Home-based upper limb stroke rehabilitation mechatronics: challenges and opportunities.

Interest in home-based stroke rehabilitation mechatronics, which includes both robots and sensor mechanisms, has increased over the past 12 years. The COVID-19 pandemic has exacerbated the existing lack of access to rehabilitation for stroke survivors post-discharge. Home-based stroke rehabilitation devices could improve access to rehabilitation for stroke survivors, but the home environment presents unique challenges compared to clinics. The present study undertakes a scoping review of designs for at-home upper limb stroke rehabilitation mechatronic devices to identify important design principles and areas for improvement. Online databases were used to identify papers published 2010-2021 describing novel rehabilitation device designs, from which 59 publications were selected describing 38 unique designs. The devices were categorized and listed according to their target anatomy, possible therapy tasks, structure, and features. Twenty-two devices targeted proximal (shoulder and elbow) anatomy, 13 targeted distal (wrist and hand) anatomy, and three targeted the whole arm and hand. Devices with a greater number of actuators in the design were more expensive, with a small number of devices using a mix of actuated and unactuated degrees of freedom to target more complex anatomy while reducing the cost. Twenty-six of the device designs did not specify their target users' function or impairment, nor did they specify a target therapy activity, task, or exercise. Twenty-three of the devices were capable of reaching tasks, 6 of which included grasping capabilities. Compliant structures were the most common approach of including safety features in the design. Only three devices were designed to detect compensation, or undesirable posture, during therapy activities. Six of the 38 device designs mention consulting stakeholders during the design process, only two of which consulted patients specifically. Without stakeholder involvement, these designs risk being disconnected from user needs and rehabilitation best practices. Devices that combine actuated and unactuated degrees of freedom allow a greater variety and complexity of tasks while not significantly increasing their cost. Future home-based upper limb stroke rehabilitation mechatronic designs should provide information on patient posture during task execution, design with specific patient capabilities and needs in mind, and clearly link the features of the design to users' needs.

Oasis Senior Supportive Living: Description of a Novel Aging-in-Place Model in Ontario.

Older adults are the fastest-growing demographic group in Canada, and the majority of older adults want to age-in-place within their communities. Many older adults live in naturally occurring retirement communities (NORCs), unplanned communities with a high proportion of older residents. NORC supportive services programs can help older adults successfully age-in-place. One such program is Oasis Senior Supportive Living, a partnership between older adults, building owners and managers, community partners, funders, and researchers. Using a qualitative approach, interviews were conducted with Oasis participants to understand their experiences of Oasis. This article will describe the three pillars upon which Oasis programming is based and provide insights from Oasis participants. It will discuss nutrition programming implemented in these NORCs and suggest how dietitians can support NORC residents.

Identification and engagement of naturally occurring retirement communities to support healthy aging in Canada: A set of methods for replication.

BACKGROUND: Naturally occurring retirement communities (NORCs), unplanned communities with a high proportion of older adult residents, offer a model to support older adults to age well in place. The aim of this paper is to provide a comprehensive description of the methods used to identify and engage NORCs appropriate for the development of supportive service programming in Canada. METHODS: Three steps were used to identify and select NORCs in which to develop supportive service programming including: 1) identification of potential NORCs using Canadian Census Dissemination Areas, the Ontario Marginalization Index and Google Maps, 2) engagement of property owner/manager to determine the availability of common space for communal programming and willingness of the owner to support programming and, 3) engagement of older adult residents within the NORC to co-design programming. RESULTS: Four cities in the south-east, south-central, and south-west of Ontario, Canada were identified to develop NORCs with supportive service programming. Using the methods described, six NORCs were identified, landlords and older adult residents were engaged, and programs initiated between April 2018 and March 2019. The sites included two private high-rise apartments, a city-owned low-rise subsidized apartment complex, two multi-building private high-rise complexes and a mobile home community. An average of 35 (min 20, max 78) older adult members were engaged in an average of 20.5 unique activity sessions at each site per month. On average, social (54%) and physical activities (30%) were more common than nutritional (10%) and knowledge-sharing (8%). CONCLUSIONS: The increased prevalence of unplanned, geographically-bound NORCs creates an opportunity for governments, social and health service providers and policy makers to support healthy aging in their communities. Our experience with the creation of six new NORCs with supportive service programming provides a tested set of methods that can be applied in other communities.

Naturally Occurring Retirement Communities: Scoping Review.

BACKGROUND: As Canada's population ages, there is a need to explore community-based solutions to support older adults. Naturally occurring retirement communities (NORCs), defined in 1986 as buildings or areas not specifically designed for, but which attract, older adults and associated NORC supportive service programs (NORC-SSPs) have been described as potential resources to support aging in place. Though the body of literature on NORCs has been growing since the 1980s, no synthesis of this work has been conducted to date. OBJECTIVE: The goal of this scoping review is to highlight the current state of NORC literature to inform future research and offer a summarized description of NORCs and how they have supported, and can support, older adults to age in place. METHODS: Using a published framework, a scoping review was conducted by searching 13 databases from earliest date of coverage to January 2022. We included English peer- and non-peer-reviewed scholarly journal publications that described, critiqued, reflected on, or researched NORCs. Aging-in-place literature with little to no mention of NORCs was excluded, as were studies that recruited participants from NORCs but did not connect findings to the setting. A qualitative content analysis of the literature was conducted, guided by a conceptual framework, to examine the promise of NORC programs to promote aging in place. RESULTS: From 787 publications, we included 64 (8.1%) articles. All publications were North American, and nearly half used a descriptive research approach (31/64, 48%). A little more than half provided a specific definition of a NORC (33/64, 52%); of these, 13 (39%) used the 1986 definition; yet, there were discrepancies in the defined proportions of older adults that constitute a NORC (eg, 40% or 50%). Of the 64 articles, 6 (9%) described processes for identifying NORCs and 39 (61%) specifically described NORC-SSPs and included both external partnerships with organizations for service delivery (33/39, 85%) and internal resources such as staff, volunteers, or neighbors. Identified key components of a NORC-SSP included activities fostering social relationships (25/64, 39%) and access to resources and services (26/64, 41%). Sustainability and funding of NORC-SSPs were described (27/64, 42%), particularly as challenges to success. Initial outcomes, including self-efficacy (6/64, 9%) and increased access to social and health supports (14/64, 22%) were cited; however, long-term outcomes were lacking. CONCLUSIONS: This review synthesizes the NORC literature to date and demonstrates that NORC-SSPs have potential as an alternative model of supporting aging in place. Longitudinal research exploring the impacts of both NORCs and NORC-SSPs on older adult health and well-being is recommended. Future research should also explore ways to improve the sustainability of NORC-SSPs.

A Systematic Review and Meta-Analysis of Exercise Interventions and Use of Exercise Principles to Reduce Fear of Falling in Community-Dwelling Older Adults.

OBJECTIVE: Fear of falling (FOF) contributes to activity restriction and institutionalization among older adults, and exercise interventions are linked to reduction in FOF. Adhering to exercise principles and adapting optimal exercise parameters are fundamental to optimizing the effectiveness of exercise interventions. The purpose of this review was to describe FOF exercise interventions in community-dwelling older adults, evaluate the extent to which these interventions followed the exercise principles and reported exercise parameters, and quantify the effect of these interventions on reducing FOF. METHODS: Randomized controlled trials (RCTs) of FOF exercise interventions in older adults (≥65 years) were identified from 4 databases. The methodological quality of RCTs was assessed using the Physiotherapy Evidence Database scale. A random-effect model was used in the meta-analysis. RESULTS: Seventy-five RCTs were included in this review. With regard to reporting exercise principles, specificity was reported in 92% of trials, progression in 72%, reversibility in 32%, overload in 31%, diminished return in 21%, and initial value in 8%. For exercise parameters, 97% of RCTs reported exercise type; 89%, frequency; and 85%, time. Only 25% reported the intensity. The pooled effect of exercise interventions on FOF among all included studies was a standard mean difference of -0.34 (95% CI = -0.44 to -0.23). CONCLUSION: This study showed a significant small to moderate effect size of exercise interventions in reducing FOF among community-dwelling older adults. Most exercise principles and intensity of exercises were not adequately reported in included trials. IMPACT: These inadequate reports could undermine efforts to examine the optimal dosage for exercise prescription. More attention must be given to designing and reporting components of therapeutic exercise programs to facilitate evidence-based practice.

Selection of a quality of life instrument for polio survivors in Northwest Nigeria.

BACKGROUND: To generate high-quality evidence, contextually relevant outcome measurement instruments are required. Quality of life evaluation among polio survivors typically involves the use of generic instruments, which are developed and validated among a different groups of people. There is no clear evidence whether these instruments are appropriate for the measurement of quality of life among polio survivors in northwest Nigeria. The purpose of this review is to identify and select a pre-existing instrument that is best suited for the measurement of quality of life among polio survivors in northwest Nigeria. METHODS: Using the findings of a previous scoping review of the literature and qualitative descriptive study, we screened 11 quality of life instruments that are used in polio literature. We identified and selected the most appropriate instrument, which reflected the perspectives of polio survivors in northwest Nigeria and at the same time exhibited good measurement properties. RESULTS: The Quality of Life Index, World Health Organization Quality of Life Brief, and Comprehensive Quality of Life Scale are consistent with the perspectives of polio survivors in northwest Nigeria and have satisfactory measurement properties. Among these instruments, the Quality of Life Index satisfied most of the screening criteria we employed and is suitable for cross-cultural adaptation in northwest Nigeria. CONCLUSION: Most instruments that are employed to evaluate the quality of life of polio survivors were not primarily designed as a measure of quality of life. To select the appropriate instrument, there is a need to consider and reflect the perspectives of the individuals, to improve the validity of the measurement.

Global cognition predicts the incidence of poor physical performance among older adults: A cross-national study.

AIM: The relationship between physical performance and cognition is well established. However, findings on the relationship between global cognition and the incidence of functional disability has been inconsistent. Using data from the International Mobility in Aging Study, we investigated the relationship between baseline cognitive function and the incidence of poor physical performance 2 years later. METHODS: A total of 1071 community-dwelling participants (aged 64-75 years) from four sites in Canada and Latin America, with a Short Physical Performance Battery score ≥9 at baseline (good performance) were included. We carried out two sets of analyses, measuring cognition with either the Leganés Cognitive Test or the Montreal Cognitive Assessment. We used three logistic regression models, controlling for either no confounders, sociodemographic confounders or sociodemographic and health confounders. The full model was also stratified by site. A score <9 on the Short Physical Performance Battery indicated poor physical performance. RESULTS: In the fully adjusted model, each 1-point increase in the baseline Leganés Cognitive Test score (range 0-32) was associated with a 10% decrease in the odds of incidence of poor physical performance at the 2-year follow-up (P = 0.019). Likewise, each 1-point increase in the baseline Montreal Cognitive Assessment score (range 0-30) was associated with a 16% decrease in the odds of developing poor physical performance (P = 0.005). When stratified by site, the results were significant at the Latin American sites (P = 0.02), but not at the Canadian sites (P = 0.08). CONCLUSIONS: Poor baseline cognition is associated with the incidence of poor physical performance in community-dwelling older adults. To prevent physical disability, interventions addressing both cognitive and physical performance are required. Geriatr Gerontol Int 2020; ••: ••-••.

Promoting Independent Mobility-related Physical ACTivity (IMPACT) in an inpatient stroke rehabilitation unit: a proof-of-concept evaluation of self-management intervention.

Purpose: To establish proof-of-concept of a novel rehabilitation self-management program that aims to optimize walking recovery after stroke through engaging patients in independent walking-related practice outside of supervised physiotherapy sessions.Materials and Methods: The Independent Mobility-related Physical ACTivity (IMPACT) Program is a coach-supported intervention that uses self-management strategies to empower patients to engage in additional autonomous walking-related activities after stroke during and after inpatient rehabilitation. The aim of this study was to assess whether implementation of this intervention would be associated with targeted patient behaviors; goal setting, negotiation and completion of a walking-related practice plan outside of formal therapy sessions. Using a pre-intervention/post-intervention design, the Independent Mobility-related Physical Activity program was implemented with a convenience sample of 10 adults (mean age 62.3; SD 11.7 years) within an inpatient stroke rehabilitation unit (mean stroke onset 25.3 [SD 10.5] days).Results: All participants were able to set a personal goal, negotiate an autonomous walking-related activity practice plan, and partially or completely adhere to that plan. Patients completed an average of 36 min/day of practice outside of supervised physiotherapy, practicing on weekdays and weekend days. All patients indicated that the Independent Mobility-related Physical Activity program helped them increase their activity, and indicated they would continue to practice walking-related activities beyond the coaching period.Implications for rehabilitationThe IMPACT program is a feasible self-management strategy to facilitate walking-related practice outside of supervised therapy time during inpatient stroke rehabilitation.Patients were able to engage in goal-setting and practice plan development with support of a therapist-coach.Patients who are able to stand and walk with minimal assist were able to practice walking-related activities outside of formal therapy sessions.Therapists may benefit from specific training and support to adopt self-management strategies into practice.

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.

Validity of the ActiGraph activity monitor for individuals who walk slowly post-stroke.

Background Slow and asymmetric gait post-stroke may reduce the accuracy of accelerometers (e.g. ActiGraph [AG]) to measure activity. Objectives To (1) determine the validity of AG step counts post-stroke; (2) develop guidelines for low frequency extension filter (LFE) use; and (3) determine the feasibility of daily accelerometer wear. Methods Adults with (n = 33) and without stroke (n = 20) wore three devices for approximately 7 h on a single day: ankle AG, waist AG, and a reference accelerometer at the ankle (REFA). AG step counts processed with and without the LFE were compared to REFA with paired difference tests. Agreement was measured with intraclass correlation coefficients (ICC3,1). Relationships between error (AG - REFA) and motor impairment and gait performance were plotted to determine a threshold for LFE application. A feasibility questionnaire was distributed to participants to investigate the applicability of the AG in clinical populations. Results Step counts from ankle AG in the stroke group (p = 0.53) and waist AG in the healthy group (p = 0.10) were similar to REFA. Waist AG under-counted, and ankle and waist AG with LFE over-counted steps in the stroke group (all p < 0.0001). ICC3,1 ranged from 0.70 to 0.82 (stroke) and 0.79-0.92 (healthy). Ankle AG error and stance time symmetry (stroke) were correlated (r = 0.41, p = 0.02); however, no threshold for LFE application was revealed. Ankle AG was rated very comfortable by 26/33 participants with stroke and 12/20 healthy participants. Conclusions The AG worn at the unaffected ankle without LFE produced the most accurate step count in people with stroke. We were unable to establish guidelines for LFE use.

Lessons about Motor Learning: How Is Motor Learning Taught in Physical Therapy Programmes Across Canada?

Purpose: This article describes the content of and delivery methods for motor learning (ML) education and the attitudes and beliefs of instructors with regard to how ML is taught in Canadian physical therapy (PT) programmes. Method: A qualitative descriptive design was employed, using an online questionnaire and semi-structured telephone interviews. A descriptive content analysis was used to develop codes and themes. An online search of PT programme Web sites was conducted to supplement missing data and collect information from schools that did not participate in the online questionnaire or interview. Results: Eight individuals representing seven schools completed the questionnaire; six of the eight also completed the interview. Responses conveyed the fact that ML content was fairly consistent across schools and was predominantly situated in the neurological curriculum. Schools differed in the delivery methods used for clinical application of ML content. Respondents believed that ML underlies PT practice and should be integrated throughout the programme. Conclusion: Current instruction may deliver adequate ML content but may not provide optimal opportunities to apply ML principles in a clinical context. Continuing education emerged as one suggestion for remediating clinicians' knowledge-practice gap and facilitating student learning on placement. Only half the eligible PT schools participated, and all were English-language programmes; thus, the findings may not be generalizable to all Canadian programmes. Future work should explore how ML can be integrated into the PT curriculum to promote the application of ML principles across different fields. Students' perspectives on their understanding of ML and ML principles and self-efficacy for entry to practice should also be explored.

Objectif : décrire le contenu et le mode de prestation de l'apprentissage moteur (AM) ainsi que les attitudes et les croyances des professeurs à l'égard du mode d'enseignement de l'AM dans les programmes de physiothérapie du Canada. Méthodologie : méthodologie descriptive qualitative à l'aide d'un questionnaire en ligne et d'entrevues téléphoniques semi-structurées. Les auteurs ont utilisé une analyse de contenu descriptive pour élaborer les codes et les thèmes. Ils ont effectué une recherche dans les sites Web des programmes de physiothérapie pour compléter les données manquantes et colliger de l'information sur les écoles qui n'avaient pas participé au questionnaire en ligne ni à l'entrevue. Résultats : huit personnes, représentant sept écoles, ont rempli le questionnaire, et six des huit ont également participé à l'entrevue. D'après les réponses, la matière sur l'AM était plutôt uniforme entre les écoles et était surtout donnée dans le volet sur la neurologie. Les modes de prestation utilisés pour l'application clinique de la matière sur l'AM variaient selon les écoles. Les répondants étaient d'avis que l'AM est à la base de la pratique de la physiothérapie et devrait être intégré dans l'ensemble du programme. Conclusion : la matière sur l'AM est appropriée dans les cours actuels, mais ne fournit peut-être pas des occasions optimales d'en appliquer les principes en situation clinique. La formation continue a été proposée pour corriger les lacunes des cliniciens et faciliter l'apprentissage des étudiants en stage. Seule la moitié des écoles de physiothérapie admissibles a participé, et toutes ces écoles étaient anglophones. Il n'est peut-être donc pas possible de généraliser les résultats à tous les programmes canadiens. Les futures recherches devraient porter sur l'intégration de l'AM au programme de physiothérapie afin de promouvoir l'application des principes s'y rapportant entre les divers volets. Il faudrait également examiner les points de vue des étudiants quant à leur compréhension de l'AM et de son application et à l'auto-efficacité au moment de commencer à exercer.

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.

Knowledge, Attitudes, and Current Practices of Canadian Physiotherapists in Preventing and Managing Diabetes.

Purpose: To describe the knowledge, attitudes, and current practices of Canadian physiotherapists in preventing and managing diabetes. Methods: Members of the Canadian Physiotherapy Association were recruited by email to participate in a Web-based survey. The survey contained 40 items in four domains: demographics and education, attitudes and beliefs, current practices, and knowledge of diabetes. A descriptive analysis was completed for all the response variables from the survey. Results: A total of 401 physiotherapists from 10 provinces and 2 territories participated. Respondents were most confident in providing education about exercise and had decreasing confidence in providing education about managing secondary complications, weight management, blood sugar control, and nutrition, respectively. Only 32.4% of participants offered diabetes management counselling, citing lack of training. Knowledge was generally good, except for activity guidelines. Conclusions: A significant proportion of physiotherapists lack confidence in providing key aspects of care to patients with diabetes. Gaps in clinical practice and knowledge of activity guidelines were also observed. This study highlights the need to review entry-level physiotherapy training and to develop continuing educational opportunities in this area.

Objectif : décrire les connaissances, attitudes et pratiques actuelles des physiothérapeutes canadiens relativement à la prévention et à la gestion du diabète. Méthodes : un sondage a été mené sur le Web auprès de participants recrutés par courrier électronique parmi les membres de l'Association canadienne de physiothérapie. Le sondage comprenait 40 questions appartenant à quatre domaines différents : démographie et formation, attitudes et croyances, pratiques actuelles et connaissances sur le diabète. Une analyse descriptive a été effectuée pour toutes les variables-réponses du sondage. Résultats : au total, 401 physiothérapeutes provenant des 10 provinces et des 2 territoires ont participé. Le niveau de confiance des répondants était à son plus haut quand il s'agissait de fournir à leurs patients de l'information sur l'exercice, mais il diminuait progressivement quand il s'agissait de les guider dans la gestion des complications secondaires, du poids, de la glycémie ou encore de la nutrition. Seulement 32,4% des participants offraient des conseils sur la gestion du diabète, les autres invoquant leur manque de formation. De façon générale, le niveau de connaissances était bon, sauf à l'égard des lignes directrices en matière d'activité physique pour les diabétiques. Conclusion : une proportion significative de physiothérapeutes n'a pas la confiance nécessaire pour offrir certains aspects essentiels de la prise en charge des patients diabétiques. Des lacunes ont aussi été observées dans la pratique clinique auprès de ces patients et dans la connaissance des lignes directrices en matière d'activité physique. L'étude met en évidence la nécessité de revoir la formation de base des physiothérapeutes et de développer la formation continue dans ce domaine.

Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial.

BACKGROUND: Falls are one of the most common medical complications post-stroke. Physical exercise, particularly exercise that challenges balance, reduces the risk of falls among healthy and frail older adults. However, exercise has not proven effective for preventing falls post-stroke. Falls ultimately occur when an individual fails to recover from a loss of balance. Thus, training to specifically improve reactive balance control could prevent falls. Perturbation training aims to improve reactive balance control by repeatedly exposing participants to postural perturbations. There is emerging evidence that perturbation training reduces fall rates among individuals with neurological conditions, such as Parkinson disease. The primary aim of this work is to determine if perturbation-based balance training can reduce occurrence of falls in daily life among individuals with chronic stroke. Secondary objectives are to determine the effect of perturbation training on balance confidence and activity restriction, and functional balance and mobility. METHODS/DESIGN: Individuals with chronic stroke will be recruited. Participants will be randomly assigned to one of two groups: 1) perturbation training, or 2) 'traditional' balance training. Perturbation training will involve both manual perturbations (e.g., a push or pull from a physiotherapist), and rapid voluntary movements to cause a loss of balance. Training will occur twice per week for 6 weeks. Participants will record falls and activity for 12 months following completion of the training program. Standardized clinical tools will be used to assess functional balance and mobility, and balance confidence before and after training. DISCUSSION: Falls are a significant problem for those with stroke. Despite the large body of work demonstrating effective interventions, such as exercise, for preventing falls in other populations, there is little evidence for interventions that prevent falls post-stroke. The proposed study will investigate a novel and promising intervention: perturbation training. If effective, this training has the potential to not only prevent falls, but to also improve safe independent mobility and engagement in daily activities for those with stroke. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN05434601 .

Varied overground walking training versus body-weight-supported treadmill training in adults within 1 year of stroke: a randomized controlled trial.

BACKGROUND: Although task-related walking training has been recommended after stroke, the theoretical basis, content, and impact of interventions vary across the literature. There is a need for a comparison of different approaches to task-related walking training after stroke. OBJECTIVE: To compare the impact of a motor-learning-science-based overground walking training program with body-weight-supported treadmill training (BWSTT) in ambulatory, community-dwelling adults within 1 year of stroke onset. METHODS: In this rater-blinded, 1:1 parallel, randomized controlled trial, participants were stratified by baseline gait speed. Participants assigned to the Motor Learning Walking Program (MLWP) practiced various overground walking tasks under the supervision of 1 physiotherapist. Cognitive effort was encouraged through random practice and limited provision of feedback and guidance. The BWSTT program emphasized repetition of the normal gait cycle while supported on a treadmill and assisted by 1 to 3 therapy staff. The primary outcome was comfortable gait speed at postintervention assessment (T2). RESULTS: In total, 71 individuals (mean age = 67.3; standard deviation = 11.6 years) with stroke (mean onset = 20.9 [14.1] weeks) were randomized (MLWP, n = 35; BWSTT, n = 36). There was no significant between-group difference in gait speed at T2 (0.002 m/s; 95% confidence interval [CI] = -0.11, 0.12; P > .05). The MLWP group improved by 0.14 m/s (95% CI = 0.09, 0.19), and the BWSTT group improved by 0.14 m/s (95% CI = 0.08, 0.20). CONCLUSIONS: In this sample of community-dwelling adults within 1 year of stroke, a 15-session program of varied overground walking-focused training was not superior to a BWSTT program of equal frequency, duration, and in-session step activity.

Physiotherapy needs assessment of people with stroke following discharge from hospital, stratified by acute functional independence measure score.

PURPOSE: To determine the physiotherapy-related needs of people with stroke at discharge, 6 months after discharge, and 1 year after discharge from hospital, and to examine the results stratified by participants' acute Functional Independence Measure (FIM) scores. METHODS: A total of 241 adults with recent stroke were recruited into this longitudinal cohort study. As well as participating in a semi-structured interview that included questions about mobility needs and barriers, participants were asked to complete and return a closed-ended needs-assessment survey. RESULTS: During the interview, participants reported needs and barriers related to motor control, walking, stairs, fatigue, prevention of falls, and access to physiotherapy services. The survey identified many more needs, including transfers, wheelchair use, higher-level balance and mobility skills, and access to physiotherapy and suitable exercise facilities. Frequencies of needs and barriers tended to be lower among participants with higher acute FIM scores. There was no consistent trend for needs and barriers to decrease over time. CONCLUSIONS: Over the first year after discharge from hospital, people with stroke report a large and varied number of persistent mobility-related needs. Physiotherapists have a role to play in advocating for adequate follow-up services and informing health policy with respect to the needs of their patients with stroke.

Objectif : Établir les besoins en physiothérapie des personnes ayant subi un accident vasculaire cérébrale (AVC) lors de leur congé de l'hôpital, 6 mois après leur congé et 1 an après leur congé, et examiner les résultats stratifiés en fonction des pointages de mesure de l'autonomie fonctionnelle aigüe (Functional Independence Measure, FIM). Méthodologie : On a recruté en tout 241 adultes ayant récemment subi un ACV pour cette étude longitudinale de cohorte. En plus de participer à une entrevue semi-structurée comprenant des questions sur leurs besoins et sur les obstacles en matière de mobilité, les participants ont dû remplir et retourner un sondage d'évaluation des besoins avec questions fermées. Résultats : Au cours de l'entrevue, les participants ont fait part de besoins et d'obstacles liés au contrôle de leur motricité, à la marche, aux escaliers, à la fatigue, à la prévention des chutes et à l'accès à des services de physiothérapie. Le sondage a permis d'établir de nombreux autres besoins, dont la nécessité de transferts, l'utilisation d'un fauteuil roulant, un plus grand équilibre et de plus grandes habiletés motrices ainsi que l'accès à la physiothérapie et à des installations adaptées à leurs besoins en exercice. La fréquence des besoins et des obstacles avait tendance à diminuer chez les participants qui avaient obtenu des pointages plus élevés à l'échelle FIM. On n'a observé aucune tendance constante de diminution des besoins et des obstacles au fil du temps. Conclusions : Au cours de la première année suivant le congé de l'hôpital, les personnes qui ont subi un AVC font état d'un grand nombre de besoins variés et persistants en matière de mobilité. Les physiothérapeutes doivent faire pression pour des services de suivi adéquat et doivent contribuer à l'inclusion des besoins des patients qui ont subi un AVC dans les politiques en matière de santé.

Varied overground walking-task practice versus body-weight-supported treadmill training in ambulatory adults within one year of stroke: a randomized controlled trial protocol.

BACKGROUND: Although task-oriented training has been shown to improve walking outcomes after stroke, it is not yet clear whether one task-oriented approach is superior to another. The purpose of this study is to compare the effectiveness of the Motor Learning Walking Program (MLWP), a varied overground walking task program consistent with key motor learning principles, to body-weight-supported treadmill training (BWSTT) in community-dwelling, ambulatory, adults within 1 year of stroke. METHODS/DESIGN: A parallel, randomized controlled trial with stratification by baseline gait speed will be conducted. Allocation will be controlled by a central randomization service and participants will be allocated to the two active intervention groups (1:1) using a permuted block randomization process. Seventy participants will be assigned to one of two 15-session training programs. In MLWP, one physiotherapist will supervise practice of various overground walking tasks. Instructions, feedback, and guidance will be provided in a manner that facilitates self-evaluation and problem solving. In BWSTT, training will emphasize repetition of the normal gait cycle while supported over a treadmill, assisted by up to three physiotherapists. Outcomes will be assessed by a blinded assessor at baseline, post-intervention and at 2-month follow-up. The primary outcome will be post-intervention comfortable gait speed. Secondary outcomes include fast gait speed, walking endurance, balance self-efficacy, participation in community mobility, health-related quality of life, and goal attainment. Groups will be compared using analysis of covariance with baseline gait speed strata as the single covariate. Intention-to-treat analysis will be used. DISCUSSION: In order to direct clinicians, patients, and other health decision-makers, there is a need for a head-to-head comparison of different approaches to active, task-related walking training after stroke. We hypothesize that outcomes will be optimized through the application of a task-related training program that is consistent with key motor learning principles related to practice, guidance and feedback. TRIAL REGISTRATION: ClinicalTrials.gov # NCT00561405.

Needs assessment of individuals with stroke after discharge from hospital stratified by acute Functional Independence Measure score.

PURPOSE: To determine the needs, barriers and facilitators of function in individuals with stroke after discharge from hospital. To examine the results stratified by the patient's acute score (<41, 41-80, >80) on the functional independence measure (FIM). METHOD: This was a cohort study of 209 patients who had been admitted to hospital because of stroke. Patients were interviewed following hospital discharge using a semi-structured interview and asked to complete and return a quantitative closed-ended survey. RESULTS: For most domains, frequencies of needs varied across the FIM groups. Combining all FIM groups, the interview showed needs related to: physical impairments (35%), time for recovery (33%), education (28%), medical advice (25%), therapies and services (21%), social needs (19%) and emotional needs (18%). From the interview, the most frequent barriers were physical impairments (55%) and emotional concerns (40%). Common facilitators were family support (54%), therapies and medical care (40%) and personal attitudes (22%). Additional needs from the survey concerned: IADL, mobility, ADL, recreation, finances, communication and employment. Additional barriers from the survey were: attitudes, social participation, environments and limited services. CONCLUSIONS: There is a large and varied number of needs and barriers following discharge from hospital that have planning and advocacy implications for rehabilitation teams.