The effect of botulinum toxin-A on neural and non-neural components of wrist hyper-resistance in adults with stroke or cerebral palsy.

BACKGROUND: Botulinum toxin-A (BoNT) is widely used to manage focal upper limb spasticity and is effective in reducing resistance to passive movement, as measured with the modified Ashworth scale. Discrimination and quantification of the underlying neural and non-neural components of hyper-resistance may further improve understanding of the effect of BoNT. OBJECTIVE: To explore the effects of BoNT on neural (NC), non-neural elastic (EC), and viscous (VC) components of resistance to passive wrist extension in adults with stroke or cerebral palsy and the association between the effects on wrist hyper-resistance components and clinical spasticity, pain and motor function scales. DESIGN: Pre-experimental study with pre- and post-intervention measurements at 6 and 12 weeks. SETTING: An outpatient clinic of a hospital. PARTICIPANTS: Adults with chronic stroke or cerebral palsy indicated for BoNT treatment for hyper-resistance in the wrist (N = 18). INTERVENTIONS: BoNT injections in the wrist and/or finger flexor muscles. MAIN OUTCOME MEASURES: Wrist hyper-resistance components, using the NeuroFlexor, and clinical scales (modified Ashworth scale, Tardieu scale, passive wrist extension, pain, Fugl-Meyer motor assessment of the upper extremity, and action research arm test). RESULTS: NC was significantly reduced 6 and 12 weeks post-intervention (median -11.96 Newton, P < .001 and median -9.34 Newton, P = .001, respectively); non-neural EC and VC showed no change. NC reduction 6 weeks post-intervention correlated significantly with BoNT dose (Pearson correlation coefficient rp = -0.56). No significant correlations were found between change scores in wrist hyper-resistance components and clinical scales. CONCLUSIONS: BoNT affected the neural component of resistance to passive wrist extension, while leaving the non-neural elastic and viscous components unaffected. This instrumented approach to quantify the effects of BoNT in the wrist and finger flexor muscles on the components of wrist hyper-resistance may have an added value for BoNT treatment evaluation in clinical practice.

Quantifying neural and non-neural components of wrist hyper-resistance after stroke: Comparing two instrumented assessment methods.

Patients with poor upper limb motor recovery after stroke are likely to develop increased resistance to passive wrist extension, i.e., wrist hyper-resistance. Quantification of the underlying neural and non-neural elastic components is of clinical interest. This cross-sectional study compared two methods: a commercially available device (NeuroFlexor®) with an experimental EMG-based device (Wristalyzer) in 43 patients with chronic stroke. Spearman's rank correlation coefficients (r) between components, modified Ashworth scale (MAS) and range of passive wrist extension (PRoM) were calculated with 95% confidence intervals. Neural as well as elastic components assessed by both devices were associated (r = 0.61, 95%CI: 0.38-0.77 and r = 0.53, 95%CI: 0.28-0.72, respectively). The neural component assessed by the NeuroFlexor® associated significantly with the elastic components of NeuroFlexor® (r = 0.46, 95%CI: 0.18-0.67) and Wristalyzer (r = 0.36, 95%CI: 0.06-0.59). The neural component assessed by the Wristalyzer was not associated with the elastic components of both devices. Neural and elastic components of both devices associated similarly with the MAS (r = 0.58, 95%CI: 0.34-0.75 vs. 0.49, 95%CI: 0.22-0.69 and r = 0.51, 95%CI: 0.25-0.70 vs. 0.30, 95%CI: 0.00-0.55); elastic components associated with PRoM (r = -0.44, 95%CI: -0.65- -0.16 vs. -0.74, 95%CI: -0.85- -0.57 for NeuroFlexor® and Wristalyzer respectively). Results demonstrate that both methods perform similarly regarding the quantification of neural and elastic wrist hyper-resistance components and have an added value when compared to clinical assessment with the MAS alone. The added value of EMG in the discrimination between neural and non-neural components requires further investigation.

To What Extent is Walking Ability Associated with Participation in People after Stroke?

OBJECTIVES: This study aims to 1) identify the relation between walking ability and participation after stroke and 2) explore whether change in walking ability is associated with change in participation over time in community living-people after stroke. MATERIALS AND METHODS: Fifty-two people after stroke were assessed at baseline and after a 6-week gait training intervention. People were included between two weeks and six months after stroke. The Utrecht Scale for Evaluation of Rehabilitation-Participation was used to measure participation. Assessment of walking ability included the six-minute walking test for walking endurance, Timed-up & Go test for functional mobility, Mini Balance Evaluation Systems Test for dynamic balance, and total duration of walking activity per day to measure walking activity. RESULTS: At baseline, six-minute walking test, Timed-up & Go test, and Mini Balance Evaluation Systems Test were univariately associated with participation (P < 0.001). Backward multiple regression analysis showed that the Mini Balance Evaluation Systems Test independently explained 55.7% of the variance in participation at baseline. Over time, only change in the six-minute walking test was positively associated with change in participation (R2 = 0.087, P = 0.040). CONCLUSIONS: Cross-sectional associations showed that walking ability, and especially dynamic balance, contributes to participation after stroke. Dynamic balance, as underlying variable for walking, was an important independently related factor to participation after stroke which needs attention during rehabilitation. Longitudinally, improvement in walking endurance was significantly associated with improvement in participation, which indicates the relevance of training walking endurance to improve participation after stroke.

Effect of Virtual Reality Gait Training on Participation in Survivors of Subacute Stroke: A Randomized Controlled Trial.

OBJECTIVE: After stroke, people experience difficulties with walking that lead to restrictions in participation in daily life. The purpose of this study was to examine the effect of virtual reality gait training (VRT) compared to non-virtual reality gait training (non-VRT) on participation in community-living people after stroke. METHODS: In this assessor-blinded, randomized controlled trial with 2 parallel groups, people were included between 2 weeks and 6 months after stroke and randomly assigned to the VRT group or non-VRT group. Participants assigned to the VRT group received training on the Gait Real-time Analysis Interactive Lab (GRAIL), and participants assigned to the non-VRT group received treadmill training and functional gait exercises without virtual reality. Both training interventions consisted of 12 30-minute sessions during 6 weeks. The primary outcome was participation measured with the restrictions subscale of the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P) 3 months postintervention. Secondary outcomes included subjective physical functioning, functional mobility, walking ability, dynamic balance, walking activity, fatigue, anxiety and depression, falls efficacy, and quality of life. RESULTS: Twenty-eight participants were randomly assigned to the VRT group and 27 to the non-VRT group, of whom 25 and 22 attended 75% or more of the training sessions, respectively. No significant differences between the groups were found over time for the USER-P restrictions subscale (1.23; 95% CI = -0.76 to 3.23) or secondary outcome measures. Patients' experiences with VRT were positive, and no serious adverse events were related to the interventions. CONCLUSIONS: The effect of VRT was not statistically different from non-VRT in improving participation in community-living people after stroke. IMPACT: Although outcomes were not statistically different, treadmill-based VRT was a safe and well-tolerated intervention that was positively rated by people after stroke. VR training might, therefore, be a valuable addition to stroke rehabilitation. LAY SUMMARY: VRT is feasible and was positively experienced by people after stroke. However, VRT was not more effective than non-VRT for improving walking ability and participation after stroke.

Perceived barriers and facilitators for gait-related participation in people after stroke: From a patients' perspective.

Background: An important focus of post-stroke physical therapy is to improve walking and walking capacity. However, many people after stroke experience difficulties with gait-related participation, which includes more than walking capacity alone. Gait-related participation involves walking with a participation goal and requires to deal with changes in the environment during walking and perform dual tasks, for example.Objective: To explore barriers and facilitators for gait-related participation from the perspective of people after stroke. This knowledge can contribute to the development of effective interventions to improve gait-related participation.Methods: Semi-structured interviews were conducted to investigate how people after stroke experience gait-related participation. Audio-recorded interviews were transcribed, anonymized, and analyzed thematically. Barriers and facilitators were categorized according to the International Classification of Functioning, Disability and Health (ICF) framework.Results: Twenty-one people after stroke participated. Median age was 65 years, median time since stroke 16 weeks. Barriers were reported in movement-related functions, cognitive functions, mobility, personal factors, and environmental factors. Facilitators were found on participation level and in personal and environmental factors, such as motivation and family support.Conclusion: People after stroke who were physically able to walk independently still described multiple barriers to gait-related participation in all components of the ICF framework.

Time Course of Wrist Hyper-Resistance in Relation to Upper Limb Motor Recovery Early Post Stroke.

Background. Patients with an upper limb motor impairment are likely to develop wrist hyper-resistance during the first months post stroke. The time course of wrist hyper-resistance in terms of neural and biomechanical components, and their interaction with motor recovery, is poorly understood. Objective. To investigate the time course of neural and biomechanical components of wrist hyper-resistance in relation to upper limb motor recovery in the first 6 months post stroke. Methods. Neural (NC), biomechanical elastic (EC), and viscous (VC) components of wrist hyper-resistance (NeuroFlexor device), and upper limb motor recovery (Fugl-Meyer upper extremity scale [FM-UE]), were assessed in 17 patients within 3 weeks and at 5, 12, and 26 weeks post stroke. Patients were stratified according to the presence of voluntary finger extension (VFE) at baseline. Time course of wrist hyper-resistance components and assumed interaction effects were analyzed using linear mixed models. Results. On average, patients without VFE at baseline (n = 8) showed a significant increase in NC, EC, and VC, and an increase in FM-UE from 13 to 26 points within the first 6 months post stroke. A significant increase in NC within 5 weeks preceded a significant increase in EC between weeks 12 and 26. Patients with VFE at baseline (n = 9) showed, on average, no significant increase in components from baseline to 6 months whereas FM-UE scores improved from 38 to 60 points. Conclusion. Our findings suggest that the development of neural and biomechanical wrist hyper-resistance components in patients with severe baseline motor deficits is determined by lack of spontaneous neurobiological recovery early post stroke.

Process evaluation of 'Brains Ahead!': an intervention for children and adolescents with mild traumatic brain injury within a randomized controlled trial.

OBJECTIVE: To investigate whether the 'Brains Ahead! Intervention for children and adolescents with mild traumatic brain injury' was implemented as intended. In addition, involvement in and satisfaction with the intervention among patients, caregivers and professionals delivering the intervention were studied. DESIGN: Mixed methods, prospective study. PARTICIPANTS: Children with mild traumatic brain injury and their caregivers, allocated to the intervention group of the randomized controlled trial in the 'Brains Ahead!' study, and the two professionals providing the intervention. INTERVENTION: The intervention consists of a standardized and individualized psychoeducational session with written take-home information, and follow-up telephone call(s). MAIN MEASURES: Registration forms, evaluation questionnaires for patients and caregivers and semi-structured interviews for professionals. DATA ANALYSIS: Qualitative data were categorized based on content. Quantitative data were reported as descriptive statistics. RESULTS: Fifty-five patients and caregivers out of 60 study-participants attended both sessions. All elements of the intervention were delivered to 53 study-participants. Evaluation questionnaires were completed by 21 of the 31 patients aged 12 years and older, and by 41 caregivers. Overall, the sessions were considered useful by 19 patients, 40 caregivers and both professionals. Reassurance, creating a better understanding and recognition of symptoms were rated as important aspects. On a scale from 1 to 10, the intervention was rated by children, caregivers and professionals with 7.6 (SD 1.2), 8.1 (SD .9) and 8.0 (SD .0), respectively. CONCLUSION: The 'Brains Ahead!' intervention was largely implemented as intended and the process evaluation revealed that it is considered feasible according to patients, caregivers and professionals.

Effectiveness of the Brains Ahead! Intervention: 6 Months Results of a Randomized Controlled Trial in School-Aged Children With Mild Traumatic Brain Injury.

OBJECTIVE: To examine the effectiveness of Brains Ahead!, a psychoeducational intervention aimed to prevent long-term problems with activities and participation in children after mild traumatic brain injury (mTBI). PARTICIPANTS: In total, 124 children, aged 6 to 18 years, diagnosed with mTBI and their caregivers. METHOD: After randomization, participants in the intervention group received a face-to-face psychoeducational session with written take-home information and follow-up telephone call(s). Participants in the control group received usual care, consisting of a concise information brochure. PRIMARY OUTCOME MEASURES: Activities and participation (Child and Adolescent Scale of Participation [CASP]). SECONDARY OUTCOMES: fatigue, postconcussive symptoms (PCSs), posttraumatic stress symptoms (PTSSs), and quality of life (QOL). RESULTS: Generalized Estimated Equation analyses showed that both groups improved over the first 6 months post-mTBI, but the intervention group did not differ significantly on the CASP. Mann-Whitney U tests showed that the intervention group reported significantly less fatigue, PCSs, and PTSSs and better QOL compared with the control group at 6 months post-MTBI. CONCLUSIONS: The Brains Ahead! intervention resulted in significant improvements compared with usual care in reducing fatigue, PCSs, and PTSSs and improving QOL. Lack of an effect on activities and participation may be due to the ceiling effect of the CASP.

Activities and Participation in the First 6 Months After Mild Traumatic Brain Injury in Children and Adolescents.

OBJECTIVE: To investigate the natural course of activities and participation of children up to 6 months after a mild traumatic brain injury (mTBI). METHODS: A prospective longitudinal cohort study with complete data sets of 231 children diagnosed with mTBI and their caregivers. MAIN MEASURES: Activities and participation assessed with the Child and Adolescent Scale of Participation (CASP) and the Children's Assessment of Participation and Enjoyment (CAPE) measured at 2 weeks, 3 months, and 6 months post-mTBI. Because of a ceiling effect, the primary outcome measure (CASP) was divided into deviant (not maximum score) or full functioning. RESULTS: Friedman's, Cochran's Q, and McNemar's tests (CASP) and repeated-measures analyses of variance (CAPE) showed significant increases in activities and participation between 2 weeks and 3 and 6 months after mTBI. Based on the parents' perspective, 67% of the children returned to full functioning at 6 months postinjury, with only 38% of the children describing themselves as functioning at their premorbid level. DISCUSSION: Findings indicate that most children return to maximum level of activities and participation over time after mTBI. In a substantial number of children, however, the level of activities and participation at 6 months postinjury is evaluated as lower than that of peers. The importance of investigating predictors for child and caregiver perspectives is emphasized.

Does upper limb strength play a prominent role in health-related quality of life in stroke patients discharged from inpatient rehabilitation?

Background: Impairments in arm function are a common problem in stroke survivors and have a large impact on health-related quality of life (HRQoL). Little is known about the longitudinal relationship between recovery of upper limb strength and changes in HRQoL. Objectives: This study aimed to determine to what extent changes in HRQoL are related to changes in upper limb strength after discharge from inpatient rehabilitation. Methods: 250 patients from an RCT were assessed at discharge from inpatient rehabilitation (baseline) and at 12 weeks post-discharge (follow-up). The Stroke Impact Scale was used to measure HRQoL, and the Motricity Index Arm was used to measure upper limb strength. Hierarchical regression analysis was performed to determine the predictive value of upper limb strength on HRQoL, relative to demographic and clinical characteristics. Regression analysis was used to determine the relation between upper limb strength improvement and HRQoL improvement. Results: Upper limb strength at baseline was a major predictor of HRQoL at follow-up, after accounting for demographic and clinical characteristics (p < .05). Improvement in HRQoL was positively related to improvement in upper limb strength (F(1, 240) = 18.351, p <.0005). Conclusions: These findings highlight the importance of upper limb strength in HRQoL, as HRQoL is associated with improvement in upper limb strength recovery. Better monitoring of recovery and treatment of upper limb strength during the outpatient rehabilitation period and beyond, i.e. outside the typical time-window of recovery in the first 3 months post-stroke, might contribute to higher quality of life for stroke survivors.

Walking activity and its determinants in free-living ambulatory people in a chronic phase after stroke: a cross-sectional study.

Background: Free-living walking activity and its contributing factors in ambulatory people with stroke is poorly investigated.Objective: Evaluating free-living walking activity and identifying factors associated with free-living walking activity.Methods: In this cross-sectional study, participants wore an accelerometer to measure their level of walking activity. They also completed the Berg Balance Scale (BBS) and the Timed Up and Go test for functional balance, the Falls Efficacy Scale, the 10-Metre Walk Test and the Geriatric Depression Scale to investigate the relation between the performance tests and walking activity.Results: The 38 analyzed participants were on average 62 (±11.4) years old and 66 (IQR 64.8) months post stroke. They took an average of 3048.3 ± 1983.1 steps, had 123.3 ± 61.3 walking bouts a day and walked for 32.5 ± 18.2 min a day. Their average speed was 90.3 ± 13.8 steps a minute. The multivariate linear analysis showed that the BBS was the only determinant that was significantly related to all outcomes, except walking bouts.Conclusion: Free-living walking activity levels in ambulatory people with chronic stroke are low. The BBS is an independent significant predictor of free-living walking activity.Implications for rehabilitationFree-living walking activity can be expressed in different outcomes measured by accelerometry.Free-living walking activity levels in ambulatory people with chronic stroke are low, therefore support to sustain walking in the own environment should be part of the rehabilitation program after stroke.Balance is an important related factor to free-living walking activity which needs attention during rehabilitation after stroke.

Predictors of activities and participation six months after mild traumatic brain injury in children and adolescents.

OBJECTIVE: This study aimed to identify predictors of long-term consequences for activities and participation in children and adolescents with mild traumatic brain injury (mTBI). METHODS: A multicentre prospective longitudinal cohort study was conducted. The primary outcome measure was activities and participation measured with the Child and Adolescent Scale of Participation - CASP and completed by children (N = 156) and caregivers (N = 231) six months post-mTBI. The CASP items were categorized into home, community, school, and environment. Predictors were categorized according to the International Classification of Functioning, Disability and Health for Children and Youth. Predictors included pre-injury personal- and environmental factors, injury-related factors, symptoms, and resumption of activities in the first two weeks after mTBI. Univariate and multivariate logistic regression analyses were used to determine the predictive value of these factors. RESULTS: Results show that predictors differ across settings and perspectives (child or caregiver). Decreased activities and participation in children with mTBI can be predicted by adverse pre-injury behavioral functioning of the child (p < .000 - p = .038), adverse pre-injury family functioning (p = .001), lower parental SES (p = .038), more stress symptoms post-injury (p = .017 - p = .032), more post-concussive symptoms (p = .016 - p = .028) and less resumption of activities (p = .006 - p = .045). DISCUSSION: Pre-injury factors, more symptoms post-injury and less resumption of activities should be considered when children are screened for unfavorable outcomes. Additional factors may add to the prediction, but injury-related factors do not. It is recommended that future research explores psychosocial factors, such as coping styles, emotion-regulation, personality traits, social support, and other comorbid problems of both children and caregivers.

Measurement Properties of the NeuroFlexor Device for Quantifying Neural and Non-neural Components of Wrist Hyper-Resistance in Chronic Stroke.

Introduction: Differentiating between the components of wrist hyper-resistance post stroke, i.e., pathological neuromuscular activation ("spasticity") and non-neural biomechanical changes, is important for treatment decisions. This study aimed to assess the reliability and construct validity of an innovative measurement device that quantifies these neural and non-neural components by biomechanical modeling. Methods: Forty-six patients with chronic stroke and 30 healthy age-matched subjects were assessed with the NeuroFlexor, a motor-driven device that imposes isokinetic wrist extensions at two controlled velocities (5 and 236°/s). Test-retest reliability was evaluated using intraclass correlation coefficients (ICC) and smallest detectable changes (SDC), and construct validity by testing the difference between patients and healthy subjects and between subgroups of patients stratified by modified Ashworth scale (MAS), and the association with clinical scales. Results: Test-retest reliability was excellent for the neural (NC) and non-neural elastic (EC) components (ICC 0.93 and 0.95, respectively), and good for the viscous component (VC) (ICC 0.84), with SDCs of 10.3, 3.1, and 0.5 N, respectively. NC and EC were significantly higher in patients compared to healthy subjects (p < 0.001). Components gradually increased with MAS category. NC and EC were positively associated with the MAS (r s 0.60 and 0.52, respectively; p < 0.01), and NC with the Tardieu scale (r s 0.36, p < 0.05). NC and EC were negatively associated with the Fugl-Meyer Assessment of the upper extremity and action research arm test (r s ≤ -0.38, p < 0.05). Conclusions: The NeuroFlexor reliably quantifies neural and non-neural components of wrist hyper-resistance in chronic stroke, but is less suitable for clinical evaluation at individual level due to high SDC values. Although construct validity has been demonstrated, further investigation at component level is needed.

Prospectively Classifying Community Walkers After Stroke: Who Are They?

OBJECTIVE: To classify patients with stroke into subgroups based on their characteristics at the moment of discharge from inpatient rehabilitation in order to predict community ambulation outcome 6 months later. DESIGN: Prospective cohort study with a baseline measurement at discharge from inpatient care and final outcome determined after 6 months. SETTING: Community. PARTICIPANTS: A cohort of patients (N=243) with stroke, referred for outpatient physical therapy, after completing inpatient rehabilitation in The Netherlands. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A classification model was developed using Classification And Regression Tree (CART) analysis. Final outcome was determined using the community ambulation questionnaire. Potential baseline predictors included patient demographics, stroke characteristics, use of assistive devices, comfortable gait speed, balance, strength, motivation, falls efficacy, anxiety, and depression. RESULTS: The CART model accurately predicted independent community ambulation in 181 of 193 patients with stroke, based on a comfortable gait speed at discharge of 0.5 meters per second or faster. In contrast, 27 of 50 patients with gait speeds below 0.5 meters per second were correctly predicted to become noncommunity walkers. CONCLUSIONS: We show that comfortable gait speed is a key factor in the prognosis of community ambulation outcome. The CART model may support clinicians in organizing community services at the moment of discharge from inpatient care.

Effectiveness of Botulinum Toxin Treatment for Upper Limb Spasticity Poststroke Over Different ICF Domains: A Systematic Review and Meta-Analysis.

OBJECTIVE: To provide a comprehensive overview of reported effects and scientific robustness of botulinum toxin (BoNT) treatment regarding the main clinical goals related to poststroke upper limb spasticity, using the International Classification of Functioning, Disability and Health. DATA SOURCES: Embase, PubMed, Wiley/Cochrane Library, and Ebsco/CINAHL were searched from inception up to May 16, 2018. STUDY SELECTION: We included randomized controlled trials comparing upper limb BoNT injections with a control intervention in patients with a history of stroke. A total of 1212 unique records were screened by 2 independent reviewers. Forty trials were identified, including 2718 patients with history of stroke. DATA EXTRACTION: Outcome data were pooled according to assessment timing (ie, 4-8wk and 12wk after injection), and categorized into 6 main clinical goals (ie, spasticity-related pain, involuntary movements, passive joint motion, care ability, arm and hand use, and standing and walking performance). Sensitivity analyses were performed for the influence of study and intervention characteristics, involvement of pharmaceutical industry, and publication bias. DATA SYNTHESIS: Robust evidence is shown for the effectiveness of BoNT in reducing resistance to passive movement, as measured with the (Modified) Ashworth Score, and improving self-care ability for the affected hand and arm after intervention (P<.005) and at follow-up (P<.005). In addition, robust evidence is shown for the absence of effect on arm-hand capacity at follow-up. BoNT was found to significantly reduce involuntary movements, spasticity-related pain, and caregiver burden, and improve passive range of motion, while no evidence was found for arm and hand use after intervention. CONCLUSIONS: In view of the robustness of current evidence, no further trials are needed to investigate BoNT for its favorable effects on resistance to passive movement of the spastic wrist and fingers, and on self-care. No trials are needed to further confirm the lack of effects of BoNT on arm-hand capacity, whereas additional trials are needed to establish the suggested favorable effects of BoNT on other body functions, which may result in clinically meaningful outcomes at activity and participation levels.

Does a Perturbation-Based Gait Intervention Enhance Gait Stability in Fall-Prone Stroke Survivors? A Pilot Study.

A recent review indicated that perturbation-based training (PBT) interventions are effective in reducing falls in older adults and patients with Parkinson's disease. It is unknown whether this type of intervention is effective in stroke survivors. We determined whether PBT can enhance gait stability in stroke survivors. A total of 10 chronic stroke survivors who experienced falls in the past 6 months participated in the PBT. Participants performed 10 training sessions over a 6-week period. The gait training protocol was progressive, and each training contained unexpected gait perturbations and expected gait perturbations. Evaluation of gait stability was performed by determining steady-state gait characteristics and daily-life gait characteristics. We previously developed fall prediction models for both gait assessment methods. We evaluated whether predicted fall risk was reduced after PBT according to both models. Steady-state gait characteristics significantly improved, and consequently, predicted fall risk was reduced after the PBT. However, daily-life gait characteristics did not change, and thus, predicted fall risk based on daily-life gait remained unchanged after the PBT. A PBT resulted in more stable gait on a treadmill and thus lower predicted fall risk. However, the more stable gait on the treadmill did not transfer to a more stable gait in daily life.

Virtual reality gait training versus non-virtual reality gait training for improving participation in subacute stroke survivors: study protocol of the ViRTAS randomized controlled trial.

BACKGROUND: A stroke often results in gait impairments, activity limitations and restricted participation in daily life. Virtual reality (VR) has shown to be beneficial for improving gait ability after stroke. Previous studies regarding VR focused mainly on improvements in functional outcomes. As participation in daily life is an important goal for rehabilitation after stroke, it is of importance to investigate if VR gait training improves participation. The primary aim of this study is to examine the effect of VR gait training on participation in community-living people after stroke. METHODS/DESIGN: The ViRTAS study comprises a single-blinded, randomized controlled trial with two parallel groups. Fifty people between 2 weeks and 6 months after stroke, who experience constraints with walking in daily life, are randomly assigned to the virtual reality gait training (VRT) group or the non-virtual reality gait training (non-VRT) group. Both training interventions consist of 12 30-min sessions in an outpatient rehabilitation clinic during 6 weeks. Assessments are performed at baseline, post intervention and 3 months post intervention. The primary outcome is participation measured with the Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P). Secondary outcomes are subjective physical functioning, functional mobility, walking ability, walking activity, fatigue, anxiety and depression, falls efficacy and quality of life. DISCUSSION: The results of the study provide insight into the effect of VR gait training on participation after stroke. TRIAL REGISTRATION: Netherlands National Trial Register, Identifier NTR6215 . Registered on 3 February 2017.

Investigating post-stroke fatigue: An individual participant data meta-analysis.

OBJECTIVE: The prevalence of post-stroke fatigue differs widely across studies, and reasons for such divergence are unclear. We aimed to collate individual data on post-stroke fatigue from multiple studies to facilitate high-powered meta-analysis, thus increasing our understanding of this complex phenomenon. METHODS: We conducted an Individual Participant Data (IPD) meta-analysis on post-stroke fatigue and its associated factors. The starting point was our 2016 systematic review and meta-analysis of post-stroke fatigue prevalence, which included 24 studies that used the Fatigue Severity Scale (FSS). Study authors were asked to provide anonymised raw data on the following pre-identified variables: (i) FSS score, (ii) age, (iii) sex, (iv) time post-stroke, (v) depressive symptoms, (vi) stroke severity, (vii) disability, and (viii) stroke type. Linear regression analyses with FSS total score as the dependent variable, clustered by study, were conducted. RESULTS: We obtained data from 14 of the 24 studies, and 12 datasets were suitable for IPD meta-analysis (total n = 2102). Higher levels of fatigue were independently associated with female sex (coeff. = 2.13, 95% CI 0.44-3.82, p = 0.023), depressive symptoms (coeff. = 7.90, 95% CI 1.76-14.04, p = 0.021), longer time since stroke (coeff. = 10.38, 95% CI 4.35-16.41, p = 0.007) and greater disability (coeff. = 4.16, 95% CI 1.52-6.81, p = 0.010). While there was no linear association between fatigue and age, a cubic relationship was identified (p < 0.001), with fatigue peaks in mid-life and the oldest old. CONCLUSION: Use of IPD meta-analysis gave us the power to identify novel factors associated with fatigue, such as longer time since stroke, as well as a non-linear relationship with age.

The Brains Ahead! intervention for children and adolescents with mild traumatic brain injury and their caregivers: rationale and description of the treatment protocol.

PURPOSE:: Approximately 20% of the children and adolescents after mild traumatic brain injury will not fully recover. They suffer long-term postconcussive symptoms and may experience limitations in activities and participation. Research suggests that early psychoeducational interventions may prevent long-term postconcussive symptoms. The Brains Ahead! intervention was developed to prevent long-term symptoms and, furthermore, to establish a more successful return to activities and participation after mild traumatic brain injury in children and adolescents. The intervention is currently being evaluated in a multicenter randomized controlled trial. RATIONALE:: Providing individualized information and personal advice in addition to standardized information about the injury and possible consequences early after the injury may enable patients and caregivers to recognize and anticipate on relevant symptoms at an early stage and to prevent problems in activities and participation. THEORY INTO PRACTICE:: The Brains Ahead! intervention is a psychoeducational intervention for children and adolescents who sustained a mild traumatic brain injury and for their caregivers. The patients will receive a partially standardized and partially individualized psychoeducational session and a telephone follow-up within the first two to eight weeks after the injury.

The role of postural control in the association between aerobic capacity and walking capacity in chronic stroke: a cross-sectional analysis.

BACKGROUND: Reports on the association between aerobic capacity and walking capacity in people after stroke show disparate results. AIM: The aim of this study was to determine: 1) if the predictive validity of peak oxygen uptake (VO2peak) for walking capacity post stroke is different from that of maximal oxygen uptake (VO2max), and 2) if postural control, hemiplegic lower extremity muscle strength, age and gender distort the association between aerobic capacity and walking capacity. DESIGN: Cross-sectional study. SETTING: General community in Utrecht, The Netherlands. POPULATION: Community-dwelling people more than three months after stroke. METHODS: Measurement of aerobic capacity were performed with cardiopulmonary exercise testing (CPET) and differentiated between the achievement of VO2peak or VO2max. Measurement of walking capacity with the 6-Minute Walk Test (6MWT), postural control with the Performance-Oriented Mobility Assessment (POMA) and hemiplegic lower extremity muscle strength with the Motricity Index (MI-LE). RESULTS: Fifty-one out of 62 eligible participants, aged 64.7±12.5 years were included. Analysis of covariance (ANCOVA) showed a nonsignificant difference between the predictive validities of VO2max (N.=22, ß=0.56; 95% CI: 0.12-0.97) and VO2peak (N.=29, ß=0.72; 95% CI: 0.38-0.92). Multiple regression analysis of the pooled sample showed a significant decrease in the ß value of VO2peak (21.6%) for the 6MWT when adding the POMA as a covariate in the association model. VO2peak remained significantly related to 6MWT after correcting for the POMA (ß=0.56, 95% CI: 0.39-0.75). CONCLUSIONS: The results suggest similar predictive validity of aerobic capacity for walking capacity in participants achieving VO2max compared to those only achieving VO2peak. Postural control confounds the association between aerobic capacity and walking capacity. Aerobic capacity remains a valid predictor of walking capacity. CLINICAL REHABILITATION IMPACT: Aerobic capacity is an important factor associated with walking capacity after stroke. However, to understand this relationship, postural control needs to be measured. Both aerobic capacity and postural control may need to be addressed during interventions aiming to improve walking capacity after stroke.