Predictive Validity and Responsiveness of the Functional Ambulation Category in Hemiparetic Patients After Stroke

Outcome Measures for Persons With Moderate to Severe Traumatic Brain Injury: Recommendations From the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force

BACKGROUND AND PURPOSE

The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work.

METHODS

An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided.

RESULTS

The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain.

DISCUSSION AND CONCLUSIONS

Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).

Examination of Simple Outcome Measures and Cut-off Values Related to Walking Independence of Inpatients with Medical Diseases in Acute Care Hospitals

Objective

The objective of the current study was to identify simple outcome measures to predict walking independence in inpatients with medical diseases in acute care hospitals and to identify the cut-off values of the relevant measures.

Methods

Two hundred inpatients aged 20 years or above who had a medical disease were enrolled in this cross-sectional study. The subjects' walking independence, physical characteristics, cognitive status, and blood test data were examined. Logistic regression analysis was performed, and cut-off values were calculated.

Results

The identified outcome measures and their respective cut-off values were as follows: the straight leg raising (SLR) repetition count, 27; the one-leg standing time (OLST), 3.6 s; and the orientation score of the mini-mental state examination (MMSE), 9/10.

Conclusions

Our study findings suggest that the SLR repetition count, OLST, and the MMSE orientation score are simple outcome measures related to walking independence in inpatients with medical diseases in acute care hospitals.

Interval circuit training for cardiorespiratory fitness is feasible for people after stroke

Aims:

To determine if community-dwelling stroke survivors can achieve exercise intensities sufficient to improve cardiorespiratory fitness during a single session of circuit training using an interval training approach.

Methods:

Thirteen independently ambulant participants within 1 year of stroke were included in this observational study (females=54%; median age=65.6 years; interquartile range=23.9). Exercise intensities were assessed throughout an individually tailored circuit of up to seven 5-minute workstations from a selection of nine functional (e.g. walking, stairs, balance) and three ergometer (upright cycle, rower, treadmill) workstations. The interval durations ranged from 5–60 seconds. Oxygen consumption (VO2) was recorded continuously using a portable metabolic system. The average VO2 during each 30-second epoch was determined. VO2≥10.5 mL/kg/min was categorised as ≥moderate intensity.

Findings:

Participants exercised at VO2≥10.5 mL/kg/min for the majority of the time on the workstations [functional: 369/472 epochs (78%), ergometer: 170/204 epochs (83%)]. Most (69%) participants exercised for ≥30 minutes. No serious adverse events occurred.

Conclusions:

Applying interval training principles to a circuit of functional and ergometer workstations enabled ambulant participants to exercise at an intensity and for a duration that can improve cardiorespiratory fitness. The training approach appears feasible, safe and a promising way to incorporate both cardiorespiratory fitness and functional training into post-stroke management.

Effects of mirror therapy combined with neuromuscular electrical stimulation on motor recovery of lower limbs and walking ability of patients with stroke: a randomized controlled study

OBJECTIVE

To investigate the effectiveness of mirror therapy combined with neuromuscular electrical stimulation in promoting motor recovery of the lower limbs and walking ability in patients suffering from foot drop after stroke.

DESIGN

Randomized controlled study.

SETTING

Inpatient rehabilitation center of a teaching hospital.

SUBJECTS

Sixty-nine patients with foot drop.

INTERVENTION

Patients were randomly divided into three groups: control, mirror therapy, and mirror therapy + neuromuscular electrical stimulation. All groups received interventions for 0.5 hours/day and five days/week for four weeks.

MAIN MEASURES

10-Meter walk test, Brunnstrom stage of motor recovery of the lower limbs, Modified Ashworth Scale score of plantar flexor spasticity, and passive ankle joint dorsiflexion range of motion were assessed before and after the four-week period.

RESULTS

After four weeks of intervention, Brunnstrom stage ( P = 0.04), 10-meter walk test ( P < 0.05), and passive range of motion ( P < 0.05) showed obvious improvements between patients in the mirror therapy and control groups. Patients in the mirror therapy + neuromuscular electrical stimulation group showed better results than those in the mirror therapy group in the 10-meter walk test ( P < 0.05). There was no significant difference in spasticity between patients in the two intervention groups. However, compared with patients in the control group, patients in the mirror therapy + neuromuscular electrical stimulation group showed a significant decrease in spasticity ( P < 0.001).

CONCLUSION

Therapy combining mirror therapy and neuromuscular electrical stimulation may help improve walking ability and reduce spasticity in stroke patients with foot drop.

Embedding an enriched environment in an acute stroke unit increases activity in people with stroke: a controlled before-after pilot study

OBJECTIVES

To determine whether an enriched environment embedded in an acute stroke unit could increase activity levels in acute stroke patients and reduce adverse events.

DESIGN

Controlled before-after pilot study.

SETTING

An acute stroke unit in a regional Australian hospital.

PARTICIPANTS

Acute stroke patients admitted during (a) initial usual care control period, (b) an enriched environment period and (c) a sustainability period.

INTERVENTION

Usual care participants received usual one-on-one allied health intervention and nursing care. The enriched environment participants were provided stimulating resources, communal areas for eating and socializing and daily group activities. Change management strategies were used to implement an enriched environment within existing staffing levels.

MAIN MEASURES

Behavioural mapping was used to estimate patient activity levels across groups. Participants were observed every 10 minutes between 7.30 am and 7.30 pm within the first 10 days after stroke. Adverse and serious adverse events were recorded using a clinical registry.

RESULTS

The enriched environment group ( n = 30, mean age 76.7 ± 12.1) spent a significantly higher proportion of their day engaged in 'any' activity (71% vs. 58%, P = 0.005) compared to the usual care group ( n = 30, mean age 76.0 ± 12.8). They were more active in physical (33% vs. 22%, P < 0.001), social (40% vs. 29%, P = 0.007) and cognitive domains (59% vs. 45%, P = 0.002) and changes were sustained six months post implementation. The enriched group experienced significantly fewer adverse events (0.4 ± 0.7 vs.1.3 ± 1.6, P = 0.001), with no differences found in serious adverse events (0.5 ± 1.6 vs.1.0 ± 2.0, P = 0.309).

CONCLUSIONS

Embedding an enriched environment in an acute stroke unit increased activity in stroke patients.

Post-stroke hemiparesis: Does chronicity, etiology, and lesion side are associated with gait pattern?

BACKGROUND

Studies that evaluate gait rehabilitation programs for individuals with stroke often consider time since stroke of more than six months. In addition, most of these studies do not use lesion etiology or affected cerebral hemisphere as study factors. However, it is unknown whether these factors are associated with post-stroke motor performance after the spontaneous recovery period.

OBJECTIVE

To investigate whether time since stroke onset, etiology, and lesion side is associated with spatiotemporal and angular gait parameters of individuals with chronic stroke.

METHODS

Fifty individuals with chronic hemiparesis (20 women) were evaluated. The sample was stratified according to time since stroke (between 6 and 12 months, between 13 and 36 months, and over 36 months), affected cerebral hemisphere (left or right) and lesion etiology (ischemic and hemorrhagic). The participants were evaluated during overground walking at self-selected gait speed, and spatiotemporal and angular gait parameters were calculated. Results Differences between gait speed, stride length, hip flexion, and knee flexion were observed in subgroups stratified based on lesion etiology. Survivors of a hemorrhagic stroke exhibited more severe gait impairment. Subgroups stratified based on time since stroke only showed intergroup differences for stride length, and subgroups stratified based on affected cerebral hemisphere displayed between-group differences for swing time symmetry ratio.

CONCLUSION

In order to recruit a more homogeneous sample, more accurate results were obtained and an appropriate rehabilitation program was offered, researchers and clinicians should consider that gait pattern might be associated with time since stroke, affected cerebral hemisphere and lesion etiology.

Using a Real-Time Location System for Assessment of Patient Ambulation in a Hospital Setting

OBJECTIVE

To assess the feasibility of using an infrared-based Real-Time Location System (RTLS) for measuring patient ambulation in a 2-minute walk test (2MWT) by comparing the distance walked and the Johns Hopkins Highest Level of Mobility (JH-HLM) score to clinician observation as a criterion standard.

DESIGN

Criterion standard validation study.

SETTING

Inpatient, university hospital.

PARTICIPANTS

Patients (N=25) in an adult neuroscience/brain rescue unit.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

RTLS and clinician-reported ambulation distance in feet, and JH-HLM score on an 8-point ordinal scale.

RESULTS

The RTLS ambulation distance for the 25 patients in the 2MWT was between 68 and 516ft. The mean difference between clinician-reported and RTLS ambulation distance was 8.4±11.7ft (2.7%±4.6%). The correlation between clinician-reported and RTLS ambulation distance was 97.9% (P<.01). The clinician-reported ambulation distance for 2 patients was +100ft and -99ft compared with the RTLS distance, implying clinician error in counting the number of laps (98ft). The correlation between the RTLS distance and clinician-reported distance excluding these 2 patients is 99.8% (P<.01). The accuracy of the RTLS for assessment of JH-HLM score for all 25 patients was 96%. The average patient speed obtained from RTLS data varied between 0.4 and 3.0mph.

CONCLUSIONS

The RTLS is able to accurately measure patient ambulation and calculate JH-HLM for a 2MWT when compared with clinician observation as the criterion standard.

Effectiveness of Active Cycling in Subacute Stroke Rehabilitation: A Randomized Controlled Trial

OBJECTIVE

To examine the effects of 3 months of aerobic training (AT) followed by coaching on aerobic capacity, strength, and gait speed after subacute stroke.

DESIGN

Randomized controlled trial.

SETTING

Inpatient rehabilitation center.

PARTICIPANTS

Patients (N=59; mean age ± SD, 65.4±10.3y; 21 women (36%); Barthel Index ≤50 in 64% of patients) with first stroke and able to cycle at 50 revolutions/min were enrolled in the study 3 to 10 weeks after stroke onset.

INTERVENTIONS

Patients were randomly allocated to a 3-month active cycling group (ACG, n=33) and education, or to a control group (CG, n=26). Afterward, patients in the ACG were randomly assigned either to a coaching (n=15) or to a noncoaching group (n=16) for 9 months.

MAIN OUTCOME MEASURES

Aerobic capacity, isometric knee extension strength, and gait ability and speed were measured before and after intervention and during follow-up at 6 and 12 months.

RESULTS

A nonsignificant difference was found in workload (Watt_peak) (P=.078) between ACG and CG after 3 months. Furthermore, after 3 months of cycling and after 9 months of coaching, all groups showed significant changes over time (P≤.027) in peak oxygen consumption, Watt_peak, leg strength, and gait speed. Also, significant changes over time (P<.001) were found in the ACG and the CG in patients with walking inability at baseline.

CONCLUSIONS

No significant differences between training groups were found over time. Although our study did not have objective exercise data from the training device during follow-up, the 3-month active cycling (AC) program combined with education sessions seemed an applicable method in subacute stroke rehabilitation. New long-term AT interventions should focus on coaching approaches to facilitate training after a supervised AC program.

Reliability and Minimum Detectable Change of the Gait Deviation Index (GDI) in post-stroke patients

The Gait Deviation Index (GDI) is a summary measure that provides a global picture of gait kinematic data. Since the ability to walk is critical for post-stroke patients, the aim of this study was to determine the reliability and Minimum Detectable Change (MDC) of the GDI in this patient population. Twenty post-stroke patients (11 males, 9 females; mean age, 55.2±9.9years) participated in this study. Patients presented with either right- (n=14) or left-sided (n=6) hemiparesis. Kinematic gait data were collected in two sessions (test and retest) that were 2 to 7days apart. GDI values in the first and second sessions were, respectively, 59.0±8.1 and 60.2±9.4 for the paretic limb and 53.3±8.3 and 53.4±8.3 for the non-paretic limb. The reliability in each session was determined by the intra-class correlation coefficient (ICC) of three strides and, in the test session, their values were 0.91 and 0.97 for the paretic and non-paretic limbs, respectively. Between-session reliability and MDC were determined using the average GDI of three strides from each session. For the paretic limb, between-session ICC, standard error of measurement (SEM), and MDC were 0.84, 3.4 and 9.4, respectively. Non paretic lower limb exhibited between-session ICC, standard error of measurement (SEM), and MDC of 0.89, 2.7 and 7.5, respectively. These MDC values indicate that very large changes in GDI are required to identify gait improvement. Therefore, the clinical usefulness of GDI with stroke patients is questionable.

Clinical utility of the modified trunk impairment scale for stroke survivors

OBJECTIVE

The present study aimed to determine the discriminant power of the modified Trunk Impairment Scale (mTIS) in stroke survivors versus healthy adults.

DESIGN

Cross-sectional.

SETTING

Inpatient rehabilitation center.

PARTICIPANTS

Fifty-five subjects with stroke and 29 healthy adults.

METHODS

Subjects were examined using the mTIS, Berg Balance Scale, and Timed Up and Go test for balance; 5-m Walk Test and Functional Ambulation Category for gait; Fugl-Meyer Assessment for motor function; Postural Assessment Scale for Stroke-Trunk Control and Trunk Control Test for trunk control; and Modified Barthel Index for activities of daily living performance.

RESULTS

The mTIS results differed significantly between stroke survivors and healthy adults (p < 0.001). In addition, mTIS scores were significantly correlated with the Berg Balance Scale (r = 0.82), Timed Up and Go test (r = -0.70), 5-m Walk Test (r = 0.73), Functional Ambulation Category (r = 0.54), Fugl-Meyer Assessment (r = 0.37-0.80), Postural Assessment Scale for Stroke-Trunk Control and Trunk Control Test (r = 0.55-0.63), and Modified Barthel Index score (r = 0.56) results (p < 0.05-0.01). The mTIS also showed 66% influence on the Berg Balance Scale, 49% on the Timed Up and Go test, 53% on the 5-m Walk Test, 28% on the Functional Ambulation Category, 12% on the Fugl-Meyer Assessment-upper extremity, 64% on the Fugl-Meyer Assessment-lower extremity, and 30% on the Modified Barthel Index. The cutoff value of the mTIS for the Modified Barthel Index classification was >10.5 points, while the area under the curve had a moderate accuracy of 73%.

CONCLUSION

The mTIS can be used to examine the degree of trunk control or the level of trunk impairment, which is seen as a prerequisite for balance, gait, motor function, and activities of daily living performance in stroke survivors. Implications for Rehabilitation The modified Trunk Impairment Scale can be used as an assessment tool to classify the degree of trunk control or its level of impairment in stroke survivors. The modified Trunk Impairment Scale may have a favorable correlation with assessing physical functions such as balance, gait, motor function, and ADL in stroke survivors.

Corticoreticular tract lesion in children with developmental delay presenting with gait dysfunction and trunk instability

The corticoreticular tract (CRT) is known to be involved in walking and postural control. Using diffusion tensor tractography (DTT), we investigated the relationship between the CRT and gait dysfunction, including trunk instability, in pediatric patients. Thirty patients with delayed development and 15 age-matched, typically-developed (TD) children were recruited. Fifteen patients with gait dysfunction (bilateral trunk instability) were included in the group A, and the other 15 patients with gait dysfunction (unilateral trunk instability) were included in the group B. The Growth Motor Function Classification System, Functional Ambulation Category scale, and Functional Ambulation Category scale were used for measurement of functional state. Fractional anisotropy, apparent diffusion coefficient, fiber number, and tract integrity of the CRT and corticospinal tract were measured. Diffusion parameters or integrity of corticospinal tract were not significantly different in the three study groups. However, CRT results revealed that both CRTs were disrupted in the group A, whereas CRT disruption in the hemispheres contralateral to clinical manifestations was observed in the group B. Fractional anisotropy values and fiber numbers in both CRTs were decreased in the group A than in the group TD. The extents of decreases of fractional anisotropy values and fiber numbers on the ipsilateral side relative to those on the contralateral side were greater in the group B than in the group TD. Functional evaluation data and clinical manifestations were found to show strong correlations with CRT status, rather than with corticospinal tract status. These findings suggest that CRT status appears to be clinically important for gait function and trunk stability in pediatric patients and DTT can help assess CRT status in pediatric patients with gait dysfunction.

Impact of Co-occurring Dysarthria and Aphasia on Functional Recovery in Post-stroke Patients

Objective

To elucidate the impact of co-occurring dysarthria and aphasia on functional recovery in post-stroke patients.

Methods

The medical records, including results of primary screening tests and secondary definite examinations for language problems, of 130 patients admitted to our institute's Department of Rehabilitation Medicine were retrospectively reviewed. Functional outcomes were assessed longitudinally using the Functional Ambulation Category (FAC), Mini-Mental State Examination-Korean version (MMSE-K), European Quality of Life-5 Dimensions 3-Level version (EQ-5D-3L), the Korean version of the Modified Barthel index (K-MBI), and Motricity Index (MI) of the hemiplegic side.

Results

Patients were classified into four groups regarding language function: aphasia only (group A, n=9), dysarthria only (group D, n=12), aphasia and dysarthria (group AD, n=46), and none (group N, n=55). The initial functional outcome scores in the group AD were significantly poor compared to those of the groups N and A. Within groups, there were significant improvements in all outcome measurements in the groups AD and N. A between-group analysis revealed significant improvements in K-MBI for the group AD after adjusting for the initial severity and patient's age compared to other groups.

Conclusion

Post-stroke patients suffering from aphasia with dysarthria showed significantly lower initial functional level and relatively wide range of recovery potential in activities of daily living compared to patients without language problems.

The efficacy of treadmill training with and without projected visual context for improving walking ability and reducing fall incidence and fear of falling in older adults with fall-related hip fracture: a randomized controlled trial

BACKGROUND

The ability to adjust walking to environmental context is often reduced in older adults and, partly as result of this, falls are common in this population. A treadmill with visual context projected on its belt (e.g., obstacles and targets) allows for practicing step adjustments relative to that context, while concurrently exploiting the great amount of walking practice associated with conventional treadmill training. The present study was conducted to compare the efficacy of adaptability treadmill training, conventional treadmill training and usual physical therapy in improving walking ability and reducing fear of falling and fall incidence in older adults during rehabilitation from a fall-related hip fracture.

METHODS

In this parallel-group, open randomized controlled trial, seventy older adults with a recent fall-related hip fracture (83.3 ± 6.7 years, mean ± standard deviation) were recruited from inpatient rehabilitation care and block randomized to six weeks inpatient adaptability treadmill training (n = 24), conventional treadmill training (n = 23) or usual physical therapy (n = 23). Group allocation was only blind for assessors. Measures related to walking ability were assessed as the primary outcome before and after the intervention and at 4-week and 12-month follow-up. Secondary outcomes included general health, fear of falling, fall rate and proportion of fallers.

RESULTS

Measures of general walking ability, general health and fear of falling improved significantly over time. Significant differences among the three intervention groups were only found for the Functional Ambulation Category and the dual-task effect on walking speed, which were in favor of respectively conventional treadmill training and adaptability treadmill training.

CONCLUSIONS

Overall, adaptability treadmill training, conventional treadmill training and usual physical therapy resulted in similar effects on walking ability, fear of falling and fall incidence in older adults rehabilitating from a fall-related hip fracture. Additional post hoc subgroup analyses, with stratification for pre-fracture tolerated walking distance and executive function, revealed several intervention effects in favor of adaptability and conventional treadmill training, indicating superiority over usual physical therapy for certain subgroups. Future well-powered studies are necessary to univocally identify the characteristics of individuals who will benefit most from a particular intervention.

TRIAL REGISTRATION

The Netherlands Trial Register ( NTR3222 , 3 January 2012).

Stroke and Falls-Clash of the Two Titans in Geriatrics

Both stroke and falls are common conditions affecting the older adult. Despite stroke being considered a well-established major risk factor for falls, there remains no evidence for effective prevention strategies for falls specifically for stroke survivors. Previous observational studies evaluating falls risk factors in stroke have mainly been uncontrolled and found similar risk factors for stroke populations compared to general older populations. Specific risk factors, however, are likely to play a greater role in stroke survivors including unilateral weakness, hemisensory or visual neglect, impaired coordination, visual field defects, perceptual difficulties and cognitive issues. In addition, individuals with stroke are also more likely to have other associated risk factors for falls including diabetes, falls risk increasing drugs, atrial fibrillation, and other cardiovascular risk factors. While anticoagulation is associated with increased risk of intracranial bleeding after a fall, the risk of suffering a further stroke due to atrial fibrillation outweigh the risk of bleeding from a recurrent fall. Similarly, while blood pressure lowering medications may be linked to orthostatic hypotension which in turn increases the risk of falls, the benefit of good blood pressure control in terms of secondary stroke prevention outweighs the risk of falls. Until better evidence is available, the suggested management approach should then be based on local resources, and published evidence for fall prevention. Multicomponent exercise and individually tailored multifactorial interventions should still be considered as published evidence evaluating the above have included stroke patients in their study population.

Care-Related Quality of Life of Informal Caregivers After Geriatric Rehabilitation

OBJECTIVES

To describe care-related quality of life (CarerQoL) of informal caregivers after geriatric rehabilitation (GR) and identify associated determinants.

DESIGN

A cross-sectional analysis within a prospective longitudinal follow-up study.

SETTING

Evaluations at 4 weeks after finishing GR in 16 skilled nursing facilities.

PARTICIPANTS

Included were 350 informal caregivers (66.2% female, age 63 years; standard deviation [SD], 13.3) and their care recipients (63.4% female, age 78 years; interquartile range [IQR], 69-84 years).

MEASUREMENTS

CarerQoL was measured with the CarerQoL-7D. This instrument describes caregiver burden in seven dimensions (ie, fulfillment, relational, mental, social, financial, perceived support, and physical). Informal caregivers were divided into low and high CarerQoL groups, based on the median CarerQoL-7D summary score (83.9 [IQR, 74.4-91.7]). Potential associated determinants were collected, including demographic variables of informal caregivers and care recipients, self-rated health and burden of informal caregivers, functioning, and cognition and depression of care recipients. Univariate logistic regression was performed for each determinant. For the multivariate regression model, a backward procedure was used, which included age, gender, and variables with P < .10.

RESULTS

Multivariate analysis showed that fair or poor health (odds ratio [OR], 1.32; 95% confidence interval [CI], 1.14-1.54), a higher self-rated burden (OR, 2.68 [95% CI, 1.23-5.85]), being happier if one could hand over all care tasks to another self-chosen person (OR, 1.33 [95% CI, 1.15-1.53]), and severely impaired cognitive performance level of the care recipient (OR, 2.52 [95% CI, 1.21-5.25]) were independently associated with having a lower CarerQoL-7D summary score (beneath the median). Happiness (OR, 0.53 [95% CI, 0.40-0.70]) was independently associated with a higher CarerQoL-7D summary score.

CONCLUSION

CarerQoL after GR in a skilled nursing facility is predominantly and independently associated with caregiver's own health, happiness, self-rated burden, and a severely impaired cognitive performance level of the care recipient at admission to the GR unit.

Prediction of Walking and Arm Recovery after Stroke: A Critical Review

Clinicians often base their predictions of walking and arm recovery on multiple predictors. Multivariate prediction models may assist clinicians to make accurate predictions. Several reviews have been published on the prediction of motor recovery after stroke, but none have critically appraised development and validation studies of models for predicting walking and arm recovery. In this review, we highlight some common methodological limitations of models that have been developed and validated. Notable models include the proportional recovery model and the PREP algorithm. We also identify five other models based on clinical predictors that might be ready for further validation. It has been suggested that neurophysiological and neuroimaging data may be used to predict arm recovery. Current evidence suggests, but does not show conclusively, that the addition of neurophysiological and neuroimaging data to models containing clinical predictors yields clinically important increases in predictive accuracy.

Reliability and minimum detectable change of the gait profile score for post-stroke patients

The objectives of this work were (i) to determine Gait Profile Score (GPS) for hemiparetic stroke patients, (ii) to evaluate its reliability within and between sessions, and (iii) to establish its minimal detectable change (MDC). Seventeen hemiparetic patients (mean age 54.9±10.5years; 9 men and 8 women; 6 hemiparetic on the left side and 11 on the right side; mean time after stroke 6.1±3.5months) participated in 2 gait assessment sessions within an interval of 2-7 days. Intra-session reliability was obtained from the intraclass correlation coefficient (ICC) between the three strides of each session. Inter-session reliability was estimated by the ICC from the averages of that three strides. GPS value of non paretic lower limb (NPLL) (13.9±2.4°) was greater than that of paretic lower limb (PLL) (12.0±2.8°) and overall GPS (GPS_O) was 13.7±2.5°. The Gait Variable Scores (GVS), GPS and GPS_O exhibited intra-session ICC values between 0.70 and 0.99, suggesting high intra-day stability. Most of GVS exhibited excellent inter-session reliability (ICC between 0.81 and 0.93). Only hip rotation, hip abduction of PLL exhibited moderate reliability with ICC/MDC values of 0.57/10.0° and 0.71/3.1°, respectively. ICC/MDC values of GPS were 0.92/2.3° and 0.93/1.9° for PLL and NPLL, respectively. GPS_O exhibited excellent test-retest reliability (ICC=0.95) and MDC of 1.7°. Given its reliability, the GPS has proven to be a suitable tool for therapeutic assessment of hemiparetic patients after stroke.

Reliability and validity of the modified functional ambulation category scale in patients with hemiparalysis

[Purpose] This study aimed to examine the inter- and intra-rater reliability and validity of the modified functional ambulation category (mFAC) scale. [Subjects and Methods] The participants were 66 stroke patients with hemiparalysis. The inter- and intra-rater validity of the mFAC was calculated using the Spearman correlation coefficient. A score comparison of the stable or maximum gait speed with regard to mFAC and modified Rivermead Mobility Index (mRMI) performances was performed as a univariate linear regression analysis to determine how the Kruskal-Wallis test affects the mRMI and stable/maximum gait speed with regard to mFAC. [Results] The inter-rater reliability of the mFAC (intraclass coefficient [ICC]) was 0.982 (0.971–0.989), with a kappa coefficient of 0.923 and a consistency ratio of 94%. In contrast, the intra-rater reliability of the mFAC (ICC) was 0.991 (0.986–0.995), with a kappa coefficient of 0.961 and a consistency ratio of 96%, showing higher reliability. Moreover, there was a significant difference in stable/maximum gait speed between the mFAC and the mRMI. [Conclusion] Since the mFAC has sufficient inter- and intra-reliability and high validity, it can be used as an assessment tool that reflects the gait performance and mobility of stroke patients.

Six-month functional recovery of stroke patients: a multi-time-point study

The aim of this study is to compare the time-course changes in neurologic impairments (trunk control, motor function, sensory, and cognition) and recovery in functional impairments (activity of daily livings and gait) simultaneously from initiating rehabilitation to 6 months after stroke. Consecutive stroke patients were recruited from the department of nervous surgery, and transferred into the department of rehabilitation medicine and continued on treatment during the acute stage. Outcome measures were examined at the initial rehabilitation baseline, 1, 2, and 4 weeks after rehabilitation treatment, and 3, 4, 5, and 6 months after stroke. Patients were assessed using the Trunk Impairment Scale, the Fugl-Meyer Motor and Sensory Assessments for the upper and lower limbs, Mini-Mental State Examination, Functional Ambulation Category, and Modified Barthel Index. Twenty consecutive patients were analyzed in the study with complete assessments. The recovery was relatively rapid during the 4 weeks after treatment (P value ranges from <0.001 to <0.007) and then to a lesser extent decelerated between 3 and 6 months after stroke (P value between <0.001 and 0.080). Statistical comparison by repeated measures analysis showed a significant interaction between time points and measures of all recovery variables (P<0.001). Significant differences in level of impairments and functional recovery were found at the different time points. In comparison with the lower leg and trunk control, the upper arm showed less recovery, with a significant difference. All variables except for leg motor function improved continuously over 6 months after stroke. Nevertheless, this study confirms the importance of the period within 3 months for recovery after stroke, during which most of the recovery occurred, ranging from 48 to 91%. Therefore, intensive treatment targeting motor and sensory functions early after stroke may be beneficial for recovery of impairments and functional performance.

Plasma Matrix Metalloproteinases in Patients With Stroke During Intensive Rehabilitation Therapy

OBJECTIVE

To study plasma levels of matrix metalloproteinases (MMPs) as potential markers of recovery during intensive rehabilitation therapy (IRT) after stroke.

DESIGN

Prospective and descriptive 3-month follow-up study.

SETTING

Rehabilitation unit and research center.

PARTICIPANTS

Patients with first-ever ischemic stroke (n=15) enrolled to IRT (≥3h/d and 5d/wk) and healthy volunteers (n=15) (N=30).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The primary outcome was to measure plasma MMP3, MMP12, and MMP13 levels and evaluate potential associations with motor/functional scales using a battery of tests (National Institutes of Health Stroke Scale, modified Rankin scale, Barthel Index, Fugl-Meyer Assessment, Functional Ambulation Categories, Medical Research Council scale, Chedoke Arm and Hand Activity Inventory, and the 10-m walk test) before IRT and at 1- and 3-month follow-ups. The secondary outcome was to evaluate the use of these MMPs as biomarkers as predictors of patient's outcome.

RESULTS

MMP levels remained stable during the study period and were similar to those in the healthy volunteer group. However, baseline MMP12 and MMP13 levels were strongly associated with stroke severity and were found to be elevated in those patients with the poorest outcomes. Interestingly, plasma MMP3 was independent of baseline stroke characteristics but was found to be increased in patients with better motor/functional recovery and in patients with larger improvements during rehabilitation.

CONCLUSIONS

MMPs might act as biologic markers of recovery during rehabilitation therapy related to their roles in both injury and tissue remodeling. Future confirmatory investigations in multicenter studies are warranted by our data.

Responsiveness of the domain climbing up and going down stairs of the Functional Evaluation scale for Duchenne Muscular Dystrophy: a one-year follow-up

OBJECTIVE:

To determine the responsiveness of the domain climbing up and going down stairs of the Functional Evaluation Scale for Duchenne Muscular Dystrophy (FES-DMD-D3) in a one-year follow-up study.

METHOD:

The study included 26 patients with DMD. Effect Size (ES) and Standardized Response Mean (SRM) described the scale's responsiveness.

RESULTS:

For climbing up stairs, ES showed that responsiveness was low in the three-month assessments (0.26; 0.35; 0.13; 0.17), low to moderate in the six-month assessments (0.58; 0.48; 0.33), moderate in the nine-month assessments (0.70; 0.68), and high in the 12-month assessment (0.88). SRM showed that responsiveness was low in the three-month assessments (0.29; 0.38; 0.18; and 0.19), low to moderate in the six-month assessments (0.59; 0.51; 0.36), moderate in the nine-month assessments (0.74 and 0.70), and high in the 12-month assessment (0.89). For going down stairs, ES showed that responsiveness was low in the three- and six-month assessments (0.16; 0.25; 0.09; 0.08 and 0.48; 0.35; 0.18, respectively), low to moderate in the nine-month assessments (0.59; 0.44), and moderate in the 12-month assessment (0.71). SRM showed that responsiveness was low in the three- and six-month assessments (0.25; 0.35; 0.12; 0.09 and 0.47; 0.38; 0.21, respectively), low to moderate in the nine-month assessment (0.62; 0.49), and moderate in the 12-month assessment (0.74).

CONCLUSION:

Climbing up stairs should be assessed at intervals of nine months or longer, when responsiveness is moderate to high. Going down stairs should be assessed annually because moderate responsiveness was observed in this period.

Falls and Fear of Falling After Stroke: A Case-Control Study

BACKGROUND

Falls are common after stroke, with potentially serious consequences. Few investigations have included age-matched control participants to directly compare fall characteristics between older adults with and without stroke. Further, fear of falling, a significant psychological consequence of falls, has only been examined to a limited degree as a risk factor for future falls in a stroke population.

OBJECTIVE

To compare the fall history between older adults with and without a previous stroke and to identify the determinants of falls and fear of falling in older stroke survivors.

DESIGN

Case-control observational study.

SETTING

Primary teaching hospital.

PARTICIPANTS

Seventy-five patients with stroke (mean age ± standard deviation, 66 ± 7 years) and 50 age-matched control participants with no previous stroke were tested.

METHODS

Fall history, fear of falling, and physical, cognitive, and psychological function were assessed. A χ² test was performed to compare characteristics between groups, and logistic regression was performed to determine the risk factors for falls and fear of falling.

MAIN OUTCOME MEASURES

Fall events in the past 12 months, Fall Efficacy Scale-International, Berg Balance Scale, Functional Ambulation Category, Fatigue Severity Scale, Montreal Cognitive Assessment, and Patient Healthy Questionnaire-9 were measured for all participants. Fugl-Meyer Motor Assessment was used to quantify severity of stroke motor impairments.

RESULTS

Twenty-three patients and 13 control participants reported at least one fall in the past 12 months (P = .58). Nine participants with stroke had recurrent falls (≥2 falls) compared with none of the control participants (P < .01). Participants with stroke reported greater concern for falling than did nonstroke control participants (P < .01). Female gender was associated with falls in the nonstroke group, whereas falls in the stroke group were not significantly associated with any measured outcomes. Fear of falling in the stroke group was associated with functional ambulation level and balance. Functional ambulation level alone explained 22% of variance in fear of falling in the stroke group.

CONCLUSIONS

Compared with persons without a stroke, patients with stroke were significantly more likely to experience recurrent falls and fear of falling. Falls in patients with stroke were not explained by any of the outcome measures used, whereas fear of falling was predicted by functional ambulation level. This study has identified potentially modifiable risk factors with which to devise future prevention strategies for falls in patients with stroke.

LEVEL OF EVIDENCE

III.

Usefulness of voxel-based lesion mapping for predicting motor recovery in subjects with basal ganglia hemorrhage: A preliminary study with 2 case reports

It is important to estimate motor recovery in the early phase after stroke. Many studies have demonstrated that both diffusion tensor tractography (DTT) and motor-evoked potentials (MEP) are valuable predictors of motor recovery, but these modalities do not directly reflect the status of the injured gray matter. We report on 2 subjects with basal ganglia hemorrhage who showed similar DTT and MEP findings, but had markedly different clinical outcomes. Specifically, Subject 1 showed no improvement in motor function, whereas Subject 2 exhibited substantial improvement 7 weeks after onset. To determine if differences in gray matter might lend insight into these different outcomes, we analyzed gray matter lesions of the 2 subjects using a novel voxel-based lesion mapping method. The lesion of Subject 1 mainly included the putamen, thalamus, and Heschl's gyri, indicating extension of the hemorrhage in the posterior direction. In contrast, the lesion of Subject 2 mainly included the putamen, insula, and pallidum, indicating that the hemorrhage extended anterior laterally. These differential findings suggest that voxel-based gray matter lesion mapping may help to predict differential motor recovery in subjects with basal ganglia hemorrhage with similar DTT and MEP findings.

Effects of Kinesio Tape application to quadriceps muscles on isokinetic muscle strength, gait, and functional parameters in patients with stroke

The aim of this study was to evaluate the effects of Kinesio Tape (KT) application to quadriceps muscles on isokinetic muscle strength, gait, and functional parameters in patients with stroke. Twenty-four patients were allocated into KT and control groups. All patients participated in the same conventional rehabilitation program 5 times/wk for 4 wk. In addition, KT was applied to quadriceps muscles bilaterally to the patients in the KT group. Compared with baseline, peak torque levels increased significantly in both groups (all p < 0.05). However, change levels were significantly higher in the KT group than the control group at 60 degrees/second angular velocity (AV) in extension (p = 0.04) and 60 and 180 degrees/second AV in flexion (both p = 0.02) on the paretic side. Moreover, the change levels were more prominent in the KT group at 60 and 180 degrees/second AV in extension (p = 0.03 and p = 0.04, respectively) on the nonparetic side. Gait, balance, mobility, and quality of life values improved significantly in both groups (all p < 0.05), yet the change levels between the groups did not reach significance (p > 0.05). KT application to quadriceps muscles in addition to conventional exercises for 4 wk is effective on isokinetic but not functional parameters.

Clinical Characteristics of Proper Robot-Assisted Gait Training Group in Non-ambulatory Subacute Stroke Patients

Objective

To identify the clinical characteristics of proper robot-assisted gait training group using exoskeletal locomotor devices in non-ambulatory subacute stroke patients.

Methods

A total of 38 stroke patients were enrolled in a 4-week robotic training protocol (2 sessions/day, 5 times/week). All subjects were evaluated for their general characteristics, Functional Ambulatory Classification (FAC), Fugl-Meyer Scale (FMS), Berg Balance Scale (BBS), Modified Rankin Scale (MRS), Modified Barthel Index (MBI), and Mini-Mental Status Examination (MMSE) at 0, 2, and 4 weeks. Statistical analysis were performed to determine significant clinical characteristics for improvement of gait function after robot-assisted gait training.

Results

Paired t-test showed that all functional parameters except MMSE were improved significantly (p<0.05). The duration of disease and baseline BBS score were significantly (p<0.05) correlated with FAC score in multiple regression models. Receiver operating characteristic (ROC) curve showed that a baseline BBS score of '9' was a cutoff value (AUC, 0.966; sensitivity, 91%–100%; specificity, 85%). By repeated-measures ANOVA, the differences in improved walking ability according to time were significant between group of patients who had baseline BBS score of '9' and those who did not have baseline BBS score of '9'

Conclusion

Our results showed that a baseline BBS score above '9' and a short duration of disease were highly correlated with improved walking ability after robot-assisted gait training. Therefore, baseline BBS and duration of disease should be considered clinically for gaining walking ability in robot-assisted training group.

Minimal clinically important difference of the lower-extremity fugl-meyer assessment in chronic-stroke

BACKGROUND

The Minimal Clinically Important Difference (MCID), the smallest difference in the treatment outcome, augments both clinical and research practice. The MCID of the Fugl-Meyer assessment: Lower extremity (FMA-LE), an important motor measure in stroke, is not known.

OBJECTIVE

To estimate MCID score of FMA-LE using an anchor-based approach in chronic poststroke hemiparetic (>6 months) stroke subjects.

METHODS

DESIGN

A prospective, observational study.

SETTING

Occupational therapy department of a rehabilitation institute.

PARTICIPANTS

Sixty-five poststroke hemiparetic subjects (Mean age = 44.22 years, 42 men, Mean poststroke duration = 16.42 months).

INTERVENTION

The conventional motor therapy based on neurophysiological approaches was provided for the affected lower extremity (30 sessions, 45 min each, 3/week).

OUTCOME MEASURES

FMA-LE, Functional ambulation classification (FAC), and global rating of patient-perceived changes (GRPPC).

RESULT

The estimated MCID of FMA-LE was found to be a score of 6 using both FAC (sensitivity 90, specificity 94) and GRPPC (sensitivity 87, specificity 91).

CONCLUSION

In chronic poststroke hemiparetic subjects, the computed MCID of FMA-LE is a score of 6. The subjects who achieve a change in a score of 6 on FMA-LE would perceive a meaningful recovery of lower-extremity function than those who do not. The reference value may be utilized in stroke rehabilitation.

Motor Imagery Training on Muscle Strength and Gait Performance in Ambulant Stroke Subjects-A Randomized Clinical Trial

INTRODUCTION

The ultimate goal of physiotherapy in stroke rehabilitation is focused towards physical independence and to restore their functional ability during activities of daily living (ADLs). Motor imagery (MI) is an active process during which a specific action is reproduced within working memory without any actual movements. MI training enhances motor learning, neural reorganization and cortical activation in stroke. The efficacy of MI training involving lower extremity mobility tasks need to be assessed.

AIM

To evaluate the effects of combining motor imagery with physical practice in paretic Lower Extremity Muscles Strength and Gait Performance in Ambulant Stroke subjects.

MATERIALS AND METHODS

A Randomized Clinical Trial was conducted in Department of Physical Therapy, Tertiary Care Hospitals, Mangalore, India which includes 40 hemi paretic subjects (>3 months post-stroke) who were ambulant with good imagery ability in both KVIQ-20 ≥ 60 and Time dependent MI screening test were recruited and randomly allocated into task-oriented training group (n=20) and task-oriented training group plus MI group (n=20). Subjects in both groups underwent task orientated training for lower extremity 45-60 minutes, 4 days per week for 3 weeks. In addition, the experimental group received 30 minutes of audio-based lower extremity mobility tasks for MI practice. Isometric muscle strength of Hip, Knee and Ankle using a hand-held dynamometer and self-selected 10 m gait speed were assessed before and after 3 weeks of intervention.

RESULTS

Both the groups had found a significant change for all the outcome measures following 3 weeks of interventions with p <.05. The experimental group had shown a significant improvement in paretic hip muscles (both flexors and extensors), knee extensors and ankle dorsiflexors and gait speed compare to control group with p < .05 between group analyses.

CONCLUSION

Additional task specific MI training improves paretic muscle strength and gait performance in ambulant stroke patients.

First results about recovery of walking function in patients with intensive care unit-acquired muscle weakness from the General Weakness Syndrome Therapy (GymNAST) cohort study

OBJECTIVES

To describe the time course of recovery of walking function and other activities of daily living in patients with intensive care unit (ICU)-acquired muscle weakness.

DESIGN

This is a cohort study.

PARTICIPANTS

We included critically ill patients with ICU-acquired muscle weakness.

SETTING

Post-acute ICU and rehabilitation units in Germany.

MEASURES

We measured walking function, muscle strength, activities in daily living, motor and cognitive function.

RESULTS

We recruited 150 patients (30% female) who fulfilled our inclusion and exclusion criteria. The primary outcome recovery of walking function was achieved after a median of 28.5 days (IQR=45) after rehabilitation onset and after a median of 81.5 days (IQR=64) after onset of illness. Our final multivariate model for recovery of walking function included two clinical variables from baseline: the Functional Status Score ICU (adjusted HR=1.07 (95% CI 1.03 to 1.12) and the ability to reach forward in cm (adjusted HR=1.02 (95% CI 1.00 to 1.04). All secondary outcomes but not pain improved significantly in the first 8 weeks after study onset.

CONCLUSIONS

We found good recovery of walking function for most patients and described the recovery of walking function of people with ICU-acquired muscle weakness.

TRIALS REGISTRATIONS NUMBER

Sächsische Landesärztekammer EK-BR-32/13-1; DRKS00007181, German Register of Clinical Trials.

Does stroke location predict walk speed response to gait rehabilitation?

OBJECTIVES

Recovery of independent ambulation after stroke is a major goal. However, which rehabilitation regimen best benefits each individual is unknown and decisions are currently made on a subjective basis. Predictors of response to specific therapies would guide the type of therapy most appropriate for each patient. Although lesion topography is a strong predictor of upper limb response, walking involves more distributed functions. Earlier studies that assessed the cortico-spinal tract (CST) were negative, suggesting other structures may be important.

EXPERIMENTAL DESIGN

The relationship between lesion topography and response of walking speed to standard rehabilitation was assessed in 50 adult-onset patients using both volumetric measurement of CST lesion load and voxel-based lesion-symptom mapping (VLSM) to assess non-CST structures. Two functional mobility scales, the functional ambulation category (FAC) and the modified rivermead mobility index (MRMI) were also administered. Performance measures were obtained both at entry into the study (3-42 days post-stroke) and at the end of a 6-week course of therapy. Baseline score, age, time since stroke onset and white matter hyperintensities score were included as nuisance covariates in regression models.

PRINCIPAL OBSERVATIONS

CST damage independently predicted response to therapy for FAC and MRMI, but not for walk speed. However, using VLSM the latter was predicted by damage to the putamen, insula, external capsule and neighbouring white matter.

CONCLUSIONS

Walk speed response to rehabilitation was affected by damage involving the putamen and neighbouring structures but not the CST, while the latter had modest but significant impact on everyday functions of general mobility and gait. Hum Brain Mapp 37:689-703, 2016. © 2015 Wiley Periodicals, Inc.

Characterizing Energy Expenditure During Sedentary Behavior After Stroke

OBJECTIVES

To measure and calculate the energy expended by people with stroke during near sedentary behaviors (lying, supported and unsupported sitting, standing, wheelchair propulsion, walking), under controlled laboratory conditions, and to compare these values with the energy expenditure of 1.5 metabolic equivalent task (MET) within the definition of sedentary behavior.

DESIGN

Cross-sectional cohort study.

SETTING

Rehabilitation institutions.

PARTICIPANTS

People with stroke (N=27; mean age, 61.0±11.7y), categorized at Functional Ambulation Categories (FAC) 0 to 5.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Energy expenditure (measured using indirect calorimetry) expressed in METs. The recorded values were calculated for every participant and averaged for each activity: lying, supported and unsupported sitting, standing, wheelchair propulsion, and walking. Calculations were done for the total group and categorized by the FAC.

RESULTS

For the total group the mean METs ± SDs were 1.04±.11 for sitting supported, 1.09±.15 for sitting unsupported, 1.31±.25 for standing, 1.91±.42 for wheelchair propulsion, and 2.52±.55 for walking. People with stroke in all FAC had METs values >1.5 when propelling a wheelchair or walking.

CONCLUSIONS

Energy expenditure during typical sedentary behaviors (ie, sitting) is narrowly bounded at approximately 1.0 MET. Energy expenditure during sitting and standing was ≤1.5 MET for all FAC, with the exception of FAC 0 (1.6 MET during standing). Independent wheelchair propulsion and walking can be categorized as light activities (≥1.5 MET).

Walking ability after stroke in patients from Argentina: predictive values of two tests in subjects with subacute hemiplegia

[Purpose] This study aimed to determine the predictive values of the trunk control test (TCT) and functional ambulation category (FAC) for independent walking up to 6 months post stroke. [Subjects] Twenty-seven subjects with hemiplegia secondary to a unilateral hemisphere stroke were included. [Methods] The protocol was started at 45 days post stroke, with the TCT and FAC as walking predictors. At 90, 120, and 180 days post stroke, the subjects’ independent walking ability was assessed by using the Wald test. [Results] The TCT was identified as an independent predictor of ambulation at 90, 120, and 180 days. Subjects who scored ≥ 49 in the initial test had 93.8% probability of achieving independent gait at 6 months. The FAC proved that 100% of the subjects who scored 2 at 45 days post stroke walked independently at 90 days, 100% of the subjects who scored 1 walked independently at 120 days, and only 33.3% of the subjects who scored 0 walked independently at 180 days. [Conclusion] The TCT and FAC can predict independent walking at 45 days post stroke. In subjects with FAC 0, the TCT should be used to predict patients who will be able to walk independently.

Group therapy task training versus individual task training during inpatient stroke rehabilitation: a randomised controlled trial

OBJECTIVE

To compare the efficacy of intensive daily applied progressive group therapy task training with equally dosed individual progressive task training on self-reported mobility for patients with moderate to severe stroke during inpatient rehabilitation.

DESIGN

Randomized controlled clinical trial.

SETTING

In-patient rehabilitation center.

SUBJECTS

A total of 73 subacute patients with stroke who were not able to walk without physical assistance at randomisation.

INTERVENTIONS

Patients were allocated to group therapy task training (GT) or individual task training (IT). Both interventions were intended to improve walking competency and comprised 30 sessions of 90 minutes over six weeks.

MAIN MEASURES

Primary outcome was the mobility domain of the Stroke Impact Scale (SIS-3.0). Secondary outcomes were the other domains of SIS-3.0, standing balance, gait speed, walking distance, stair climbing, fatigue, anxiety and depression.

RESULTS

No adverse events were reported in either arm of the trial. There were no significant differences between groups for the SIS mobility domain at the end of the intervention (Z= -0.26, P = 0.79). No significant differences between groups were found in gait speed improvements (GT:0.38 ±0.23; IT:0.26±0.35), any other gait related parameters, or in non-physical outcomes such as depression and fatigue.

CONCLUSION

Inpatient group therapy task training for patients with moderate to severe stroke is safe and equally effective as a dose-matched individual task training therapy. Group therapy task training may be delivered as an alternative to individual therapy or as valuable adjunct to increase time spent in gait-related activities.

A comparison study on the efficacy of SpinoMed® and soft lumbar orthosis for osteoporotic vertebral fracture

BACKGROUND

Osteoporosis is one of the major health problems in aging population and may lead to osteoporotic vertebral fracture that causes severe back pain and reduced functional independency.

OBJECTIVES

To compare the efficacy of SpinoMed® and soft lumbar orthosis at the subacute stage (the second and third weeks of disease onset) of the patients with osteoporotic vertebral fracture.

STUDY DESIGN

Prospective randomized trial, pilot trial.

METHODS

A total of 51 female subjects aged 55 years or above with osteoporotic vertebral fracture were randomly distributed to the soft lumbar orthosis (control group, n = 24) and SpinoMed® (test group, n = 27) groups after the acute stage (the first week of disease onset). The pain level was assessed by obtaining verbally feedback in 10-point scale scoring, while functional mobility level was estimated with Functional Independence Measure-motor Scores, Elderly Mobility Scale, and Modified Functional Ambulation Category. The thoracic kyphosis angle was measured from standing X-ray on 10 out of 51 subjects.

RESULTS AND CONCLUSION

Both groups showed significant reduction in the patients' pain level and limitations of daily life (p < 0.05). The effect of the two types of spinal orthoses on the pain level reduction and functional mobility level gain did not show significant difference (p > 0.05) at the subacute stage.

CLINICAL RELEVANCE

In this study, SpinoMed® could not provide additional treatment benefits to patients with osteoporotic vertebral fracture regarding pain relief and functional independence improvement at the subacute stage. The effects of SpinoMed® in muscle-strengthening and thoracic kyphotic angle reduction for patients with osteoporotic vertebral fracture need to be further verified in a more intensive and longer-term training program.

Mobile Phone-Connected Wearable Motion Sensors to Assess Postoperative Mobilization

Background

Early mobilization after surgery reduces the incidence of a wide range of complications. Wearable motion sensors measure movements over time and transmit this data wirelessly, which has the potential to monitor patient recovery and encourages patients to engage in their own rehabilitation.

Objective

We sought to determine the ability of off-the-shelf activity sensors to remotely monitor patient postoperative mobility.

Methods

Consecutive subjects were recruited under the Department of Neurosurgery at Columbia University. Patients were enrolled during physical therapy sessions. The total number of steps counted by the two blinded researchers was compared to the steps recorded on four activity sensors positioned at different body locations.

Results

A total of 148 motion data points were generated. The start time, end time, and duration of each walking session were accurately recorded by the devices and were remotely available for the researchers to analyze. The sensor accuracy was significantly greater when placed over the ankles than over the hips (P<.001). Our multivariate analysis showed that step length was an independent predictor of sensor accuracy. On linear regression, there was a modest positive correlation between increasing step length and increased ankle sensor accuracy (r=.640, r²=.397) that reached statistical significance on the multivariate model (P=.03). Increased gait speed also correlated with increased ankle sensor accuracy, although less strongly (r=.444, r²=.197). We did not note an effect of unilateral weakness on the accuracy of left- versus right-sided sensors. Accuracy was also affected by several specific measures of a patient’s level of physical assistance, for which we generated a model to mathematically adjust for systematic underestimation as well as disease severity.

Conclusions

We provide one of the first assessments of the accuracy and utility of widely available and wirelessly connected activity sensors in a postoperative patient population. Our results show that activity sensors are able to provide invaluable information about a patient’s mobility status and can transmit this data wirelessly, although there is a systematic underestimation bias in more debilitated patients.

Mobile Phone-Connected Wearable Motion Sensors to Assess Postoperative Mobilization

BACKGROUND

Early mobilization after surgery reduces the incidence of a wide range of complications. Wearable motion sensors measure movements over time and transmit this data wirelessly, which has the potential to monitor patient recovery and encourages patients to engage in their own rehabilitation.

OBJECTIVE

We sought to determine the ability of off-the-shelf activity sensors to remotely monitor patient postoperative mobility.

METHODS

Consecutive subjects were recruited under the Department of Neurosurgery at Columbia University. Patients were enrolled during physical therapy sessions. The total number of steps counted by the two blinded researchers was compared to the steps recorded on four activity sensors positioned at different body locations.

RESULTS

A total of 148 motion data points were generated. The start time, end time, and duration of each walking session were accurately recorded by the devices and were remotely available for the researchers to analyze. The sensor accuracy was significantly greater when placed over the ankles than over the hips (P<.001). Our multivariate analysis showed that step length was an independent predictor of sensor accuracy. On linear regression, there was a modest positive correlation between increasing step length and increased ankle sensor accuracy (r=.640, r(2)=.397) that reached statistical significance on the multivariate model (P=.03). Increased gait speed also correlated with increased ankle sensor accuracy, although less strongly (r=.444, r(2)=.197). We did not note an effect of unilateral weakness on the accuracy of left- versus right-sided sensors. Accuracy was also affected by several specific measures of a patient's level of physical assistance, for which we generated a model to mathematically adjust for systematic underestimation as well as disease severity.

CONCLUSIONS

We provide one of the first assessments of the accuracy and utility of widely available and wirelessly connected activity sensors in a postoperative patient population. Our results show that activity sensors are able to provide invaluable information about a patient's mobility status and can transmit this data wirelessly, although there is a systematic underestimation bias in more debilitated patients.

Effects of additional, dynamic supported standing practice on functional recovery in patients with sub-acute stroke: a randomized pilot and feasibility trial

OBJECTIVE

To evaluate the feasibility and preliminary effectiveness of additional dynamic versus static passive standing performed by patients with sub-acute stroke supervised by trained helpers.

DESIGN

Assessor blinded, randomized pilot and feasibility trial.

SETTING

Neurological rehabilitation centre.

PARTICIPANTS

Non-ambulatory participants in the sub-acute phase after stroke.

INTERVENTION

Usual care plus additional standing training, consisting of either dynamic standing practice in a modified standing frame (intervention group, n=14) or static standing practice in a conventional standing frame (control group, n=14) for 5 weeks.

MAIN MEASURES

Feasibility was assessed through occurrence of adverse events, patient satisfaction and operability of the technical device handled by trained helpers. Preliminary effectiveness was assessed with the Berg Balance Scale (primary outcome) and other measures of physical functioning.

RESULTS

Trained helpers were capable to apply the intervention, and no adverse events occurred. Both groups were comparable at baseline. Within-group changes tended to be higher for the intervention group, but did not reach a significant level except for the Functional Ambulation Categories. Specifically, median pre-post improvements in the Berg Balance Scale tended to be higher in the dynamic (20, inter quartile range (IQR): 2-33 points) than in the static standing group (4.5, IQR: 0-16 points; U=62; P=0.052; effect size=0.478).

CONCLUSIONS

In severely affected individuals after stroke, dynamic supported standing practice can be performed safely by trained helpers. In a larger-scale phase III study, a total of 116 patients would be needed to prove the preliminary effectiveness found in this study.

Reliability and validity of the German translation of the de Morton Mobility Index (DEMMI) performed by physiotherapists in patients admitted to a sub-acute inpatient geriatric rehabilitation hospital

BACKGROUND

Mobility is a key outcome in geriatric rehabilitation. The de Morton Mobility Index (DEMMI) is an internationally well-established, unidimensional measure of mobility with good psychometric properties. The aim of this study was to examine the reliability and construct validity of the German translation of the DEMMI in geriatric inpatients.

METHODS

This cross-sectional study included patients admitted to a sub-acute inpatient geriatric rehabilitation hospital (reliability sample: N = 33; validity sample: N = 107). Reliability, validity, and unidimensionality were investigated.

RESULTS

Inter-rater reliability between two graduate physiotherapists was excellent, with intra-class correlation coefficient of 0.94 (95% confidence interval: 0.88-0.97). The minimal detectable change with 90% confidence was 9 points. Construct validity for the DEMMI was evidenced by significant moderate to strong correlations with other measures of mobility and related constructs (Performance Oriented Mobility Assessment: rho = 0.89; Functional Ambulation Categories: rho = 0.70; six-minute walk test: rho = 0.73; gait speed: rho = 0.67; Falls Efficacy Scale International: rho = -0.68). Known-groups validity was indicated by significant DEMMI mean group differences between independent versus dependent walkers and walking aid users versus non-users. Unidimensionality of the German DEMMI translation was confirmed by Rasch analysis.

CONCLUSIONS

The German translation of the DEMMI is a unidimensional instrument producing valid and reproducible measurement of mobility in an inpatient geriatric rehabilitation setting.

Circuit class therapy or seven-day week therapy for increasing rehabilitation intensity of therapy after stroke (CIRCIT): a randomized controlled trial

BACKGROUND

Increased therapy has been linked to improvements in functional ability of people with stroke.

AIM

To determine the effectiveness of two alternative models of increased physiotherapy service delivery (seven-day week therapy or group circuit class therapy five days a week) to usual care.

METHOD

Three-armed randomized controlled trial with blinded assessment of outcome. People admitted with a diagnosis of stroke, previously independently ambulant and with a moderate level of disability were recruited. 'Usual care' was individual physiotherapy provided five-days a week. Seven-day week therapy was usual care physiotherapy provided seven-days a week. Participants in the circuit class therapy arm of the trial received physiotherapy in group circuit classes in two 90-min sessions, five-days a week. Primary outcome was distance walked on the six-minute walk test at four-weeks post-randomization.

RESULTS

Two hundred eighty-three participants were randomized; primary outcome data were available for 259 (92%). In the seven-day arm participants received an additional three hours of physiotherapy and those in the circuit class arm an additional 22 h. There were no significant between-group differences at four-weeks in walking distance (P = 0.72). Length of stay was shorter for seven-day (mean difference -2.9 days, 95% confidence interval -17.9 to 12.0) and circuit class participants (mean difference -9.2 days, 95% confidence interval -24.2 to 5.8) compared to usual care, but this was not significant.

CONCLUSIONS

Both seven-day therapy and group circuit class therapy increased physiotherapy time, but walking outcomes were equivalent to usual care.

Protocol variations and six-minute walk test performance in stroke survivors: a systematic review with meta-analysis

Objective. To investigate the use of the six-minute walk test (6MWT) for stroke survivors, including adherence to 6MWT protocol guidelines and distances achieved. Methods. A systematic search was conducted from inception to March 2014. Included studies reported a baseline (intervention studies) or first instance (observational studies) measure for the 6MWT performed by stroke survivors regardless of time after stroke.  Results. Of 127 studies (participants n = 6,012) that met the inclusion criteria, 64 were also suitable for meta-analysis. Only 25 studies made reference to the American Thoracic Society (ATS) standards for the 6MWT, and 28 reported using the protocol standard 30 m walkway. Thirty-nine studies modified the protocol walkway, while 60 studies did not specify the walkway used. On average, stroke survivors walked 284 ± 107 m during the 6MWT, which is substantially less than healthy age-matched individuals. The meta-analysis identified that changes to the ATS protocol walkway are associated with reductions in walking distances achieved. Conclusion. The 6MWT is now widely used in stroke studies. The distances achieved by stroke patients indicate substantially compromised walking ability. Variations to the standard 30 m walkway for the 6MWT are common and caution should be used when comparing the values achieved from studies using different walkway lengths.

Reliability and validity of the Falls Efficacy Scale-International after hip fracture in patients aged ≥ 65 years

PURPOSE

To assess the measurement properties of the Falls Efficacy Scale-International (FES-I) in patients after a hip fracture aged ≥ 65 years.

METHODS

In a sample of 100 patients, we examined the structural validity, internal consistency and construct validity. For the structural validity a confirmatory factor analysis was carried out. For construct validity predetermined hypotheses were tested. In a second sample of 21 older patients the inter-rater reliability was evaluated.

RESULTS

The factor analysis yielded strong evidence that the FES-I is uni-dimensional in patients with a hip fracture; the Cronbach's alpha was 0.94. When testing the reliability, the intra-class correlation coefficient was 0.72, while the Standard Error of Measurement was 6.4 and the Smallest Detectable Change was 17.7 (on a scale from 16 to 64). The Spearman correlation of the FES-I with the one-item fear of falling instrument was high (r = 0.68). The correlation was moderate with instruments measuring functional performance constructs and low with instruments measuring psychological constructs.

CONCLUSIONS

Reliability and structural validity of the FES-I in patients after a hip fracture are good. The construct validity appears more closely related to functional performance constructs than to psychological constructs, suggesting that the concept measured by the FES-I may not capture all aspects of fear of falling.

IMPLICATIONS FOR REHABILITATION

The Falls Efficacy Scale-International (FES-I), which is commonly used to measure fear of falling in community-dwelling older persons, can also be used to assess fear of falling in patients after a hip fracture. The reliability and the structural validity of the FES-I for these hip patients are good, whereas the construct validity of the FES-I is not optimal. The FES-I may not capture all aspects of fear of falling and may be more closely related to functional performance than to psychological concepts such as anxiety.

The effectiveness of powered, active lower limb exoskeletons in neurorehabilitation: A systematic review

OBJECTIVE

This review examines the utility of current active, powered, wearable lower limb exoskeletons as aids to rehabilitation in paraplegic patients with gait disorders resulting from central nervous system lesions.

METHODS

The PRISMA guidelines were used to review literature on the use of powered and active lower limb exoskeletons for neurorehabilitative training in paraplegic subjects retrieved in a search of the electronic databases PubMed, EBSCO, Web of Science, Scopus, ProQuest, and Google Scholar.

RESULTS

We reviewed 27 studies published between 2001 and 2014, involving a total of 144 participants from the USA, Japan, Germany, Sweden, Israel, Italy, and Spain. Seventy percent of the studies were experimental tests of safety or efficacy and 29% evaluated rehabilitative effectiveness through uncontrolled (22%) or controlled (7%) clinical trials.

CONCLUSIONS

Exoskeletons provide a safe and practical method of neurorehabilitation which is not physically exhausting and makes minimal demands on working memory. It is easy to learn to use an exoskeleton and they increase mobility, improve functioning and reduce the risk of secondary injury by reinstating a more normal gait pattern. A limitation of the field is the lack of experimental methods for demonstrating the relative effectiveness of the exoskeleton in comparison with other rehabilitative techniques and technologies.

A sock for foot-drop: a preliminary study on two chronic stroke patients

BACKGROUND

Foot-drop is a common motor impairment of chronic stroke patients, which may be addressed with an ankle foot orthosis. Although there is reasonable evidence of effectiveness for ankle foot orthoses, user compliance is sometimes poor. This study investigated a new alternative to the ankle foot orthosis, the dorsiflex sock.

CASE DESCRIPTION AND METHODS

The dorsiflex sock was evaluated using an A-B single case experimental design. Two community-dwelling, chronic stroke patients with foot-drop participated in this study. Measures were selected to span the International Classification of Function, Disability and Health domains and user views on the dorsiflex sock were also collected.

FINDINGS AND OUTCOMES

The dorsiflex sock was not effective in improving participants' walking symmetry, speed or energy expenditure. Participant 1 showed improvement in the distance he could walk in 6 min when using the dorsiflex sock, but this was in keeping with a general improvement trend over the course of this study. However, both participants viewed the dorsiflex sock positively and reported a positive effect on their walking.

CONCLUSION

Despite positive user perceptions, the study found no clear evidence that dorsiflex sock is effective in improving foot-drop.

CLINICAL RELEVANCE

Although the dorsiflex sock offers an attractive alternative to an ankle foot orthosis, the case studies found no clear evidence of its efficacy. Clinicians should view this device with caution until further research becomes available.