). We will compare the proportion of active and inactive individuals at 6 months post intervention using mixed-model logistic regression, with fixed effects of time and phase and random effect of cluster (site). ETHICS AND DISSEMINATION: To date, research ethics approval has been received from five of the six sites, with conditional approval granted by the sixth site. Results will be disseminated directly to study participants at the end of the trial, and to other stake holders via publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02951338; Pre-results.

Does Perturbation Training Prevent Falls after Discharge from Stroke Rehabilitation? A Prospective Cohort Study with Historical Control.

BACKGROUND: Individuals with stroke fall frequently, and no exercise intervention has been shown to prevent falls post stroke. Perturbation-based balance training (PBT), which involves practicing reactions to instability, shows promise for preventing falls in older adults and individuals with Parkinson's disease. This study aimed to determine if PBT during inpatient stroke rehabilitation can prevent falls after discharge into the community. METHODS: Individuals with subacute stroke completed PBT as part of routine inpatient rehabilitation (n = 31). Participants reported falls experienced in daily life for up to 6 months post discharge. Fall rates were compared to a matched historical control group (HIS) who did not complete PBT during inpatient rehabilitation. RESULTS: Five of 31 PBT participants, compared to 15 of 31 HIS participants, reported at least 1 fall. PBT participants reported 10 falls (.84 falls per person per year) whereas HIS participants reported 31 falls (2.0 falls per person per year). When controlled for follow-up duration and motor impairment, fall rates were lower in the PBT group than the HIS group (rate ratio: .36 [.15, .79]; P = .016). CONCLUSIONS: These findings suggest that PBT is promising for reducing falls post stroke. While this was not a randomized controlled trial, this study may provide sufficient evidence for implementing PBT in stroke rehabilitation practice.