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Purpose: Hamstring spasticity is prevalent following neurological injury. The standardized assessment involves passive knee extension, in a position of 90° hip flexion. This creates passive insufficiency of the muscle and lacks ecological validity for walking, whereby the hip typically flexes to a maximum of 40° during swing phase, while the knee extends. This study compared assessment outcomes when completed in 40° and 90° hip flexion. Methods: The Modified Ashworth Scale and Modified Tardieu Scale, were performed on 35 adults with a neurological condition. Each participant was assessed by three assessors, resulting in 105 trials at 40° and 90°. Results: There was a significant increase in the proportion of trials rated as spastic using the Modified Ashworth Scale (p=.012, phi=.27), and Modified Tardieu Scale (p<.001, phi=.36), and the severity of spasticity using the Modified Ashworth Scale (p<.001, effect size (ES)=.50), and Modified Tardieu Scale (p<.001 ES=.47), at 90° hip flexion. The angle of reaction occurred 32° earlier at 90° hip flexion (p<.001, ES = 1.61). Conclusions: Completing hamstring assessments in 40° hip flexion may reduce the passive insufficiency and improve the ecological validity of assessment, for walking. This may assist in the selection of patients requiring intervention, when their goal relates to walking. IMPLICATIONS FOR REHABILITATION: The position of the hip joint impacts hamstring spasticity assessment outcomes, regardless of the clinical outcome measure chosen The application of bedside assessment methods in a manner reflective of functional tasks may assist in selecting individuals who require active spasticity intervention As per international guidelines, the use of validated outcome measures in a goal directed and patient centered manner is required to maximize patient care [ABSTRACT FROM AUTHOR]

To determine, in patients undergoing total knee arthroplasty (TKA), whether increasing context specificity of selected items of the shortened version of the Western Ontario and McMaster Universities Osteoarthritis Index function (WOMAC-F) scale (ShortMAC-F) (1) enhanced the convergent validity of the ShortMAC-F with performance-based mobility measures (ii) affected mean scale score, structural validity, reliability, and interpretability. Secondary analysis of randomized clinical trial data. A tertiary teaching hospital. Patients undergoing TKA (N=114). Not applicable. The ShortMAC-F was modified by specifying the "ascending stairs" and "rising from sitting" items to enquire about difficulty in performing the tasks without reliance on compensatory strategies, whereas the modified "level walking" item enquired about difficulty in walking 400 m. Before and 12 weeks after TKA, patients completed the WOMAC-F questionnaire, modified ShortMAC-F questionnaire, knee pain scale questionnaire, sit-to-stand test, fast gait speed test, and stair climb test. Interpretability was evaluated by calculating anchor-based substantial clinical benefit estimates. The modified ShortMAC-F correlated significantly more strongly than ShortMAC-F or WOMAC-F with pooled performance measures (differences in correlation values, 0.12-0.14). Increasing item context specificity of the ShortMAC-F did not influence its psychometric properties of unidimensionality (comparative fit and Tucker–Lewis indices, >0.95; root mean square error of approximation, 0.05-0.08), reliability (Cronbach's α, 0.75-0.83), correlation with pain intensity (correlation values, 0.48-0.52), and substantial clinical benefit estimates (16 percentage points); however, it resulted in lower mean score (4.5-4.8 points lower). The modified ShortMAC-F showed sufficient measurement properties for clinical application, and it seemed more adept than WOMAC-F at correlating with performance-based measures in TKA. [ABSTRACT FROM AUTHOR]

Objective: To determine if the intention to perform an exercise at speed leads to beneficial alterations in kinematic and kinetic components of the movement in people with post-stroke hemiplegia. Design: Comparative study. Setting: Subacute metropolitan rehabilitation hospital. Participants: Convenience sample of patients admitted as an inpatient or outpatient with a diagnosis of stroke with lower limb weakness, functional ambulation category score ≥3, and ability to walk ≥14metres. Methods: Participants performed a single leg squat exercise on their paretic and nonparetic legs on a leg sled under three conditions: 1) self-selected speed (SS), 2) fast speed (FS), 3) jump squat (JS). Measures of displacement, flight time, peak concentric velocity, and muscle excitation (via electromyography) were compared between legs and conditions. Results: Eleven participants (age: 56 ± 17 years; median time since stroke onset: 3.3 [IQR 3,41] months) were tested. All participants achieved a jump during the JS, as measured by displacement and flight time respectively, on both their paretic (0.25 ± 0.16 m and 0.42 ± 0.18 s) and nonparetic (0.49 ± 0.36 m and 0.73 ± 0.28 s) legs; however it was significantly lower on the non-paretic leg (p < 0.05). Peak concentric velocity increased concordantly with intended movement speed (JS-FS paretic: 0.96 m/s, non-paretic: 0.54 m/s; FS-SS paretic 0.69 m/s, nonparetic 0.38 m/s; JS-SS paretic 1.66 m/s, non-paretic 0.92 m/s). Similarly, muscle excitation increased significantly (p < 0.05) with faster speed for the paretic and nonparetic vastus lateralis. For gastrocnemius, the only significant difference was an increase during nonparetic JS vs. SS and FS. Conclusions: Speed affects the kinematic and kinetic components of the movement. Performing exercises ballistically may improve training outcomes for people post-stroke. [ABSTRACT FROM AUTHOR]

Context: Aquatic plyometric training may provide benefits due to reduced joint loading compared with land plyometric training; however, the reduced loading may also limit performance gains. Objective: To systematically review the effect of aquatic plyometric training on strength, performance outcomes, soreness, and adverse events in healthy individuals. Evidence acquisition: Five databases were searched from inception to June 2020. Quality assessment and data extraction were independently completed by 2 investigators. When similar outcome measures were used, standardized mean differences were calculated. Evidence synthesis: A total of 19 randomized controlled trials with 633 participants (mean age, range 14-30 y) were included. Aquatic plyometric training was most commonly performed in waist to chest deep water (12/19 studies), 2 to 3 times per week for 6 to 12 weeks (18/19 studies), with final program foot contacts ranging from 120 to 550. Meta-analyses were not completed due to the clinical and statistical heterogeneity between studies. Compared with land plyometric training, aquatic plyometric training exercises and dosage were replicated (15/16 studies) and showed typically similar performance gains (3/4 knee extensor strength measures, 2/4 leg extensor strength measures, 3/4 knee flexor strength measures, 7/10 vertical jump measures, 3/3 sprint measures). In total, 2 of 3 studies monitoring muscle soreness reported significantly less soreness following training in water compared with on land. Compared with no active training (no exercise control group or passive stretching), most effect sizes demonstrated a mean improvement favoring aquatic plyometric training (23/32 measures). However, these were not significant for the majority of studies measuring isokinetic knee strength, vertical jump, and sprinting. The effect sizes for both studies assessing leg press strength indicated that aquatic plyometric training is significantly more effective than no training. Conclusion: Aquatic plyometric training appears similarly effective to land plyometric exercise for improving strength, jumping, and sprinting and may be indicated when joint impact loading needs to be minimized. However, the low quality of studies limits the strength of the conclusions. [ABSTRACT FROM AUTHOR]

In people recovering from traumatic brain injury, is a 3-month ballistic resistance training program targeting three lower limb muscle groups more effective than non-ballistic exercise rehabilitation for improving mobility, strength and balance? Does improved mobility translate to better health-related quality of life? A prospective, multicentre, randomised trial with concealed allocation, intention-to-treat analysis and blinded measurement. A total of 144 people with a neurological movement disorder affecting mobility as a result of traumatic brain injury. For 3 months, the experimental group had three 60-minute sessions of non-ballistic exercise rehabilitation per week replaced by ballistic resistance training. The control group had non-ballistic exercise rehabilitation of equivalent time. The non-ballistic exercise rehabilitation consisted of balance exercises, lower limb stretching, conventional strengthening exercises, cardiovascular fitness training and gait training. The primary outcome was mobility measured using the High-Level Mobility Assessment Tool (HiMAT). Secondary outcomes were walking speed, strength, balance and quality of life. They were measured at baseline (0 months), after completion of the 3-month intervention (3 months) and 3 months after cessation of intervention (6 months). After 3 months of ballistic resistance training, the experimental group scored 3 points (95% CI 0 to 6) higher on the 54-point HiMAT than the control group and remained 3 points (95% CI –1 to 6) higher at 6 months. Although there was a transient decrement in balance at 3 months in the experimental group, the interventions had similar effects on all secondary outcomes by 6 months. Participants with a baseline HiMAT < 27 gained greater benefit from ballistic training: 6 points (1 to 10) on the HiMAT. This randomised trial shows that ballistic resistance training has a similar or better effect on mobility than non-ballistic training in people with traumatic brain injury. It may be better targeted towards those with more severe mobility limitations. ACTRN12611001098921. [ABSTRACT FROM AUTHOR]

Background:Muscle weakness is well established as the primary impairment that affects walking after stroke and strength training is an effective intervention to improve this muscle weakness. Observation of clinical practice however has highlighted an evidence-practice gap in the implementation of evidence-based strength training guidelines. Objective: To explore perceived barriers and facilitators that influence Australian physiotherapy practices when prescribing strength training with stroke survivors undergoing gait rehabilitation. Methods: Semi-structured interviews were conducted with a convenience sample of physiotherapists currently providing rehabilitation services to patients following stroke in Australia. Interviews were transcribed verbatim and line-by-line thematic analysis was undertaken to create themes and sub-themes. Results: Participants were 16 physiotherapists (12 females) with 3 months – 42 years experience working with people after stroke. Major themes identified were1) patient factors influence the approach to strength training; 2) interpretation and implementation of strength training principles is diverse; and 3) workplace context affects the treatment delivered. Physiotherapists displayed wide variation in their knowledge, interpretation and implementation of strength training principles and strength training exercise prescription was seldom evidence or guideline based. Workplace factors included the clinical preference of colleagues, and the need to modify practice to align with workforce resources. Conclusions: Implementation of strength training to improve walking after stroke was diverse. Therapist-related barriers to the implementation of effective strength training programs highlight the need for improved knowledge, training and research engagement. Limited resourcing demonstrates the need for organizational prioritization of stroke education and skill development. Narrowing the evidence-practice gap remains a challenge. [ABSTRACT FROM AUTHOR]

Objective The step test (ST) is a common clinical assessment of dynamic balance among survivors of stroke. The ST assesses a person's ability to place their paretic (paretic ST) or nonparetic (nonparetic ST) foot rapidly and repeatedly on and off a standardized block while standing. No study has formally explored if the 2 tests are interchangeable. Our study aimed to: (1) differentiate the correlates of paretic and nonparetic ST, and (2) compare their associations with physical function and falls. Methods Eighty-one survivors of stroke were consecutively recruited from inpatient rehabilitation units (n = 4) and were assessed within 1 week prior to discharge. In addition to the ST, a handheld dynamometer and computerized posturography were used to measure lower limb muscle strength and standing balance, respectively. Self-selected gait speed and Timed Up and Go test were also assessed as measures of physical function. Falls data were monitored for 12 months post discharge using monthly calendars. Multivariable regression analyses were used to differentiate (1) the correlates of paretic and nonparetic STs, and (2) their associations with physical function and falls. Results The median score for the paretic and nonparetic STs were 8 and 9 steps, respectively. Paretic ankle plantar-flexor and dorsiflexor strength were the strongest correlates of nonparetic ST, whereas both paretic ankle and knee extensor strength were the strongest correlates of paretic ST. In multivariable analyses adjusting for each other, both STs were independently associated with gait speed and Timed Up and Go scores. Paretic ST (odds ratio = 0.37; 95% CI = 0.22 to 0.62) was a stronger predictor than nonparetic ST (odds ratio = 0.51; 95% CI = 0.34 to 0.78) in predicting future falls. Conclusion This study confirmed that the paretic and nonparetic STs are noninterchangeable. ST scores should be assessed separately to achieve a more complete interpretation. Impact To our knowledge, this study is the first to objectively evaluate the similarities and differences between paretic and nonparetic STs. This information may refine the use and interpretation of the 2 STs for survivors of stroke. [ABSTRACT FROM AUTHOR]

Objective Technology is being increasingly used for physical assessment and interventions in health care settings. However, clinical adoption is relatively slow, and the factors affecting use remain underexplored. This study aimed to investigate factors influencing technology use by clinicians working in neurorehabilitation. Methods In this qualitative study, 9 physical therapists and 9 occupational therapists (N = 18) were recruited from urban and regional locations in Australia and in Singapore. Three 60-minute focus groups were conducted via video conferencing. Each group comprised 3 physical therapists and 3 occupational therapists working across different neurorehabilitation settings. Participants were asked to discuss which technologies they used in their workplace for physical assessment and treatment and barriers, motivators, and future desires for technology use. Transcripts were analyzed independently using an inductive approach to generate codes and themes. Results Our results comprised 3 themes and 7 categories. These were encompassed by a single overarching theme, namely "Technology use is influenced by the benefits and challenges of the technology itself, users, and organizational context." Themes showed that technology should promote effective interventions, is preferred if easy to use, and should be dependable. Furthermore, clinical reasoning is important, and users have varying levels of receptivity and confidence in technology use. Also, organizational resources are required, along with supportive cultures and processes, to facilitate technology use. Conclusions The themes identified multiple and interlinking factors influencing clinicians' use of technology in neurorehabilitation settings. Clinicians often consider context-specific benefits and challenges when deciding whether to use technology. Although our study found that clinicians generally perceived technology as having a beneficial role in improving health outcomes, there were several challenges raised. Therefore, the characteristics of the technology itself, individual users, and organizational context should be considered. Impact These findings will guide successful technology implementation and future developments. [ABSTRACT FROM AUTHOR]

Background: Rising from a chair is an important functional measure after stroke. Originally developed as a measure of lower-limb strength, the five times sit-to-stand test has shown associations with other measures of impairment, such as balance ability. We aimed to compare strength and balance in their relationship with the five times sit-to-stand test following stroke.Methods: Sixty-one participants following stroke were recruited from two hospitals in this cross-sectional observational study. Participants underwent assessment of the five times sit-to-stand (measured with a stopwatch), bilateral lower-limb muscle strength of seven individual muscle groups (hand-held dynamometry), and standing balance (computerised posturography). Partial correlations (controlling for body mass and height) were used to examine bivariate associations. Regression models with partial F-tests (including pertinent covariates) compared the contribution of strength (both limbs) and balance to five times sit-to-stand time.Results: The strength of the majority of lower-limb muscle groups (6/7) on the paretic side had a significant (P < 0.05) partial correlation with five times sit-to-stand time (r = -0.34 to -0.47) as did all balance measures (r = -0.27 to -0.56). In our regression models, knee extensor strength, total path length, and anteroposterior path velocity provided the largest contribution to five times sit-to-stand over covariates amongst strength and balance measures (R2 = 16.6 to 17.9 %). Partial F-tests revealed that both lower-limb strength and balance contribute to five times sit-to-stand time independent of each other. A regression model containing knee extensor strength and anteroposterior path velocity accounted for 25.5 % of the variance in five times sit-to-stand time over covariates.Conclusions: The strength of the knee extensor muscle group along with measures of standing balance ability (total path length and anteroposterior path velocity) both independently contribute to five times sit-to-stand time. Further research is required to examine how other important impairments post stroke impact five times sit-to-stand performance. [ABSTRACT FROM AUTHOR]

To develop a prediction model for postoperative day 3 mobility limitations in patients undergoing total knee arthroplasty (TKA). Prospective cohort study. Inpatients in a tertiary care hospital. A sample of patients (N=2300) who underwent primary TKA in 2016-2017. Not applicable. Candidate predictors included demographic variables and preoperative clinical and psychosocial measures. The outcome of interest was mobility limitations on post-TKA day 3, and this was determined a priori by an ordinal mobility outcome hierarchy based on the type of the gait aids prescribed and the level of physiotherapist assistance provided. To develop the model, we fitted a multivariable proportional odds regression model with bootstrap internal validation. We used a model approximation approach to create a simplified model that approximated predictions from the full model with 95% accuracy. On post-TKA day 3, 11% of patients required both walkers and therapist assistance to ambulate safely. Our prediction model had a concordance index of 0.72 (95% confidence interval, 0.68-0.75) when evaluating these patients. In the simplified model, predictors of greater mobility limitations included older age, greater walking aid support required preoperatively, less preoperative knee flexion range of movement, low-volume surgeon, contralateral knee pain, higher body mass index, non-Chinese race, and greater self-reported walking limitations preoperatively. We have developed a prediction model to identify patients who are at risk for mobility limitations in the inpatient setting. When used preoperatively as part of a shared-decision making process, it can potentially influence rehabilitation strategies and facilitate discharge planning. [ABSTRACT FROM AUTHOR]

To investigate whether a three-dimensional (3-D) camera (Microsoft Kinect) and a smartphone can be used to accurately quantify the joint angular velocity and range of motion (ROM) compared to a criterion-standard 3-D motion analysis system during a lower limb spasticity assessment. Observational, criterion-standard comparison study. Large rehabilitation center. A convenience sample of 35 controls, 35 patients with a neurologic condition, and 34 rehabilitation professionals (physiotherapists and rehabilitation doctors) participated (N=104). Not applicable. The Modified Tardieu Scale was used to assess spasticity of the quadriceps, hamstrings, soleus, and gastrocnemius. Data for each trial were collected concurrently using the criterion-standard Optitrack 3-D motion analysis (3DMA) system, Microsoft Kinect, and a smartphone. Each healthy control participant was assessed by 1 health professional and each patient with a neurological condition was assessed by 3 health professionals. Spearman correlation coefficient and intraclass correlation coefficient with 95% confidence intervals were used to report the strength of the relationships investigated. The smartphone and Microsoft Kinect demonstrated excellent concurrent validity with the 3DMA system. Overall, 74.8% of the relationships investigated demonstrated a very strong (≥0.80) correlation across all of the testing parameters. The Microsoft Kinect was superior to the smartphone for measuring joint start and end angle, the smartphone was superior for measuring joint angular velocity, and the 2 systems were comparable for measuring total joint ROM. These findings provide preliminary evidence that user-friendly, low-cost technologies can be used to facilitate accurate measurements of joint angular velocity and angles during a lower limb spasticity assessment in a clinical setting. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to discuss how knowledge of the biomechanics of walking can be used to inform the prescription of resistance exercises for people with mobility limitations. Muscle weakness is a key physical impairment that limits walking in commonly occurring neurologic conditions such as cerebral palsy, traumatic brain injury, and stroke. Few randomized trials to date have shown conclusively that strength training improves walking in people living with these conditions. This appears to be because (1) the most important muscle groups for forward propulsion when walking have not been targeted for strengthening, and (2) strength training protocols have focused on slow and heavy resistance exercises, which do not improve the fast muscle contractions required for walking. We propose a theoretical framework to improve exercise prescription by integrating the biomechanics of walking with the principles of strength training outlined by the American College of Sports Medicine to prescribe exercises that are specific to improving the task of walking. The high angular velocities that occur in the lower limb joints during walking indicate that resistance exercises targeting power generation would be most appropriate. Therefore, we propose the prescription of plyometric and ballistic resistance exercise, applied using the American College of Sports Medicine guidelines for task specificity, once people with neurologic conditions are ambulating, to improve walking outcomes. This new theoretical framework for resistance training ensures that exercise prescription matches how the muscles work during walking. [ABSTRACT FROM AUTHOR]

Abstract Objective To establish the feasibility and effectiveness of a 6-week ballistic strength training protocol in people with stroke. Design Randomized, controlled, assessor-blinded study. Setting Subacute inpatient rehabilitation. Participants Consecutively admitted inpatients with a primary diagnosis of first-ever stroke with lower limb weakness, functional ambulation category score of ≥3, and ability to walk ≥14 m were screened for eligibility to recruit 30 participants for randomization. Interventions Participants were randomized to standard therapy or ballistic strength training 3 times per week for 6 weeks. Main Outcome Measures The primary aim was to evaluate feasibility and outcomes included recruitment rate, participant retention and attrition, feasibility of the exercise protocol, therapist burden, and participant safety. Secondary outcomes included measures of mobility, lower limb muscle strength, muscle power, and quality of life. Results A total of 30 participants (11% of those screened) with mean age of 50 years (SD 18) were randomized. The median number of sessions attended was 15 of 18 and 17 of 18 for the ballistic and control groups, respectively. Earlier than expected discharge to home (n=4) and illness (n=7) were the most common reasons for nonattendance. Participants performed the exercises safely, with no study-related adverse events. There were significant (P <.05) between-group changes favoring the ballistic group for comfortable gait velocity (mean difference [MD] 0.31m/s, 95% confidence interval [CI]: 0.08-0.52), muscle power, as measured by peak jump height (MD 8cm, 95% CI: 3-13), and peak propulsive velocity (MD 64cm/s, 95% CI: 17-112). Conclusions Ballistic training was safe and feasible in select ambulant people with stroke. Similar rates of retention and attrition suggest that ballistic training was acceptable to patients. Secondary outcomes provide promising results that warrant further investigation in a larger trial. [ABSTRACT FROM AUTHOR]

Purpose: Individuals following anterior cruciate ligament reconstruction (ACLR) with concomitant meniscal pathology have a higher risk of developing knee osteoarthritis (OA) compared to those with isolated ACLR. Knee extensor weakness and altered dynamic knee joint biomechanics have been suggested to play a role in the development of knee OA following ACLR. This study investigated whether these factors differ in people following ACLR who have concomitant meniscal pathology compared to patients with isolated ACLR.Methods: Thirty-three patients with isolated ACLR and 34 patients with ACLR and meniscal pathology underwent strength and gait assessment 12-24 months post-operatively. Primary measures were peak isometric knee extensor torque and knee adduction moment (peak and impulse). Secondary measures included peak knee flexion moment and knee kinematics (sagittal and transverse).Results: There were no between-group differences in knee extensor strength [mean difference (95 % CI) 0.09 (-0.23 to 0.42) Nm/kg, n.s.], peak knee adduction moment [-0.02 (-0.54 to 0.49) Nm/(BW × HT) %, n.s.] or knee adduction moment impulse [0.01 (-0.15 to 0.17) Nm/(BW × HT) %, p = n.s.]. No between-group differences were found for any secondary measures.Conclusions: No evidence was found to suggest that the higher prevalence of OA in patients with ACLR and meniscal pathology compared to patients with isolated ACLR is attributed to reduced knee muscle strength or altered knee joint biomechanics assessed 1-2 years post-surgery. Given that there is a higher incidence of knee OA in patients with concomitant meniscal pathology and ACLR, further investigation is needed so that population-specific rehabilitation protocols can be developed.Level Of Evidence: III. [ABSTRACT FROM AUTHOR]

The Microsoft Xbox One Kinect™ (Kinect V2) contains a depth camera that can be used to manually identify anatomical landmark positions in three-dimensions independent of the standard skeletal tracking, and therefore has potential for low-cost, time-efficient three-dimensional movement analysis (3DMA). This study examined inter-session reliability and concurrent validity of the Kinect V2 for the assessment of coronal and sagittal plane kinematics for the trunk, hip and knee during single leg squats (SLS) and drop vertical jumps (DVJ). Thirty young, healthy participants (age = 23 ± 5yrs, male/ female = 15/15) performed a SLS and DVJ protocol that was recorded concurrently by the Kinect V2 and 3DMA during two sessions, one week apart. The Kinect V2 demonstrated good to excellent reliability for all SLS and DVJ variables (ICC ≥ 0.73). Concurrent validity ranged from poor to excellent (ICC = 0.02 to 0.98) during the SLS task, although trunk, hip and knee flexion and two-dimensional measures of knee abduction and frontal plane projection angle all demonstrated good to excellent validity (ICC ≥ 0.80). Concurrent validity for the DVJ task was typically worse, with only two variables exceeding ICC = 0.75 (trunk and hip flexion). These findings indicate that the Kinect V2 may have potential for large-scale screening for ACL injury risk, however future prospective research is required. [ABSTRACT FROM AUTHOR]

Objective To integrate the literature investigating factors associated with post-stroke physical activity. Data Sources A search was conducted from database inception to June 2016 across 9 databases: Cochrane, MEDLINE, ProQuest, Web of Science, PsycINFO, Scopus, Embase, CINAHL, and Allied and Complementary Medicine Database. The reference lists of included articles were screened for secondary literature. Study Selection Cohort and cross-sectional studies were included if they recruited community-dwelling stroke survivors and measured factors associated with physical activity. Data Extraction Risk of bias was evaluated using the Quality in Prognosis Studies checklist. A meta-analysis was conducted for correlates where there were at least 2 studies that reported a correlation value. Correlation values were used in an effect size measure and converted to a standardized unit with Fisher r to z transformation and conversion back to r method. Results were described qualitatively for studies that could not be pooled. Data Synthesis There were 2161 studies screened and 26 studies included. Age (meta r =−.17; P ≤.001) and sex (meta r =−.01; P =.02) were the nonmodifiable factors that were found to be associated with post-stroke physical activity. The modifiable factors were physical function (meta r =.68–.73; P <.001), cardiorespiratory fitness (meta r =.35; P ≤.001), fatigue (meta r =−.22; P =.01), falls self-efficacy (meta r =−.33; P <.001), balance self-efficacy (meta r =.37; P <.001), depression (meta r =−.58 to .48; P <.001), and health-related quality of life (meta r =.38–.43; P <.001). The effect of side of infarct, neglect, and cognition on post-stroke physical activity was inconclusive. Conclusions Age, sex, physical function, depression, fatigue, self-efficacy, and quality of life were factors associated with post-stroke physical activity. The cause and effect of these relations are unclear, and the possibility of reverse causality needs to be addressed. [ABSTRACT FROM AUTHOR]

Purpose: Impairments in quadriceps force control and altered quadriceps and hamstring muscle activation strategies have been observed following anterior cruciate ligament reconstruction; however, the functional implications of these impairments are unclear. This study examined the cross-sectional associations between quadriceps force control, quadriceps activation, hamstring coactivation and clinically assessed knee function following anterior cruciate ligament reconstruction with a hamstring graft.Methods: Sixty-six patients (18 ± 3 months following surgery) and 41 uninjured individuals participated. Quadriceps force control was assessed using an isometric knee extension task. Participants cyclically increased and decreased quadriceps force at slow speeds between 5 and 30 % maximum voluntary isometric contraction matching a moving target displayed on a screen. Quadriceps activation and hamstring coactivation were assessed concurrently using surface electromyography. Knee function was assessed with the Cincinnati Knee Rating Scale and three single-leg hop tests.Results: The reconstructed group completed the task with 48 % greater root-mean-square error (RMSE), indicating significantly worse quadriceps force control (p < 0.001). In a multivariable model adjusted for sex, greater RMSE and greater lateral hamstring coactivation were significantly associated with worse knee function that is greater odds of scoring <85 % on one or more knee functional assessment.Conclusions: Less-accurate quadriceps force output and greater hamstring coactivation are associated with worse knee joint function following anterior cruciate ligament reconstruction and may contribute to irregular knee joint loading and the onset or progression of knee osteoarthritis. Impairments in quadriceps force control and altered muscle activation strategies may be modifiable through neuromuscular training, and this is an area for future research.Level Of Evidence: Case-control study, Level III. [ABSTRACT FROM AUTHOR]

Objective To investigate the effectiveness of aquatic exercise in improving lower limb strength in people with musculoskeletal conditions. Data Sources A systematic search used 5 databases, including MEDLINE, CINAHL, Embase, SPORTDiscus, and The Cochrane Library. Study Selection Randomized controlled trials evaluating aquatic exercise with a resistance training component for adults with musculoskeletal conditions compared with no intervention or land-based exercise were identified. Fifteen studies from the initial yield of 1214 met these criteria. Data Extraction Data related to participant demographics, study design, and methods, interventions, and outcomes, including numerical means and SDs, were extracted independently by 2 reviewers. Data Synthesis Nine of the 15 studies were of high quality, scoring at least 6 on the Physiotherapy Evidence Database Scale. Limited consideration of the prescription of resistance in the aquatic exercise and application of resistance training principles existed. Low- or very low–quality evidence indicates there was no difference in average effect between aquatic exercise and no exercise in improving hip abductor strength (standardized mean difference [SMD], .28; 95% confidence interval [CI], −.04 to .59), knee extensor strength (SMD, .18; 95% CI, −.03 to .40), knee flexor strength (SMD, .13; 95% CI, −.20 to .45), or lower limb endurance (SMD, .35; 95% CI, −.06 to .77). Low-quality evidence indicates no difference in average effect between aquatic and land exercise for knee extensor (SMD, −.24; 95% CI, −.49 to .02) or flexor strength (SMD, −.15; 95% CI, −.53 to .22). Conclusions It is likely that the inadequate application of resistance in water is a significant contributor to the limited effectiveness of aquatic exercise interventions in improving hip and knee muscle strength in people with musculoskeletal conditions. Future research is needed to quantify resistance with aquatic exercises and to determine if using opportunities for greater resistance in aquatic rehabilitation and appropriate resistance training principles can be more effective in improving muscle strength. [ABSTRACT FROM AUTHOR]

Aim: To document the range of physiotherapy interventions undertaken by stroke patients with mobility deficits during 'usual care' in inpatient rehabilitation. Methods: Twenty consecutively admitted adults were approached to participate if they met the inclusion criteria: diagnosis of first stroke with leg weakness; functional ambulation category score ≥3; able to mobilise ≥14 metres on level ground; and able to provide consent. All individual physiotherapy sessions for each participant were observed for one day. The duration of each therapy session was recorded, as well as the duration and type of specific physiotherapy interventions. Findings: Twenty participants (12 males, 8 females; mean ± SD age: 69 ± 20 years) were observed. All participants attended at least one individual session of physiotherapy on the day this study was conducted. Physiotherapy sessions lasted 47.8 ± 7.6 minutes, with an average of 17.9 ± 6.9 minutes spent resting. The most frequently provided therapies were: gait training (10.8 ± 4.7 minutes per session); strength training (8.5 ± 7.0 minutes per session); and balance training (6.2 ± 3.6 minutes per session). Conclusions: In this sample of ambulant patients following stroke, inpatient physiotherapy rehabilitation focused on gait training, lower limb strengthening and balance training. Active therapy time was low and long rest periods with no prescribed activity were evident, which suggests therapy time is not optimally utilised in this population. [ABSTRACT FROM AUTHOR]

Objective: To identify factors which influence physical activity levels (PALs) of people with traumatic brain injury (TBI). Data sources: Eight electronic databases. Study selection: A systematic search was performed to identify articles that reported the measurement (quantity) of PALs of individuals with TBI. Data extraction/synthesis: Two authors reviewed andextracted the data independently. Article quality was evaluated using the Law critical review tool. Results: Six studies were identified that met the inclusion criteria. All studies found that PALs of participants with TBI were below those recommended for health benefits. Although a number of environmental and personal barriers restricted PA participation, motivation and exercise self-efficacy were the most frequently identified facilitators of PA in the TBI population. Despite apparent links, the relationship between mobility capacity and PALs was unclear from the results of this systematic review. Conclusion: The results of this systematic review demonstrated that little is known about PALs of individuals with TBI. PALs of participants with TBI were less than required for health maintenance. Self-efficacy to exercise and motivation were the most frequently identified facilitators of PA in the TBI population. [ABSTRACT FROM PUBLISHER]

Primary objectives: To determine the predictors of physical activity levels (PALs) of people with traumatic brain injury (TBI) during the transition from hospital to home. Research design: A prospective cohort study. Participants: Twenty-three individuals with TBI, consecutively admitted to TBI inpatient rehabilitation, who had independent community mobility potential on inpatient discharge. Methods and procedures: PALs (steps per day) were monitored at three time points: (T1) final week of inpatient rehabilitation, (T2) first week at home and (T3) 6 weeks following discharge. Measures across the physical, emotional and cognitive domains were performed at T1 and compared with PALs at T3. Results: PALs decreased significantly on hospital discharge (T2), compared to T1, and remained below recommended guidelines for maintenance of health and wellbeing at 6 weeks post discharge (T3). Motivation to exercise was the primary predictor of PALs at T3 (p < 0.01), with fatigue (p < 0.05) and anxiety (p < 0.05) also being significantly associated. Measures of physical ability were not correlated with PALs at T3. Conclusions: PALs decreased significantly on discharge from hospital and remained below inpatient levels despite physical capacity for higher PALs. Motivation, fatigue and anxiety were important influencers of PALs during the transition home period. [ABSTRACT FROM PUBLISHER]

Objective: The aim of this systematic review was to identify literature examining associations between isometric strength and gait velocity following stroke. Methods: An electronic search was performed using six online databases. Targeted searching of reference lists of included articles and three relevant journals was also performed. Two independent reviewers identified relevant articles, extracted data and assessed the methodological quality of included articles. Inclusion criteria involved studies that assessed univariate correlations between gait velocity and isometric strength of individual lower limb muscle groups in a stroke population. Results: Twenty-one studies were included for review. The majority of included studies had a relatively small sample size. After accounting for sample size and methodological quality, the knee extensors showed poor-to-moderate correlations with gait velocity while the ankle dorsiflexors showed the strongest association with gait velocity. Conclusions: Current evidence suggests that the strength of the ankle dorsiflexors has a stronger correlation to gait velocity compared with other lower limb muscle groups. Consequently, a focus on increasing ankle dorsiflexor strength to improve gait velocity following stroke may be beneficial. However, due to limitations of the research identified, further research is needed to determine the associations between lower limb strength and gait velocity following stroke. [ABSTRACT FROM AUTHOR]

Background: The Microsoft Kinect has been used previously to assess spatiotemporal aspects of gait; however the reliability of this system for the assessment of people following stroke has not been established. This study examined the reliability and additional information that the Kinect provides when instrumenting a gait assessment in people living with stroke. Methods: The spatiotemporal variables of step length, step length asymmetry, foot swing velocity, foot swing velocity asymmetry, peak and mean gait speed and the percentage difference between the peak and mean gait speed were assessed during gait trials in 30 outpatients more than three months post-stroke and able to stand unsupported. Additional clinical assessments of functional reach (FR), step test (ST), 10 m walk test (10MWT) and the timed up and go (TUG) were performed, along with force platform instrumented assessments of center of pressure path length velocity during double-legged standing balance with eyes closed (DLEC), weight bearing asymmetry (WBA) and dynamic medial-lateral weight-shifting ability (MLWS). These tests were performed on two separate occasions, seven days apart for reliability assessment. Separate adjusted multiple regressions models for predicting scores on the clinical and force platform assessments were created using 1) the easily assessed clinically-derived gait variables 10MWT time and total number of steps; and 2) the Kinect-derived variables which were found to be reliable (ICC > 0.75) and not strongly correlated (Spearman's ρ < 0.80) with each other (i.e. non-redundant). Results: Kinect-derived variables were found to be highly reliable (all ICCs > 0.80), but many were redundant. The final regression model using Kinect-derived variables consisted of the asymmetry scores, mean gait velocity, affected limb foot swing velocity and the difference between peak and mean gait velocity. In comparison with the clinically-derived regression model, the Kinect-derived model accounted for >15% more variance on the MLWS, ST and FR tests and scored similarly on all other measures. Conclusions: In conclusion, instrumenting gait using the Kinect is reliable and provides insight into the dynamic balance capacity of people living with stroke. This system provides a minimally intrusive method of examining potentially important gait characteristics in people living with stroke. [ABSTRACT FROM AUTHOR]

Aim: To document the range of physiotherapy interventions undertaken by stroke patients with mobility deficits during ‘usual care’ in inpatient rehabilitation. Methods: Twenty consecutively admitted adults were approached to participate if they met the inclusion criteria: diagnosis of first stroke with leg weakness; functional ambulation category score ≥3; able to mobilise ≥14 metres on level ground; and able to provide consent. All individual physiotherapy sessions for each participant were observed for one day. The duration of each therapy session was recorded, as well as the duration and type of specific physiotherapy interventions. Findings: Twenty participants (12 males, 8 females; mean±SD age: 69±20 years) were observed. All participants attended at least one individual session of physiotherapy on the day this study was conducted. Physiotherapy sessions lasted 47.8±7.6 minutes, with an average of 17.9±6.9 minutes spent resting. The most frequently provided therapies were: gait training (10.8±4.7 minutes per session); strength training (8.5±7.0 minutes per session); and balance training (6.2±3.6 minutes per session). Conclusions: In this sample of ambulant patients following stroke, inpatient physiotherapy rehabilitation focused on gait training, lower limb strengthening and balance training. Active therapy time was low and long rest periods with no prescribed activity were evident, which suggests therapy time is not optimally utilised in this population. [ABSTRACT FROM AUTHOR]

Conventional methods for strength training in neurologic rehabilitation are not task specific for walking. Ballistic strength training was developed to improve the functional transfer of strength training; however, no research has investigated this in neurologic populations. The aim of this pilot study was to evaluate the feasibility of applying ballistic principles to conventional leg strengthening exercises in individuals with mobility limitations as a result of neurologic injuries. Eleven individuals with neurologic injuries completed seated and reclined leg press using conventional and ballistic techniques. A 2 x 2 repeated-measures analysis of variance was used to compare power measures (peak movement height and peak velocity) between exercises and conditions. Peak jump velocity and peak jump height were greater when using the ballistic jump technique rather than the conventional concentric technique (P < 0.01). These findings suggest that when compared with conventional strengthening exercises, the incorporation of ballistic principles was associated with increased peak height and peak velocities. [ABSTRACT FROM AUTHOR]

The article presents a study which examined the feasibility and potential efficacy of the Nintendo Wii for balance rehabilitation after stroke. Phase II, randomized controlled trial was carried out. Twenty one percent of individuals were recruited for the examination. All participants reported enjoying the sessions and most felt that the Wii-based approach, in addition to standard care, was beneficial. The Wii-based approached was noted feasible for post-stroke balance rehabilitation.

Abstract: Objective: To use low-cost Nintendo Wii Balance Boards (NWBB) to assess weight-bearing asymmetry (WBA) in people who have undergone anterior cruciate ligament reconstruction (ACLR), and to compare their results with a matched control group. Design: Quantitative clinical study using a cross-sectional design. Setting: Orthopedic clinic of a private hospital. Participants: ACLR participants (n=41; mean age ± SD, 26.0±9.8y; current Cincinnati sports activity level, 75.3±19.8) performed testing in conjunction with their routine 6- or 12-month clinical follow-up, and a control group (n=41) was matched for age, height, body mass, and physical activity level. Interventions: Participants performed double-limb squats while standing on 2 NWBBs, 1 under each foot. Main Outcome Measures: The WBA variables mean mass difference as a percentage of body mass, time favoring a single limb by >5% body mass, absolute symmetry index, and symmetry index relative to the operated or matched control limb were derived. Mann-Whitney U tests were performed to assess between-group differences. Results: Significant (P<.05) increases in asymmetry in the ACLR group were found for all outcome measures except symmetry index relative to the operated limb. Conclusions: People who have undergone ACLR are likely to possess WBA during squats, and this can be assessed using low-cost NWBBs in a clinical setting. Interestingly, the observed asymmetry was not specific to the surgical limb. Future research is needed to assess the relationship between WBA early in the rehabilitation process and long-term outcomes. [Copyright &y& Elsevier]

Abstract: Objectives: To assess the presence of fear-induced activity limitation (FIAL) in a sample of patients 1 year after total knee arthroplasty (TKA), and to develop a preliminary prediction model to predict the risk of FIAL. Design: Prospective cohort study. Setting: A tertiary teaching hospital. Participants: Patients (N=72; mean age, 70±6y) undergoing primary, unilateral TKA participated. Interventions: Not applicable. Main Outcome Measures: Preoperative candidate predictors were age, sex, body mass index, previous falls history, number of comorbidities, self-report physical function, gait speed, knee range of motion, knee pain, and standing balance. Outcome measure at 1-year follow-up was the level of FIAL, measured by the Survey of Activities and Fear of Falling in the Elderly. Results: Thirty-one patients (41%; 95% confidence interval, .31–.55) had FIAL, of whom 15 had moderate to severe FIAL. Multivariable predictors of FIAL included preoperative habitual gait speed and velocity of postural sway in the anterior-posterior axis. A 2-variable nomogram-based prediction model was constructed, and this model showed moderately good discrimination (optimism-corrected c-index, .76) and adequate calibration. Conclusions: In our sample of patients with TKA, FIAL is common, and early identification of patients at risk of FIAL would bring them into appropriate modes of preventive care. Our prediction model shows some promise in identifying patients with FIAL, but prospective validation studies are needed. [Copyright &y& Elsevier]

Abstract: Clark RA, Williams G, Fini N, Moore L, Bryant AL. Coordination of dynamic balance during gait training in people with acquired brain injury. Objective: To investigate movement of the center of mass (COM) during different gait training methods in people with neurologic conditions. Design: Coordination of the gait cycle, represented by mediolateral COM displacement amplitude, timing, and stability, was assessed during a variety of gait training methods performed in a single session. Setting: Gait laboratory. Participants: People who were unable to walk unassisted due to an acquired brain injury (n=17) and healthy control subjects (n=25). Interventions: The participants performed 7 alternative gait training methods in a randomized order. These were therapist manual facilitation, the use of a gait assistive device, treadmill walking with handrail support, and 4 variations of body weight–support treadmill training with combinations of handrail and/or therapist support. Main Outcome Measures: Mediolateral COM movement was analyzed in terms of displacement amplitude (overall range of motion), timing (relative to stride time), and stability (steadiness of the movement). Normative values for these measures were acquired from 25 healthy participants walking at a self-selected comfortable pace. Results: Body weight–support treadmill training without any additional support resulted in significantly (P<.05) greater amplitude, altered timing, and reduced movement stability compared with nonpathologic gait. Allowing handrail support or therapist facilitation reduced this effect and resulted in treadmill training (± body weight support) having lower movement amplitudes when compared with the other training methods. Therapist manual facilitation most closely matched nonpathologic gait for timing and stability. Conclusions: In the context of overall dynamic gait coordination, no single method of training provides the optimal stimulus. A training program that uses a variety of techniques may provide a beneficial rehabilitation response. [Copyright &y& Elsevier]

The article provides information on improving the weight distribution of the lower leg during the squat using portable and simple-to-use system of the Nintendo Wii Balance Boards (NWBBs). It discusses the method that measures including the mean mass difference (MMD) of the limbs, interlimb symmetry index (ISI) and the time spent favoring a single limb (TFSL) percentage. The method tested the NWBB system in real-time feedback for weight-bearing asymmetry (WBA).

Abstract: Pua Y-H, Clark RA, Bryant AL. Physical function in hip osteoarthritis: relationship to isometric knee extensor steadiness. Objective: To evaluate, in a community hip osteoarthritis sample, the cross-sectional associations of isometric strength and steadiness of the knee extensors and their interaction with physical performance measures of physical function. Design: Cross-sectional. Setting: Human movement laboratory of a university. Participants: Sixty-seven adults (27 men and 40 women; age, 61±10y) with radiographically confirmed symptomatic hip osteoarthritis. Interventions: Not applicable. Main Outcome Measures: Participants performed isometric knee extensor steadiness and strength testing on a dynamometer. Physical function was assessed by using the habitual timed walk test and the self- and fast-paced stair-climbing tests. Results: In the hierarchical regression models, although there were clear main effects of knee extensor steadiness on fast-paced stair performance, greater knee steadiness predictively associated with faster stair-climbing performance particularly in individuals with high knee extensor strength. In contrast, knee extensor steadiness was not related to gait speed regardless of knee extensor strength levels. Conclusions: In patients with hip OA, knee extensor steadiness was positively associated with stair-climbing performance, particularly in those with high levels of knee extensor strength. These findings are of importance in developing intervention strategies, but they call for further study. [Copyright &y& Elsevier]

Abstract: Impaired standing balance has a detrimental effect on a person''s functional ability and increases their risk of falling. There is currently no validated system which can precisely quantify center of pressure (COP), an important component of standing balance, while being inexpensive, portable and widely available. The Wii Balance Board (WBB) fits these criteria, and we examined its validity in comparison with the ‘gold standard’—a laboratory-grade force platform (FP). Thirty subjects without lower limb pathology performed a combination of single and double leg standing balance tests with eyes open or closed on two separate occasions. Data from the WBB were acquired using a laptop computer. The test–retest reliability for COP path length for each of the testing devices, including a comparison of the WBB and FP data, was examined using intraclass correlation coefficients (ICC), Bland–Altman plots (BAP) and minimum detectable change (MDC). Both devices exhibited good to excellent COP path length test–retest reliability within-device (ICC=0.66–0.94) and between-device (ICC=0.77–0.89) on all testing protocols. Examination of the BAP revealed no relationship between the difference and the mean in any test, however the MDC values for the WBB did exceed those of the FP in three of the four tests. These findings suggest that the WBB is a valid tool for assessing standing balance. Given that the WBB is portable, widely available and a fraction of the cost of a FP, it could provide the average clinician with a standing balance assessment tool suitable for the clinical setting. [Copyright &y& Elsevier]

Objective To determine whether resistance training to improve mobility outcomes after stroke adheres to the American College of Sports Medicine (ACSM) guidelines, and whether adherence was associated with better outcomes. Data Sources Online databases searched from 1975 to October 30, 2016. Study Selection Randomized controlled trials examining the effectiveness of lower limb strength training on mobility outcomes in adult participants with stroke. Data Extraction Two independent reviewers completed data extraction. Quality of trials was determined using the Cochrane Risk of Bias Tool. Trials were scored based on their protocol's adherence to 8 ACSM recommendations. To determine if a relation existed between total adherence score and effect size, Spearman ρ was calculated, and between individual recommendations and effect size, Mann-Whitney U or Kruskal-Wallis tests were used. Data Synthesis Thirty-nine trials met the inclusion criteria, and 34 were scored on their adherence to the guidelines. Adherence was high for frequency of training (100% of studies), but few trials adhered to the guidelines for intensity (32%), specificity (24%), and training pattern (3%). Based on the small number of studies that could be included in pooled analysis (n=12), there was no relation between overall adherence and effect size (Spearman ρ=−.39, P =.21). Conclusions Adherence to the ACSM guidelines for resistance training after stroke varied widely. Future trials should ensure strength training protocols adhere more closely to the guidelines, to ensure their effectiveness in stroke can be accurately determined. [ABSTRACT FROM AUTHOR]