Protocol for a randomized controlled clinical trial investigating the effectiveness of Fast muscle Activation and Stepping Training (FAST) for improving balance and mobility in sub-acute stroke.

BACKGROUND: Following stroke, many people have difficulty activating their paretic muscles quickly and with sufficient power to regain their balance by taking quick and effective steps. Reduced dynamic balance and mobility following stroke, or 'walking balance', is associated with reduced self-efficacy and restrictions in daily living activities, community integration, and quality of life. Targeted training of movement speeds required to effectively regain balance has been largely overlooked in post-stroke rehabilitation. The Fast muscle Activation and Stepping Training (FAST) program incorporates fast functional movements known to produce bursts of muscle activation essential for stepping and regaining standing balance effectively. The purpose of this study is to: 1) compare the effectiveness of an outpatient FAST program to an active control outpatient physiotherapy intervention in improving walking balance following stroke, and 2) explore potential mechanisms associated with improvements in walking balance. METHODS/DESIGN: This will be an assessor-blinded, parallel group randomized controlled trial design. Sixty participants (30 per group) who have sustained a stroke within the previous six months will be randomly assigned with stratification for lower limb motor recovery to receive twelve 45-minute 1:1 physiotherapy intervention sessions over 6 - 10 weeks in an outpatient setting of either: 1) FAST intervention - systematic and progressive practice of fast squatting and stepping exercises, or 2) active control - conventional physiotherapy directed at improving balance and mobility that includes no targeted fast movement training. The same blinded research physiotherapist will assess outcomes at three time points: 1) baseline (prior to intervention), 2) follow up (within one week post-intervention); and 3) retention (one month post-intervention). The primary outcome is dynamic balance assessed using the Community Balance and Mobility Scale. We will also assess fast and self-selected walking speed, balance self-efficacy, and the ability to respond to internal and external perturbations to balance and associated changes in postural muscle activation. DISCUSSION: The targeted training of fast functional movements in the FAST program is expected to improve walking balance following stroke compared to the active control intervention. Unique to this study is the investigation of potential mechanisms associated with improvements in walking balance. TRIAL REGISTRATION: NCT01573585.

Evaluating the Educational Experience of Physiotherapy Students Using the Fitness and Mobility Exercise (FAME) Programme to Learn about Neurological Conditions: An Exploratory Study.

Purpose: Group exercise has the potential to be a cost-effective way to improve functional outcomes for those living with neurological injury. Leading group exercise is a foundational competency for entry-to-practice for physiotherapy students. The overall objective of this study was to examine the student experience of using the Fitness and Mobility Exercise (FAME) programme to learn about neurological conditions in a group setting. Methods: Sixteen physiotherapy students filled out a single point in time survey at the end of their placement during which they had the opportunity to use FAME with their clients twice a week. The survey had Likert and open-ended questions and demographic information. Likert responses were calculated as means. Open-ended questions were analyzed using thematic analysis. Results: The Likert questions were answered with almost entirely positive results. The main themes from the open-ended questions were how to personalize the class, characteristics of individual clients shape the class experience and factors that make the class successful. Conclusions: Overall, the physiotherapy students found using FAME to be a positive experience. From the student perspective, using FAME during placement was an effective way to learn about neurological conditions as well as to develop skills to manage a group exercise class.

Objectif: les exercices de groupe ont le potentiel d'être un moyen rentable d'améliorer les résultats fonctionnels des personnes qui vivent avec une atteinte neurologique. La direction d'exercices de groupe est une compétence fondamentale d'accès à la pratique chez les étudiants en physiothérapie. L'objectif global de cette étude consistait à examiner l'expérience des étudiants à l'égard de l'utilisation du programme d'exercices pour la forme physique et la mobilité (FAME, d'après l'acronyme anglais Fitness and Mobility Exercise) et à en apprendre davantage sur les atteintes neurologiques dans un contexte de groupe. Méthodologie: au total, seize étudiants en physiothérapie ont rempli un seul sondage à la fin de leur stage, au cours duquel ils avaient pu utiliser le programme FAME deux fois par semaine avec leurs clients. Le sondage contenait des questions de type échelle de Likert, des questions ouvertes et des renseignements démographiques. Les chercheuses ont analysé les réponses de type échelle de Likert sous forme de moyennes et les questions ouvertes, sous forme d'analyse thématique. Résultats: les réponses aux questions de type échelle de Likert étaient presque toujours positives. Les principaux thèmes des questions ouvertes étaient comment personnaliser le cours, les caractéristiques des clients individuels façonnent l'expérience du cours et les facteurs qui font du cours une réussite. Conclusions: dans l'ensemble, les étudiants en physiothérapie ont trouvé que l'utilisation du programme FAME était une expérience positive. De l'avis des étudiants, l'utilisation du programme FAME pendant le stage était un moyen efficace d'en apprendre davantage au sujet des maladies neurologiques et d'acquérir des compétences pour gérer un cours d'exercice de groupe.

Relationships amongst osteoarthritis biomarkers, dynamic knee joint load, and exercise: results from a randomized controlled pilot study.

BACKGROUND: Little is known about the relationships of circulating levels of biomarkers of cartilage degradation with biomechanical outcomes relevant to knee osteoarthritis (OA) or biomarker changes following non-pharmacological interventions. The objectives of this exploratory, pilot study were to: 1) examine relationships between biomarkers of articular cartilage degradation and synthesis with measures of knee joint load during walking, and 2) examine changes in these biomarkers following 10 weeks of strengthening exercises. METHODS: Seventeen (8 male, 9 female; 66.1 +/- 11.3 years of age) individuals with radiographically-confirmed medial tibiofemoral OA participated. All participants underwent a baseline testing session where serum and urine samples were collected, followed by a three-dimensional motion analysis. Motion analysis was used to calculate the external knee adduction moment (KAM) peak value and impulse. Following baseline testing, participants were randomized to either 10 weeks of: 1) physiotherapist-supervised lower limb muscle strengthening exercises, or 2) no exercises (control). Identical follow-up testing was conducted 11 weeks after baseline. Biomarkers included: urinary C-telopeptide of type II collagen (uCTX-II) and type II collagen cleavage neoepitope (uC2C), serum cartilage oligomeric matrix protein (sCOMP), serum hyaluronic acid (sHA) and serum C-propeptide of type II procollagen (sCPII). Linear regression analysis was used to examine relationships between measures of the KAM and biomarker concentrations as baseline, as well as between-group differences following the intervention. RESULTS: KAM impulse predicted significant variation in uCTX-II levels at baseline (p = 0.04), though not when controlling for disease severity and walking speed (p = 0.33). KAM impulse explained significant variation in the ratio uCTX-II;sCPII even when controlling for additional variables (p = 0.04). Following the intervention, changes in sCOMP were significantly greater in the exercise group compared to controls (p = 0.04). On average those in the control group experienced a slight increase in sCOMP and uCTX-II, while those in the exercise group experienced a reduction. No other significant findings were observed. CONCLUSIONS: This research provides initial evidence of a potential relationship between uCTX-II and knee joint load measures in patients with medial tibiofemoral knee OA. However, this relationship became non-significant after controlling for disease severity and walking speed, suggesting further research is necessary. It also appears that sCOMP is amenable to change following a strengthening intervention, suggesting a potential beneficial role of exercise on cartilage structure. TRIAL REGISTRATION: Clinicaltrials.gov NCT01241812.

Reliability of measurement of maximal isometric lateral trunk-flexion strength in athletes using handheld dynamometry.

CONTEXT: Lateral trunk-flexion strength is an important determinant of overall trunk stability and function, but the reliability in measuring this outcome clinically in athletic individuals is not known. OBJECTIVE: To determine the interrater and intrarater reliability of lateral trunk-flexion strength measurement in athletic individuals using handheld dynamometry. DESIGN: Reliability study. SETTING: Research laboratory. PARTICIPANTS: 12 healthy, athletic individuals. INTERVENTION: Lateral trunk-flexion strength was measured using handheld dynamometry across 2 different trunk placements (lateral aspect of the axilla and laterally at the level of the midtrunk) and 2 testing occasions by 2 therapists. Three maximum-effort trials during a "make test" at each placement were completed for each therapist on both occasions. MAIN OUTCOME MEASURES: Maximum force output was identified and converted to a torque. Intraclass correlation coefficients (ICC2,1) were calculated for each dynamometer placement, therapist, and test occasion to determine intrarater and interrater reliability. RESULTS: Intrarater reliability was moderate to good (ICC2,1= .53-.77), while interrater reliability was good to very good (ICC2,1 =.79-.81) at the axilla position. For the midtrunk position, intrarater reliability was good to very good (ICC2,1 = .80-.86), while interrater reliability was very good on both days (ICC2,1 = .87-.88). Finally, the standard errors of measurement were low for the axilla position (0.20 Nm/kg; 95% CI .15, .28) and midtrunk position (0.09 Nm/kg; 95% CI .07, .12). CONCLUSIONS: Maximum lateral trunk-flexion strength can be reliably measured in athletic individuals with greater overall strength. Based on the 2 positions used in this study, measurement with a dynamometer placement at the midtrunk may be more reliable than that obtained at the axilla.

Does the stimulus provoking a stepping reaction correlate with step characteristics and clinical measures of balance and mobility post-stroke?

BACKGROUND: Retraining stepping reactions in people post-stroke is vital. However, the relationship between the stimulus and resulting stepping performance in people post-stroke is unknown. We explored relationships between stepping stimulus and stepping reactions initiated by either paretic or non-paretic legs of people post-stroke and controls. Relationships were examined in the context of clinical measures of balance. METHODS: Centre of mass dynamics were measured during self-initiated destabilizing leaning stimuli that required stepping reactions by paretic and non-paretic legs of people post-stroke (n = 10) and controls (n = 10) to recover balance. Step characteristics of the first two steps of stepping reactions were measured. Correlations were calculated between clinical measures of balance and mobility and the centre of mass and step characteristics. FINDINGS: Steps were shorter and slower with decreased centre of mass fore-aft and downward displacement and velocity when initiated by paretic and non-paretic legs compared with controls. However, increase in centre of mass displacement and velocity in the fore-aft and downward direction tended to be associated with a greater increase in step length and speed when stepping reactions were initiated by the paretic and non-paretic legs compared with controls. Time to step initiation in response to onset of falling stimulus did not differ between groups. Strong positive correlations were found between clinical balance and mobility scores and centre of mass and step dynamics in fore-aft and vertical directions. INTERPRETATION: These results support objective measurement of centre of mass to quantify the stimulus influencing step dynamics and stepping performance during retraining interventions following stroke.

Rate of perceived stability as a measure of balance exercise intensity in people post-stroke.

PURPOSE: This study investigates the reproducibility and concurrent validity of the Rate of Perceived Stability (RPS) Scale in people with stroke. METHODS: On two separate days (2-10 days apart), participants provided their RPS ratings during clinical measures: 1)16 tasks from Community Balance and Mobility Scale (CB&M), 2)6-minute walk test (6MWT), and 3)self-paced gait speed. Intraclass correlations (ICCs) assessed between day test-retest reliability of RPS ratings. Standard error of measurement (SEM) and smallest detectable change (SDC) addressed level of between day agreement. Spearman rank correlations (rs) quantified relationships between RPS, and general rating of perceived challenge, task-performance scores. RESULTS: Thirty participants with stroke (50% female) participated. ICC ranged from 0.46 to 0.93 across tasks with 12/19 tasks showing ICCs above 0.75 (good test-retest reliability). SEM was 1-point for each task and SDC ranged from 2 to 4 across tasks. Concurrent validity between RPS and ratings of perceived challenge was good-to-excellent (rs ranged 0.78-0.94, p < 0.01). Higher RPS (indicative of feeling less stable) was associated with lower balance performance scores on CB&M tasks, negative relationships ranged in strength from fair to good-to-excellent in 10/16 tasks (rs ranged -0.46 to -0.81, p ≤ 0.01). CONCLUSIONS: RPS shows promise as a measure of balance intensity in people with stroke.IMPLICATIONS FOR REHABILITATIONThe RPS is a reliable and valid measure of balance intensity in ambulatory people with stroke.The RPS scale may be a useful clinical tool to address the gap in practice of measuring balance intensity during rehabilitation of walking balance post-stroke.

Virtual Arm Boot Camp (V-ABC): study protocol for a mixed-methods study to increase upper limb recovery after stroke with an intensive program coupled with a grasp count device.

BACKGROUND: Encouraging upper limb use and increasing intensity of practice in rehabilitation are two important goals for optimizing upper limb recovery post stroke. Feedback from novel wearable sensors may influence practice behaviour to promote achieving these goals. A wearable sensor can potentially be used in conjunction with a virtually monitored home program for greater patient convenience, or due to restrictions that preclude in-person visits, such as COVID-19. This trial aims to (1) determine the efficacy of a virtual behaviour change program that relies on feedback from a custom wearable sensor to increase use and function of the upper limb post stroke; and (2) explore the experiences and perceptions of using a program coupled with wearable sensors to increase arm use from the perspective of people with stroke. METHODS: This mixed-methods study will utilize a prospective controlled trial with random allocation to immediate or 3-week delayed entry to determine the efficacy of a 3-week behaviour change program with a nested qualitative description study. The intervention, the Virtual Arm Boot Camp (V-ABC) features feedback from a wearable device, which is intended to increase upper limb use post stroke, as well as 6 virtual sessions with a therapist. Sixty-four adults within 1-year post stroke onset will be recruited from seven rehabilitation centres. All outcomes will be collected virtually. The primary outcome measure is upper limb use measured by grasp counts over 3 days from the wearable sensor (TENZR) after the 3-week intervention. Secondary outcomes include upper limb function (Arm Capacity and Movement Test) and self-reported function (Hand Function and Strength subscale from the Stroke Impact Scale). Outcome data will be collected at baseline, post-intervention and at 2 months retention. The qualitative component will explore the experiences and acceptability of using a home program with a wearable sensor for increasing arm use from the point of view of individuals with stroke. Semi-structured interviews will be conducted with participants after they have experienced the intervention. Qualitative data will be analysed using content analysis. DISCUSSION: This study will provide novel information regarding the efficacy and acceptability of virtually delivered programs to improve upper extremity recovery, and the use of wearable sensors to assist with behaviour change. TRIAL REGISTRATION: ClinicalTrials.gov NCT04232163 . January 18, 2020.

Rib stress fracture in a male adaptive rower from the arms and shoulders sport class: case report.

Adaptive rowing is rowing or sculling for rowers with a physical disability. It debuted at the Paralympic Games in 2008. In order to ensure an equitable playing field, rowers with similar levels of physical function and disability are classified into different sport classes for competition. Rowers with an inability to use a sliding seat and impaired trunk function resulting in an inability to perform trunk forward and backward lean via hip flexion/extension are assigned to the Arms and Shoulders (AS) class. AS rowers have to use a chest strap set immediately below the chest in order to localize any trunk movement in AS class. Conditions created by adaptations of rowing equipment and technique within the AS class create unique stresses on the upper thoracic region. The following case report demonstrates how etiology and management of a rib stress fracture in an AS rower differs in comparison to able-body rowers. Of significant importance were the limitations imposed on the rower's ability to maintain rowing-specific fitness, due to the nature of the rib stress fracture and requirement to decrease force transmission through the ribs for several weeks. The rower's gradual return to full training was further impacted by obligatory use of the chest strap, which directly applied pressure over the injured area. Protective orthosis for the chest was designed and applied in order to dissipate pressure of the chest strap over the thorax during rowing (most importantly at the catch position) both on the ergometer and in the boat.

Mapping of electrodermal activity (EDA) during outdoor community-level mobility tasks in individuals with lower-limb amputation.

INTRODUCTION: Balance confidence and perception of task challenge is an important construct to measure in rehabilitation of people with lower-limb amputation (LLA). Measurement of electrodermal activity (EDA) captures physiological arousal responses reflecting an individual's perceived challenge in a task. This study explores the feasibility of the use of EDA during outdoor walking tasks to capture task-specific physiological arousal changes associated with perception of challenge in people with amputation. OBJECTIVE: To develop and demonstrate feasibility of a portable EDA/GPS system mapping physiological arousal while challenging walking balance outdoors in individuals with LLA and controls. METHODS: Sixteen people (eight with LLA and eight age-/sex-matched controls) completed an outdoor walking course in the community (3 laps). A battery-powered portable device was developed containing EDA/GPS sensors with data logged on a microcontroller. Phasic EDA response was extracted from EDA signal to explore the physiological arousal response to walking tasks. RESULTS: Physiological arousal demonstrated task-specific modulation with ascending stairs without a handrail showing higher levels of phasic EDA than walking on a paved incline (p = 0.01) or a gravel decline (p = 0.01) in people with LLA. While evidence of habituation over repeated trials was shown in controls with lap 1 of walking down a gravel decline showing higher levels of phasic EDA than lap 3 (p = 0.01). Phasic EDA maps, representative of arousal levels throughout the walking course, showed individual-specific response. CONCLUSION: Mapping of EDA during outdoor walking is feasible. Modulation of physiological arousal between outdoor walking tasks and over repeated trials is suggestive of clinical utility. Further research is warranted to explore how EDA may be incorporated into assessment of response to outdoor walking amongst individuals following LLA.

Relationships Between Stepping-Reaction Movement Patterns and Clinical Measures of Balance, Motor Impairment, and Step Characteristics After Stroke.

OBJECTIVE: Successful stepping reactions, led by either the paretic or nonparetic leg, in response to a loss of balance are critical to safe mobility poststroke. The purpose of this study was to measure sagittal plane hip, knee, ankle, and trunk kinematics during 2-step stepping reactions initiated by paretic and nonparetic legs of people who had stroke and members of a control group. METHODS: Principal component analysis (PCA) was used to reduce the data into movement patterns explaining interlimb coordination of the stepping and stance legs. Correlations among principal components loading scores and clinical measures of balance ability (as measured on the Community Balance and Mobility scale), motor impairment (as measured on the foot and leg sections of the Chedoke-McMaster Stroke Assessment), and step characteristics (length and velocity) were used to examine the effect of stroke on stepping reaction movement patterns. RESULTS: The first 5 principal components explained 95.9% of the movement pattern of stepping reactions and differentiated between stepping reactions initiated by paretic legs, nonparetic legs, or the legs of controls. Moderate-strong associations (ρ/r > 0.50) between specific principal component loading scores and clinical measures and step characteristics were dependent on the initiating leg. Lower levels of motor impairment, higher levels of balance ability, and faster and longer steps were associated with stepping reactions initiated by the paretic leg that comprised paretic leg flexion and nonparetic leg extension. Step initiation with the nonparetic leg showed associations between higher scores on clinical measures and movement patterns of flexion in both paretic and nonparetic legs. CONCLUSIONS: Movement patterns of stepping reactions poststroke were influenced by the initiating leg. After stroke, specific movement patterns showed associations with clinical measures depending on the initiating leg, suggesting that these movement patterns are important to retraining of stepping reactions. Specifically, use of flexion patterning and assessment of between-leg pattern differentiation may be important aspects to consider during retraining of stepping reactions poststroke. IMPACT: Evidence-based interventions targeting balance reactions are still in their infancy. This investigation of stepping reactions poststroke addresses a major gap in research.

Challenging Standing Balance Reduces the Asymmetry of Motor Control of Postural Sway Poststroke.

Background: Ankle plantarflexor muscle impairment contributes to asymmetrical postural control poststroke. Objective: This study examines the relationship of plantarflexor electromyography (EMG) with anterior-posterior center of pressure (APCOP) in people poststroke during progressive challenges to standing balance. Methods: Ten people poststroke and 10 controls participated in this study. Anteriorly directed loads of 1% body mass (BM) were applied to the pelvis every 25-40 s until 5%BM was reached. Cross-correlation values between plantarflexor EMG and APCOP (EMG:APCOP) position and velocity were compared. Results: EMG:APCOP velocity correlations were stronger than EMG:APCOP position across all muscles (p < .01), and correlations were predominately stronger in the nonparetic compared with the paretic leg (p < .05). Increasing challenge to standing balance reduced asymmetry of EMG:APCOP relationships. Conclusions: These data suggest that sensory information reflected in APCOP velocity interacts more strongly with plantarflexor activity in people poststroke and controls than APCOP position. Furthermore, increasing challenge to standing balance reduces postural control asymmetry between legs poststroke.

Validation of the Fitbit Flex in an Acute Post-Cardiac Surgery Patient Population.

Purpose: This study examined the validity of the Fitbit Flex activity monitor for step count and distance walked among post-cardiac surgery patients. Method: Participants (n=20) from a major urban cardiac surgery centre were recruited 1-2 days before hospital discharge. The Fitbit Flex step count and distance walked outputs and video recording of each participant performing the 6-minute walk test were collected. Fitbit Flex output was compared with criterion measures of manual step count obtained from the video recording and manual measurement of distance walked. Statistical analysis compared the output and criterion measures using paired sample t-tests, Pearson correlation coefficients, Lin's concordance correlations, and Bland-Altman plots. Sub-analysis compared slower walking (<0.8 m/s; n=11) and faster walking (≥0.8 m/s; n=8) group speeds (1 participant was excluded from analysis). Results: Steps counted and distance walked were significantly different between the Fitbit Flex outputs and criterion measures (p<0.05). The Fitbit Flex steps counted and distance walked showed moderate association with manual measure steps counted (r=0.67) and distance walked (r=0.45). Lin's concordance coefficients revealed a lack of agreement between the Fitbit Flex and the criterion measurement of both steps counted (concordance correlation coefficient [CCC]=0.43) and distance walked (CCC=0.36). The percentage of relative error was -18.6 (SD 22.7) for steps counted and 25.4 (SD 45.8) for distance walked. Conclusions: The Fitbit Flex activity monitor was not a valid measure of step count and distance walked in this sample of post-cardiac surgery patients. The lack of agreement between outputs and criterion measures suggests the Fitbit Flex alone would not be an acceptable clinical outcome measure for monitoring walking progression in the early postoperative period.

Objectif : examiner la validité du moniteur d'activité Fitbit Flex pour calculer le compte des pas et la distance parcourue chez des patients après une chirurgie cardiaque. Méthodologie : les chercheurs ont recruté les participants (n=20) dans un grand centre de chirurgie cardiaque urbain un ou deux jours avant leur congé de l'hôpital. Ils ont recueilli les résultats du compte de pas et la distance parcourue à l'aide du moniteur Fitbit Flex et l'enregistrement vidéo de chaque participant qui effectue le texte de marche de six minutes (TM6M). Ils ont comparé les résultats du moniteur Fitbit Flex aux critères du compte manuel des pas obtenus par l'enregistrement vidéo et la mesure manuelle de la distance parcourue. Par l'analyse statistique, ils ont comparé les résultats et les critères à l'aide d'échantillons de tests de Student appariés, du coefficient de corrélation de Pearson, de la corrélation de concordance de Lin et du graphique de Bland-Altman. Ils ont effectué la sous-analyse en comparant la vitesse de marche plus lente (<0,8 m/s; n=11) et plus rapide (≥0,8 m/s; n=8) des groupes (un participant a été exclu de l'analyse). Résultats : le compte de pas et la distance parcourue différaient considérablement entre les résultats du moniteur Fitbit Flex et des critères (p<0,05). Le compte de pas et la distance parcourue calculés à l'aide du moniteur Fitbit Flex ont révélé une association modérée avec la mesure manuelle du compte de pas (r =0,67) et la distance parcourue (r=0,45). Les coefficients de concordance de Lin ont révélé une absence de concordance entre le moniteur Fitbit Flex et les critères pour ce qui est du compte de pas (CCC=0,43) et de la distance parcourue (CCC=0,36). L'erreur relative du compte de pas était de −18,6 (ÉT 22,7) et celle de la distance parcourue, de 25,4 (ÉT 45,8). Conclusions : le moniteur d'activité Fitbit Flex n'est pas une mesure valide du nombre de pas et de la distance parcourue dans cet échantillon de patients après une chirurgie cardiaque. Selon l'absence de concordance entre les résultats et les critères, le moniteur Fitbit Flex ne serait pas une mesure de résultat clinique acceptable pour surveiller la progression de la marche au début de la période postopératoire.

Use of Rasch Analysis to Evaluate and Refine the Community Balance and Mobility Scale for Use in Ambulatory Community-Dwelling Adults Following Stroke.

BACKGROUND: The Community Balance and Mobility Scale (CB&M) is increasingly used to evaluate walking balance following stroke. OBJECTIVE: This study applied Rasch analysis to evaluate and refine the CB&M for use in ambulatory community-dwelling adults following stroke. METHODS: The CB&M content was linked to task demands and motor skill classifications. Rasch analysis was used to evaluate internal construct validity (structural validity) and refine the CB&M for use with ambulatory community-dwelling adults following stroke. The CB&M data were collected at 3 time points: at discharge from inpatient rehabilitation and at 6 and 12 months postdischarge (N=238). Rasch analysis evaluated scale dimensionality, item and person fit, item response bias, scoring hierarchy, and targeting. Disordered scoring hierarchy was resolved by collapsing scoring categories. Highly correlated and "misfitting" items were removed. Sensitivity to change was evaluated with standardized response means (SRMs) and one-way repeated-measures analysis of variance. RESULTS: The CB&M was primarily linked to closed body transport task demands. Significant item-trait interaction, disordered scoring hierarchies, and multidimensionality were found. Scoring categories were collapsed in 15/19 items, and 5 misfitting items were removed. The resulting stroke-specific 14-item unidimensional CB&M (CB&MStroke) fit Rasch model expectations, with no item response bias, acceptable targeting (13% floor effects and 0% ceiling effects), and moderate-to-strong sensitivity to change at 6 months postdischarge (SRM=0.63; 95% confidence interval=-1.523, -0.142) and 12 months postdischarge (SRM=0.73; 95% confidence interval=-2.318, -0.760). LIMITATIONS: Findings are limited to a modest-sized sample of individuals with mild-to-moderate balance impairment following stroke. CONCLUSIONS: The CB&MStroke shows promise as a clinical scale for measuring change in walking balance in ambulatory community-dwelling adults poststroke. Future studies are recommended in a larger sample to validate and further refine the scale for use in this clinical population.

Motoneurone afterhyperpolarisation time-course following stroke.

OBJECTIVE: Our aim was to investigate any changes in the estimated time-course of the afterhyperpolarisation (AHP) in motoneurones innervating the tibialis anterior following stroke, with a secondary objective to compare the results from two different AHP estimation techniques. METHODS: Motor units from tibialis anterior on the paretic and non-paretic sides of 15 subjects with chronic stroke were recorded using intramuscular electrodes during voluntary isometric contraction. Participants varied the motor unit firing rate from its lowest rate to approximately 10 Hz. The AHP duration was estimated using the interval death rate (IDR) and transition point methods. RESULTS: The AHP decay time-constant was significantly different between sides (paretic: 41.7 ± 8.5 ms, non-paretic: 36.2 ± 6.4 ms). Additionally, the paretic AHP time-constant was significantly longer in participants with low motor recovery (45.9 ± 9.1 ms) than with high motor recovery (39.3 ± 10.0 ms) as measured by CMSA score. The AHP estimates from the two techniques were correlated (r=0.78). CONCLUSIONS: The AHP time-course prolongation on the paretic side of people with chronic stroke is more pronounced in people with low motor recovery. SIGNIFICANCE: Changes in the motoneurone AHP time course post-stroke were related to muscle function and may play a role in the commonly-observed reduction of motor unit discharge rate during voluntary contractions following stroke.

Validation of the Fitbit One activity monitor device during treadmill walking.

OBJECTIVES: In order to quantify the effects of physical activity such as walking on chronic disease, accurate measurement of physical activity is needed. The objective of this study was to determine the validity and reliability of a new activity monitor, the Fitbit One, in a population of healthy adults. DESIGN: Cross-sectional study. METHODS: Thirty healthy adults ambulated at 5 different speeds (0.90, 1.12, 1.33, 1.54, 1.78 m/s) on a treadmill while wearing three Fitbit One activity monitors (two on the hips and one in the pocket). The order of each speed condition was randomized. Fitbit One step count output was compared to observer counts and distance output was compared to the calibrated treadmill output. Two-way repeated measures ANOVA, concordance correlation coefficients, and Bland and Altman plots were used to assess validity and intra-class correlation coefficients (ICC) were used to assess reliability. RESULTS: No significant differences were noted between Fitbit One step count outputs and observer counts, and concordance was substantial (0.97-1.00). Inter-device reliability of the step count was high for all walking speeds (ICC ≥ 0.95). Percent relative error was less than 1.3%. The distance output of the Fitbit One activity monitors was significantly different from the criterion values for each monitor at all speeds (P<0.001) and exhibited poor concordance (0.0-0.05). Inter-device reliability was excellent for all treadmill speeds (ICC ≥ 0.90). Percent relative error was high (up to 39.6%). CONCLUSIONS: The Fitbit One activity monitors are valid and reliable devices for measuring step counts in healthy young adults. The distance output of the monitors is inaccurate and should be noted with caution.

Use of the challenge point framework to guide motor learning of stepping reactions for improved balance control in people with stroke: a case series.

BACKGROUND AND PURPOSE: Stepping reactions are important for walking balance and community-level mobility. Stepping reactions of people with stroke are characterized by slow reaction times, poor coordination of motor responses, and low amplitude of movements, which may contribute to their decreased ability to recover their balance when challenged. An important aspect of rehabilitation of mobility after stroke is optimizing the motor learning associated with retraining effective stepping reactions. The Challenge Point Framework (CPF) is a model that can be used to promote motor learning through manipulation of conditions of practice to modify task difficulty, that is, the interaction of the skill of the learner and the difficulty of the task to be learned. This case series illustrates how the retraining of multidirectional stepping reactions may be informed by the CPF to improve balance function in people with stroke. CASE DESCRIPTION: Four people (53-68 years of age) with chronic stroke (>1 year) and mild to moderate motor recovery received 4 weeks of multidirectional stepping reaction retraining. Important tenets of motor learning were optimized for each person during retraining in accordance with the CPF. OUTCOMES: Participants demonstrated improved community-level walking balance, as determined with the Community Balance and Mobility Scale. These improvements were evident 1 year later. Aspects of balance-related self-efficacy and movement kinematics also showed improvements during the course of the intervention. DISCUSSION: The application of CPF motor learning principles in the retraining of stepping reactions to improve community-level walking balance in people with chronic stroke appears to be promising. The CPF provides a plausible theoretical framework for the progression of functional task training in neurorehabilitation.

Reduced quadriceps motor-evoked potentials in an individual with unilateral knee osteoarthritis: a case report.

One male with unilateral osteoarthritis (OA) of the knee underwent testing of corticospinal (CS) excitability (as quantified from motor-evoked potentials (MEPs) in the rectus femoris (RF) using transcranial magnetic stimulation) and quadriceps muscle strength. Baseline data indicated reduced MEP amplitudes in the RF of the affected limb compared to the unaffected limb. Increases in RF MEP amplitudes from both limbs were observed immediately following a 30-minute exercise session focusing on muscle strengthening. Following an 8-week muscle strengthening intervention, the participant exhibited increased MEP amplitudes and muscle strength in the affected limb. These findings suggest that alterations in peripheral muscle function found in patients with knee OA may have an origin centrally within the motor cortex and that interlimb differences may be evident in those with unilateral disease. These findings also suggest that CS excitability may be improved following a muscle strengthening intervention.