Effects of weight-shift training on walking

ability, ambulation, and weight distribution

in individuals with chronic stroke: a pilot
study
Pontus Andersson1 and Erika Franzén2,3
Segeltorp Physiotherapy Ltd., Stockholm, Sweden, 2Department of Neurobiology, Care Sciences and Society,
1

Karolinska Institutet, Stockholm, Sweden, 3Department of Physical Therapy, Karolinska University Hospital,
Stockholm, Sweden

Background: People with gait difficulties after a stroke usually have an asymmetrical gait and slower gait speed
than age-matched controls. These difficulties restrict people with stroke in their daily life activities.
Objective: This pilot study sought to evaluate the effects of weight-shift training on gait, weight distribution in
standing, and ambulation in people with gait difficulties after a stroke.
Methods: Ten subjects with chronic stroke (3–11 years since insult) and remaining gait difficulties participated in
a 3-week weight-shift training program. Spatial and temporal gait parameters were assessed pre-, post-, and
3-month post-training with a motion analysis system. Weight distribution was assessed with force plates and
ambulation with the Swedish version of the Clinical Outcome Variables Scale (S-COVS). Wilcoxon signed-rank
tests were used to explore differences between test occasions.
Results: Significant changes were seen between pre-and post-tests in decreased stance time on the non-paretic
leg (P = 0.005) and increased score on the S-COVS (P = 0.043). At the 3-month follow-up test, the subjects had
also increased their gait speed significantly (P = 0.037). Standing weight distribution did not change between
pre- and post-tests (P = 0.575), but between the pre-and follow-up tests it shifted from the paretic leg to the
non-paretic (P = 0.007).
Conclusion: Weight-shift training seems to improve gait and ambulation in subjects with chronic stroke, but
not with standing weight distribution. However, this pilot study has several limitations and a larger sample size
with a control group is necessary.
Keywords:  Exercise, Gait, Asymmetry, Force Plate, Cerebral lesion

Introduction originates in the inability to maintain single-limb sup-

Motor function may improve early after stroke, thanks
to recovery of marginally functional neurons, and later
to reorganization or relearning of neural functions, i.e.,
neuroplasticity.1,2 Critical principles of motor learning
include: mimicking of movements of everyday life,3
muscle activation with focused attention,4 repetition of
desired movements5, and training specificity.6 The most
often-stated goal of stroke sufferers is improved ambu-
lation and gait function.7–9 Gait function, represented by
gait speed, is highly correlated to gait asymmetry.10,11
The asymmetrical gait commonly seen in stroke often
Correspondence to: Erika Franzén, Division of Physiotherapy,
Department of Neurobiology, Care sciences and Society,
Karolinska Institutet, Alfred Nobels Allé 23, 23100, 141 83,
Huddinge, Sweden. Email: erika.franzen@ki.se
port on the paretic leg for the same duration as on the
non-paretic leg.12 Therefore, to improve gait symmetry,
training to shift weight toward the paretic leg during gait
should be important. The unwillingness to shift, or anxiety
about shifting, weight to the paretic leg in stroke sub-
jects is a logical response since the paretic side often has
muscle weakness,13 restricted joint movement,14 limited
sensory input and perception problems originating in the
brain15,16, or even neglect.17,18 The exception is patients
with pusher syndrome who, on the contrary, shift weight
toward their paretic side.19 These patients are often trained
with wall-support on their non-paretic side to prevent
them from pushing.19 Training patients without ‘pusher
syndrome’, by far the largest group,20 using wall-support
on the paretic side, instead, might work as a somatosensory

© W. S. Maney & Son Ltd 2016

DOI 10.1179/1074935715Z.0000000052 Topics in Stroke Rehabilitation   2015  VOL. 22   NO. 6 437
Andersson and Franzén  Effects of weight-shift training on walking ability, ambulation, and weight distribution in individuals with chronic stroke

input helping the person to correct symmetry as well as Procedure

constituting a safety measure to prevent falls, common A single-group pre-test and post-test design with a
among the stroke population.21,22 Our group has recently 3-month follow-up was used. At baseline, clinical and
shown improved balance control in individuals with laboratory measurements were taken on each subject. This
chronic stroke after training static and dynamic balance was followed by 3 weeks of individual training four times
with visual feedback and gait training with wall-support.23 a week. The measurements were repeated directly after
While the wall-supported gait training might have con- the training period and again 3 months post intervention.
tributed to improved balance control, the effects on gait The subjects were not allowed to participate in any other
have not previously been evaluated. The simplicity and type of training, besides their regular daily-life activities
easily accessible qualities of this training method, com- from the start of the intervention until the follow-up test
bined with the possibility of incorporating the principles was completed. All measurements were blinded to the
of motor learning, prompted us to investigate this training physical therapist leading the training. During the lab-
method, particularly its effect on gait, ambulation, and oratory measurements, the subjects wore their regular
standing weight distribution in people with gait difficulties socks and shoes, tight cycle-shorts, and nothing on the
after a stroke. upper body (bra on females). The laboratory measure-
ments always started with standing weight distribution.
Materials and Methods The subjects were instructed to stand in their preferred
Subjects stance with one foot on each force plate imbedded in the
Ten subjects (four females) with chronic stroke (3–11 years floor. The distance between the heels was measured to
since insult) and remaining gait difficulties participated in ensure accurate reproduction in the follow-up measure-
a 3-week weight-shift training program with a 3-month ments. Sway data from the force plates were then recorded
follow-up. Mean age was 70.2, SD 10.9 years. Five had for 10 seconds. Gait parameters were recorded while the
suffered a lesion in their right hemisphere and five in the subject walked for 10 trials at their preferred speed along
left, see Table 1 for subject characteristics. Subjects were 7 m-long walkway. After the laboratory measurements,
included if gait difficulties remained at least 6 months after each subject's ambulation (S-COVS) was assessed within
stroke, and if they had been clinically evaluated by a phys- 3 days at another location to limit the influence of fatigue
ical therapist as having asymmetrical gait, and were using on the measurements.
walking aids due to their stroke. Subjects were excluded
if they either were incapable of understanding and/or fol- Gait parameters
lowing instructions or could walk less than 20 m with or The gait analyses was performed using an ELITE 2000
without walking aids. The subjects were recruited from system (BTS Incorporated, Milan, Italy) composed of
three outpatient physical therapy clinics in the vicinity of eight optoelectronic cameras recording kinematic data
Stockholm. Twelve subjects were initially enrolled, but with a sampling frequency of 100 Hz and a calibrated
two were excluded, one due to a cardiac infarction before space of 2 × 2 × 2 minutes. Twenty-two spherical reflec-
the training period and one for personal reasons during the tive markers with a diameter of 15 mm were applied to
training period. Informed consent was obtained from each the skin with double-sided tape over specific anatomical
subject and the project was approved by the local Ethics landmarks on lower limbs according to Davis's protocol.24
Committee in Stockholm (2005/179-31/4). Gait cycle events were defined interactively with GAIT
Eliclinic software (BTS Inc.) by defining heel strike, toe-
off, and heel strike again from the kinetics and kinematics.
Gait cycle time was normalized to 100% and temporal and
Table 1 Subjects’ demographics spatial gait parameters were calculated in the software.
Age Paretic Time since
Subject (years) Gender side stroke (years) Standing weight distribution
1 72 M left 7 Two 500  × 500 mm force plates (Kistler, Winterthur,
2 76 F right 4
3 62 F left 3 Switzerland) were used to record three-dimensional ground
4 43 F right 6 reaction forces at a sampling frequency of 100 Hz. An index
5 81 M right 10
6 72 F right 8
of asymmetry of the vertical force (Fz) between paretic and
7 63 M left 5 non-paretic leg was calculated for each trial25 as follows:
8 77 M left 11
9 72 M right 4
10 73 M left 6 Fz ofpareticleg–perfectsymmetry (meanofFz ofbothlegs)
Median 72 6 perfectsymmetry
M: male; f: female. (1)

438 Topics in Stroke Rehabilitation    2015  VOL. 22   NO. 6

 Andersson and Franzén  Effects of weight-shift training on walking ability, ambulation, and weight distribution in individuals with chronic stroke
Zero percent indicates symmetry between sides and 100%
indicates maximal asymmetry between sides. Positive val-
ues indicate greater loading on paretic side.
Ambulation
Ambulation was assessed with the Swedish Clinical
Outcome Variables Scale (S-COVS).26 This scale con-
sists of 13 motor tasks where the examiner rates from
1 (dependent) to 7 (normal) the level of performance in
different motor tasks. The test permits measurement of
activities regarding transportation, gait, postural control
in sitting position, handling a wheel-chair, and arm/hand
function. In this study, only items five to eight, repre-
senting ambulation variables, were assessed. These were
human support, walking aids, endurance, and velocity.
The individual scores were summarized (maximum 28).
The S-COVS was run before, directly after and 3 months
after training. It has been tested for inter-rater reliability
for the total scores of the test and showed a 0.97 corre-
lation coefficient: 0.93 for the specific items used in this
study.26
Intervention
The training period consisted of four 1 hour sessions a
week for 3 weeks. Every subject trained individually with
the same physical therapist.
The subjects’ symmetry training consisted of three tasks:
1) walking with wall-support (Fig. 1A): the subjects walked
with the paretic side close to a wall. They were instructed
to place the foot of the paretic leg on a 3- cm-wide and
10- m-long line running 20 cm from the wall. During
the stance phase of the paretic leg, the subjects were
instructed to shift their trunk so that the shoulder of the
affected side touched the wall. Wearing regular shoes,
they walked along the wall in this manner 10 times in
three sets with 2 minutes rest between each set.
Figure 1  The intervention: symmetry-training in three different tasks. Left panel (A): walking with wall-support. Middle panel (B):
stepping up and down on a platform with wall-support. Right panel (C): rising from and sitting down on a chair with wall-support.
 Topics in Stroke Rehabilitation    2015  VOL. 22   NO.
2) stepping up and down on a platform with wall-support
(Fig. 1B): the subjects stepped, with the paretic side
nearest the wall, up onto a 14- cm high, 90- cm long, and
35- cm wide platform. They had to step up and down
walking forwards and then backwards, always with the
paretic side against the wall. To be able to step and lift the
non-paretic leg, the subjects had to transfer weight to the
paretic leg so that the shoulder of the paretic side touched
the wall. This task was executed 10 times in three sets with
2 minutes break between each set.
3) sitting down and rising from a chair with wall-support
(Fig. 1C): the subjects sat on a chair without armrests,
with the paretic side close to a wall. The paretic foot was
positioned with a fairly large knee angle ( ≤ 90°) closer
to the chair than the non-paretic foot. The subjects had
to stand up and sit down while shifting body weight to
the paretic side so that the shoulder of the paretic side
touched the wall. They repeated the task 15 times in three
sets with 2 minutes break between each set.
In the first session, the subjects were told to lean toward
the wall during the stance phase on the paretic leg. This
was to make them feel their weight bearing and the con-
tact of the shoulder with the wall. The wall was used to
create a somatosensory input for the subjects to know
when they had executed the right weight transfer. Many
subjects said they were afraid of falling when shifting their
weight toward the paretic side, so the wall was a safety
item preventing them from falling.
As soon as the subjects had learned to control the
weigh shift, they were asked to do the exercises without
touching the wall. The goal was to walk without the wall
as a touch reference or safety item. The progression from
having the subjects lean toward the wall to not touch-
ing the wall was decided by the clinician as soon as the
subjects managed to control their weight shift with the
right amount of force to touch the wall, not missing it or
hitting it too hard, and managed this in a 10 m session. The
6 439
Andersson and Franzén  Effects of weight-shift training on walking ability, ambulation, and weight distribution in individuals with chronic stroke

Table 2 Gait parameters for paretic and non-paretic side, Variable Pre- Post- 3-month P-value
median (range) follow-up
T2–T3
Variable Pre- Post- 3-month P-value
P = 0.444
follow-up
Stance 62 (52–76) 59 (43–74) 58 T1–T2
Velocity 0.65 0.67 0.72 T1–T2 phase (49–72) P = 0.037
(m/s) (0.2–1.1) (0.2–1.2) (0.3–1.2) P = 0.203 (% gait
T1–T3 cycle)
P = 0.037 T1–T3
T2–T3 P = 0.218
P = 0.074 T2–T3
Cadence 88.9 88.4 92.6 T1–T2 P = 1.000
(steps/ (47.5– (46.5– (57.0– P = 0.203
min) 107.5) 111.8) 117.8) Bold indicates P < 0.05.
T1–T3
P = 0.074
T2–T3 number of repetitions of each exercise was individually
P = 0.241
Paretic adjusted and ranged between 30 and 45.
Walking with wall-support took approximately
Step 431 452 464 T1–T2
length (240–655) (204–559) (253–609) P = 0.507
15–20 minutes. The subjects walked at about 0.5 m/s for
(mm) 300 m with 2 minutes break after every 100 m. They also
T1–T3 needed about 5 seconds between each 10 m session to
P = 0.575
T2–T3 refocus and to adjust their body position. The stepping up
P = 0.059 and down task took approximately 20 minutes (30 repeti-
Stride 813 (561– 871 (552– 903 (504– T1–T2
tions); here, the subjects needed about 30 seconds to step
length 1263) 1293) 1348) P = 0.139
(mm) up and down with 2 minutes break between each set. The
T1–T3 sitting down and rising from a chair task took approxi-
P = 0.059
T2–T3 mately 15 minutes (45 repetitions) in which the subjects
P = 0.444 needed about 10 seconds for each rising and sitting down
Stance 709 (530– 835 (603– 739 (565– T1–T2 and 2 minutes break between each set. When the subjects
time (ms) 1505) 1785) 1243) P = 0.093
T1–T3 had executed the minimum amount of repetitions for each
P = 0.959 task, they were asked if they could manage to execute more
T2–T3
P = 0.203
repetitions. Likewise, they were also asked to report if they
Stance 57 (43–59) 56 (50–63) 56 T1–T2 felt overtired and the trainer/clinician were observant if the
phase (53–60) P = 0.047 subjects were too tired or trained at a too low intensity level.
(% gait
cycle) The clinician leading the training always stood next
T1–T3 to the participants during the step- and -sit-to-stand exer-
P = 0.169 cises. During the gait training he walked close behind as
T2–T3
P = 0.415 a safety precaution in case participants should lose their
Non-pa- balance.
retic
Step 371 400 428 T1–T2
length (222–620) (284–665) (263–724) P = 0.241 Statistical analyses
(mm) Statistical analyses were performed using the STATISTICA
T1–T3
P = 0.332 computer package (Version 10, Statsoft. Inc., Tulsa, OK,
T2–T3 USA). Descriptive statistics (median and range) were calcu-
P = 0.959
lated for all variables. Non-parametric statistics (Wilcoxon
Stride 829 (585– 883 (495– 885 T1–T2
length 1311) 1214) (263–724) P = 0.721 signed-rank test) was used due to the small number of sub-
(mm) jects and skewed distribution of data. P values less than
T1–T3
P = 0.878 0.05 were considered as statistically significant.
T2–T3
P = 0.074 Results
Stance 878 (643– 795 (448– 734 (498– T1–T2
time (ms) 1935) 1768) 1510) P = 0.005 All 10 subjects attended every training session during the
T1–T3 3 week intervention, i.e., 100% compliance.
P = 0.005

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 Andersson and Franzén  Effects of weight-shift training on walking ability, ambulation, and weight distribution in individuals with chronic stroke

Figure 2  Mean gait velocity in m/s, pre-training, post-training and 3 months after training are shown in the upper panel. Upper
left (A): group values and significant (P < 0.05) improvement in velocity between pre-training and follow-up, marked with a
*. Upper right (B): individual trend of gait velocity between different test occasions, all 10 subjects. The lower panel shows
standing weight distribution according to the asymmetry index on the three different test occasions. Lower left (C): weight
distribution for whole group and significant change (P < 0.01), marked with an **. Lower right (D): very diverse individual trends
of weight-bearing between the different test occasions, all 10 subjects.

Gait parameters Conversely, at follow-up compared to pre-test, there was a

The gait velocities were similar (P = 0.203) between the
pre- and post-tests. However, at follow-up, the gait veloc-
ity had increased significantly (P = 0.037) from median
0.65 (range 0.2–1.1 m/s) before the intervention to 0.72
(range 0.3–1.2 m/s), see Table 2 and Fig. 2A and B. This
increase in velocity can partly be explained by a tendency
to an increase (P = 0.074) in cadence, with a change from
median 88 steps/min at baseline to 93 steps/min at fol-
low-up, as well as a tendency (P = 0.059) to increased step
and stride length in the paretic side.
The stance phase decreased in the paretic leg (P = 0.047)
as well as in the non-paretic leg (P = 0.037) between base-
line and post-tests. However, the decrease was larger in
the non-paretic leg (P = 0.014), leading to a similar stance
phase in both legs at post-test and follow-up (P>0.05). The
stance time of the non-paretic leg also decreased between
pre-and post-tests as well as between the pre-test and fol-
low-up (P = 0.005).
significant change in the asymmetry index indicating more
weight on the non-paretic leg (median: − 10%, range: 3 to
− 29) than before the intervention (median: 2%, range: 46
to °17), P = 0.007. However, as seen in Fig. 2D, there were
large differences between subjects.
Ambulation
The gait-related item scores on the S-COVS improved
after the intervention from median 23 points (range:
17–28) to 25 points (range: 21–28), P = 0.043, and this
improvement was maintained at the 3-month follow-up as
compared to baseline [median 25 points, (range:21–28),
P = 0.018]. The items that changed most were endurance
and velocity. Seven subjects increased their scores enough
to move up at least one category. For example, one subject
increased his score in gait velocity from 4 (0.1–0.3 m/s)
before training to 5 (0.3–0.6 m/s) after training and 7
(>0.9 m/s) at follow-up.

Standing weight distribution Discussion

The standing weight distribution (Fig. 2C) calculated with The results of this pilot study show an increase in walk-
the asymmetry index did not change from pre-test to post-test ing speed, normalization of stance phases, and improved
(P = 0.575) or between post-test and follow-up (P = 0.169). ambulation, after 3  weeks of symmetry-training with

 Topics in Stroke Rehabilitation    2015  VOL. 22   NO. 6 441

Andersson and Franzén  Effects of weight-shift training on walking ability, ambulation, and weight distribution in individuals with chronic stroke
wall-support. In contrast, the standing weight distribu-
tion shifted from the paretic to the non-paretic leg. The
improvement in gait velocity seen at the follow-up but not
directly after the training period could be due to motor
learning, i.e., that the subjects had had to learn a ‘new’
gait pattern by transferring more weight to their paretic
leg during the intervention, which in fact slowed their gait
speed down. Later on, with more time to adapt to their
new gait pattern, they were able to walk faster. This is
supported by the model on motor learning by Vereijken
et al.27 where the learner initially simplifies the move-
ment to reduce the degrees of freedom by constraining
several joints, which he/she gradually releases as the skill
is learned. On the other hand, the increase in gait speed
which only appeared at 3 months follow-up could arguably
be due to a reversion to a more asymmetrical gait pattern
since the weight-shift was again more to their non-paretic
leg. This may indicate a learned bad use28 where compen-
satory movements compete with more ‘normal’ move-
ments after the training period, when the individuals with
stroke were left on their own to maintain their gait pattern.
An increase in stride length and cadence significantly
correlates to an increase in gait velocity.29,30 Although
there were no significant changes in cadence, stride, or
step length between the test occasions, they all showed
a tendency to increase and, combined, could explain the
increase in gait velocity seen at follow-up. The stance
phase decreased in both legs directly after the training
session, but this did not persist 3 months after the training.
However, the decrease led to a similar and more normally
distributed stance phase in both legs. Persons with balance
deficits have a longer stance phase than normal subjects.31
The normalization of the stance phases seen after the pres-
ent intervention might be due to an increase in dynamic
balance gained from the wall-supported gait training.
The weight distribution in standing shifted from more
weight on the paretic leg before the training period to
more weight on the non-paretic leg at follow-up. This
contradicts the results on stance phase and stance time,
indicating a more symmetrical gait after the training
period. However, the weight distribution here was meas-
ured during quiet stance and not during gait. Carry-over
effects of weight distribution from standing tasks to gait
are also limited,32 a finding in agreement with another
study by our group23 which also found no improvement
in standing weight distribution after wall-supported gait
training.
Since the S-COVS is an ordinal scale, small changes in
motor ability do not alter scores. For example, in item 8
(walking velocity), a subject had to increase from < 0.3 m/s
to < 0.6 m/s to score higher. Our subjects with chronic
stroke had significantly improved their ambulation score
directly after the training session and also at follow-up.
442 Topics in Stroke Rehabilitation    2015  VOL. 22   NO.
This could reflect an increase in dynamic balance con-
trol – which is highly correlated with gait symmetry.33
At individual level, 7 out of 10 subjects improved their
ambulation scores enough to gain one higher increment,
a significant increase spread through all items. Among
the seven subjects who increased their ambulation scores,
three managed a one-increment increase, two a two-incre-
ment increase, and two a three-increment increase. One
subject, for example, only managed to walk over 10 m
before training; while after training, he could walk over
100 m – which he sustained at follow-up.
One way of interpreting the results in a clinical context
would be by comparing them to minimal clinical impor-
tance differences (MCID). MCID has been investigated
on gait speed in individuals with stroke and found to be
0.16 m/s.34 Only one of our subjects improved gait velocity
more than 0.16 m/s. However, the above study took place
during the first 60 days post-stroke and is not comparable
to our sample of chronic-stroke subjects.34
This pilot study has several limitations. The sam-
ple size was small and there was no control group.
This may have compromised the generalizability of the
results. The lack of control group makes it plausible
that the results would have appeared even without an
intervention, although spontaneous improvements must
be considered less likely in this group. Likewise, this
study permits no conclusions concerning the benefit
of this training in comparison to other interventions.
The intervention period was quite short although the
number of sessions (n = 12) was similar to those in
other studies.35–37 In addition, weight distribution was
assessed during standing instead of during walking,
which would have been more specific to the exercises
in the intervention.
In conclusion, symmetry training with wall-support
seems to improve gait and ambulation in subjects with
chronic stroke, but not standing weight distribution. This
study adds evidence to the fact that individuals with stroke
can improve their physical performance several years after
their stroke.38 It highlights the importance of rehabilitation
programs in the chronic stage of stroke. However, given
its several limitations, a larger sample size with a control
group is necessary.
Acknowledgements
We thank all the subjects participating in this study,
associate professor Helga Hirschfeld for helping with
the design and acquisition of gait parameters, Eva
Eriksson, physical therapist student, for analysis of
weight distribution in standing, and Heidi Andersson,
physical therapist, for help with clinical testing. Thanks
also to Ingmarie Apel for technical assistance during
the laboratory tests.
6
 Andersson and Franzén  Effects of weight-shift training on walking ability, ambulation, and weight distribution in individuals with chronic stroke
Disclaimer Statements
None
Contributors
Both authors made substantial contributions to the con-
ception or design of this study, or to data collection, anal-
ysis or interpretation of data. PA was responsible for the
drafting of the manuscript and EF contributed to its critical
revision for important intellectual content. Both authors
critically reviewed and approved the submitted version
of the manuscript.
Funding
The study was supported by the local Swedish Medical
Council (Hirschfeld).
Conflicts of interest
The authors declare no conflicts of interest. The
authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Ethics approval
The project was approved by the local Ethics Committee
in Stockholm (2005/179-31/4).
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