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BACKGROUND AND PURPOSE: Previous data suggest that large amounts of high-intensity stepping training in variable contexts (tasks and environments) may improve locomotor function, aerobic capacity, and treadmill gait kinematics in individuals poststroke. Whether similar training strategies are tolerated and efficacious for patients with other acute-onset neurological diagnoses, such as motor incomplete spinal cord injury (iSCI), is unknown. Individuals with iSCI potentially have greater bilateral impairments. This case series evaluated the feasibility and preliminary short- and long-term efficacy of high-intensity variable stepping practice in ambulatory participants for more than 1 year post-iSCI. CASE SERIES DESCRIPTION: Four participants with iSCI (neurological levels C5-T3) completed up to 40 one-hour sessions over 3 to 4 months. Stepping training in variable contexts was performed at up to 85% maximum predicted heart rate, with feasibility measures of patient tolerance, total steps/session, and intensity of training. Clinical measures of locomotor function, balance, peak metabolic capacity, and gait kinematics during graded treadmill assessments were performed at baseline and posttraining, with more than 1-year follow-up. OUTCOMES: Participants completed 24 to 40 sessions over 8 to 15 weeks, averaging 2222 ± 653 steps per session, with primary adverse events of fatigue and muscle soreness. Modest improvements in locomotor capacity where observed at posttraining, with variable changes in lower extremity kinematics during treadmill walking. DISCUSSION: High-intensity, variable stepping training was feasible and tolerated by participants with iSCI although only modest gains in gait function or quality were observed. The utility of this intervention in patients with more profound impairments may be limited.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A200).

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We investigated the relationships between average gait speed collected with the 10Meter Walk Test (Comfortable and Fast) and 6Minute Walk Test (6MWT) in 346 people with Parkinson disease (PD) and how the relationships change with increasing disease severity. Pearson correlation and linear regression analyses determined relationships between 10Meter Walk Test and 6MWT gait speed values for the entire sample and for sub-samples stratified by Hoehn & Yahr (H&Y) stage I (n=53), II (n=141), III (n=135) and IV (n=17). We hypothesized that redundant tests would be highly and significantly correlated (i.e. r>0.70, p<0.05) and would have a linear regression model slope of 1 and intercept of 0. For the entire sample, 6MWT gait speed was significantly (p<0.001) related to the Comfortable 10 Meter Walk Test (r=0.75) and Fast 10Meter Walk Test (r=0.79) gait speed, with 56% and 62% of the variance in 6MWT gait speed explained, respectively. The regression model of 6MWT gait speed predicted by Comfortable 10 Meter Walk gait speed produced slope and intercept values near 1 and 0, respectively, especially for participants in H&Y stages II-IV. In contrast, slope and intercept values were further from 1 and 0, respectively, for the Fast 10Meter Walk Test. Comfortable 10 Meter Walk Test and 6MWT gait speeds appeared to be redundant in people with moderate to severe PD, suggesting the Comfortable 10 Meter Walk Test can be used to estimate 6MWT distance in this population.

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BACKGROUND AND PURPOSE: Impairments in metabolic capacity and economy (O2cost) are hallmark characteristics of locomotor dysfunction following stroke. High-intensity (aerobic) training has been shown to improve peak oxygen consumption in this population, with fewer reports of changes in O2cost. However, particularly in persons with subacute stroke, inconsistent gains in walking function are observed with minimal associations with gains in metabolic parameters. The purpose of this study was to evaluate changes in aerobic exercise performance in participants with subacute stroke following high-intensity variable stepping training as compared with conventional therapy. METHODS: A secondary analysis was performed on data from a randomized controlled trial comparing high-intensity training with conventional interventions, and from the pilot study that formed the basis for the randomized controlled trial. Participants 1 to 6 months poststroke received 40 or fewer sessions of high-intensity variable stepping training (n = 21) or conventional interventions (n = 12). Assessments were performed at baseline (BSL), posttraining, and 2- to 3-month follow-up and included changes in submaximal (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2submax) and O2cost at fastest possible treadmill speeds and peak speeds at BSL testing. RESULTS: Significant improvements were observed in (Equation is included in full-text article.)O2submax with less consistent improvements in O2cost, although individual responses varied substantially. Combined changes in both (Equation is included in full-text article.)O2submax and (Equation is included in full-text article.)O2 at matched peak BSL speeds revealed stronger correlations to improvements in walking function as compared with either measure alone. DISCUSSION AND CONCLUSIONS: High-intensity stepping training may elicit significant improvements in (Equation is included in full-text article.)O2submax, whereas changes in both peak capacity and economy better reflect gains in walking function. Providing high-intensity training to improve locomotor and aerobic exercise performance may increase the efficiency of rehabilitation sessions.Video Abstract available for more insights from the authors (see Supplemental Digital Content, http://links.lww.com/JNPT/A142).

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BACKGROUND: Converging evidence suggests that the amount of stepping practice is an important training parameter that influences locomotor recovery poststroke. More recent data suggest that stepping intensity and variability are also important, although such strategies are often discouraged early poststroke. OBJECTIVE: The present study examined the efficacy of high-intensity, variable stepping training on walking and nonwalking outcomes in individuals 1 to 6 months poststroke as compared with conventional interventions. Methods Individuals with unilateral stroke (mean duration = 101 days) were randomized to receive ≤40, 1-hour experimental or control training sessions over 10 weeks. Experimental interventions consisted only of stepping practice at high cardiovascular intensity (70%-80% heart rate reserve) in variable contexts (tasks or environments). Control interventions were determined by clinical physical therapists and supplemented using standardized conventional strategies. Blinded assessments were obtained at baseline, midtraining, and posttraining with a 2-month follow-up. Results A total of 32 individuals (15 experimental) received different training paradigms that varied in the amount, intensity, and types of tasks performed. Primary outcomes of walking speed (experimental, 0.27 ± 0.22 m/s vs control, 0.09 ± 0.09 m/s) and distances (119 ± 113 m vs 30 ± 32 m) were different between groups, with stepping amount and intensity related to these differences. Gains in temporal gait symmetry and self-reported participation scores were greater following experimental training, without differences in balance or sit-to-stand performance. Conclusion Variable intensive stepping training resulted in greater improvements in walking ability than conventional interventions early poststroke. Future studies should evaluate the relative contributions of these training parameters.

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BACKGROUND: Freezing of gait (FOG) is a relatively common and remarkably disabling impairment associated with Parkinson disease (PD). Laboratory-based measures indicate that individuals with FOG (PD+FOG) have greater balance deficits than those without FOG (PD-FOG). Whether such differences also can be detected using clinical balance tests has not been investigated. We sought to determine if balance and specific aspects of balance, measured using Balance Evaluation Systems Test (BESTest), differs between PD+FOG and PD-FOG. Furthermore, we aimed to determine if time-efficient clinical balance measures (i.e. Mini-BESTest, Berg Balance Scale (BBS)) could detect balance differences between PD+FOG and PD-FOG. METHODS: Balance of 78 individuals with PD, grouped as either PD+FOG (n=32) or PD-FOG (n=46), was measured using the BESTest, Mini-BESTest, and BBS. Between-groups comparisons were conducted for these measures and for the six sections of the BESTest using analysis of covariance. A PD composite score was used as a covariate. RESULTS: Controlling for motor sign severity, PD duration, and age, PD+FOG had worse balance than PD-FOG when measured using the BESTest (p=0.008, F=7.35) and Mini-BESTest (p=0.002, F=10.37), but not the BBS (p=0.27, F=1.26). BESTest section differences were noted between PD+FOG and PD-FOG for reactive postural responses (p<0.001, F=14.42) and stability in gait (p=0.003, F=9.18). CONCLUSIONS: The BESTest and Mini-BESTest, which specifically assessed reactive postural responses and stability in gait, were more likely than the BBS to detect differences in balance between PD+FOG and PD-FOG. Because it is more time efficient to administer, the Mini-BESTest may be the preferred tool for assessing balance deficits associated with FOG.

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BACKGROUND: Assessment of fall risk in an individual with Parkinson disease (PD) is a critical yet often time consuming component of patient care. Recently a simple clinical prediction tool based only on fall history in the previous year, freezing of gait in the past month, and gait velocity <1.1 m/s was developed and accurately predicted future falls in a sample of individuals with PD. METHODS: We sought to externally validate the utility of the tool by administering it to a different cohort of 171 individuals with PD. Falls were monitored prospectively for 6 months following predictor assessment. RESULTS: The tool accurately discriminated future fallers from non-fallers (area under the curve [AUC] = 0.83; 95% CI 0.76-0.89), comparable to the developmental study. CONCLUSION: The results validated the utility of the tool for allowing clinicians to quickly and accurately identify an individual's risk of an impending fall.

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BACKGROUND: Optimal physical therapy strategies to maximize locomotor function in patients early poststroke are not well established. Emerging data indicate that substantial amounts of task-specific stepping practice may improve locomotor function, although stepping practice provided during inpatient rehabilitation is limited (<300 steps/session). OBJECTIVE: The purpose of this investigation was to determine the feasibility of providing focused stepping training to patients early poststroke and its potential association with walking and other mobility outcomes. METHODS: Daily stepping was recorded on 201 patients <6 months poststroke (80% < 1 month) during inpatient rehabilitation following implementation of a focused training program to maximize stepping practice during clinical physical therapy sessions. Primary outcomes included distance and physical assistance required during a 6-minute walk test (6MWT) and balance using the Berg Balance Scale (BBS). Retrospective data analysis included multiple regression techniques to evaluate the contributions of demographics, training activities, and baseline motor function to primary outcomes at discharge. RESULTS: Median stepping activity recorded from patients was 1516 steps/d, which is 5 to 6 times greater than that typically observed. The number of steps per day was positively correlated with both discharge 6MWT and BBS and improvements from baseline (changes; r = 0.40-0.87), independently contributing 10% to 31% of the total variance. Stepping activity also predicted level of assistance at discharge and discharge location (home vs other facility). CONCLUSION: Providing focused, repeated stepping training was feasible early poststroke during inpatient rehabilitation and was related to mobility outcomes. Further research is required to evaluate the effectiveness of these training strategies on short- or long-term mobility outcomes as compared with conventional interventions.

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BACKGROUND: The natural progression of balance decline in individuals with Parkinson disease (PD) is not well understood. OBJECTIVES: We aimed to: 1) compare the utility of three standardized clinical measures for detecting balance decline over 1-year, 2) identify components of balance susceptible to decline, and 3) identify factors useful for predicting future balance decline. METHODS: Eighty people with PD (59% male; mean age 68.2 ± 9.3; Hoehn & Yahr range I-IV) completed Balance Evaluation Systems Test (BESTest), Mini-BESTest, and Berg Balance Scale (BBS) assessments. Baseline predictor variables included the MDS-UPDRS III sub-score, presence of freezing, 6-month fall history, age, gender, and physical activity. Balance and MDS-UPDRS III assessments were repeated at 6 (n = 51) and 12 months (n = 44). RESULTS: BESTest and Mini-BESTest score declined over 6 and 12 months (P < 0.01). Postural responses, stability limits, and sensory orientation were most susceptible to decline. BBS score did not change (P > 0.01). MDS-UPDRS III score was unchanged over 6 months (P > 0.01), but declined over 12 months (P < 0.01). Change in BESTest score over 6 months was related to baseline MDS-UPDRS III, H&Y, freezing, and fall history (P < 0.05). Change in BESTest score over 12 months was related to baseline MDS-UPDRS III and freezing (P < 0.05). Change in Mini-BESTest over 12 months was related to baseline MDS-UPDRS III and age (P < 0.05). CONCLUSIONS: The BESTest and Mini-BESTest were responsive to balance decline in individuals with PD and helped to identify decline in underlying balance components. Disease severity and freezing most consistently predicted balance decline in persons with PD.

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BACKGROUND: During the physical rehabilitation of individuals poststroke, therapists are challenged to provide sufficient amounts of task-specific practice in order to maximize outcomes of multiple functional skills within limited visits. Basic and applied studies have suggested that training of one motor task may affect performance of biomechanically separate tasks that utilize overlapping neural circuits. However, few studies have explicitly investigated the impact of training one functional task on separate, nonpracticed tasks. OBJECTIVE: The purpose of this preliminary study was to investigate the potential gains in specific nonlocomotor assessments in individuals poststroke following only stepping training of variable, challenging tasks at high aerobic intensities. METHODS: Individuals with locomotor deficits following subacute and chronic stroke (n=22) completed a locomotor training paradigm using a repeated-measures design. Practice of multiple stepping tasks was provided in variable environments or contexts at high aerobic intensities for ≥40 sessions over 10 weeks. The primary outcome was timed Five-Times Sit-to-Stand Test (5XSTS) performance, with secondary measures of sit-to-stand kinematics and kinetics, clinical assessment of balance, and isometric lower limb strength. RESULTS: Participants improved their timed 5XSTS performance following stepping training, with changes in selected biomechanical measures. Statistical and clinically meaningful improvements in balance were observed, with more modest changes in paretic leg strength. CONCLUSIONS: The present data suggest that significant gains in selected nonlocomotor tasks can be achieved with high-intensity, variable stepping training. Improvements in nonpracticed tasks may minimize the need to practice multiple tasks within and across treatment sessions.

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BACKGROUND: Previous data suggest that the amount and aerobic intensity of stepping training may improve walking poststroke. Recent animal and human studies suggest that training in challenging and variable contexts can also improve locomotor function. Such practice may elicit substantial stepping errors, although alterations in locomotor strategies to correct these errors could lead to improved walking ability. OBJECTIVE: This unblinded pilot study was designed to evaluate the feasibility and preliminary efficacy of providing stepping practice in variable, challenging contexts (tasks and environments) at high aerobic intensities in participants >6 months and 1-6 months post-stroke. METHODS: A total of 25 participants (gait speeds <0.9 m/s with no more than moderate assistance) participated in ≤40 training sessions (duration of 1 hour) within 10 weeks. Stepping training in variable, challenging contexts was performed at 70% to 80% heart rate reserve, with feasibility measures of total steps/session, ability to achieve targeted intensities, patient tolerance, dropouts, and adverse events. Gait speed, symmetry, and 6-minute walk were measured every 4 to 5 weeks or 20 sessions, with a 3-month follow-up (F/U). RESULTS: In all, 22 participants completed ≥4 training weeks, averaging 2887 ± 780 steps/session over 36 ± 5.8 sessions. Self-selected (0.38 ± 0.27 to 0.66 ± 0.35 m/s) and fastest speed (0.51 ± 0.40 to 0.99 ± 0.58 m/s), paretic single-limb stance (20% ± 5.9% to 25% ± 6.4%), and 6-minute walk (141 ± 99 to 260 ± 146 m) improved significantly at posttraining. CONCLUSIONS: This preliminary study suggests that stepping training at high aerobic intensities in variable contexts was tolerated by participants poststroke, with significant locomotor improvements. Future studies should delineate the relative contributions of amount, intensity, and variability of stepping training to maximize outcomes.

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BACKGROUND: The newly developed brief-balance evaluation system test (brief-BESTest) may be useful for measuring balance and predicting falls in individuals with Parkinson disease (PD). OBJECTIVES: The purposes of this study were: (1) to describe the balance performance of those with PD using the brief-BESTest, (2) to determine the relationships among the scores derived from the 3 versions of the BESTest (i.e., full BESTest, mini-BESTest, and brief-BESTest), and (3) to compare the accuracy of the brief-BESTest with that of the mini-BESTest and BESTest in identifying recurrent fallers among people with PD. DESIGN: This was a prospective cohort study. METHODS: Eighty participants with PD completed a baseline balance assessment. All participants reported a fall history during the previous 6 months. Fall history was again collected 6 months (n=51) and 12 months (n=40) later. RESULTS: At baseline, participants had varying levels of balance impairment, and brief-BESTest scores were significantly correlated with mini-BESTest (r=.94, P<.001) and BESTest (r=.95, P<.001) scores. Six-month retrospective fall prediction accuracy of the Brief-BESTest was moderately high (area under the curve [AUC]=0.82, sensitivity=0.76, and specificity=0.84). Prospective fall prediction accuracy over 6 months was similarly accurate (AUC=0.88, sensitivity=0.71, and specificity=0.87), but was less sensitive over 12 months (AUC=0.76, sensitivity=0.53, and specificity=0.93). LIMITATIONS: The sample included primarily individuals with mild to moderate PD. Also, there was a moderate dropout rate at 6 and 12 months. CONCLUSIONS: All versions of the BESTest were reasonably accurate in identifying future recurrent fallers, especially during the 6 months following assessment. Clinicians can reasonably rely on the brief-BESTest for predicting falls, particularly when time and equipment constraints are of concern.

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Introduction. We analyzed the ability of four balance assessments to predict falls in people with Parkinson Disease (PD) prospectively over six and 12 months. Materials and Methods. The BESTest, Mini-BESTest, Functional Gait Assessment (FGA), and Berg Balance Scale (BBS) were administered to 80 participants with idiopathic PD at baseline. Falls were then tracked for 12 months. Ability of each test to predict falls at six and 12 months was assessed using ROC curves and likelihood ratios (LR). Results. Twenty-seven percent of the sample had fallen at six months, and 32% of the sample had fallen at 12 months. At six months, areas under the ROC curve (AUC) for the tests ranged from 0.8 (FGA) to 0.89 (BESTest) with LR+ of 3.4 (FGA) to 5.8 (BESTest). At 12 months, AUCs ranged from 0.68 (BESTest, BBS) to 0.77 (Mini-BESTest) with LR+ of 1.8 (BESTest) to 2.4 (BBS, FGA). Discussion. The various balance tests were effective in predicting falls at six months. All tests were relatively ineffective at 12 months. Conclusion. This pilot study suggests that people with PD should be assessed biannually for fall risk.

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BACKGROUND AND PURPOSE: The Balance Evaluation Systems Test(BESTest) has been shown to be a reliable and valid measure of balance in individuals with Parkinson disease (PD). A less time-consuming assessment may increase clinical utility. We compared the discriminative fall risk ability of the Mini-BESTest with that of the BESTest and determined the reliability and normal distribution of scores for each section of the BESTest and the Mini-BESTest in individuals with PD. METHODS: Eighty individuals with idiopathic PD were assessed using the BESTest and Mini-BESTest. A faller was defined as an individual with 2 or more falls in the prior 6 months. Subsets of individuals were used to determine interrater (n = 15) and test-retest reliability (n = 24). RESULTS: The Mini-BESTest, total BESTest score, and all sections of the BESTest showed a significant difference between the average scores of fallers and nonfallers. For both the Mini-BESTest and BESTest, interrater (intraclass correlation ICC ≥ 0.91) and test-retest (ICC ≥ 0.88) reliability was high. The Mini-BESTest and BESTest were highly correlated (r = 0.955). Accuracy of identifying a faller was comparable for the Mini-BESTest and BESTest (area under the receiver operating characteristic plots = 0.86 and 0.84, respectively). DISCUSSION: No specific section of the BESTest captured the primary balance deficit for individuals with PD. The posttest probabilities for discriminating fallers versus nonfallers were comparable-to-slightly stronger when using the Mini-BESTest. CONCLUSION: Although the Mini-BESTest has fewer than half of the items in the BESTest and takes only 15 minutes to complete, it is as reliable as the BESTest and has comparable-to-slightly greater discriminative properties for identifying fallers in individuals with PD.

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OBJECTIVES: To (1) determine intrarater and test-retest reliability of the Five times sit-to-stand test (FTSTS) in Parkinson's disease (PD), (2) characterize FTSTS performance in PD at different disease stages, (3) determine predictors of FTSTS performance in PD, and (4) determine the utility of the FTSTS for discriminating between fallers and nonfallers with PD, identifying an appropriate cutoff score to delineate between these groups. DESIGN: Measurement study of community-dwelling individuals with idiopathic PD. SETTING: A medical school laboratory. PARTICIPANTS: Participants (N=82) were recruited via population-based sampling. The final sample included 80 participants. Two were excluded because of exclusion criteria and an unrelated illness, respectively. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FTSTS time (seconds) was the primary outcome measure. Secondary outcome measures included the Mini-Balance Evaluation Systems Test (Mini-BEST), Maximal Voluntary Isometric Contraction-Quadriceps, 9-Hole Peg Test (9HPT), 6-minute walk, Freezing of Gait Questionnaire, Activities-Specific Balance Confidence Scale, Physical Activity Scale for the Elderly, Parkinson's Disease Questionnaire-39, and Movement Disorders Society-Unified Parkinson's Disease Rating Scale. RESULTS: Interrater and test-retest reliability for the FTSTS were high (intraclass correlation coefficients: .99 and .76, respectively). Mean FTSTS performance was 20.25 ± 14.12 seconds. All mobility measures were significantly correlated with FTSTS (P<.01). The Mini-BEST and 9HPT together explained 53% of the variance in FTSTS. Receiver operating characteristic analysis determined a cutoff of 16.0 seconds (sensitivity, .75; specificity, .68) for discriminating between fallers and nonfallers, with an area under the curve of .77. CONCLUSIONS: The FTSTS is a quick, easily administered measure that is useful for gross determination of fall risk in individuals with PD.

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BACKGROUND: Gait impairments, balance impairments, and falls are prevalent in individuals with Parkinson disease (PD). Although the Berg Balance Scale (BBS) can be considered the reference standard for the determination of fall risk, it has a noted ceiling effect. Development of ceiling-free measures that can assess balance and are good at discriminating "fallers" from "nonfallers" is needed. OBJECTIVE: The purpose of this study was to compare the Functional Gait Assessment (FGA) and the Balance Evaluation Systems Test (BESTest) with the BBS among individuals with PD and evaluate the tests' reliability, validity, and discriminatory sensitivity and specificity for fallers versus nonfallers. DESIGN: This was an observational study of community-dwelling individuals with idiopathic PD. METHODS: The BBS, FGA, and BESTest were administered to 80 individuals with PD. Interrater reliability (n=15) was assessed by 3 raters. Test-retest reliability was based on 2 tests of participants (n=24), 2 weeks apart. Intraclass correlation coefficients (2,1) were used to calculate reliability, and Spearman correlation coefficients were used to assess validity. Cutoff points, sensitivity, and specificity were based on receiver operating characteristic plots. RESULTS: Test-retest reliability was .80 for the BBS, .91 for the FGA, and .88 for the BESTest. Interrater reliability was greater than .93 for all 3 tests. The FGA and BESTest were correlated with the BBS (r=.78 and r=.87, respectively). Cutoff scores to identify fallers were 47/56 for the BBS, 15/30 for the FGA, and 69% for the BESTest. The overall accuracy (area under the curve) for the BBS, FGA, and BESTest was .79, .80, and .85, respectively. LIMITATIONS: Fall reports were retrospective. CONCLUSION: Both the FGA and the BESTest have reliability and validity for assessing balance in individuals with PD. The BESTest is most sensitive for identifying fallers.

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