These results indicate incidences of falls during turning following stroke may not be due to impaired movement patterns but due to the many other factors that are associated with falls, such as deficits in cognitive processes--attention or central integration--and/or sensory deficits.

Impairments in gait coordination may be a factor in falls and mobility limitations after stroke. Therefore, rehabilitation targeting gait coordination may be an effective way to improve walking post-stroke. This review sought to examine current treatments that target impairments of gait coordination, the theoretical basis on which they are derived and the effects of such interventions. Few high quality RCTs with a low risk of bias specifically targeting and measuring restoration of coordinated gait were found. Consequently, we took a pragmatic approach to describing and quantifying the available evidence and included non-randomised study designs and limited the influence of heterogeneity in experimental design and control comparators by restricting meta-analyses to pre- and post-test comparisons of experimental interventions only. Results show that physiotherapy interventions significantly improved gait function and coordination. Interventions involving repetitive task-specific practice and/or auditory cueing appeared to be the most promising approaches to restore gait coordination. The fact that overall improvements in gait coordination coincided with increased walking speed lends support to the hypothesis that targeting gait coordination gait may be a way of improving overall walking ability post-stroke. However, establishing the mechanism for improved locomotor control requires a better understanding of the nature of both neuroplasticity and coordination deficits in functional tasks after stroke. Future research requires the measurement of impairment, activity and cortical activation in an effort to establish the mechanism by which functional gains are achieved.

Functional electrical stimulation and ankle foot orthoses have an equally positive therapeutic effect on walking speed in non-progressive central nervous system diagnoses. The current randomized controlled trial evidence base does not show whether this improvement translates into the user's own environment or reveal the mechanisms that achieve that change. Future studies should focus on measuring activity, muscle activity and gait kinematics. They should also report specific device details, capture sustained therapeutic effects and involve a variety of central nervous system diagnoses.

Data suggest that, in contrast to assumptions that predict FES superiority, ankle foot orthoses have equally positive combined-orthotic effects as FES on key walking measures for foot-drop caused by stroke. However, further long-term, high-quality RCTs are required. These should focus on measuring the mechanisms-of-action; whether there is translation of improvements in impairment to function, plus detailed reporting of the devices used across diagnoses. Only then can robust clinical recommendations be made.

Abstract:Background: Turning is an integral component of independent mobility in which stroke

Objective To compare the clinical effectiveness of a programme of physiotherapy and occupational therapy with standard care in care home residents who have mobility limitations and are dependent in performing activities of daily living. Design Cluster randomised controlled trial, with random allocation at the level of care home. Setting Care homes within the NHS South Birmingham primary care trust and the NHS Birmingham East and North primary care trust that had more than five beds and provided for people in the care categories "physical disability" and "older people." Participants Care home residents with mobility limitations, limitations in activities of daily living (as screened by the Barthel index), and not receiving end of life care were eligible to take part in the study. Intervention A targeted three month occupational therapy and physiotherapy programme. Main outcome measures Scores on the Barthel index and the Rivermead mobility index. Results 24 of 77 nursing and residential homes that catered for residents with mobility limitations and dependency for activities of daily living were selected for study: 12 were randomly allocated to the intervention arm (128 residents, mean age 86 years) and 12 to the control arm (121 residents, mean age 84 years). Participants were evaluated by independent assessors blind to study arm allocation before randomisation (0 months), three months after randomisation (at the end of the treatment period for patients who received the intervention), and again at six months after randomisation. After adjusting for home effect and baseline characteristics, no significant differences were found in mean Barthel index scores at six months post-randomisation between treatment arms (mean effect 0.08, 95% confidence interval −1.14 to 1.30; P=0.90), across assessments (−0.01, −0.63 to 0.60; P=0.96), or in the interaction between assessment and intervention (0.42, −0.48 to 1.32; P=0.36). Similarly, no significant differences were found in the mean Rivermead mobility index scores between treatment arms (0.62, −0.51 to 1.76; P=0.28), across assessments (−0.15, −0.65 to 0.35; P=0.55), or interaction (0.71, −0.02 to 1.44; P=0.06).Conclusions The three month occupational therapy and physiotherapy programme had no significant effect on mobility and independence. On the other hand, the variation in residents' functional ability, the prevalence of cognitive impairment, and the prevalence of depression were considerably higher in this sample than expected on the basis of previous work. Further research to clarify the efficacy of occupational therapy and physiotherapy is required if access to therapy services is to be recommended in this population. Trial registration ISRCTN79859980

Computational methods to estimate muscle forces during walking are becoming more common in biomechanical research but not yet in clinical gait analysis. This systematic review aims to identify the current state-of-the-art, examine the differences between approaches, and consider applicability of the current approaches in clinical gait analysis. A systematic database search identified studies including estimated muscle force profiles of the lower limb during healthy walking. These were rated for quality and the muscle force profiles digitised for comparison. From 13.449 identified studies, 22 were finally included which used four modelling approaches: static optimisation, enhanced static optimisation, forward dynamics and EMG-driven. These used a range of different musculoskeletal models, muscle-tendon characteristics and cost functions. There is visually broad agreement between and within approaches about when muscles are active throughout the gait cycle. There remain, considerable differences (CV 7%-151%, range of timing of peak forces in gait cycle 1%-31%) in patterns and magnitudes of force between and within modelling approaches. The main source of this variability is not clear. Different musculoskeletal models, experimental protocols, and modelling approaches will clearly have an effect as will the variability of joint kinetics between healthy individuals. Limited validation of modelling approaches, particularly at the level of individual participants, makes it difficult to conclude if any of the approaches give consistently better estimates than others. While muscle force modelling has clear potential to enhance clinical gait analyses future research is needed to improve validation, accuracy and feasibility of implementation in clinical practice.

Background. Upper-limb impairment in patients with chronic stroke appears to be partly attributable to an upregulated reticulospinal tract (RST). Here, we assessed whether the impact of corticospinal (CST) and RST connectivity on motor impairment and skill-acquisition differs in sub-acute stroke, using transcranial magnetic stimulation (TMS)–based proxy measures. Methods. Thirty-eight stroke survivors were randomized to either reach training 3-6 weeks post-stroke (plus usual care) or usual care only. At 3, 6 and 12 weeks post-stroke, we measured ipsilesional and contralesional cortical connectivity (surrogates for CST and RST connectivity, respectively) to weak pre-activated triceps and deltoid muscles with single pulse TMS, accuracy of planar reaching movements, muscle strength (Motricity Index) and synergies (Fugl-Meyer upper-limb score). Results. Strength and presence of synergies were associated with ipsilesional (CST) connectivity to the paretic upper-limb at 3 and 12 weeks. Training led to planar reaching skill beyond that expected from spontaneous recovery and occurred for both weak and strong ipsilesional tract integrity. Reaching ability, presence of synergies, skill-acquisition and strength were not affected by either the presence or absence of contralesional (RST) connectivity. Conclusion. The degree of ipsilesional CST connectivity is the main determinant of proximal dexterity, upper-limb strength and synergy expression in sub-acute stroke. In contrast, there is no evidence for enhanced contralesional RST connectivity contributing to any of these components of impairment. In the sub-acute post-stroke period, the balance of activity between CST and RST may matter more for the paretic phenotype than RST upregulation per se.