Lightning Oral Presentation Australian and New Zealand Stroke Organisation Conference 2026

A systematic review of challenge modification in the rehabilitation of walking after stroke. (139404)

Andrea Saverymuthapulle 1 , Sandra Brauer 1 , Nada Signal 2 , Niruthikha Mahendran 1 3
  1. School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
  2. School of Allied Health, Auckland University of Technology, Auckland, New Zealand
  3. STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), Metro North Health, Brisbane, Queensland, Australia

Background/aims: Challenge is a dimension of dose that reflects the nominal, functional and perceived difficulty of performing a task1. Understanding how challenge can be optimised and tailored to an individual’s ability is essential to advancing rehabilitation outcomes 2, 3. Therefore, this review aims to investigate how challenge is modified and reported in rehabilitation trials and determine its effects on walking outcomes after stroke.

Methods: Searches were conducted across ten databases (e.g., MEDLINE, CINAHL, Pubmed, Scopus etc). Two authors independently screened titles and abstracts and full texts. Eligible studies included randomised and non-randomised trials that explored the effect of modifying challenge on walking outcomes (walking independence, speed or endurance) in adults with stroke. Risk of bias will be assessed using the Cochrane ROB-2 assessment tool, and certainty of evidence determined using the GRADE tool. Post-intervention scores will be used to obtain a pooled effect on walking outcomes. PROSPERO ID: CRD420551062978.

Results: The search identified 6,132 records, with 332 articles retrieved for full-text review, with screening ongoing. To date, 20 randomised studies have been included (n=691; age range 18–83 years), predominantly involving individuals with chronic stroke (n=16 studies, 671 participants). Challenge was modified using physical (e.g. brain stimulation, task demands, assistance level) or cognitive (e.g. dual tasking, feedback) strategies. Synthesis is ongoing.

Conclusion: This systematic review has identified a substantial body of literature examining challenge modification in walking rehabilitation after stroke. Preliminary screening indicates heterogeneity across included studies. Meta-analysis will clarify the effects of challenge modification on walking outcomes after stroke.

  1. Gomes, E., Alder, G., Bright, F. A. S., & Signal, N. (2025). Understanding task "challenge" in stroke rehabilitation: An interdisciplinary concept analysis. Disability and Rehabilitation 47(3), 560-570. https://doi.org/10.1080/09638288.2024.2356010
  2. Maier, M., Ballester, B. R., & Verschure, P. F. M. J. (2019). Principles of neurorehabilitation after stroke based on motor learning and brain plasticity mechanisms. Frontiers in Systems Neuroscience 13, 74-74. https://doi.org/10.3389/fnsys.2019.00074
  3. Olsen, S., Alder, G., Rashid, U., Gomes, E., Aislabie, M., Chee, F., Smith, C., Kean, B., Towersey, N., & Signal, N. (2023). Challenge level contributes to the efficacy of treadmill interventions after stroke: A systematic review and meta-analysis. Brain Science 13(12), 1729. https://doi.org/10.3390/brainsci13121729