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Qualitative descriptive study.To gain insight into if and how participation in intensive balance training impacted the daily lives and risk of falling of people living with incomplete spinal cord injury or disease (SCI/D), as well as to understand what motivated participation and what benefits and challenges, if any, they experienced while completing training.Tertiary rehabilitation hospital.Semi-structured interviews were conducted three to four months after 20 participants with incomplete SCI/D completed either Perturbation-based Balance Training or Conventional Intensive Balance Training as part of a randomized clinical trial. Interviews were transcribed verbatim and coded using conventional content analysis by two researchers. Codes were discussed for consensus, and subcategories and categories were created, which were confirmed by another two researchers.The following categories were identified: 1) goals of balance training, 2) valuable components of balance training, 3) physical gains from balance training, 4) psychosocial gains from participating in balance training, and 5) unique aspects of Perturbation-based Balance Training. Each category consisted of several subcategories.Collecting qualitative data facilitated the evaluation of the meaningfulness of the balance training programs to the participants. These findings demonstrate that balance training was perceived as beneficial and enjoyable for individuals with incomplete SCI/D, and that these programs provided challenge and educational opportunities for the participants while improving balance confidence and reducing perceived fall risk. These findings have implications to direct future research studies or implementation of balance training in rehabilitation.

Reactive stepping is one of the only strategies that can lead to successful stabilization following a large challenge to balance. Improving function of specific muscles associated with reactive stepping may improve features of reactive balance control. Accordingly, this study aimed to determine the relationship between lower limb muscle strength and explosive force with force plate-derived timing measures of reactive stepping. Nineteen young, healthy adults (27.6 ± 3.0 years of age; 10 women: 9 men) responded to 6 perturbations (~13-15% of body weight) using an anterior lean-and-release system (causing a forward fall), where they were instructed to recover balance in as few steps as possible. Foot-off, swing, and restabilization times were estimated from force plates. Peak isokinetic torque, isometric torque, and explosive force of the knee extensors/flexors and plantar/dorsiflexors were measured using isokinetic dynamometry. Correlations were run based on a priori hypotheses and corrected for the number of comparisons (Bonferroni) for each variable. Knee extensor explosive force was negatively correlated with swing time (r = −0.582, p = 0.009). Knee flexor peak isometric torque also showed a negative association with restabilization time (r = −0.459, p = 0.048), however this was not statistically significant after correcting for multiple comparisons. There was no significant relationship between foot-off time and knee or plantar flexor explosive force (p > 0.025). These findings suggest that there may be utility to identifying specific aspects of reactive step timing when studying the relationship between muscle strength and reactive balance control. Exercise training aimed at improving falls risk should consider targeting specific aspects of muscle strength depending on specific deficits in reactive stepping.

Objective People exhibiting post-stroke lateropulsion actively push their body across the midline to the more affected side and/or resist weight shift toward the less affected side. Despite its prevalence and associated negative rehabilitation outcomes, no clinical practice guidelines exist for the rehabilitation of post-stroke lateropulsion. We aimed to develop consensus-based clinical practice recommendations for managing post-stroke lateropulsion using an international expert panel. Design This Delphi panel process conformed with Guidance on Conducting and Reporting Delphi Studies recommendations. Participants Panel members had demonstrated clinical and/or scientific background in the rehabilitation of people with post-stroke lateropulsion. Main Measures The process consisted of four electronic survey rounds. Round One consisted of 13 open questions. Subsequent rounds ascertained levels of agreement with statements derived from Round One. Consensus was defined a priori as ≥75% agreement (agree or strongly agree), or ≥70% agreement after excluding ‘unsure’ responses. Results Twenty participants completed all four rounds. Consensus was achieved regarding a total of 119 recommendations for rehabilitation approaches and considerations for rehabilitation delivery, positioning, managing fear of falling and fatigue, optimal therapy dose, and discharge planning. Statements for which ‘some agreement’ (50%–74% agreement) was achieved and those for which recommendations remain to be clarified were recorded. Conclusions These recommendations build on existing evidence to guide the selection of interventions for post-stroke lateropulsion. Future research is required to elaborate specific rehabilitation strategies, consider the impact of additional cognitive and perceptual impairments, describe positioning options, and detail optimal therapy dose for people with lateropulsion.

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.

BackgroundPeople with stroke often have asymmetric motor impairment. Investigating asymmetries in, and dynamic properties of, centre of pressure movement during quiet standing can inform how well balance is controlled.Research questionWhat are the test-retest reliabilities of novel measures of quiet standing balance control in people with chronic stroke?MethodsTwenty people with chronic stroke (>6 months post-stroke), who were able to stand for at least 30 seconds without support, were recruited. Participants completed two 30-second quiet standing trials in a standardized position. Novel measures of quiet standing balance control included: symmetry of variability in centre of pressure displacement and velocity, between-limb synchronization, and sample entropy. Root mean square of centre of pressure displacement and velocity in the antero-posterior and medio-lateral directions were also calculated. Intraclass correlation coefficients (ICCs) were used to determine test-retest reliability, and Bland-Altman plots were created to examine proportional biases.ResultsICC3,2were between 0.79 and 0.95 for all variables, indicating ‘good’ to ‘excellent’ reliability (>0.75). However, ICC3,1for symmetry indices and between-limb synchronization were SignificanceThese findings suggest that centre of pressure measures extracted from a single 30-second quiet standing trial may have sufficient reliability for some research studies in chronic stroke. However, for clinical applications, the average of at least two trials may be required.

The ability to self-evaluate motor performance or estimate performance errors is beneficial for motor learning or relearning in the context of neurologic injury. Some evidence suggests those with injury like stroke may be unable to accurately self-evaluate their performance; however, it is unclear if individuals who are absent of injury are accurate in this domain. We aimed to investigate the accuracy of self-evaluation and potential influencing factors by conducting a systematic search to identify literature involving the self- and objective-evaluation of upper-extremity motor tasks. Twenty-three studies satisfied inclusion criteria. Data revealed a moderate positive correlation between self- and objective evaluations across a variety of tasks, from trivial button pressing to specialized surgical suturing. Both under- and overestimation of performance was found across the papers. Key factors identified to influence the accuracy of self-evaluation were the task purpose, familiarity, difficulty, and whether an individual received a demonstration. This review identified some limitations in this field of research. Most notably, we found that very few studies have investigated the accuracy of self-evaluation of motor performance with the primary goal of comparison to objective performance. Many studies reported the data but did not make direct statistical comparisons. Moreover, due to inconsistencies between how self and objective-evaluations were conducted, we argue that in this area of investigation self-evaluation tools need to replicate the objective evaluation method, or at minimum the self-evaluation tool should ask questions specific to the construct of performance that is being measured objectively.

Background: ‘Perturbation-based balance training’ was developed to improve balance reactions to unexpected losses of balance. Although this training method is effective, its practical usage in the field of physical-therapy in Israel and world-wide is still unclear. Aims: This study aimed to evaluate the extent of perturbation-based balance training use in physical-therapy clinics in Israel, to identify the significant barriers to/facilitators for implementing perturbation-based balance training in clinical practice among physical therapists, and to determine which aspects of perturbation-based balance training most interest physical therapists in Israel. Methods: Physical therapists in Israel completed a survey using a questionnaire regarding their knowledge and use of perturbation-based balance training in their clinical practices. We compared the specific use of perturbation-based balance training among users; non-users; and open-to-use physical therapists. The odds ratios of the facilitators and barriers were calculated using univariate and multivariate logistic regression models. Results: Four-hundred and two physical therapists responded to a yes/no question regarding their use of perturbation-based balance training. Three-quarters (75.4%) of physical therapists reported using perturbation-based balance training in their practices. The most prevalent barrier cited was insufficient space for setting up equipment and most prevalent facilitator was having a colleague who uses perturbation-based balance training. Most of the respondents wanted to learn more about perturbation-based balance training, and most of the non-users wanted to expand their knowledge and mastery of perturbation-based balance training principles. Conclusions: There are misconceptions and insufficient knowledge about perturbation-based balance training among physical therapists in Israel. Reliable information may help to improve general knowledge regarding perturbation-based balance training, and to facilitate the more widespread implementation of perturbation-based balance training as an effective fall-prevention intervention method.

Temporal gait asymmetry (TGA) affects 55% of people with stroke. This study investigated the effects of augmented feedback during overground gait training, on TGA.Eighteen people with chronic stroke were randomized to receive one of two feedback displays (A or B) and one of three feedback frequencies; no feedback (0%), after alternate walking trials (50%) or after every trial (100%). Display A depicted the TGA ratio as a vertical line along a horizontal axis with perfect symmetry in the middle. Display B depicted single limb stance duration of each leg as a bar graph. Participants completed 25 repetitions of 30 second trials with their assigned feedback (acquisition). Participants completed 10 repetitions of 30 second trials without feedback 24 hours later (retention). A pressure sensitive mat recorded TGA and speed. Changes in TGA and speed were investigated by plotting individual motor learning curves and fitting a curve with locally estimated scatterplot smoothing (LOESS) for each feedback group. An effect of feedback was defined a priori as a LOESS fitted curve with a decreasing slope from acquisition to retention.LOESS curve exhibited a decreasing slope for TGA in the 100B group only and for speed in the 50A and 0FB groups.This study provides preliminary evidence that visual feedback delivered at a high frequency during a single session of overground walking can change TGA post-stroke without reducing gait speed. An overground gait intervention with high frequency visual feedback to improve TGA post-stroke is worthwhile to investigate.

ObjectiveTo determine the publication rate of motor-rehabilitation trials poststroke and the consistency between registry records and their corresponding main publications in trial design, primary objectives and outcomes, eligibility criteria, and sample size.MethodsWe searched 18 clinical trial registries to identify randomized controlled trials of motor-based stroke rehabilitation registered after July 2005 and completed before April 2017. Eligible trials included adults with stroke, with at least one outcome measure related to motor function. Information in the registry records was compared with that of their main publications, if any.ResultsThree hundred twenty-three trials met our eligibility criteria; we were unable to find a peer-reviewed publication reporting the main findings for 46% (150/323) of these. Of the 169 trials with peer-reviewed articles published in English, 141 (83%) were consistent with the registry record in trial design, 100 (59%) were consistent in primary objectives, 71 (42%) were consistent in primary outcomes, 28 (17%) were consistent in eligibility criteria, and 74 (44%) were consistent in sample size.ConclusionsApproximately half of motor-based stroke rehabilitation trials were not published, even more than 3 years after the end of the trial. When main publications were found, they substantially deviated from information in the registry record. These findings highlight the importance of trial registries for identifying unpublished stroke rehabilitation trials and of searching trial registries when conducting systematic reviews and meta-analysis to help ensure that reviews are unbiased.

Youth with cerebral palsy generally participate in less physical activity than typically developing peers. In adults with physical disabilities, balance confidence is a strong predictor of participation and community re-integration. However, balance confidence has not been studied in youth with cerebral palsy.Qualitative descriptive methodology with interviews of eight youth with cerebral palsy (9-17 years old, three girls) in Gross Motor Function Classification System Levels I-III, and eight parents (five mothers) of youth with cerebral palsy (9-17 years old, two girls) in Levels I-III.Three themes arose: (1) youth in Gross Motor Function Classification System Levels I-II are more concerned about losing their balance during physical activities than those in Level III; (2) when balance is lost, embarrassment and frustration are more common than fear, especially for those in Levels I-II; and (3) social factors can create a favorable participation environment when balance confidence is low, especially for youth in Levels I-II.Balance confidence may have greater influence on physical activity participation for youth in Gross Motor Function Classification System Levels I-II than those in Level III. Youth in Levels I-II may draw greater benefit from interventions targeting balance confidence when addressing physical activity goals.IMPLICATIONS FOR REHABILITATIONBalance confidence may have a greater influence on activity avoidance for youth with cerebral palsy in Gross Motor Function Classification System Levels I and II (who are independently ambulatory without walkers or cane(s)) than for those in Level II (who use walkers or cane(s) to ambulate).Youth who are independently ambulatory without walkers or cane(s) may benefit more from interventions directed at balance confidence (e.g., enactive mastery and verbal persuasion) to address their physical activity participation goals.For youth who are independently ambulatory without walkers or cane(s), addressing factors that could reduce the influence of balance confidence on physical activity participation, such as providing a positive and supportive social environment in which to participate, may be beneficial.

Background and purpose Aerobic exercise is a recommended part of stroke best practices; yet, access to aerobic exercise programs within stroke rehabilitation remains limited and inconsistent. The purpose of this scoping review was to describe the nature and extent of barriers and facilitators to aerobic exercise implementation with adults post-stroke as reported by health care professionals. Methods MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, and AMED Allied and Complementary Medicine were searched from inception to October 16, 2019. Research studies that examined health care professionals' barriers and facilitators to aerobic exercise implementation in adults post-stroke were included. Two reviewers independently conducted title and abstract screening, full-text evaluation, data extraction, and quality appraisal. The Theoretical Domains Framework was used to map the identified barriers or facilitators and to analyze and interpret the results. Results Four studies were included in the review. All studies involved surveys conducted among physical therapists and reported barriers related to "environmental context and resources" (eg, lack of equipment, time, staff), insufficient "knowledge" and "skills" (eg, safe aerobic exercise prescription and implementation), "beliefs about capabilities" (eg, uncertainty about exercise intensity and screening tools), and professional role and identity (eg, aerobic exercise not a priority). Access to and continued education in structured aerobic exercise programs and safety monitoring were identified facilitators. Discussion and conclusions Some of the identified barriers could be overcome with modeling and training in best practice, while others may require interventions targeting organizational environment and leadership. Future knowledge translation interventions should target the identified barriers and facilitators to implementing aerobic exercise.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A312).

Objective The benefits of aerobic exercise early after stroke are well known, but concerns about cardiovascular risk are a barrier to clinical implementation. Symptom-limited exercise testing with electrocardiography (ECG) is recommended but not always feasible. The purpose of this study was to determine the frequency of and corresponding exercise intensities at which ECG abnormalities occurred during submaximal exercise testing that would limit safe exercise prescription beyond those intensities. Methods This study was a retrospective analysis of ECGs from 195 patients who completed submaximal exercise testing during stroke rehabilitation. A graded submaximal exercise test was conducted with a 5- or 12-lead ECG and was terminated on the basis of predetermined endpoint criteria (heart rate, perceived exertion, signs, or symptoms). ECGs were retrospectively reviewed for exercise-induced abnormalities and their associated heart rates. Results The peak heart rate achieved was 65.4% (SD = 10.5%) of the predicted maximum heart rate or 29.1% (SD = 15.5%) of the heart rate reserve (adjusted for beta-blocker medications). The test was terminated more often because of perceived exertion (93/195) than because of heart rate limits (60/195). Four patients (2.1%) exhibited exercise-induced horizontal or downsloping ST segment depression of ≥1 mm. Except for 1 patient, the heart rate at test termination was comparable with the heart rate associated with the onset of the ECG abnormality. Conclusion A graded submaximal exercise test without ECG but with symptom monitoring and conservative heart rate and perceived exertion endpoints may facilitate safe exercise intensities early after stroke. Symptom-limited exercise testing with ECG is still recommended when progressing to higher intensity exercise. Impact Concerns about cardiovascular risk are a barrier to physical therapists implementing aerobic exercise in stroke rehabilitation. This study showed that, in the absence of access to exercise testing with ECG, submaximal testing with conservative heart rate and perceived exertion endpoints and symptom monitoring can support physical therapists in the safe prescription of aerobic exercise early after stroke. Lay Summary It is recommended that people with stroke participate in aerobic exercise as early as possible during their rehabilitation. A submaximal exercise test with monitoring of heart rate, perceived exertion, blood pressure, and symptoms can support physical therapists in safely prescribing that exercise.

Objective Reactive stepping is critical for preventing falls and is impaired in people with multiple sclerosis (PwMS); however, which aspects of stepping relate to falls remains poorly understood. Identifying outcomes most related to falls is a first step toward improving rehabilitation for fall prevention. The purpose of this study was to assess whether reactive step latency or length during forward and backward losses of balance were related to a history of falls in PwMS. Methods Of the 111 PwMS who participated in this study, 76 reported no falls in the previous 6 months, whereas 36 reported 1 or more falls. Participants completed 3 forward and 3 backward treadmill-induced reactive steps from stance. Step length (centimeters) and step latency (milliseconds) were measured using motion capture and analyzed via MATLAB. Results Participants with a history of falls had significantly slower step latencies during backward stepping, but not forward stepping, than those without a history of falls. Step length did not differ between groups. Slower step latencies during backward stepping significantly increased the odds of having experienced a fall (β = .908, SE = 0.403, odds ratio = 2.479, 95% CI = 1.125 to 5.464). Conclusion PwMS and a history of falling show delayed step onsets during backward reactive stepping. Specifically, for every 10-millisecond increase in step latency, PwMS were 2.5 times more likely to have a fall history. Although clinical trials are necessary to determine whether interventions targeting reactive stepping reduce falls in PwMS, the current work indicates that the latency of steps may be a relevant target for this work. Impact Subsequent fall prevention clinical trials should consider targeting backward reactive step latency to further assess its relevance for rehabilitation in PwMS. Lay Summary If you have MS and a history of falls, you may be more likely to have delayed reactive step latencies.

Objective Reactive balance training (RBT) is an emerging approach to reducing falls risk in people with balance impairments. The purpose of this study was to determine the effect of RBT on falls in daily life among individuals at increased risk of falls and to document associated adverse events. Methods Databases searched were Ovid MEDLINE (1946 to March 2022), Embase Classic and Embase (1947 to March 2022), Cochrane Central Register of Controlled Trials (2014 to March 2022), and Physiotherapy Evidence Database (PEDro; searched on 22 March 2022). Randomized controlled trials of RBT were included. The literature search was limited to the English language. Records were screened by 2 investigators separately. Outcome measures were number of participants who reported falls after training, number of falls reported after training, and the nature, frequency, and severity of adverse events. Authors of included studies were contacted to obtain additional information. Results Twenty-nine trials were included, of which 17 reported falls and 21 monitored adverse events. Participants assigned to RBT groups were less likely to fall compared with control groups (fall risk ratio = 0.76; 95% CI = 0.63–0.92; I2 = 32%) and reported fewer falls than control groups (rate ratio = 0.61; 95% CI = 0.45–0.83; I2 = 81%). Prevalence of adverse events was higher in RBT (29%) compared with control groups (20%). Conclusion RBT reduced the likelihood of falls in daily life for older adults and people with balance impairments. More adverse events were reported in RBT than control groups. Impact Balance training that evokes balance reactions can reduce falls among people at increased risk of falls. Older adults and individuals with balance problems were less likely to fall in daily life after participating in RBT compared with traditional balance training. Lay summary If you are an older adult and/or have balance problems, your physical therapist may prescribe reactive balance training rather than traditional balance training in order to reduce your likelihood of falling in daily life.

Post-stroke lateropulsion is prevalent. The global inconsistency in terminology used to describe the condition presents obstacles in accurately comparing research results, reaching consensus on use of measurement tools, agreeing upon a consistent approach to rehabilitation, and translating research to clinical practice. Commencing in 2021, 20 international experts undertook a Delphi Process that aimed to compile clinical practice recommendations for the rehabilitation of lateropulsion. As a part of the process, the panel agreed to aim to reach consensus regarding terminology used to describe the condition. Improved understanding of the condition could lead to improved management, which will enhance patient outcomes after stroke and increase efficiency of healthcare resource utilisation. While consensus was not reached, the panel achieved some agreement that 'lateropulsion' is the preferred term to describe the phenomenon of 'active pushing of the body across the midline toward the more affected side, and / or actively resisting weight shift toward the less affected side'. This group recommends that 'lateropulsion' is used in future research and in clinical practice.

Data consists of baseline clinical assessments of gait, mobility, and fall risk at the time of admission of 54 adults with dementia. Furthermore, it includes the participants' daily medication intake in three medication categories, and frequent assessments of gait performed via a computer vision-based ambient monitoring system.

Fall risk is high for older adults with dementia. Gait impairment contributes to increased fall risk, and gait changes are common in people with dementia, although the reliable assessment of gait is challenging in this population. This study aimed to develop an automated approach to performing gait assessments based on gait data that is collected frequently and unobtrusively, and analysed using computer vision methods. Recent developments in computer vision have led to the availability of open source human pose estimation algorithms, which automatically estimate the joint locations of a person in an image. In this study, a pre-existing pose estimation model was applied to 1066 walking videos collected of 31 older adults with dementia as they walked naturally in a corridor on a specialized dementia unit over a two week period. Using the tracked pose information, gait features were extracted from video recordings of gait bouts and their association with clinical mobility assessment scores and future falls data was examined. A significant association was found between extracted gait features and a clinical mobility assessment and the number of future falls, providing concurrent and predictive validation of this approach., Using recorded videos of natural gait of people with dementia, we showed concurrent and predictive validation for the use of human pose estimation for gait assessment and eventual use for fall prevention.

Background Gait impairments contribute to falls in people with dementia. In this study, we used a vision-based system to record episodes of walking over a 2-week period as participants moved naturally around their environment, and from these calculated spatiotemporal, stability, symmetry, and acceleration gait features. The aim of this study was to determine whether features of gait extracted from a vision-based system are associated with falls, and which of these features are most strongly associated with falling. Methods Fifty-two people with dementia admitted to a specialized dementia unit participated in this study. Thirty different features describing baseline gait were extracted from Kinect recordings of natural gait over a 2-week period. Baseline clinical and demographic measures were collected, and falls were tracked throughout the participants’ admission. Results A total of 1,744 gait episodes were recorded (mean 33.5 ± 23.0 per participant) over a 2-week baseline period. There were a total of 78 falls during the study period (range 0–10). In single variable analyses, the estimated lateral margin of stability, step width, and step time variability were significantly associated with the number of falls during admission. In a multivariate model controlling for clinical and demographic variables, the estimated lateral margin of stability (p = .01) was remained associated with number of falls. Conclusions Information about gait can be extracted from vision-based recordings of natural walking. In particular, the lateral margin of stability, a measure of lateral gait stability, is an important marker of short-term falls risk.

Introduction Loss of mobility is common in advanced dementia and has important negative consequences related to fall risk, loss of independence, and lack of participation in meaningful activities. The causes of decline are multifactorial, including disease-specific changes in motor function, behavior, and cognition. To optimize clinical management of mobility, there is a need to better characterize capacity for safe and independent mobility. This study aimed to identify key factors that impact on mobility in dementia. Methods Expert input was gathered using a modified Delphi consensus approach. The primary criterion for participation was specialist knowledge in mobility or dementia, either as a clinician or a researcher. Participants rated elements of mobility for importance and feasibility of assessment in advanced dementia and prioritized items for inclusion in a mobility staging tool. Descriptive statistics and qualitative content analysis were used to summarize responses. Results Thirty-six experts completed the first survey with an 80% retention rate over three rounds. One-third of 61 items reached consensus for being both important and feasible to assess, representing five categories of elements. Items reaching agreement for a staging tool included walking, parkinsonism, gait, impulsivity, fall history, agitation, transfers, and posture control. Discussion This study highlights the need for a multidimensional, dementia-specific approach to mobility assessment. Results have implications for development of assessment methods and management guidelines to support the clinical care of mobility impairment in people with dementia.

CONTEXT/OBJECTIVES: Aquatic therapy (AT) has been reported to be beneficial for individuals with spinal cord injury or disorder (SCI/D); however, AT has also been reported to be underutilized in SCI/D rehabilitation. We aimed to understand the knowledge and current practice of AT for clients with SCI/D by physiotherapists, physiotherapy assistants and kinesiologists across Canada. DESIGN/METHOD: A survey with closed- and open-ended questions was distributed (July-October 2019) to professionals through letters sent by professional associations. Non-parametric analyses were used to compare AT knowledge and practice between AT and non-AT users; content analysis was used to identify the themes from open-ended questions. RESULTS: Seventy-eight respondents from 10 provinces were included in the analysis: 33 physiotherapists, 5 physiotherapy assistants and 40 kinesiologists. Respondents using AT (73%) reported greater knowledge of AT benefits and confidence to apply AT than respondents not using AT (p

This study aimed to determine the effect of perturbation magnitude on stance and stepping limb muscle activation during reactive stepping using functional data analysis. Nineteen healthy, young adults responded to 6 small and 6 large perturbations using an anterior lean-and-release system, evoking a single reactive step. Muscle activity from surface electromyography was compared between the two conditions for medial gastrocnemius, biceps femoris, tibialis anterior, and vastus lateralis of the stance and stepping limb using functional data analysis. Stance limb medial gastrocnemius and biceps femoris activation increased in the large compared to small perturbation condition immediately prior to foot-off and at foot contact. In the stepping limb, significant increases in medial gastrocnemius, biceps femoris, and tibialis anterior activity occurred immediately prior to foot-off during the large perturbations. Similar to the stance limb, medial gastrocnemius and biceps femoris activity significantly increased during and following foot contact in the large, compared to small, perturbation condition. Lastly, vastus lateralis activity significantly increased for large, compared to small, perturbations during foot-off and immediately following foot contact. These findings highlight lower limb muscle activity modulation associated with perturbation magnitude throughout reactive stepping and the additional benefit of implementing functional data analysis to study reactive balance control.

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.

BackgroundCurrently, there is uncertainty as to whether movement variability is errorful or exploratory.Research questionThis study aimed to determine if gait variability represents exploration to improve stability. We hypothesized that 1) spatiotemporal gait features will be more variable prior to an expected perturbation than during unperturbed walking, and 2) increased spatiotemporal gait variability pre-perturbation will correlate with improved stability post-perturbation.MethodsSixteen healthy young adults completed 15 treadmill walking trials within a motion simulator under two conditions: unperturbed and expecting a perturbation. Participants were instructed not to expect a perturbation for unperturbed trials, and to expect a single transient medio-lateral balance perturbation for perturbed trials. Kinematic data were collected during the trials. Twenty steps were recorded post-perturbation. Unperturbed and pre-perturbation gait variabilities were defined by the short- and long-term variabilities of step length, width, and time, using 100 steps from pre-perturbation and unperturbed trials. Paired t-tests identified between-condition differences in variabilities. Stability was defined as the number of steps to centre of mass restabilization post-perturbation. Multiple regression analyses determined the effect of pre-perturbation variability on stability.ResultsLong-term step width variability was significantly higher pre-perturbation compared to unperturbed walking (mean difference=0.28cm, p=0.0073), with no significant differences between conditions for step length or time variabilities. There was no significant relationship between pre-perturbation variability and post-perturbation restabilization.SignificanceIncreased pre-perturbation step width variability was neither beneficial nor detrimental to stability. However, the increased variability in medio-lateral foot placement suggests that participants adopted an exploratory strategy in anticipation of a perturbation.

Background The characteristics of experimentally induced slips (low-friction surfaces and non-motorized platforms) in laboratory settings are influenced by participant gait velocity, contact surface area, and level of friction between the foot and surface. However, motorized platforms that could account for these factors during slip-like paradigms have not been extensively used. Research question How does slip-like perturbations evoked via a motorized platform change gait characteristics and postural stability during overground walking? Methods Ten healthy young adults performed 4 overground, self-paced walking trials, with the 4th trial including an unexpected forward support surface translation at heel-strike during steady state walking. Kinematic and kinetic data were collected, with step characteristics (time, distance, velocity) and postural stability calculated to compare between normal gait and slip-like trials. Slip foot characteristics were also determined. Results Peak slipping foot velocity variability was considerably smaller compared to previously reported low-friction and non-motorized perturbations. The centre of mass was shifted more posteriorly (thus in a less stable location) by the end of the platform acceleration phase compared to the same time point post-heel strike during normal gait trials. Participants successfully responded to every slip-like perturbation by significantly increasing step time, decreasing step distance, and decreasing step velocity. Significance Our results demonstrate the repeatability and consistency of a motorized support surface paradigm to induce slip-like perturbations. Furthermore, stability and step characteristic results confirm posterior shifts in stability and appropriate stepping responses, mimicking how participants would react if responding to a real world slip.

BackgroundCharacterizing reactive stepping is important to describe the response’s effectiveness. Measures of reactive stepping related to step initiation, execution, and termination phases have been frequently reported to characterize reactive balance control. However, the test-retest reliability of these measures are unknown.Research questionsWhat is the between- and within-session test-retest reliability of various force plate-derived measures of reactive stepping?MethodsNineteen young, healthy adults responded to 6 small (~8-10% of body weight) and 6 large perturbations (~13-15% of body weight) using an anterior lean-and-release system. Tests were conducted on two visits separated by at least two days. Participants were instructed to recover balance in as few steps as possible. Step onset, foot-off, swing, and restabilization times were extracted from force plates. Relative test-retest reliability was determined through intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs). Absolute test-retest reliability was assessed using the standard error of the measurement (SEM).ResultsFoot-off and swing times had the highest between- and within-session test-retest reliabilities regardless of perturbation size (between-session ICC=0.898–0.942; within-session ICC=0.455–0.753). Conversely, step onset and restabilization time had lower ICCs and wider CIs (between-session ICC=0.495–0.825; within-session ICC=−0.040–0.174). Between-session test-retest reliability was higher (ICC=0.495-0.942) for all measures than within-session test-retest reliability (ICC=−0.040–0.753). SEMs were low (3–10% of mean) for all measures, except time to restabilization (SEM=15-20% of mean), indicating good absolute reliability.SignificanceThese findings suggest multiple baseline sessions are needed for measuring restabilization and step onset times. The SEMs provide an index for measuring meaningful change due to an intervention.

Objective:Perceived upright depends on three main factors: vision, graviception, and the internal representation of the long axis of the body. We assessed the relative contributions of these factors in individuals with sub-acute and chronic stroke and controls using a novel tool; the Oriented Character Recognition Test (OCHART). We also considered whether individuals who displayed active pushing or had a history of pushing behaviours had different weightings than those with no signs of pushing.Method:Three participants experienced a stroke 6 months prior: eight with a history of pushing. In total, 12 participants served as healthy aged-matched controls. Visual and graviceptive cues were dissociated by orienting the visual background left, right, or upright relative to the body, or by orienting the body left, right, or upright relative to gravity. A three-vector model was used to quantify the weightings of vision, graviception, and the body to the perceptual upright.Results:The control group showed weightings of 13% vision, 25% graviception, and 62% body. Some individuals with stroke showed a similar pattern; others, particularly those with recent stroke, showed different patterns, for example, being unaffected by one of the three factors. The participant with active pushing behaviour displayed an ipsilesional perceptual bias (>30°) and was not affected by visual cues to upright.Conclusion:The results of OCHART may be used to quantify the weightings of multisensory inputs in individuals post-stroke and may help characterize perceptual sources of pushing behaviours.

The purpose of this thematic synthesis review was to identify and synthesise published qualitative research on the perspectives of individuals with spinal cord injuries with respect to physical rehabilitation interventions.The peer-reviewed literature was searched across seven databases and identified abstracts were independently screened by two reviewers. A thematic synthesis methodology was used to code and synthesise the results from the included studies.In total, 7233 abstracts were identified; 31 articles were selected for inclusion, representing 26 physical rehabilitation interventions. The methodological quality of studies was moderate (Standards for Reporting Qualitative Research mean ± standard deviation = 14.39 ± 3.61). The four main themes developed were: (1) Benefits of physical rehabilitation, (2) Challenges of physical rehabilitation, (3) Need for support, and (4) Issue of control.This qualitative thematic synthesis provides key insights into the experiences of individuals with spinal cord injuries who received physical rehabilitation. Recommendations for practice, based on the findings, include creating a diverse, encouraging, and educational physical rehabilitation experience with supportive staff who focus on communication and person-centred care. Implications for Rehabilitation Physical rehabilitation provides psychological as well as physical benefits to people with spinal cord injuries, including motivation, hope, improved self-confidence, and acceptance. Challenges identified during physical rehabilitation for people with spinal cord injuries, such as comparisons, negative emotions, recovery expectations, and slow progress, should be addressed by healthcare professionals to ensure person-centred care. People with spinal cord injuries identified a need for support from health care professionals, family, and friends, as well other people with spinal cord injuries. There is an issue of control in physical rehabilitation for people with spinal cord injuries, which can result in a fight with oneself or with healthcare professionals to regain the control that has been lost.

OCCUPATIONAL APPLICATIONS Better understanding of lower limb muscle activations and habituation processes has implications for injury prevention. This study examined the influence of repeated expos...