Adverse Events During Submaximal Aerobic Exercise Testing in People With Subacute Stroke: A Scoping Review.

BACKGROUND AND PURPOSE: Concern for adverse cardiovascular events and limited guidance regarding how to conduct aerobic exercise (AEx) testing for individuals poststroke are key barriers to implementation by physical therapists in stroke rehabilitation. This study aimed to describe the nature and safety of submaximal AEx testing protocols for people with subacute stroke (PwSS) and the nature of comorbidity of PwSS who underwent submaximal AEx testing. METHODS: We conducted a scoping review and searched MEDLINE, EMBASE, PsycINFO, CINAHL, and SPORTDiscus from inception to October 29, 2020. Studies involving submaximal AEx testing with PwSS, reporting on participant comorbidity and on adverse events during testing, were eligible. Two reviewers independently conducted title and abstract and full-text screening. One reviewer extracted data; a second reviewer verified data. RESULTS: Thirteen studies involving 452 participants and 19 submaximal AEx testing protocols (10 field test, 7 incremental, and 2 constant load) were included. Hypertension (41%), diabetes (31%), and dyslipidemia (27%) were the most common comorbidities reported. No protocols resulted in a serious adverse event. The most common test termination criterion was a heart rate (HR) limit (9 protocols); a limit of 85% age-predicted maximal HR (APM-HR) most frequently reported. Average APM-HR achieved, computed using mean age and mean peak HR, ranged from 59% to 88% across 13 protocols. DISCUSSION AND CONCLUSION: Diverse submaximal AEx testing protocols with conservative test termination criteria can be safely implemented with PwSS. Results can inform clinical practice guidelines and address physical therapists' concerns with the occurrence of serious adverse events during submaximal AEx testing.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A430 ).

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 (ABC) Scale and the ABC-6. Concussion symptoms were characterized using the Sport Concussion Assessment Tool version 5 (SCAT5) symptom checklist. Instrumented measures of balance and gait included center of pressure velocity and double support time, respectively. Balance was also assessed using the mBESS. RESULTS: The ABC and ABC-6 were strongly correlated (ρ=0.980, P<.001). Cronbach α for ABC and ABC-6 was 0.966 and 0.940, respectively. Factor analysis verified the existence of 2 components of the ABC, 1 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 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 effect of concussion on perceptions of the ability to perform functional tasks that challenge balance and mobility.

Identifying priorities for balance interventions through a participatory co-design approach with end-users.

BACKGROUND: Most individuals living with spinal cord injuries/diseases (SCI/D) or stroke experience at least one fall each year; hence, the development of interventions and technologies that target balance control is needed. The purpose of this study was to identify and explore the priorities for balance-focused interventions and technologies from the perspectives of end-users to assist with the design of an intervention that combines functional electrical stimulation (FES) with visual feedback training for standing balance. METHODS: Two individuals with SCI/D, one individual with stroke, two physical therapists (PT) and one hospital administrator were recruited. Participants attended three focus group meetings that followed a participatory co-design approach. A semi-structured interview guide, developed from the FAME (Feasibility, Appropriateness, Meaningfulness, Effectiveness, Economic Evidence) framework, was used to lead the discussion, querying participants' experiences with balance deficits and interventions, and FES. Meetings were audio-recorded and transcribed verbatim. An iterative and reflexive inductive thematic analysis was applied to the transcripts by three researchers. RESULTS: Four themes were identified: (1) Balance is meaningful for daily life and rehabilitation. Participants acknowledged various factors influencing balance control and how balance deficits interfered with participation in activities. End-users stressed the importance of continuing to work on one's balance after discharge from hospital-based rehabilitation. (2) Desired characteristics of balance interventions. Participants explained that balance interventions should be tailored to an individual's unique needs and goals, relevant to their lives, balance their safety and risk, and be engaging. (3) Prior experiences with FES to inform future therapeutic use. Participants with stroke or SCI/D described initial apprehension with FES, but experienced numerous benefits that motivated them to continue with FES. Challenges with FES were mentioned, including wires, cost, and time of set up. (4) Potential role of FES in balance interventions. Participants felt that FES would complement balance interventions; however, they had not experienced this combination of therapies previously. CONCLUSIONS: End-users described how their experiences with balance deficits, rehabilitation, and FES informed their priorities for balance interventions. The findings inform the design and implementation of future balance interventions for individuals with SCI/D or stroke, including an intervention involving FES and visual feedback training.

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.

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.

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.

Aerobic Training in Canadian Stroke Rehabilitation Programs.

BACKGROUND AND PURPOSE: Aerobic training (AT) is recommended for people after stroke, yet uptake and operationalization of AT in clinical practice in Canada have not been measured. We surveyed inclusion of structured AT and barriers to implementation in public inpatient/outpatient stroke rehabilitation programs across Canada. METHODS: A Web-based questionnaire was sent to 89 stroke rehabilitation program leads. RESULTS: Forty-six programs from 7 of 9 eligible Canadian provinces/territories completed the questionnaire. Seventy-eight percent of programs reported including AT, with most (75%) excluding participants with severe physical impairments, and 28% excluding those with coexisting cardiac conditions. A greater proportion of dedicated stroke rehabilitation programs prescribed AT, compared to nondedicated stroke units (68.8% vs 31.3%, P = 0.02). The top 2 challenges for programs that included and did not include AT were "insufficient time within therapy sessions" and "length of stay in rehabilitation." Programs that did not include AT ranked "not a goal of most patients" and "not an organizational/program priority" as third and fourth, whereas they were ranked eighth and thirteenth by programs with AT. Best practice recommendations were inconsistently followed for conducting preparticipation exercise testing (36.1%) and for monitoring patients from higher-risk populations, specifically people with diabetes at risk for hypoglycemia (78.8%) and hypertension (36.6%). Of programs conducting preparticipation exercise testing, 91% did not monitor electrocardiography. DISCUSSION AND CONCLUSIONS: Most stroke rehabilitation programs across Canada include AT. People with severe physical impairment and those with cardiac, metabolic, and hemodynamic comorbidities may be excluded or not appropriately monitored during exercise. More detailed guidelines and training practices are needed to address these challenges.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A233).

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.

Reactive Stepping After Stroke: Determinants of Time to Foot Off in the Paretic and Nonparetic Limb.

BACKGROUND AND PURPOSE: Impaired features of reactive stepping, specifically delays in the early time to foot off (TFO) phase, are associated with increased fall rates after stroke. This study aimed to determine differences in, and determinants of, paretic and nonparetic limb TFO, and to determine whether both paretic and nonparetic TFO were associated with perturbation-evoked falls. METHODS: Retrospective chart review of 105 individuals with stroke was performed within an inpatient rehabilitation setting; each had received a standardized assessment of reactive balance control (in response to a perturbation) at time of discharge. RESULTS: There were no significant differences in paretic (351 ms) and nonparetic (365 ms) TFO. The capacity to maximally load the nonparetic limb, the amplitude of the perturbation, and the capacity to load the paretic limb were all negatively associated with paretic step TFO, explaining 23.8% of the variance. The amplitude of the perturbation and the preperturbation load under the nonparetic stepping limb were, respectively, negatively and positively associated with nonparetic step TFO, explaining 22.7% of the variance. The likelihood of a perturbation-evoked fall was associated with mean nonparetic limb TFO but not paretic limb TFO. DISCUSSION AND CONCLUSIONS: Unique stroke-related impairments of dynamic balance control and limb-load asymmetry may differentially influence paretic and nonparetic reactive step TFO, in response to a loss of balance. The amplitude of the perturbation influences reactive step TFO in both limbs. The results of the current study have implications for the future development of standardized clinical assessment methodologies and training strategies to evaluate and remediate reactive stepping and reduce fall risk.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A133).

The Impact of Falls on Motor and Cognitive Recovery after Discharge from In-Patient Stroke Rehabilitation.

BACKGROUND: Falls are common among community-dwelling stroke survivors. The aims of this study were (1) to compare motor and cognitive outcomes between individuals who fell in the 6 months' postdischarge from in-patient stroke rehabilitation and those who did not fall, and (2) to explore potential mechanisms underlying the relationship between falls and recovery of motor and cognitive function. METHODS: Secondary analysis of a prospective cohort study of individuals discharged home from in-patient rehabilitation was conducted. Participants were recruited at discharge and completed a 6-month falls monitoring period using postcards with follow-up. Nonfallers and fallers were compared at the 6-month follow-up assessment on the Berg Balance Scale (BBS), the Chedoke-McMaster Stroke Assessment (CMSA), gait speed, and the Montreal Cognitive Assessment (MoCA). Measures of balance confidence and physical activity were also assessed. RESULTS: Twenty-three fallers were matched to 23 nonfallers on age and functional balance scores at discharge. A total of 43 falls were reported during the study period (8 participants fell more than once). At follow-up, BBS scores (P = .0066) and CMSA foot scores (P = .0033) were significantly lower for fallers than for nonfallers. The 2 groups did not differ on CMSA leg scores (P = .049), gait speed (P = .47), or MoCA score (P = .23). There was no significant association between change in balance confidence scores and change in physical activity levels among all participants from the first and third questionnaire (r = .27, P = .08). CONCLUSIONS: Performance in balance and motor recovery of the foot were compromised in fallers when compared to nonfallers at 6 months post discharge from in-patient stroke rehabilitation.

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 .

Spatial-temporal gait variability poststroke: variations in measurement and implications for measuring change.

OBJECTIVE: To determine the responsiveness to change of spatial-temporal gait parameters among stroke survivors for 3 different variability measures: SD, coefficient of variation (CV), and median absolute deviation (MAD). DESIGN: Retrospective chart review. SETTING: Clinical laboratory in a Canadian hospital. PARTICIPANTS: Stroke survivors (N=74) receiving inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Spatial-temporal gait variability was calculated for step length, step width, stance time, swing time, and double support time. Responsiveness to change was determined by comparing (1) trials without versus trials with a concurrent cognitive task and (2) admission to discharge from rehabilitation. RESULTS: Variability estimators (SD, CV, and MAD) increased with the addition of a cognitive task and decreased from admission to discharge of rehabilitation. However, these changes were not statistically significant when change in gait velocity was included as a covariate. The effect size values were similar for all variability estimators with a trend toward a greater SD response to temporal parameters. The CV displayed a larger response to change for step length than did the SD and MAD. Although gait variability decreased between admission and discharge, the effect size was larger for the condition without the cognitive task than for the condition with the cognitive task. CONCLUSIONS: Our results show that gait variability estimators demonstrate a similar responsiveness to a concurrent cognitive task and improved walking ability with recovery from stroke. Future work may focus on evaluating the clinical utility of these measures in relation to informing therapy and response to gait-specific training protocols.

Does participation in standardized aerobic fitness training during inpatient stroke rehabilitation promote engagement in aerobic exercise after discharge? A cohort study.

OBJECTIVE: To determine whether attending an aerobic fitness program during inpatient stroke rehabilitation is associated with increased participation in physical activity after discharge. DESIGN: This was a prospective cohort study. Patients who received inpatient stroke rehabilitation and were discharged into the community (n = 61; mean age, 65 years) were recruited. Thirty-five participants attended a standardized aerobic fitness program during inpatient rehabilitation, whereas 26 did not. The Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) and adherence to the American College of Sports Medicine (ACSM) guidelines were assessed up to 6 months after discharge. RESULTS: Participants in the fitness group had PASIPD scores and adherence to ACSM guidelines similar to those of participants in the nonfitness group up to 6 months after discharge. There was no significant correlation between volume of exercise performed during the inpatient program and amount of physical activity after discharge. CONCLUSION: Participation in an inpatient fitness program did not increase participation in physical activity after discharge in individuals with stroke. A new model of care that encourages patients to pursue physical activity after discharge and reduces the potential barriers to participation should be developed.

Using wireless technology in clinical practice: does feedback of daily walking activity improve walking outcomes of individuals receiving rehabilitation post-stroke? Study protocol for a randomized controlled trial.

BACKGROUND: Regaining independent ambulation is the top priority for individuals recovering from stroke. Thus, physical rehabilitation post-stroke should focus on improving walking function and endurance. However, the amount of walking completed by individuals with stroke attending rehabilitation is far below that required for independent community ambulation. There has been increased interest in accelerometer-based monitoring of walking post-stroke. Walking monitoring could be integrated within the goal-setting process for those with ambulation goals in rehabilitation. The feedback from these devices can be downloaded to a computer to produce reports. The purpose of this study is to determine the effect of accelerometer-based feedback of daily walking activity during rehabilitation on the frequency and duration of walking post-stroke. METHODS: Participants will be randomly assigned to one of two groups: feedback or no feedback. Participants will wear accelerometers daily during in- and out-patient rehabilitation and, for participants in the feedback group, the participants' treating physiotherapist will receive regular reports of walking activity. The primary outcome measures are the amount of daily walking completed, as measured using the accelerometers, and spatio-temporal characteristics of walking (e.g. walking speed). We will also examine goal attainment, satisfaction with progress towards goals, stroke self-efficacy, and community-integration. DISCUSSION: Increased walking activity during rehabilitation is expected to improve walking function and community re-integration following discharge. In addition, a focus on altering walking behaviour within the rehabilitation setting may lead to altered behaviour and increased activity patterns after discharge. TRIAL REGISTRATION: ClinicalTrials.gov NCT01521234.

Clinicians' Experiences of Implementing a Telerehabilitation Toolkit During the COVID-19 Pandemic: Qualitative Descriptive Study.

BACKGROUND: Although the COVID-19 pandemic resulted in a rapid implementation and scale-up of telehealth for patients in need of rehabilitation, an overall slower scaling up to telerehabilitation has been documented. OBJECTIVE: The purpose of this study was to understand experiences of implementing telerehabilitation during the COVID-19 pandemic as well as using the Toronto Rehab Telerehab Toolkit from the perspective of rehabilitation professionals across Canada and internationally. METHODS: The study adopted a qualitative descriptive approach that consisted of telephone- or videoconference-supported interviews and focus groups. Participants included rehabilitation providers as well as health care leaders who had used the Toronto Rehab Telerehab Toolkit. Each participant took part in a semi-structured interview or focus group, lasting approximately 30-40 minutes. Thematic analysis was used to understand the barriers and enablers of providing telerehabilitation and implementing the Toronto Rehab Telerehab Toolkit. Three members of the research team independently analyzed a set of the same transcripts and met after each set to discuss their analysis. RESULTS: A total of 22 participants participated, and 7 interviews and 4 focus groups were included. The data of participants were collected from both Canadian (Alberta, New Brunswick, and Ontario) and international sites (Australia, Greece, and South Korea). A total of 11 sites were represented, 5 of which focused on neurological rehabilitation. Participants included health care providers (ie, physicians, occupational therapists, physical therapists, speech language pathologists, and social workers), managers and system leaders, as well as research and education professionals. Overall, 4 themes were identified including (1) implementation considerations for telerehabilitation, encompassing 2 subthemes of "infrastructure, equipment, and space" and "leadership and organizational support"; (2) innovations developed as a result of telerehabilitation; (3) the toolkit as a catalyst for implementing telerehabilitation; and (4) recommendations for improving the toolkit. CONCLUSIONS: Findings from this qualitative study confirm some of the previously identified experiences with implementing telerehabilitation, but from the perspective of Canadian and international rehabilitation providers and leaders. These findings include the importance of adequate infrastructure, equipment, and space; the key role of organizational or leadership support in adopting telerehabilitation; and availing resources to implement it. Importantly, participants in our study described the toolkit as an important resource to broker networking opportunities and highlighted the need to pivot to telerehabilitation, especially early in the pandemic. Findings from this study will be used to improve the next iteration of the toolkit (Toolkit 2.0) to promote safe, accessible, and effective telerehabilitation to those patients in need in the future.

TeleRehabilitation with Aims to Improve Lower extremity recovery in community-dwelling individuals who have had a stroke: protocol for a multisite, parallel group, assessor-blinded, randomised attention-controlled trial.

INTRODUCTION: Telerehabilitation is an accessible service delivery model that may support innovative lower extremity rehabilitation programmes that extend the stroke recovery continuum into the community. Unfortunately, there is limited evidence on the provision of exercises for lower extremity recovery after stroke delivered using telerehabilitation. In response, we developed the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke (TRAIL) programme, a 4-week progressive exercise and self-management intervention delivered synchronously using video-conferencing technology. Our primary hypothesis is that individual within 1-year poststroke who participate in TRAIL will experience significantly greater improvements in functional mobility than individuals in an attention-controlled education programme (EDUCATION). METHODS AND ANALYSIS: In this multisite, parallel group, assessor-blinded randomised attention-controlled trial, 96 community-living stroke survivors within 1-year poststroke will be recruited from five sites (Vancouver, Winnipeg, Toronto, London and Halifax, Canada) from the CanStroke Recovery Trials Platform which is a network of Canadian hospital sites that are affiliated with academic institutions to facilitate participant recruitment and quality trial practices. Participants will be randomised on a 1:1 basis to TRAIL or EDUCATION. Participants randomised to TRAIL will receive eight telerehabilitation sessions where they will perform exercises and receive self-management support to improve lower extremity recovery from a TRAIL physical therapist. The primary outcome will be measured using the Timed Up and Go. Secondary outcomes include lower extremity muscle strength, functional balance, motor impairment, balance self-efficacy, health-related quality of life and health service use for our economic evaluation. Measurements will be taken at baseline, immediately after the intervention, 3-month and 6-month postintervention. ETHICS AND DISSEMINATION: Ethics approval for this research has been obtained by all participating sites. All study participants will provide their informed consent prior to enrolling them in the study. Findings from this trial will be disseminated in peer-reviewed journals and presentations at international scientific meetings. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04908241.

The Toronto Concussion Study: a prospective investigation of characteristics in a cohort of adults from the general population seeking care following acute concussion, 2016-2020.

Purpose: There is limited research regarding the characteristics of those from the general population who seek care following acute concussion. Methods: To address this gap, a large cohort of 473 adults diagnosed with an acute concussion (female participants = 287; male participants = 186) was followed using objective measures prospectively over 16 weeks beginning at a mean of 5.1 days post-injury. Results: Falls were the most common mechanism of injury (MOI) (n = 137, 29.0%), followed by sports-related recreation (n = 119, 25.2%). Male participants were more likely to be injured playing recreational sports or in a violence-related incident; female participants were more likely to be injured by falling. Post-traumatic amnesia (PTA) was reported by 80 participants (16.9 %), and loss of consciousness (LOC) was reported by 110 (23.3%). In total, 54 participants (11.4%) reported both PTA and LOC. Male participants had significantly higher rates of PTA and LOC after their injury compared to their female counterparts. Higher initial symptom burden was associated with a longer duration of recovery for both male and female participants. Female participants had more symptoms and higher severity of symptoms at presentation compared to male participants. Female participants were identified to have a longer recovery duration, with a mean survival time of 6.50 weeks compared to 5.45 weeks in male participants (p < 0.0001). A relatively high proportion of female and male participants in this study reported premorbid diagnoses of depression and anxiety compared to general population characteristics. Conclusion: Although premorbid diagnoses of depression and/or anxiety were associated with higher symptom burden at the initial visit, the duration of symptoms was not directly associated with a pre-injury history of psychological/psychiatric disturbance. This cohort of adults, from the general population, seeking care for their acute concussion attained clinical and functional recovery over a period of 4-12 weeks.

Determinants of limb preference for initiating compensatory stepping poststroke.

OBJECTIVE: To investigate the determinants of limb preference for initiating compensatory stepping poststroke. DESIGN: Retrospective chart review. SETTING: Inpatient rehabilitation. PARTICIPANTS: Convenience sample of individuals admitted to inpatient rehabilitation with poststroke hemiparesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Compensatory stepping responses were evoked using a lean-and-release postural perturbation. The limb used to initiate compensatory stepping was determined. The relationships between stepping with the paretic limb and premorbid limb dominance, weight bearing on the paretic limb in quiet standing, ability to bear weight on the paretic limb, preperturbation weight bearing on the paretic limb, and lower-limb motor recovery scores were determined. RESULTS: The majority (59.1%) of responses were steps initiated with the nonparetic limb. Increased lower-limb motor recovery scores and preperturbation weight bearing on the nonparetic limb were significantly related to increased frequency of stepping with the paretic limb. When the preferred limb was physically blocked, an inappropriate response was initiated in 21% of trials (ie, nonstep responses or an attempt to step with the blocked limb). CONCLUSIONS: This study reveals the challenges that individuals with poststroke hemiparesis face when executing compensatory stepping responses to prevent a fall after a postural perturbation. The inability or challenges to executing a compensatory step with the paretic limb may increase the risk for falls poststroke.

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.

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.