Measuring Neuroplasticity in Response to Cardiovascular Exercise in People With Stroke: A Critical Perspective.

BACKGROUND: Rehabilitative treatments that promote neuroplasticity are believed to improve recovery after stroke. Animal studies have shown that cardiovascular exercise (CE) promotes neuroplasticity but the effects of this intervention on the human brain and its implications for the functional recovery of patients remain unclear. The use of biomarkers has enabled the assessment of cellular and molecular events that occur in the central nervous system after brain injury. Some of these biomarkers have proven to be particularly valuable for the diagnosis of severity, prognosis of recovery, as well as for measuring the neuroplastic response to different treatments after stroke. OBJECTIVES: To provide a critical analysis on the current evidence supporting the use of neurophysiological, neuroimaging, and blood biomarkers to assess the neuroplastic response to CE in individuals poststroke. RESULTS: Most biomarkers used are responsive to the effects of acute and chronic CE interventions, but the response appears to be variable and is not consistently associated with functional improvements. Small sample sizes, methodological variability, incomplete information regarding patient's characteristics, inadequate standardization of training parameters, and lack of reporting of associations with functional outcomes preclude the quantification of the neuroplastic effects of CE poststroke using biomarkers. CONCLUSION: Consensus on the optimal biomarkers to monitor the neuroplastic response to CE is currently lacking. By addressing critical methodological issues, future studies could advance our understanding of the use of biomarkers to measure the impact of CE on neuroplasticity and functional recovery in patients with stroke.

Development of a virtual reality-based intervention for community walking post stroke: an integrated knowledge translation approach.

PURPOSE: To develop a virtual reality (VR) based intervention targeting community walking requirements. METHODS: Two focus groups each involving 7 clinicians allowed exploring optimal features, needed support and perceived favorable/unfavorable factors associated with the use of the VR-based intervention from the clinicians' perspective. Three stroke survivors and 2 clinicians further interacted with the intervention and filled questionnaires related to acceptability and favorable/unfavorable perceptions on the VR intervention. Stroke participants additionally rated their perceived effort (NASA Tax Load Index), presence (Slater-Usoh-Steed) and cybersickness (Simulator Sickness Questionnaire). RESULTS: Results identified optimal features (patient eligibility criteria, task complexity), needed support (training, human assistance), as well as favorable (cognitive stimulation, engagement, representativeness of therapeutic goals) and unfavorable factors (misalignment with a natural walking pattern, client suitability, generalization to real-life) associated with the intervention. Acceptability scores following the interaction with the tool were 28 and 42 (max 56) for clinicians and ranged from 43 to 52 for stroke participants. Stroke participants reported moderate perceptions of effort (range:20-33/max:60), high levels of presence (29-42/42) and minimal cybersickness (0-3/64). CONCLUSION: Findings collected in the early development phase of the VR intervention will allow addressing favorable/unfavorable factors and incorporating desired optimal features, prior to conducting effectiveness and implementation studies.

This study presents the development process of a new virtual reality (VR) intervention for community walking and participation in stroke survivors.Results from the focus group and hands-on pilot trial suggest that the VR intervention is feasible and accepted by clinicians and stroke survivors.Addressing favorable/unfavorable factors and incorporating features desired by clinicians in the development of the VR tool should promote its eventual implementation in clinical setting.

A Pilot Study to Assess Visual Vertigo in People with Persistent Postural-Perceptual Dizziness with a New Computer-Based Tool.

BACKGROUND: Visual vertigo (VV) is a common symptom in people with persistent postural-perceptual dizziness (PPPD). Few subjective scales are validated for assessing the intensity of VV, yet these scales are limited by recall bias, as they require individuals to rate their symptoms from memory. The computer-Visual Vertigo Analogue Scale (c-VVAS) was developed by adapting five scenarios from the original paper-VVAS (p-VVAS) into 30 s video clips. The aim of this pilot study was to develop and test a computerized video-based tool for the assessment of visual vertigo in people with PPPD. METHODS: PPPD participants (n = 8) and age- and sex-matched controls (n = 8) completed the traditional p-VVAS and the c-VVAS. A questionnaire about their experiences using the c-VVAS was completed by all participants. RESULTS: There was a significant difference between the c-VVAS scores from the PPPD and the control group (Mann-Whitney, p < 0.05). The correlation between the total c-VVAS scores and the total c-VVAS scores was not significant (r = 0.668, p = 0.07). The study showed a high acceptance rate of the c-VVAS by participants (mean = 91.74%). CONCLUSION: This pilot study found that the c-VVAS can distinguish PPPD subjects from healthy controls and that it was well-received by all participants.

Instantaneous effect of real-time avatar visual feedback on interlimb coordination during walking post-stroke.

BACKGROUND: Gait asymmetry, which is common after stroke, is typically characterized using spatiotemporal parameters of gait that do not consider the aspect of movement coordination. In this manuscript, we examined whether an avatar-based feedback provided as a single-session intervention to improve gait symmetry also improved inter-limb coordination among people with stroke and we examined the relationship between changes in coordination and step length symmetry. METHODS: Twelve stroke participants walked on a self-paced treadmill with and without a self-avatar that replicated their locomotor movements in real time. Continuous relative phase and angular coefficient of correspondence calculated using bilateral sagittal hip movements were used to quantify temporal and spatial interlimb coordination, respectively. Spatial gait symmetry, previously shown to improve with the avatar feedback, was quantified using step length ratio between both limbs, with the largest value as numerator. FINDINGS: Participants who improved their spatial symmetry during avatar exposure also improved their temporal coordination, while spatial coordination remained unchanged. Overall, improvements in spatial symmetry correlated positively with improvements in temporal coordination. The non-paretic hip and paretic ankle angle excursion in the sagittal plane also significantly increased during avatar exposure. INTERPRETATION: Improvements in gait symmetry may be explained by changes in interlimb coordination. Current data and existing literature further suggest that such improvements are largely driven by adaptations in non-paretic leg movements, notably at the hip. By providing real-time information on walking movements not affordable in other ways, avatar-based feedback shows great potential to improve gait symmetry and interlimb coordination post-stroke.

Biomedical Research and Informatics Living Laboratory for Innovative Advances of New Technologies in Community Mobility Rehabilitation: Protocol for Evaluation and Rehabilitation of Mobility Across Continuums of Care.

BACKGROUND: Rapid advances in technologies over the past 10 years have enabled large-scale biomedical and psychosocial rehabilitation research to improve the function and social integration of persons with physical impairments across the lifespan. The Biomedical Research and Informatics Living Laboratory for Innovative Advances of New Technologies (BRILLIANT) in community mobility rehabilitation aims to generate evidence-based research to improve rehabilitation for individuals with acquired brain injury (ABI). OBJECTIVE: This study aims to (1) identify the factors limiting or enhancing mobility in real-world community environments (public spaces, including the mall, home, and outdoors) and understand their complex interplay in individuals of all ages with ABI and (2) customize community environment mobility training by identifying, on a continuous basis, the specific rehabilitation strategies and interventions that patient subgroups benefit from most. Here, we present the research and technology plan for the BRILLIANT initiative. METHODS: A cohort of individuals, adults and children, with ABI (N=1500) will be recruited. Patients will be recruited from the acute care and rehabilitation partner centers within 4 health regions (living labs) and followed throughout the continuum of rehabilitation. Participants will also be recruited from the community. Biomedical, clinician-reported, patient-reported, and brain imaging data will be collected. Theme 1 will implement and evaluate the feasibility of collecting data across BRILLIANT living labs and conduct predictive analyses and artificial intelligence (AI) to identify mobility subgroups. Theme 2 will implement, evaluate, and identify community mobility interventions that optimize outcomes for mobility subgroups of patients with ABI. RESULTS: The biomedical infrastructure and equipment have been established across the living labs, and development of the clinician- and patient-reported outcome digital solutions is underway. Recruitment is expected to begin in May 2022. CONCLUSIONS: The program will develop and deploy a comprehensive clinical and community-based mobility-monitoring system to evaluate the factors that result in poor mobility, and develop personalized mobility interventions that are optimized for specific patient subgroups. Technology solutions will be designed to support clinicians and patients to deliver cost-effective care and the right intervention to the right person at the right time to optimize long-term functional potential and meaningful participation in the community. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/12506.

Canadian Stroke Best Practice Recommendations: Virtual Stroke Rehabilitation Interim Consensus Statement 2022.

ABSTRACT: The seventh edition of the Canadian Stroke Best Practice Recommendations for Rehabilitation and Recovery following Stroke includes a new section devoted to the provision of virtual stroke rehabilitation. This consensus statement uses Grading of Recommendations, Assessment, Development and Evaluations methodology and Appraisal of Guidelines for Research & Evaluation II principles. A literature search was conducted using PubMed, Embase, and Cochrane databases. An expert writing group reviewed all evidence and developed recommendations, as well as consensus-based clinical considerations where evidence was insufficient for a recommendation. All recommendations underwent internal and external review. These recommendations apply to hospital, ambulatory care, and community-based settings where virtual stroke rehabilitation is provided. This guidance is relevant to health professionals, people living with stroke, healthcare administrators, and funders. Recommendations address issues of access, eligibility, consent and privacy, technology and planning, training and competency (for healthcare providers, patients and their families), assessment, service delivery, and evaluation. Virtual stroke rehabilitation has been shown to safely and effectively increase access to rehabilitation therapies and care providers, and uptake of these recommendations should be a priority in rehabilitation settings. They are key drivers of access to high-quality evidence-based stroke care regardless of geographical location and personal circumstances in Canada.

Intensity matters: protocol for a randomized controlled trial exercise intervention for individuals with chronic stroke.

RATIONALE: Cardiovascular exercise is an effective method to improve cardiovascular health outcomes, but also promote neuroplasticity during stroke recovery. Moderate-intensity continuous cardiovascular training (MICT) is an integral part of stroke rehabilitation, yet it may remain a challenge to exercise at sufficiently high intensities to produce beneficial adaptations to neuroplasticity. High-intensity interval training (HIIT) could provide a viable alternative to achieve higher intensities of exercise by using shorter bouts of intense exercise interspersed with periods of recovery. METHODS AND DESIGN: This is a two-arm, parallel-group multi-site RCT conducted at the Jewish Rehabilitation Hospital (Laval, Québec, Canada) and McMaster University (Hamilton, Ontario, Canada). Eighty participants with chronic stroke will be recruited at both sites and will be randomly allocated into a HIIT or MICT individualized exercise program on a recumbent stepper, 3 days per week for 12 weeks. Outcomes will be assessed at baseline, at 12 weeks post-intervention, and at an 8-week follow-up. OUTCOMES: The primary outcome is corticospinal excitability, a neuroplasticity marker in brain motor networks, assessed with transcranial magnetic stimulation (TMS). We will also examine additional markers of neuroplasticity, measures of cardiovascular health, motor function, and psychosocial responses to training. DISCUSSION: This trial will contribute novel insights into the effectiveness of HIIT to promote neuroplasticity in individuals with chronic stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT03614585 . Registered on 3 August 2018.

Rehabilitation Supported by Technology: Protocol for an International Cocreation and User Experience Study.

BACKGROUND: Living labs in the health and well-being domain have become increasingly common over the past decade but vary in available infrastructure, implemented study designs, and outcome measures. The Horizon 2020 Project Virtual Health and Wellbeing Living Lab Infrastructure aims to harmonize living lab procedures and open living lab infrastructures to facilitate and promote research activities in the health and well-being domain in Europe and beyond. This protocol will describe the design of a joint research activity, focusing on the use of innovative technology for both rehabilitation interventions and data collection in a rehabilitation context. OBJECTIVE: With this joint research activity, this study primarily aims to gain insight into each living lab's infrastructure and procedures to harmonize health and well-being living lab procedures and infrastructures in Europe and beyond, particularly in the context of rehabilitation. Secondarily, this study aims to investigate the potential of innovative technologies for rehabilitation through living lab methodologies. METHODS: This study has a mixed methods design comprising multiple phases. There are two main phases of data collection: cocreation (phase 1) and small-scale pilot studies (phase 2), which are preceded by a preliminary harmonization of procedures among the different international living labs. An intermediate phase further allows the implementation of minor adjustments to the intervention or protocol depending on the input that was obtained in the cocreation phase. A total of 6 small-scale pilot studies using innovative technologies for intervention or data collection will be performed across 4 countries. The target study sample comprises patients with stroke and older adults with mild cognitive impairment. The third and final phases involve Delphi procedures to reach a consensus on harmonized procedures and protocols. RESULTS: Phase 1 data collection will begin in March 2022, and phase 2 data collection will begin in June 2022. Results will include the output of the cocreation sessions, small-scale pilot studies, and advice on harmonizing procedures and protocols for health and well-being living labs focusing on rehabilitation. CONCLUSIONS: The knowledge gained by the execution of this research will lead to harmonized procedures and protocols in a rehabilitation context for health and well-being living labs in Europe and beyond. In addition to the harmonized procedures and protocols in rehabilitation, we will also be able to provide new insights for improving the implementation of innovative technologies in rehabilitation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/34537.

Walking with robot-generated haptic forces in a virtual environment: a new approach to analyze lower limb coordination.

BACKGROUND: Walking with a haptic tensile force applied to the hand in a virtual environment (VE) can induce adaptation effects in both chronic stroke and non-stroke individuals. These effects are reflected in spatiotemporal outcomes such as gait speed. However, the concurrent kinematic changes occurring in bilateral lower limb coordination have yet to be explored. METHODS: Chronic stroke participants were stratified based on overground gait speed into lower functioning (LF < 0.8 m/s, N = 7) and higher functioning (HF ≥ 0.8 m/s, N = 7) subgroups. These subgroups and an age-matched control group (N = 14, CG) walked on a self-paced treadmill in a VE with either robot-generated haptic leash forces delivered to the hand and then released or with an instrumented cane. Walking in both leash (10 and 15 N) and cane conditions were compared to pre-force baseline values to evaluate changes in lower limb coordination outcomes. RESULTS: All groups showed some kinematic changes in thigh, leg and foot segments when gait speed increased during force and post-force leash as well as cane walking. These changes were also reflected in intersegmental coordination and 3D phase diagrams, which illustrated increased intersegmental trajectory areas (p < 0.05) and angular velocity. These increases could also be observed when the paretic leg transitions from stance to swing phases while walking with the haptic leash. The Sobolev norm values accounted for both angular position and angular velocity, providing a single value for potentially quantifying bilateral (i.e. non-paretic vs paretic) coordination during walking. These values tended to increase (p < 0.05) proportionally for both limbs during force and post-force epochs as gait speed tended to increase. CONCLUSIONS: Individuals with chronic stroke who increased their gait speed when walking with tensile haptic forces and immediately after force removal, also displayed moderate concurrent changes in lower limb intersegmental coordination patterns in terms of angular displacement and velocity. Similar results were also seen with cane walking. Although symmetry was less affected, these findings appear favourable to the functional recovery of gait. Both the use of 3D phase diagrams and assigning Sobolev norm values are potentially effective for detecting and quantifying these coordination changes.

Obstacle Avoidance and Dual-Tasking During Reaching While Standing in Patients With Mild Chronic Stroke.

Background. Poststroke individuals use their paretic arms less often than expected in daily life situations, even when motor recovery is scored highly in clinical tests. Real-world environments are often unpredictable and require the ability to multitask and make decisions about rapid and accurate arm movement adjustments. Objective. To identify whether and to what extent cognitive-motor deficits in well-recovered individuals with stroke affect the ability to rapidly adapt reaching movements in changing cognitive and environmental conditions. Methods. Thirteen individuals with mild stroke and 11 healthy controls performed an obstacle avoidance task in a virtual environment while standing. Subjects reached for a virtual juice bottle with their hemiparetic arm as quickly as possible under single- and dual-task conditions. In the single-task condition, a sliding glass door partially obstructed the reaching path of the paretic arm. A successful trial was counted when the subject touched the bottle without the hand colliding with the door. In the dual-task condition, subjects repeated the same task while performing an auditory-verbal working memory task. Results. Individuals with stroke had significantly lower success rates than controls in avoiding the moving door in single-task (stroke: 51.8 ± 21.2%, control: 70.6 ± 12.7%; P = .018) and dual-task conditions (stroke: 40.0 ± 27.6%, control: 65.3 ± 20.0%; P = .015). Endpoint speed was lower in stroke subjects for successful trials in both conditions. Obstacle avoidance deficits were exacerbated by increased cognitive demands in both groups. Individuals reporting greater confidence using their hemiparetic arm had higher success rates. Conclusion. Clinically well-recovered individuals with stroke may have persistent deficits performing a complex reaching task.

Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials.

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Slip-Fall Predictors in Community-Dwelling, Ambulatory Stroke Survivors: A Cross-sectional Study.

BACKGROUND AND PURPOSE: Considering the multifactorial nature and the often-grave consequences of falls in people with chronic stroke (PwCS), determining measurements that best predict fall risk is essential for identifying those who are at high risk. We aimed to determine measures from the domains of the International Classification of Functioning, Disability and Health (ICF) that can predict laboratory-induced slip-related fall risk among PwCS. METHODS: Fifty-six PwCS participated in the experiment in which they were subjected to an unannounced slip of the paretic leg while walking on an overground walkway. Prior to the slip, they were given a battery of tests to assess fall risk factors. Balance was assessed using performance-based tests and instrumented measures. Other fall risk factors assessed were severity of sensorimotor impairment, muscle strength, physical activity level, and psychosocial factors. Logistic regression analysis was performed for all variables. The accuracy of each measure was examined based on its sensitivity and specificity for fall risk prediction. RESULTS: Of the 56 participants, 24 (43%) fell upon slipping while 32 (57%) recovered their balance. The multivariate logistic regression analysis model identified dynamic gait stability, hip extensor strength, and the Timed Up and Go (TUG) score as significant laboratory-induced slip-fall predictors with a combined sensitivity of 75%, a specificity of 79.2%, and an overall accuracy of 77.3%. DISCUSSION AND CONCLUSIONS: The results indicate that fall risk measures within the ICF domains-body, structure, and function (dynamic gait stability and hip extensor strength) and activity limitation (TUG)-could provide a sensitive laboratory-induced slip-fall prediction model in PwCS.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A323).

Changes in arm kinematics of chronic stroke individuals following "Assist-As-Asked" robot-assisted training in virtual and physical environments: A proof-of-concept study.

INTRODUCTION: In this proof-of-concept study, we introduce a custom-developed robot-assisted training protocol, named "Assist-As-Asked", aiming at improving arm function of chronic stroke subjects with moderate-to-severe upper extremity motor impairment. The study goals were to investigate the feasibility and potential adverse effects of this training protocol in both physical and virtual environments. METHODS: A sample of convenience of four chronic stroke subjects participated in 10 half-hour sessions. The task was to practice reaching six targets in both virtual and physical environments. The robotic arm used the Assist-As-Asked paradigm in which it helped subjects to complete movements when asked by them. Changes in the kinematics of the reaching movements and the participants' perception of the reaching practice in both environments were the outcome measures of interest. RESULTS: Subjects improved their reaching performance and none of them reported any adverse events. There were no differences between the two environments in terms of kinematic measures even though subjects had different opinions about the environment preference. CONCLUSIONS: Using the Assist-As-Asked protocol in moderate-to-severe chronic stroke survivors is feasible and it can be used with both physical and virtual environments with no evidence of one of them to be superior to the other based on users' perspectives and movement kinematics.

Recovery of Sensorimotor Functional Outcomes at Discharge from In-Patient Rehabilitation in Three Stroke Units in the Province of Quebec.

Purpose: This study aimed to portray the characteristics, process variables, and sensorimotor outcomes of patients who had received their usual post-stroke in-patient rehabilitation in three stroke rehabilitation units in Quebec in 2013-2014. Method: We assessed patients (n = 264) at admission and discharge with a subset of a standardized assessment toolkit consisting of observational and performance-based assessment tools. Results: The patients, with a mean age of 60.3 (SD 15.4) years, were admitted 27.7 (SD 8.4) days post-stroke onset. They had a mean admission FIM score of 83.0 (SD 24.0), a mean length of stay of 48.4 (SD 31.1) days, a mean FIM discharge score of 104.0 (SD 17.0), and a mean FIM efficiency score of 0.44 (SD 0.29). All patient outcomes were significantly improved (p < 0.001) and clinically meaningful at discharge (moderate to large Glass's Δ effect sizes) with the improvements greater than or equal to the minimal detectable change at the 95% confidence level in 34%-75% of the patients. Improvements were larger on five of seven outcomes in a sub-group of patients with more severe stroke. Conclusions: The use of a combination of observational and performance assessment tools was essential to capture the full range of disabilities. We have documented significant and clinically meaningful improvements in functional independence, disability, and upper and lower extremity functions after usual post-stroke in-patient rehabilitation in the province of Quebec and provided baseline data for future studies.

Objectif : décrire les caractéristiques, le processus de réadaptation et les résultats sensorimoteurs de patients ayant reçu les services de réadaptation habituels après un accident vasculaire cérébral (AVC) dans trois unités de réadaptation du Québec en 2013 et 2014. Méthodologie : évaluation des patients (n = 264) à l'admission et au congé à l'aide du sous-ensemble d'une trousse d'évaluation standardisée composée d'outils d'évaluation fondés sur l'observation et la performance. Résultats : les patients, qui avaient un âge moyen de 60,3 ans (ÉT 15,4), ont été hospitalisés en réadaptation 27,7 jours (ÉT 8,4) après leur AVC. Leur mesure d'autonomie fonctionnelle (MAF) à l'admission était de 83,0 (ÉT 24,0), et leur séjour en réadaptation a duré 48,4 jours (ÉT 31,1); leur score de MAF au congé était de 104,0 (ÉT 17,0), pour un score d'efficacité de la MAF de 0,44 (ÉT 0,29). Tous les résultats cliniques des patients s'étaient considérablement améliorés (p < 0,001) et étaient cliniquement significatifs au congé (effet de taille delta de Glass de modéré à grand), et ces améliorations étaient supérieures ou égales au changement minimal décelable à un niveau de confiance de 95 % chez 34 % à 75 % des patients. Ces améliorations pour cinq des sept mesures étaient plus élevées dans le sous-groupe de patients ayant un AVC plus grave. Conclusion : une combinaison d'outils d'évaluation d'observation et de performance s'est avérée essentielle pour saisir tout l'éventail d'incapacités. Les auteures ont constaté des améliorations importantes et cliniquement significatives de l'autonomie fonctionnelle, de l'incapacité et de la fonction des membres supérieurs et inférieurs après l'hospitalisation en réadaptation habituelle des patients ayant un AVC dans la province de Québec et ont fourni des données de référence en vue de prochaines études.

Real-Time Avatar-Based Feedback to Enhance the Symmetry of Spatiotemporal Parameters After Stroke: Instantaneous Effects of Different Avatar Views.

Gait asymmetry, one of the hallmarks of post stroke locomotion, often persists despite gait rehabilitation interventions, impacting negatively on functional mobility. Real-time feedback and biological cues have been studied extensively in recent years, but their applicability to post-stroke gait symmetry remain questionable. This proof-of-concept study examined the feasibility and instantaneous effects of real-time visual feedback provided in the form of an avatar in twelve participants with stroke on gait symmetry and other gait-related outcomes. The visual avatar was presented via three different views from the back, front and paretic side. Avatar feedback from the paretic side view showed significant increase in bilateral step length, paretic swing time and treadmill walking speed, but no significant differences were found in symmetry measures in any of the three views. Those who had changes in symmetry ratio >0 were grouped as responders to spatial symmetry improvement in the side view. The responders had a significantly higher Chedoke-McMaster Stroke Assessment foot score and presented with a larger initial step length on the paretic side. Furthermore, all participants provided positive feedback and no adverse effects were observed during the experiment. Overall, these findings suggest that real-time avatar-based feedback can be used as an intervention to improve post-stroke gait asymmetry.

Adding Light Touch While Walking in Older Adults: Biomechanical and Neuromotor Effects.

Adding haptic input may improve balance control and help prevent falls in older adults. This study examined the effects of added haptic input via light touch on a railing while walking. Participants (N = 53, 75.9 ± 7.9 years) walked normally or in tandem (heel to toe) with and without haptic input. During normal walking, adding haptic input resulted in a more cautious and variable gait pattern, reduced variability of center of mass acceleration and margin of stability, and increased muscle activity. During tandem walking, haptic input had minimal effect on step parameters, decreased lower limb muscle activity, and increased cocontraction at the ankle closest to the railing. Age was correlated with step width variability, stride length variability, stride velocity, variability of medial-lateral center of mass acceleration, and margin of stability for tandem walking. This complex picture of sensorimotor integration in older adults warrants further exploration into added haptic input during walking.

Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Community Participation following Stroke. Part One: Rehabilitation and Recovery Following Stroke; 6th Edition Update 2019.

The sixth update of the Canadian Stroke Best Practice Recommendations: Rehabilitation, Recovery, and Reintegration following Stroke. Part one: Rehabilitation and Recovery Following Stroke is a comprehensive set of evidence-based guidelines addressing issues surrounding impairments, activity limitations, and participation restrictions following stroke. Rehabilitation is a critical component of recovery, essential for helping patients to regain lost skills, relearn tasks, and regain independence. Following a stroke, many people typically require rehabilitation for persisting deficits related to hemiparesis, upper-limb dysfunction, pain, impaired balance, swallowing, and vision, neglect, and limitations with mobility, activities of daily living, and communication. This module addresses interventions related to these issues as well as the structure in which they are provided, since rehabilitation can be provided on an inpatient, outpatient, or community basis. These guidelines also recognize that rehabilitation needs of people with stroke may change over time and therefore intermittent reassessment is important. Recommendations are appropriate for use by all healthcare providers and system planners who organize and provide care to patients following stroke across a broad range of settings. Unlike the previous set of recommendations, in which pediatric stroke was included, this set of recommendations includes primarily adult rehabilitation, recognizing many of these therapies may be applicable in children. Recommendations related to community reintegration, which were previously included within this rehabilitation module, can now be found in the companion module, Rehabilitation, Recovery, and Community Participation following Stroke. Part Two: Transitions and Community Participation Following Stroke.

Reading text messages at different stages of pedestrian circumvention affects strategies for collision avoidance in young and older adults.

BACKGROUND: Reading text messages is associated with accidents while walking in community places. RESEARCH QUESTION: To what extent does reading text messages at different stages of obstacle circumvention affect avoidance strategies while walking in young vs. older adults? METHODS: Sixteen healthy young and 14 older adults were assessed while walking and viewing a virtual environment (VE) simulating a subway station with three virtual pedestrians positioned 7.5 m away from the participant in the centre (0°), left and right (±40°). As participants advanced 0.5 m towards a target in the far space, a virtual pedestrian randomly approached them. Text messages were delivered at onset of pedestrian movement (0.5 m; early message) or during obstacle circumvention (2.5 m; late message). A Vicon motion capture system captured trajectory displacement while walking. RESULTS: In both age groups, accuracy of message report (AMR) was reduced for early compared to late messages (p < 0.001), although older adults showed larger deterioration (p < 0.001) compared to younger participants. Locomotor outcomes (obstacle clearance, onset time of avoidance and walking speed) showed no differences between young and older participants (p > 0.05). Early messages led to slower walking speed (p < 0.001) and more frequent collisions compared to late messages and the no-message condition. Late messages yielded faster walking speed (p < 0.001) and onset time of avoidance (p < 0.02) compared to the other conditions. SIGNIFICANCE: Results indicate that the stage of an avoidance strategy at which text messages are received impacts on pedestrian circumvention, with early messages posing a greater challenge to collision avoidance. In older adults, the reduced AMR suggests larger dual-task interference and prioritization of the walking task. The lack of further walking speed reduction in older vs. young adults may put them at greater risk of collisions in crowded, unpredictable community environments.