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Objective. The purpose of this study was to examine the feasibility of a progressive virtual exercise and self-management intervention, the TeleRehabilitation with Aims to Improve Lower extremity recovery poststroke program (TRAIL), in individuals with stroke. Methods. A single group pre-post study design was used. Thirty-two participants were recruited who were aged 19 years or older, had a stroke within 18 months of the beginning of the study, had hemiparesis of the lower extremity, and were able to tolerate 50 minutes of activity. Participants completed TRAIL, a synchronous exercise and self-management program delivered via videoconferencing. Participants received 8 telerehabilitation sessions over 4 weeks that were 60 to 90 minutes, with a trained physical therapist in a [less than or equal to]2 to 1 participant-to-therapist ratio. Feasibility indicators in the areas of process (recruitment and retention rates, perceived satisfaction), resources (treatment fidelity and adherence, participant and assessor burden, therapist burden), management (equipment, processing time), and scientific indicators (safety, treatment response, treatment effect) were collected throughout the study using a priori criteria for success. The treatment effect was examined on the Timed "Up & Go" test, the virtual Fugl--Meyer Lower Extremity Assessment, the 30-Second Sit-to-Stand Test, the Functional Reach, the Tandem Stand, the Activities-Specific Balance Confidence Scale, the Stroke Impact Scale, and the Goal Attainment Scale. Results. Forty-seven individuals were screened, of which 32 (78% male; median age of 64.5 years) were included for the study from 5 sites across Canada. Nine feasibility indicators met our study-specific threshold criteria for success: retention rate (0 dropouts), perceived satisfaction, treatment fidelity, adherence, therapist burden, equipment, and safety. In terms of treatment response and effect, improvements were observed in Timed "Up & Go" test (Cohen d = 0.57); Fugl--Meyer Lower Extremity Assessment (d = 0.76); 30-Second Sit-to-Stand Test (d = 0.89); and Goal Attainment Scale (d = 0.95). Conclusion. The delivery of TRAIL, a lower extremity stroke rehabilitation program using videoconferencing technology, is feasible and appears to have positive influences on mobility, lower extremity impairment, strength, and goal attainment. Impact. Community-based telerehabilitation programs, such as TRAIL, could extend the continuum of care during the transition back to community postdischarge or during global disruptions, such as Coronavirus Disease 2019 (COVID-19). Delivery of synchronous lower extremity rehabilitation via videoconferencing to community-dwelling stroke survivors is feasible. Keywords: Adult, Mobility, Rehabilitation, Stroke, Telemedicine, Introduction Lower extremity impairment is common after stroke, leading to restrictions in functional mobility and performance of activities of daily living. (1,2) In fact, 80% of individuals after stroke report [...]

Objective. The iWalk study showed significant increase in use of the 10-Meter Walk Test (10MWT) and 6-Minute Walk Test (6MWT) poststroke following provision of a toolkit. This paper examined the influence of contextual circumstances on use of the toolkit and implementation strategy across acute care and inpatient and outpatient rehabilitation settings. Methods. A theory-based toolkit and implementation strategy was designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting poststroke. The toolkit comprised a mobile app, video, and educational guide outlining instructions for 3 learning sessions. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, the study compared and synthesized site-specific context-mechanism-outcome descriptions across sites to refine an initial theory of how the toolkit would influence practice. Results. Analysis revealed 3 context-mechanism-outcomes: (1) No onsite facilitator? No practice change in acute care: Without an onsite facilitator, participants lacked authority to facilitate and coordinate the implementation strategy; (2) Onsite facilitation fostered integration of select practices in acute care: When onsite facilitation occurred in acute care, walk test administration and use of reference values for patient education were adopted variably with high functioning patients; (3) Onsite facilitation fostered integration of most practices in rehabilitation settings: When onsite facilitation occurred, many participants incorporated 1 or both tests to evaluate and monitor walking capacity, and reference values were applied for inpatient and outpatient education and goal setting. Participants preferentially implemented the 10MWT over the 6MWT because set-up and administration were easier and a greater proportion of patients could walk 10 m. Conclusion. Findings underscore contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings. Impact. This study shows that to foster recommended walking assessment practices, an onsite facilitator should be present to enable learning sessions and toolkit use. Keywords: Guidelines, Knowledge Translation, Standardized Assessment, Stroke, Toolkit, Walking, Introduction Stroke rehabilitation guidelines provide recommendations to guide diverse aspects of physical therapist practice. (1-4) Toolkits are a potentially low-cost strategy to support widespread implementation of recommendations for assessment and [...]

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription--the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012 to 2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. The AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke., Stroke is the second most common cause of death and third leading cause of disability worldwide. (1) Its long-term effects can be pernicious, resulting in a vicious cycle of declines [...]

Neural networks in the spinal cord, referred to as "central pattern generators" (CPGs), are capable of producing rhythmic movements, such as swimming, walking, and hopping, even when isolated from the brain and sensory inputs. This article reviews the evidence for CPGs governing locomotion and addresses other factors, including supraspinal, sensory, and neuromodulatory influences, that interact with CPGs to shape the final motor output. Supraspinal inputs play a major role not only in initiating locomotion but also in adapting the locomotor pattern to environmental and motivational conditions. Sensory afferents involved in muscle and cutaneous reflexes have important regulatory functions in preserving balance and ensuring stable phase transitions in the locomotor cycle. Neuromodulators evoke changes in cellular and synaptic properties of CPG neurons, conferring flexibility to CPG circuits. Briefly addressed is the interaction of CPG networks to produce intersegmental coordination for locomotion. Evidence for CPGs in humans is reviewed, and although a comprehensive clinical review is not an objective, examples are provided of animal and human studies that apply knowledge of CPG mechanisms to improve locomotion. The final section deals with future directions in CPG research. [MacKay-Lyons M. Central pattern generation of locomotion: a review of the evidence. Phys Ther. 2002;82:69-83.] Key Words: Central pattern generator, Locomotion, Movement sciences, Rehabilitation, Spinal cord., Walking is a complicated motor act requiring the coordination of trunk and limb muscles, crossing many joints. How the nervous system manages to accomplish this complex task has intrigued investigators [...]

Background and Purpose. External support of body weight, a technique used for the gait training of patients with neurologic conditions, may also be beneficial for tests of exercise capacity in people whose impairments in motor function and balance have traditionally precluded such testing. The purpose of this study was to investigate the effect of using external support of 15% of body mass during treadmill exercise testing of adults without impairments. Subjects and Methods. Seven men and 8 women (mean age=53.2 years, SD=11.3, range=43-82) performed 3 treadmill tests with random assignment of testing condition: (1) no body weight support (BWS)--standard test, (2) 0% BWS--harness in place but no use of external support, and (3) 15% BWS--use of external support for 15% of body mass. Expired gas was analyzed to determine oxygen uptake, carbon dioxide production, minute ventilation, tidal volume, heart rate, and respiratory exchange ratio. Results. Use of external support for 15% of body mass did not affect the end-expiratory gas exchange variables, although the time to achieve peak values was lengthened. Maximal tidal volume was lower in the 15% BWS test, but maximal minute ventilation was not different. Discussion and Conclusion. Because 15% BWS did not affect the exercise capacity of adults without known impairments, future study of its application to testing of patients with neurologic injuries is warranted. [MacKay-Lyons M, Makrides L, Speth S. Effect of 15% body weight support on exercise capacity of adults without impairments. Phys Ther. 2001;81:1790-1800.] Key Words: Energy metabolism, Exercise, Exercise test, Oxygen consumption, Rehabilitation., Over the past 2 decades, the conceptual framework guiding rehabilitation of people with neurologic conditions has undergone changes. With the emergence of the systems model of motor control, the historical [...]

Background and Purpose. Understanding the nature and extent of fluctuations in spatial and temporal variables of gait (eg, speed, stride length [SL], stride time [ST]) over the course of the levodopa (L-dopa) cycle of individuals with advanced Parkinson disease (PD) is important in order to assess patients and examine the effectiveness of interventions. The purpose of this study was to determine whether gait variables are sufficiently stable to be used as outcome measures in a clinical trial involving patients with advanced PD. Subjects. Five volunteers (3 male, 2 female; mean age=67.8 years; Hoehn and Yahr stages 3-4) with idiopathic PD of a mean duration of 15.0 years participated. Methods. Gait speed, SL, and ST were measured as the subjects walked 7.2 m at self-selected speeds. To evaluate the full "on-off" sequence of the L-dopa response, this analysis was repeated 11 times, at intervals of 10% of the L-dopa cycle. Each subject was analyzed on 3 separate days, with approximately 1 month between tests. Two-way repeated-measures analyses of covariance, with 2 within subject factors (percentage of L-dopa cycle and day) and 1 covariate (height), were applied, and coefficients of variation were calculated to determine the extent of change in speed, SL, and ST over the L-dopa cycle and over the 3 days. Results. The subjects' overall mean gait speed was 70.:39 cm/s, representing 55.4% of the age-related normative values. There were no effects of percentage of the L-dopa cycle or day or of the interaction of percentage of the L-dopa cycle and day on speed, SL, and ST. The coefficients of variation for speed and SL were consistently higher than the normative values, ranging from 13.5% to 23.8% and from 13.9% to 23.3% at 20% of the L-dopa cycle, respectively. Conclusion and Discussion. When interpreting spatiotemporal measurements of gait of patients with advanced PD, fluctuations can be extensive and may not follow a predictable pattern. [MacKay-Lyons M. Variability in spatiotemporal gait characteristics over the course of the L-dopa cycle in people with advanced Parkinson disease. Phys Ther. 1998;78:1083-1094.], Key Words: Gait, Levodopa, Motor fluctuations, Parkinson disease. Parkinson disease (PD) generally becomes manifest with a degeneration of 60% to 80% of the dopaminergic neurons in the substantia nigra or [...]