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Stepping is a common strategy to recover postural stability and maintain upright balance. Postural perturbations have been linked to neuroelectrical markers such as the N1 potential and theta frequency dynamics. Here, we investigated the role of cortical midfrontal theta dynamics of balance monitoring, driven by balance perturbations at different initial standing postures. We recorded electroencephalography, electromyography, and motion tracking of human participants while they stood on a platform that delivered a range of forward and backward whole-body balance perturbations. The participants’ postural threat was manipulated prior to the balance perturbation by instructing them to lean forward or backward while keeping their feet-in-place in response to the perturbation. We hypothesized that midfrontal theta dynamics index the engagement of a behavioral monitoring system and, therefore, that perturbation-induced theta power would be modulated by the initial leaning posture and perturbation intensity. Targeted spatial filtering in combination with mixed-effects modeling confirmed our hypothesis and revealed distinct modulations of theta power according to postural threat. Our results provide novel evidence that midfrontal theta dynamics subserve action monitoring of human postural balance. Understanding of cortical mechanisms of balance control is crucial for studying balance impairments related to aging and neurological conditions (e.g. stroke).

Background and objectives In people with hereditary spastic paraplegia (HSP), reduced gait adaptability is common and disabling. Gait impairments result from lower extremity spasticity, muscle weakness, and impaired proprioception. The aim of this study was to assess the efficacy of a 5-week gait-adaptability training in people with pure HSP. Method We conducted a randomized clinical trial with a cross-over design for the control group, and a 15-week follow-up period after training. Thirty-six people with pure HSP were randomized to 5 weeks of (i) gait-adaptability training (10 hours of C-Mill training—a treadmill equipped with augmented reality) or (ii) a waiting-list control period followed by 5 weeks gait-adaptability training. Both groups continued to receive usual care. The primary outcome was the obstacle subtask of the Emory Functional Ambulation Profile. Secondary outcome measures consisted of clinical balance and gait assessments, fall rates, and spatiotemporal gait parameters assessed via 3D motion analysis. Results The gait-adaptability training group (n = 18) did not significantly decrease the time required to perform the obstacle subtask compared to the waiting-list control group (n = 18) after adjusting for baseline differences (mean: −0.33 seconds, 95% CI: −1.3, 0.6). Similar, non-significant results were found for most secondary outcomes. After merging both groups (n = 36), the required time to perform the obstacle subtask significantly decreased by 1.3 seconds (95% CI: −2.1, −0.4) directly following 5 weeks of gait-adaptability training, and this effect was retained at the 15-week follow-up. Conclusions We found insufficient evidence to conclude that 5 weeks of gait-adaptability training leads to greater improvement of gait adaptability in people with pure HSP.

Objective Hereditary spastic paraplegia (HSP) is characterized by a bilaterally spastic gait pattern. During gait, increased trunk movements are often observed. People with HSP likely generate trunk movements to improve foot clearance and step length, but there may be additional explanations. Here, we investigate whether there is an association between reduced balance performance and increased trunk movements, as an increase in trunk movements may partly reflect balance correcting strategies. Methods We analyzed an historic cohort of 86 people with HSP who underwent gait analysis and balance examination. Two researchers reviewed gait analyses videos and classified the observed trunk movement as (1) normal, (2) moderately increased, or (3) markedly increased, and categorized participants as ‘toe walkers’ (yes/no). Balance performance and spatiotemporal gait parameters were collected from the medical files. Parameters were compared between people with normal vs. moderately increased trunk movements, moderately vs. markedly increased trunk movements, and normal vs. markedly increased trunk movements. Results Patients with moderately increased trunk movements during gait scored lower on the Berg Balance Scale (p = 0.002) and/or the Mini Balance Evaluation Test (p = 0.043) than patients with normal trunk movements. Likewise, patients with markedly increased trunk movements performed worse on the BBS (p = 0.037) and/or the Mini-BESTest (p = 0.004) than patients with moderately increased trunk movements. Patients with markedly increased trunk movements were more often toe walkers than patients with moderately increased (68% vs. 6%; p Conclusions We found an association between increased trunk movements and reduced balance capacity. This may have several—not mutually exclusive—explanations. One of these explanations is that trunk movements, at least partly, reflect balance correcting strategies. With the disease progression, ankle strategies and foot placement strategies become impaired and insufficient to restore balance after intrinsic perturbations. Hip strategies are then potentially recruited to maintain balance, resulting in increased trunk movements.

Contains fulltext : 293126.pdf (Publisher’s version ) (Open Access)

Children with Developmental Coordination Disorder (DCD-C) have motor coordination deficits which lead to difficulties in sports and play activities that require adaptations of the walking pattern. Sports and play often involve performing dual tasks, which affects performance in DCD-C more than in typically developing children (TD-C). So far, testing the impact of dual tasking on walking adaptability in DCD-C has received little scientific attention.We tested the hypothesis that 6-12 year old DCD-C will show lower levels of walking adaptability than TD-C, and that due to problems with automatization this difference will increase when they are forced to divide their attention between tasks when a concurrent visuo-motor or cognitive task is added.Twenty-six DCD-C and sixty-nine TD-C were included in this cross-sectional study. They performed a challenging walking adaptability (WA) task on a treadmill as a single, a visuo-motor dual and a cognitive dual task at a pace of 3.5 km/h. Repeated measures ANCOVAs were performed with condition (single/dual task) as within-subjects factor, group (TD/DCD) as between-subjects factor, and age as covariate.DCD-C performed poorer on the WA task than TD-C. The group differences increased when a concurrent visuo-motor task was added, but not when adding a concurrent cognitive task. A significant effect of age was found with younger children performing worse on all tasks.The results highlight the problems DCD-C have with walking adaptability and dual tasks, which capacities are essential for full participation in sports and play activities. Future research should investigate whether DCD-C may benefit from task-specific walking adaptability training.

Background Regaining gait capacity is an important rehabilitation goal post stroke. Compared to clinically available robotic gait trainers, robots with an assist-as-needed approach and multiple degrees of freedom (AANmDOF) are expected to support motor learning, and might improve the post-stroke gait pattern. However, their benefits compared to conventional gait training have not yet been shown in a randomized controlled trial (RCT). The aim of this two-center, assessor-blinded, RCT was to compare the effect of AANmDOF robotic to conventional training on the gait pattern and functional gait tasks during post-stroke inpatient rehabilitation. Methods Thirty-four participants with unilateral, supratentorial stroke were enrolled (mDOF robotic (combination of training in LOPES-II and conventional gait training) or conventional gait training (30 min, 3–5 times a week), focused on pre-defined training goals. Randomization and allocation to training group were carried out by an independent researcher. External mechanical work (WEXT), spatiotemporal gait parameters, gait kinematics related to pre-defined training goals, and functional gait tasks were assessed before training (T0), after training (T1), and at 4-months follow-up (T2). Results Two participants, one in each group, were excluded from analysis because of discontinued participation after T0, leaving 32 participants (AANmDOF robotic n = 17; conventional n = 15) for intention-to-treat analysis. In both groups, WEXT had decreased at T1 and had become similar to baseline at T2, while gait speed had increased at both assessments. In both groups, most spatiotemporal gait parameters and functional gait tasks had improved at T1 and T2. Except for step width (T0–T1) and paretic step length (T0–T2), there were no significant group differences at T1 or T2 compared to T0. In participants with a pre-defined goal aimed at foot clearance, paretic knee flexion improved more in the AANmDOF robotic group compared to the conventional group (T0–T2). Conclusions Generally, AANmDOF robotic training was not superior to conventional training for improving gait pattern in subacute stroke survivors. Both groups improved their mechanical gait efficiency. Yet, AANmDOF robotic training might be more effective to improve specific post-stroke gait abnormalities such as reduced knee flexion during swing. Trial registration Registry number Netherlands Trial Register (www.trialregister.nl): NTR5060. Registered 13 February 2015.

Background and Objectives:Compensation strategies are essential in Parkinson’s disease (PD) gait rehabilitation. However, besides external cueing, these strategies have rarely been investigated systematically. We aimed to: (1) establish the patients’ perspective on the efficacy and usability of five different compensation strategies; (2) quantify the efficacy of these strategies on spatiotemporal gait parameters; and (3) explore associations between the effects of specific strategies and patient characteristics.Methods:We recruited persons with PD and self-reported disabling gait impairments for this lab-based, within-subject study. Clinimetrics included: questionnaires (NFOG-Q, VMIQ-2, GMSI), cognitive assessments (ANT, MoCA, Brixton), and physical examinations (MDS-UPDRS III, Mini-BEST, tandem gait, rapid turns test). Gait assessment consisted of six 3-minute trials of continuous walking around a 6-meter walkway. Trials comprised: 1) baseline gait; 2) external cueing; 3) internal cueing; 4) action observation; 5) motor imagery; and 6) adopting a new walking pattern. Spatiotemporal gait parameters were acquired using 3D motion capture analysis. Strategy efficacy was determined by the change in gait variability compared to baseline gait. Associated patient characteristics were explored using regression analyses.Results:101 participants (50 men; median[range] age: 66[47-91] years) were included. The effects of the different strategies varied greatly among participants. While participants with higher baseline variability showed larger improvements using compensation strategies, participants without freezing of gait, with lower MDS-UPDRS III scores, higher balance capacity and better performance in orienting attention, also showed greater improvements in gait variability. Higher MoCA scores were associated with greater efficacy of external cueing.Discussion:Our findings support the use of compensation strategies in gait rehabilitation for PD, but highlight the importance of a personalized approach. Even patients with high gait variability are able to improve through the application of compensation strategies, but certain levels of cognitive and functional reserve seem necessary to optimally benefit from them.Classification of Evidence:This study provides Class III evidence that gait compensation strategies can be effective in persons with PD.

The goal of this study was to determine whether the cortical responses elicited by whole-body balance perturbations were similar to established cortical markers of action monitoring. Postural changes imposed by balance perturbations elicit a robust negative potential (N1) and a brisk increase of theta activity in the electroencephalogram recorded over midfrontal scalp areas. Because action monitoring is a cognitive function proposed to detect errors and initiate corrective adjustments, we hypothesized that the possible cortical markers of action monitoring during balance control (N1 potential and theta rhythm) scale with perturbation intensity and the eventual execution of reactive stepping responses (as opposed to feet-in-place responses). We recorded high-density electroencephalogram from eleven young individuals, who participated in an experimental balance assessment. The participants were asked to recover balance following anteroposterior translations of the support surface at various intensities, while attempting to maintain both feet in place. We estimated source-resolved cortical activity using independent component analysis. Combining time-frequency decomposition and group-level general linear modeling of single-trial responses, we found a significant relation of the interaction between perturbation intensity and stepping responses with multiple cortical features from the midfrontal cortex, including the N1 potential, and theta, alpha, and beta rhythms. Our findings suggest that the cortical responses to balance perturbations index the magnitude of a deviation from a stable postural state to predict the need for reactive stepping responses. We propose that the cortical control of balance may involve cognitive control mechanisms (i.e., action monitoring) that facilitate postural adjustments to maintain postural stability.

Contains fulltext : 218678.pdf (Publisher’s version ) (Closed access) BACKGROUND: Stroke survivors often show reduced walking velocity and gait asymmetry. These gait abnormalities are associated with reduced propulsion of the paretic leg. This review aimed to provide an overview of the potential effectiveness of post-stroke rehabilitation interventions to improve paretic propulsion, ankle kinetics and walking velocity. METHODS: A systematic search was performed in Pubmed, Web of Science, Embase, and Pedro. Studies were eligible if they reported changes in propulsion measures (impulse, peak value and symmetry ratios) or ankle kinetics (moment and power) following intervention in stroke survivors (group size >/=10). Study selection, data extraction and quality assessment were performed independently by two authors. FINDINGS: A total of 28 studies were included, of which 25 studies applied exercise interventions, two studies focused on surgical interventions, and one on non-invasive brain stimulation. The number of high-quality trials was limited (N=6; score Downs and Black scale >/=19). Propulsion measures were the primary outcome in eight studies. In general, mixed results were reported with 14 interventions yielding improvements in propulsion and ankle kinetics. In contrast, gains in walking velocity were observed in the vast majority of studies (N=20 out of 23). INTERPRETATION: Interventions that yielded gains in propulsion appeared to have in common that they challenged and/or enabled the utilization of latent propulsive capacity of the paretic leg during walking. Walking speed generally increased, regardless of the observed change in propulsion, suggesting the use of compensatory mechanisms. Findings should, however, be interpreted with some caution, as the evidence base for this emerging focus of rehabilitation is limited.

Contains fulltext : 250632.pdf (Publisher’s version ) (Open Access) Background: Benefits of peroneal functional electrical stimulation in people with post-stroke drop foot may particularly emerge in environments that require continual gait adaptation. Such adaption is known to increase the attentional demands of gait. Research questions: Is performance of a target stepping task more accurate and less attention demanding with electrical stimulation ON compared to OFF in people with post-stroke drop foot? Methods: Thirteen people with an implanted electrical stimulation system participated in this observational study. Participants performed a walking task with irregularly spaced targets on a self-paced treadmill, both as a single task and combined with an auditory Stroop task. Participants performed each task with electrical stimulation ON and OFF. In the OFF condition participants were allowed to use their own ankle-foot orthosis. The effects of Device (ON, OFF) and interaction of Device*Task (single, dual) on stepping performance in mediolateral and anteroposterior direction were tested based on the total error of foot placement relative to the targets, using repeated measurements ANOVA. Differences between electrical stimulation ON and OFF on auditory Stroop task accuracy were assessed using a non-parametric Wilcoxon signed-rank test. Non-parametric correlations were calculated to associate changes in stepping performance with paretic leg motor function (Fugl-Meyer Assessment – leg score). Results: Data of 12 participants were used for analysis. Mediolateral total error was smaller with peroneal functional electrical stimulation ON compared to OFF (Δ = 1.0 cm, p = 0.011). In the anteroposterior direction, no significant effects of Device were found. There were no significant interaction effects of Device*Task in either direction. Changes in total error (ON vs OFF) were not significantly associated with leg motor function. Stroop task accuracy was not statistically different between ON and OFF. Significance: Implanted electrical stimulation may have benefits with regard to mediolateral accuracy of a continual target stepping task, although the effect size is relatively small. This benefit seems to be independent of the performance of a concurrent attention-demanding task and may reflect better gait stability in the mediolateral direction, which is known to be a problem in people with stroke. 9 p.

Contains fulltext : 248675.pdf (Publisher’s version ) (Open Access) BACKGROUND: Children with Developmental Coordination Disorder (DCD) have motor coordination deficits leading to difficulties in sports and play that require adaptations of the walking pattern. Children with DCD indeed demonstrate poorer walking adaptability (WA) compared to typically developing children, but it remains elusive whether WA can be improved by training. RESEARCH QUESTION: Does augmented-reality treadmill training lead to improvements in WA in children with DCD? METHODS: Seventeen children with DCD were included in this proof-of-concept intervention study. They received a six-session training on the C-mill, a treadmill on which gait adjustments can be evoked by projected visual context. The effect of the training was evaluated before (M1), directly after training (M2) and after 6 months follow-up (M3) using the WAL-K (single and double run) and WA-tasks on the C-mill (as a single and with concurrent visuo-motor and cognitive task). In addition, parents completed a questionnaire on their perception of the training. Linear Mixed Model analyses were performed to assess the differences in WAL-K scores and success rates on the WA-tasks between M1-M2 and M1-M3. RESULTS: Children significantly improved on the WAL-K double run and on all three WA-tasks between M1-M2 and M1-M3. Children did not improve on the WAL-K single run. Parents found the training useful and fun for their child and indicated that their child fell less frequently. SIGNIFICANCE: The results show that C-mill training had positive and task-specific effects on WA in children with DCD, which effects generalized to an overground task and were retained at 6 months follow-up. This may help children with DCD to better participate in daily activities. Future research should include a control group to examine the effectiveness of the training program compared to receiving no training and may also examine the effect of the training on participation in daily life.

Contains fulltext : 251388.pdf (Publisher’s version ) (Closed access) PURPOSE: Walking adaptability is essential for children to participate in daily life, but no objective measurement tools exist. We determined psychometric properties of the Walking Adaptability Ladder test for Kids (WAL-K) in 6-12 year old children. MATERIALS AND METHODS: In total, 122 typically developing (TD) children and 26 children with Developmental Coordination Disorder (DCD) completed the single and double run conditions of the WAL-K. Intra-rater, inter-rater and test-retest reliability were determined by ICCs and Smallest Detectable Change (SDC) in 53 TD children. Construct validity was determined by comparing WAL-K scores between 69 TD and all DCD children and correlating these scores with age and MABC-2 scores. RESULTS: ICCs for reliability varied between 0.76 and 0.99. Compared to the first test performance, WAL-K scores were lower (i.e., better) at retest. SDCs for test-retest reliability varied between 20.8 and 26.1% of the mean scores. WAL-K scores were significantly higher (i.e., worse) in DCD children compared to TD children (p

Background Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has shown promise for rehabilitation after stroke. Ipsilesional anodal tDCS (a-tDCS) over the motor cortex increases corticospinal excitability, while contralesional cathodal tDCS (c-tDCS) restores interhemispheric balance, both resulting in offline improved reaction times of delayed voluntary upper-extremity movements. We aimed to investigate whether tDCS would also have a beneficial effect on delayed leg motor responses after stroke. In addition, we identified whether variability in tDCS effects was associated with the level of leg motor function. Methods In a cross-over design, 13 people with chronic stroke completed three 15-min sessions of anodal, cathodal and sham stimulation over the primary motor cortex on separate days in an order balanced across participants. Directly after stimulation, participants performed a comprehensive set of lower-extremity tasks involving the paretic tibialis anterior (TA): voluntary ankle-dorsiflexion, gait initiation, and backward balance perturbation. For all tasks, TA onset latencies were determined. In addition, leg motor function was determined by the Fugl-Meyer Assessment – leg score (FMA-L). Repeated measures ANOVA was used to reveal tDCS effects on reaction times. Pearson correlation coefficients were used to establish the relation between tDCS effects and leg motor function. Results For all tasks, TA reaction times did not differ across tDCS sessions. For gait initiation and backward balance perturbation, differences between sham and active stimulation (a-tDCS or c-tDCS) did not correlate with leg motor function. Yet, for ankle dorsiflexion, individual reaction time differences between c-tDCS and sham were strongly associated with FMA-L, with more severely impaired patients exhibiting slower paretic reaction times following c-tDCS. Conclusion We found no evidence for offline tDCS-induced benefits. Interestingly, we found that c-tDCS may have unfavorable effects on voluntary control of the paretic leg in severely impaired patients with chronic stroke. This finding points at potential vicarious control from the unaffected hemisphere to the paretic leg. The absence of tDCS-induced effects on gait and balance, two functionally relevant tasks, shows that such motor behavior is inadequately stimulated by currently used tDCS applications. Trial registration The study is registered in the Netherlands Trial Register (NL5684; April 13th, 2016).

Contains fulltext : 248588.pdf (Publisher’s version ) (Open Access) OBJECTIVE: Gait impairment in persons with Parkinson disease is common and debilitating. Compensation strategies (eg, external cues) are an essential part of rehabilitation, but their underlying mechanisms remain unclear. Using electroencephalography (EEG), we explored the cortical correlates of 3 categories of strategies: external cueing, internal cueing, and action observation. METHODS: Eighteen participants with Parkinson disease and gait impairment were included. We recorded 126-channel EEG during both stance and gait on a treadmill under 4 conditions: (1) uncued, (2) external cueing (listening to a metronome), (3) internal cueing (silent rhythmic counting), and (4) action observation (observing another person walking). To control for the effects of sensory processing of the cues, we computed relative power changes as the difference in power spectral density between walking and standing for each condition. RESULTS: Relative to uncued gait, the use of all 3 compensation strategies induced a decrease of beta band activity in sensorimotor areas, indicative of increased cortical activation. Parieto-occipital alpha band activity decreased with external and internal cueing, and increased with action observation. Only internal cueing induced a change in frontal cortical activation, showing a decrease of beta band activity compared to uncued gait. INTERPRETATION: The application of compensation strategies resulted in changed cortical activity compared to uncued gait, which could not be solely attributed to sensory processing of the cueing modality. Our findings suggest there are multiple routes to control gait, and different compensation strategies seem to rely on different cortical mechanisms to achieve enhanced central motor activation in persons with Parkinson disease. ANN NEUROL 2022;91:329-341.

Objective To identify the role of hyperexcitable short-latency stretch reflexes (SLRs) on balance control in people with hereditary spastic paraplegia (PwHSP). Methods Sixteen PwHSP with triceps surae spasticity and 9 healthy control subjects were subjected to toes-up support-surface perturbations. EMG data were recorded from gastrocnemius, soleus and tibialis anterior. Furthermore, center-of-mass trajectories were recorded. Results PwHSP were less able to withstand the perturbations. Triceps surae SLRs (40–80 ms post perturbation) in PwHSP were increased compared to healthy subjects. Furthermore, a sustained triceps surae EMG activity at 220–320 ms post perturbation was observed in PwHSP, whereas control subjects demonstrated suppression of triceps surae activity. Center of mass trajectories started to diverge between PwHSP and controls only after ∼500 ms, with greater excursions being observed in the PwHSP. Conclusions The present results confirm that balance control is impaired in PwHSP. However, the late instant of center of mass divergence argues against a direct, causative role of hyperexcitable SLRs in the triceps surae. Significance We postulate that enhanced short-latency stretch reflexes of the triceps surae do not underlie poor balance control in PwHSP. Instead, we suggest the lack of suppression of later triceps surae activity to be the main cause.

Purpose: Sedentary behavior is common in people with stroke and has devastating impact on their health. Quantifying it is important to provide people with stroke with adequate physical behavior rec...

Background After stroke, some individuals have latent, propulsive capacity of the paretic leg, that can be elicited during task-specific gait training. The aim of this proof-of-concept study was to investigate the effect of five-week robotic gait training for improving propulsion symmetry by increasing paretic propulsion in chronic stroke survivors. Methods Twenty-nine individuals with chronic stroke and impaired paretic propulsion (≥ 8% difference in paretic vs. non-paretic propulsive impulse) were enrolled. Participants received ten 60-min sessions of individual robotic gait training targeting paretic propulsion (five weeks, twice a week), complemented with home exercises (15 min/day) focusing on increasing strength and practicing learned strategies in daily life. Propulsion measures, gait kinematics and kinetics, self-selected gait speed, performance of functional gait tasks, and daily-life mobility and physical activity were assessed five weeks (T0) and one week (T1) before the start of intervention, and one week (T2) and five weeks (T3) after the intervention period. Results Between T0 and T1, no significant differences in outcomes were observed, except for a marginal increase in gait speed (+ 2.9%). Following the intervention, propulsion symmetry (+ 7.9%) and paretic propulsive impulse had significantly improved (+ 8.1%), whereas non-paretic propulsive impulse remained unchanged. Larger gains in propulsion symmetry were associated with more asymmetrical propulsion at T0. In addition, following the intervention significantly greater paretic trailing limb angles (+ 6.6%) and ankle plantarflexion moments (+ 7.1%) were observed. Furthermore, gait speed (+ 7.2%), 6-Minute Walk Test (+ 6.4%), Functional Gait Assessment (+ 6.5%), and daily-life walking intensity (+ 6.9%) had increased following the intervention. At five-week follow-up (T3), gains in all outcomes were retained, and gait speed had further increased (+ 3.6%). Conclusions The post-intervention gain in paretic propulsion did not only translate into improved propulsion symmetry and gait speed, but also pertained to performance of functional gait tasks and daily-life walking activity levels. These findings suggest that well-selected chronic stroke survivors may benefit from task-specific targeted training to utilize the residual propulsive capacity of the paretic leg. Future research is recommended to establish simple baseline measures for identification of individuals who may benefit from such training and confirm benefits of the used training concepts in a randomized controlled trial. Trial registration: Registry number ClinicalTrials.gov (www.clinicaltrials.gov): NCT04650802, retrospectively registered 3 December 2020.

Contains fulltext : 287121.pdf (Publisher’s version ) (Open Access) PURPOSE: Elucidating the complex interactions between physical activity (PA), a multidimensional concept, and physical capacity (PC) may reveal ways to improve rehabilitation interventions. This cross-sectional study aimed to explore which PA dimensions are related to PC in people after minor stroke. MATERIALS AND METHODS: Community dwelling individuals >6 months after minor stroke were evaluated with a 10-Meter-Walking-Test (10MWT), Timed-Up & Go, and the Mini Balance Evaluation System Test. The following PA outcomes were measured with an Activ8 accelerometer: counts per minute during walking (CPM(walking); a measure of intensity), number of active bouts (frequency), mean length of active bouts (distribution), and percentage of waking hours in upright positions (duration). Multivariable linear regression models, adjusted for age, sex and BMI, were used to assess the relationships between PC and PA outcomes. RESULTS: Sixty-nine participants [62.2 ± 9.8 years, 61% male, 20 months post onset (IQR 13.0-53.5)] were included in the analysis. CPM(walking) was significantly associated to PC in the 10MWT (std. ß = 0.409, p = 0.002), whereas other associations between PA and PC were not significant. CONCLUSIONS: The PA dimension intensity of walking is significantly associated with PC, and appears to be an important tool for future interventions in rehabilitation after minor stroke.Implications for rehabilitationIt is recommended to express physical activity after minor stroke in multiple dimensions such as intensity, frequency, duration and distribution.In particular, intensity of physical activity measured with accelerometer counts is most closely related to physical capacity.The findings of this study underline the importance of being physically active beyond a certain intensity.In future development of interventions and guidelines that aim to promote daily physical activity, intensity should be taken into account.

Changes in human balance control can objectively be assessed using system identification techniques in combination with support surface translations. However, large, expensive and complex motion platforms are required, which are not suitable for the clinic. A treadmill could be a simple alternative to apply support surface translations. In this paper we first validated the estimation of the joint stiffness of an inverted pendulum using system identification methods in combination with support surface translations, by comparison with the joint stiffness calculated using a linear regression method. Second, we used the system identification method to investigate the effect of horizontal ground reaction forces on the estimation of the ankle torque and the dynamics of the stabilizing mechanism of 12 healthy participants. Ankle torque and resulting frequency response functions, which describes the dynamics of the stabilizing mechanism, were calculated by both including and excluding horizontal ground reaction forces. Results showed that the joint stiffness of an inverted pendulum estimated using system identification is comparable to the joint stiffness estimated by a regression method. Secondly, within the induced body sway angles, the ankle torque and frequency response function of the joint dynamics calculated by both including and excluding horizontal ground reaction forces are similar. Therefore, the horizontal ground reaction forces play a minor role in calculating the ankle torque and frequency response function of the dynamics of the stabilizing mechanism and can thus be omitted.

Contains fulltext : 229732.pdf (Publisher’s version ) (Closed access)

Contains fulltext : 244790.pdf (Publisher’s version ) (Open Access) INTRODUCTION: The StartReact (SR) effect is the accelerated release of a prepared movement when a startling acoustic stimulus is presented at the time of the imperative stimulus (IS). SR paradigms have been used to study defective control of balance and gait in people with neurological conditions, but differences in emotional state (e.g. fear of failure) may be a potential confounder when comparing patients to healthy subjects. In this study, we aimed to gain insight in the effects of postural threat on the SR effect by manipulating surface height during a postural (lateral step) task and a non-postural (wrist extension) task. METHODS: Eleven healthy participants performed a lateral step perpendicular to the platform edge, and 19 participants performed a wrist extension task while standing at the platform edge. Participants initiated the movement as fast as possible in response to an IS that varied in intensity across trials (80 dB to 121 dB) at both low and high platform height (3.2 m). For the lateral step task, we determined anticipatory postural adjustments (APA) and step onset latencies. For the wrist extension task, muscle onset latencies were determined. We used Wilcoxon signed-rank tests on the relative onset latencies between both heights, to identify whether the effect of height was different for IS intensities between 103 and 118 dB compared to 121 dB. RESULTS: For both tasks, onset latencies were significantly shortened at 121 dB compared to 80 dB, regardless of height. In the lateral step task, the effect of height was larger at 112 dB compared to 121 dB. The absolute onset latencies showed that at 112 dB there was no such stimulus intensity effect at high as seen at low surface height. In the wrist extension task, no differential effects of height could be demonstrated across IS intensities. CONCLUSIONS: Postural threat had a significant, yet modest effect on shortening of RTs induced by a loud IS, with a mere 3 dB difference between standing on high versus low surface height. Interestingly, this effect of height was specific to the postural (i.e. lateral stepping) task, as no such differences could be demonstrated in the wrist extension task. This presumably reflects more cautious execution of the lateral step task when standing on height. The present findings suggest that applying stimuli of sufficiently high intensity (≥115 dB) appears to neutralize potential differences in emotional state when studying SR effects.

Contains fulltext : 220586.pdf (Publisher’s version ) (Open Access) The need to perform multiple tasks more or less simultaneously is a common occurrence during walking in daily life. Performing tasks simultaneously typically impacts task performance negatively. Hypothetically, such dual-task costs may be explained by a lowered state of preparation due to competition for attentional resources, or alternatively, by a 'bottleneck' in response initiation. Here, we investigated both hypotheses by comparing 'StartReact' effects during a manual squeezing task under single-task (when seated) and dual-task (when walking) conditions. StartReact is the acceleration of reaction times by a startling stimulation (a startling acoustic stimulus was applied in 25% of trials), attributed to the startling stimulus directly releasing a pre-prepared movement. If dual-task costs are due to a lowered state of preparation, we expected trials both with and without an accompanying startling stimulus to be delayed compared to the single-task condition, whereas we expected only trials without a startling stimulus to be delayed if a bottleneck in response initiation would underlie dual-task costs. Reaction times of the manual squeezing task in the flexor digitorum superficialis and extensor carpi radialis muscle were significantly delayed (approx. 20 ms) when walking compared to the seated position. A startling acoustic stimulus significantly decreased reaction times of the squeezing task (approx. 60 ms) both when walking and sitting. Dual-task costs during walking are, therefore, likely the result of lowered task preparation because of competition for attentional resources.

Postural responses that effectively recover balance following unexpected postural changes need to be tailored to the characteristics of the postural change. We hypothesized that cortical dynamics involved in top-down regulation of postural responses carry information about directional postural changes (i.e., sway) imposed by sudden perturbations to standing balance (i.e., support surface translations). To test our hypothesis, we evaluated the single-trial classification of perturbation-induced directional changes in postural stability from high-density EEG. We analyzed EEG recordings from six young able-bodied individuals and three older individuals with chronic hemiparetic stroke, which were acquired while individuals reacted to low-intensity balance perturbations. Using common spatial patterns for feature extraction and linear discriminant analysis or support vector machines for classification, we achieved classification accuracies above random level (p < 0.05; cross-validated) for the classification of four different sway directions (one vs. the rest scheme). Screening of spectral features (3-50 Hz) revealed that the highest classification performance occurred when low-frequency (3-10 Hz) spectral features were used. Strikingly, the participant-specific classification results were qualitatively similar between young able-bodied individuals and older individuals with chronic hemiparetic stroke. Our findings demonstrate that low-frequency spectral components, corresponding to the cortical theta rhythm, carry direction-specific information about changes in postural stability. Our work presents a new perspective on the cortical representation of postural stability and the possible role of the theta rhythm in the modulation of (directional) reactive balance responses. Importantly, our work provides preliminary evidence that the cortical encoding of direction-specific changes in postural stability is present in chronic hemiparetic stroke.

Background Hereditary spastic paraplegia (HSP) is a group of inherited disorders characterized by progressive spastic paresis of the lower limbs. Treatment is often focused on reducing spasticity and its physical consequences. To better address individual patients’ needs, we investigated a broad range of experienced complaints, activity limitations, and loss of motor capacities in pure HSP. In addition, we aimed to identify patient characteristics that are associated with increased fall risk and/or reduced walking capacity. Methods We developed and distributed an HSP-specific online questionnaire in the Netherlands. A total of 109 out of 166 questionnaires returned by participants with pure HSP were analyzed. Results Participants experienced the greatest burden from muscle stiffness and limited standing and walking activities, while 72% reported leg and/or back pain. Thirty-five and 46% reported to use walking aids (e.g. crutches) indoors and outdoors, respectively; 57% reported a fall incidence of at least twice a year (‘fallers’); in 51% a fall had led to an injury at least once; and 73% reported fear of falling. Duration of spasticity and incapacity to rise from the floor were positively associated with being a ‘faller’, whereas non-neurological comorbidity and wheelchair use were negatively associated. Higher age, experienced gait problems, not being able to stand for 10 min, and incapacity to open a heavy door showed a negative association with being a ‘walker without aids’ (> 500 m). Conclusions Our results emphasize the large impact of spastic paraparesis on the lives of people with pure HSP and contribute to a better understanding of possible targets for rehabilitation.

Background Falls are one of the most common complications after stroke, with a reported incidence ranging between 7% in the first week and 73% in the first year post stroke. This is an updated version of the original Cochrane Review published in 2013. Objectives To evaluate the effectiveness of interventions aimed at preventing falls in people after stroke. Our primary objective was to determine the effect of interventions on the rate of falls (number of falls per person-year) and the number of fallers. Our secondary objectives were to determine the effects of interventions aimed at preventing falls on 1) the number of fall-related fractures; 2) the number of fall-related hospital admissions; 3) near-fall events; 4) economic evaluation; 5) quality of life; and 6) adverse effects of the interventions. Search methods We searched the trials registers of the Cochrane Stroke Group (September 2018) and the Cochrane Bone, Joint and Muscle Trauma Group (October 2018); the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 9) in the Cochrane Library; MEDLINE (1950 to September 2018); Embase (1980 to September 2018); CINAHL (1982 to September 2018); PsycINFO (1806 to August 2018); AMED (1985 to December 2017); and PEDro (September 2018). We also searched trials registers and checked reference lists. Selection criteria Randomised controlled trials of interventions where the primary or secondary aim was to prevent falls in people after stroke. Data collection and analysis Two review authors (SD and WS) independently selected studies for inclusion, assessed trial quality and risk of bias, and extracted data. We resolved disagreements through discussion, and contacted study authors for additional information where required. We used a rate ratio and 95% confidence interval (CI) to compare the rate of falls (e.g. falls per person-year) between intervention and control groups. For risk of falling we used a risk ratio and 95% CI based on the number of people falling (fallers) in each group. We pooled results where appropriate and applied GRADE to assess the quality of the evidence. Main results We included 14 studies (of which six have been published since the first version of this review in 2013), with a total of 1358 participants. We found studies that investigated exercises, predischarge home visits for hospitalised patients, the provision of single lens distance vision glasses instead of multifocal glasses, a servo-assistive rollator and non-invasive brain stimulation for preventing falls. Exercise compared to control for preventing falls in people after stroke The pooled result of eight studies showed that exercise may reduce the rate of falls but we are uncertain about this result (rate ratio 0.72, 95% CI 0.54 to 0.94, 765 participants, low-quality evidence). Sensitivity analysis for single exercise interventions, omitting studies using multiple/multifactorial interventions, also found that exercise may reduce the rate of falls (rate ratio 0.66, 95% CI 0.50 to 0.87, 626 participants). Sensitivity analysis for the effect in the chronic phase post stroke resulted in little or no difference in rate of falls (rate ratio 0.58, 95% CI 0.31 to 1.12, 205 participants). A sensitivity analysis including only studies with low risk of bias found little or no difference in rate of falls (rate ratio 0.88, 95% CI 0.65 to 1.20, 462 participants). Methodological limitations mean that we have very low confidence in the results of these sensitivity analyses. For the outcome of number of fallers, we are very uncertain of the effect of exercises compared to the control condition, based on the pooled result of 10 studies (risk ratio 1.03, 95% CI 0.90 to 1.19, 969 participants, very low quality evidence). The same sensitivity analyses as described above gives us very low certainty that there are little or no differences in number of fallers (single interventions: risk ratio 1.09, 95% CI 0.93 to 1.28, 796 participants; chronic phase post stroke: risk ratio 0.94, 95% CI 0.73 to 1.22, 375 participants; low risk of bias studies: risk ratio 0.96, 95% CI 0.77 to 1.21, 462 participants). Other interventions for preventing falls in people after stroke We are very uncertain whether interventions other than exercise reduce the rate of falls or number of fallers. We identified very low certainty evidence when investigating the effect of predischarge home visits (rate ratio 0.85, 95% CI 0.43 to 1.69; risk ratio 1.48, 95% CI 0.71 to 3.09; 85 participants), provision of single lens distance glasses to regular wearers of multifocal glasses (rate ratio 1.08, 95% CI 0.52 to 2.25; risk ratio 0.74, 95% CI 0.47 to 1.18; 46 participants) and a servo-assistive rollator (rate ratio 0.44, 95% CI 0.16 to 1.21; risk ratio 0.44, 95% CI 0.16 to 1.22; 42 participants). Finally, transcranial direct current stimulation (tDCS) was used in one study to examine the effect on falls post stroke. We have low certainty that active tDCS may reduce the number of fallers compared to sham tDCS (risk ratio 0.30, 95% CI 0.14 to 0.63; 60 participants). Authors' conclusions At present there exists very little evidence about interventions other than exercises to reduce falling post stroke. Low to very low quality evidence exists that this population benefits from exercises to prevent falls, but not to reduce number of fallers. Fall research does not in general or consistently follow methodological gold standards, especially with regard to fall definition and time post stroke. More well-reported, adequately-powered research should further establish the value of exercises in reducing falling, in particular per phase, post stroke. ispartof: Cochrane Database Of Systematic Reviews vol:10 issue:10 ispartof: location:England status: published

Corticospinal lesions cause impairments in voluntary motor control. Recent findings suggest that some degree of voluntary control may be taken over by a compensatory pathway involving the reticulospinal tract. In humans, evidence for this notion mainly comes from StartReact studies. StartReact is the acceleration of reaction times by a startling acoustic stimulus (SAS) simultaneously presented with the imperative stimulus. As previous StartReact studies mainly focused on isolated single-joint movements, the question remains whether the reticulospinal tract can also be utilized for controlling whole-body movements. To investigate reticulospinal control, we applied the StartReact paradigm during gait initiation in 12 healthy controls and 12 patients with ‘pure’ hereditary spastic paraplegia (HSP; i.e., retrograde axonal degeneration of corticospinal tract). Participants performed three consecutive steps in response to an imperative visual stimulus. In 25% of 16 trials a SAS was applied. We determined reaction times of muscle (de)activation, anticipatory postural adjustments (APA) and steps. Without SAS, we observed an overall delay in HSP patients compared to controls. Administration of the SAS accelerated tibialis anterior and rectus femoris onsets in both groups, but more so in HSP patients, resulting in (near-)normal latencies. Soleus offsets were accelerated in controls, but not in HSP patients. The SAS also accelerated APA and step reaction times in both groups, yet these did not normalize in the HSP patients. The reticulospinal tract is able to play a compensatory role in voluntary control of whole-body movements, but seems to lack the capacity to inhibit task-inappropriate muscle activity in patients with corticospinal lesions.

Item does not contain fulltext BACKGROUND: Finding ways to quantify resilience as a predictor of a person's resistance to health challenges is important to improve healthy aging. This study investigated a unique sample of high-functioning older persons in whom traditional markers of frailty and functional decline are largely absent. Translating complex dynamical systems theory to humans, dynamical indicators of resilience in postural balance time series may sensitively discriminate levels of resilience. METHODS: This study investigated 240 high-functioning older adults (mean age 83.9 +/- 2.9 years, 59% male), of whom 94 hikers of the Nijmegen Four Days Marches. Participants stood upright on a force plate with eyes open and feet at shoulder width for 30 seconds. Center of pressure data were analyzed for dynamical indicators of resilience (variance and temporal autocorrelation). After 1 year, participants were compared on a modified Successful Aging Index. RESULTS: Mediolateral center of pressure displacement of hikers exhibited significantly lower variance (2.2 vs 2.8 mm, p < .001) and temporal autocorrelation (0.59 vs 0.65, p = .006), compared with nonhikers. Multivariably adjusted, mediolateral variance was significantly associated with successful aging at baseline (b = -1.43, p = .003) and 1-year follow-up (b = -1.94, p < .001), while mediolateral temporal autocorrelation was not. CONCLUSIONS: Two dynamical indicators of resilience (variance and temporal autocorrelation) calculated on time series of mediolateral center of pressure displacement differed between hikers and nonhikers within a group of high-functioning older adults. In the whole group, variance was independently associated with successful aging at baseline and after 1 year. Our results support the hypothesis that resilience of older persons may be estimated from time series of natural fluctuations of bodily functions.

Defective muscle coordination for balance recovery may contribute to stroke survivors’ propensity for falling. Thus, we investigated deficits in muscle coordination for postural control and their association to body sway following balance perturbations in people with stroke. Specifically, we compared the automatic postural responses of 8 leg and trunk muscles recorded bilaterally in unimpaired individuals and those with mild to moderate impairments after unilateral supratentorial lesions (>6 months). These responses were elicited by unexpected floor translations in 12 directions. We extracted motor modules (ie, muscle synergies) for each leg using nonnegative matrix factorization. We also determined the magnitude of perturbation-induced body sway using a single-link inverted pendulum model. Whereas the number of motor modules for balance was not affected by stroke, those formed by muscles with long latency responses were replaced by atypically structured paretic motor modules (atypical muscle groupings), which hints at direct cerebral involvement in long-latency feedback responses. Other paretic motor modules had intact structure but were poorly recruited, which is indicative of indirect cerebral control of balance. Importantly, these paretic deficits were strongly associated with postural instability in the preferred activation direction of the impaired motor modules. Finally, these deficiencies were heterogeneously distributed across stroke survivors with lesions in distinct locations, suggesting that different cerebral substrates may contribute to balance control. In conclusion, muscle coordination deficits in the paretic limb of stroke survivors result in direction-specific postural instability, which highlights the importance of targeted interventions to address patient-specific balance impairments.

ObjectiveTo assess, in a cross-sectional study, the feasibility and immediate efficacy of laser shoes, a new ambulatory visual cueing device with practical applicability for use in daily life, on freezing of gait (FOG) and gait measures in Parkinson disease (PD).MethodsWe tested 21 patients with PD and FOG, both “off” and “on” medication. In a controlled gait laboratory, we measured the number of FOG episodes and the percent time frozen occurring during a standardized walking protocol that included FOG provoking circumstances. Participants performed 10 trials with and 10 trials without cueing. FOG was assessed using offline video analysis by an independent rater. Gait measures were recorded in between FOG episodes with the use of accelerometry.ResultsCueing using laser shoes was associated with a significant reduction in the number of FOG episodes, both “off” (45.9%) and “on” (37.7%) medication. Moreover, laser shoes significantly reduced the percent time frozen by 56.5% (95% confidence interval [CI] 32.5–85.8; p = 0.004) when “off” medication. The reduction while “on” medication was slightly smaller (51.4%, 95% CI −41.8 to 91.5; p = 0.075). These effects were paralleled by patients' positive subjective experience on laser shoes' efficacy. There were no clinically meaningful changes in the gait measures.ConclusionsThese findings demonstrate the immediate efficacy of laser shoes in a controlled gait laboratory, and offer a promising intervention with potential to deliver in-home cueing for patients with FOG.Classification of evidenceThis study provides Class III evidence that for patients with PD, laser shoes significantly reduce FOG severity (both number and duration of FOG episodes).