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ObjectivesNo intervention has been shown to prevent falls poststroke. We aimed to determine if perturbation-based balance training (PBT) can reduce falls in daily life among individuals with chronic stroke.DesignAssessor-blinded randomised controlled trial.SettingTwo academic hospitals in an urban area.InterventionsParticipants were allocated using stratified blocked randomisation to either ‘traditional’ balance training (control) or PBT. PBT focused on improving responses to instability, whereas traditional balance training focused on maintaining stability during functional tasks. Training sessions were 1 hour twice/week for 6 weeks. Participants were also invited to complete 2 ‘booster’ training sessions during the follow-up.ParticipantsEighty-eight participants with chronic stroke (>6 months poststroke) were recruited and randomly allocated one of the two interventions. Five participants withdrew; 42 (control) and 41 (PBT group) were included in the analysis.Primary and secondary outcome measuresThe primary outcome was rate of falls in the 12 months post-training. Negative binomial regression was used to compare fall rates between groups. Secondary outcomes were measures of balance, mobility, balance confidence, physical activity and social integration.ResultsPBT participants reported 53 falls (1.45 falls/person-year) and control participants reported 64 falls (1.72 falls/person-year; rate ratio: 0.85(0.42 to 1.69); p=0.63). Per-protocol analysis included 32 PBT and 34 control participants who completed at least 10/12 initial training sessions and 1 booster session. Within this subset, PBT participants reported 32 falls (1.07 falls/person-year) and control participants reported 57 falls (1.75 falls/person-year; rate ratio: 0.62(0.29 to 1.30); p=0.20). PBT participants had greater improvement in reactive balance control than the control group, and these improvements were sustained 12 months post-training. There were no intervention-related serious adverse effects.ConclusionsThe results are inconclusive. PBT may help to prevent falls in daily life poststroke, but ongoing training may be required to maintain the benefits.Trial registration numberISRCTN05434601; Results.

BackgroundDespite increasing evidence for the effectiveness of virtual reality (VR)-based therapy in stroke rehabilitation, few knowledge translation (KT) resources exist to support clinical integration. KT interventions addressing known barriers and facilitators to VR use are required. When environmental barriers to VR integration are less amenable to change, KT interventions can target modifiable barriers related to therapist knowledge and skills.MethodsA multi-faceted KT intervention was designed and implemented to support physical and occupational therapists in two stroke rehabilitation units in acquiring proficiency with use of the Interactive Exercise Rehabilitation System (IREX; GestureTek). The KT intervention consisted of interactive e-learning modules, hands-on workshops and experiential practice. Evaluation included the Assessing Determinants of Prospective Take Up of Virtual Reality (ADOPT-VR) Instrument and self-report confidence ratings of knowledge and skills pre- and post-study. Usability of the IREX was measured with the System Usability Scale (SUS). A focus group gathered therapist experiences. Frequency of IREX use was recorded for 6 months post-study.ResultsEleven therapists delivered a total of 107 sessions of VR-based therapy to 34 clients with stroke. On the ADOPT-VR, significant pre-post improvements in therapist perceived behavioral control (p = 0.003), self-efficacy (p = 0.005) and facilitating conditions (p =0.019) related to VR use were observed. Therapist intention to use VR did not change. Knowledge and skills improved significantly following e-learning completion (p = 0.001) and was sustained 6 months post-study. Below average perceived usability of the IREX (19th percentile) was reported. Lack of time was the most frequently reported barrier to VR use. A decrease in frequency of perceived barriers to VR use was not significant (p = 0.159). Two therapists used the IREX sparingly in the 6 months following the study. Therapists reported that client motivation to engage with VR facilitated IREX use in practice but that environmental and IREX-specific barriers limited use.ConclusionsDespite increased knowledge and skills in VR use, the KT intervention did not alter the number of perceived barriers to VR use, intention to use or actual use of VR. Poor perceived system usability had an impact on integration of this particular VR system into clinical practice.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1807-6) contains supplementary material, which is available to authorized users.

Spatiotemporal parameters can characterize the gait patterns of individuals, allowing assessment of their health status and detection of clinically meaningful changes in their gait. Video-based markerless motion capture is a user-friendly, inexpensive, and widely applicable technology that could reduce the barriers to measuring spatiotemporal gait parameters in clinical and more diverse settings. Two studies were performed to determine whether gait parameters measured using markerless motion capture demonstrate concurrent validity with those measured using marker-based motion capture and pressure sensitive gait mats. For the first study, thirty healthy adults performed treadmill gait at self-selected speeds while marker-based motion capture and synchronized video data were recorded simultaneously. For the second study, twenty-five healthy adults performed over-ground gait at self-selected speeds while footfalls were recorded using a gait mat and synchronized video data were recorded simultaneously. Kinematic heelstrike and toe-off gait events were used to identify the same gait cycles between systems. Nine spatiotemporal gait parameters were measured by each system and directly compared between systems.Measurements were compared using Bland-Altman methods, mean differences, Pearson correlation coefficients, and intraclass correlation coefficients. The results indicate that markerless measurements of spatiotemporal gait parameters have good to excellent agreement with marker-based motion capture and gait mat systems, except for stance time and double limb support time relative to both systems and stride width relative to the gait mat. These findings indicate that markerless motion capture can adequately measure spatiotemporal gait parameters during treadmill and overground gait.

These findings suggest that PBT is promising for reducing falls post stroke. While this was not a randomized controlled trial, this study may provide sufficient evidence for implementing PBT in stroke rehabilitation practice.

PurposeTherapists use motor learning strategies (MLSs) to structure practice conditions within stroke rehabilitation. Virtual reality (VR)-based rehabilitation is an MLS-oriented stroke intervention, yet little support exists to assist therapists in integrating MLSs with VR system use.MethodA pre-post design evaluated a knowledge translation (KT) intervention incorporating interactive e-learning and practice, in which 11 therapists learned how to integrate MLSs within VR-based therapy. Self-report and observer-rated outcome measures evaluated therapists’ confidence, clinical reasoning and behaviour with respect to MLS use. A focus group captured therapists’ perspectives on MLS use during VR-based therapy provision.ResultsThe intervention improved self-reported confidence about MLS use as measured by confidence ratings (p <0.001). Chart-Stimulated Recall indicated a moderate level of competency in therapists’ clinical reasoning about MLSs following the intervention, with no changes following additional opportunities to use VR (p = .944). On the Motor Learning Strategy Rating Instrument, no behaviour change with respect to MLS use was noted (p = 0.092). Therapists favoured the strategy of transferring skills from VR to real-life tasks over employing a more comprehensive MLS approach.ConclusionThe KT intervention improved therapists’ confidence but did not have an effect on clinical reasoning or behaviour with regard to MLS use during VR-based therapy.

Background Slow and asymmetric gait post-stroke may reduce the accuracy of accelerometers (e.g. ActiGraph [AG]) to measure activity. Objectives To (1) determine the validity of AG step counts post-stroke; (2) develop guidelines for low frequency extension filter (LFE) use; and (3) determine the feasibility of daily accelerometer wear. Methods Adults with (n = 33) and without stroke (n = 20) wore three devices for approximately 7 h on a single day: ankle AG, waist AG, and a reference accelerometer at the ankle (REFA). AG step counts processed with and without the LFE were compared to REFA with paired difference tests. Agreement was measured with intraclass correlation coefficients (ICC). Relationships between error (AG - REFA) and motor impairment and gait performance were plotted to determine a threshold for LFE application. A feasibility questionnaire was distributed to participants to investigate the applicability of the AG in clinical populations. Results Step counts from ankle AG in the stroke group (p = 0.53) and waist AG in the healthy group (p = 0.10) were similar to REFA. Waist AG under-counted, and ankle and waist AG with LFE over-counted steps in the stroke group (all p < 0.0001). ICC ranged from 0.70 to 0.82 (stroke) and 0.79-0.92 (healthy). Ankle AG error and stance time symmetry (stroke) were correlated (r = 0.41, p = 0.02); however, no threshold for LFE application was revealed. Ankle AG was rated very comfortable by 26/33 participants with stroke and 12/20 healthy participants. Conclusions The AG worn at the unaffected ankle without LFE produced the most accurate step count in people with stroke. We were unable to establish guidelines for LFE use.

BackgroundFalls are one of the most common medical complications post-stroke. Physical exercise, particularly exercise that challenges balance, reduces the risk of falls among healthy and frail older adults. However, exercise has not proven effective for preventing falls post-stroke. Falls ultimately occur when an individual fails to recover from a loss of balance. Thus, training to specifically improve reactive balance control could prevent falls. Perturbation training aims to improve reactive balance control by repeatedly exposing participants to postural perturbations. There is emerging evidence that perturbation training reduces fall rates among individuals with neurological conditions, such as Parkinson disease. The primary aim of this work is to determine if perturbation-based balance training can reduce occurrence of falls in daily life among individuals with chronic stroke. Secondary objectives are to determine the effect of perturbation training on balance confidence and activity restriction, and functional balance and mobility.Methods/designIndividuals with chronic stroke will be recruited. Participants will be randomly assigned to one of two groups: 1) perturbation training, or 2) ‘traditional’ balance training. Perturbation training will involve both manual perturbations (e.g., a push or pull from a physiotherapist), and rapid voluntary movements to cause a loss of balance. Training will occur twice per week for 6 weeks. Participants will record falls and activity for 12 months following completion of the training program. Standardized clinical tools will be used to assess functional balance and mobility, and balance confidence before and after training.DiscussionFalls are a significant problem for those with stroke. Despite the large body of work demonstrating effective interventions, such as exercise, for preventing falls in other populations, there is little evidence for interventions that prevent falls post-stroke. The proposed study will investigate a novel and promising intervention: perturbation training. If effective, this training has the potential to not only prevent falls, but to also improve safe independent mobility and engagement in daily activities for those with stroke.Trial registrationCurrent Controlled Trials: ISRCTN05434601.