The development and feasibility of treadmill-induced fall recovery training applied to individuals with chronic stroke

Jamie Pigman, Darcy S Reisman, Ryan T Pohlig, Tamara R Wright, Jeremy R Crenshaw, Jamie Pigman, Darcy S Reisman, Ryan T Pohlig, Tamara R Wright, Jeremy R Crenshaw

Abstract

Background: Exercise has failed to reduce falls in those with chronic stroke. A limitation of traditional exercise is that the motor responses needed to prevent a fall are not elicited (i.e. they lack processing specificity). Balance reactions often require compensatory steps. Therefore, interventions that target such steps have the potential to reduce falls. Computerized treadmills can deliver precise, repeatable, and challenging perturbations as part of a training protocol. The objective of this study was to develop and determine the feasibility of such training applied to those with chronic stroke. We developed the training to address specificity, appropriate duration and repetition, and progressive overloading and individualization. We hypothesized that our intervention would be acceptable, practical, safe, and demonstrate initial signs of efficacy.

Methods: In this single-arm study, thirteen individuals with chronic stroke (29-77 years old, 2-15 years post stroke) performed up to six training sessions using a computer-controlled treadmill. Each session had separate progressions focused on initial steps with the non-paretic or paretic limbs in response to anterior or posterior falls. Perturbation magnitudes were altered based on performance and tolerance. Acceptability was determined by adherence, or the number of sessions completed. Practicality was documented by the equipment, space, time, and personnel. Adverse events were documented to reflect safety. In order to determine the potential-efficacy of this training, we compared the proportion of successful recoveries and the highest perturbation magnitude achieved on the first and last sessions.

Results: The training was acceptable, as evident by 12/13 participants completing all 6 sessions. The protocol was practical, requiring one administrator, the treadmill, and a harness. The protocol was safe, as evident by no serious or unanticipated adverse events. The protocol demonstrated promising signs of efficacy. From the first to last sessions, participants had a higher proportion of successful recoveries and progressed to larger disturbances.

Conclusions: Using a computerized treadmill, we developed an approach to fall-recovery training in individuals with chronic stroke that was specific, considered duration and repetition, and incorporated progressive overloading and individualization. We demonstrated that this training was acceptable, practical, safe, and potentially beneficial for high-functioning individuals with chronic stroke.

Trial registration: Retrospectively registered at clinicaltrials.gov ( NCT03638089 ) August 20, 2018.

Keywords: Balance; Falls; Perturbation training; Rehabilitation; Stability.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
A flowchart depicting a single fall-recovery training session. Participants performed training in this order for each of the six training sessions
Fig. 2
Fig. 2
Individuals with chronic stroke participate in trip-recovery (left) and slip-recovery (right) training. Treadmill-induced disturbances were applied to standing participants, necessitating steps to prevent a fall into a safety harness. On the left, a participant fell in response to a simulated trip (a = 4.5 m/s2) on the first training session. On the last training session, he successfully recovered from the same disturbance, initially stepping with his paretic limb. On the right, a participant fell in response to a simulated slip (a = 5.0 m/s2) during the first session. On the last training session, he successfully recovered from the same disturbance, initially stepping with his non-paretic limb

References

    1. Batchelor FA, Mackintosh SF, Said CM, Hill KD. Falls after stroke. Int J Stroke. 2012;7(6):482–490. doi: 10.1111/j.1747-4949.2012.00796.x.
    1. Gordon A, Morris R. Falls and neurological disorders. C Geriatr Med. 2008;10(3):107–113.
    1. Forster A, Young J. Incidence and consequences of falls due to stroke: a systematic inquiry. BMJ. 1995;311(6997):83–86. doi: 10.1136/bmj.311.6997.83.
    1. Jorgensen L, Jacosen BK. Higher incidence of falls in long-term stroke survivors than in Populationn controls. Stroke. 2002;33:542–547. doi: 10.1161/hs0202.102375.
    1. Sherrington C, Michaleff ZA, Fairhall N, Paul SS, Tiedemann A, Whitney J, et al. Exercise to prevent falls in older adults: an updated systematic review and meta-analysis. Br J Sports Med. 2017;51(24):1750 LP–1751758. doi: 10.1136/bjsports-2016-096547.
    1. Verheyden GS a F, Weerdesteyn V, Pickering RM, Kunkel D, Lennon S, Geurts ACH, et al. Interventions for preventing falls in people after stroke. Cochrane Database Syst Rev. 2013;5(5):CD008728.
    1. Batchelor FA, Hill K, MacKintosh S, Said C. What works in falls prevention after stroke?: a systematic review and meta-analysis. Stroke. 2010;41(8):1715–1722. doi: 10.1161/STROKEAHA.109.570390.
    1. Schmidt R, Lee T. Motor Control and Learning: A Behavioral Emphasis [Internet]. Human Kinetics. 2011. 592 p. Available from: .
    1. Schmid AA, Yaggi HK, Burrus N, McClain V, Austin C, Ferguson J, et al. Circumstances and consequences of falls among people with chronic stroke. J Rehabil Res Dev. 2013;50(9):1277–1286. doi: 10.1682/JRRD.2012.11.0215.
    1. Pavol MJ, Owings TM, Foley KT, Grabiner MD. Mechanisms leading to a fall from an induced trip in healthy older adults. J Gerontol A Biol Sci Med Sci. 2001;56(7):M428–M437. doi: 10.1093/gerona/56.7.M428.
    1. Redfern MS, Cham R, Gielo-Perczak K, Grönqvist R, Hirvonen M, Lanshammar H, et al. Biomechanics of slips. Ergonomics. 2001;44(13):1138–1166. doi: 10.1080/00140130110085547.
    1. Honeycutt CF, Nevisipour M, Grabiner MD. Characteristics and adaptive strategies linked with falls in stroke survivors from analysis of laboratory-induced falls. J Biomech. 2016;49(14):3313–3319. doi: 10.1016/j.jbiomech.2016.08.019.
    1. Inness EL, Mansfield A, Biasin L, Brunton K, Bayley M, McIlroy WE. Clinical implementation of a reactive balance control assessment in a sub-acute stroke patient population using a “lean-and-release” methodology. Gait Posture. 2015;41:529–534. doi: 10.1016/j.gaitpost.2014.12.005.
    1. Inness EL, Mansfield A, Lakhani B, Bayley M, McIlroy WE. Impaired reactive stepping among patients ready for discharge from inpatient stroke rehabilitation. Phys Ther. 2014;94(12):1755–1764. doi: 10.2522/ptj.20130603.
    1. Mansfield A, Wong JSS, McIlroy WEE, Biasin L, Brunton K, Bayley M, et al. Do measures of reactive balance control predict falls in people with stroke returning to the community? Physiotherapy. 2015;101(4):373–380. doi: 10.1016/j.physio.2015.01.009.
    1. Patel PJ, Bhatt T. Does aging with a cortical lesion increase fall-risk: examining effect of age versus stroke on intensity modulation of reactive balance responses from slip-like perturbations. Neuroscience. 2016;333:252–263. doi: 10.1016/j.neuroscience.2016.06.044.
    1. Salot P, Patel P, Bhatt T. Reactive balance in individuals with chronic stroke: biomechanical factors related to perturbation-induced backward falling. Phys Ther. 2016;96(3):338–347. doi: 10.2522/ptj.20150197.
    1. Kajrolkar T, Bhatt T. Falls-risk post-stroke: examining contributions from paretic versus non paretic limbs to unexpected forward gait slips. J Biomech. 2016;49(13):2702–2708. doi: 10.1016/j.jbiomech.2016.06.005.
    1. de Kam D, Roelofs JMB, Bruijnes AKBD, Geurts ACH, Weerdesteyn V. The next step in understanding impaired reactive balance control in people with stroke: the role of defective early automatic postural responses. Neurorehabil Neural Repair. 2017;31(8):708–716. doi: 10.1177/1545968317718267.
    1. Martinez KM, Mille ML, Zhang Y, Rogers MW. Stepping in persons poststroke: comparison of voluntary and perturbation-induced responses. Arch Phys Med Rehabil. 2013;94(12):2425–2432. doi: 10.1016/j.apmr.2013.06.030.
    1. Mansfield A, Inness EL, Lakhani B, McIlroy WE. Determinants of limb preference for initiating compensatory stepping poststroke. Arch Phys Med Rehabil. 2012;93(7):1179–1184. doi: 10.1016/j.apmr.2012.02.006.
    1. Marigold DS, Eng JJ. Altered timing of postural reflexes contributes to falling in persons with chronic stroke. Exp Brain Res. 2006;171(4):459–468. doi: 10.1007/s00221-005-0293-6.
    1. Hocherman S, Dickstein R, Pillar T. Platform training and postural stability in hemiplegia. Arch Phys Med Rehabil. 1984;65(10):588–592.
    1. Dickstein R, Hocherman S, Dannenbaum E, Shina N, Pillar T. Stance stability and EMG changes in the ankle musculature of Hemiparetic patients trained on a moveable platform. Neurorehabil Neural Repair. 1991;5(4):201–209. doi: 10.1177/136140969100500402.
    1. Kajrolkar T, Yang F, Pai YC, Bhatt T. Dynamic stability and compensatory stepping responses during anterior gait-slip perturbations in people with chronic hemiparetic stroke. J Biomech. 2014;47(11):2751–2758. doi: 10.1016/j.jbiomech.2014.04.051.
    1. Mansfield A, Aqui A, Danells CJ, Knorr S, Centen A, DePaul VG, et al. Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial. BMJ Open. 2018;8(8):e021510. doi: 10.1136/bmjopen-2018-021510.
    1. Mansfield A., Wong J. S., Bryce J., Knorr S., Patterson K. K. Does Perturbation-Based Balance Training Prevent Falls? Systematic Review and Meta-Analysis of Preliminary Randomized Controlled Trials. Physical Therapy. 2014;95(5):700–709. doi: 10.2522/ptj.20140090.
    1. Mansfield A, Schinkel-Ivy A, Danells CJ, Aqui A, Aryan R, Biasin L, et al. Does perturbation training prevent falls after discharge from stroke rehabilitation? A prospective cohort study with historical control. J Stroke Cerebrovasc Dis. 2017;26(10):2174–2180. doi: 10.1016/j.jstrokecerebrovasdis.2017.04.041.
    1. Mansfield A, Maki BE. Are age-related impairments in change-in-support balance reactions dependent on the method of balance perturbation? J Biomech. 2009;42(8):1023–1031. doi: 10.1016/j.jbiomech.2009.02.007.
    1. Grabiner MD, Crenshaw JR, Hurt CP, Rosenblatt NJ, Troy KL. Exercise-based fall prevention: can you be a bit more specific? Exerc Sport Sci Rev. 2014;42(4):161–168. doi: 10.1249/JES.0000000000000023.
    1. Bieryla KA, Madigan ML, Nussbaum MA. Practicing recovery from a simulated trip improves recovery kinematics after an actual trip. Gait Posture. 2007;26(2):208–213. doi: 10.1016/j.gaitpost.2006.09.010.
    1. Kaufman KR, Wyatt MP, Sessoms PH, Grabiner MD. Task-specific fall prevention training is effective for warfighters with Transtibial amputations. Clin Orthop Relat Res. 2014;472(10):3076–3084. doi: 10.1007/s11999-014-3664-0.
    1. Crenshaw JR, Kaufman KR, Grabiner MD. Compensatory-step training of healthy, mobile people with unilateral, transfemoral or knee disarticulation amputations: a potential intervention for trip-related falls. Gait Posture. 2013;38(3):500–506. doi: 10.1016/j.gaitpost.2013.01.023.
    1. Crenshaw JR, Bernhardt KA, Fortune E, Kaufman KR. The accuracy of rapid treadmill-belt movements as a means to deliver standing postural perturbations. Med Eng Phys. 2019;64:93–99. doi: 10.1016/j.medengphy.2018.12.017.
    1. Owings TM, Pavol MJ, Grabiner MD. Mechanisms of failed recovery following postural perturbations on a motorized treadmill mimic those associated with an actual forward trip. Clin Biomech. 2001;16(9):813–819. doi: 10.1016/S0268-0033(01)00077-8.
    1. Yang F, Bhatt T, Pai YC. Generalization of treadmill-slip training to prevent a fall following a sudden (novel) slip in over-ground walking. J Biomech. 2013;46(1):63–69. doi: 10.1016/j.jbiomech.2012.10.002.
    1. Bowen DJ, Kreuter M, Spring B, Linnan L, Weiner D, Bakken S, et al. How we design feasibility studies. Am J Prev Med. 2010;36(5):452–457. doi: 10.1016/j.amepre.2009.02.002.
    1. Kanis JA, Melton LJ, Christiansen C, Johnston CC, Khaltaev N. The diagnosis of osteoporosis. J Bone Miner Res. 2009;9(8):1137–1141. doi: 10.1002/jbmr.5650090802.
    1. Crenshaw JR, Bernhardt KA, Atkinson EJ, Khosla S, Kaufman KR, Amin S. The relationships between compensatory stepping thresholds and measures of gait, standing postural control, strength, and balance confidence in older women. Gait Posture. 2018;65(June):74–80. doi: 10.1016/j.gaitpost.2018.06.117.
    1. Mansfield A, Peters AL, B a L, Maki BE. A perturbation-based balance training program for older adults: study protocol for a randomised controlled trial. BMC Geriatr. 2007;7:12. doi: 10.1186/1471-2318-7-12.
    1. Mansfield A, Aqui A, Centen A, Danells CJ, DePaul VG, Knorr S, et al. Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. BMC Neurol. 2015;15:87. doi: 10.1186/s12883-015-0347-8.
    1. Haff GH, Coburn W, Malek J. NSCA’s essentials of personal training. 2nd ed. Champaign: kinetics, human. 2012. Resistance Program Design; pp. 347–388.
    1. Kleim JA, Jones TA. Principles of Experience-Dependent Neural Plasticity: Implications for Rehabilitation After Brain Damage. J Speech Lang Hear Res [Internet]. 2008;51(1):S225. Available from: .
    1. Pijnappels M, Bobbert MF, Van Dieën JH. How early reactions in the support limb contribute to balance recovery after tripping. J Biomech. 2005;38(3):627–634. doi: 10.1016/j.jbiomech.2004.03.029.
    1. Pijnappels M, Bobbert MF, Van Dieën JH. Push-off reactions in recovery after tripping discriminate young subjects, older non-fallers and older fallers. Gait Posture. 2005;21:388–394. doi: 10.1016/j.gaitpost.2004.04.009.
    1. Crenshaw JR, Rosenblatt NJ, Hurt CP, Grabiner MD. The discriminant capabilities of stability measures, trunk kinematics, and step kinematics in classifying successful and failed compensatory stepping responses by young adults. J Biomech. 2012;45(1):129–133. doi: 10.1016/j.jbiomech.2011.09.022.
    1. Eng JJ, D a W, Patla a E. Strategies for recovery from a trip in early and late swing during human walking. Exp Brain Res. 1994;102(2):339–349. doi: 10.1007/BF00227520.
    1. Sawers XA, Pai YC, Bhatt T, Ting LH. Control of movement neuromuscular responses differ between slip-induced falls and recoveries in older adults. 2018. pp. 509–522.
    1. Yang F, Espy D, Bhatt T, Pai YC. Two types of slip-induced falls among community dwelling older adults. J Biomech. 2012;45(7):1259–1264. doi: 10.1016/j.jbiomech.2012.01.036.
    1. Cham R, Redfern MS. Lower extremity corrective reactions to slip events. J Biomech. 2001;34(11):1439–1445. doi: 10.1016/S0021-9290(01)00116-6.
    1. Troy KL, Donovan SJ, Marone JR, Lou BM, Grabiner MD. Modifiable performance domain risk-factors associated with slip-related falls. Gait Posture. 2008;28(3):461–465. doi: 10.1016/j.gaitpost.2008.02.008.
    1. Patel Prakruti, Bhatt Tanvi. Adaptation to large-magnitude treadmill-based perturbations: improvements in reactive balance response. Physiological Reports. 2015;3(2):e12247. doi: 10.14814/phy2.12247.
    1. GRABINER MARK D., BAREITHER MARY LOU, GATTS STRAWBERRY, MARONE JANE, TROY KAREN L. Task-Specific Training Reduces Trip-Related Fall Risk in Women. Medicine & Science in Sports & Exercise. 2012;44(12):2410–2414. doi: 10.1249/MSS.0b013e318268c89f.
    1. Rosenblatt Noah J., Marone Jane, Grabiner Mark D. Preventing Trip-Related Falls by Community-Dwelling Adults: A Prospective Study. Journal of the American Geriatrics Society. 2013;61(9):1629–1631. doi: 10.1111/jgs.12428.
    1. Lee A, Bhatt T, Liu X, Wang Y, Pai YC. Can higher training practice dosage with treadmill slip-perturbation necessarily reduce risk of falls following overground slip? Gait Posture. 2018;61(January):387–392. doi: 10.1016/j.gaitpost.2018.01.037.
    1. McCrum C, Meijer K, Karamanidis K, Willems P, Zijlstra W. Retention, savings and interlimb transfer of reactive gait adaptations in humans following unexpected perturbations. Commun Biol. 2018;1(1) Available from: 10.1038/s42003-018-0238-9.
    1. Rosenblatt N, Marone J, Grabiner MD. Task-specific training decreases falls by older women in the community: 6 month prospective data. Gerontologist. 2010;50:412.
    1. Mansfield A, Inness EL, Komar J, Biasin L, Brunton K, Lakhani B, et al. An individual with stroke. Phys Ther. 2011;91(6):958–969. doi: 10.2522/ptj.20100212.
    1. Lee A, Bhatt T, Pai Y-C. Generalization of treadmill perturbation to overground slip during gait: effect of different perturbation distances on slip recovery. J Biomech. 2016;49(2):149–154. doi: 10.1016/j.jbiomech.2015.11.021.
    1. Yang F, Wang TY, Pai YC. Reduced intensity in gait-slip training can still improve stability. J Biomech. 2014;47(10):2330–2338. doi: 10.1016/j.jbiomech.2014.04.021.
    1. Cyr MA. Smeesters C. Maximum allowable force on a safety harness cable to discriminate a successful from a failed balance recovery. J Biomech. 2009;42:1566–1569. doi: 10.1016/j.jbiomech.2009.04.003.
    1. FDA. Reporting serious problems to FDA - What is a serious adverse event? [Internet]. 2 January 2016. Office of the Commissioner; 2016 [cited 2018 Aug 20]. Available from:
    1. Pang MYC, Eng JJ. Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density. Osteoporos Int. 2008;19(7):919–927. doi: 10.1007/s00198-007-0519-5.
    1. Danks KA, Pohlig RT, Roos M, Wright TR, Reisman DS. Relationship between walking capacity, biopsychosocial factors, self-efficacy, and walking activity in persons Poststroke. J Neurol Phys Ther. 2016;40(4):232–238. doi: 10.1097/NPT.0000000000000143.
    1. French MA, Moore MF, Pohlig R, Reisman D. Self-efficacy mediates the relationship between balance/walking performance, activity, and participation after stroke. Top Stroke Rehabil. 2016;23(2):77–83. doi: 10.1080/10749357.2015.1110306.
    1. Marigold DS, Eng JJ, Dawson AS, Inglis JT, Harris JE, Gylfadottir S. Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke. J Am Geriatr Soc. 2005;53(3):416–423. doi: 10.1111/j.1532-5415.2005.53158.x.
    1. Zijlstra GAR, Van Haastregt JCM, Van Rossum E, Van Eijk JTM, Yardley L, Kempen GIJM. Interventions to reduce fear of falling in community-living older people: a systematic review. J Am Geriatr Soc. 2007;55(4):603–615. doi: 10.1111/j.1532-5415.2007.01148.x.
    1. Geurts ACHHA, de HM, van NI, Duysens J, De Haart M, van Nes IJWW, et al. A review of standing balance recovery from stroke. Gait Posture. 2005;22(3):267–281. doi: 10.1016/j.gaitpost.2004.10.002.
    1. Holt RR, Simpson D, Jenner JR, Kirker SG, Wing AM. Ground reaction force after a sideways push as a measure of balance in recovery from stroke. Clin Rehabil. 2000;14(1):88–95. doi: 10.1191/026921500668655351.
    1. McIlroy WE, Maki BE. The control of lateral stability during rapid stepping reactions evoked by antero-posterior perturbation: does anticipatory control play a role? Gait Posture. 1999;9(3):190–198. doi: 10.1016/S0966-6362(99)00013-2.
    1. Crenshaw JR, Kaufman KR. The intra-rater reliability and agreement of compensatory stepping thresholds of healthy subjects. Gait Posture. 2014;39(2):810–815. doi: 10.1016/j.gaitpost.2013.11.006.
    1. Mackintosh SF, Goldie P, Hill K. Falls incidence and factors associated with falling in older, community-dwelling. Aging Clin Exp Res. 2005;17(2):74–81. doi: 10.1007/BF03324577.
    1. Hyndman D, Ashburn A, Stack E. Fall events among people with stroke living in the community: circumstances of falls and characteristics of fallers. Arch Phys Med Rehabil. 2002;83(February):165–170. doi: 10.1053/apmr.2002.28030.
    1. Gücüyener D, Ugur C, Uzuner N, Özdemir G. The importance of falls in stroke patients. Ann Saudi Med. 2000;20(3–4):322–323. doi: 10.5144/0256-4947.2000.322.
    1. Joyce BM, Kirby RL. Canes, crutches and walkers. Am Fam Physician. 1991;43(2):535–542.
    1. Kuan T, Tsou J. Hemiplegic gait of stroke patients : the effect of using a cane. Am Congr Rehabil Med Am Acad Phys Med Rehabil. 1999;80:777–784.
    1. Bateni H, Heung E, Zettel J, Mcllroy WE, Maki BE. Can use of walkers or canes impede lateral compensatory stepping movements ? Gait Posture. 2004;20:74–83. doi: 10.1016/S0966-6362(03)00098-5.
    1. Hall CD, Jensen JL. The effect of cane use on the compensatory step following posterior perturbations. Clin Biomech. 2004;19:678–687. doi: 10.1016/j.clinbiomech.2004.05.002.
    1. Boonsinsukh R, Saengsirisuwan V, Carlson-kuhta P, Horak FB. A cane improves postural recovery from an unpracticed slip during walking in people with Parkinson disease. Phys Ther. 2012;92(9):1117–1129. doi: 10.2522/ptj.20120036.
    1. Eldridge Sandra M., Lancaster Gillian A., Campbell Michael J., Thabane Lehana, Hopewell Sally, Coleman Claire L., Bond Christine M. Defining Feasibility and Pilot Studies in Preparation for Randomised Controlled Trials: Development of a Conceptual Framework. PLOS ONE. 2016;11(3):e0150205. doi: 10.1371/journal.pone.0150205.

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