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ObjectiveTo determine the publication rate of motor-rehabilitation trials poststroke and the consistency between registry records and their corresponding main publications in trial design, primary objectives and outcomes, eligibility criteria, and sample size.MethodsWe searched 18 clinical trial registries to identify randomized controlled trials of motor-based stroke rehabilitation registered after July 2005 and completed before April 2017. Eligible trials included adults with stroke, with at least one outcome measure related to motor function. Information in the registry records was compared with that of their main publications, if any.ResultsThree hundred twenty-three trials met our eligibility criteria; we were unable to find a peer-reviewed publication reporting the main findings for 46% (150/323) of these. Of the 169 trials with peer-reviewed articles published in English, 141 (83%) were consistent with the registry record in trial design, 100 (59%) were consistent in primary objectives, 71 (42%) were consistent in primary outcomes, 28 (17%) were consistent in eligibility criteria, and 74 (44%) were consistent in sample size.ConclusionsApproximately half of motor-based stroke rehabilitation trials were not published, even more than 3 years after the end of the trial. When main publications were found, they substantially deviated from information in the registry record. These findings highlight the importance of trial registries for identifying unpublished stroke rehabilitation trials and of searching trial registries when conducting systematic reviews and meta-analysis to help ensure that reviews are unbiased.

Reaching movements generate reaction forces that affect postural stability, requiring sophisticated coordination between body and arm movement to maintain balance. In voluntary movement, this coordination involves feedforward shifts of posture, and such anticipatory postural muscle activity also accompanies the rapid modulation of an ongoing point to suddenly a shifting target (double-step). However, it is unknown if this early postural activity depends on target-shift predictability and whether arm and body motion are similar coordinated to voluntary movement. Body and arm motion coordination during double-step pointing movements from standing were done under differing conditions of target-shift predictability. In a proportion of trials, the pointing target was displaced, with the predictability of target-shift direction varied between two peripheral targets (target-shift direction known) and two central targets (target-shift direction uncertain). The target jump evoked an adjustment in the arm then body response, opposite to the pointing responses to the initial target. The triggered arm-then-body ordering was consistent across target-shift predictability, although known target-shift direction resulted in closer timing of arm and body onsets. The altered coordination in triggered corrections suggests that the body component in triggered reactions depend on response predictability, showing an altered control of arm and body motion.

Background The characteristics of experimentally induced slips (low-friction surfaces and non-motorized platforms) in laboratory settings are influenced by participant gait velocity, contact surface area, and level of friction between the foot and surface. However, motorized platforms that could account for these factors during slip-like paradigms have not been extensively used. Research question How does slip-like perturbations evoked via a motorized platform change gait characteristics and postural stability during overground walking? Methods Ten healthy young adults performed 4 overground, self-paced walking trials, with the 4th trial including an unexpected forward support surface translation at heel-strike during steady state walking. Kinematic and kinetic data were collected, with step characteristics (time, distance, velocity) and postural stability calculated to compare between normal gait and slip-like trials. Slip foot characteristics were also determined. Results Peak slipping foot velocity variability was considerably smaller compared to previously reported low-friction and non-motorized perturbations. The centre of mass was shifted more posteriorly (thus in a less stable location) by the end of the platform acceleration phase compared to the same time point post-heel strike during normal gait trials. Participants successfully responded to every slip-like perturbation by significantly increasing step time, decreasing step distance, and decreasing step velocity. Significance Our results demonstrate the repeatability and consistency of a motorized support surface paradigm to induce slip-like perturbations. Furthermore, stability and step characteristic results confirm posterior shifts in stability and appropriate stepping responses, mimicking how participants would react if responding to a real world slip.

Locomotion requires both proactive and reactive control strategies to maintain balance. The current study aimed to: (i) ascertain upper body postural responses following first exposure to a forward (slip) support-surface perturbation; (ii) investigate effects of repeated perturbation exposure; (iii) establish relationships between arms and other response components (trunk; center of mass control). Young adults (N = 11) completed 14 walking trials on a robotic platform; six elicited a slip response. Kinematic analyses were focused on extrapolated center of mass position (xCoM), bilateral upper- and forearm elevation velocity, trunk angular velocity, and step parameters. Results demonstrated that postural responses evoked in the first slip exposure were the largest in magnitude (e.g., reduced backward stability, altered reactive stepping, etc.) and preceded by anticipatory anterior adjustments of xCoM. In relation to the perturbed leg, the large contra- and ipsilateral arm responses observed (in first exposure) were characteristically asymmetric and scaled to the degree of peak trunk extension. With repeated exposure, xCoM anticipatory adjustments were altered and in turn, reduced posterior xCoM motion occurred following a slip (changes plateaued at second exposure). The few components of the slip response that persisted across multiple exposures did so at a lesser magnitude (e.g., step length and arms).

Maintaining the centre of mass (CoM) of the body within the base of support is a critical component of upright balance; the ability to accurately quantify balance recovery mechanisms is critical for many research teams.The purpose of this study was to investigate how exclusion of specific body segments in an anthropometric CoM model influenced a dynamic measure of postural stability, the margin of stability (MoS), following a support-surface perturbation.Healthy young adults (n = 10) were instrumented with kinematic markers and a safety harness. Sixteen support-surface translations, scaled to ensure responses did not involve a change in base of support, were then issued (backwards, forwards, left, or right). Whole-body CoM was estimated using four variations of a 13-segment anthropometric model: i) the full-model (WFM), and three simplified models, ii) excluding upper limbs (NAr); iii) excluding upper and lower limbs (HTP); iv) pelvis CoM (CoMp). The CoM calculated for each variant was then used to estimate extrapolated CoM (xCoM) position and the resulting MoS within the plane of postural disturbance.Comparisons of simplified models to the full model revealed significant differences (p 0.05) in MoS for all models in each perturbation condition; however, the largest differences were following sagittal plane based perturbations. Poor estimates of WFM MoS were most evident for HTP and CoMp models; these were associated with the greatest values of RMS/maximum error, poorest correlations, etc. The simplified models provided low-error approximates for frontal plane perturbations.Findings suggest that simplified calculations of CoM can be used by researchers without reducing MoS measurement accuracy; however, the degree of simplification should be context-dependent. For example, CoMp models may be appropriate for questions pertaining to frontal plane MoS; sagittal plane MoS necessitates inclusion of lower limb and HTP segments to prevent underestimation of postural stability.

The ability to counteract destabilizing external forces while simultaneously executing a complex task presents a novel way to ascertain one's ability to generate adaptive postural control responses to avoid a potential fall. In this study, participants performed an upper limb object transport task requiring a lateral change in support on a robotic platform that could remain fixed in space or translated (mimicking a slip or trip perturbation). No significant stability differences were observed at initial recovery step between slip and trip perturbations. Variability measures were greatest during the trip perturbations; though stability was at its greatest level preceding these perturbations. These results will aid in the design of future studies that will investigate adaptive postural control responses generated by older adults when executing similar, ongoing complex upper body tasks interrupted by a destabilizing support surface perturbation.

A simultaneous turn and step motion is a vital component of many complex movements and may provide insight into age related balance and stability deficits during a weight transfer task. In this study, nine young adults and ten healthy, community dwelling older adults performed a simultaneous “turn and step” task from a quiet standing position under two self-selected speeds, self-paced and as quickly and efficiently as possible. Whole-body center of mass was estimated to investigate stability, segmental coordination, and variability. Older adults performed the task with greater variability, however they were unable to alter stability nor segmental coordination across the self-selected speeds; absence of this modulation portrays a trade-off between stability and manoeuvrability. An increase in variability with no observed directional differences suggests that the simultaneous turn and step task may be a sensitive discriminatory motor task helpful in elucidating the adoption of altered control strategies used by elderly populations.

Investigating an ecologically relevant upper limb task, such as manually transporting an object with a concurrent lateral change in support (sidestepping alongside a kitchen counter), may provide greater insight into potential deficits in postural stability, variability and motor coordination in older adults. Nine healthy young and eleven older, community dwelling adults executed an upper limb object transport task requiring a lateral change in support in two directions at two self-selected speeds, self-paced and fast-paced. Dynamic postural stability and movement variability was quantified via whole-body center of mass motion. The onset of lead lower limb movement in relation to object movement onset was quantified as a measure of motor coordination. Older adults demonstrated similar levels of stability and variability as their younger counterparts, but at slower peak movement velocity and increased task duration. Furthermore, older adults demonstrated asymmetrical motor coordination between left and right task directions, while younger adults remained consistent regardless of task direction. Thus, older adults significantly modulated movement speed and motor coordination to maintain similar levels of stability and variability compared to their younger counterparts.

Background: Reactive balance training (RBT) has been previously found to reduce fall risk in individuals with sub-acute stroke; however, our understanding of the effects of RBT on specific balance impairments is lacking.Objective: To quantify changes in common balance reaction impairments in individuals with sub-acute stroke resulting from RBT, relative to traditional balance training, using a prospective cohort study design with a historical control group.Methods: Individuals with sub-acute stroke completed either RBT or traditional balance training as part of their routine care during physiotherapy in inpatient rehabilitation. Reactive balance control was assessed using lean-and-release perturbations pre-intervention, post-intervention, and 6-months post-intervention (follow-up). Individuals with impaired balance reactions (delayed foot-off times, slide steps, and/or a preference for stepping with the preferred limb) at the pre-intervention assessment were identified using video and force plate data. Outcome measures (foot-off times, frequency of trials with slide steps, and stepping with the preferred limb) from the RBT participants with impaired reactions were compared for each of the three assessments to the mean values for the participants with impaired reactions in the historical control group.Results: Improvements were observed in all outcome measures for the RBT participants between pre-intervention and post-intervention, and/or between post-intervention and follow-up. These improvements were generally equivalent to, if not better than, the improvements demonstrated by the historical control group.Conclusions: Findings further support the use of RBT for post-stroke inpatient rehabilitation, and provide insight into specific balance reaction impairments that are improved by RBT.

ObjectiveAsymmetric walking after stroke is common, detrimental, and difficult to treat, but current knowledge of underlying physiological mechanisms is limited. This study investigated electromyographic (EMG) features of temporal gait asymmetry (TGA).MethodsParticipants post-stroke with or without TGA and control adults (n=27, 8, and 9, respectively) performed self-paced overground gait trials. EMG, force plate, and motion capture data were collected. Lower limb muscle activity was compared across groups and sides (more/less affected). Correlation between burst timing variables and asymmetry ratios was examined.ResultsSignificant group by side interaction effects were found: fewer TGA group dorsiflexor bursts during swing (p=.0009), more affected plantarflexor stance activity ended early (p=.0006) and less affected dorsiflexor on/off time was delayed (pConclusionsTemporal patterns of muscular activation, particularly about the ankle around the stance-to-swing transition period, are associated with TGA. The results may reflect specific impairments or compensations that affect locomotor coordination.SignificanceNeuromuscular underpinnings of spatiotemporal asymmetry have not been previously characterized. These novel findings may inform targeted therapeutic strategies to improve gait quality after stroke.

Rapid motor learning may occur in situations where individuals perceive a threat of injury if they do not perform a task well. This rapid motor learning may be facilitated by improved motor performance and, consequently, more errorless practice. As a first step towards understanding the role of perceived threat on rapid motor learning, the purpose of this study was to determine how performance of a motor task is affected in situations where perceived threat of injury is high. We hypothesized that perceived threat of injury in a virtual environment would result in improved performance of a walking task (i.e., walking on a narrow beam). Results demonstrated that increased perceived threat of injury yielded slightly greater, but not statistically significant, balance performance in virtual environments (median percentage of successful steps: 78.8%, 48.3%, and 55.2% in the real low-threat, virtual low-threat, and virtual high-threat environments, respectively). These results may be partially attributed to habituation to threat over time and practice. If implemented carefully, virtual reality technology can be an effective tool for investigating walking balance in environments that are perceived as threatening.

This study aimed to determine the validity of the centre of mass position (COM) position and extrapolated COM (XCOM), relative to the base of support, for predicting stability during a walking task where the base of support is constrained. Nine young healthy participants walked on a narrow beam. Three-dimensional motion capture was used to calculate the COM and XCOM relative to the base of support. Steps were classified as having either the COM or XCOM inside or outside the base of support, and were classified as successful (stable – foot placed on the beam) or failed (unstable – foot stepped off the beam). If the COM or XCOM are valid measures of stability, they should be within the base of support for successful steps and outside the base of support for failed steps. Classifying the COM and XCOM inside or outside the base of support correctly predicted successful or failed steps in 69% and 58% of cases, respectively. When the COM or XCOM were outside the base of support, walking faster seemed to help participants to maintain stability. The further the COM or XCOM were outside the base of support during a successful step, the more likely participants were to fail on a subsequent step. The results of this study suggest that both COM and XCOM are valid measures of stability during a beam walking task, but that classifying COM and XCOM as inside or outside the base of support may be over-simplistic.

A "reach and transport object" task that represents common activities of daily living may provide improved insight into dynamic postural stability and movement variability deficits in older adults compared to previous lean to reach and functional reach tests. Healthy young and older, community dwelling adults performed three same elevation object transport tasks and two multiple elevation object transport tasks under two self-selected speeds, self-paced and fast-paced. Dynamic postural stability and movement variability was quantified by whole-body center of mass motion. Older adults demonstrated significant decrements in frontal plane stability during the multiple elevation tasks while exhibiting the same movement variability as their younger counterparts, regardless of task speed. Interestingly, older adults did not exhibit a tradeoff in maneuverability in favour of maintaining stability throughout the tasks, as has previously been reported. In conclusion, the multi-planar, ecologically relevant tasks employed in the current study were specific enough to elucidate decrements in dynamic stability, and thus may be useful for assessing fall risk in older adults with suspected postural instability.

Rapid motor learning may occur in situations where individuals perceive a threat if they do not perform a task well. This rapid motor learning may be facilitated by improved motor performance and, consequently, more errorless practice. As a first step towards understanding the role of perceived threat on rapid motor learning, the purpose of this study was to determine how performance of a motor task is affected in situations where perceived threat is high. We hypothesized that perceived threat in a virtual environment would result in improved performance of a walking task (i.e., walking on a narrow beam). Results demonstrated that increased perceived threat did not yield statistically significantly greater balance performance in the high-threat virtual environment (median percentage of successful steps: 78.8%, 48.3%, and 55.2% in the real low-threat, virtual low-threat, and virtual high-threat environments, respectively). These results may be partially attributed to habituation to threat over time and practice. If implemented carefully, virtual reality technology can be an effective tool for investigating walking balance in environments that are perceived as threatening.

IntroductionRegular exercise is essential in the chronic phase of stroke recovery for improving or maintaining function, and reducing the risk of a second stroke. To achieve these goals, multiple components of fitness should be targeted with poststroke exercise, including aerobic capacity, strength and balance. However, following the recommended frequency and duration of each component separately can take a long time and lead to fatigue in people with stroke. Therefore, finding types of exercise that target multiple components of fitness all together is valuable.Reactive balance training (RBT) is a novel type of exercise where individuals repeatedly lose their balance in order to practise balance reactions. When people do RBT, they increase their heart rate and exert forces with their leg muscles which could improve aerobic fitness and muscle strength, respectively. This means that RBT could have the potential to improve multiple components of fitness, simultaneously.Methods and analysisThis is a randomised controlled non-inferiority trial with internal pilot study. Participants with chronic stroke will be randomly assigned to one of two groups: (1) RBT or (2) aerobic and strength training (AST). Participants in both groups will complete 1 hour of exercise, three times/week for 12 weeks. The primary objective is to determine the effect of RBT on aerobic capacity and knee muscles’ strength. The secondary objective is to determine the effects of RBT and AST on balance control and balance confidence. We expect to find that RBT is superior to AST in terms of improving balance control and balance confidence, yet not inferior to AST in terms of its effects on aerobic capacity and strength.Ethics and disseminationResearch ethics approval has been received. Results will be disseminated directly to study participants at the end of the trial, and to other stakeholders via publication in a peer-reviewed journal.Trial registration numberNCT04042961.

Background: Although perturbation-based balance training (PBT) may be effective in improving reactive balance control and/or reducing fall risk in individuals with stroke, the characteristics of reactive balance responses that improve following PBT have not yet been identified. This study aimed to determine if reactive stepping characteristics and timing in response to support-surface perturbations improved to a greater extent following PBT, compared to traditional balance training. Materials and methods: This study represents a substudy of a multisite randomized controlled trial. Sixteen individuals with chronic stroke were randomly assigned to either perturbation-based or traditional balance training, and underwent 6-weeks of training as a part of the randomized controlled trial. Responses to support-surface perturbation were evaluated pre- and post-training, and 6-months post-training. Reactive stepping characteristics and timing were compared between sessions within each group, and between groups at post-training and 6-months post-training while controlling for each measure at the pre-training session. Results: The frequency of extra steps in response to perturbations decreased from pre-training to post-training for the PBT group, but not for the control group. Conclusions: Improvements in reactive balance control were identified after PBT in individuals with chronic stroke. Findings provide insight into the mechanism by which PBT improves reactive balance control poststroke, and support the use of PBT in balance rehabilitation programs poststroke.

Dysequilibrium of cervicogenic origin can result from pain and injury to cervical paraspinal tissues post-whiplash; however, the specific physiological mechanisms still remain unclear. Central sensitization is a neuradaptive process which has been clinically associated with conditions of chronic pain and hypersensitivity. Strong links have been demonstrated between pain hypersensitivity and postural deficits post-whiplash; however, the precise mechanisms are still poorly understood. The purpose of this study was to explore the mechanisms of cervicogenic disequilibrium by investigating the effect of experimentally induced central sensitization in the cervical spine on postural stability in young healthy adults. Sixteen healthy young adults (7 males (22.6±1.13 years) and 9 females (22±2.69 years)) performed 30-s full-tandem stance trials on an AMTI force plate under normal and centrally sensitized conditions. The primary outcome variables included the standard deviation of the center of pressure (COP) position in medio-lateral (M-L) and antero-posterior (A-P) directions; sway range of the COP in M-L and A-P directions and the mean power frequency (MPF) of the COP and horizontal ground shear forces. Variability and sway range of the COP decreased with experimental induction of central sensitization, accompanied by an increase in MPF of COP displacement in both M-L and A-P directions, suggesting an increase in postural stiffening post-sensitization versus non-sensitized controls. Future studies need to further explore this relationship in clinical (whiplash, chronic pain) populations.

To date, little work has focused on whether cognitive-task interference during postural response execution is influenced by the direction and/or magnitude of the perturbation applied. Hypothetically, the increased difficulty associated with a backward loss of balance could necessitate increased allocation of cognitive resources to counteract destabilizing forces. The current study investigated these relationships using a paradigm in which individuals performed a cognitive task (auditory Stroop task during quiet stance; baseline condition). In certain trials, a translation of the support surface was concurrently evoked (magnitude: small or large; direction: forward or backward) which required a postural response to maintain balance. Ten healthy young adults completed four blocks of these experimental trials (26 randomized trials/block). Postural stability during balance recovery was evaluated using the margin of stability (MoS), while Stroop task performance was based on reaction time cost (RTC) and differences between experimental conditions. Results showed no effect of perturbation direction on RTC, but there was an observed MoS increase at peak extrapolated center of mass excursion following a small perturbation evoked concurrently with the cognitive task. No effect of cognitive-task performance was detected for MoS during stepping strategies (followed large perturbations). Instead, increased RTC were observed relative to the fixed base of support responses. In general, young adults adopted a “posture-first” strategy, regardless of perturbation direction, reinforcing the importance of cognition in the maintenance of upright balance.

Background The feasibility of using a multiple segment (full-body) kinematic model in clinical gait assessment is difficult when considering obstacles such as time and cost constraints. While simplified gait models have been explored in healthy individuals, no such work to date has been conducted in a stroke population. The aim of this study was to quantify the errors of simplified kinematic models for chronic stroke gait assessment. Methods Sixteen individuals with chronic stroke (> 6 months), outfitted with full body kinematic markers, performed a series of gait trials. Three centre of mass models were computed: (i) 13-segment whole-body model, (ii) 3 segment head-trunk-pelvis model, and (iii) 1 segment pelvis model. Root mean squared error differences were compared between models, along with correlations to measures of stroke severity. Findings Error differences revealed that, while both models were similar in the mediolateral direction, the head-trunk-pelvis model had less error in the anteroposterior direction and the pelvis model had less error in the vertical direction. There was some evidence that the head-trunk-pelvis model error is influenced in the mediolateral direction for individuals with more severe strokes, as a few significant correlations were observed between the head-trunk-pelvis model and measures of stroke severity. Interpretation These findings demonstrate the utility and robustness of the pelvis model for clinical gait assessment in individuals with chronic stroke. Low error in the mediolateral and vertical directions is especially important when considering potential stability analyses during gait for this population, as lateral stability has been previously linked to fall risk.

This study aimed to determine the validity of the centre of mass position (COM) position and extrapolated COM (XCOM), relative to the base of support, for predicting medio-lateral stability during a walking task where the base of support width is limited. Nine young healthy participants walked on a narrow beam. Three-dimensional motion capture was used to calculate the COM and XCOM relative to the base of support. Steps were classified as having either the COM or XCOM inside or outside the base of support, and were classified as successful (stable - foot placed on the beam) or failed (unstable - foot stepped off the beam). If the COM or XCOM are valid measures of stability, they should be within the base of support for successful steps and outside the base of support for failed steps. Classifying the COM and XCOM inside or outside the base of support correctly predicted successful or failed steps in 69% and 58% of cases, respectively. When the COM or XCOM were outside the base of support, walking faster seemed to help participants to maintain stability. The further the COM or XCOM were outside the base of support during a successful step, the more likely participants were to fail on a subsequent step. The results of this study suggest that both COM and XCOM are valid measures of stability during a beam walking task, but that classifying COM and XCOM as inside or outside the base of support may be over-simplistic.

Balance disruptions induced by voluntary focal arm actions are accommodated via anticipatory postural adjustments, but how this coordinated control is organized by the central nervous system remains unclear: either as combined or separate streams of postural-focal motor commands. For example, a focal arm task that dictates extremely tight temporal constraints may induce a focal response in absence of an anticipatory postural adjustment, providing evidence for separate focal-postural control streams. This study sought to probe the organization of focal-postural control via an interceptive task with very little available response time, and to determine whether focal-postural coordination depends on temporal and/or spatial foreknowledge of the task. Ten healthy young adults (5 males and 5 females; 20–29 years) reacted to catch a ball when standing under four conditions of temporal and spatial foreknowledge. Response onset was characterized by muscle activity from both postural and focal arm muscles. The catching task resulted in rapid muscle responses, but there was no difference between the fastest focal and postural muscle onsets. As expected, temporal cuing resulted in faster focal and postural onsets compared to spatial and control cuing trials. The accompaniment and time-locking of focal and postural muscle onsets, suggests that postural-focal coupling remains intact even under external time constraints and provides evidence for a single combined command stream of postural and focal control under such circumstances.

Performance decrements in balance tasks are often observed when a secondary cognitive task is performed simultaneously. This study aimed to determine whether increased cognitive load resulted in altered reactive stepping in individuals with sub-acute stroke, compared to a reactive stepping trial with no secondary task. The secondary purpose was to determine whether differences existed between the first usual-response trial, subsequent usual-response trials, and the dual-task condition. Individuals with sub-acute stroke were exposed to external perturbations to elicit reactive steps. Perturbations were performed under a usual-response (single-task) and dual-task condition. Measures of step timing and number of steps were based on force plate and video data, respectively; these measures were compared between the usual-response and dual-task trials, and between the first usual-response trial, later usual-response trials (trials 2–5) and a dual-task trial. A longer time of unloading onset and greater number of steps were identified for the first usual-response trial compared to later usual-response trials. No significant differences were identified between usual-response and dual-task trials. Although improvements were observed from the first to subsequent usual-response lean-and-release trials, performance then tended to decrease with the introduction of the dual-task condition. These findings suggest that when introduced after usual-response trials, the dual-task trial may represent the first trial of a new condition, which may be beneficial in reducing the potential for adaptation that may occur after multiple repetitions of a reactive stepping task. Therefore, these findings may lend support to the introduction of a new condition (i.e. a dual-task trial) in addition to usual-response trials when assessing reactive balance in individuals with stroke.