#002- Articles on Spinal Cord Injury, Stroke and Multiple Neurological Disease.


Effective Interventions to reduce fear of falling in Neurological disease.

A Care bundle to prevent urinary tract damage in patients with SCI and Neurogenic bladder.

Backward walking improves balance in stroke patients!

Insufficient evidence for resistance training in stroke rehabilitation.

Estimated reading time: 5 minutes, 35 seconds.


Effective Interventions to reduce fear of falling in Neurological disease.

A systematic review and meta-analysis: 61 Trials including 3954 participants with either Stroke, Parkinson’s Disease (PD), Multiple sclerosis (MS) or Spinal cord injury (SCI).

Interventions included: Balance training, Gait training, Virtual Reality (VR), educational interventions, generic exercise and general fitness training, dual task training, treadmill training, task oriented balance training, upper limb training, Unsupported sitting task specific training, Core stability, Individualized balance exercise with Nintendo Wii Fit, sensory strategies group balance exercise (CoDuSe), Clinical Pilates, Perturbation-based balance training, Early locomotor training, Perturbation-based balance training, Dynamic balance training and Tai chi.


  • No Evidence on which PT intervention is the most effective for Stroke and SCI patients to reduce fear of falling.
  • Very low to moderate evidence that PT interventions reduce fear of falling in patients with stroke.
  • Low quality evidence for PT interventions in patients with SCI.
  • For MS and PD, interventions that include gait with balance training and home based or leisure exercise are effective in reducing Fear of falling. (Low to moderate quality evidence)
  • For PD: Home-based-gait combined with balance training and fall prevention advice for 30/day 5 times/week for 12 weeks reduces fear of falling.
  • Balance training alone was not effective in reducing fear of falling compared to usual care in patients with PD, MS and SCI.

A Care bundle to prevent urinary tract damage in patients with SCI and Neurogenic bladder.

Neurogenic bladder is collection of urinary conditions that hinders the ability to control the bladder, it can be a result of diseases such as MS, Parkinson’s disease, diabetes, stroke, infection of the brain and spinal cord, spinal cord injuries and major pelvic surgery.

The review included 11 studies (8 low level studies, 3 high level studies)

They developed a 3 elements care bundle to prevent upper urinary tract damage, this bundle may reduce intravesical pressure, prevent urinary tract infection, and improve urinary‐related neuromuscular function.

Elements in care bundle:

  1. Clean intermittent catheterization
  2. Bladder function training
  3. Neuromuscular function training

See the detailed bundle here

Caution: This bundle is based on small number of studies

Nonetheless, it is good when a research provides us with straight forward protocol to actually use in clinical practice.

Backward walking improves balance in stroke patients!

This systematic review and meta-analysis provide us with evidence on backward walking in stroke, apparently, there are 4 meta analyses before this one, these articles reported that backward walking can improve balance and also influence the spatial-temporal gait characteristics.

10 RCTs and 255 Participant included in the study.

Results: Backward walking compared to control group which may include: forward walking or balance training or conventional methods focusing on strengthening, function, mobility activities and gait training.

Gait Characteristics:

  • Backward walking might improve gait velocity, cadence and paretic step length (Very low Evidence).
  • No significant results for double and single support period, gait cycle, stance phase, swing phase, step time and stride length.
  • 1 Study found a significant reduction in gait symmetry ratio after backward walking, this pilot RCT also concluded that lateral walking training is more effective than backward walking.

Backward walking influence on BBS, walk test, symmetry index and TUG:

  • Berg balance score improved significantly after backward walking (Moderate Evidence).
  • Walk test performance improved significantly after backward walking (Very Low Evidence).
  • No influence on symmetry index.
  • 1 Study found a significant reduction in Timed up and go score after backward walking.*

Intervention Dose:

  • Time: 10 Minutes/day (2 Studies), 20 Minutes/day (1 Study) and 30 minutes/day (7 Studies).
  • Frequency: 3 Session/week (4 Studies), 5 Session/week (3 Studies), 6 Session/week (2 Studies) and 8 Session/week (1 Study).
  • Duration: 3 weeks (6 Studies), 4 weeks (4 Studies).

This article suggest that backward walking can be included in your treatment plan to improve gait, balance and walking ability of stroke patients, also the authors mentioned this study, which indicated that greater cardiovascular, neuromuscular, perceptual and metabolic demands were required for Backward walking than forward walking, therefore these factors should be considered when prescribing backward walking.

*The journal site was down when I tried to access it, I will update the report once it is up again.

There is insufficient evidence for resistance training in stroke rehabilitation.

  • This systematic review and meta-analysis defined resistance training as type of strength training that uses free weights, machine weights, body weight or resistance band, which have to be overcome by voluntary muscular effort.
  • The literature provides conflicting results, for example, some studies show that strength training improves muscular force and gait recovery after stroke while other state that it does improve force but not gait ability.

Included studies: 30 Trials with 1051 participants.

Resistance training versus no intervention:

  • 403 Participant, showed that resistance training is more effective than no intervention. (Duh!).
  • Improved: Muscular force of lower limbs, quality of life, independence and reintegration, mobility, balance, postural control and other health-relevant physiological indicators.
  • Some data shows better results for resistance training for gait, spasticity and hypertonia and emotional state.
  • Eccentric training had less effect compared to concentric exercise, no difference between unilateral and bilateral training.

Resistance training versus other intervention:

  • Results from 581 Participant showed that resistance training improve muscular force and motor function of lower and upper limbs, quality of life, independence and reintegration and other health relevant physiological indicators.
  • For cardiorespiratory fitness, resistance training is inferior to ergometer training. (Makes sense!)
  • When compared to therapeutic gait and balance training, the results were equivocal.
  • No difference between unilateral and bilateral training or between eccentric and concentric contraction.

Here comes the weird stuff:

  • Regarding the improvement of the gait ability, resistance training is superior to stretching training and stroke management education, but less efficient than passive mobilization and range of motion exercises. (Uhh, what, How!)

(I’ll try and make sense of this in a later Physiokeys plus report)

Resistance training versus other resistance training:

  • Results from 286 participant showed that the type of resistance exercise protocol may significantly influence the recovery after stroke.
  • Leg press is more effective than knee extension exercise.
  • Lower body exercises lead to greater amelioration of parameters assessed than upper body exercises.
  • High intensity training is superior to low intensity training.
  • Eccentric and concentric exercise are better than isometric exercise.

The authors concluded that the evidence is insufficient to change clinical practice, (That’s disappointing), but change it from what, resistance training is already part of almost every stroke recovery plan, the authors explained that this happens because of the large variability of interventions and populations, as well as inhomogeneity of parameters assessed, this statement is very common in similar articles, when are we going to solve this problem.

Good Note ?

  • Urinary tract damage and neurogenic bladder are difficult problems that burdens patients suffering from it, am glad that this care bundle was made and I hope they keep on improving it.
  • We now have somewhat decent evidence that backward walking can improve balance in stroke, I also encourage you to read the article that investigated lateral walking.

Bad Note ?

  • It is sad that commonly used treatment method such as resistance training is yet to have good evidence to support it.


  1. Effectiveness of Physical Therapy Interventions in Reducing Fear of Falling Among Individuals With Neurologic Diseases: A Systematic Review and Meta-analysis. (Restricted Access)
  2. A nonsurgical and nonpharmacological care bundle for preventing upper urinary tract damage in patients with spinal cord injury and neurogenic bladder. (Restricted Access)
  3. Effectiveness of backward walking for people affected by stroke: A systematic review and meta-analysis of randomized controlled trials. (Open Access)
  4. Resistance training in stroke rehabilitation: systematic review and meta-analysis. (Restricted Access)

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