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.

Effects of Visual Feedback During Recumbent Stepping in Individuals With Chronic Stroke.

OBJECTIVE: To investigate the effects of intermittent visual feedback (using the Balanced Power program on the NuStep Transitt) during recumbent stepping on strength, balance, and functional mobility in individuals with chronic stroke. DESIGN: Quasi-experimental 1-group pretest-posttest study. SETTING: Human performance research laboratory. PARTICIPANTS: Adults (N=11; 7 female; mean age, 58.7±13.6y), >6 months post stroke. INTERVENTIONS: Eight 45-minute training sessions on the NuStep Transitt (visits 2-9) twice a week (5-minute warm-up and cooldown with 35 minutes of training [5min with and then without visual feedback regarding left/right lower extremity percentage effort]). Visits 1 and 10: pre- and post assessment. MAIN OUTCOME MEASURES: Self-selected and fast gait speeds; maximum voluntary contractions (MVCs) of knee extension and flexion and ankle dorsiflexion and plantarflexion; and 5 times sit-to-stand (5TSTS). RESULTS: Significant improvements in 5TSTS (14.2s, P=.007) and fast gait (hemi: 4.9 cm [P=.024], nonhemi: 4.5cm (P=.019) stride length; nonhemi step length 2.3 cm (P=.024]). MVC and self-selected gait parameters showed no significant changes. CONCLUSIONS: The NuStep Transitt is a valuable tool that provides real-time feedback about percentage of use of the hemiparetic leg. This intervention study has demonstrated that the addition of visual feedback about left/right percentage effort while exercising on the Transitt has significant and clinically relevant effects on the functional mobility of individuals with chronic stroke.

Treatment interventions for pusher syndrome: A case series.

BACKGROUND: Pusher syndrome (PS) is a clinical disorder that causes decreased postural balance and active pushing away from the non-hemiparetic side in patients with right or left brain damage. Therapists are challenged by needing to manage both the hemiparetic and the pushing/non-hemiparetic sides. There is a minimal amount of evidence about effective treatment interventions for PS. OBJECTIVE: To describe treatment interventions that reduce pushing behavior and improve functional outcomes in patients with PS. METHODS: Five individuals (aged 42-76, admitted 5-16 days post-stroke) with PS participated in this case series. The participants received 90 minutes of physical therapy (5 days/week) with an average length of stay of 27 days. Treatment focused on regaining their sense of midline (balance and transfers), mobility retraining, and neuro re-education activities. Outcome measures examined pushing behavior, transfer ability, and sitting balance. RESULTS: All five participants demonstrated improvements in pushing behavior, balance and transfer status. CONCLUSIONS: These outcomes provide preliminary evidence of decreased pushing behavior, and improved balance and transfers following a program of interventions designed to improve the functional outcomes of patients with PS. Larger studies are needed to confirm these findings, and whether these interventions are effective for patients with less severe pushing behavior.

Video Movement Analysis Using Smartphones (ViMAS): A Pilot Study.

The use of smartphones in clinical practice is steadily increasing with the availability of low cost/freely available "apps" that could be used to assess human gait. The primary aim of this manuscript is to test the concurrent validity of kinematic measures recorded by a smartphone application in comparison to a 3D motion capture system in the sagittal plane. The secondary aim was to develop a protocol for clinicians on the set up of the smartphone camera for video movement analysis. The sagittal plane knee angle was measured during heel strike and toe off events using the smart phone app and a 3D motion-capture system in 32 healthy subjects. Three trials were performed at near (2-m) and far (4-m) smartphone camera distances. The order of the distances was randomized. Regression analysis was performed to estimate the height of the camera based on either the subject's height or leg length. Absolute measurement errors were least during toe off (3.12 ± 5.44 degrees) compared to heel strike (5.81 ± 5.26 degrees). There were significant (p < 0.05) but moderate agreements between the application and 3D motion capture measures of knee angles. There were also no significant (p > 0.05) differences between the absolute measurement errors between the two camera positions. The measurement errors averaged between 3 - 5 degrees during toe off and heel strike events of the gait cycle. The use of smartphone apps can be a useful tool in the clinic for performing gait or human movement analysis. Further studies are needed to establish the accuracy in measuring movements of the upper extremity and trunk.

Validity of an Interactive Functional Reach Test.

INTRODUCTION: Videogaming platforms such as the Microsoft (Redmond, WA) Kinect(®) are increasingly being used in rehabilitation to improve balance performance and mobility. These gaming platforms do not have built-in clinical measures that offer clinically meaningful data. We have now developed software that will enable the Kinect sensor to assess a patient's balance using an interactive functional reach test (I-FRT). The aim of the study was to test the concurrent validity of the I-FRT and to establish the feasibility of implementing the I-FRT in a clinical setting. SUBJECTS AND METHODS: The concurrent validity of the I-FRT was tested among 20 healthy adults (mean age, 25.8±3.4 years; 14 women). The Functional Reach Test (FRT) was measured simultaneously by both the Kinect sensor using the I-FRT software and the Optotrak Certus(®) 3D motion-capture system (Northern Digital Inc., Waterloo, ON, Canada). The feasibility of implementing the I-FRT in a clinical setting was assessed by performing the I-FRT in 10 participants with mild balance impairments recruited from the outpatient physical therapy clinic (mean age, 55.8±13.5 years; four women) and obtaining their feedback using a NASA Task Load Index (NASA-TLX) questionnaire. RESULTS: There was moderate to good agreement between FRT measures made by the two measurement systems. The greatest agreement between the two measurement system was found with the Kinect sensor placed at a distance of 2.5 m [intraclass correlation coefficient (2,k)=0.786; P<0.001] from the participant. Participants with mild balance impairments whose balance was assessed using the I-FRT software scored their experience favorably by assigning lower scores for the Frustration, Mental Demand, and Temporal Demand subscales on the NASA/TLX questionnaire. CONCLUSIONS: FRT measures made using the Kinect sensor I-FRT software provides a valid clinical measure that can be used with the gaming platforms.

Validity, reliability and minimum detectable change of the maximum step length test in people with stroke.

Stroke is a significant cause of deficits in balance, mobility and disability. Although tests of stepping speed are associated with balance performance after stroke, relationships between clinical tests of stepping distance and balance performance have not been investigated in people with stroke. A validated test of stepping distance and balance in older adults (the maximum step length [MSL] test), and two clinical measures associated with balance in people with stroke (the five-times-sit-to-stand test [FTSST] and gait speed) were evaluated in nineteen independent community-dwelling people with chronic stroke. There were strong relationships between MSL and performance on the clinical balance measures (Pearson's r 0.69 to -0.88), suggesting that MSL is a valid measure of balance after stroke. Test-retest reliability coefficients were excellent for the MSL tests (ICC both limbs; 0.98). Standard error of measurement expressed as a percentage of mean MSL was computed as 5.6% (hemiparetic leg) and 5.4% (unaffected leg), indicative of low levels of measurement error and excellent absolute reliability of the MSL test in people with stroke. Minimum detectable change expressed as a percentage of mean MSL was low (14.9% to 15.4%), suggesting that MSL may be sensitive to detecting change in physical performance in people with stroke. Advantages of the MSL test are that it is easy to administer, requiring minimal training, equipment, time or space. These advantages, together with the validity of the MSL test, its excellent test-retest and absolute reliability, and its low minimum change percent value suggest that MSL may be a useful measure of balance capabilities in people with stroke.