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Objective: To consolidate the evidence on the effect of physical exercise on fear of falling in individuals with stroke., Data Sources: PubMed, CINAHL, Cochrane Database and MEDLINE., Methods: An extensive database search was conducted to identify the randomised controlled trials that examined the effect of physical exercise on fear of falling post-stroke. Grading of Recommendation, Assessment, Development and Evaluation (GRADE) was used to assess the quality of evidence for each meta-analysis., Results: Fourteen trials totalling 1211 participants were included in this review. Thirteen of these (1180 participants) were included in the meta-analyses. In the primary analysis, very low-quality evidence suggested that exercise reduced fear of falling post-stroke (standardized mean difference (SMD) 0.48; 95% confidence interval (CI) 0.23 to 0.72). The effect was diminished at three- to six-month follow-up after exercise training ended (SMD -0.09; 95% CI -0.27 to 0.10; high-quality evidence). In the sensitivity analyses, the treatment effect was more pronounced in individuals with a lower baseline Berg balance score (BBS ≤45; SMD 0.53; 95%CI 0.17 to 0.88) and for those trials with exercise frequency of ≥3 sessions per week (SMD 0.70; 95%CI 0.39 to 1.01). Compared with circuit-based training consisting of a combination of walking, balance and strengthening exercises (SMD 0.27; 95% CI -0.09 to 0.63), walking programmes seemed to generate a larger effect on fear of falling (SMD 1.06; 95%CI 0.43 to 1.70)., Conclusion: Physical exercise was beneficial for reducing fear of falling in individuals with stroke, particularly those with poorer balance ability.

Objective: To determine the long-term effects of low-frequency repetitive transcranial magnetic stimulation (LF-rTMS) over the contralesional M1 preceding motor task practice on the interhemispheric asymmetry of the cortical excitability and the functional recovery in subacute stroke patients with mild to moderate arm paresis., Methods: Twenty-four subacute stroke patients were randomly allocated to either the experimental or control group. The experimental group underwent rTMS over the contralesional M1 (1 Hz), immediately followed by 30 minutes of motor task practice (10 sessions within 2 weeks). The controls received sham rTMS and the same task practice. Following the 2-week intervention period, the task practice was continued twice weekly for another 10 weeks in both groups. Outcomes were evaluated at baseline (T0), at the end of the 2-week stimulation period (T1), and at 12-week follow-up (T2)., Results: The MEP (paretic hand) and interhemispheric asymmetry, Fugl-Meyer motor assessment, Action Research Arm Test, and box and block test scores improved more in the experimental group than controls at T1 ( p < 0.05). The beneficial effects were largely maintained at T2., Conclusion: LF-rTMS over the contralesional M1 preceding motor task practice was effective in enhancing the ipsilesional cortical excitability and upper limb function with reducing interhemispheric asymmetry in subacute stroke patients with mild to moderate arm paresis. Significance. Adding LF-rTMS prior to motor task practice may reduce interhemispheric asymmetry of cortical excitabilities and promote upper limb function recovery in subacute stroke with mild to moderate arm paresis., Competing Interests: Submitting authors are responsible for coauthors declaring their interests. The authors declare that there is no conflict of interest regarding the publication of this article., (Copyright © 2022 Ka Yan Luk et al.)

Questions: What are the degree and pattern of dual-task interference during walking in people after stroke? How do these vary with disease chronicity and different component tasks in people after stroke? How does dual-task interference differ between people after stroke and people without stroke?, Design: Systematic review with meta-analysis of studies reporting gait-related dual-task interference., Participants: People after stroke and people without stroke., Outcome Measures: Measures of walking and secondary (cognitive or manual) task performance under dual-task conditions relative to those under single-task conditions., Results: Seventy-six studies (2,425 people after stroke and 492 people without stroke) were included. Manual and mental tracking tasks imposed the greatest dual-task interference on gait speed, although there was substantial uncertainty in these estimates. Among mental tracking tasks, the apparently least-complex task (serial 1 subtractions) induced the greatest dual-task interference (-0.17 m/s, 95% CI -0.24 to -0.10) on gait speed, although there was substantial uncertainty in these estimates. Mutual interference (decrement in both walking and secondary component task performances during dual-tasking) was the most common dual-task interference pattern. The results of the sensitivity analyses for studies involving people with chronic stroke were similar to the results of the primary analyses. The amount of dual-task interference from a mental tracking or manual task during walking was similar between people with or without stroke., Conclusions: The degree and pattern of dual-task interference vary with the choice of component tasks. When evaluating limitations to functional mobility during dual-tasking conditions and in planning interventions accordingly, clinicians should select dual-task assessments that correspond to the daily habits and physical demands of people after stroke., Registration: CRD42017059004., (Copyright © 2021 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to examine the fall predictive value of single-task walking tests and extent of interference observed in dual-task walking tests in ambulatory individuals post stroke., Design: This is an observational study with prospective cohort., Setting: The study was conducted at the university laboratory., Participants: A total of 91 community-dwelling individuals with chronic stroke participated in the study., Main Outcome Measures: Time required to complete a 10-m walk test with and without obstacle negotiation was measured in isolation and in conjunction with performance of a verbal fluency task (category naming). Fall incidence, circumstances, and related injuries were recorded by monthly telephone calls for 12 months., Results: A total of 91 individuals (mean (SD) age = 62.7 (8.3) years; mean (SD) post-stroke duration = 8.8 (5.3) years) participated in the study; 29 (32%) of them reported at least one fall during the follow-up period, with a total of 71 fall episodes. There was a significant difference in obstacle-crossing time under single-task (mean difference = 8.3 seconds) and dual-task (mean difference = 7.4 seconds) conditions, and also the degree of interference in mobility performance (increased dual-task obstacle-crossing time relative to the single-task obstacle-crossing time; mean difference = 3.3%) between the fallers and the non-fallers ( P  < 0.05). After adjusting for the effects of other relevant factors, a greater degree of interference in mobility performance remained significantly associated with a decreased risk of falling (adjusted odds ratio = 0.951, 95% CI = 0.907-0.997, P  = 0.037)., Conclusion: The degree of mobility interference during dual-task obstacle-crossing was the most effective in predicting falls among all the single-task and dual-task walking measure parameters tested. This simple dual-task walking assessment has potential clinical utility in identifying people post stroke at high risk of future falls.

Objective: To explore the reliability and validity of a series of dual-task mobility assessments among individuals post-stroke., Design: Observational study with repeated measures., Setting: University laboratory., Participants: Thirty community-dwelling individuals with chronic stroke., Interventions: Not applicable., Main Measures: Each of the two mobility tasks (1-minute level-ground walking with and without obstacle-negotiation) was performed concurrently with each of the eight cognitive tasks (auditory Stroop test, serial subtraction, shopping list recall and category naming at two difficulty levels). Walking distance and obstacle hitting rate (OHR) indicated dual-task mobility performance. Number of correct responses (NCR) indicated cognitive performance. Reaction time was additionally measured for the auditory Stroop test. Construct validity was examined by correlations between the dual-task assessments. The dual-task assessments were repeated within 7-14 days for test-retest reliability., Results: Excellent test-retest reliability in walking distance and OHR was found (intraclass correlation coefficient, ICC(3,1) = 0.891-0.984, P < 0.05). Moderate to excellent reliability was found in NCR and reaction time (ICC(3,1) = 0.480-0.911, P < 0.01). Correlations between walking distance were excellent ( r s  = 0.840-0.985, P < 0.01). Correlations of NCR and reaction time between low- and high-level cognitive tasks were mostly moderate to excellent ( r s   = 0.515-0.793, P < 0.01). Generally no significant correlations were found in NCR between the dual-task assessments with different cognitive domains., Conclusion: The dual-task walking assessments are reliable and valid for evaluating cognitive-motor interference in community-dwelling individuals post-stroke. The lack of correlations between the tasks of different cognitive domains indicates the need of using different cognitive domains in dual-task walking assessment post-stroke.

Background and Purpose- Functional community ambulation requires the ability to perform mobility and cognitive task simultaneously (dual-tasking). This single-blinded randomized controlled study aimed to examine the effects of dual-task exercise in chronic stroke patients. Methods- Eighty-four chronic stroke patients (24 women; age, 61.2±6.4 years; time since stroke onset, 75.3±64.9 months) with mild to moderate motor impairment (Chedoke-McMaster leg motor score: median, 5; interquartile range, 4-6) were randomly allocated to the dual-task balance/mobility training group, single-task balance/mobility group, or upper-limb exercise (control) group. Each group exercised for three 60-minute sessions per week for 8 weeks. The dual-task interference effect was measured for the time to completion of 3 mobility tests (forward walking, timed-up-and-go, and obstacle crossing) and for the correct response rate during serial-3-subtractions and verbal fluency task. Secondary outcomes included the Activities-specific Balance Confidence Scale, Frenchay Activities Index, and Stroke-specific Quality of Life Scale. The above outcomes were measured at baseline, immediately after, and 8 weeks after training. Fall incidence was recorded for a 6-month period posttraining. Results- Only the dual-task group exhibited reduced dual-task interference in walking time posttraining (forward walking combined with verbal fluency [9.5%, P=0.014], forward walking with serial-3-subtractions [9.6%, P=0.035], and the timed-up-and-go with verbal fluency [16.8%, P=0.001]). The improvements in dual-task walking were largely maintained at the 8-week follow-up. The dual-task cognitive performance showed no significant changes. The dual-task program reduced the risk of falls and injurious falls by 25.0% (95% CI, 3.1%-46.9%; P=0.037) and 22.2% (95% CI, 4.0%-38.4%; P=0.023), respectively, during the 6-month follow-up period compared with controls. There was no significant effect on other secondary outcomes ( P>0.05). Conclusions- The dual-task program was effective in improving dual-task mobility, reducing falls and fall-related injuries in ambulatory chronic stroke patients with intact cognition. It had no significant effect on activity participation or quality of life. Clinical trial registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02270398.

Background: The ability to perform a cognitive task while walking simultaneously (dual-tasking) is important in real life. However, the psychometric properties of dual-task walking tests have not been well established in stroke., Objective: To assess the test-retest reliability, concurrent and known-groups validity of various dual-task walking tests in people with chronic stroke., Design: Observational measurement study with a test-retest design., Methods: Eighty-eight individuals with chronic stroke participated. The testing protocol involved four walking tasks (walking forward at self-selected and maximal speed, walking backward at self-selected speed, and crossing over obstacles) performed simultaneously with each of the three attention-demanding tasks (verbal fluency, serial 3 subtractions or carrying a cup of water). For each dual-task condition, the time taken to complete the walking task, the correct response rate (CRR) of the cognitive task, and the dual-task effect (DTE) for the walking time and CRR were calculated. Forty-six of the participants were tested twice within 3-4 days to establish test-retest reliability., Results: The walking time in various dual-task assessments demonstrated good to excellent reliability [Intraclass correlation coefficient (ICC2,1) = 0.70-0.93; relative minimal detectable change at 95% confidence level (MDC95%) = 29%-45%]. The reliability of the CRR (ICC2,1 = 0.58-0.81) and the DTE in walking time (ICC2,1 = 0.11-0.80) was more varied. The reliability of the DTE in CRR (ICC2,1 = -0.31-0.40) was poor to fair. The walking time and CRR obtained in various dual-task walking tests were moderately to strongly correlated with those of the dual-task Timed-up-and-Go test, thus demonstrating good concurrent validity. None of the tests could discriminate fallers (those who had sustained at least one fall in the past year) from non-fallers., Limitation: The results are generalizable to community-dwelling individuals with chronic stroke only., Conclusions: The walking time derived from the various dual-task assessments generally demonstrated good to excellent reliability, making them potentially useful in clinical practice and future research endeavors. However, the usefulness of these measurements in predicting falls needs to be further explored. Relatively low reliability was shown in the cognitive outcomes and DTE, which may not be preferred measurements for assessing dual-task performance.

The early and accurate stratification of intracranial cerebral artery stenosis (ICAS) is critical to inform treatment management and enhance the prognostic outcomes in patients with cerebrovascular disease (CVD). Digital subtraction angiography (DSA) is an invasive and expensive procedure but is the gold standard for the diagnosis of ICAS. Over recent years, transcranial color-coded Doppler ultrasound (TCCD) has been suggested to be a useful imaging method for accurately diagnosing ICAS. However, the diagnostic accuracy of TCCD in stratifying ICASs among patients with CVD remains unclear. Therefore, this systematic review and meta-analysis aimed at evaluating the diagnostic accuracy of TCCD in the stratification of intracranial steno-occlusions among CVD patients. A total of six databases—Embase, CINAHL, Medline, PubMed, Google Scholar, and Web of Science (core collection)—were searched for studies that assessed the diagnostic accuracy of TCCD in stratifying ICASs. The meta-analysis was performed using Meta-DiSc 1.4. The Quality Assessment of Diagnostic Accuracy Studies tool version 2 (QUADAS-2) assessed the risk of bias. Eighteen studies met all of the eligibility criteria. TCCD exhibited a high pooled diagnostic accuracy in stratifying intracranial steno-occlusions in patients presenting with CVD when compared to DSA as a reference standard (sensitivity = 90%; specificity = 87%; AUC = 97%). Additionally, the ultrasound parameters peak systolic velocity (PSV) and mean flow velocity (MFV) yielded a comparable diagnostic accuracy of "AUC = 0.96". In conclusion, TCCD could be a noble, safe, and accurate alternative imaging technique to DSA that can provide useful diagnostic information in stratifying intracranial steno-occlusions in patients presenting with CVD. TCCD should be considered in clinical cases where access to DSA is limited. [ABSTRACT FROM AUTHOR]