Trunk Endurance Tests in Persons With Multiple Sclerosis: Reliability and Comparison to Healthy Matched Controls
J Freund, D.M. Stetts, J. Magill, M.D. Fedorcha, A. Hardison, K.A. Long, and S. Vallabhajosula. Elon University, Elon, North Carolina.
Purpose/Hypothesis: Trunk muscles are involved in multiple functions including respiration, postural stability, and mobility. Evidence of impaired trunk performance in persons with multiple sclerosis (PwMS) suggests a relationship between trunk performance and functional disability. Timed trunk endurance tests are reliable in young, healthy populations; however, research on trunk endurance in PwMS is lacking. The purpose of this study was to determine the reliability of timed trunk endurance tests (flexion, extension, right/left side plank) in PwMS and compare trunk endurance in PwMS to healthy persons.
Number of Subjects: Ambulatory persons with MS and age and gender-matched healthy controls were recruited from the community. Each group had 5 females and 1 male with a mean age of 51.8 (PwMS), 51.7 (healthy) years.
Materials/Methods: Each subject was tested by 2 raters on timed trunk endurance tests (extension, flexion, right and left side plank) and the 10-meter walk test (10MWT) at each of 2 sessions within 3 to 7 days.
Results: Interrater reliability was good (ICC > 0.99) for both groups on all timed trunk endurance tests across both testing sessions. Test-retest reliability for timed trunk endurance tests was moderate (ICC range = 0.52 right plank to 0.74 extension) for healthy subjects and poor to good (ICC range = 0.04 flexion to 0.97 extension) for PwMS. The poor ICC for trunk flexion in PwMS was related to the variability of performance of one subject; without that subject, ICC for trunk flexion in PwMS was 0.92. Side plank tests had poor (ICC = 0.47) to moderate (ICC = 0.69) test-retest reliability for PwMS and healthy persons. Healthy persons had significantly (P < 0.05) greater endurance for all timed trunk endurance tests than PwMS. Mean gait speeds (m/s) for self-selected and fast pace were 1.04 and 1.46 (PwMS) and 1.70 and 2.82 (healthy persons).
Conclusions: Timed trunk endurance tests for flexion and extension had good reliability in PwMS. Side plank endurance tests may not be reliable measures for PwMS or older individuals due to the difficulty of the test and subjective measurement of deviation from the test position.
Clinical Relevance: Trunk endurance tests (flexion and extension) should be considered in the examination of persons with MS. Future research is needed to determine the correlation of trunk endurance and function in PwMS.
Effects of Diet and Exercise on Physiological, Functional, and Self-report Outcomes in a Person With Multiple Sclerosis—A Case Study
J. Cunningham, J. Freund, G. Balilionis
Department of Physical Therapy Education, Elon University, Elon, North Carolina. M. Bopp, Bopp Nutrition Therapy, Greensboro, North Carolina.
Purpose/Hypothesis: Multiple sclerosis (MS) is a disease affecting the central nervous system and has no known cure. Recently, a Paleolithic (Paleo) diet has been recommended as an alternative treatment for autoimmune diseases, such as MS. A Paleo diet is based on what was believed to be eaten by hunter-gatherers during the Paleolithic time period. Exercise interventions have increased functional capacity, strength and cardiovascular endurance, reduced fatigue, and improved quality of life in persons with MS. There is minimal research on the combined effects of a Paleo diet and exercise on persons with MS. The purpose of this case study was to investigate the effects of a Paleo diet and a home exercise program on the functional, physiological, and self-report outcome measures in a woman with MS.
Number of Subjects: 1.
Materials/Methods: A 64-year-old nonambulatory female diagnosed with primary progressive MS 14 years ago participated in this A-B single-subject case study. The study consisted of a 3-week preintervention (pre-I) and 6-week intervention period. Outcome measures were administered in the morning every 7 to 10 days during the pre-I and intervention periods. The subject followed her usual diet and exercise program during the pre-I. During the intervention period, the subject followed the Paleo diet and a gradual progression of her prior exercise program.
Results: Subject reported intervention adherence levels of 4/10 for hydration and 6/10 for diet on a 10-point (10 = full adherence) verbal analog scale. From pre-I to the end of the intervention period, the subject's Box and Blocks Test (left hand), Modified Fatigue Impact Scale, and cholesterol levels improved, and her body weight decreased 5.9 kg. There were no significant changes in the subject's Box and Blocks Test (right hand), Sitting Balance Scale, grip strength, and Fatigue Visual Numeric Scale. At a 4-month follow-up of adherence, the subject reported 4/10 for hydration and 1/10 for diet.
Conclusions: The Paleo diet and exercise may be useful for weight loss, improving cholesterol and triglyceride levels, improving manual dexterity, and decreasing fatigue in persons with MS. The subject reported that the diet was appetizing, satisfying, and made her feel healthier and happier. There were several limitations to the study including limited duration of the intervention period and inability to fully adhere to the diet and exercise guidelines. As a single-case study, cause and effect can not be determined.
Clinical Relevance: The Paleo diet and exercise may be beneficial additions to a treatment plan for persons with MS, specifically for the treatment of decreased manual dexterity and fatigue. The Paleo diet and exercise may also be useful for weight loss and improving cholesterol levels in persons with MS.
Manual Wheelchair Skills and Associations With Societal Participation: Findings From the SCIRehab Project
S. Taylor, Allied Health, Rehabilitation Institute of Chicago, Chicago, Illinois. A. Natale, Allied Health, Craig Hospital, Englewood, Colorado.
Purpose/Hypothesis: Predict societal participation with patient and injury characteristics and time spent on wheelchair (WC) skills in acute rehabilitation for patients with paraplegia.
Number of Subjects: 332 patients with paraplegia at 6 inpatient rehabilitation centers in a practice-based evidence, observational, cohort design.
Materials/Methods: Physical therapists (PTs) and occupational therapists (OTs) providing regular care to patients with SCI documented the content of each therapy session using portable electronic devices featuring customized software, including the number of manual WC skill sessions focused on curbs, wheelies, and propulsion. Patient interviews were conducted at 1-year postinjury; responses were quantified for report of participation in outdoor recreational activities (ORA) and community activities (shopping, restaurant, community events, tours, park, theatre/movies, religious event, and museum), as well as the 4 Craig Handicap Assessment and Reporting Technique (CHART) domains of Physical Independence, Mobility, Social Integration, and Occupation. Logistic regression was used to associate patient characteristics and treatment with outcomes. Number of WC therapy sessions was divided into tertiles (low, middle, high) and CHART scores were dichotomized to high and low participation by median split because distributions were skewed.
Results: Higher CHART Physical Independence score was associated negatively with body mass index (BMI), and positively with female gender and the middle tertile of number of sessions of curbs, wheelies, or propulsion (odds ratio [OR] 2.2, confidence interval [CI] 1.3-3.9). Mobility was negatively associated with age and positively associated with female gender but not with any WC skills. CHART occupation score was negatively associated with the middle tertile of WC propulsion sessions (OR 0.42, CI 0.24-0.74). There were no significant associations of CHART social integration and any WC skills. ORAs were positively associated with the high tertile of curb sessions (OR 2.3, CI 1.3-4.1). Community activities did not have an association with age, sex, BMI, or any WC skills.
Conclusions: For patients with paraplegia, moderate levels of practice intensity of specific WC skills are generally associated with higher levels of social participation 1-year postinjury. Body mass index, female gender, and age also have significant associations. High levels of practice intensity are not associated with high levels of societal participation. The proportion of cases that were at the ceiling of CHART scores illustrates the reduced sensitivity of the CHART as an outcome measure for patients with SCI who are at a higher level of function while using a WC.
Clinical Relevance: PTs and OTs can increase the association of patient's return to social participation 1 year postinjury by spending time during inpatient rehabilitation addressing WC mobility training.
Sensory Amplitude Electrical Stimulation Delivered via Glove Electrode During Task-Based Exercise Improves Arm Function in Individuals With Chronic Stroke: A Pilot Study
M. Girardi, M. Hensley, J. Rohaus, C. Schewe, C. Whittey, J.E. Sullivan, Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois. K. Muir, P. Hansen, Rehabilitation Institute of Chicago, Chicago, Illinois.
Purpose/Hypothesis: Both sensory amplitude electrical stimulation (SES) and task-specific exercise have been shown to decrease impairment and improve function in the arm following stroke. These 2 interventions are generally implemented separately. The purpose of this study was to determine the effects of SES delivered by a glove electrode during task-specific exercise on arm movement, function, and sensation in chronic stroke.
Number of Subjects: 11 subjects (4 female, 7 male) with chronic arm hemiparesis following stroke. The mean time since stroke onset was 7.2 ± 4.1 years.
Materials/Methods: Subjects engaged in task-based exercise at home for 30 minutes, twice daily, for 5 weeks, while receiving SES via glove electrode. Subjects returned to the lab for supervised practice at least twice during intervention period. Outcome measures administered at pretest, posttest, and 3-month follow up included Jebsen-Taylor Hand Function Test (JTHFT), Stroke Rehabilitation Assessment of Movement—UE subscale (STREAM), Motor Activity Log-14—amount and quality subscales (MAL), and Nottingham Stereognosis Assessment (NSA). Data were analyzed using t tests (JTHFT) and Wilcoxon sign-ranks tests (STREAM, MAL, NSA).
Results: Significant changes were found in group mean pre-/posttest comparisons on the NSA (P = 0.042), MAL amount subscale (P = 0.047), and JTHFT (with writing item excluded) (P = 0.003) and in pretest to follow up comparisons on NSA (P = 0.027) and JTHFT (writing item excluded) (P = 0.009). There was no significant change on the STREAM (P = 1.0). Individuals with a greater baseline motor capacity determined by STREAM scores (P = 0.048) and more recent stroke (P = 0.014) had significantly greater improvements.
Conclusions: Combining task-specific exercise with SES delivered via glove electrode in individuals with chronic stroke resulted in changes in arm sensation and function that were maintained at 3-month follow-up.
Clinical Relevance: This study suggests that SES during task-specific exercise may be successfully implemented in a home-based intervention with limited on-site supervision to produce significant changes in arm function in chronic stroke.
The Effects of Unilateral Step Training With tDCS: A Case Study
H.R. Roth, R. Tappan, Rehabilitation Institute of Chicago, Chicago, Illinois. L.M. Rogers, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois.
Background and Purpose: Many stroke survivors who regain the ability to walk continue to experience spatial gait asymmetries. Asymmetric step length is correlated with an impaired ability to generate propulsive forces in the paretic limb, poor dynamic balance, and severity of hemiparesis. Split-belt treadmill training (SBTT) manipulates the stepping speed for each individual limb to improve gait symmetry. A clinically feasible alternative to SBTT is unilateral step training (UST) where the impaired leg remains stationary off the treadmill (TM) track, while the unimpaired leg continuously steps on the TM. There is preliminary evidence to support efficacy of this paradigm in improving gait symmetry and speed, but the amount of change observed was limited, and transient. Noninvasive brain stimulation, such as transcranial direct current stimulation (tDCS), applied to enhance between-hemisphere symmetry in motor cortical excitability has been shown to have a beneficial effect on motor learning and behavior. tDCS could serve as an adjuvant to UST, enhancing the degree of improvement and retention, by pairing more symmetrical cortical excitability with relearning symmetrical gait. This case study was designed to compare changes in gait asymmetry following 20-minute UST sessions paired with tDCS to decrease, increase, or not change cortical excitability asymmetry.
Case Description: A 59-year-old male 5 years s/p stroke with hemiplegia participated in UST with 3 conditions of tDCS, with a > 48-hour washout period. Training included 20 minutes of UST initiated at self-selected velocity (SSV) and progressively increased. The 3 sessions included (1) Anodal (excitatory) tDCS over the lesioned hemisphere (tDCS-LH), (2) Anodal tDCS over the nonlesioned hemisphere (tDCS-NLH), and (3) Sham tDCS. The goal of the sessions was to decrease spatial gait asymmetry (expressed as a percentage of pretraining trials) while increasing walking speed as measured on the GaitMat prior to training, and then 10 and 20 minutes after each session.
Outcomes: The largest improvements in spatial gait asymmetry at 20 minutes post-UST were seen with tDCS-LH (9.05% improvement). Both the sham and tDCS-NLH demonstrated an increase (worsening) in gait asymmetry (2.31%, 4.06%, respectively). Further, although all groups demonstrated an increase in gait speed, the largest improvement was seen with tDCS-LH 20 minutes after UST (+0.10 m/s in fast velocity).
Discussion: When tDCS was utilized as an adjuvant with the goal of improving cortical excitability symmetry, the subject's gait symmetry also demonstrated improvements retained up to 20 minutes postintervention. In tDCS-NLH with the intention of temporarily decreasing cortical excitability symmetry, the individual's gait symmetry worsened. Further, tDCS-LH demonstrated a more robust improvement in gait velocity after 20 minutes of UST on the TM at FV than with UST alone (sham). These findings suggest that gait asymmetries and between-hemisphere motor excitability may be related, and that improving excitability asymmetry during gait training targeted to improve spatial symmetry may improve outcomes.
The Effects of Virtual Reality Treadmill Training on Balance, Community Balance Confidence, and Gait in People With Stroke
N. Kim, B. Lee, S. Lee, Physical Therapy, Sahmyook University, Seoul, Republic of Korea.
Purpose/Hypothesis: The purpose of this dissertation was to investigate the therapeutic effects of virtual reality treadmill training on balance ability, community balance confidence, and gait ability in stroke subjects.
Number of Subjects: 27.
Materials/Methods: 27 participants who were in stroke were selected according to the conditions of the study and then divided into three groups: virtual reality treadmill training group (VR group) (n = 10), community ambulation training group (CA group) (n = 10), and control group (n = 7). All participants were given conventional physical therapy, which was conducted 1 hour per day, 5 times per week over a 4-week period. The subjects in the VR group received community-based virtual reality on treadmill training and the subjects in the CA group received community-based ambulation training. Both groups were performed for 30 minutes per day, 3 times per week over a 4-week period. To confirm the effects of intervention, static/dynamic balance ability, community balance confidence, temporal/spatial gait ability, and gait endurance were measured.
Results: The results shows that static balance was significantly improved after intervention compared to before intervention within the VR group (P < 0.05) and it was significantly greater in the VR group compared with the CA group and the control group (P < 0.05). Dynamic balance and community balance confidence were significantly improved between pre- and postintervention within the VR group and the CA group (P < 0.05) and it was significantly greater in the VR group and the CA group compared with the control group (P < 0.05). In the case of gait, temporal/spatial gait ability were significantly increased in paretic limb after intervention compared to before intervention within the VR group and the CA group (P < 0.05). Gait endurance was significantly increased between pre- and postintervention within the VR group and the CA group (P < 0.05) and it was significantly greater in the CA group compared with the control group (P < 0.05).
Conclusions: Virtual reality treadmill training improves static/dynamic balance, community balance confidence, temporal/spatial gait, and gait endurance in people with stroke, and community ambulation training improves dynamic balance, community balance confidence, temporal/spatial gait, and gait endurance in stroke patients.
Clinical Relevance: Virtual reality treadmill training and community-based ambulation training are feasible and beneficial for improving community ambulation in poor community ambulators with stroke. This method of virtual reality training might complement hospital-based intervention and community services
Characteristics of Patients With Primary Diagnosis of Concussion Referred to Physical Therapy
K. Cherian, Sports Therapy and Rehabilitation, Cleveland Clinic, Cleveland, Ohio. S. Linder, J. Alberts, R. Rizk, LRI-Biomedical Engineering, Cleveland Clinic, Cleveland, Ohio.
Purpose/Hypothesis: To summarize characteristics of patients with the diagnosis of concussion referred to physical therapy at the Cleveland Clinic. A secondary purpose was to identify patterns of interventions implemented in this patient population.
Number of Subjects: 78.
Materials/Methods: The Concussion Center provided education on the basic epidemiology, physiology, and evidence-based PT management strategies of concussion injuries to a select group of physical therapists in our health care system. Several months after the training session, a retrospective chart review was performed to identify referrals to PT with the diagnosis of concussion. Demographic information, mechanism of injury, symptoms, examination findings, and interventions were examined.
Results: 78 concussion patients were identified (45 male, 33 female). Sixty-three of the 78 concussions were sport related and the most common sports identified were football and soccer. The average ages were male 18.6, female 21.9 years.
Outcome Measures (With Mean Score in Parentheses): the Headache Disability Index (x = 35), Neck Disability Index (x = 27 with neck pain, x = 23 without neck pain), Dizziness Handicap Inventory (x = 30 for patients with dizziness, x = 35 for those with imbalance). The most common symptoms reported were headaches (73/78), dizziness (50/78), neck pain (43/78), and imbalance (31/78). Our 3 primary interventions focused on cervical spine mechanics, balance, and oculomotor deficits. The average number of treatment sessions was 5. The average days from injury to PT assessment for sport-related injury was 33 days, in nonsport concussion patients it was 112 days.
Conclusions: While our review is consistent with current literature in the identification of the most common symptoms after a concussion, we recognize the cervical spine is a large contributor to these symptoms. Due to the common complaint of neck pain, addressing the cervical spine dysfunction was our primary intervention, which has been suggested in the literature but not translated to evidence-based clinical practice to date. Lastly, as a team, we have identified the value of vestibular-trained therapists in the management of patients with concussions and the need for consistent use of outcome measures.
Clinical Relevance: Orthopedic and neurologically based physical therapists should be prepared to identify and treat the functional deficits of patients with concussions. When utilized systematically, standardized outcomes can drive clinical practice.
Virtual Reality Training Using Xbox Kinect in Stroke Survivors With Hemiplegia
H. Sin, Public Health & Health Care Management, Inje Institute of Advanced Studies, Seoul, Republic of Korea. G. Lee, Physical therapy, Kyungnam University, Changwon-si, Gyeongsangnam-do, Republic of Korea.
Purpose/Hypothesis: Stroke survivors with upper extremity functional limitation are particularly susceptible to problems in performing the independent activities of daily living, such as eating, dressing, and self-care. Therefore, maximizing stroke survivors' ability to live as independently as possible through functional recovery is the main goal of rehabilitation, and virtual reality (VR) devices have been suggested and have begun to be used in stroke rehabilitation. Recently, studies using video games such as PlayStation and Nintendo Wii for VR rehabilitation have been reported. However, few studies have clinically investigated the application of Xbox Kinect in stroke rehabilitation. Thus, this study investigated the effect of additional VR training using Xbox Kinect on the functioning of the upper extremity in poststroke survivors, in order to determine its applicability in a clinical setting.
Number of Subjects: 40.
Materials/Methods: The study was a randomized controlled trial. Forty participants were randomly allocated to either the experimental or control groups; the experimental group (n = 20) underwent VR training using Xbox Kinect and conventional occupational therapy, and the control group (n = 20) underwent conventional occupational therapy alone. The time since the onset of stroke was 7.22 months in the experimental group and 8.47 months in the control group. At baseline and after 6 weeks of intervention, ROM of the upper extremity was measured, and Fugl-Meyer Assessment (FMA) and the Box and Block Test (BBT) were performed.
Results: After intervention, significant improvements from baseline values in ROM of the upper extremity, FMA scores, and BBT scores were observed in the experimental and control groups (P < 0.05). At follow-up, there were significant differences between the 2 groups in ROM (except for the wrist), FMA scores, and BBT scores (P < 0.05).
Conclusions: Hemiplegic stroke survivors who received VR training using Xbox Kinect showed significantly improved function of the upper extremity. However, the effects of the VR training using Xbox Kinect may have been due to the greater total intervention time in the training group compared to the control group. Thus, the potential efficacy of Xbox Kinect in the rehabilitation of poststroke survivors needs to be investigated in greater depth.
Clinical Relevance: The results of our study are similar to those of previous studies using such devices, and this shows the potential for the use of Xbox Kinect in the rehabilitation of poststroke survivors. Training using Xbox Kinect may be particularly suitable given the recent trend toward moving rehabilitation out of the hospital environment and into the home environment.
Efficacy and Task Structure of Bimanual Training Poststroke: A Systematic Review
A. Wolf, R. Scheiderer, N. Napolitan, C. Belden, L. Shaub, M. Whitford, Walsh University, North Canton, Ohio.
Purpose/Hypothesis: This systematic review aimed to (i) determine the efficacy of bimanual training poststroke and (ii) explore the structure of bimanual training interventions.
Number of Subjects: 11 articles were included: 9 randomized control trials and 2 cohort pre-/postdesigns.
Materials/Methods: A systematic review of PsycINFO, The Cochrane Library, CINAHL, and PubMed was conducted according to PRISMA guidelines. Study inclusion criteria were as follows: (i) investigation of the effects of bimanual training on paretic upper extremity (UE) impairments and/or function in individuals poststroke, (ii) detailed description of intervention protocol, and (iii) a motor-based outcome measure. Within- and between-group effect sizes were calculated in addition to summarization of individual study outcomes. Training task structure (symmetry in time and space, commonality of goals of UEs) and contents were also explored.
Results: Three types of bimanual training were identified: Functional Task Training (FTT), Bilateral Arm Training with Rhythmic Auditory Cues (BATRAC), and Robot-Assisted Therapy (RAT). Within-group effect sizes across 5 studies showed trivial to moderate effects in impairment measures, trivial to small effects for fine motor activity, small to large for gross motor activity, and trivial to small effects in participation measures. In comparison studies, FTT, BATRAC, and RAT showed no significant differences in efficacy as compared to conventional therapy. Three FTT studies concluded that bimanual training had less of an effect on dexterity and perception of use compared to unilateral training or constraint induced movement therapy (CIMT). Bimanual training had greater effects on proximal control and reaching kinematics compared to unilateral training or CIMT in 3 studies. All protocols used bimanual tasks that were carried out simultaneously in time. Of the included studies, 7 used bimanual tasks that were symmetrical in space, while 4 used both symmetrical and asymmetrical tasks. All but 2 studies used bimanual tasks with 2 distinct goals, versus 1 complementary goal.
Conclusions: Bimanual training interventions are efficacious in improving paretic UE movement in individuals with subacute and/or chronic stroke. In comparison to other interventions, bimanual training appears to have greater proximal control benefits, whereas CIMT may be more efficacious at improving subjects' dexterity and perception of use. There was not enough information to determine the effects of training task structure; however, preliminary findings suggest that tasks with 1 complimentary goal may more closely assimilate the effects of CIMT. Current gaps support future research investigating bimanual training task structure and delivery methods in subjects poststroke with differing levels of acuity and severity.
Clinical Relevance: Bimanual training is an efficacious intervention to use with patients subacute or chronic poststroke to improve proximal strength and overall activity. Use of a combined protocol (bimanual training + CIMT) in the clinic may reap the optimal benefits.
Therapeutic Integration of Golf for Exercise Rehabilitation in Someone With an Incomplete Spinal Cord Injury
G. Moriello, R. Cole, B. Ryan, A. Schuck, S.R. Swift, Physical Therapy Department, The Sage Colleges, Troy, New York.
Background and Purpose: Individuals with spinal cord injury (SCI) often demonstrate impairments in strength, balance, coordination, muscle tone, and sensation that can interfere with the ability to participate in leisure activities. There is a lack of current research studying outcomes following use of golf rehabilitation programs in individuals with SCI. The purpose of this case report was to document outcomes following a rehabilitation program in someone with an incomplete SCI whose goal was to play golf.
Case Description: The participant was a 58-year-old male who sustained an incomplete C3-C6 SCI. He was unable to play a round of golf though he could putt up to 25′ and drive the ball 95′ with contact assistance. When driving the ball, he used his arms as the club driving force while keeping his body in a static position making it more of a “glorified putt” than a drive. The rehabilitation program was divided into 3 phases. Phase 1 (9 sessions) consisted of balance, strengthening, and flexibility activities to prepare him to play golf. Phase 2 (12 sessions) not only emphasized the biomechanical aspects of a golf swing but also included flexibility, strengthening, and balance activities. Phase 3 (7 sessions) focused on task-oriented training at a golf course. Outcome measures were taken before and after the intervention and included the Berg Balance Scale (BBS), Spinal Cord Independence Measure–III (SCIM-III), Walking Index for Spinal Cord Injury (WISCI-II), muscle strength, Quality of Life Profile for Adults with Physical Disabilities (QOLP-PD), 6-minute walk test (6MWT), putting accuracy, driving distance, quality of golf swing, and ability to golf.
Outcomes: At the conclusion of the study, the participant was able to play 9 holes of golf with assistance to drive the cart, pick up the ball, and move his walker prior to swing. He could independently drive the ball 149′ on average. He was better able to shift weight to the appropriate leg and rotate his body over a stable base when driving the ball. He had a better grip on the club and kept the club more stable throughout swing. Improvements were also noted on the BBS (32/56 to 41/56), SCIM-III (76/100 to 83/100), WISCI-II (13 to 16), QOLP-PD (3.17 to 3.43), and 6MWT (230 m to 240 m). Muscle strength and putting accuracy did not change.
Discussion: A comprehensive, 3-phase training program focusing on balance, flexibility, weight shifting, and golf swing biomechanics may have helped our participant achieve his goal of playing 9 holes of golf. It is important to note that this individual was able to return to golf even though he still used an assistive device to walk. There also may have been added benefits to his everyday life, as improvements in balance, physical functioning, walking capacity, and quality of life were noted. Therapists may wish to discuss leisure goals, like golf, with individuals with SCI and incorporate interventions that allow them to safely return.
Improvement in Perceived Fatigue, Gait, and Quality of Life of Patients With Secondary Progressive Multiple Sclerosis Following a Multimodal Intervention
B.B. Angara, W.G. Darling, Department of Health and Human Physiology, University of Iowa, Iowa City, Iowa. E. Shivapour, Department of Neurology, University of Iowa, Iowa City, Iowa. S.K. Lutgendorf, Department of Psychology, University of Iowa, Iowa City, Iowa. L.G. Snetselaar, Department of Epidemiology, University of Iowa, Iowa City, Iowa. M. Zimmerman, Department of Biostatistics, University of Iowa, Iowa City, Iowa. M.J. Hall, Department of Psychiatry, Veterans Administration, Iowa City, Iowa. T.L. Wahls, Department of Internal Medicine, Veterans Administration, Iowa City, Iowa.
Purpose/Hypothesis: Muscle weakness and fatigue lead to gait disability and reduced quality of life in individuals with multiple sclerosis (MS). A patient with SPMS (TW) achieved dramatic improvement in gait (transition from scooter dependence to mild gait disability) following a complex intervention including neuromuscular electrical stimulation (NMES), a progressive exercise program (PEP), intensive directed nutrition consisting of modified Paleolithic diet and nutritional supplements and stress management (SM). In a phase 1 feasibility and safety study, we investigated the effects of this complex intervention for 12 months in subjects with SPMS and demonstrated good compliance, no significant adverse events, and significant improvement in perceived fatigue, waking performance, and general health. We are now investigating effects of a similar intervention but with a focused nutritional supplement regimen (Methyl B12, methyl folate, and vitamin D used only if subject was deficient). We hypothesized that this intervention would produce improvements in perceived fatigue, gait, and quality of life of subjects with progressive MS.
Number of Subjects: 9.
Materials/Methods: Subjects with progressive MS were enrolled into a 2-week run-in phase during which they were asked to follow the study diet and perform stretches of lower limbs and back muscles. The study diet consisted of green leafy vegetables, sulfur-containing vegetables, intensely colored fruits and vegetables, plant and animal protein, seaweed, nondairy milks, and excluded gluten-containing grains, eggs, and dairy. After enrollment into main study, subjects were instructed on a personalized PEP, facilitated by NMES, consisting of strengthening exercises of lower limbs and trunk muscles. Twenty minutes of daily SM were recommended.
Results: Thirteen subjects with progressive MS participated in the run-in phase and 11 were enrolled for 12-month main study. Data of 9 subjects (7 SPMS, 2 primary progressive MS) who have completed 6 months are presented here. The baseline characteristics were (mean, range): Age and sex (50.6, 37-66 years, 2 males) and EDSS (6.4, 3.5-8). Compliance was measured as average % compliant days and was 98.5% (range, 91%-100%) for diet and 80% (range, 49%-100%) for NMES/exercise program. No serious adverse events were reported. At 6 months, average perceived fatigue as assessed with fatigue severity scale decreased by 1.3 points (P = 0.006), average duration of Timed Up and Go test decreased by 18% (range, −76.7% to 80.4%), average walking speed during 25-foot walk increased by 15.6% (range, −48.2% to 55.4%) and significant improvement in SF36 energy (P = 0.01) and general health (P = 0.037) subscales were observed.
Conclusions: This multimodal intervention is a safe and effective method to improve quality of life and fatigue in progressive MS subjects and may also improve gait.
Clinical Relevance: Our study demonstrates that lifestyle modifications may improve quality of life, fatigue, and gait in a patient population that shows progressive decline.
Effects of Treadmill Training on Standing and Walking Function After Chronic Incomplete Cervical Spinal Cord Injury: A Case Study
K. Mattern-Baxter, A. Lutsyk, M. Casey, L. Salcedo, Physical Therapy, California State University, Sacramento, Sacramento, California.
Purpose/Hypothesis: The benefits of walking in regard to bone mineral density, cardiovascular function, metabolism, and quality of life after (spinal cord injury) SCI have been reported in the literature. Intensive treadmill training (TT) has been shown to improve walking function after SCI even in the absence of neurological recovery, with best results achieved in younger subjects. This case study examined whether an intensive program of TT could restore therapeutic walking function in a highly motivated, nonambulatory young patient with chronic C5 incomplete SCI.
Number of Subjects: A 19-year-old former high school football athlete who suffered a C3/C4 burst fracture during a football game 3 years prior to study onset, resulting in incomplete SCI at C5, ASIA Impairment Scale (AIS) C, who was nonambulatory.
Materials/Methods: The patient received 43 sessions of intensive TT over the course of 13 weeks for 3 to 4 sessions/week in addition to once weekly functional overground training with a platform walker. The patient was evaluated at baseline, after 7 weeks (22 TT sessions), and after 13 weeks (43 TT sessions). Outcome measures included the timed 10-meter walk test (10MWT), the 2-minute walk test (2MWT), the Walking Index for Spinal Cord Injury–II (WISCI), the Energy Expenditure Index (EEI), the Mobility Section of the Spinal Cord Independence Measure (SCIM), and independent standing balance in seconds.
Results: The patient achieved walking ability with a platform walker, improving from 2-person assist (WISCII 6) to supervision (WISCI 13), with an increase in self-selected walking speed from 0.05 m/s to 0.16 m/s. The 2MWT increased from 4.95 m to 19.11 m with an improved EEI from 11.3 beats/meter to 2 beats/meter. Improvements in transfers were reported by the patient on the SCIM and the patient doubled his independent standing time.
Conclusions: This case study demonstrates that significant gains in walking ability can be made after an intensive TT protocol in the absence of additional neurological recovery in a young subject with chronic incomplete cervical SCI, who was previously nonambulatory. TT restored therapeutic walking with decreased amount of support, clinically significant increase in walking speed and walking distance, while lowering energy cost during ambulation. Additional improvements were found in transfers and independent standing balance. These gains were hypothesized to be due to an increase in muscular endurance as well as confidence in the upright position.
Clinical Relevance: Intensive TT led to significant gains in meaningful walking ability in a young, motivated patient with cervical incomplete chronic SCI even after prolonged wheelchair use. Even though the patient did not achieve functional ambulation speeds, he was able to ambulate for meaningful therapeutic distances and made clinically significant improvements in walking speed. Additional gains were made in transfer ability and independent standing balance, even without specific training.
Impact of the Balance-Based Torso-Weighting System on Balance, Gait, Vestibular-Ocular Function, and Symptom Self-report in an Individual With Vestibular Dysfunction
C. Durborow, Outpatient Physical Therapy, Bryn Mawr Rehabilitation Hospital, Malvern, Pennsylvania. V. Malizzia, Physical Therapy, Lebanon Valley College, Annville, Pennsylvania.
Background and Purpose: Balanced-Based Torso-Weighting (BBTW), a treatment approach in which small amounts of weight are strategically placed on the trunk to address a person's balance deficits, has shown clinical improvements in balance, gait mechanics, gait speed, and visual function in individuals with diagnoses such as multiple sclerosis, Parkinson disease, and stroke. Limited evidence exists for use in people with vestibular dysfunction (VD). The purpose of this case report was to investigate the effect of BBTW on balance, gait, vestibular-ocular function (VO), and symptom self-report in an individual with VD.
Case Description: A 29-year-old female presented with general VD occurring after she underwent robotic laparoscopy performed in the extreme Trendelenberg position. She participated in outpatient vestibular physical therapy (PT) for 17 sessions in order to address her symptoms of dizziness, vertigo, diplopia/blurry vision, lightheadedness, nausea, and multistimulus intolerance. Prior to implementing BBTW, she attended 8 sessions of standard vestibular PT. Due to the intensity of her vertigo and dizziness, the interventions were unable to be performed correctly. BBTW was then utilized in 9 sessions in conjunction with the standard vestibular PT interventions. The individual was weighed with 0.5 pounds along her lateral right trunk, and 0.25 pounds to the left of the first lumbar vertebrae.
Outcomes: While utilizing BBTW, improvements were noted in static and dynamic balance (Sensory Organization Testing, Rhomberg/Sharpened Rhomberg stance with eyes open/closed), VO, quality of gait and symptom severity/duration. The greatest improvements were noted with visual fixation, saccades, vestibular-ocular reflex, Gaze Stabilization, and Dynamic Visual Acuity. After removal of BBTW, scores 2 days later remained above baseline but demonstrated decline compared to previous session, with the exception of Dynamic Visual Acuity, which remained improved. The individual reported decreased dizziness/nausea, and a return to baseline with decreased time of rest with the use of BBTW.
Discussion: These findings suggest that the utilization of BBTW may be beneficial in the treatment of VD. The individual in this case study was initially unable to demonstrate progress during PT and was unable to tolerate the most appropriate interventions due to the onset of severe dizziness/vertigo. An improvement in VO, aided by the use of BBTW, allowed this individual to better tolerate treatment sessions, enabling successful completion of interventions and resulting in more optimal outcomes. With the use of BBTW, the individual also demonstrated improvements in gait kinematics and balance, which may allow for decreased risk of falls and faster return to prior level of function. Limitations included patient fatigue, as this individual was unable to tolerate multiple trials of each assessment in a session due to symptom exacerbation. Further research is needed to continue to explore the effects of BBTW in those with VD.
Arm and Hand Use During Functional Tasks in Healthy Elderly Adults
M. Whitford, L.K. Murray, Walsh University, North Canton, Ohio.
Purpose/Hypothesis: We don't currently have a complete understanding of arm and hand use from which we can build our rehabilitation interventions for patients poststroke. The primary purpose of the study was to describe arm and hand use during specific functional tasks in healthy elderly adults across different age groups. We hypothesized that arm and hand use would vary (i) based on the task and (ii) as a function of age.
Number of Subjects: 33 healthy elderly participants (12 males, 21 females; mean age of 71.48 ± 8.30 years; range: 60.09 to 89.59 years; 32 right handers) participated. Based on our stratification by age, there were 18 subjects in the “young old group” (60-70 years old), and 15 subjects in the “older old” group (70-89 years old).
Materials/Methods: During each single session data collection, each subject completed 50 different functional arm and hand tasks in a randomized order while sitting or standing. Standardized instructions and positions were used, and arm and hand use was rated by an investigator. Rating included the number of hands (1 = unimanual or 2 = bimanual), symmetry of bimanual hand use in space (asymmetrical or symmetrical), and function of the hand (stabilizer or mover). Interrater reliability was calculated on the first 6 subjects: frequencies were calculated by hand, and χ2 through use of online software (Graphpad software, La Jolla, California). Additional statistical analyses were carried out using SPSS v. 21.0 (IBM; Armonk, New York). Descriptive statistics were run (averaged across subjects) for all arm and hand rating categories for (i) the groups of tasks (averaged) and (ii) each individual task. Mann-Whitney U tests were run to assess differences for each category of hand use across age groups for each task; significance was set at P ≤ 0.001 after Bonferroni adjustments.
Results: Interrater reliability ranged from moderate to excellent (0.71-1.00) across the hand rating categories. On average, 81.16 ± 28.39% of the tasks were carried out bimanually compared with 17.64 ± 27.20% unimanually. Bimanual tasks were carried out asymmetrically in space 60.94 ± 33.23% of the time. The right hand functioned as a mover for 92.61 ± 15.76% of the tasks, whereas the left hand was a mover for 57.09 ± 40.34% of the tasks. Age did not have a significant effect on the number of hands used or symmetry of bimanual hand use.
Conclusions: Healthy elderly adults carry out functional tasks bimanually more often than unimanually. Bimanual hand use during function is more often asymmetrical in space. Both hands have more of a movement function, particularly the right hand in this predominantly right hand dominant sample. Age did not impact the number of hands used or symmetry of use during our evaluated bimanual tasks.
Clinical Relevance: Bimanual functional task training should be incorporated in the rehabilitation of patients who are elderly. This training should include asymmetrical tasks, whereby the right hand is typically functioning as a mover. These observations may be particularly relevant in guiding the bimanual training task structure of patients poststroke.
Perturbation-Induced Stepping in Persons Poststroke and Controls
T. Fairbank, J. Payaggapandha, K. Martinez, Northwestern University, Chicago, Illinois.
Purpose/Hypothesis: Stroke survivors are at an increased risk for falls partly due to impaired reactive balance control. The purpose of this study was to determine the frequency and characteristics of perturbation-induced protective stepping at 4 different anterior waist-pull intensities and to compare the results to 2 clinical measures of dynamic balance, the Step Test (ST) and the Lean Test (LT), in subjects poststroke and age-/gender-matched controls. We hypothesized (1) that subjects poststroke would step slower, more often, and at a lower perturbation intensity than controls and (2) that scores on the LT and ST would strongly correlate to the number of perturbation-induced steps.
Number of Subjects: 14 community-dwelling ambulatory stroke survivors (SS) (8 male, 6 female; 8 left and 6 right side paretic] mean onset 13.9 ± 9.4 years and mean age 56 ± 10.4 years, and 9 controls (CS) [5 males, 4 females] mean age 54 ± 12.9 years.
Materials/Methods: The ST and LT were administered prior to perturbation testing. Dominant leg for CS was determined by subject report and paired with nonparetic leg of SS. The number of steps for each leg was recorded for the ST. Ordinal score of 0 to 3 for the LT was based on the number of steps and ability to stay upright. An anterior waist-pull perturbation was produced by a mechanical weight drop system at 4 different intensities, 2%, 5%, 8%, and 10% of body weight (BW). Six trials at each BW and 6 catch trials at 1% BW were randomly applied. Subjects were instructed to stand with feet shoulder width apart, equal weight on each leg, and to respond naturally to the perturbations. VICON PEAK motion analysis system was used to record step characteristics (onset, height, length, and duration) and number of steps up to 3 for each trial.
Analysis: Mann-Whitney U test was used to determine group differences and Spearman rank order correlation for correlations.
Results: There was a significant difference between SS and CS for the mean number of induced steps at 10% BW (P < 0.01). There was a fair to moderate correlation between the mean number of steps taken at 10% BW and the forward LT (rs = −0.42, P < 0.05) and backward LT (rs = −0.46, P < 0.05) and a moderate correlation with the ST paretic/nondominant leg (rs = −0.55, P < 0.01) across all subjects. There was no difference in the perturbation-induced step characteristics at 10% BW between SS and CS.
Conclusions: The lack of difference in mean number of steps between groups at 2%, 5%, and 8% BW may indicate similar capacities for upright control at lower balance challenges. The relationship between the LT and paretic/nondominant leg ST to perturbation-induced steps may reflect similarities in their balance requirements. The lack of difference in step characteristics between groups indicates similarity in execution of induced first step; however, termination of stepping may be an issue as SS required significantly more steps to maintain upright control.
Clinical Relevance: Dynamic balance training in chronic stroke survivors should include perturbations of at least 10% BW as this is where induced protective stepping differed from age-gender match controls.
Functional Recovery of a Patient With Limb Apraxia: It's Just Like Riding a Bike
C. Goepp, P.M. Spigel, Brooks Rehabilitation Hospital, Jacksonville, Florida. E.J. Fox, University of Florida, Gainesville, Florida.
Background and Purpose: Apraxia is a disorder of higher motor cognition that can be present in a variety of forms making it both difficult to diagnose and treat. Patients with ideomotor apraxia may benefit from treatment focused on multiple cues and strategy-training for improvement in motor planning and motor control. The use of these approaches to improve recreational activities, however, has not been examined. The purpose of this case report is to describe the use of multiple cues and strategy-training to promote recovery of functional mobility tasks, including bike riding in an individual with ideomotor apraxia.
Case Description: A 36-year-old man with ideomotor apraxia following an anoxic brain injury from a cardiac arrest participated in strategy-training 3 to 4×/week for 10 weeks, as part of a comprehensive day-treatment program. The training was divided into 3 phases and focused on the practice of restoring mobility tasks, including mounting and riding a bicycle, which the individual reported to be a primary goal. Phase 1 included the first 4 weeks of treatment and consisted of multiple cues, involving verbal, auditory, and tactile cues to improve task performance. Phase 2 included 3 weeks of treatment focused on strategy training, where motor tasks were divided into task initiation, execution, and outcomes to maximize task performance. Phase 3 included the final 3 weeks of treatments and involved combining strategies learned in phases 1 and 2 and translating them to functional mobility tasks, including bike riding, while focusing on internal feedback and error correction to decrease the reliance on external feedback.
Outcomes: Following 10 weeks of strategy-training, the patient demonstrated improvements in a variety of mobility tasks, including bike riding. His 10 Meter Walk Test improved from 7.70 to 6.37 seconds for comfortable pace and from 5.70 to 4.65 seconds for fast pace. His 5 Times Sit to Stand Test score improved from 8.30 to 6.89 seconds, while his Functional Gait Assessment score improved from 24 to 27/30 and his High-Level Mobility Assessment Test score improved from 34 to 43/54. Additionally, the patient achieved his goal and was able to get on and off a bike with standby assistance and cycle with supervision.
Discussion: Following a 3-phase program of strategy-training and use of multiple cues, a patient with severe limb apraxia made gains in functional mobility and was able to ride a bike. As limb apraxia is a disorder of motor cognition, rehabilitation interventions focused on the principles of motor learning and feedback may be particularly useful. Future research should focus on physical therapy assessment and intervention strategies for patients with apraxia to enhance recovery of functional mobility, including recreational activities.
Prevalence of Dizziness in Patients With Chronic Headaches: A 2-Year Review
K. Cherian, Rehabilitation and Sports Therapy, Cleveland Clinic, Cleveland, Ohio. C.M. Durrough, Vanderbilt University Medical Center, Pi Beta Phi Rehabilitation Institute, Nashville, Tennessee. S. Krause, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.
Purpose/Hypothesis: The purpose of this study was to determine the prevalence of dizziness in the chronic headache population. A secondary purpose was to identify common patterns of dizziness in order to develop better treatment protocols for patients with chronic headaches.
Number of Subjects: 234.
Materials/Methods: Retrospective chart review of patients enrolled in the Cleveland Clinic's 3-week intensive Interdisciplinary Method for the Assessment and Treatment of Chronic Headaches (IMATCH) program over a 2-year period (April 2010-2012). Participants' pre- and postintervention scores on the Dizziness Handicap Inventory (DHI), Headache Disability Index (HDI), and Neck Disability Index (NDI) were analyzed.
Results: Dizziness was reported in 93% of the patients (26% mild, 44% moderate, and 24% severe impairment). Of these patients, 83% demonstrated improvement by an average of 21 points on the DHI. The HDI improved by an average of 36 points in 95% of the patients. The NDI also improved in 80% of the patients by an average of 9 points. Positional dizziness was reported by 82% of patients, and of these 64% improved with treatment, 12% reported worsening symptoms, and 24% had no change. Of patients with positional symptoms that improved, the average initial score was 48/100, 47 for those that worsened, and the no-change group scored 43 initially. Specific questions were asked about looking up, bending over, rolling over. Of the group that improved in positional symptoms, 81% reported either a yes or sometimes on looking up, 44% reported a yes or sometimes with rolling over, and 93% reported a yes or sometimes with bending over.
Conclusions: Physical therapy interventions assisted not only in improvement of headache but also in dizziness and neck pain in the chronic headache population. In our findings, dizziness was very common and clinically significant in chronic headache patients and was improved in most of the patients. Positional symptoms were clearly identified in the DHI by looking at questions 1, 13, and 25, and this can easily be used as a screen in any patient.
Clinical Relevance: The results of this study clearly show that additional questions about dizziness need to be asked when obtaining a history in headache patients. Current research identifies that manual interventions and exercise are beneficial treatments for headache patients. We would like to suggest that positional testing should be implemented in this population to assist with determination of the cause of dizziness for improved outcomes.
Does Treatment of the Cervical Spine Change Postural Stability in Dizzy Patients?
C.M. Durrough, Pi Beta Phi Rehabilitation Institute, Vanderbilt University Medical Center, Nashville, Tennessee. A. Cassady, K. Cherian, Rehabilitation and Sports Therapy, Cleveland Clinic, Cleveland, Ohio.
Background and Purpose: Literature to date has shown that individuals with cervicogenic dizziness subjectively report neck pain and dizziness and present with musculoskeletal impairments in the cervical region and postural instability that can be identified with posturography. Physical therapy protocols that include manual therapy without balance or vestibular rehabilitation have been shown to improve the symptoms of cervicogenic dizziness. However, there is limited research regarding objective changes in postural stability in individuals with cervicogenic dizziness following manual therapy. Specifically, this literature review revealed no studies that included posturography to assess the integration of the sensory systems involved in balance, such as the Sensory Organization Test or Head Shake Sensory Organization Test. Also, gross changes in cervical active range of motion have not been consistently reported in the literature. Overall, the number and quality of studies regarding manual therapy for cervicogenic dizziness is limited. This study is designed to address gaps in the literature to help determine the effect of manual therapy on balance and range of motion in individuals with cervicogenic dizziness.
Case Description: The patient was a 75-year-old male referred to physical therapy for dizziness, gait abnormalities, imbalance, and drop foot. Patient also had a history of falls. Patient denied neck pain or headaches at initial evaluation; however, he reported numbness in upper extremities and cervical ROM restrictions were observed. On second visit, outcome measures were completed upon arrival and immediately following a treatment session consisting of manual therapy for his cervical region.
Outcomes: Cervical spine active range of motion was assessed via CROM, and NeuroCom Sensory Organization Test (SOT) and Head Shake-Sensory Organization Test (HS-SOT) were completed immediately before and after a treatment session that consisted of interventions for the cervical spine. Before intervention, the patient's SOT composite score was 51 (abnormal) with abnormal use of the vestibular and visual systems for balance. Additionally, his HS-SOT was abnormal with equilibrium scores of 0.96 on condition 2 and 0 on condition 5 (falls on 6/6 trials). After intervention, his SOT improved to 70 (within normal limits) with appropriate use of all sensory systems for balance. His HS-SOT was essentially unchanged with an equilibrium score of 0.94 on condition 2 and 0 on condition 5. Notable improvements were demonstrated in cervical extension AROM (from 50° preintervention to 64° postintervention) and left rotation (from 50° to 58°).
Discussion: The results of this study indicate a strong connection between the cervical spine and balance for this patient. His SOT shows a significant change in postural stability as a result of physical therapy interventions for the neck. These outcomes suggest the need for further research regarding this connection and cervical interventions for patients with imbalance.
Gait Speed Correlates Stronger With Lower Extremity Coordination Than Strength in Persons With Amyotrophic Lateral Sclerosis
D. Lanzino, J. Evens, J. Myhre, K. Urness, J.H. Hollman, Mayo Clinic, Rochester, Minnesota.
Purpose/Hypothesis: Objective clinical biomarkers are needed for monitoring the progression of Amyotrophic Lateral Sclerosis (ALS). While gait speed is well-established as a functional measure, it has only recently been studied in persons with ALS. Current evidence suggests that gait speed is moderately correlated with overall disease progression. We hypothesized that gait speed impairments are due, in part, to upper motor neuron dysfunction known to result in weakness and impaired alternating motion rates. Therefore, the purpose of the current study was to examine the relationship between gait speed and measures of lower extremity strength and timed coordination.
Number of Subjects: 26 subjects, diagnosed with ALS within the 18 months prior to the study, recruited from the ALS Clinic at Mayo Clinic, Rochester, Minnesota.
Materials/Methods: Tests were conducted during one session at an outpatient setting. Knee flexion and hip extension strength were assessed with a hand-held dynamometer. A stopwatch was used to record time to complete 5 repetitions of foot tap, heel-to-knee/ankle, and heel-on-shin. Preferred and fast gait speeds were measured using the 10-meter walk test. Correlations between timed coordination performance, strength measures, and gait speed were assessed with Pearson product-moment correlation coefficients (α = 0.05). Data were analyzed with IBM SPSS 21 software.
Results: In general, gait speed correlated more strongly with timed coordination performance than strength. Of the 3 coordination tests, foot tap had the strongest correlation with both preferred and fast gait speed (r = −0.752 and r = −0.794, respectively). Of the strength measures, hip extension had the strongest correlation (preferred gait speed, r = 0.433, and fast gait speed, r = 0.511).
Conclusions: In the population of persons with ALS in the current study, gait speed appeared more strongly correlated with distal motor function in the lower extremity, as measured by timing 5 repetitions of foot tap, than the more gross measures of leg coordination or isolated leg strength tests. Dorsiflexion weakness is a presenting symptom in a subset of patients with ALS and may have resulted in slowed foot tapping in our sample, along with lower extremity spasticity. Dorsiflexion was not assessed for strength in our study and is worth considering for future research.
Clinical Relevance: Assessing timed motor function at the ankle may be important to aid in evaluating the need for therapeutic interventions aimed at improving or mitigating declines in gait speed in persons with ALS. In instances where gait speed cannot be measured, assessing timed foot tapping may be otherwise reflective of gait performance.
Acute Muscle Fatigue Reduces Anticipatory Postural Control in Parkinson Disease
E.V. Papa, L.E. Dibble, K.B. Foreman, Department of Physical Therapy, University of Utah, Salt Lake City, Utah. P.S. Dyer, Department of Mechanical Engineering, University of Utah, Salt Lake City, Utah.
Purpose/Hypothesis: Postural instability is an important contributor to fall risk in persons with Parkinson disease (PD). While acute muscle fatigue has been shown to alter measures of anticipatory postural control in healthy young and elderly individuals, investigators have yet to examine fatigue's influence on persons with PD. Therefore, the purpose of this report was to explore the effect of acute muscle fatigue on anticipatory postural control during a balance task in persons with PD. We hypothesized that acute muscle fatigue would decrease the reach distance and the magnitude of the anticipatory postural shift, while increasing the variability of the center of pressure (COP) position throughout the balance task.
Number of Subjects: 7 persons with PD consented to participate (Mean age = 64.7 years; Mean HY = 2.08).
Materials/Methods: Lower extremity and COP kinematics were tested prior to and immediately following a bout of lower extremity muscle fatiguing exercise. Fatigue was defined as a 30% decline in a subject's baseline peak torque (Paillard, 2012) measured on a computerized eccentric ergometer. Prior to performing a lower extremity reach task (LERT), participants were instrumented with reflective markers using a standardized full body marker set. Lower extremity kinematic and COP data were gathered using a Vicon 10-camera motion analysis system and an AMTI in-ground force plate. Outcome measures were the peak anticipatory postural COP shift, LERT reach distance, and COP variability under the stance limb during the LERT task. Pre- and postfatigue differences were tested using paired samples t tests and a preset level of significance of P = 0.05.
Results: Peak COP shift was diminished (P = 0.037) and horizontal COP variability was increased (P = 0.046) following the acute bout of muscle fatigue. LERT reach distance was decreased after fatigue but did not achieve statistical significance.
Conclusions: This report suggests that an acute bout of intense muscle fatiguing exercise may increase hypokinesia and instability during balance tasks driven by anticipatory postural control in persons with PD. While resistance training is gaining popularity in the rehabilitation of persons with PD, to our knowledge, this is the first study to recognize the potential negative effects of acute intense muscle training.
Clinical Relevance: The degradation of postural control following acute muscle fatigue in persons with PD is clinically relevant in that it indicates the potential for iatrogenic increases in fall risk, and for improvements in muscle endurance as a potential target for rehabilitation interventions.
Dynamic Overground Body Weight Support Training in Patients With Pusher Syndrome After Stroke: A Case Series
D. Ness, Mayo Clinic, Rochester, Minnesota.
Background and Purpose: This case series describes the use of a dynamic unloading, overground body weight support (BWS) gait training system in patients with lateropulsion. Some stroke patients with hemiparesis demonstrate lateropulsion or “pusher” behavior. Lateropulsion is considered a negative predictor of rehabilitation recovery time and presents challenges to patient and staff safety. Few studies have investigated therapeutic interventions for patients with lateropulsion or the use of dynamic overground BWS.
Objective: To investigate 3-minute walk test (3MWT), walking distance, lateropulsion and Functional Independence Measure (FIM) changes after gait training in a dynamic overground BWS system in patients with lateropulsion.
Participants: Three patients with lateropulsion after stroke Burke Lateropulsion Scale (BLS) of 8-13/17 undergoing comprehensive inpatient rehabilitation.
Intervention: Patients received 30-minute, 2 time/week sessions of dynamic overground BWS training, 30% unloading, in addition to standard physical therapy sessions (total treatment time 90 minutes/day).
Outcomes: 3MWT and walking distance without rest breaks were recorded with and without dynamic overground BWS at admission, weekly and dismissal from the inpatient setting. FIM and BLS scores were also collected at admission and dismissal. All 3 patients made improvements in 3MWT distance (mean Δ = 83.6 ft), total distance walked (mean Δ = 123.3 ft), change in total FIM (mean Δ = 37.6), and BLS (mean Δ = 10 points) scores. All patients had data collected with overground gait training alone for at least 1 week prior to the dynamic overground BWS implementation. There was also improvement in the 3MWT and total distance walk data when the dynamic overground BWS training was initiated compared to prior to initiation of BWS training.
Discussion: Patients with lateropulsion or “Pusher syndrome” pose a unique challenge to physical therapists in the rehabilitation process. Individuals with this pathology have poor body in space awareness and push strongly toward their hemiplegic side. Often early mobilization is difficult. The use of a dynamic unloading overground BWS allows the patients to ambulate in a safe, controlled manner. The benefit of the dynamic overground device is that it is lightweight, allows the use of gait assistive devices, and gait on uneven surfaces. The dynamic overground BWS system also automatically follows the patient so that the patient only feels vertical unloading forces. The upward unloading force during locomotion seems to be an effective method for reducing the pushing behavior, possibly because it recalibrates a biased sense of verticality. This case series described improvement in 3MWT and total distance walked after the implementation of dynamic overground BWS training. In addition, improvements were demonstrated in total FIM and BLS dismissal scores. Further research is needed to investigate parameters of dynamic overground BWS training with the lateropulsion patient population.
Assessing Life-Space After Spinal Cord Injury: Test-Retest Reliability and Influencing Factors
D. Lanzino, E. Sander, B. Mansch, A. Jones, M. Gill, J.H. Hollman, Mayo Clinic, Rochester, Minnesota.
Purpose/Hypothesis: Life-space refers to the extent to which a person mobilizes into the surrounding environment, taking into account the need for equipment and assistance. Life-space is measured using the Life Space Assessment (LSA), a questionnaire created for use with older adults at risk for decreased mobility. Persons with spinal cord injury (SCI) are also at risk for mobility impairments, but the psychometric properties of the LSA in a SCI-only population are unknown. The purposes of this study were to determine test-retest reliability of the assessment tool and to examine factors that potentially influence LSA scores among persons with SCI.
Number of Subjects: Fifty subjects were recruited from the Mayo Clinic SCI database. Subjects were community-dwelling, aged between 18 and 65 years (45 ± 13), and diagnosed with ASIA A, B, C, or D at least 1 year prior to the study.
Materials/Methods: Cross-sectional design with participants grouped according to level of injury (C7 and above, n = 25; T1 and below, n = 25). The LSA was conducted by phone interview on 2 separate occasions, 2 weeks apart. The ICC estimated test-retest reliability of LSA responses. Pearson correlation coefficients examined associations between scores among groups. ANOVA and t tests examined differences between participants with varying SCI classifications, symptoms, and living status, with Bonferroni corrections for multiple comparisons.
Results: Test-retest reliability of LSA scores was strong (ICC = 0.889; 95% CI = 0.813-0.936). Persons ambulating full-time, employed, or reporting no pain, fatigue, or spasticity had significantly greater scores (ie, larger life-space) than full-time wheelchair users, persons unemployed or who reported pain, fatigue, or spasticity (P < 0.05). Scores did not differ based on level of injury, age, ASIA classification, gender, presence of pressure sores, or whether or not the participant lived alone.
Conclusions: In persons with SCI, the LSA is reliable and stable over at least a 6-week time frame. Having a higher-level injury (ie, cervical) did not impact life space any differently than injuries at lower spinal levels. The ability to ambulate full- or part-time, employment, and the absence of pain, spasticity, and/or fatigue positively impacted life space.
Clinical Relevance: The LSA may be useful for assessing environmental mobility in persons with SCI, particularly to measure the impact of therapeutic interventions focused on relieving spasticity, pain, or fatigue.
Differences in Cortical Activations Patterns in Working Memory Following Traumatic Brain Injury
J. Lojovich, C. Rust, B. Radtke, D. Rizzo, R. Ringeisen, University of Minnesota Program in Physical Therapy, Minneapolis, Minnesota.
Purpose/Hypothesis: The purpose of this study was to investigate the difference in the intensity and volume of brain activation in the Default Mode Network (DFN) and cognition during a working memory task in neurologically intact and traumatic brain injury (TBI) subjects.
Number of Subjects: Five neurologically intact adult males (mean age 24 years, SD = ± 0.632) and 5 TBI adult males (mean age 45 years ± 14.83) subjects. TBI subjects presented with moderate to severe, nonpenetrating injuries (mean time since TBI 8 years ± 9.35).
Materials/Methods: Cortical activation data were obtained using a 3T fMRI scanner during a visual fixation condition (control), 0-back, and 2-back of the N-back working memory task. Tasks were done in a pseudorandomized block design. Brain Voyageur software package was used to analyze location, volume, and intensity of activation during N-back task performance. Regions of interest included the DLPFC, PCC, and PreC. Measurements of reaction time and accuracy during the N-back tasks were measured using E-Prime software. A Mann-Whitney U test was used to analyze data (α < .05).
Results: Results show a significant decrease in voxels in the right DFN during the 0-back task in the TBI subjects (DLPFC P < 0.01, PreC P < 0.04, PCC P < 0.03). In the 2-back task the left PreC decrease in intensity approached significance in the TBI subjects (P < 0.09) compared with the neurologically intact subjects. For both the 0-back and 2-back task, TBI subjects also performed significantly less accurately and had slower reaction times (P < 0.001).
Conclusions: Decreased right DFN volume of activation during the 0-back task and decreased left PreC intensity on the left during the 2-back task is consistent with previous literature. These findings demonstrate differences in activation patterns during cognition following TBI that are consistent with impairments with working memory.
Clinical Relevance: This study contributes to the limited evidence supporting that TBI subjects have a change in working memory and cortical activation. These data are part of a larger study looking at the effects of exercise and increasing working memory in TBI subjects.
The Effects of an Intensive Balance Exercise Program on Near Falls, Balance, and Falls Self-efficacy in Near-Fallers With Parkinson Disease
S. Crandall, P. Padgett, K. Hendron, T. DeAngelis, L.E. Brown, T. Ellis, Center for Neurorehabilitation, Boston University College of Health & Rehabilitation Sciences, Boston, Massachusetts.
Purpose/Hypothesis: It is well known that falls are prevalent, costly, and lead to high injury and disability rates in people with Parkinson disease (PD). While near falls have been reported in PD, the definitions of a fall, near-fall, and near-miss vary across studies, and few studies have prospectively tracked and differentiated falls and near falls in people with PD. Near falls may indicate a decline in balance and risk for future falls in a relatively high-functioning population, including patients without documented postural instability. This pilot study aimed to determine whether an intensive balance intervention successfully reduced near falls and improved balance and falls self-efficacy, with the goal of reducing risk for future falls in people with PD who are on the cusp of falling.
Number of Subjects: 23 subjects with idiopathic PD, reporting at least 1 near fall in the past 3 months, mean Hoehn & Yahr stage: 2.45, mean years since diagnosis: 4.54.
Materials/Methods: A single group pretest, posttest design was used. The intervention consisted of group exercise for 90 minutes, twice per week, for a total of 24 sessions, consisting of progressive balance and strengthening exercises. Patients rated perceived difficulty of maintaining balance during each activity on a scale of 0 to 10, which was used to progress exercises to maintain high intensity. The MiniBESTEST (MiniBEST) and Falls Efficacy Scale-International (FES-I) were administered pre- and postintervention, while near falls and falls were tracked prospectively with fall diaries and in-person interviews at each intervention session. Two-tailed paired t tests were used to analyze changes in pre-/postscores for the FES-I and MiniBEST. A linear regression analysis was used to detect change in near fall frequency over the course of the intervention.
Results: During the 3-month intervention period, participants experienced a total of 123 near falls and 20 falls. There was a statistically significant linear decrease in frequency of near falls over 24 sessions (P = 0.004). A statistically significant improvement was noted in FES-I scores (P = 0.002), with 53% of subjects achieving a lower fall risk category. A statistically significant improvement was found in MiniBEST scores (P = 0.002), and improvements in 53% of subjects exceeded the minimal detectable change or reached a ceiling effect.
Conclusions: People with PD who experience near falls can improve their balance and falls self-efficacy and reduce incidence of near falls with intensive, balance-specific interventions.
Clinical Relevance: This study indicates that patients with PD who experience near falls but may not be classified as fallers benefit from early, progressive, intensive balance interventions. These patients experience a reduction in near falls, improved balance, and improved balance self-efficacy, which may prolong time until falling or reduce risk of falls. This study suggests the importance of monitoring near falls.
Diaphragm Pacing and Respiratory Outcomes in 2 Individuals With Cervical Spinal Cord Injury
T. Faw, J. McParland, Physical Therapy, Brooks Rehabilitation, Gainesville, Florida. E.J. Fox, Brooks Rehabilitation & University of Florida, Gainesville, Florida. A.J. Kerwin, Acute Care Surgery, University of Florida & Shands Jacksonville, Jacksonville, Florida. D.J. Hoh, Neurosurgery, University of Florida & Shands, Gainesville, Florida. M. Lane, P.J. Reier, Neuroscience, University of Florida, Gainesville, Florida. B.K. Smith, D. Fuller, Physical Therapy, University of Florida, Gainesville, Florida.
Background and Purpose: Diaphragm pacing is an emerging approach to restore respiratory function in individuals with cervical spinal cord injury (C-SCI). Largely used for those with respiratory dysfunction after chronic C-SCI, pacers are now being implanted acutely. This approach may reduce secondary complications and promote respiratory recovery. Patients with acute C-SCI and a diaphragmatic pacer (DP) have unique rehabilitation needs and some patients may wean from the DP and recover independent respiration. However, the factors associated with weaning and respiratory recovery have not been identified. The purpose of this case series is to describe the rehabilitation progression and long-term outcomes in 2 individuals with acute C-SCIs who received early DP placement.
Case Description: Both individuals incurred C-SCIs secondary to trauma and required mechanical ventilation (Patient A, C4-5 AIS A; Patient B, C-2, AIS C). Both received a DP during acute hospitalization (patient A, 6 weeks postinjury; patient B, 1 week postinjury), and subsequently were weaned from mechanical ventilation within 72 hours after pacer implantation. Both individuals participated in inpatient rehabilitation, which included progressive respiratory muscle training 3 to 5 days/week for 4 weeks. Respiratory exercises included incentive spirometry, quick breaths, triplicate inspiration, and resisted breathing. During brief periods when the DP was disconnected (ie, battery change), both individuals required mechanical assistance to breathe.
Outcomes: Following inpatient rehabilitation, both individuals were discharged home and required a power wheelchair for mobility and ongoing DP use. Both individuals reported improved respiratory muscle activation, cough production, and voice volume. Four months post-DP implantation, patient A reported the ability to breathe independently for brief periods. The DP device was removed 10 months after implantation, after it was established that the patient had regained the ability to breathe independent of external support. At 2-year follow-up, patient B continues to require full-time use of the DP, and however, is completely ventilator independent.
Discussion: Numerous factors may influence outcomes following C-SCI and DP use. Here we present 2 cases with disparate outcomes. The specific factors associated with weaning from a DP have not been identified but may be related to injury characteristics and specific rehabilitation strategies. We hypothesize that diaphragm pacing may promote respiratory recovery in some patients by initiating plasticity in the phrenic motor system.
The Effects of Balance Training in Bilateral Distal Spinal Muscular Atrophy: A Case Study
L.B. Perillo, Physical Therapy, NYU Langone Medical Center, New York, New York.
Background and Purpose: Distal spinal muscular atrophy is a neuromuscular disorder characterized by progressive muscle weakness, impairments in muscle function, and neurological control, often impairing balance and increasing risk of falls. Limited evidence on physical therapy management forces therapist to speculate interventions based on interventions for individuals with similar pathologies. The purpose of this case study was to provide researchers/clinicians with evidence of a balance intervention to aid in treatment of individuals with distal spinal muscular atrophy.
Case Description: A 53-year-old female referred physical therapy diagnosed with bilateral distal spinal muscular atrophy. Musculoskeletal system review indicated muscle weakness at the ankle joint. The Berg Balance was used to measure change in static balance and balance during functional tasks, while the DGI provided information more specific to dynamic balance/stability during gait. Assessment using these outcome measures revealed deficits in standing balance. She received physical therapy twice per week for 30-minute sessions, over a period of 6 weeks. Baseline measures were reassessed at 4 weeks and 6 weeks to differentiate gains made from possible neuronal adaptations versus physiological muscle changes. The intervention consisted of balance training to improve both static and dynamic balance coupled with an HEP consisting of AROM and Romberg activities. The therapy was provided in an open physical therapy gym and the following equipment was utilized: parallel bars, air-ex balance pad, 12″ cones, 4″ cones, trampoline, soccer ball, tennis balls, tilt board, incline boards, and towels.
Outcomes: There were consistent improvements in MMT grades at the ankle joint. Changes in static and dynamic balance were demonstrated by improvements in her performance on both the Berg Balance Scale and DGI. The Berg Balance Scale score improved by 9 points at 4 weeks and 10 points at the end of the intervention. Her scores on the DGI improved by 3 points. Subjective reports expressed improvements in function and community access.
Discussion: Current evidence of balance training in individuals with distal spinal muscular atrophy is limited. This case study demonstrates the effectiveness of a balance program for one individual and recommends additional research to aid physical therapists in the rehabilitation management of individuals with distal spinal muscular atrophy. It aides in highlighting the importance of balance training as a component of physical therapy management for individuals with distal spinal muscular atrophy.
Impact of LSVT BIG on Patients at Stage 1 of Parkinson's Disease: A Pilot Study
E. Vesey, B. Millage, M. Anheluk, M. Finkelstein, Sister Kenny Rehab Institute, Allina Health - Mercy Hospital, Coon Rapids, Minnesota.
Purpose/Hypothesis: Patients with Parkinson's disease (PD) are not often referred for physical therapy until they or their care partner notes severe mobility issues or falls are occurring. LSVT BIG has been shown to be an effective intervention to improve mobility for people with PD in a variety of stages of the disease (Ebersbach et al, 2010; Farley et al, 2005). To our knowledge, there are no studies that have evaluated the effectiveness of LSVT BIG exclusively at stage 1 of PD. The primary objective of this pilot study was to demonstrate that LSVT BIG can benefit individuals with PD who are in stage 1. We hypothesize that early intervention, at stage 1 of PD, can provide improvements in mobility. A secondary objective was to explore the relationship of adherence to medication requirements and exercise recommendations. It is well established that persons with PD function at their best when exercise and medications are combined in treatment regimens. Current evidence indicates that adherence to medications is a serious problem for persons with PD with suboptimal adherence as high as 67% (Davis et al, 2010; Kulkarni et al, 2007).
Number of Subjects: 10, using a single-stage Phase II model for sample size (Fleming, 1982).
Materials/Methods: The LSVT BIG protocol is conducted in an outpatient therapy gym by LSVT certified physical therapists. Participants attend four 1-hour sessions per week for 4 weeks. They are instructed to exercise at home 2× per day on nontherapy days and 1× per day on therapy days. They also participate in a 2× per month community reenforcement class post-LSVT BIG training. Outcome measures include Berg Balance Assessment (BBA)*, Functional Gait Assessment (FGA)*, Gait Speed*, 4-Square Step Test, StepWiz, UPDRS Motor Section*, PDQ-39, and the Morisky-Green (Medication Adherence Survey). These tests are performed at baseline, post-BIG, and 3-months post-BIG training. To test our hypothesis, we define success as a minimum of 6 participants achieving Minimal Clinically Important Difference (MCID) on at least 1 mobility outcome measure having a defined MCID (* items). Participants are contacted by phone twice monthly to answer questions regarding medication and exercise adherence.
Results: At the time of submission, 5 subjects have been recruited, 2 having completed LSVT BIG training. Preliminary results show 1 subject achieving MCID in both gait speed of 1.24 ft/s and Berg Balance Assessment of 4 points. Most importantly, both participants achieved MCID on the UPDRS Motor Section.
Conclusions: Preliminary results show that LSVT BIG training in stage 1 of PD can improve posture, gait, and coordination. There is also evidence that training improves gait speed and static balance and possibly dynamic balance.
Clinical Relevance: Demonstration of efficacy of LSVT BIG in stage 1 of PD can provide physicians the evidence to refer at the early stage of the disease to help maintain higher levels of mobility.
Effect of Mirror Therapy on Lower Extremity Motor Control and Gait in Patients With Stroke
L.J. Barnes, K.C. Wilcox, Physical Therapy, University of Mississippi Medical Center/School of Health Related Professions, Jackson, Mississippi. K.H. Hood, A. Fountain, R. McRae, B. Ong, P. Stegall, University Rehabilitation Center, University of Mississippi Medical Center, Jackson, Mississippi.
Purpose/Hypothesis: Stroke often leads to decreased function of the lower extremity contralateral to the side of lesion that can impair strength, functional mobility, and motor control. Mirror therapy (MT) is a therapeutic intervention in which a patient performs specific exercises of the unaffected limb while observing the mirrored image of that limb being visually overlaid on the contralateral side. The mirrored image produces the appearance of movement on the involved side. This simulation has been shown to increase cortical activity on the side of the brain that controls the affected limb, which may facilitate return of motor control. The purpose of this study was to examine the effect of MT on residual lower extremity impairments in patients with subacute stroke.
Number of Subjects: 30.
Materials/Methods: Participants were patients with stroke who were recruited following admission to an inpatient rehabilitation facility. Explanation of the study was presented to potential participants, and those who agreed to participate in the study signed an informed consent. Patients who met the inclusion/exclusion criteria were randomly assigned to either the control group or the treatment group by a computer-generated randomization process. Participants in the control group received traditional physical therapy rehabilitation, while the participants in the treatment group received traditional physical therapy interventions with the addition of MT exercises for 15 minutes per day. Data were collected by the research team upon admission and at discharge for statistical analysis.
Results: Thirty patients participated in the study, ranging in age from 26 to 79 years. Seventeen participants were randomly assigned to the control group and 13 were randomly assigned to the treatment group. Statistical analysis indicated that participants showed improved mean scores for all outcome measures at discharge. Multivariate analysis of variance (MANOVA) indicated a statistically significant difference in between group scores for lower extremity function measured by the Stroke Rehabilitation Assessment of Movement (STREAM) (P < 0.05); however, the control group had higher scores than the treatment group. No statistically significant differences were found in the discharge scores for the Functional Independence Measure (FIM) locomotor score, the Timed up and Go (TUG), or the basic mobility scores in the STREAM.
Conclusions: This study did not expand the evidence supporting the effectiveness of MT in the recovery of lower extremity function after stroke. Additional research is needed to determine the value of MT in the rehabilitation of patients with subacute stroke.
Clinical Relevance: The incorporation of MT for the lower extremity as an adjunct intervention in the rehabilitation of patients with subacute stroke may be clinically beneficial in improving lower extremity motor control and gait, but this study did not indicate significant differences in functional outcomes when compared to traditional physical therapy.
Acute Care Physical Therapy Intervention for a 40-Year-Old Female With Stiff Person Syndrome
K. Smith, S. George, University of Florida, Gainesville, Florida. C. Roman, Select Specialty Hospital, Gainesville, Florida.
Background and Purpose: Patients with stiff person syndrome (SPS) generally present with severe spasms and fluctuating rigidity, which limit functional mobility and independence. The purpose of this case report was to describe how physical therapy intervention with an emphasis on range of motion and functional mobility might potentially benefit a patient with SPS in terms of modifying impairments (spasticity and range of motion) and quality of life as determined by the patient's perspective (SF-36 physical and mental summary components and Barthel Index).
Case Description: The patient was a 40-year-old female who was diagnosed with SPS 6 years earlier and admitted to a long-term acute care facility for 18 days because of complications with intubation. At initial evaluation, the patient had increased spasticity and limited range of motion across all lower extremity joints along with decreased abilities to transfer independently from wheelchair to bed. It was determined that standardized acute care physical therapy was appropriate for this patient. The patient received eight treatment sessions throughout her hospitalization with interventions including range of motion, manual stretches, transfer training, therapeutic exercises, balance training, and proprioceptive neuromuscular facilitation. Treatment sessions were variable in time and intervention techniques due to the patient's medical management taking priority in this setting.
Outcomes: Modified Ashworth Scale scores showed fluctuating changes with unknown clinical significance. Improvements with minimal detectable changes were noted in lower extremity range of motion values. Minimal clinically important differences were noted in the SF-36 physical and mental summary components and the Barthel Index.
Discussion: The patient demonstrated improvements in bilateral knee and left ankle range of motion, transfers, and functional mobility at the time of discharge. Results from the SF-36 physical and mental component summaries and the Barthel Index demonstrated that the patient's perception of her quality of life improved throughout the course of her hospital stay. Additionally, it was determined that quantifying spasticity, and therefore the use of the Modified Ashworth Scale, may not be an appropriate outcome measure for a patient with SPS. Overall, physical therapy interventions focusing on ROM and functional mobility are appropriate to help improve the quality of life for a patient with SPS.
The Effect of Text Messaging on Reactive Balance and the Temporal and Spatial Characteristics of Gait in Unimpaired Individuals
J.J. Ganske, H. Schulte, J. Chestnut, J. Whitthoft, M.L. Peterson, A. Strubhar, Physical Therapy & Health Science, Bradley University, Peoria, Illinois.
Purpose/Hypothesis: The aim of this study was to determine the effects texting has on gait characteristics and reactive balance.
Number of Subjects: 32.
Materials/Methods: Thirty-two healthy subjects (mean 23.6 years) were recruited. Data were collected on texting ability (number of errors, character/second) in standing, while walking and while in perturbed stance. Data on gait parameters (velocity, cadence, step length, heel-to-heel base of support, and percentage of time spent in double limb versus single limb stance) using the GAITRite™ was collected while walking normally and while walking and texting. Data on reactive balance in perturbed stance (DMA score, time of balance task) using the PROPRIO 5000™ was collected while standing and while standing and texting. Repeated-measures statistics were applied.
Results: No practical difference in texting ability was found between the 3 conditions of standing, walking, and perturbed stance. A significant difference was found between mean gait characteristics of velocity, cadence, double limb support, and step length during normal walking and walking while texting (P = 0.00). No statistical significance was shown between mean heel to heel support. A significant difference was found between reactive balance ability (mean DMA score) in perturbed stance and perturbed stance while texting (P = 0.007). No significance difference was shown between the time of the balance task in perturbed stance and perturbed stance while texting.
Conclusions: The data imply that gait and balance are negatively impacted while texting and that subjects will maintain their baseline texting speed and accuracy at the expense of gait speed and impaired balance.
Clinical Relevance: Individuals with gait and balance issues may display increased manifestations of balance impairments while texting and performing other dual motor tasks.
Conservative Physical Therapy Treatment in an Individual With Tinnitus, Headaches, and a Chiari Malformation Type I
L.M. Brindley, C.L. Lewis, Elon University, Elon, North Carolina. D. Haley-Rezac, Rezac and Associates Physical Therapy, Colorado Springs, Colorado.
Background and Purpose: This case report describes the effects of conservative physical therapy treatment with an individual with a Chiari Malformation (CM) Type I. The resulting pressure on the cerebellum and brain stem from protrusion or herniation into the foramen magnum may affect functions of these areas. Previously, only surgical treatment has shown effectiveness in the management of patients with CM of any type. No researchers have reported conservative treatment of these individuals.
Case Description: Patient was a 43-year-old male, software engineer with a diagnosis of CM Type I. His goals were to improve concentration for work duties and to participate in an exercise routine. Chief complaints were tinnitus, drowsiness, headaches, general sleepiness, and difficulty concentrating at work with increased frequency of symptoms over the past 10 years. Patient participated in physical therapy 2×/wk for 12 weeks and was compliant with his home program. Treatment consisted of soft tissue mobilization, exercises for musculoskeletal strengthening and stretching of appropriate musculature to address postural impairments found on initial evaluation, balance and gait reeducation, vestibular reeducation, vestibular-ocular reeducation, kinesiotaping, trigger point dry needling, and hydrotherapy, which may be effective in improving function and quality of life for an individual with CM Type I.
Outcomes: Neck Disability Questionnaire (NDI) (3/50 to 0/50), Mandibular Functional Impairment Questionnaire (MFIQ) (3/68 to 0/68), Dynamic Gait Index (DGI) (22/24 to 23/24). Global Rate of Change (self-rating) (GROC) as a 5/5 at his final session. Cervical lateral flexion active ROM (left 45°-65°; right 52°-66°). Single leg stance with eyes opened and closed from 15 and 3 seconds, respectively, to 30+ seconds bilaterally. Cranial nerve (CN) impairments improved in CN III and VII. Vestibular ocular reflex (VOR) x1 horizontal and smooth pursuit testing from abnormal to normal visual tracking.
Discussion: The program described previously benefited this individual having CM type I. Moderate validity and test-retest reliability are reported for both the NDI with an MCD of 10.2 and MCID of 7.0 for patients with cervical radiculopathy. Moderate to excellent validity and test-retest reliability are reported for the MFIQ with an MCID of 7 and an MCD of 14 for patients with painfully restricted tempomandibular joints, and excellent validity and test-retest reliability for DGI with MCID of 13 and MCD of 2.7 for patients with chronic stroke. The GROC has adequate test-retest reliability with MCD of 0.45 and MCID of 2 points on an 11-point scale. This case report provides support for continued research on conservative physical therapy interventions for individuals with nonsevere CM.
Frontotemporal Oxyhemoglobin Dynamics Predict Performance Accuracy of Dance Simulation Gameplay
S. Bronner, ADAM Center, Department of Physical Therapy, Northeastern University, Boston, Massachusetts. Y. Ono, Y. Nomoto, S. Tanaka, K. Sato, S. Shimada, Department Electronics and Bioinformatics, Meiji University, Kanagawa, Japan. A. Tachibana, Faculty of Care and Rehabilitation (Physiology), Seijoh University, Tohkai, Japan. J. Noah, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut.
Purpose/Hypothesis: We utilized the high temporal resolution of functional near-infrared spectroscopy to explore how visual and rhythmic auditory cues are processed in cortical areas of multimodal integration to achieve coordinated motor output during unrestricted dance simulation gameplay. Two cortical regions of interest (ROI) were selected for study, the middle temporal gyrus (MTG) and frontopolar cortex (FPC). We hypothesized that activity in FPC would indicate top-down regulatory mechanisms of motor behavior; while MTG would be sustained because of bottom-up integration of visual and auditory cues throughout the task. We also hypothesized that a correlation would exist between behavioral performance and temporal patterns of the hemodynamic responses in these ROI.
Number of Subjects: Twenty-six healthy subjects (mean age ± SE = 26.1 ± 1.7 years).
Materials/Methods: Subjects played a dance simulation video game, similar to the commercial game Dance Dance Revolution (Konami Corp., Tokyo, Japan) in a block-design. Subjects played the game 2 times each in 2 alternating conditions of (1) with music (WM) and (2) without music (NM). We used a 22-channel functional near-infrared spectroscopy topography system OMM-3000 (Shimadzu Co, Kyoto, Japan) in a 3 × 5 optical probe array positioned over the left prefrontal to temporal lobes. Performance accuracy was determined by the mean number of temporally accurate steps. We performed 2 types of analyses with hemodynamic signals in FPC and MTG. First, we determined the time to the positive and negative peak of the change in oxyHb signal, between 10s prior to 10s after the task period at each ROI. Second, we calculated the integral of the waveform of normalized oxyHb signal during the task period at each ROI in each condition (area under the curve [AUC]). We further calculated the difference of normalized oxyHb signals between the 2 conditions by subtracting those in NM from those in the WM condition (WM-NM) and their AUC at each ROI.
Results: Results indicated that greater temporal accuracy of dance steps positively correlated with persistent activation of MTG and cumulative suppression of FPC. When auditory cues were absent, modifications in cortical responses were found depending on the gameplay performance. In MTG, high-performance players showed an increase, but low-performance players displayed a decrease in cumulative amount of oxyHb response in the NM condition compared with that in the WM condition.
Conclusions: These results suggest that the MTG plays an important role in successful integration of visual and rhythmic cues and FPC may work as top-down control to compensate for insufficient integrative ability of visual and rhythmic cues in MTG. The relative relationships between these cortical areas indicated high- to low-performance levels when performing cued motor tasks.
Clinical Relevance: We propose that changes in these relationships can be monitored to gauge performance increases in motor learning and rehabilitation programs.
A Massed Practice Approach to Improving Gait and Functional Balance for Individuals With Chronic Stroke: A Pilot Study
H.K. Henderson, B. Boquist, L. Marston, E. McCarthy, N. Oddo, J. Virgo, Physical Therapy, Rosalind Franklin University, North Chicago, Illinois.
Purpose/Hypothesis: The purpose of this study was to determine the effect of intensive massed practice intervention (3 hours/day for 2 consecutive weeks) on gait and balance for individuals with chronic stroke.
Number of Subjects: Five individuals with chronic stroke participated in intensive 2 weeks, 3 hours/day massed practice intervention.
Materials/Methods: A single-subject pre- and posttest quasi-experimental design was utilized in this pilot study. Treatment outcomes were assessed utilizing: GAITRite, Berg Balance Scale, Dynamic Gait Index, Timed Up and Go, Gait Velocity, and 6 Minute Walk Test. Data were collected, preintervention, postintervention, and 6 months following intervention. Intervention focused on massed practice of functional tasks related to gait and balance, utilizing a forced use paradigm. Interventions were 3 hours per day for 2 consecutive weeks.
Results: Every participant in the study demonstrated improvements in all measures from pretest to posttest, and most maintained improvements beyond their pretest measures at the 6-month follow-up. However, all differences did not reveal a statistical significance. Statistically significant improvements were found in the following measures for pre- and posttest only: Timed up and Go (P = 0.041) and 6 minute walk (P = 0.005). There were no statistically differences found between pretest and at the 6-month follow-up.
Conclusions: Intensive massed practice intervention is a feasible, effective intervention in improving balance and aspects of ambulatory function in patients with chronic stroke.
Clinical Relevance: More than 50% of individuals poststroke will be left with some form of motor dysfunction. Improving gait and balance is a major goal for individuals after a stroke. A massed practice approach for persons with chronic stroke is being utilized with Constraint Induced Movement Therapy for the upper extremity, but the translation to the lower extremity has lagged significantly behind. This pilot study attempts to utilize a forced use paradigm with the lower extremity in an intensive massed practice approach to determine if changes can be made in gait and balance after chronic stroke.
Minimum Detectable Change in the Timed Up and Go and the Step Test in People With Stroke
V. Pardo, A. Fileccia, S. Lewis, J. Sesta, Physical Therapy, Wayne State University, Detroit, Michigan. A. Goldberg, Department of Health Care Sciences, Program in Physical Therapy, Mobility Research Laboratory, Institute of Gerontology, Wayne State University, Detroit, Michigan.
Purpose/Hypothesis: The Timed Up and Go (TUG) is a test of functional mobility and dynamic balance. The Step Test is a measure of standing balance, motor control, coordination, and the ability to load weight on 1 leg. Minimum detectable change (MDC) represents a value for real change that exceeds chance variation in performance and measurement. MDC can be used to interpret whether changes in these measures over time represent real change or are within the boundaries of measurement error. The purpose of this study was to quantify measurement error and MDC in the TUG and the Step Test in people who have had a stroke.
Number of Subjects: Twenty participants with a history of stroke who could walk without physical assistance were recruited from the Metro Detroit area.
Materials/Methods: The TUG was measured by having participants stand from a chair with armrests, walk 3 m at their self-determined safe walking speed, turn around, return to the chair, and sit down. The Step Test was measured by counting how many times the participant could touch the top of a 7.5-cm step with the bottom of one foot in 15 seconds. The intraclass coefficient (ICC 2.1) was computed to assess the relative reliability of each test. Standard error of measurement (SEM), which quantifies measurement error in absolute values, was calculated as the standard deviation x √(1 − ICC). MDC at a 95% confidence level (MDC95) was calculated as z*SEM*√2 where z = 1.96.
Results: Mean TUG was 16.27 seconds, with an ICC of 0.98 (SEM was 1.28 seconds, MDC95 was 3.55 seconds). Measurement error and MDC95 expressed as a percentage of mean TUG were 7.9% and 21.8%, respectively. Mean Step Test with the involved leg was 10.48 steps, with an ICC of 0.97 (SEM was 0.91 steps; MDC95 was 2.52 steps). Measurement error and MDC95 expressed as a percentage of mean Step Test with the involved leg were 8.7% and 24.1%, respectively. Mean Step Test with the uninvolved leg was 11.85 steps, with an ICC of 0.97 (SEM was 0.85 steps; MDC95 was 2.35 steps). Measurement error and MDC95 expressed as a percentage of mean Step Test with the uninvolved leg were 7.2% and 19.8%, respectively.
Conclusions: The high ICCs for the TUG and the Step Test (for both the involved and uninvolved leg) suggest high relative reliability. The low SEM% for the TUG and the Step Test is suggestive of low measurement error and good absolute reliability. The moderately low MDC95% for the TUG and the Step Test suggests that these tests may be able to detect real change in physical performance in people with stroke.
Clinical Relevance: In patients with stroke, real change was computed to be >3.55 seconds for the TUG, >2.52 steps for the Step Test (involved), and >2.35 steps for the Step Test (uninvolved). These results will assist clinicians and researchers in interpreting whether real change has occurred when comparing repeated measures of the TUG and the Step Test.
Use of the X-Box Kinect to Improve Balance, Gait Speed, Endurance, and Quality of Life in a Female With Chronic Stroke
R. Trommelen, L. Blaylock, A. Comeaux, E. Danna, Physical Therapy, Louisiana State University Health New Oleans, New Orleans, Louisiana.
Background and Purpose: A stroke often results in impairments in balance and gait, which can lead to decreased functional mobility and quality of life. While the use of the Wii has been investigated in the literature and used in the clinic as an intervention for balance retraining, the potential uses of the Kinect gaming system has not been explored. The format of the Kinect provides favorable conditions for motor learning, such as use of modeling, implicit learning, self-control of practice schedule, dyad practice, and intrinsic and extrinsic feedback. The purpose of this case study was to determine the effects of the Kinect on treatment of balance, gait, endurance, and quality of life on a 47-year-old female with a chronic stroke.
Case Description: The subject was a 47-year-old female with a chronic ischemic stroke right internal carotid artery. Balance was measured using the Activities-specific Balance Confidence Scale, Functional Gait Assessment, and NeuroCom Balance Master. Comfortable gait speed was measured with a stopwatch. Endurance was measured using the Six Minute Walk Test (6MWT). Quality of life was measured using the Stroke Impact Scale (SIS). The participant completed 18 sessions (45 minutes) utilizing the Kinect over a 7-week period. The games played focused on endurance and dynamic balance activities such as stepping in all directions, reaching, weight-shifting, and jumping.
Outcomes: The participant's overall Activities-specific Balance Confidence score increased by 37.5%. The score on the SIS increased by 5.93%, exceeding the reported minimally clinically important difference (MCID) in the ADL/IADL domain. The Functional Gait Assessment increased by 3 points. The participant increased her gait speed by 0.17 m/s, exceeding the MCID gait speed of 0.16 m/s in subacute stroke. The participant improved her distance on the 6MWT by 25 m and ambulated no longer needed a Swedish knee cage. Functional endurance improved on the 6MWT with a 16 beat per minute decrease on posttest heart rate. On the 5 domains, the participant made improvements with a decrease in magnitude of force used to overcome upward perturbations, decrease in reaction time when perturbed in all directions, improvements in directional control in the left/right directions, increase in endpoint excursions in all directions, increase in maximum excursions in all directions except the left, and more middle COG alignment.
Discussion: In this subject, the use of Kinect gaming system improved the patient's objective and subjective balance, endurance, and quality of life. Her increased balance confidence and gait speed improvements aid in her ability to participate in community mobility. This case study could indicate that using the Kinect can be a safe and effective treatment to improve balance, gait speed, endurance, and quality of life in an individual with a chronic stroke; however, further research is needed to establish the use of the Kinect in rehabilitation of balance and gait impairments in individuals with chronic stroke.
Comparison of Fall Risk Older Adults on the Clinical and Instrumented Timed up and Go Test
M.J. Thompson, P.R. Trueblood, Department of Physical Therapy, California State University, Fresno, Fresno, California.
Purpose/Hypothesis: It is well documented that one third of community-dwelling older adults (CDA) will fall at least once a year. The purpose of this project is to compare the effectiveness of a computerized balance testing device with a clinical balance measure typically used to identify fall risk, the clinical Timed Up and Go (C-TUG) test. A weakness of the C-TUG test is that it relies on only 1 measure, time, to objectively quantify performance of the task. As such it may lack information on components of the task that could reveal more specific problems with balance or fall risk. We hypothesized that the I-TUG would be superior in identifying individuals at risk for falling when compared to the C-TUG.
Number of Subjects: Subjects were recruited through a local fall risk screening program. The average age of the subjects in this sample of convenience was 76.7 ± 6.27 (n = 23; 4 males, 19 females).
Materials/Methods: The Fullerton Advanced Balance Scale was used as the gold standard to determine fall risk (16 at risk, 7 not at risk). The clinical tool utilized for assessment in this study was the 8-foot C-TUG test. The C-TUG was compared to the instrumented 25 foot I-TUG, which uses body-worn accelerometers for an objective measure of the spatial and temporal components of the functional task. Variables that were able to identify fallers from nonfallers (t test) were analyzed using a receiver operator characteristic (ROC) curve to determine how well the variable was able to discriminate between the 2 groups. Test cutoff scores were then determined based upon the optimal sensitivity (Sn), specificity (Sp), and positive/negative Likelihood Ratios (LR+/LR−).
Results: Components of both tests were found to have very good discriminate ability, with area under the curve values > 0.75 for C-TUG (time) and for I-TUG (number of turn steps, gait single and double stance time). The only test variable with greater discriminate power was the I-TUG Turn Time, with an area under the curve of 0.92 (95% CI 0.840-1.00). A cutoff value of ≥ 3.23 seconds for the turn time had a 0 0.86 Sn, 0.13 Sp, an LR+ of 1.14, and LR− of 0.00.
Conclusions: Within the limited sample size and uneven distribution of fall-risk and no-fall-risk subjects, there was no difference in the ability of the 2 tests to discriminate between fallers and nonfallers. By objectively measuring multiple components of the functional task with the I TUG, we revealed mobility deficits that were not evident with the stopwatch measure.
Clinical Relevance: Although the C-TUG time parameter effectively discriminated between individuals at risk, the discriminate power of a wider variety of the spatial and temporal components of the functional task may offer the most sensitive option for early detection of balance and mobility deficits in higher functioning CDA.
The Effect of BCI-Based FES Training on Balance, Gait, and Brain Activation for Patient With Stroke
S. Lee, B. Lee, Physical Therapy, Sahmyook University, Seoul, Republic of Korea. E. Chung, Physical Therapy, Andong Science College, Andong-si, Republic of Korea.
Purpose/Hypothesis: This study was to evaluate the effect of Brain Computer Interface (BCI)-based Functional Electrical Stimulation (FES) training to improve on balance, gait function, brain activation for patient with stroke.
Number of Subjects: 25.
Materials/Methods: The participants were randomly divided into 2 group: BCI-based FES (BCI-based FES) group (n = 13) and FES group (n = 12). The control group received conventional therapy for 5 sessions 60 minutes per week during 5 weeks and FES therapy for 5 sessions 30 minutes per week during 5 weeks. BCI-based FES group practiced additional BCI-based FES training 3 sessions 30 minutes per week during 5 weeks.
Results: The results of this study showed significant improvement in balance, gait function, EEG. There was significant improvement by BCI-based FES training that outcomes of the balance from Timed Up and Go Test, Berg Balance Scale (P < 0.05). There was significant improvement by BCI-based FES training that outcomes of the gait abilities from gait velocity, cadence, step length, stride length, single limb support of affected side (P < 0.05). There were significant differences by BCI-based FES training that outcomes of the EEG from mu rhythm of C3, C4, Beta power of Fp1, P3, P4 and concentration (SMR+Mid Beta/Theta wave) of Fp1, Fp2, P4 (P < 0.05).
Conclusions: The BCI-based FES training improves balance, gait function, brain activation.
Clinical Relevance: The BCI-based FES training is feasible and suitable for individuals with a stroke.
Treatment of Horizontal Canal Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis
B. Buzzell, K. Frank, A. Williams, A. Goode, R. Clendaniel, Doctor of Physical Therapy Division, Duke University School of Medicine, Durham, North Carolina.
Purpose/Hypothesis: Benign paroxysmal positional vertigo (BPPV) is a condition causing brief episodes of severe vertigo with head positional changes. BPPV most commonly affects the posterior canal, and treatment of this variant is clearly demonstrated in the literature. Little is known about the efficacy of treatment for horizontal canal BPPV. The purpose of this investigation is to evaluate current research of treatment methods for horizontal canal BPPV canalithiasis to determine most efficacious methods.
Number of Subjects: 1005 subjects across 10 studies were examined in the systematic review and 460 subjects across 5 studies were examined in the meta-analysis.
Materials/Methods: A literature search of MEDLINE, CINAHL, Google Scholar, Pedro, SportDiscus, Cochrane, and PsycINFO using key words related to horizontal canal BPPV treatment was performed. DerSimonian and Laird random effect models were used to determine differences within treatment groups individually for the Gufoni maneuver and the canalith repositioning maneuver modified for the horizontal canal, commonly referred to as the Barbeque roll, compared to sham intervention. The relative efficacy between Gufoni maneuver and Barbeque roll pooled effect estimates was determined by testing pooled effect estimate homogeneity. Risk ratios (RR) and 95% confidence intervals (CI) were determined as estimates of effect, and the relative efficacy was tested at an alpha of P < 0.05. Heterogeneity of included studies was determined with both I2 and chi-square P values.
Results: Six different treatment techniques were identified in 10 articles that met the inclusion criteria. Five articles were appropriate for meta-analysis. Two different head shaking maneuvers and the Modified Semont maneuver were shown to have low efficacy while the Forced Prolonged Position, Barbeque roll, and Gufoni maneuvers were shown to have good efficacy. For the 3 studies that compared the Gufoni maneuver against a sham treatment, the success rate for the Gufoni maneuver was 68.6% (105/153), compared to 28% (37/132) for sham treatment. For the 3 studies that compared the Barbeque maneuver to a sham treatment, the success rate for the Barbeque maneuver was 69.2% (83/120), compared to 43.7% (45/103) for sham treatment. Meta-analysis indicated that both the Gufoni maneuver (RR 2.61 with 95% CI 1.35-5.08, P = 0.016) and the Barbeque roll maneuver (RR 1.67 with 95% CI 1.01-2.78, P = 0.029) were more effective than sham treatment. There was no demonstrated difference in the effectiveness of the Gufoni maneuver compared to the Barbeque roll maneuver (P = 0.3).
Conclusions: Current literature supports the use of several treatment techniques without one technique standing out as most effective. Additional high-quality RCTs are needed to further evaluate these techniques. The Barbeque roll and Gufoni maneuver currently have the most support in the literature.
Clinical Relevance: It is appropriate for clinicians to choose between the 3 more efficacious techniques based on patient presentation and preference.
Long-term Exercise Improves Physical Function in Parkinson's Disease: A 2-Year Randomized Controlled Trial
J. Prodoehl, Physical Therapy Program, Midwestern University, Downers Grove, Illinois. M.R. Rafferty, F.J. David, C. Poon, D.M. Corcos, J.A. Robichaud, Department of Kinesiology & Nutrition, University of Illinois at Chicago, Chicago, Illinois. D.E. Vaillancourt, Applied Physiology & Kinesiology, University of Florida, Gainsville, Florida. C.L. Comella, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois. S.E. Leurgans, Rush Alzheimers Disease Center, Rush University Medical Center, Chicago, Illinois. W.M. Kohrt, Division of Geriatric Medicine, University of Colorado Denver, Aurora, Colorado.
Purpose/Hypothesis: Progressive resistance exercise (PRE) improves Parkinsonian motor signs over 24 months compared to a nonprogressive modified Fitness Counts (mFC) exercise program recommended by the National Parkinson Foundation (modified to exclude progressive weights and aerobic conditioning). This prospective longitudinal study compared the effects of long-term PRE and mFC on physical function, balance, and quality of life in individuals with Parkinson disease (PD).
Number of Subjects: 48 individuals with PD completed 6 months, and 38 completed 24 months of intervention.
Materials/Methods: This 24-month randomized controlled trial compared PRE and mFC after random assignment matching on sex and disease severity. Patients exercised for 60 to 90 minutes, 2 days/week for 24 months. Both sessions were with a certified personal trainer for the first 6 months. Thereafter, 1 day/week was one-on-one training and 1×/week was on their own. The PRE group lifted weights of progressively increasing load. The mFC group performed a nonprogressive flexibility, balance, and strengthening program. Blinded assessors obtained outcomes every 6 months, with nonparametric statistics performed at 6 and 24 months to compare the effects of short-term and long-term exercise. Outcome measures were the on medication change scores from baseline of (1) physical function (modified Physical Performance Test [mPPT], Timed Up and Go [TUG], 5 time sit to stand [STS], 6-minute walk test [6MWT], walk speed [walk speed]); (2) balance (Berg Balance Scale [BBS], Functional Reach Test [FRT]; and (3) quality of life (39 item Parkinson's Disease Questionnaire [PDQ-39]).
Results: Pooling PRE and mFC groups, all physical function and balance measures significantly improved from baseline to 24 months (P's < 0.0001) with the exception of 6MWT, which approached significance (P = 0.068). Median change at 24 months for mPPT was 2.0 points, 95% CI = 1.0 to 3.0; TUG −0.9 seconds, 95% CI = −1.0 to −0.5; STS −1.2 seconds, 95% CI = −1.8 to −0.5; walk speed 0.2 m/s, 95% CI = 0.05 to 0.4; BBS 0.5 points, 95% CI = 0.00 to 1.0; FRT 3.7 cm, 95% CI = 2.5 to 6.0. The treatment groups did not differ significantly at baseline on any measure. There were no between-group differences on any of the physical function or balance measures at either 6 or 24 months (P > 0.1). Quality of life showed significantly more improvement in PRE compared to the mFC group at 6 months (PDQ-39 between-group difference 3.9, 95% CI = 0.6-7.4), but there was no difference between groups on quality of life at 24 months.
Conclusions: Long-term exercise (24 months), regardless of whether it is progressive or nonprogressive in nature, improves overall physical function and balance in individuals with PD.
Clinical Relevance: Consistent participation in both progressive and nonprogressive exercise programs can achieve and maintain improvements in function over 24 months in individuals with PD. The findings support the use of long-term exercise in the therapeutic plan for individuals with PD.
Effectiveness of Treadmill Versus Overground Gait Training for Optimizing Gait Speed in Early Poststroke Rehabilitation: A Systematic Review With Meta-analysis
K.L. Deaton, E.M. Foppe, D.L. Sroka, R.A. Varner, A. Goode, J.A. Feld, Department of Community and Family Medicine, Duke University, Durham, North Carolina.
Purpose/Hypothesis: Decreased gait speed contributes to long-term disability poststroke. As a task-specific, high repetition intervention, treadmill training has received focused attention in poststroke rehabilitation. There is currently no consensus on the optimal treatment to enhance gait speed in early poststroke rehabilitation. The purpose of this review was to assess and compare the effectiveness of treadmill (TM) versus overground (OG) gait training to optimize gait speed in early poststroke rehabilitation. We hypothesized that there would be no significant difference in gait speed outcomes between TM and OG gait training.
Number of Subjects: 435 subjects in the systematic review and 212 subjects in the meta-analysis.
Materials/Methods: This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A computer-assisted search was conducted with MEDLINE, CINAHL, and Google Scholar with key words related to stroke and gait training. A hand search of included article references was conducted. Study inclusion criteria were (1) randomized controlled trial (RCT); (2) compared TM to OG gait training; (3) conducted on patients <6 months poststroke; and (4) included a measure of gait speed as an outcome. Quality assessment of included studies was performed using the Physiotherapy Evidence Database (PEDro) scale with those studies having a summary score of 6 to 8 indicating a fair overall quality and those ≥9 indicating good overall quality. Studies reporting baseline mean measures of gait speed were pooled using DerSimonian and Laird random effects models with a standardized mean difference (SMD) and 95% confidence interval (CI) as the measure of effect. An I-squared (I2) value >50% and Cochrane's-Q P value < 0.10 were the criteria to indicate significant heterogeneity.
Results: The employed search strategy revealed 6 articles that met the inclusion criteria. PEDro assessment revealed 4 studies with fair and 2 with good quality. Significant within-group differences between TM and OG gait training were found with all included studies, but only 1 study showed significant between-group differences. Four studies met inclusion for meta-analysis, with no significant difference in gait speed between TM and OG gait training (SMD = 0.31; 95% CI −0.16-0.78) during early poststroke rehabilitation. A significant amount of heterogeneity was found between studies (I2 = 63.3%, Q = P = 0.07).
Conclusions: The results indicate that there is no significant difference in the effectiveness of TM versus OG gait training in optimizing gait speed during early poststroke rehabilitation. The findings are limited by the variations in study samples and differences in intervention intensities that may account for the significant heterogeneity.
Clinical Relevance: Both TM and OG gait training appear to be viable options for optimizing gait speed for patients in early poststroke rehabilitation.
Physical Therapy Management of Benign Paroxysmal Positional Vertigo (BPPV)
A.K. Galgon, Physical Therapy, Temple University, Philadelphia, Pennsylvania. W. Webb Schoenewald, Physical Therapy, WWS Physical Therapy and Associates, Doylestown, Pennsylvania. A. Tate, Physical Therapy, Willow Grove Physical Therapy, Willow Grove, Pennsylvania.
Purpose/Hypothesis: If physical therapists are to effectively manage BPPV, they must accurately perform and document diagnostic procedures and interventions. The purposes of this retrospective chart review from 2 outpatient vestibular practices were to identify (1) the incidence and types of BPPV, (2) intervention strategies, and (3) documentation practices, and (4) determine the feasibility of performing a prospective study on horizontal canal BPPV.
Number of Subjects: 242.
Materials/Methods: Charts were identified from November 2011 through May 2012. The total number of cases, percent of canal involvement, side and type, Canalithiasis (CA), or Cupulolithiasis (CU) were calculated. Documentation was analyzed for inclusion of 4 elements: (1) testing positions, (2) side, (3) direction, (4) duration of nystagmus for posterior (PC) and anterior canal (AC), and (4) intensity of nystagmus for horizontal canal (HC). Diagnoses were analyzed for inclusion of 3 criteria: (1) canal and (2) side of involvement and (3) type. Interventions were recorded. The percent of resolved cases were also calculated for each diagnostic group: PC, AC, and HC.
Results: Canal involvement was 82.2% PC, 4.5% AC, and 13.2% HC. For PC, 59.7% were right, 42.7% left, 7.5% bilateral. 95% were CA and 5% were CU. For AC, 45.5% were right, 54.5% were left, 73% were CA, and 27% were CU. For HC, 37.5% were right, 50% left, 12.5% were undetermined, 53% were CA, and 47% were CU. Therapists documented 4 examination elements in 11.5%, 37%, and 27% of the cases of PC, HC, and AC BPPV, respectively. Position and side of positive test was documented in 100% of cases. Three diagnostic criteria were included in 25%, 78%, and 36.3% of the cases of PC, HC, and AC BPPV, respectively. Therapists consistently used canalith-repositioning maneuvers for PC and AC CA and liberatory maneuvers for PC and AC CU cases. Therapists were more variable in their use of maneuvers for HC cases. Therapists used 2.3, 2.6, and 2.9 maneuvers per session for PC, HC, and AC, respectively. Outcome data were not available in 11.6%, 31%, and 9% of cases for PC, HC, and AC, respectively. In documented cases 88% of PC, 90% of HC and 70% of AC had resolution on or before the third session.
Conclusions: Physical therapy practices specializing in vestibular rehab successfully treat a significant number of BPPV cases including HC BPPV. Therapists documented more examination elements and diagnostics criteria in HC BPPV compared to AC and PC, but side of involvement was less likely to be diagnosed. Patients with HC BPPV were likely to receive several types of maneuvers. Inconsistencies in documentation and follow-up after intervention limited the ability to fully determine effectiveness of interventions.
Clinical Relevance: The number of HC BPPV cases appears adequate to support a prospective study. However standardization of examination and documentation and accuracy of diagnosis must be established. Therapists may need to be educated in additional examination procedures to determine side of involvement for HC BPPV. Further studies could determine whether additional testing impacts diagnosis and clinical outcome.
Fall Status and Balance Performance Differences Between Older Men and Women Using 4 Outcome Measures
K.K. Cleary, K.L. Prescott, E. Skornyakov, Physical Therapy, Eastern Washington University, Spokane, Washington.
Purpose/Hypothesis: Falls are the leading cause of physical injury related to death and hospitalization in older adults. Current literature suggests that some well-established balance performance outcome measures are good at predicting first time and recurrent fallers, and discriminating between persons who have fallen and those who have not. A few studies point to gender differences in fall incidence, with women falling more often than men. The purpose of this study was to investigate differences in balance performance and fall status between men and women using 4 well-established balance measures.
Number of Subjects: Forty-six subjects (14 men, 32 women) from a senior living community aged 65 and older (x = 84 years) participated. Inclusion criteria were: live independently, able to walk inside home without help from another person, and able to provide informed consent.
Materials/Methods: Four balance performance instruments were used in this study: Berg Balance Scale (BBS), Timed Up and Go (TUG), Tinetti Assessment Tool (Tinetti), and Four Square Step Test (FSST). Demographic data, including fall status and fear of falling, were collected. Subjects were divided into groups by gender, and then descriptive statistics, independent samples t tests (2-tailed), and chi-square were calculated with SPSS v19.0 (P = 0.05).
Results: Characteristics of male and female groups were similar including fall history (36% of male and 34% of female subjects were fallers) and fear of falling, but more women lived alone (P = 0.01). Mean scores for men were better than means for women on all 4 balance performance instruments, but differences were not statistically significant. All instrument means for men were better than fall risk thresholds; however, women's means were poorer than threshold scores on both the TUG and FSST. A greater percentage of women were classified at high risk of falls on all 4 instruments. The association between fall risk and gender was statistically significant using the TUG, with more women at high risk of falling (P = 0.049).
Conclusions: Instrument risk classifications indicated that many subjects were at risk of falling, despite their community-dwelling status. There was no difference in fall history or fear of falling between men and women in this study, and balance performance mean scores were statistically similar for both gender groups. However, women performed poorer than men on all 4 balance measures. Further, women's mean scores were worse than fall risk thresholds on 2 of the instruments, and more women were classified at high risk of falling.
Clinical Relevance: It is important to assess balance among community-dwelling older adults, and to consider the implications on fall risk. Findings indicate women may be at greater risk due to poorer balance, although studies with larger sample sizes are needed to further explore the role of gender in balance performance and fall risk.
Effectiveness of External Cueing for Improving Movement in Persons With Parkinson's Disease: A Systematic Review
R.J. Allen, Physical Therapy & Neuroscience, University of Puget Sound, Tacoma, Washington. J.D. Calhoun, J.P. McArdel, Physical Therapy, University of Puget Sound, Tacoma, Washington.
Purpose/Hypothesis: To determine whether visual, auditory, or somatosensory cues are an effective intervention for improving gait or functional tasks for persons with Parkinson's disease.
Number of Subjects: Twelve quantitative research studies from peer-reviewed research journals fit the inclusion/exclusion criteria for this systematic review. Each study included at least 1 external cue as a treatment intervention for individuals with Parkinson's disease and had at least 1 outcome measure relating to gait or functional tasks.
Materials/Methods: PubMed, Cochrane Library, and PEDro were searched between February 9, 2012, and November 20, 2012, for “Parkinson/s/‘s disease,” “kinesia paradoxa,” “freezing,” “auditory, visual, cue/s/ing.” All subject ages were included, and all publication years preceding the search date were accepted. Articles were excluded if the full text was not available in English. Search terms resulted in the retrieval of 20 potential articles. Two reviewers independently evaluated all 20 articles using the PEDro scale. Articles receiving a score of 5 or greater were included in this review.
Results: Twelve studies fit the final inclusion/exclusion criteria. These papers were then organized by primary outcome measures, 8 studies primarily investigated gait parameters, and 4 studies examined functional tasks. Review of the included articles pertaining to improvements of gait parameters indicates strong evidence for use of auditory cues found in 6 out of 8 studies, moderate evidence for visual cueing in 2 out of 3 studies, and weak evidence for somatosensory cueing in 1 out of 2 studies. Two studies reported that integrated auditory, visual, and somatosensory cueing showed improvements in performing functional tasks while another 2 studies showed no significant improvements with only auditory cueing.
Conclusions: There is good evidence in current literature supporting the use of external sensory cueing for improving gait and functional movement in patients with Parkinson's disease. External cueing may take the form of visual, auditory, somatosensory, or combined input. Based on the studies evaluated for this review, the use of auditory cues for gait enhancement has the strongest support in the literature.
Clinical Relevance: Disruption of normal movement for individuals with Parkinson's disease may include akinesia, freezing of gait, decreased gait velocity and step length, leading to an increase in fall risks, reduced level of independence, and lower quality of life. Implementation of external cueing may purpose a cost-effective treatment intervention that is easily accessible and can significantly improve impaired gait performance and execution of functional tasks.
Brain Motor Control Assessment: A Neurophysiological Assessment of Motor Control
J.A. Bruce, B. McKay, R. Alexander, K. Tansey, Hulse SCI Laboratory, Shepherd Center, Atlanta, Georgia.
Purpose: The Brain Motor Control Assessment (BMCA) is a method for quantitatively characterizing impaired motor control that covers the spectrum from paralysis to recovery. The method relies on high-quality, multimuscle surface EMG recording and the careful presentation under controlled conditions of motor tasks selected to examine initiation, termination, and coordination of muscle control.
Description: Protocols designed to evaluate control of neck and shoulder, trunk, upper limb, and/or lower-limb muscles in the supine position have been developed and tested. All recordings begin with calibration and electrode test segments that verify the quality of the recorded signals and the appropriateness of the connections. The categories of motor control examined include relaxation, reinforcement (central excitability), voluntary control of movement, responsiveness to tonic and phasic stretch, withdrawal from cutaneous stimulation, and its volitional suppression. All aspects of the BMCA protocol are quantifiable including the degree of responsiveness to reinforcement and reflex activation. Voluntary movement control is quantified in the form of an index that is calculated from the multimuscle EMG patterns and indicates how different those patterns are from the patterns recorded from neurologically intact control subjects. Additional parameters of motor control such as the ability to volitionally recruit motor units and cease their firing on command can also be quantitatively evaluated. Further, this core protocol can be expanded with additional motor tasks to include assessment in sitting, standing, and stepping.
Summary of Use: Unlike most neurophysiological testing methods, the BMCA has undergone rigorous validation through peer-reviewed publication. That process included testing of internal and test-retest reliability and sensitivity to differentiate patient from noninjured, between groups of patients, and changes occurring during recovery. More recently, the BMCA method has been used to monitor the return of motor control during the acute phase of recovery post-SCI, augmenting the clinical evaluation by documenting the return of voluntary activation of paralyzed muscles, the development of coactivation and spasticity, and the reintegration of disrupted motor control.
Importance to Members: Currently efforts are under way to validate the BMCA-measured parameters of motor control relative to accepted clinical measures of function. From this work will also come neurophysiological profiles that may aid in treatment planning. Also, in clinical application, it offers objective criteria for the selection of intervention strategies and the quantification of treatment effects in persons with disorders that impact motor control. Finally, the main importance of the BMCA approach is to offer objective measurement of motor control parameters, an additional dimension of information designed to supplement the currently used standard measures.
Comparison of Balance and Gait Characteristics Between Those Who Intentionally Exercise and a Control Group in Community-Dwelling Older Adults
M. Danks, B. Johnson, R. Blom, L. Johnson, K. Palczewski, B. White, R.L. Mabey, Physical Therapy, University of North Dakota, Grand Forks, North Dakota.
Purpose/Hypothesis: Decline in physiologic capacity each decade in older adults contributes to decreased functional ability responsible for increased fall risk. Lack of physical activity is a significant risk factor for increasing disability. Research has demonstrated exercise may decrease balance deficits. This study compared functional balance characteristics and gait in individuals involved in exercise to a control group of individuals who did not meet the exercise requirements. The purpose of this study was to determine if regular exercise has benefits to balance and gait performance in community-dwelling older adults. The research hypothesize for this study were: (1) Community-dwelling older adults who intentionally exercise will demonstrate better balance scores and/or confidence and gait velocity and (2) there will be a positive correlation between balance confidence and balance performance scores and faster gait velocity.
Number of Subjects: 22.
Materials/Methods: Subjects were divided into 2 groups: those who intentionally exercise at least 30 minutes 3 times/week (n = 13) and a control group of those who did not exercise (n = 9). Inclusion criteria included the following: community-dwelling, able to walk 200 m independently, and able to follow instructions. Functional balance and gait velocity were measured using Maximum Step Length (MSL), Fullerton Advanced Balance (FAB) assessment, Activities Balance Confidence–6 (ABC-6) questionnaire, and GAITRite instrumented walkway.
Results: When comparing the exercise group to the control group, only the gait velocity demonstrated a significant difference between groups (P < 0.005). The exercise group mean gait velocity was 126.64 ± 16.13 cm/s versus the control group gait velocity mean of 99.20 ± 19.49 cm/s. There was no significant difference between groups for age, gender, MSL, ABC-6, or FAB (P > .05). Also, significant positive correlation was observed between the ABC-6 when compared to MSL, FAB, and gait velocity.
Conclusions: Participants who reported intentionally exercising performed better only on gait velocity. Gait velocity has well-documented predictive value for major health-related outcomes (functional ability/balance/etc.) There was a significant positive correlation between balance confidence and the scores of the MSL, FAB, and gait velocity.
Clinical Relevance: Physical therapist role in prevention and wellness needs to include encouraging regular exercise in community-dwelling older adults. Based on this study results and current literature, regular exercise has been shown to improve function in community-dwelling older adults. Physical therapist should educate community-dwelling older adults on the benefits of regular exercise and provide information about appropriate programs available in the local community.
Examining the Effectiveness of the Nintendo Wii Fit on Lower Limb Corticospinal Excitability and Balance Outcomes Poststroke: A Case Report
O. Oomiyale, S. Madhavan, University of Illinois at Chicago, Chicago, Illinois.
Background and Purpose: The use of interactive video games as an effective alternative to traditional rehabilitation is increasing. The Nintendo Wii Fit has been marketed as a fitness tool for people of all ages and is one of the most widely used gaming consoles in the health care sector. Despite the increased popularity and potential applications of these consumer gaming systems in rehabilitation, very few reports have been published on the use of basic Wii Fit gaming system in stroke survivors. None among them have addressed the neurophysiological mechanisms associated with the Wii Fit balance training. Hence, the purpose of this case report was to examine the effectiveness of a 4-week Wii Fit training paradigm on corticospinal mechanisms pertaining to the lower limb motor cortex in addition to other clinical measures of balance, postural control, and balance confidence in an individual in the subacute stages of stroke.
Case Description: The participant was a 52-year-old female who suffered left-hemisphere ischemic stroke 2 months prior to the study. She presented with right-side hemiparesis with a motor power of 3 in the right upper and lower limbs and walked with a hemiplegic gait. Participant received balance training on the Wii Fit, which included the ski salom, table tilt, and soccer heading games, for a period of 45 minutes, 3 times a week for 4 weeks. Participant did not receive any other intervention during this period.
Outcomes: Clinical outcome measures included the Berg Balance Scale, Timed Up and Go test, and 10-meter walk test. Postural control was quantified using body weight distribution symmetry. Participant's perception of balance confidence was assessed using the Activity specific Balance Confidence questionnaire. Transcranial magnetic stimulation was used to measure cortical excitability of the tibialis anterior muscle representation. We assessed the participant at baseline and after 4 weeks of the Wii Fit intervention.
Discussion: At the end of the 4-week Wii Fit intervention, cortical excitability of the paretic tibialis anterior improved by 29% (measured using changes in motor evoked potential amplitude). Participant also showed improvements in performing the Timed Up and Go test. Balance confidence increased by 55%. The results of this case study illustrate that the changes in balance observed using the Nintendo Wii Fit balance training may be accompanied by improvements in the corticospinal drive to the paretic lower limb muscles, suggesting the Wii Fit has the potential be an important component of physical rehabilitation after stroke to influence neural plasticity and thereby functional recovery.
Vestibular Rehabilitation and Multiple Sclerosis: Do Patients With Infratentorial Lesions Benefit More?
J.R. Hebert, Physical Medicine and Rehabilitation, and Neurology, University of Colorado, Aurora, Colorado.
Purpose/Hypothesis: Multiple sclerosis (MS) frequently affects infratentorial structures including the brainstem and cerebellum, resulting in impaired balance often leading to advanced disability. Evidence is evolving that indicates interventions targeting brain lesion involvement may prove more effective. Yet to be determined is whether vestibular rehabilitation is most effective for those with brainstem and/or cerebellar involvement. To this point, the objective of this investigation was to determine if vestibular rehabilitation, consisting of balance and eye movement training, is most effective for persons with MS who have brainstem and/or cerebellar involvement.
Number of Subjects: 12.
Materials/Methods: Single-group, secondary data analysis from a 3-group (N = 38 persons with MS), 14-week randomized controlled trial, where the experimental group underwent vestibular rehabilitation (balance and eye movement exercises). Experimental group-only (N = 12) analysis of change in balance as a function of central sensory integration (dynamic posturography) was performed based on 2 strata: participants with brainstem and/or cerebellar lesion involvement (n = 8) and participants without (n = 4).
Results: Balance improved significantly for participants with brainstem and/or cerebellar involvement (21.6, P = 0.005) and insignificantly for those without (12.2, P = 0.138), with a large between-group standard effect size (d = 0.88; P = 0.189).
Conclusions: A 6-week vestibular rehabilitation program demonstrated statistically significant and clinically relevant improvements in balance for persons with MS who have brainstem and/or cerebellar involvement. The small sample size is a limitation; however, the results warrant larger investigations.
Clinical Relevance: The results from this report provide early evidence of which patients with MS are likely to have greater benefits from participating in a balance and eye movement exercise program, further promoting more accurate treatment prescription aimed at improving balance in persons with MS.
Effect of Transcranial Direct Cortical Stimulation on the Expression of Upper Extremity Flexor Synergy in a Chronic Hemiparetic Stroke Population
J. Drogos, C. Anderson, L. Imming, J. Concha Urday Zaa, J. Yao, Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois. J. Dewald, Physical Therapy and Human Movement Sciences, Biomedical Engineering, Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois.
Purpose/Hypothesis: Previous research has demonstrated that reaching ability of the affected upper extremity (UE) in individuals with stroke decreases with increased abduction loads due to the obligatory coupling between shoulder abduction (SABD) and elbow flexion (ie, flexion synergy). Two different neuromechanisms have been proposed to explain this synergy. The first states that individuals with stroke lack required pathways in the lesioned hemisphere and therefore progressively recruit muscles with the nonlesioned hemisphere, primarily via highly branched brainstem pathways. The second mechanism cites increased inhibition from the nonlesioned hemisphere blocking the use of resources from the lesioned side. The purpose of this study was to examine each theory by using transcranial direct cortical stimulation (tDCS) to modulate cortical activity and quantify changes in EMG activity and reaching ability with various SABD loads in individuals with stroke.
Hypothesis: Anodal stimulation of the lesioned motor cortices will increase excitability of residual corticospinal pathways, reducing synergy and expressed by increased triceps activation and greater reaching distance. Cathodal stimulation of the nonlesioned motor cortices will reduce interhemispheric inhibition, reducing synergy, and increasing triceps activation and reaching distance.
Number of Subjects: Eight individuals with chronic stroke.
Materials/Methods: All participants performed a repeated reaching task with various SABD loads (supported on a haptic surface, 0%, 25%, and 50% max voluntary SABD torque) in random order. Surface EMG was recorded for triceps, biceps, and intermediate deltoid. After initial reaching assessment, the participant was randomized to anodal tDCS to the lesioned side, cathodal tDCS to the nonlesioned side, or sham for 15 minutes. Immediately after tDCS, another reaching assessment was completed. Testing was done in 2 sessions over 2 weeks, consisting of anodal/cathodal stimulation; or sham + anodal/cathodal stimulation. The maximum reaching distance was calculated for each condition.
Results: A 2-factor repeated-measures ANOVA reported a significant interaction between stimulation and SABD load (P < 0.05). Anodal tDCS significantly increased reaching distance on the haptic surface. Cathodal tDCS significantly reduced maximal reaching distance overall (P < 0.1).
Conclusions: Increased cortical activity in the lesioned hemisphere may increase reaching ability, supporting the brainstem pathway theory. Decreased cortical activity in the nonlesioned hemisphere reduces reaching ability, which does not support interhemispheric inhibition theory.
Clinical Relevance: This study helps to further understand the pathophysiology of upper extremity movement impairments in chronic stroke. Anodal tDCS to the lesioned hemisphere demonstrates remaining neural plasticity in individuals poststroke that can be utilized using targeted physical and pharmacological interventions to stimulate the use of remaining corticofugal projections from the lesioned hemisphere.
Vestibular Functioning and Migraine: Comparing Those With and Without Vertigo on a Measure of Participation
B.J. Baker, Physical Therapy, Grand Valley State University, Grand Rapids, Michigan. A. Curtis, Interdisciplinary Health Sciences, Western Michigan University, Kalamazoo, Michigan. P.R. Trueblood, Physical Therapy, California State University, Fresno, Fresno, California. E. Vangnes, physician assistants studies, Western Michigan University, Kalamazoo, Michigan.
Purpose/Hypothesis: This study compared vestibular functioning, as defined by a participation/quality of life (QOL) measure, of 2 groups with migraine: one with migraine and vertigo (MV) and one with migraine and no vertigo (MØV). The QOL selected was the Vestibular Disorders Activities of Daily Living (VADL) scale. It was hypothesized that people with MV would have lower scores on the VADL during a migrainous period as compared to people with MØV.
Number of Subjects: 38.
Materials/Methods: Participants with a diagnosed history of migraines, MV (n = 19) and MØV (n = 19), were tested using the VADL both during a nonmigrainous period and during a migrainous period. A mixed-measure, repeated-measures ANOVA was used for data analysis to examine differences both between the MØV and the MV groups at each time point and within groups during the nonmigrainous period versus the migrainous period.
Results: The groups, MV and MØV, did not differ from each other during a nonmigrainous period, but the MV group reported lower QOL during a migrainous period compared to the MØV group (P < 0.001). In addition, both groups had lower QOL during the migrainous period as compared to the nonmigrainous period (P < 0.0001 for MV and MØV).
Conclusions: QOL is lower in a MV group versus an MØV group during a migraine, however similar during a nonmigrainous period. Both MV and MØV group's QOL was lower during a migraine versus during a nonmigrainous period.
Clinical Relevance: Participation measures, such as the VADL, are important assessment and outcome measures for MV, and this research emphasizes why vestibular rehabilitation, with the goal of improving QOL, is an important treatment for this population.
Backward Walking to Improve Balance and Mobility in a Person With a Chronic Spinal Cord Injury
H.E. Foster, L. DeMark, P.M. Spigel, Brooks Rehabilitation, Jacksonville, Florida. D.K. Rose, E.J. Fox, Brooks Rehabilitation & University of Florida, Gainesville, Florida.
Background and Purpose: Although locomotor training is a beneficial approach for restoring walking after incomplete spinal cord injury (ISCI), individuals often continue to walk with gait impairments and at a very slow pace. These impairments may persist due to impaired motor control, decreased strength, and poor balance. Backward walking is an emerging rehabilitation intervention that has been shown to improve balance, lower extremity muscle strength, and walking function. Few studies have examined the use of backward walking and the effect of backward walking on individuals with ISCI has not been reported. The purpose of this case study was to examine the effect of backward walking on balance and forward gait in a patient with a chronic ISCI.
Case Description: The patient was a 28-year-old female, 11 years post-ISCI, classified as a C4 AIS D. She participated in an intense backward walking program for 3, 60-minute sessions/week for 6 weeks. Backward walking training was performed on a treadmill with partial body weight support and overground. Locomotor training principles, which emphasize intense, repetitive stepping with appropriate kinematics, maximal loading on the legs, and reducing compensations, were applied to this protocol. The intensity of each training session was monitored by counting the number of steps. Balance and walking function were assessed pre-, mid-, and posttraining. Balance was assessed using the Berg Balance Scale and Sensory Organization Testing (SOT) on the NeuroCom SMART Balance Master. Gait speed and spatiotemporal characteristics of her gait were calculated as she walked over a 12-foot instrumented walkway (GAITRite). Forward gait also was assessed using the Timed Up and Go (TUG) and 10 Meter Walk Test (10MWT). Backward walking was assessed using the 3 Meter Backward Walk Test.
Outcomes: Following 18 sessions of an intense backward walking program, the patient demonstrated improved balance and forward gait. Her Berg Balance Scale score improved from 20/56 to 37/56, while the composite SOT score improved from a 27 to a 40. Her TUG time improved from 57 seconds to 32.7 seconds, while her 10MWT time improved from 0.23 m/s to 0.31 m/s. Gait velocity calculated using GAITRite software improved from 0.2 m/s to 0.27 m/s, while cadence improved from 36 to 42 steps/minute. Time to complete the 3 Meter Backward Walk Test improved from 0.07 m/s to 0.12 m/s.
Discussion: Intense training of backward walking was effective for improving balance and forward walking in a patient with chronic ISCI. Locomotor training principles were used to guide the intervention and for progression. The combined use of backward walking and specific training principles may have challenged the patient in a novel way and also activated the nervous system during rhythmic stepping movements. Future research should investigate the long-term effect of backward walking, both overground and on a treadmill, as well as carryover to other functional activities in individuals with neurologic injuries.
Concurrent Validity of Walking Speed Values Calculated via the GAITRite Electronic Walkway and 3 Meter Walk Test in the Chronic Stroke Population
A. Middleton, D.M. Peters, S. Fritz, Exercise Science, University of South Carolina, Columbia, South Carolina. J.W. Donley, Palmetto Health–University of South Carolina Mobility Research Clinic, Columbia, South Carolina. E.L. Blanck, University of South Carolina School of Medicine, Columbia, South Carolina.
Purpose/Hypothesis: Walking speed (WS) is gaining popularity as an objective measure in clinical assessment. The purpose of this study was to provide novel information regarding the concurrent validity (primary aim) and reliability (secondary aim) of WS calculated via the GAITRite electronic walkway system and 3-meter walk test in the chronic stroke population. The 3-meter walk test is a feasible option for clinicians, especially those working in environments where space is limited. However, no evidence is currently available regarding the test's psychometric properties.
Number of Subjects: 49 individuals, 162 WS observations.
Materials/Methods: Participants were stratified into 3 groups based on WS categories developed by Perry et al: household ambulators (self-selected WS <0.4 m/s, 9 participants, 31 observations, average time since stroke 30 [29.7] months, average age 59.6 [11.4] years), limited community ambulators (self-selected WS 0.4-0.8 m/s, 20 participants, 60 observations, average time since stroke 42 [35.8] months, average age 64.5 [10.3] years), and community ambulators (self-selected WS >0.8 m/s, 20 participants, 71 observations, average time since stroke 26.7 [21.4] months, average age 62.6 [14.9] years). Three consecutive trials of GAITRITE and 3-meter walk test were performed at participant's self-selected WS. First trial was for practice and trials 2 and 3 were analyzed to determine concurrent validity and reliability of the 2 measures.
Results: WS measurements differed significantly (P < 0.05) between the GAITRite and 3-meter walk test for all 3 groups. Household ambulator group: GAITRite 0.25 (0.11) m/s, 3-meter walk test 0.27 (0.11) m/s; limited community ambulator group: GAITRite 0.56 (0.11) m/s, 3-meter walk test 0.52 (0.10) m/s; community ambulator group: GAITRite 1.03 (0.16) m/s, 3-meter walk test 0.89 (0.15) m/s. Both WS measures had excellent within-session reliability (ICCs ranging from 0.85 to 0.97, SEM95 from <0.01 to 0.02 m/s, and MDC95 from 0.01 to 0.06 m/s). Reliability was highest for household ambulators on both measures.
Conclusions: Although both the 3-meter walk test and the GAITRite are reliable measures of WS for individuals with chronic stroke, the 2 measures do not demonstrate concurrent validity.
Clinical Relevance: When comparing a patient's walking speed to either their previous assessment or a reference chart, clinicians should exercise caution if different measures were used and the concurrent validity of these measures has not been established.
The Effects of Exercise on Activities of Daily Living in People With Alzheimer's Disease: A Systematic Review
A.K. Rao, A. Chou, B.T. Bursley, J.P. Smulofsky, J.K. Jezequel, Physical Therapy, Columbia University, New York, New York.
Purpose/Hypothesis: Alzheimer's disease (AD) results in a loss of independence in activities of daily living (ADL), which reduces the quality of life in patients and increases the burden on caregivers. There is limited research examining the influence of exercise (aerobic, balance, and strength training) on ADL in people with AD.
Number of Subjects: Six randomized controlled trials (total of 446 participants) that fit the inclusion criteria were analyzed. All studies (Oxford level of evidence 1b-2b) included exercise interventions for patients diagnosed with AD. We selected trials that included ADL as the primary outcome measure.
Materials/Methods: We searched PubMed, The Cochrane Library, MEDLINE, Google Scholar, and the ISI Web of Knowledge. We included only randomized controlled trials (RCTs) and excluded studies that tested patients diagnosed with other forms of dementia, mild cognitive impairment, or Parkinson's disease.
Results: Exercise training was well tolerated by patients with AD and with minimal adverse effects. None of the studies mentioned worsening of ADL as a result of the exercise intervention. Exercise training either improved ADL performance or reduced decline of ADL, indicated by a statistically significant change in ADL outcome measures when compared to the control group (z score = 4.07; P < 0.0001; average effect size = 0.7). The effect of exercise on secondary outcomes (physical performance, cognition, and mood) were also assessed. Physical performance (z score = 3.54; P < 0.0004) and cognition (z score = 1.05; P < 0.29) in the exercise group demonstrated a trend toward improvement and depressive symptoms decreased.
Conclusions: Exercise that includes elements of aerobic, balance, and strength training can improve or decrease the decline of ADL among patients with AD. Furthermore, this review showed that patients with AD can tolerate an exercise regimen and show positive results from such a program.
Clinical Relevance: The effect of exercise in improving ADL in patients with AD demonstrated a large effect size in 6 RCTs analyzed. Exercise had beneficial effects across settings (long-term care and home). Second, exercise was beneficial despite variations in who delivers the exercise program as long as the exercises are correctly performed. However, it may be important for physical therapists to prescribe and supervise exercise programs because of their training in identifying and addressing compensations, and guarding (if needed) to minimize adverse events such as falls. Third, the type of intervention does not matter as long as the exercise program includes elements of aerobic, strength, balance, and coordination components. Fourth, longer exercise interventions do not necessarily correlate with better outcome measurements. Fifth, and of particular importance, these studies show the clinical feasibility of exercise in patients with AD. It is recommended that patients diagnosed with AD begin an exercise program that consists of aerobic, strength, balance, and coordination activities as soon as possible to prevent functional decline.
The Use of a Driver Alert Device to Improve Midline Head Position for Patients With Neurological and Orthopedic Conditions
R. Peng, Outpatient Physical Therapy, Kessler Institute for Rehabilitation, Chester, New Jersey.
Purpose: The purpose of this poster presentation is to share a novel approach to improve midline head position in patients with both neurological and orthopedic problems.
Description: The technique uses an auditory signal that is set off when the head or body is either flexed forward or tilted laterally and which is turned off when the head or body is positioned in midline. The auditory signal is provided by a commercial driver alert device, which is designed to alert a driver when he or she is falling asleep while behind the wheel.
Summary of Use: For the past year, the author has been using a driver alert device for patients with head and body tilt or forward head position. This poster describes one patient who had a cerebral vascular accident and one patient who had myofascial cervical pain associated with significant forward head position. Biofeedback, including auditory feedback, provides knowledge of performance that is continuous, objective, and concurrent (Salmoni, Schmidt, et al, 1984). Improved posture is determined by the lack of auditory signal during a functional task or while sitting or standing. Carryover is noted by putting the device on the patient at subsequent sessions without triggering the device as well as by therapist postural assessment.
Importance to Members: Poor or impaired posture is a common problem associated with many conditions treated by physical therapists. Effort in PT sessions is made to improve posture to improve balance or reduce pain for function. Using this device, patients have been able to attain and maintain erect head posture without verbal cues. This device is inexpensive and easy to apply and has been well tolerated by all patients using it to date.
Effort and Muscle Force/Activation Depend on Impairment Level in Stroke Survivors
W. Liu, T.K. Jain, S. McGuff, B. Hozie, Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas. C.N. Wauneka, Bioengineering Program, University of Kansas, Lawrence, Kansas.
Purpose/Hypothesis: Various intensities of resistance have been tried in strength training of stroke survivors, but it is unclear whether there exists an optimal effort level during motor training. Past research evidence has shown that motor recovery in stroke survivors depends on initial impairment level. However, it is unknown whether the optimal effort level during motor training for a specific stroke survivor may also depend on the impairment level. The purpose of this preliminary study is to examine the effect of different effort levels on the elbow joint torque and muscle activation level during sense of effort testing in chronic stroke survivors and healthy adults.
Number of Subjects: Five healthy subjects and 13 chronic stroke survivors (mild impairment, n = 9; moderate impairment, n = 4) were enrolled.
Materials/Methods: All subjects completed testing in 2 sessions on 2 different days. During the first session, the maximum isometric voluntary elbow joint torque contraction (MVC) and maximal muscle activation (EMG) for biceps brachii, triceps, and other auxiliary muscles were established for flexion and extension on the unaffected side of the stroke survivors and the dominant side of the healthy subjects using the Biodex dynamometer. The subjects were then asked to contract elbow muscles isometrically in flexion and extension at different effort levels of MVC (30%, 50%, 70%, and 90%). During the second session, the affected side (stroke survivors) or nondominant side (healthy subjects) was tested in the same way. Muscle torques and activation levels at different effort levels including the maximal effort for biceps brachii, triceps, and other auxiliary muscles in both flexion and extension were recorded during the test. The recorded data were normalized to MVC/maximal muscle activation for data analysis.
Results: Healthy subjects demonstrated an expected pattern of linear increases in torque and agonist EMG with minimal coactivation from antagonistic and auxiliary muscle groups. Stroke subjects with mild impairment demonstrated the similar pattern as the healthy subjects. However, the pattern in stroke subjects with moderate impairment differed from this linear progression; in other words, an increase in the effort level did not necessary lead to increased muscle torque or activation levels in this subgroup of the subjects.
Conclusions: The results of our study indicate that stroke survivors, depending on their levels of motor impairment, may/may not be able to scale their motor command according to a desired effort level. In this type of task, the stroke survivors with mild impairment showed similar behavior as healthy adults, while individuals with moderate impairment presented with abnormal behavior. This may be due to differences in the severity of disrupted motor neuron pathways after stroke.
Clinical Relevance: Motor training with high resistance/high level of effort may benefit stroke survivors with mild impairment, but not necessary beneficial in individuals with moderate/severe impairment.
Virtual Reality Based Therapy Compared With Customized Physical Therapy in the Rehabilitation of Patients With Vestibular Disorders
K.A. Alahmari, Medical Rehabilitation Sciences, King Khalid University, Abha, Saudi Arabia. P.J. Sparto, G.F. Marchetti, S. Whitney, Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania. M.S. Redfern, J.M. Furman, Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania.
Purpose/Hypothesis: Patients with vestibular disorders can become more symptomatic while ambulating in visually complex environments and this has been termed “space and motion discomfort,” “space phobia,” “supermarket syndrome,” “height vertigo,” or “visual vertigo.” Visually provocative habituation exercises have been shown to be useful during vestibular rehabilitation. Several groups have used provocative visual stimulation to habituate dizziness in people with vestibular disorders. The purpose of this research was to compare changes in self-report and performance measures in persons with vestibular disorders after a 6-week intervention program of customized vestibular physical therapy (PT) or virtual reality-based therapy (VRBT).
Number of Subjects: 38 persons with vestibular disorders participated.
Materials/Methods: Subjects were assigned into 2 groups: VRBT or PT with both groups receiving 6 treatment sessions over 6 weeks. Subjects in the VRBT group were treated in a specially designed virtual reality grocery store environment. Subjects were assessed before, 1 week after the intervention, and at 6 months follow-up using self-report measures including the Activities-specific Balance Confidence scale (ABC), the Dizziness Handicap Inventory (DHI), and the Situational Characteristics Questionnaire part A and B (SCQ); and performance-based measures including the Dynamic Gait Index (DGI) and the Sensory Organization Test.
Results: Groups were similar at baseline in all self-report and performance measures. The ANOVA revealed that there was no significant effect of group or interaction between group and time for any of the self-report and performance measures. However, there was a significant time effect for most of measures (P < 0.001). On average, the entire sample demonstrated significant improvements in 3 of the 4 self-report measures, and in 4 of the 5 performance measures, and maintained these improvements 6 months after the intervention ended. The amount of improvement did not differ among the interventions.
Conclusions: Our findings suggest that using VRBT in vestibular rehabilitation produces equivalent functional outcomes for patients with vestibular disorders when compared with the clinically accepted physical therapy.
Clinical Relevance: Virtual reality-based therapy may be a promising new intervention for individuals with vestibular disorders that can be used as a form of habituation training for symptoms induced in visually complex environments.
A Systematic Review of the Effects of Split-Belt Treadmill Training on Gait in Patients With Hemiplegia
J. Kopack, A. Malone, C. Salvo, M. Sofia, R.M. Hakim, Physical Therapy, University of Scranton, Scranton, Pennsylvania.
Purpose/Hypothesis: The purpose of this systematic review was to describe the impact of split-belt treadmill training (SBTT) on gait outcome measures in individuals with hemiplegia.
Number of Subjects: N/A.
Materials/Methods: A literature search of CINAHL, PubMed, HighWire, and ProQuest Central was conducted to identify research studies examining the effects of SBTT on gait in patients with hemiplegia. Inclusion criteria were peer-reviewed journals published in English, gait outcome measure(s), subjects with hemiplegia, human subjects, and utilization of SBTT. Studies were excluded if they did not report on gait parameters or if the treadmill did not have a split belt. Four reviewers independently assessed each study for methodological quality and came to consensus based on PEDro guidelines.
Results: A total of 129 articles were screened for eligibility in this review. Following a detailed appraisal, 5 studies (3 quasi-experimental, 1 case report, 1 case series) fulfilled the inclusion/exclusion criteria and were included in this systematic review. The quality assessment ranged from a PEDro score of 3 to 4/10 with an average of 3.8. The intensity, frequency, and duration of treatment parameters varied greatly across studies. Outcome measures included self-selected walking speed, fast walking speed, TUG scores, lower extremity Fugl-Meyer scale, step length, monofilament testing, stance time, stride time, gait symmetry, and double support time. Sample sizes ranged from 1 to 73 participants with a total of 135. Ninety-four of the 135 participants had hemiplegia secondary to stroke and 41 were healthy control subjects. All 5 articles showed improvement in at least 1 gait outcome measure and displayed more symmetrical locomotion when transferred to over ground walking.
Conclusions: There is weak evidence in support of using SBTT as a primary treatment intervention in patients with hemiplegia. Limitations included small sample sizes and a lack of randomization, controls, uniform gait outcome measures, and long-term follow-up. Future research using randomized controlled clinical trials is needed to determine the most effective treatment parameters to optimize SBTT and improve gait in patients with hemiplegia.
Clinical Relevance: Preliminary evidence on the use of SBTT shows promise as a task-specific treatment option for patients with lower extremity hemiplegia across different clinical settings. SBTT is a safe, controlled, and efficient method of improving the quality of hemiplegic gait. Future applications will be dependent upon the availability of resources and equipment.
Improvement in Walking Speed and Endurance by Combining Body-Weight–Supported Treadmill Training and Spasticity Management of a Patient With Poststroke Spastic Hemiplegia
J. Nesbit, Outpatient Neurological Therapy Services, Scottsdale Healthcare, Scottsdale, Arizona.
Background and Purpose: More than 50% of stroke survivors are unable to walk and require rehabilitation to regain some function in ambulation. Body-weight supported treadmill training (BWSTT) provides a safe environment for repetitive and forced gait training and has been shown to improve gait speed and endurance with overground walking with patients poststroke. However, various limitations in body functions and structures poststroke may delay or halter the potential progress BWSTT may offer. One of these limitations is hypertonicity. This case study illustrates the importance of treating the body functions and structures as well as physical limitations in order to improve gait speed and endurance.
Case Description: A 51-year-old female presenting with right hemiparesis s/p intracerebral hemorrhage with left frontotemporal craniotomy and resection of hematoma. Patient was seen for 83 visits while taking oral baclofen, receiving intensive therapy and attempts of use of BWSTT. BWSTT was not successful due to spasticity-limiting ability to advance and weight bear through right lower extremity (R LE) and required 2 person assist. Intrathecal baclofen (ITB) pump placement was recommended by therapist and physician to provide increased dosage of direct baclofen for more intensive spasticity management. As spasticity decreased, BWSTT was able to be implemented more effectively. Therapy consisted of 3×/week of BWSTT and 2×/week of regular therapy for 8 weeks.
Outcomes: On oral Baclofen Ashworth scores were 4 in hip, knee, and ankle extensor muscles. Gait speed after 83 visits was 0.63 ft/s and endurance plateaued at 500 ft with a single point cane (SPC) and 100 ft with no assistive device (AD). Post-ITB pump placement, Ashworth scales improved to a 2 in hip and knee extensor muscles. Ankle extensors remained an Ashworth score of 4 but controlled with an ankle foot orthoses. Gait speed improved to 1.37 ft/s overground with the use of SPC and endurance improved to >1000 ft with the use of SPC and 500 ft with no AD.
Discussion: This case illustrates the benefits of spasticity management, via ITB pump, in combination with PT interventions to improve gait speed and endurance. Prior to ITB pump placement, BWSTT was difficult to perform and resulted in no carry-over secondary to extensor hypertonicity. As spasticity decreased, BWSTT was able to be implemented more aggressively and with increased independence. Baseline flexibility in the affected leg was necessary in this patient case to achieve swing phase of gait for BWSTT to be effective. In conclusion, therapists have an important role in monitoring and advocating for spasticity management to successfully perform therapy interventions.
Modifiable Characteristics of Near Falls in High-Level Patients With Parkinson Disease
P. Padgett, S. Crandall, K. Hendron, T. DeAngelis, L.E. Brown, T. Ellis, Boston University, Boston, Massachusetts.
Purpose/Hypothesis: Falls cause health-related decline and increased medical costs in people with Parkinson disease (PD). Identification of future fallers and interventions to prevent falls are important to mitigate a decline in health status. Identifying near falls may aid in the identification of future fallers. Near falls can be further characterized by factors such as location, direction, or activity during the near fall event. These factors may be amenable to change through a variety of interventions, including high-intensity balance interventions. The purpose of this study was to describe the characteristics of near falls in people with PD and determine which factors were modifiable with participation in a progressive group balance exercise program.
Number of Subjects: 23 participants with idiopathic PD with at least 1 near fall in the past 3 months, mean Hoehn & Yahr: 2.4, mean years since diagnosis: 4.5.
Materials/Methods: Participants enrolled in a 90-minute group exercise program for 24 sessions over 3 months. Each session included high-intensity balance and strengthening exercises. Number of near falls that occurred over the intervention period were collected prospectively with fall diaries and in-person interviews during each session. Near falls were characterized by location, direction, and activity during near fall event. Change in frequency and characteristics of near falls over the course of the intervention were examined using linear regression.
Results: During the course of the intervention, 123 near falls were recorded. The majority of near falls were noted indoor (n = 93) versus outdoor (n = 24) and with walking (n = 56) versus transfers, reaching and standing combined (n = 37) and activities of daily living (n = 12). Near falls decreased significantly (P = 0.004) over the intervention period. A statistically significant decrease in indoor (P = 0.003), backward (P = 0.003), and lateral (P = 0.009) near falls, and near falls with transfers, standing and reaching (P = 0.022) occurred over the course of the intervention. Conversely, no significant change was noted in near falls outdoor, in the forward direction, or with walking.
Conclusions: An intensive balance program was effective in significantly decreasing near falls in people with mild PD over the course of 24 sessions, particularly in the indoor environment, backward and lateral directions, and during transfers, standing, and reaching. Specificity of training may explain why indoor near falls and near falls during transfers, standing, and reaching. Reduction in backward and lateral near falls suggests that perhaps some directions were more responsive to balance interventions than others.
Clinical Relevance: This study highlights the positive effect of intensive, progressive balance interventions on reducing near falls and the need to monitor near falls in people with PD who may not yet be falling. The differential effect in reduction of near falls based on direction, environment, and activity may indicate that training needs to be both task and context specific.
Clinical Competence Assessment
L. Snowdon, Kessler Institute for Rehabilitation, West Orange, New Jersey, United States.
Purpose: To outline an expanded clinical competency process consisting of didactic training, peer lab practice, and standardized evaluation testing as a beneficial and effective method of assessing therapists' competence in the treatment of patients presenting status post spinal cord injury and brain injury.
Description: Assessment of clinical competence has been a long-standing practice in many hospital settings, including the inpatient rehabilitation department at Kessler Institute for Rehabilitation. At Kessler, all physical therapists are evaluated both during their 90-day introductory period of employment, and annually on core elements of the job role including infection control practices, understanding of precautions, and discipline-specific knowledge such as the ability to appropriately prescribe assistive devices or orthotics. However, due to the complexity and specialized needs of the diagnostic populations served, it was determined that best practice for evaluating therapists' clinical performance would be to expand the existing competency assessment model.
Summary of Use: The managers and senior staff of the spinal cord injury and brain injury units at Kessler developed a systematic training methodology in specific clinical skill areas to facilitate comprehensive treatment of complex clients. Examples of competency elements include demonstration of different strategies to transfer patients, train mat mobility transitions, and perform advanced wheelchair skills. In-services based on current evidence and resources are provided with both photo and video content to enhance carryover. Following the lecture components, practice lab sessions are implemented to give therapists opportunities to trial skills on their peers. The culmination of the clinical competence process involves lab practical testing in which therapists demonstrate skills on a lab partner in all core areas for each competency.
Importance to Members: Therapy staff have reported this method of assessment to be more focused and comprehensive for treatment strategies and lead-up task activities as compared to the standard competency approach, and view the process as a valuable adjunct to promote continued learning and skill development. Since the inception of this clinical competency program in early 2012, it has become integrated as a standard of practice for evaluating new clinicians, students, therapists rotating to a different diagnostic category, and staff who require consistent or more extensive training to build their treatment repertoire. A comprehensive clinical competence assessment utilizing this methodology of didactic training, hands-on peer lab practice, and practical testing can be an effective process for assessing physical therapists' competence in the treatment of complex patients in varied practice settings.
Clinical Application of the Wheelchair Skills Program: A Case Study Report
L. Snowdon, Kessler Institute for Rehabilitation, West Orange, New Jersey, United States. B. Garrett, Kessler Institute for Rehabilitation, West Orange, New Jersey.
Background and Purpose: The Wheelchair Skills Program (WSP) is a reliable and valid method of evaluating and training manual and power wheelchair users and caregivers. The program utilizes the Wheelchair Skills Test (WST) to evaluate users on 32 items in 3 broad categories including indoor, community, and advanced skills. Individuals are graded via a pass/fail score on both skill performance and safety of each item. Following completion of the WST, the Wheelchair Skills Training Program (WSTP) is utilized to systematically teach skills that were failed or considered unsafe during initial testing. Specifically, the WSTP provides training tips including how to guard, provide feedback, and practice skills to facilitate passing scores upon reassessment. Despite the fact that there is significant evidence to support implementation of the WSP, it is not consistently utilized in varied settings. Therefore, a Wheelchair Skills Class was implemented at Kessler Institute for Rehabilitation to incorporate the WSP testing and training methodology for all patients during their inpatient rehabilitation stay. While patients have noted improvements in their abilities related to wheelchair management since inception of this program, a case study of one manual and one power wheelchair user presenting status post spinal cord injury was conducted to objectively assess these changes.
Case Description: A 31-year-old female with T12 AIS A paraplegia was evaluated using the WST for the Manual User, receiving initial scores of 11/32 (34%) for skill performance and 11/32 (34%) for safety. Her treatment focused on using lead-up task strategies outlined by the WSTP, such as training wheelies in soft foam to decrease rolling resistance. A 55-year-old male presenting with C5 AIS B tetraplegia was assessed using the WST for the Power User. He presented with initial scores of 10/32 (31%) on performance and 12/32 (38%) for safety. His individualized WSTP emphasized community skills training such as door management, and advanced skills including negotiation of thresholds and inclines.
Outcomes: Both patients were reassessed after 4 weeks of training 2 times per week using WSTP strategies. The manual wheelchair user achieved a score of 22/32 (69%) for skill performance and 23/32 (72%) for safety, doubling her percentage scores on the WST. The power mobility user also demonstrated significant improvement on reassessment, with a score of 18/32 (52%) for skill performance and 24/32 (75%) for safety. Both clients reported the training received via the WSP allowed them to focus on specific areas using objective and progressive interventions to enhance overall skill achievement.
Discussion: The WSP is a reliable and valid method of testing and training wheelchair skills for both manual and power users. More consistent implementation of this objective, standardized program in rehabilitation settings can be beneficial to ensure patients are developing the ability to successfully and safely perform varied wheelchair skills at the indoor, community, and advanced level.
Increasing the Dosage of Intensive Mobility Training Improves Fast Gait Speed and Functional Balance in Individuals With Chronic TBI
D.M. Liuzzo, J. Greene, D.M. Peters, A. Middleton, S. Fritz, Exercise Science, University of South Carolina, Columbia, South Carolina. E.L. Blanck, University of South Carolina School of Medicine, Columbia, South Carolina.
Purpose/Hypothesis: To determine if outcomes are related to dosage. To do this, we investigated if 20 days of intensive mobility training (IMT) produces more gains in gait and functional balance activities when compared to 10 days of IMT for individuals with chronic traumatic brain injury (TBI).
Number of Subjects: 10 individuals with TBI (average age 35.4 [14.06] years, average time since TBI 11.7 [9.2] years).
Materials/Methods: The participants underwent 20 consecutive days of treatment (5 days/wk × 4 wks), total of 60 hours of therapy. They were required to complete 50 minutes in 3 distinct domains of activities (total 150 minutes/session): (1) balance, (2) gait training with a body weight–supported treadmill system, and (3) strength, coordination, and range-of-motion activities. All activities were patient specific and progressed when appropriate. An evaluator, who was not involved in the treatment, assessed the participants before they began the intervention, after 10 sessions (interim), and after 20 sessions (posttest). Outcome measures included Dynamic Gait Index (DGI) and self-selected and fast-paced gait speed using the 10 Meter Walk test (10MWT). The pre to interim and pre- to posttest group comparisons were analyzed using paired t tests for the 10MWT and Wilcoxon signed-rank test for the DGI.
Results: There were significant differences (α = 0.05) between pretest and interim measurements for 10MWT fast-paced velocity (P = 0.006, d = 0.19) and DGI scores (P = 0.049, d = 0.17). Participants demonstrated significant changes in the same outcomes at posttest: 10MWT fast-paced velocity (P = 0.002, d = 0.36) and DGI (P = 0.49, d = 0.18). Effect sizes are higher for pre- to posttest outcomes than the pre to interim measures; while the changes are slight, they show a pattern toward increasing effects as dosage increases. Self-selected gait speed did not statically improve.
Conclusions: Individuals with chronic TBI demonstrated gains in fast gait speed and dynamic, functional balance activities following IMT. It is possible that self-selected gait speed did not increase due to the focus of the intervention on improving kinematics of gait. Gains for fast gait speed and functional balance outcomes improved as the number of treatment sessions increased. Despite increased gains with increased time in the study, 20 days of therapy did not double the outcomes assessed at 10 days of therapy.
Clinical Relevance: This research supports that intensive training can result in increases in gait speed and functional activities for individuals with chronic deficits from TBI. An increased dosage can continue to improve the gait speed and functional balance of individuals with chronic TBI.
Stroke Outcomes Before and After Implementation of the Prospective Payment System for Inpatient Rehabilitation Facilities
C.C. Bassile, S.E. Edery-Altas, M. Choi, R. Gil, D.A. Langaker, Program in Physical Therapy, Columbia University, New York, New York.
Purpose/Hypothesis: Length of stay (LOS) at inpatient rehabilitation facilities (IRFs) began declining prior to the implementation of the Prospective Payment System (PPS) in 2002. Aside from the financial implications for institutional resources, this decrease may negatively impact functional outcomes (FO) for individuals being discharged from IRFs. The purpose of this systematic review was to examine LOS, as well as FO & discharge disposition (DD), for patients (pts) with stroke before and after implementation of the PPS for IRFs.
Number of Subjects: Six studies (889,501 pts) were included in this review.
Materials/Methods: A search of ISI Web of Knowledge, PubMed, and MEDLINE was conducted to find articles that reported LOS, FO, and DD for pts with stroke at IRFs. Search terms included length of stay, prospective payment system, stroke and rehabilitation centers. Linear regression analyses were performed to determine rate changes for the 2 time periods: 1997–2001 (pre-PPS) and 2002–2008 (post-PPS) for the following variables: LOS, FIM admission (FIMadm) discharge (FIMd/c) and change (FIM Δ) scores, and percentage of pts discharged home (% Hd/c).
Results: The data reported from 6 studies were analyzed. A negative rate of change was demonstrated for all variables spanning both time periods. From 1997 to 2008, mean LOS declined from 21.54 to 16.50 days, FIMadm scores decreased by 6.91 points, FIMd/c scores decreased by 12.95 points, FIM Δ scores decreased by 6.05 points, and % Hd/c dropped from 91.53 to 69.50%. The novel findings of this review indicate that during the post-PPS time period, 3 variables had a greater negative rate of change in comparison to the pre-PPS time period. LOS declined at a rate of 0.27 days/year during the post-PPS time period and 0.12 days/year during pre-PPS time period, FIMadm scores decreased 1.22 points/year vs. 0.04 points/year, and FIMd/c scores decreased 1.38 points/year vs. 0.82 points/year. FIM Δ scores post-PPS appeared to plateau with a rate of 0.05 points/year as compared to a decrement of 0.90 points/year for pre-PPS period. Similarly % Hd/c post-PPS slowed down with a −0.98% rate of change vs. a −2.44%/year pre-PPS time period.
Conclusions: With the Centers for Medicare & Medicaid Services 2013 update requiring functional limitation improvement reporting for reimbursement, this review is timely. The continued negative rate of change for most variables post-PPS for pts with stroke highlights a potential problem for reimbursement. We suggest that reimbursement include an additional tier system based on FO, which includes increased FIMd/c and FIM Δ scores.
Clinical Relevance: Presently, physical therapists working with pts with stroke in IRFs have little time to deliver optimal care and improve pt function. This review demonstrates the continued decline in FO for pts with stroke after the implementation of the PPS for IRFs. It is imperative that the profession emphasize “improved care delivery AND patient function” are complementary and essential for parties engaged in rehabilitation.
The 3-Meter Backward Walk Test and Its Ability to Predict Fall History in Older Individuals
V. Carter, J. James, M.W. Cornwall, Physical Therapy, Northern Arizona University, Flagstaff, Arizona. K. Wing, Physical Therapy, SWAN Rehab, Phoenix, Arizona. A. Aldrich, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
Purpose/Hypothesis: Outcome measures with fall predictability are critical clinical tools that aid health care professionals in determining interventions and prognoses for their patients. Current tools utilize either a typical or atypical mobility task. These tests, however, may not be the most appropriate or valid measures for predicting fall risk in certain patient populations with disease-specific deficits such as those in the early stages of Parkinson's disease or multiple sclerosis. A new test, referred to as the 3-meter backward walk test (3MBWT), has been advocated to address these issues. Unfortunately, the predictive value of the 3MBWT has not been demonstrated. The purpose of this study, therefore, was to determine the ability of the 3MBWT to predict whether an older individual had fallen within the previous year.
Number of Subjects: 58 individuals (F: 38, M: 20) with a mean age of 72 years and no history of neurological deficit participated in the study.
Materials/Methods: After providing informed consent, subjects completed a retrospective fall history questionnaire and were scored on the 3MBWT. Participants were asked to perform this test as quickly but as safely as possible. The average of the 3 trials were used in the subsequent analysis. In addition to descriptive statistics, a ROC curve and logistic regression analysis were performed in order to determine whether the 3MBWT could identify those individuals with a prior history of falls.
Results: The 3MBWT had a mean value of 4.0 ± 2.1 seconds. The mean 3MBWT for individuals without a history of falling in the past year was 3.5 ± 1.3 seconds, while those with a history of falls was 4.8 ± 2.6 seconds. The mean 3MBWT scores for these 2 groups were statistically significant (P < 0.05). The logistic regression analysis indicated that those with a history of falls within the past year were 3.6 times more likely to have a 3MBWT score of 3.5 seconds or more compared to those without a history of falls (CI = 1.17-10.96). The sensitivity of the 3MBWT was found to be 60.9% while its specificity was 69.7%.
Conclusions: The results of this study show that the 3MBWT has significant predictive ability to identify individuals who had fallen within the past 12 months.
Clinical Relevance: The 3MBWT is a simple functional test that clinicians can use to assess an individual's balance as well as identify whether they were likely to have fallen within the previous 12 months and therefore would benefit from therapeutic intervention to prevent a future fall.
Clinical Test Changes and Neurophysiologic Adaptations in Response to an Activity-Based Upper Extremity Intervention in Persons With Stroke
G. Fluet, A.S. Merians, E. Tunik, H. Bagce, Q. Qiu, S. Saleh, Department of Rehabilitation and Movement Science, University of Medicine and Dentistry of New Jersey, Newark, New Jersey. S. Adamovich, Department of Biomedical Engineering, New Jersey Institute of Technology, Newark, New Jersey.
Purpose/Hypothesis: Differentiating the effects of rehabilitation interventions using clinical tests of motor function in persons with stroke is challenging. The purpose of this preliminary analysis is to compare changes in, functional MRI activation, and first dorsal interossei motor map with changes in standard tests of upper extremity motor function demonstrated by a group of subjects with stroke following a motor intervention.
Number of Subjects: 15 subjects with mild to moderate upper extremity hemiplegia due to chronic stroke.
Materials/Methods: All 15 subjects performed the Upper Extremity Fugyl Meyer Assessment, and Wolf Motor Function Test prior to training and immediately after and 3 months after training. In addition, subgroups were analyzed for BOLD signal changes during a finger movement task as measured by functional magnetic resonance imaging (n = 9), and first dorsal interossei motor map changes as measured by transcranial magnetic stimulation (n = 7) prior to and immediately following training. All subjects trained together for 8 three-hour sessions in a circuit class format. There were 12 activity-based stations incorporating gross motor and fine motor tasks. Eight tasks were unimanual and 4 were bimanual.
Results: The 15-subject group demonstrated statistically significant decreases in WMFT time (mean = 22 seconds, 95% CI = 3-41) and JTHF time (mean = 11 seconds, 95% CI = 2-19). This group increased their UEFMA score a statistically significant 2 points (95% CI = 1-4). Four of the 7 subjects tested demonstrated medial shifts in the center of M1 excitability as measured by transcranial magnetic stimulation and 3 of these subjects demonstrated a lateral shift. Direction of this shift was not related to improvements in clinical test scores. Two of the 7 subjects evaluated with fMRI demonstrated a shift in control of the hemiplegic UE from the contra-lesional motor cortex to the lesioned motor cortex in response to training. Interestingly, this switch in control was consistent with a poor performance at posttest and retention for WMFT, UEFMA, and JTHF.
Conclusions: A variety of patterns of change in brain function were demonstrated by subjects making comparable changes in motor function as measured by standard clinical measures.
Clinical Relevance: Trials examining rehabilitation interventions may need to include measures of brain function to thoroughly analyze the impact of rehabilitation interventions on persons with stroke. In smaller sample trials, a wider range of measurements could identify treatment variables with the potential to elicit the largest impact on long-term function.
A Novel Cognitive-Balance Control Training Paradigm to Reduce Fall Risk in Chronic Stroke Survivors
S. Subramaniam, T. Bhatt, Rehabilitation Sciences, UIC, Chicago, Illinois.
Purpose/Hypothesis: Up to 70% of chronic stroke survivors experience an annual fall, mainly due to balance-related impairments. However, recent research indicates that cognitive deficits can also significantly increase the risk of falls. An intervention paradigm that aims to counter the cognitive and balance (dual task-DT) deficits is paramount. But only few studies have evaluated the efficacy of balance training under DT conditions. To our best knowledge, this is the first study to propose a novel, combined cognitive-balance training using off-the-shelf virtual gaming in conjunction with cognitive training. The training mimics real-life DT environmental conditions that would predispose this population to fall risk. We hypothesized that compared to pretraining, posttraining, participants will show significant improvements in their balance control, under DT conditions.
Number of Subjects: 8.
Materials/Methods: Community-dwelling individuals with hemiparetic stroke (N = 8) received a balance-control training using the commercially available Nintendo Wii Fit in conjunction with cognitive training provided via tasks such as word list generation (WLG), counting backward (CB), and memory recall games. Intervention was given for 5 consecutive days for 1 hour/day. The change in balance control posttraining was evaluated by the Limits of Stability test (LOS; Neurocom Inc). Subjects performed the LOS balance test in the forward and backward directions, under single-task (ST) and DT condition; the latter consisted of a cognitive task, WLG. The WLG task was also performed in sitting (ST) for the same duration as the balance tests. Cognitive ability was recorded for ST and DT for all the conditions by the number of words recited for an alphabet. The posttraining changes in self-initiated center of pressure response time, the movement velocity and the maximum excursion were examined for both ST and DT conditions. “Balance cost” and “Cognitive cost” were computed for all the variables ([ST − DT]/ST*100). Resulting changes in motivation were examined via pre- and postadministration of the Intrinsic Motivation Inventory.
Results: Posttraining all variables improved significantly. The response time under the DT conditions was significantly reduced (pre vs post, P < 0.05), leading to a significantly lower balance cost (P < 0.05) for both directions. Similarly, posttraining, movement velocity and maximum excursion were significantly higher under DT (P < 0.05 for both). Cognitive performance improved for DT conditions for both directions (pre vs post, P < 0.01) with the cognitive cost being significantly lower (pre vs post, P < 0.05) as well. There was a significant increase in Intrinsic Motivation Inventory scores (pre vs post, P < 0.05).
Conclusions: Results validate the efficacy of this high-intensity, short-duration protocol for improving cognitive-balance control in chronic hemiparetic stroke survivors.
Clinical Relevance: The increased motivation observed supports the increased compliance. Future studies should examine the dose-response effects and longer-term changes in falls efficacy of this DT paradigm.
Functional Outcomes of Early Mobilization on Stroke Recovery: A Systematic Review
J.C. Layman, J. Bennett, D. Cayce, D. Choate, Physical Therapy, Southwest Baptist University, Bolivar, Missouri.
Purpose/Hypothesis: Physical therapy interventions usually do not begin until 2 to 3 days after the patient is admitted. The purpose of this review was to evaluate if the effectiveness of early mobilization on stroke recovery is superior to traditional therapeutic methods in relation to functional outcomes. For the purpose of this review, early mobilization is defined as treatment within 48 hours of onset of stroke, compared to traditional therapeutic methods beginning after 72 hours.
Number of Subjects: 776 (total across all articles included in the systematic review).
Materials/Methods: A search of Academic Search Premier, CINAHL Plus, and MEDLINE, using the terms “Early Mobilization and Stroke” was performed. The search was narrowed to exclude the articles not pertaining to the clinical question resulting in 8 articles included in this review. All the articles included in this review were randomized controlled trials.
Results: The findings of the 8 articles chosen were ranked for quality using the PEDro Scale with all articles being of good or excellent quality. Outcomes were measured differently in each article reviewed. The various measurement tools included the Fugel-Meyer, Barthel index, Rivermead Motor Assessment, and scales to measure: safety outcomes, mental stability, quality of life, and secondary complications. Each study listed whether or not the patients improved, and if so, in what area.
Conclusions: Seven of the 8 articles used as the foundation for the review strongly supported the use of early mobilization with stroke patients. Each of the articles provided good evidence as to why they believed that very early mobilizations should be used as treatment for stroke patients. One of the articles did not support the use of early mobilization as strongly as the others. This article stated that in the trials conducted, early mobilization did not show an increased positive outcome over the traditional treatment provided; therefore, the testers in this particular study did not favor the use of early mobilizations over other therapeutic techniques.
Clinical Relevance: The results of this review indicate that early mobilization increases functional outcomes, psychological well-being, and quality of life in poststroke patients. Mobilization should begin within 48 hours poststroke. Although early mobilization after a stroke has been shown to improve patient's overall physical and mental health, the researchers concluded that further research studies are needed to clarify the appropriate application and anticipated benefits of this intervention. Further studies should be done to determine appropriate protocols, exercise intensities, and which rating scale should be used for best results.
Constraint-Induced Therapy Outcomes on the Lower Extremity: A Systematic Review
J.C. Layman, L. Bohl, A. Richards, N. Scandrett, Physical Therapy, Southwest Baptist University, Bolivar, Missouri.
Purpose/Hypothesis: While Constraint Induced Movement Therapy (CIMT) as a treatment for the UE has been successful, the effectiveness of UE CIMT on the LE in regard to gait and mobility is still questionable. Less research has been done looking at the effect of UE CIMT on the LE. The purpose of this systematic review is to determine if the current research supports the use of CIMT to treat LE disorders related to balance and gait and answer the question, “In patients with hemiplegia, is constraint-induced movement therapy superior to traditional physical therapy in improving gait characteristics?”
Number of Subjects: 73 (total across all articles included in the systematic review).
Materials/Methods: A search of Academic Search Premier, CINAHL Plus, and MEDLINE, using the terms “constraint induced movement therapy” AND “gait” AND “balance” was conducted. Exclusion of duplicates, editorials, or commentaries, doctoral theses, articles not published in a scholarly peer-reviewed journal, and nonresearch articles covering CIMT filtered down the results to 4 articles. These articles were graded using a level of quality scale from the AACPDM's Methodology to Develop Systematic Reviews of Treatment Interventions (Revision 1.2).
Results: The studies ranged from 8 to 37 test subjects with hemiplegia resulting from stroke or cerebral palsy. Three of the studies were of moderate methodological quality, all of which were cohort studies without controls. The fourth study was of weak quality; however, it was classified as a smaller randomized controlled trial. All 4 of the studies included in this review are limited because they are without masked assessors and control groups to prevent potential bias. Additionally, each of the studies had a small sample size and lack of long-term follow-up data.
Conclusions: Positive outcomes (improved balance, gait velocity, and gait characteristics) were found in patients who received CIMT. The current evidence is moderate at best. The evidence for the use of CIMT would be strengthened by masking assessors to eliminate bias, comparing it with a control group that receives traditional physical therapy treatment, and larger sample sizes to increase the clinical significance. In addition to pre- and posttreatment data, long-term follow-up data would enhance the results found following CIMT to patients with LE hemiplegia.
Clinical Relevance: Clinicians should be mindful of the limitations of the studies when considering UE CIMT as an intervention for patients with LE hemiplegia. Overall, CIMT has weak evidence indicating that it can improve gait characteristics in patients with hemiplegia but there is no evidence that CIMT is superior to other physical therapy techniques for improving gait. Therefore, if improving a patient's gait is a primary goal, it should be addressed directly and CMIT should not be used at the sole intervention for gait.
The Effects of Dry Needling on Spasticity in the Upper Extremity of Individuals Postcerebral Vascular Insult: A Pilot Study Using Shear Wave Elastography and Joint Position Sense
R.M. Maher, D.M. Hayes, J.P. Welch, Physical Therapy, University of North Georgia, Dahlonega, Georgia.
Purpose/Hypothesis: This purpose of this pilot study was to establish the effects dry needling (DN) has on spasticity in the biceps brachii (BB) in individuals poststroke.
Number of Subjects: Three female subjects (age 39.67 ± 8.3 years).
Materials/Methods: Two participants presented with right-sided hemiparesis and the other with left-sided hemiparesis. All data were collected in supine. Elbow AROM and PROM was assessed followed by assessment of tone using the Tardieu scale. Joint position sense was determined using a kinesthesiometer while participants attempted to reach a target elbow angle with eyes closed. This angle was defined as an angle at 50% of the AROM of elbow extension. Participants were then placed in a standardized position using a brace locked at 90° of elbow flexion with the wrist and hand in neutral. The region of interest (ROI) was identified as a point mid way between the acromion and the olecranon. An ultrasound device with shear wave elastography (US-SWE) was used to acquire images within the ROI. The BB was then palpated for the stiffest area within the ROI which was dry needled (DN) with a solid filament needle to a standard depth of 50 mm. Sweeps or up and down motion of the needle was standardized at 10. US-SWE images were repeated at the following time points followed by a repeat of all baseline measures: immediately post DN, 24 hour post, 3 days post, 1 week to establish the longevity of any effects.
Results: A mean change in BB stiffness demonstrated a descending trend (reduction in stiffness) following DN with a slope of −2.5 that persisted 1 week post. Mean AROM excursion for the BB was variable but demonstrated a positive slope of 0.75. The most profound response post DN was the improvement in joint position sense. Tardieu scores, R1 (catch elicited by fast velocity movement) trended down indicating the catch occurred later in the ROM from flexion toward extension immediately post DN and up to 15 minutes post. A sustained effect continued at 72 hours and 1 week post. All subjects reported feeling more relaxed in the involved upper limb and reported improved function during activities of daily living. Two subjects reported an increased tingling sensation in the hand 15 minutes and 24 hours post DN. One subject had not had any sensation in her hand for several years.
Conclusions: Clinically relevant trends were noted in addition to positive subjective responses from all participants regarding their activities of daily living. Changes in tissue stiffness were evident post DN. Further study is needed on a larger population to determine if DN has an effect on muscle tone in those poststroke or indeed other types of acquired brain injuries.
Clinical Relevance: DN can have a significant impact on muscle tone in healthy individuals with myofascial trigger points. The mechanism of how this occurs is poorly understood; however, it is hypothesized that the neural pathway for the remote effects of DN appears to be a spinal reflex. Consequently, we hypothesized similar effects may occur in spastic muscle.
Exercise Responses to High-Intensity Interval Training (HIT) in Chronic Stroke: Protocol Comparisons
P. Boyne, K. Dunning, D. Carl, Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio. J. Khoury, Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. M. Gerson, Internal Medicine, Cardiology and Radiology, University of Cincinnati, Cincinnati, Ohio. B. Kissela, Neurology, University of Cincinnati, Cincinnati, Ohio.
Purpose/Hypothesis: Accumulating evidence suggests that exercise intensity, rather than frequency or duration, may be the most important factor determining gains in aerobic capacity, cardiovascular protection, and functional recovery after stroke. High-intensity Interval Training (HIT) is a strategy that augments exercise intensity using bursts of concentrated effort alternated with recovery periods. HIT has been associated with improved outcomes for healthy adults and persons with heart disease and stroke. However, there is no stroke-specific evidence to guide HIT protocol selection. The purpose of this study was to compare exercise responses between 3 different HIT protocols for persons with chronic stroke.
Number of Subjects: This study will include at least 18 subjects at the time of presentation.
Materials/Methods: Preliminary analysis includes 5 subjects with median (range) age of 58 (49-64) years, 3.6 (0.5-5.4) years poststroke with a comfortable walking speed of 0.92 (0.44-0.96) m/s. Each subject first underwent maximal-effort graded treadmill exercise testing to determine eligibility and peak oxygen uptake (
O2peak). The 3 HIT sessions were then performed in random order, with a 1-week washout period between sessions. Each session included 5 minutes (min) warm-up, 20 min HIT and 5-min cool-down. HIT involved repeated 30-sec bursts of treadmill walking at maximum tolerated speed, alternated with rest periods. The 3 HIT protocols were different based on length of the rest periods: 30 sec (P30), 1 min (P1) or 2 min (P2). Outcome variables included: treadmill speed (average during bursts);
O2 (total time spent at >40%, 60% and 85%
O2peak); steps (total number). Friedman's ANOVA was used to compare protocols (SPSS, v21), with a level of significance of 0.05.
Results: The different protocols elicited the following exercise responses. Treadmill speed (m/s): P30 1.28 (0.82-1.54); P1 1.30 (0.84-1.61); P2 1.28 (0.79-1.52). Time (min) >40%
O2peak: P30 19.9 (16.9-20.0); P1 18.4 (17.6-19.4); P2 11.9 (5.2-15.6). Time (min) >60%
O2peak: P30 14.7 (4.8-18.9); P1 5.9 (0-18.2); P2 0.3 (0-8.4). Time (min) > 85%
O2peak: P30 2.2 (0-10.7); P1 0 (0-6.9); P2 0 (0-0.5). Total number of steps: P30 1970 (1730-2888); P1 1492 (1380-2525); P2 1240 (1048-2020). Significant differences between protocols were found for time >40%
O2peak (P = 0.015), > 60%
O2peak (P = 0.008) and >85%
O2peak (P = 0.050), and total steps (P = 0.007).
Conclusions: Persons with stroke were able to achieve high relative walking speeds and
O2 while performing over 1000 steps during 30-minute HIT sessions. The length of recovery periods affected
O2 and step counts. Our larger sample at the time of presentation is needed to confirm and expand on these results.
Clinical Relevance: HIT is a promising exercise strategy for improving stroke recovery. This study provides preliminary data to guide HIT protocol selection in this population. This research has been supported in part with a Magistro Family Foundation Research Grant from the Foundation for Physical Therapy and a University of Cincinnati Provost award.
Validation of a Modified Four Square Step Test and Quality Score in Community-Dwelling Elderly
A. Fergus, L. Raskin, B. Mitchell, N. Kephart, Shenandoah University, Winchester, Virginia.
Purpose/Hypothesis: The purposes of the present study were to (1) determine the validity, interrater, and intrarater reliability of a proposed quality score for the modified Four Square Step Test (mFSST) and assess its predictive value for fall risk in community dwelling older adults and (2) examine the validity of the FSST with the use of an AD.
Number of Subjects: A sample of 94 community-dwelling adults over the age of 65 (mean age, 83.46 ± 8.18 years) was recruited from 5 assisted living facilities in Virginia. Seventy-three percent (n = 69) of the subjects were female, 35% (n = 33) had a previous history of at least 1 fall, and 43.6% (n = 41) used an AD for mobility.
Materials/Methods: There were 2 distinct phases of data collection. Phase I: Forty-eight participants filled out a medical questionnaire and the Activities Specific Balance Confidence (ABC) Scale. Participants then performed 3 trials of the Timed Up and Go (TUG) Test, a gross motor screen, a 6-item cognitive screen, and 3 trials of the FSST in random order. If a participant reported daily use of an AD, they were asked to perform 4 trials of each balance assessment: 2 with an AD and 2 without. Phase II: Forty-six participants followed the same procedure outlined in phase I, but participants completed 3 trials of the FSST with the proposed quality tool (qFSST), 2 trials completed with one administrator, and the last trial completed with a different administrator. Each participant followed the same sequence, with no random assignment given.
Results: The modified FSST was found to have strong concurrent validity with the TUG (r = 0.758, P < 0.01). The quality score was also found to have strong concurrent validity with the TUG (r = −0.776, P < 0.01) and had good intrarater (ICC = 0.93) and interrater reliability (ICC = 0.83). Neither the mFSST nor qFSST was able to significantly discriminate between fallers and nonfallers. At a cutoff of 14 seconds, the mFSST had a sensitivity of 69% and a specificity of 42% for 1 or more falls. A qFSST score greater than 8 was the best predictor of falling, with a sensitivity of 68% and specificity of 55% for 1 or more falls.
Conclusions: This study supported the reliability and concurrent validity of the mFSST and qFSST for individuals who do and do not use AD. Additional research is needed to determine the discriminant validity of the mFSST and qFSST and to enhance the predictive ability of these tools.
Clinical Relevance: The mFSST and qFSST are clinically relevant measures that can be used to examine balance and fall risk. Together, these tools provide both quantitative and qualitative information that will guide clinicians in a more comprehensive approach to improving balance and decreasing falls in a wide population of community-dwelling elderly.
Randomized, Placebo-Controlled, Double-Blind Pilot Study of D-Cycloserine in Chronic Stroke
A. Butler, J. Kallos, Physical Therapy, Georgia State University, Atlanta, Georgia. M. LaPlaca, K. Ressler, S.F. Traynelis, S.L. Wolf, Emory University, Atlanta, Georgia.
Purpose/Hypothesis: Stroke is a leading cause of death and disability, affecting approximately 6.4 million Americans. While motor function therapies exist, up to 60% of patients do not fully recover despite intensive treatment. Activation of N-methyl-D-aspartate receptors (NMDA-R) is important for inducing various forms of synaptic plasticity. D-cyloserine (DCS) is an established antibiotic for the chronic treatment of tuberculosis, the application of which can enhance certain models of plasticity, such as long-term potentiation, by promoting the activity of NMDA-R. Robotic-assisted physiotherapy (RAP) is an approach designed to promote the return of movement and function in a paralyzed limb. We hypothesize that DCS, when combined with RAP would result in greater gains compared with placebo+RAP.
Number of Subjects: 14.
Materials/Methods: Patients were administered either DCS or placebo before 2 hours of RAP, 2 of 3 treatment days per week for 3 weeks. Functional, cognitive, and health-related quality of life (HRQL) measures were used to assess recovery. Variables were compared by repeated-measures ANOVA, followed by post hoc ANCOVA. Average HRQL scores were examined using a 2×2 odds ratio (OR) comparing the number of categories exhibiting average clinically relevant improvements between the 2 groups.
Results: Across all subjects, UE function (grip strength of the affected hand), cognition (reaction time, DETECT score), and HRQL measures (SIS mood) improved. From baseline to 3 weeks, the DCS group showed a significant pre-/postdifference (10.0 ± 12.6), whereas the control group did not have a significant difference (13.3 ± 23.2) (P = 0.013, η22 P = 0.573). Analysis revealed large (ηp ≥ 0.190) effect sizes for grip strength of the affected hand, 4/8 SIS and stroke recovery domains, and the daily robotic measures. While lacking a sufficient sample size to have sensitivity to reject the null, a strong association between treatment group and the number of SIS categories that improved ≥10 points was observed, considering the OR effect size estimate (OR: 10.0, 95% CI: 0.452-221.080, P = 0.145) with a strong degree of association between the 2 (φ2 = 0.471, P = 0.036). No significant association was found between treatment group and the number of SIS categories that improved (OR: 0.10, 95% CI: 0.452-221.080, P = 0.145), although there was a strong degree of association between the 2 (φ2 = 0.222, P = 0.036).
Conclusions: The main study hypothesis was that DCS+RAP was superior to control for increasing upper limb motor function. This was only supported for SIS hand use domain. The large effect size estimates for the SIS domains suggest that DCS clinically enhanced stroke recovery, which a sufficiently powered study may have elucidated. The extent to which improvements associated with DCS in our study were a result of DCS, the RAP or a combination of the 2 remains unclear and requires further study.
Clinical Relevance: Combined physical rehabilitative therapy, e.g., RAP, with an agent that enhances neuroplasticity, e.g., DCS, could potentially improve UE function in patients following stroke.
Decreased Muscle Volume in the Upper Extremity After Chronic Stroke Affects the Ability to Perform Horizontal and Overhead Reaches
B. Binder-Markey, L. Garmirian, W. Murray, J. Dewald, Biomedical Engineering, Physical Therapy & Human Movement Science, Northwestern University, Chicago, Illinois.
Purpose/Hypothesis: Impairment of the paretic arm after a stroke is related to a loss of descending corticofugal pathways that cause secondary changes in muscle. A recent, pilot, MRI study has demonstrated that muscles in the paretic arm in chronic stroke decrease in volume by as much as 45%. It is unknown how this atrophy affects functional use of the arm following stroke. We hypothesize that decreased muscle volume, and the concomitant decrease in force-generating ability, limits the ability to complete overhead and horizontal reaching tasks.
Number of Subjects: N/A.
Materials/Methods: A dynamic biomechanical model of the upper extremity, modified from a model developed by Saul et al., was used to simulate horizontal and overhead reaches. The simulations included 5 DOF at the shoulder, elbow, and wrist, 7 elbow muscles, and 5 wrist muscles. We used an optimal control algorithm (computed muscle control) to solve for the muscle excitation levels needed to track elbow and wrist extension during horizontal and overhead reaching tasks. The maximum force-generating ability of each muscle was reduced in the model by 35% (elbow) and 45% (wrist) to reflect changes in muscle volume seen in stroke subjects; the required excitations were then recalculated. The area under the excitation curve of each muscle was computed; results were compared for simulations with unimpaired and decreased strength. The excitations optimized for the unimpaired model were also used to run forward simulations with the weakened model and the resulting movements were compared.
Results: When muscle excitations were optimized for the weakened limb, excitation magnitudes were substantially larger than in the unimpaired simulations. In horizontal reach, excitations of the triceps brachii increased from an average of 0.39 to 0.57; wrist extensor excitations increased from 0.27 to 0.34. In overhead reach, the areas under the excitation curves of the lateral and medial triceps increased from 0.64 to 0.78. When the control signals optimized for the unimpaired limb were used as inputs to the weakened limb, both horizontal and overhead reaches took longer to complete, neither of the reaches could achieve sustained wrist extension, and the time to extend the elbow was prolonged in overhead reach compared to the same simulation with unimpaired strength.
Conclusions: Our simulation results demonstrate that muscle atrophy in chronic stroke has the potential to contribute to impairments in the paretic arm. Simulations where muscle excitations were optimized for the weakened limb suggest that even if the descending control to the arm adapts to the atrophy, a significant metabolic cost will be introduced. Without such adaptation, muscle atrophy yields a slower reaching task and the inability to maintain wrist extension.
Clinical Relevance: Developing and implementing physical interventions that reduce muscle atrophy, starting in the acute stage poststroke, are postulated to further augment the positive effects of recently developed synergy reducing robotic interventions (Ellis et al, 2009).
The Reliability of the Numeric Dizziness Scale
T.A. Rice, C. Mancinelli, R.R. Utzman, Physical Therapy, West Virginia University, Morgantown, West Virginia. S. Wetmore, Otolaryngology, West Virginia University, Morgantown, West Virginia.
Purpose/Hypothesis: The purpose of this study was to determine the reliability of the 0 to 10 Numeric Dizziness Scale (NDS) in individuals with dizziness.
Number of Subjects: Twenty-six participants (15 female, 11 male), age 30 to 87 (M = 62.54, SD = 14.89) years participated in the study.
Materials/Methods: All participants had referrals from an otolaryngologist and experienced dizziness more than once per week. Upon arrival to the clinic, each participant completed questionnaires consisting of the Dizziness Handicap Inventory (DHI), the Activities-Specific Balance Confidence scale (ABC), and the Numeric Dizziness Scale (trial 1). Four additional diversionary questionnaires were included. Thirty minutes later the second trial of the Numeric Dizziness Scale was completed. The Numeric Dizziness Scale consists of 3 separate 0 to 10 Likert scales assessing current dizziness, as well as best and worst dizziness in the past 24 hours. Statistical analysis was performed for the average Numeric Dizziness Scale scores (current, best, and worst in the past 24 hours). Reliability was analyzed using responses for the Numeric Dizziness Scale trial 1 and trial 2.
Results: Tests of normality revealed normally distributed data for both trial one of the Numeric Dizziness Scale [S-W(26) = 0.947, P > .05] and for trial 2 of the Numeric Dizziness Scale [S-W(26) = 0.934, P > 0.05]; therefore, a Pearson correlation coefficient was utilized to determine the relationship between the 2 trials of the Numeric Dizziness Scale. There was a strong positive correlation between the 2 trials [r(24) = 0.79, P < 0.01] indicating good test-retest reliability.
Conclusions: The Numeric Dizziness Scale is a reliable tool for the assessment of dizziness. Further research is indicated to validate the Numeric Dizziness Scale.
Clinical Relevance: The quantification of dizziness with a quick easy-to-use Likert scale has the potential to enhance physical therapy examination and intervention. The findings of the present study support the use of such a scale to serve as a reliable, efficient assessment of dizziness intensity.
The Effect of Tactile Feedback (Novel Treatment) on Body Sway in the Elderly Compared to Age-Matched Diabetic Subjects
F. Alshammari, J. Petrofsky, N. Daher, E. Alzoghbieh, S. Dehom, M. Laymon, Loma Linda University, Loma Linda, California.
Purpose/Hypothesis: Balance is the steadiness of human body and ability to maintain posture against static or dynamic stressors. With aging, body balance deteriorates due to aging process itself and high incidence of diseases. Balance is even worse in elderly with diabetes because of the effect of diabetes on peripheral and central nervous system. Tactile feedback may improve body balance by increasing stability since it improves sensory feedback to the brain. The purpose of this study was to examine the effects of tactile feedback on sway in elderly (75.5 ± 8.2 years) compared to age-matched participants with diabetes diabetics (70.5 ± 1.0 years).
Number of Subjects: 8.
Materials/Methods: Eight subjects 65-90 years old were recruited, 4 elderly and 4 elderly diabetics. A balance platform was used to measure average body sway pre- and postintervention. Four conditions were used to test body sway: (1) standing on the platform with eyes open; (2) standing on the platform with eyes closed; (3) standing on the foam with eyes open; and (4) standing on the foam with eyes closed. Intervention consisted of 2 sessions: (A) standing on platform for 4 minutes while holding still and (B) standing on foam for 2 minutes while holding still. An electrical stimulation provided tingling sensation on the lower leg if the sway exceeds 50% of subject's average body sway.
Results: Body sway decreased in all conditions following intervention except in the first condition in elderly group. The body sway slightly increased in the first condition postintervention when compared to preintervention (0.9 ± 0.5 vs 0.8 ± 0.1) in elderly group, but decreased in diabetic group (0.8 ± 0.4 vs 0.9 ± 0.4). Sway decreased in old group in the second condition post intervention when compared to preintervention (1.6 ± 0.9 vs 2.3 ± 0.9). Sway decreased in diabetic group in the second condition postintervention in comparison to preintervention (0.9 ± 0.2 vs 1.2 ± 0.9). Sway decreased in old group in the third condition postintervention in comparison to preintervention (1.1 ± 0.2 vs 2.2 ± 0.3). Sway decreased in diabetic group in the third condition postintervention in comparison to preintervention (1.5 ± 0.4 vs 1.9 ± 0.7). Sway decreased in old group in the 4th condition postintervention in comparison to preintervention (1.9 ± 0.6 vs 3.9 ± 1.1). Sway decreased in diabetics in the fourth condition postintervention in comparison to preintervention (1.9 ± 0.6 vs 2.5 ± 0.7). Old group showed more reduction in body sway when compared to diabetics in all conditions except the first condition. Sway reduction was significantly more in elderly group in fourth condition when compared to diabetic group (2.0 ± 0.9 vs 0.6 ± 0.9; P = 0.04).
Conclusions: Body sway reduced more in elderly group than diabetic group following intervention except while standing on platform with eyes open.
Clinical Relevance: This novel treatment might be used in PT clinics and facilities to improve balance and body stability in elderly population.
Canine Assisted Therapy: Use of a Novel Modality in TBI Rehabilitation
C. Tassini, MossRehab, Elkins Park, Pennsylvania.
Purpose: Patients who have sustained a traumatic brain injury (TBI) present with a variety of impairments including cognitive deficits such as impaired attention, memory, and awareness as well as motor deficits such as impaired initiation and motor planning which can impact an individual's mobility and independence. One of the challenges in TBI rehabilitation is to actively engage patients in tasks or activities that address these impairments. Canine assisted therapy (CAT) is one way in which patient engagement and participation may be enhanced in this population. Canine assisted therapy is the use of a specially trained dog as a modality to achieve a therapeutic goal. CAT may improve patient participation and motivation due to the natural interaction between human and animal, a familiar activity, or simply an externally driven response that is greater than can be generated by a therapist alone. This poster will present 2 case examples of the clinical application of CAT to achieve therapeutic goals in an inpatient rehabilitation setting.
Description: The clinical application of utilizing CAT in the TBI population will be presented using 2 case examples: Case 1 is a 21-year-old man who sustained a TBI and was limited in therapy by his ability to attend to and persist with tasks. His attention to task was initially under 10 seconds. Within a session, the patient's attention improved from 5 to 10 seconds completing traditional therapeutic tasks to 15 minutes when presented with the dog as part of his therapy, with tasks such as petting, grooming, walking, and fetch. Case 2 is an 18-year-old man who sustained a TBI as a result of a GSW to the head. He presented with impaired body position awareness and with pusher behavior. The patient was unable to maintain static sitting due to pushing with his unaffected upper extremity toward his hemiplegic side. Traditional methods of facilitating weight bearing through the unaffected limb were unsuccessful. When the dog was placed on his unaffected side, the patient used the unaffected limb to pet the dog or place the hand in an abducted position over the dog, thus avoiding any pushing behavior and allowing him to maintain sitting balance in an upright position without any physical assistance.
Summary of Use: Canine assisted therapy is a novel modality that can be used to treat a variety of deficits associated with TBI. This poster demonstrates only 2 of several ways in which CAT may augment conventional physical therapy and result in improved patient participation and performance. While the exact mechanism by which CAT works is not known we hypothesize that using a dog replicates familiar activities, increases patient drive, and utilizes the natural responses of people interacting with animals.
Importance to Members: Use of CAT can be considered as an adjunct modality for patients rehabilitating from TBI. Highly trained animals can provide a novel aspect of patient care that cannot be generated by human clinicians alone.
The Effect of Visual Feedback on Sway in Elderly Compared to Age-Matched Diabetic Subjects
F. Alshammari, J. Petrofsky, N. Daher, E. Alzoghbieh, S. Dehom, M. Laymon, Loma Linda University, Loma Linda, California.
Purpose/Hypothesis: Balance is the ability of the body to maintain posture during static or dynamic stressors. Sway from the center of gravity results in less body stability. Body sway increases in the elderly due to the aging process and diseases. Body sway is worse in the diabetic elderly because of peripheral and central nervous system impairments due to diabetes. The purpose of this study was to examine the effects of visual feedback on sway in the elderly (74.7 ± 10.6 years) compared to age-matched diabetics (74.33 ± 4.13 years). Visual feedback might improve body balance by increasing stability, since vision may partially replace proprioceptive and vestibular input during a training session.
Number of Subjects: 12.
Materials/Methods: Twelve subjects 65 to 90 years old were recruited, 6 elderly, and 6 elderly diabetics. The conditions used to test the body sway were (1) standing on the platform with eyes open; (2) standing on the platform with eyes closed; (3) standing on the foam with eyes open; and (4) standing on the foam with eyes closed. Intervention consisted of 2 sessions: (A) standing on platform for 4 minutes while holding still and (B) standing on foam for 2 minutes while holding still. The subject was asked to hold the center of gravity as constant as possible on a balance platform.
Results: Sway in diabetic elderly group while standing on foam with eyes open postintervention was significantly less when compared to preintervention (1.4 ± 0.5 vs 2.6 ± 1.2, P = 0.028). In the same group, sway while standing on foam with eyes closed postintervention was significantly less than sway in the same situation preintervention (2.3 ± 0.8 vs 4.2 ± 2.7, P = 0.046). There was a significant difference in sway reduction between the diabetic group and the elderly group (1.2 ± 0.8 vs 0.3 ± 0.4, P = 0.037) while standing on foam with eyes open. The reduction of sway in the diabetic group while standing on foam with eyes open was 3.5 times more than that in elderly group in the same situation. On the other hand, the reduction in sway in the diabetic group while standing on foam with eyes closed was 2 times more than the reduction of sway in elderly group.
Conclusions: The elderly group had less reduction in body sway on foam in comparison to the age-matched diabetic group.
Clinical Relevance: This treatment might be used in PT facilities to improve balance and body stability in old diabetic population.
Use of a Body-Weight–Supported Treadmill in Conjunction With Progressive Over Ground Gait Training to Improve Gait Velocity and Endurance in a Patient With Charcot-Marie-Tooth Disease
B. Fernandez, S. George, Department of Physical Therapy, University of Florida, Gainesville, Florida. T.D. Faw, NeuroRestorative at Avalon Park, Orlando, Florida.
Background and Purpose: Charcot-Marie-Tooth (CMT) disease is the most common inherited neuromuscular disorder, affecting 10 to 30 people per 100 000 globally. Individuals with CMT demonstrate a distal to proximal pattern of sensory loss and muscular weakness, foot abnormalities, and abnormal gait patterns. The altered gait cycle results in higher energy cost leading to decreased walking tolerance, reduced cardiovascular fitness, and decreased functional mobility. Current rehabilitation models for CMT focus on strength training to increase function rather than improving walking efficiency, gait velocity, and endurance. At the same time, most studies involving gait training with a body-weight support treadmill (BWST) focus on providing sensory input consistent with normal walking to improve motor control and gait kinematics. Due to the pathophysiology and nature of CMT, individuals do not typically experience recovery of motor control and strength; therefore, a BWST system may be used as a permissive environment for increased exercise tolerance rather than a means for increased motor control and facilitation of a more normal gait pattern. This case report describes a 6-week program of gait training using a BWST and progressive overground gait training in conjunction with standard physical therapy to improve gait speed, endurance, and functional mobility in a patient with CMT.
Case Description: The patient is a 51-year-old female who was referred to physical therapy with a diagnosis of CMT as well as 2 alternate diagnoses, including a T12-L1 schwannoma measuring 3.3 cm and a 14 mm right posterior parafalcine meningioma. Her long-term goals were to increase ambulation speed, endurance, and functional mobility in the community. The patient was seen 2 to 3 times a week for 3 weeks for conventional physical therapy followed by a 6-week program, which included 6 sessions of gait training using a body-weight support treadmill and progressive overground ambulation. The patient also ambulated at home on a standard treadmill twice per week at reduced speeds and using hand rails as needed to supplement the 6-week clinical BWST program.
Outcomes: Following the BWST and overground gait training program, the patient demonstrated a meaningful change in gait speed on her “fast speed” 10-meter walk test from 1.16 m/s to 1.44 m/s (MCID = 0.25 m/s), 55.03-m improvement during the 6-minute walk test (MDC = 50 m), and improvements on SF-36 physical functioning, bodily pain, and global health scores over the course of the treatment. There were no clinically significant changes noted in the patient's Dynamic Gait Index or Timed Up and Go scores.
Discussion: This case demonstrates a unique model for improving cardiovascular endurance and walking speed in patients with CMT. It also outlines an atypical utilization of the BWST as a permissive environment for increased activity tolerance rather than as a means to facilitate normal gait kinematics for improved motor control.
Dose-Response Time Course of Changes in Poststroke Gait Performance Within a Gait Retraining Session
T. Kesar, M.J. Sauer, Rehabilitation Medicine, Emory University, Atlanta, Georgia. D. Reisman, S. Binder-Macleod, Physical Therapy, University of Delaware, Newark, Delaware. J.L. Kurkowski, Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia. C.A. Silverman, C.L. Spade, Biology, Emory University, Atlanta, Georgia.
Purpose/Hypothesis: Recent rehabilitation research has focused on developing new gait retraining treatments and testing the comparative efficacy of gait rehabilitation interventions. However, the effects of treatment dose (duration of training) on the effectiveness of gait rehabilitation have not been systematically investigated. The purpose of this study is to elucidate the dose-response time courses within 1 session of poststroke gait retraining. We used a novel intervention combining fast treadmill training and intermittent functional electrical stimulation of ankle dorsi- and plantar-flexors (FastFES), and a gait outcome targeted during training (paretic push-off integral or POI) to evaluate dose-response. Our objective was to determine how paretic POI evolves with increasing durations of walking practice as a single training session proceeds.
Number of Subjects: Ten stroke survivors (age 67 ± 6 years, time poststroke 29 ± 28 months, lower extremity Fugl-Meyer score 12-31) were recruited for this study.
Materials/Methods: Study participants completed a session of FastFES gait training comprising five 6-minute bouts of treadmill walking with rest breaks between bouts (total 30 minutes of walking). Paretic push-off forces during terminal stance were measured throughout the session using force plates embedded within treadmill belts. Data from the first minute of each of the 5 training bouts (no electrical stimulation) were used to characterize the dose-response time course of changes in paretic POI during training. For each subject, we determined the bout when the first improvement in paretic POI beyond the baseline value was observed (threshold dose) and the bout when the maximum paretic POI was achieved.
Results: Data for 7 participants have been analyzed to date. Five participants showed an increase in propulsion throughout training (mean increase of 0.14 ± 0.25% bodyweight-seconds). For these 5 participants, the threshold dose was determined at bouts 2 or 3, the peak POI occurred at or after bout 3, and was maintained or continued to improve during the remainder of the session. For the remaining 2 participants, the paretic POI did not increase during the training session.
Conclusions: Our preliminary analysis of dose-response time courses within a single gait training session suggest that the FastFES gait training may elicit improvements in paretic POI after 6 to 12 minutes of training have been completed, and these improvements may continue to occur throughout the 30 minutes of training.
Clinical Relevance: This study is a first step toward exploring dose-response relationships underlying poststroke gait rehabilitation. An understanding of the minutes of gait training needed to elicit and maintain an improvement in the targeted gait parameter during each training session is critical for the development of evidence-based gait rehabilitation dosing regimens. Future studies will investigate how many sessions of training must the optimal within-session dose be maintained to produce clinically meaningful improvements in walking function.
Vertigo, Nausea, and Headache After Mild Blast-Induced Traumatic Brain Injury: A Case Report of Rehabilitation With Persistent Complicating Symptoms
J. Gordon, Fairbanks Physical Therapy, Fairbanks, Alaska. G.F. Marchetti, Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania.
Background and Purpose: Mild TBI (mTBI) has become a prominent injury associated with the wars in Iraq and Afghanistan. The leading cause of mTBI during those conflicts has been exposure to explosive blasts. The purpose of this case report is to describe physical therapy management of a 37-year-old male active-duty service member who suffered a mild, blast-induced traumatic brain injury in combat, with chronic, severe vertigo, nausea, and headache.
Case Description: Four types of interventions were attempted over 2 separate episodes of care. The first episode began 3 months after injury and consisted of oculomotor coordination training for vertigo, conditioning exercise for activity intolerance, and habituation exercises for motion sensitivity. Habituation exercises continued independently after 8 months postinjury. Episode 2 began 14 months after injury and consisted of manual therapy and proprioceptive exercise for cervicogenic headache and vertigo.
Outcomes: The Dizziness Handicap Inventory (DHI) score was 58% at 3 months postinjury, 70% at 14 months, and 42% at 19 months. Headache Disability Index (HDI) and Headache Impact Test (HIT) scores were 86% and 50% respectively at 14 months postinjury, and 88% and 54% respectively at 19 months. The Motion Sensitivity Quotient (MSQ) score was 74% at 6 months after injury, and 53% at 19 months.
Discussion: This case demonstrates an example of one patient with blast-induced traumatic brain injury whose vertigo, nausea, and headache were severe and difficult to treat effectively with a range of rehabilitation-based and medical interventions, and who made very little measurable functional improvement over a period of time during which most victims of brain injury would show greatest improvement. The literature shows that even within the category of mTBI, outcomes can vary greatly and some patients' symptoms can be extremely difficult to manage. Documentation of the rehabilitation course in which nausea and vertigo remained severe and intractable long after mTBI is not common and can be a differential diagnostic and interventional challenge to clinicians. Given the variability of mTBI presentation, the presence of severe and potentially debilitating symptoms as barriers to successful rehabilitation should be further investigated to raise clinical awareness.
Motor Imagery of Rhythmic Ankle Dorsiflexion in Individuals Poststroke
P. Nair, J. Gayed, N. Hauck, L. Tripodi, L. Watts, Physical Therapy, Seton Hall University, South Orange, New Jersey. J. Shemmel, School of Physical Education, University of Otago, Dunedin, New Zealand. J. Stinear, Department of Sport and Exercise Science, University of Auckland, Auckland, New Zealand.
Purpose/Hypothesis: Neuroimaging studies have demonstrated that motor imagery and actual movements share at least in part common neural substrates. Motor imagery could, therefore, be a useful tool for promoting beneficial cortical plasticity poststroke. Previous studies of upper extremity motor imagery have demonstrated temporal modulation of cortical excitability similar to the performance of the actual task in the contralateral primary motor cortex. However, it is unclear if lower extremity motor imagery produces a temporal pattern of activation resembling that observed in actual task performance. The present study examined if motor imagery of rhythmic ankle dorsiflexion can produce dynamic changes in the excitability of motor cortex in individuals poststroke.
Number of Subjects: Nine participants (5 male, 4 female), in the age range of 50 to 87 with chronic, poststroke unilateral impairment (4 right, 5 left), were selected.
Materials/Methods: Time Dependent Motor Imagery (TDMI) and The Kinesthetic and Visual Imagery Questionnaire (KVIQ) were administered to assess motor imagery ability. Participants were instructed to either perform or imagine repetitive ankle dorsiflexion movements at 1 Hz, which were coupled to an auditory cue. Electromyographs were recorded from the tibialis anterior (TA) of the impaired limb. A low-frequency transcranial magnetic stimulation (TMS) coil was applied over the central fissure and magnetic stimulation was delivered at 200, 400, 600, 800, and 1000 ms after the auditory cue at an intensity that was 110% of resting threshold for the TA muscles. The correlation between the amplitude of the imagined motor evoked potentials (MEPs) across the time points was compared to the amplitude of the actual task for the impaired limb for each individual.
Results: All 9 subjects were able to engage in motor imagery as reported during TDMI testing. However, some subjects had difficulty in generating vivid internal representations of analyzed movements as observed on the KVIQ scores. Application of TMS and evaluation of the MEP amplitudes revealed that imagined dorsiflexion induced time-dependent changes in corticospinal excitability which mirrored those observed during active dorsiflexion in 4 out of the 9 subjects. For these 4 individuals, the Pearson correlation coefficient between the MEP amplitude of the actual and the imagined task across time points ranged from moderate (r = 0.61) to high (r = 0.94).
Conclusions: The data support the idea that motor imagery of the paretic lower limb can have dynamic effects on the excitability of motor cortex similar to that observed during actual task performance. Screening measures such as the TDMI and KVIQ scores did not correlate with the changes observed in corticospinal excitability in response to imagined dorsiflexion. Their utility in screening individuals fit for motor imagery needs to be studied further.
Clinical Relevance: Motor imagery may be a useful tool for promoting beneficial cortical plasticity poststroke.
Comparison of Aerobic Exercise Prescription Methods in Chronic Stroke
S. Buhr, P. Boyne, D. Carl, B. Rockwell, B. Barney, K. Dunning, Rehabilitation Sciences, University of Cincinnati, Cincinnati, Ohio. M. Gerson, Internal Medicine, Cardiology and Radiology, University of Cincinnati, Cincinnati, Ohio. J. Khoury, Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio. B. Kissela, Neurology, University of Cincinnati, Cincinnati, Ohio.
Purpose/Hypothesis: Treadmill aerobic exercise is known to improve walking ability, aerobic capacity, and cardiovascular health after stroke. Target heart rate (HR) is a key parameter of aerobic exercise prescription. Several methods have been proposed for determining initial target HR for persons with stroke, including HR at the ventilatory threshold (HRvt), 40% HR reserve and 50% maximal HR, based on either a maximal-effort exercise test (HRpeak) or age-predicted maximal HR (AP-HRmax). Differences between these methods have not been previously investigated. Therefore, the purpose of this study was to compare the target HRs obtained using different methods of exercise prescription for persons with stroke. Since motor impairments often limit HR peak in this group, we hypothesized that there would be significant differences between prescription methods.
Number of Subjects: This cross-sectional cohort study will include a minimum of 18 subjects with chronic stroke at the time of presentation. Six subjects are included in this preliminary analysis.
Materials/Methods: Ambulatory persons with chronic stroke and residual gait impairment were recruited. Subjects had a median (range) age of 58 (49-66) years, 3.9 (0.5-6.3) years poststroke and a median comfortable walking speed of 0.75 (0.23-0.96) m/s. Each subject performed a single, maximal effort, graded treadmill exercise test, including gas exchange analysis. Target HRs obtained with the different methods were compared using Friedman's ANOVA and pairwise comparisons were made with Wilcoxon signed rank tests. SPSS, v21, was used for analysis. The level of significance was set at 0.05.
Results: Median HRpeak (143 bpm) was significantly lower than AP-HRmax (157 bpm) (P = 0.046). The different exercise prescription methods presented the following target HR medians (ranges) in bpm: 50% HRpeak, 72 (56-78); 50% AP-HRmax, 78 (54-84); 40% HRreserve, 94 (73-106); 40% AP-HRreserve, 99 (72-110); HRvt, 107 (83-116). The overall model identified significant differences between target HRs (P < 0.001). Post hoc tests were significant comparing 50% HRpeak to 40% AP-HRR (P = 0.019) and HRvt (P = 0.001) and comparing 50% AP-HRmax to HRvt (P = 0.01).
Conclusions: The results suggest discrepancies among common prescription methods for poststroke aerobic exercise. Therefore, it appears that exercise prescriptions cannot be used interchangeably and comparisons among programs should be done with caution. Further studies are needed to determine the optimal exercise prescription method for persons with stroke.
Clinical Relevance: Accurate target HR prescription allows clinicians to optimize intensity for aerobic work, potentially creating improved outcomes and decreasing exercise risks. By investigating differences between currently recommended prescription methods, this study provides the first step toward standardizing poststroke aerobic exercise intensity. This research has been supported in part with a Magistro Family Foundation Research Grant from the Foundation for Physical Therapy and a University of Cincinnati Provost award.
Effects of Shoulder Abduction/Adduction Torque on Hand Opening and Closing in Chronic Hemiparetic Stroke
J. Dewald, Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois. L.C. Miller, Biomedical Engineering, Northwestern University, Chicago, Illinois.
Purpose/Hypothesis: Paretic arm movement in hemiparetic stroke survivors is often constrained to 2 abnormal muscle coactivation patterns, described as the flexion synergy (FS; shoulder abduction (SABD) coupled with elbow [EF], wrist [WF], and finger flexion [FF]) and the extension synergy (ES); shoulder adduction (SADD) coupled with elbow extension (EE) and possibly wrist extension and FF). Based on experimental joint torque and EMG results, the FS and ES become more pronounced with increased SABD or SADD torque, postulated to be caused by recruitment of corticobulbospinal pathways due to increased descending drive required to complete the task. The ES has been less frequently addressed experimentally than the FS, and it has not been quantified at the hand. Therefore, one goal of the study was to do so by quantifying the involuntary behavior of paretic wrist/fingers during various levels of SADD torque generation. We hypothesized that increases in SADD torque would produce less WF/FF torque compared to those produced with SABD torques. Another goal of the study was to examine to what extent stroke survivors are constrained to the FS and ES at the hand by quantifying the effect of SABD/SADD torque on the ability to open and close the paretic hand. We hypothesized that hand opening would be greater during SADD and that hand closing would be greater during SABD.
Number of Subjects: Both arms of 5 participants with chronic hemiparetic stroke and moderate to severe motor impairment were tested.
Materials/Methods: Seated with the arm casted to a 6-DOF load cell and wrist/finger torque sensor, participants performed each of 3 isometric SABD and SADD torques at 17, 33, and 50% maximum voluntary torque while completing each of 3 conditions at the hand (no task, hand open, hand close).
Results: In the no-task condition, increases in SABD and SADD torque in the paretic limb resulted in increasing involuntary EF and EE torque, respectively. However, at the wrist and fingers, there was no effect of shoulder torque direction, with both SABD and SADD producing comparable involuntary WF and FF torque. During the hand open condition, at all SABD/SADD levels participants were constrained to the involuntary WF and FF torque and were able to lessen it only slightly. During the hand close condition, participants produced the same amount of WF/FF torque at each SABD/SADD torque level.
Conclusions: SABD and SADD have differential effects on involuntary elbow torque. In contrast, SABD and SADD result in involuntary wrist torques in the same direction. All involuntary torques generated increase as a function of SABD or SADD torque. Results suggest that bulbospinal pathways can couple the shoulder and elbow by exciting groups of flexors or extensors, but at the hand they have strong connections to primarily flexors.
Clinical Relevance: Results support the theory of increased influence of bulbospinal motor pathways following stroke and suggest that activation of the proximal upper limb must be considered when seeking to understand, rehabilitate, or develop devices to assist the paretic hand.
Effectiveness of Peroneal Neural Prosthesis Versus Standard Orthotic Management for Patients With Chronic Stroke
A. Golda, Rehabilitation and Movement Sciences, University of Medicine and Dentistry of New Jersey, Newark, New Jersey. K. D'Amico, W. Delfing, C. Mancuso, F. Naqvi, A. Pirak, K. Shieh, K. Ulasevich, G.G. Fluet, Rehabilitation and Movement Sciences, Rutgers University, Newark, New Jersey.
Purpose/Hypothesis: The purpose of this study was to investigate the newest literature from a 2006 meta-analysis to present to determine if a recent advance in functional electrical stimulation (FES) technology, peroneal neural prothesis (PNP), significantly improves the gait of patients with foot drop poststroke.
Number of Subjects: Six peer-reviewed articles were used to investigate the literature.
Materials/Methods: Our search included 2 databases, CINAHL and PubMed. The key words used were “chronic stroke,” “foot drop,” “neuroprosthesis,” and “functional electrical stimulation.” Articles were included if the subject pool included patients with chronic hemiparesis with foot drop (>6 months), community-dwelling adults, articles published since 2006, and if gait outcomes were measured with either gait speed or 6-minute walk test. Studies that met the inclusion criteria were analyzed based on an established minimal clinically importance difference and functional classification of gait speed.
Results: Six articles matched our criteria: 3 randomized control trials and 3 cohort studies. Four out of the 5 studies that measured gait speed as an outcome met the minimal clinically important difference. Three out of the 5 studies showed an increase in gait speed large enough to move up a functional category. Additional outcome measures that were found to have significant improvements were obstacle course navigation, carpet walking, and gait asymmetry.
Conclusions: PNP yields greater improvement in gait outcomes when compared to AFO or standard physical therapy treatment. The gains in gait speed after the use of PNP for foot drop have been shown in the literature to be both functionally significant by improving to community-dwelling gait speeds and clinically significant by meeting the established minimal clinically important difference.
Clinical Relevance: PNP devices, such as the Bioness L300, are a viable option for patients who experience lingering foot drop in the chronic phase of stoke that is hindering functional mobility. PTs should be aware of this technology as a way to augment gains in gait speed and functional mobility in patients with chronic stroke.
Impact of Anxiety and Depression on Outcome in Patients With Unilateral Vestibular Hypofunction: Preliminary Results
L. Heusel-Gillig, Emory Healthcare, Atlanta, Georgia. C. Brawner, C. Dillon, A.C. Jones, S. Herdman, Emory University, Atlanta, Georgia.
Purpose/Hypothesis: Although vestibular exercises are known to reduce symptoms in patients with unilateral vestibular hypofunction (UVH), up to 25% do not improve. We hypothesized that patients with uncontrolled anxiety and/or depression (A/D) will demonstrate poorer outcomes than patients with no or with controlled A/D. The purpose of this preliminary study was to identify the relationship between the presence of A/D and rehabilitation outcome in patients with UVH.
Number of Subjects: Twenty patients who met the inclusion criteria of a documented peripheral UVH and multiple sessions of vestibular rehabilitation were identified and included in the final analyses.
Materials/Methods: The presence of A/D was based on past medical history and diagnosis by a neurologist. Outcome measures included balance confidence, disability score, percent time symptoms interfere with activities, Vestibular Rehabilitation Benefits Questionnaire, intensity of oscillopsia, dysequilibrium, and head movement-induced dizziness and psychometric tools (Positive Affect, Negative Affect Scale [PANAS], Beck Anxiety Inventory [BAI], and Hospital Anxiety and Depression Scale [HADS]). Measures were obtained at initial visit and at discharge. Bivariate correlations were used to determine the strength of the relationship between psychometric measures at initial visit. Relative strengths of correlations were defined as 0.25 to 0.50 = fair to moderate, 0.50 to 0.75 = moderate to good, and 0.75 to 1.00 = strong relationships. Differences in outcomes between patients with A/D and those without were determined using Student t tests; level of significance was set at P < 0.006 to control for the large number of variables examined.
Results: Patients without A/D had a greater asymmetry (92.5 + 19.8%) than did patients with A/D (54.1 + 31.2%) (P < 0.006). There were no differences between groups in age, time from onset, or the number of PT treatments. Concurrent validity of the PANAS scale was demonstrated by fair to good correlations between initial scores of PANAS(A) and HADS(A) (r = 0.777), VRBQ(A) (r = 0.434), and BAI (r = 0.658); moderate to good correlation was found between PANAS (D) and HADS(D) (r = −0.581). Patients with A/D demonstrated a trend of poorer outcomes on 9/9 subjective outcome measures compared to patients without A/D.
Conclusions: The results of this preliminary study suggest that the presence of A/D has a negative effect on outcome in terms of subjective complaints. Degree of deficit was probably not a factor because the patients without A/D had the greater degree of deficit. The results of the correlation analyses suggest that PANAS is adequate to measure both A/D within this population.
Clinical Relevance: These results provide evidence that the presence of A/D may negatively affect intensity of subjective complaints at discharge in patients with UVH. If this finding is upheld in a larger population, clinicians should assess baseline anxiety and depression levels for optimal rehabilitation outcomes.
The Effect of Aerobic Exercise Training on Hyperglycemia-Related Peripheral Neuropathy: A Systematic Review and Meta-analysis
F. Ferlin, A. McCarthy, B. Smoot, J. Lee, D.D. Allen, UCSF/SFSU, San Francisco, California.
Purpose/Hypothesis: Diabetes mellitus (DM) affects 26 million people in the United States and is increasing in prevalence. Diabetic peripheral neuropathy (DPN) affects at least half of those with DM and results in more than 60% of all nontraumatic amputations. Decreases in peripheral nerve function associated with DPN lead to impaired conduction between and within the motor and sensory systems, which may lead to impairments in strength, postural stability, balance, and gait, and decreases in quality of life. Additionally, impaired glucose tolerance (IGT), a common prediabetic state, affects 79 million people and is also associated with peripheral neuropathy. Unfortunately, pharmacological approaches for DPN have resulted in no to moderate improvement in clinical trials and lack the ability to reverse DPN. However, regular aerobic exercise has the potential to stabilize or possibly reverse DPN since it helps regulate blood glucose levels, decrease hyperlipidemia, improve circulation, reduce oxidative stress, increase neurotrophic factors, and promote nerve regeneration. The purpose of this meta-analysis is to investigate the effect of regular aerobic exercise on nerve health in adults with DM or IGT.
Number of Subjects: Five studies were included in this meta-analysis, with a total of 113 participants with hyperglycemia (DM or IGT), who may or may not have developed peripheral neuropathy.
Materials/Methods: A search of the literature was conducted using MEDLINE, Cochrane Collaboration, and CINAHL. Studies were selected if researchers used objective diagnostics, such as nerve conduction velocity (NCV) and intra-epidermal nerve fiber density (IENFD), to assess peripheral neuronal function and structure before and after an intervention that included regular aerobic exercise. Pooled within-group effect sizes with 95% confidence intervals were calculated for NCV and IENFD. No between-group analyses could be performed.
Results: One hundred fifty articles were located and reviewed. Five of these met eligibility criteria and all of these reported a correlation between aerobic exercise and improved nerve health. Data from these primary articles were pooled to calculate single group grand effect size. NCV improved significantly with a grand effect size of 0.43 (0.12, 0.74). A grand effect size of 0.24 (−0.16, 0.64) for IENFD demonstrated improvement that was not statistically significant. No minimal clinically important difference values were found for NCV or IENFD. Exercise protocols across primary articles varied in the type of aerobic exercise used with an intensity range of 40% to 85% maximum heart rate, an average of 150 minutes per week at least 2 times per week.
Conclusions: Further investigation is needed, but limited evidence indicates that regular, aerobic exercise may be effective in preventing, delaying, or mitigating the effects of DPN on NCV and IENFD.
Clinical Relevance: Physical therapists should consider incorporating regular aerobic exercise into their treatment plans for patients with hyperglycemia.
The Use of Optokinetic YouTube Videos as a Treatment Option for the Dizzy Patient
C.D. DiSanto, Rehabilitation and sports therapy, Cleveland Clinic, Cleveland, Ohio.
Background and Purpose: Reported dizziness and balance impairments can cause severe functional disability in a person's life. The use of optokinetic stimulation has shown promise in diminishing dizziness when combined with other vestibular rehabilitation exercises. As the use of the Internet and computer technology becomes a part of our daily lives, the use of online videos may have a part in an individual's home exercise program. This case study demonstrates the improvement noted by one patient in which optokinetic video via YouTube was utilized.
Case Description: A 32-year-old female presented with a diagnosis of Meniere's disease. She reported vertigo and blackouts for approximately 2 years. Her Dizziness Handicap Index (DHI) score was 70/100 and rated as severe disability. She was unable to stand on a piece of foam with her eyes closed greater than 2 seconds without complete loss of balance and she reported falling at home at least once a week. This patient participated in vestibular therapy consisting of balance and VOR exercises as well as the addition of an optokinetic YouTube video, which she watched for 2 minutes 3 times a day.
Outcomes: After 7 visits and compliance to her daily home exercise program, the patient demonstrated an improvement of her DHI score to 31/100, an ABC score of 78%, zero reported falls since her initial visit 5 weeks ago and minimal sway when she closed her eyes on a foam pad for 40 seconds.
Discussion: This patient easily incorporated the use of a YouTube video into her home exercise program with reported improvement in her dizziness and falls. Online videos, as demonstrated by this case, can be affordable and convenient treatment options for the dizzy patient, but more work needs to be done to better identify the specific use of these videos.
Effect of Upper Extremity Support During Gait Training on Overground Gait and Balance Following Chronic Stroke
C. Husted, UNC Hospitals, Chapel Hill, North Carolina. M.D. Lewek, Division of Physical Therapy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
Purpose/Hypothesis: The use of handrails and assistive devices (AD) during gait training limits arm swing and shifts limb support to the upper extremity (UE). This shift in limb support may reduce lower extremity (LE) effort during gait and minimize LE responses to perturbations. Thus, there is concern that UE support will minimize gains in gait speed and balance following training. The purpose of this study was to determine the effect of UE support on overground gait speed and balance following gait training for individuals with chronic stroke. We hypothesized that those who relied on UE support during training would demonstrate smaller improvements in gait speed and balance measures than those who could train without UE support.
Number of Subjects: 19 subjects with chronic (>6 month) stroke (13M/6F, 61 ± 12 years old, 51 ± 36 months poststroke).
Materials/Methods: Subjects were enrolled in an ongoing RCT to evaluate the role of movement errors during training on spatiotemporal symmetry. All subjects completed 18 sessions of treadmill and overground walking with a safety harness and UE support on a handrail/AD, as needed. Subjects were considered not to require UE support (n = 9) if they walked on the treadmill without UE support for more than 75% of training time (20 minutes) and performed overground training without an AD during the majority of sessions. Prior to and 1 week following training, overground gait [comfortable (CGS) and fast gait speed (FGS)] and balance measures [Berg Balance Scale (BBS), Four Square Step Test (4STT), Functional Gait Assessment (FGA)] were performed. Repeated-measures ANOVAs (α = 0.05) compared pre- and posttraining data between subjects who used and did not use UE support. Paired t tests were used as post hoc tests.
Results: The UE support group displayed slower gait speeds and lower balance scores at baseline than the non-UE support group. There was no interaction effect (group × time) for any gait or balance measures (P > 0.088). Those who used UE support demonstrated significant improvement in all gait and balance measures (all P < 0.033), including a 0.08 ± 0.07 m/s increase in CGS and a 4 ± 4 point gain in the BBS. Those who did not use UE support demonstrated significant improvements in both CGS (P = 0.002) and FGS (P = 0.004), including a 0.12 ± 0.08 m/s increase in CGS. They demonstrated significant improvement in the FGA (P = 0.021) but no change in the BBS (P = 0.081) or 4STT (P = 0.384).
Conclusions: Subjects who required UE support during training ambulated slower and had more impaired balance compared to those who trained without UE support. Comparable improvements in gait speed and balance can be made following gait training among subjects who require UE support and those who are able to train without UE support. The use of UE support during training does not appear to impair the ability to improve gait and balance.
Clinical Relevance: Following chronic stroke, those who are able to perform gait training without UE support show no greater improvements in gait and balance than more impaired individuals who require use of UE support.
Relaxation Techniques as an Adjuvant to Decrease Hemiballism in a Patient Poststroke
G.D. Willard, P.M. Spigel, J. Osborne, Brooks Rehabilitation, Jacksonville, Florida. E.J. Fox, University of Florida, Gainesville, Florida.
Background and Purpose: Hemiballism is a rare hyperkinetic movement disorder that can occur following stroke and results in severe functional impairments. Rehabilitation interventions often are minimally effective if the involuntary, excessive movements cannot be controlled. Relaxation techniques have been reported to temporarily decrease symptoms of hemiballism. The combined use of relaxation techniques with physical therapy interventions may be a successful strategy to decrease involuntary movements and improve function, but this approach has not been examined. Therefore, the purpose of this case report is to describe the combined use of relaxation techniques with task-specific physical therapy interventions to promote functional recovery in a patient poststroke with hemiballism.
Case Description: A 33-year-old female participated in an outpatient rehabilitation day treatment program, 3 months after a multifocal stroke following cocaine use. Diagnostic imaging revealed infarcts in the left temporal lobe and bilateral cerebellar hemispheres and vermis. The patient received 8 weeks of physical therapy treatment, for 2 to 4 one-hour sessions per week. Relaxation techniques (deep breathing exercises, classical music) were integrated simultaneously into a physical therapy program to decrease hemiballism and allow for implementation of task-specific practice, including transfer training, gait training, and bed mobility. A novel ordinal scale (0-3), the Hemiballism Severity Scale (HSS), was created to quantify the severity of hemiballism, (from no involuntary movement (0) to severe hemiballism (3)) and to monitor change in response to interventions.
Outcomes: At rest, the patient's hemiballism was present and classified as severe (3) throughout the right lower extremity on the HSS. Immediately upon implementation of relaxation techniques, the amplitude and force of contractions markedly decreased, gradually ceasing completely (HSS = 0). Symptoms returned fully when the patient was not utilizing these techniques. Overall functional progress was made within the 8-week intervention period, progressing from ambulation with the assistance of 3 people to ambulation with assistance from one person upon completion of the program.
Discussion: Relaxation techniques were effective and allowed the patient to decrease or ameliorate the hemiballism, but no long-term changes were observed. The patient, however, used the relaxation techniques as a strategy to temporarily increase her ability to perform functional activities. Identifying interventions that have lasting effects on hemiballism is critical so that rehabilitation approaches may effectively retrain functional movements. Use of biofeedback may be one strategy for increasing the durable effects of relaxation techniques when combined with rehabilitation.
Influence of the Foot-Up Ankle Brace on Gait Parameters and Stair Climbing in People With Foot Drop
S.G. Siegel, C. Butterfield, K. Ireland, A. Marceau, R. Worcester, Husson University, Bangor, Maine.
Purpose/Hypothesis: Foot drop is seen in people with a variety of neurological conditions, and is commonly treated with the prescription of an ankle-foot-orthosis (AFO). An alternative to a traditional AFO is an off-the-shelf brace by Ossur, the Foot-Up. This brace provides dorsiflexion assist via an elastic strap connecting the shoe to an ankle cuff, and can be worn with a variety of shoes. While the Foot-Up is used clinically, there is currently no evidence to support its effectiveness. Therefore, the purpose of this study was to evaluate the influence of the Foot-Up on several gait parameters in people with foot drop.
Number of Subjects: 8.
Materials/Methods: Participants included adults who wore AFOs for foot drop and could ambulate independently. Participation was not limited by diagnosis, in order to increase the generalizability of the findings. A brief questionnaire was administered, after which strength, range of motion, and balance were assessed for descriptive purposes only. Participants then performed three 30-foot walking trials, each with a different bracing condition. Bracing conditions included no brace (NB), usual AFO (AFO), and the Ossur Foot-Up (OFU). Reflective markers were placed on the foot and knee to allow for kinematic analysis, focusing on foot-to-floor angle at the point of initial contact. All walking trials were video-recorded for this analysis. Other gait-related outcome measures included velocity, cadence, and step length. Additionally, single leg stance time was tested for each condition. Finally, if participants were accustomed to climbing stairs, they were timed while ascending and descending 9 stairs with the same 3 bracing conditions. Statistical analysis was performed comparing AFO to OFU, and comparing OFU to NB, using paired t-tests with a Bonferroni correction. This statistic was chosen due to the small sample size.
Results: Results revealed significantly greater foot-to-floor angles at initial contact with the AFO compared to the OFU (P = 0.023) and with the OFU compared to NB (P = 0.001). Step length was greatest with the AFO, but was greater with the OFU than with NB (P = 0.02). Gait velocity was fastest with the AFO, followed by the OFU, and then NB. Velocity differences approached statistical significance. No significant differences were found among the conditions for single leg stance or stair climbing times.
Conclusions: Our findings support the superiority of the customized AFO for the measured gait parameters, but also demonstrate that the OFU is clearly advantageous compared to wearing no brace. Surprisingly, none of the 3 conditions was associated with superior stair climbing or single leg stance times.
Clinical Relevance: While the OFU may not correct gait to the extent that an AFO does, it improves gait significantly compared to wearing no brace at all. It provides an alternative for people who prefer wearing a variety of shoe types and heel heights. It is simple to don and doff and is less visible than an AFO, thus it may promote to greater adherence, thereby improving patient safety, activity, and participation.
The Type of Secondary Task Matters in Dual Task Walking During the Timed Up and Go
T.L. McIsaac, S.Q. Glover, F. Porciuncula, Biobehavioral Sciences, Teachers College, Columbia University, New York, New York.
Purpose/Hypothesis: Walking while simultaneously performing a cognitive or manual task typically alters gait, particularly in people with Parkinson's disease (PD). Difficulties in turning are also associated with the disease and can be related to falls. However, the relationship of the attention requirements of different types of secondary tasks and walking with turns and transitions to and from sitting is unclear. Therefore, we examined the effects of the type of secondary task on performance costs to dual-task walking and turning.
Number of Subjects: Fourteen participants with PD (Hoehn and Yahr stages 1-3, mean age 60.4 ± 8.0 years) and 8 healthy controls (mean age 59.0 ± 8.1 years).
Materials/Methods: Movements were assessed using wearable inertial sensors during the instrumented Timed Up and Go (TUG) under 6 conditions; single-task and in 5 dual task conditions: (1) carrying water, (2) serial-3 subtractions, (3) combined water and subtraction tasks, (4) dialing a cell phone, and (5) buttoning a coat. The cost to performance from dual tasking was compared across conditions and groups for the sit-to-stand, 7-meter walk, turn, walk back, and turn-to-sit components of the TUG, using mixed design ANOVAs on each component (total duration, stride length, sit-to-stand peak velocity, turn duration, and turn-to-sit peak velocity).
Results: All participants sustained performance costs from dual tasking in all gait measures to different degrees according to the type of secondary task (P < 0.005), with the least cost in the serial-3 subtraction condition, and the greatest costs during walking while carrying water and subtracting. Compared to controls, participants with PD sustained greater dual task costs to stride length in all conditions and in turning to sit while dialing the phone (P < 0.05).
Conclusions: We conclude that the type of secondary task performed exacts different costs on the walking and turning components of the TUG.
Clinical Relevance: Our results indicate that for individuals with PD, everyday activities such as carrying a cup or dialing a phone while walking may pose particular risks to balance, especially when turning and maneuvering to sit. Training in functional dual task activities may be particularly important during walking and specifically during transitions from walking to sitting.
A Bioinspired Self-powered Walking System to Facilitate Walking for People With Severe Disabilities
B. Glaister, J. Schoen, C. Kawahara, A. Pacanowsky, Cadence Biomedical, Seattle, Washington. M. Zachar, Gary Berke Prosthetics, Redwood City, California. N. Byl, University of California at San Francisco, San Francisco, California.
Background and Purpose: Weakness in the hip flexor muscles is the leading cause of impairment for stroke survivors and people with other neurological conditions. Medical professionals are largely limited to ankle-foot-orthoses and functional electrical stimulation systems to assist weak ankle dorsiflexors, but these devices can do nothing to assist patients in lifting their legs off of the ground to swing through for the next step. Affordable devices that assist hip flexion in home and community environments are needed. In this paper, we present the design and early clinical results of the Kickstart Walking System, a bioinspired self-powered walking system that assists hip flexion. Kickstart utilizes a long spring that stretches from the hip to the ankle to store energy in the beginning of a step and then return that energy to facilitate hip flexion to initiate swing phase.
Case Description: We present 2 cases: One of a man with an incomplete spinal cord injury (SCI) and one recovering from a cerebrovascular accident (CVA) who both used Kickstart as part of their normal clinical care. Clinical outcomes were measured over a 5-month period and included the 6-minute walk test, 10-meter walk test, and timed up and go test.
Outcomes: With the Kickstart Walking System, the SCI subject was able to make substantial gains in both walking speed and endurance. His walking speed improved at its maximum to 0.4 m/s, a substantial increase from the 0.2 m/s he was able to achieve without the device and above threshold considered for limited community ambulation. Endurance improved even more dramatically, with 6-minute walk distances improving from 25 m to 125 m, a 5-fold increase. The CVA subject also demonstrated significant improvements in all metrics. His walking speed improved from 0.5 m/s to 0.92 m/s, which is fast enough to be classified as an independent community ambulator, as this speed is fast enough to cross the street before a stop light changes. His endurance also improved dramatically (123 m in the 6-minute walk to 224 m). And his TUG improved as well, reducing to 14.6 seconds from a pre-Kickstart maximum of 24 seconds. This is clinically significant as his TUG times with Kickstart are within the range considered minimally at risk for falling.
Discussion: In this paper we present the Kickstart Walking System as a practical bioinspired alternative to powered exoskeletons and a more functional option than ankle-foot-orthoses or functional electrical stimulation systems for patients with hip flexion weakness. We also demonstrated its rehabilitative potential with 2 clinical cases. In both cases, walking speed and endurance improved dramatically to a community level and, in the one case in which it was measured, risk of falling was considerably reduced.
Long-term Effects of Ventriculoperitoneal Shunt on Gait Performance in Elderly Individuals With Normal Pressure Hydrocephalus: Preliminary Results
S. Kim, J. Stephenson, Physical Therapy & Rehabilitation Sciences, University of South Florida, Tampa, Florida. N. Abel, S. Agazzi, Neurosurgery, University of South Florida, Tampa, Florida.
Purpose/Hypothesis: Gait disturbance is a major concern in elderly people with normal pressure hydrocephalus (NPH). Ventriculoperitoneal (VPS) surgery is known to be an effective intervention to improve gait performance. However, the long-term effects of the surgical procedure on gait have not been clearly understood. The purpose of this study was to identify if gait improvements after VPS surgery can be maintained over 2 years in elderly individuals with NPH.
Number of Subjects: Two male (68- and 94-year-old) and one female (85-year-old) older adults with NPH participated in this study.
Materials/Methods: Subjects had VPS surgery based on clinical assessments including magnetic resonance imaging, neuropsychological tests, and objective gait assessment. Gait performance was assessed during comfortable walking at baseline (prior to surgery) and at 3 follow-up tests (1 month, 1 year, and 2 years after surgery) using a GAITRite Walkway System. Changes in gait velocity, step length, double limb support time (% of gait cycle), and step length symmetry (difference in step length between right and left legs) were calculated across the 4 test sessions. There was no statistical analysis due to the limited number of subjects.
Results: All 3 subjects demonstrated clear improvement in gait velocity (21%-41% increase) after VPS surgery compared to baseline. The improvements continued at 1-year follow-up test (53%-68% increase) and were retained at 2-year follow-up test (46%-55% increase). Step length increased 18%-35% following VPS surgery. The amount of increase was even greater at 1-year (35-42%) and 2-year follow-up tests (38%-41%). Double limb support time decreased 6% to 25% after VPS surgery. Further decreases were observed at 1-year (17%-35% decrease) and 2-year follow-up tests (14%-39% decrease). Step length symmetry improved from 16% to 28% difference at baseline to 5% to 17% difference at 1-month follow-up test. Step length symmetry further improved at 1-year (3%-8% difference) and 2-year follow-up tests (1%-7% difference).
Conclusions: Preliminary results of this study indicate that gait improvements (ie, increase in gait velocity, increase in step length, and decrease in double limb support time) following VPS surgery in elderly people with NPH were retained over a 2-year period. The gait symmetry also improved over 2 years, which has not been shown in the literature.
Clinical Relevance: Elderly individuals with NPH benefit from VPS surgery and the effects are retained over 2 years.
Atypical Autonomic Dysreflexia During Robotic Assisted Body Weight-Supported Treadmill Training in an Individual With Motor Incomplete Spinal Cord Injury
P. Geigle, S. Frye, W. Scott, J. Perreault, P. Gorman, University Maryland, Baltimore, Maryland.
Background and Purpose: For individuals with spinal cord injury at T6 or above, autonomic dysreflexia occurs frequently including both blood pressure greater than 20 to 30 mmHg with relative bradycardia. This case report details the potential relationship between robotic assisted body weight-supported treadmill training (BWSTT) and autonomic dysreflexia in an individual with C6 ASIA C chronic SCI.
Case Description: J.W., a 41-year-old man with a chronic history of C6 AIS C Spinal Cord Injury, enrolled in a robotic assisted BWSTT and aquatic exercise research protocol, presented with atypical autonomic dysreflexia during BWSTT. This randomized clinical trial, approved by 2 institutional review boards, evaluates the cardiovascular and mobility effects of 3 months of robotic assisted BWSTT exercise versus aquatic-based exercise in people with chronic C4- T12 motor incomplete spinal cord injury.
Outcomes: After successfully completing 36 sessions of aquatic exercise, J.W. presented with atypical AD during his tenth BWSTT session. J.W.'s initial 9 Lokomat sessions were significant only for minor knee pain, resolving spontaneously, and discomfort from the harness, resolving with repositioning. On the tenth session, preexercise blood pressure was 104/52. After 20 minutes, J.W. complained of volitional fatigue, with blood pressure at 220/80 and rose to 260/110 on a repeat measure. Upon removal from the BWSTT device, his blood pressure quickly fell to 98/50. No skin changes were noted at possible friction points and support straps were not obstructing urine flow from his external collection system. The subsequent 3 sessions followed a similar course. Seated blood pressures in the harness before and after suspension were normal prior to robotic activation and without volitional movement. J.W.'s participation in the research study was terminated due to concern about these repeated episodes of elevation in blood pressure during robotic assisted BWSTT.
Discussion: Clinician increased awareness of potential atypical AD during robotic assisted BWSTT for individuals with chronic motor incomplete SCI is required as clinical signs are not always present with occurrence. Frequent vital sign assessment prior to, during, and at completion of each body weight supported treadmill session is strongly recommended. Both aerobic exercise and AD may be new occurrences for individuals with motor incomplete SCI; therefore, difficult for the individual with SCI as well as the practitioner to identify the source of symptoms. A larger clinical concern is the cost-benefit analysis of exercise on cardiovascular health and the potential AD, which may occur during robotic assisted BWSTT for individuals with SCI at or above T6. The stimuli of J.W.'s BP fluctuations are unknown, but atypical AD is potentially detrimental to health, and should be monitored as part of best practice. This work was supported by the DOD Clinical Trial Award SC090147.
Predicting Peak Oxygen Consumption in Individuals With Chronic Incomplete Spinal Cord Injury
P. Geigle, W. Scott, J. Perreault, P. Gorman, University Maryland Rehabilitation Institute, University of Maryland, Baltimore, Maryland. L. Vanhiel, K. Tansey, B. Smith, Research Center, The Shepherd Center, Atlanta, Georgia. K. Chen, Complementary Medicine, University of Maryland, Baltimore, Maryland.
Purpose/Hypothesis: Based on our screening data for an exercise randomized controlled trial (RCT) with individuals with chronic incomplete motor spinal cord injury, we observed an apparent relationship among several variables and peak oxygen consumption. As we began to enter our screening data we asked: Can aerobic capacity be predicted by using easily obtained clinical screening parameters for individuals with chronic incomplete spinal cord injury?
Number of Subjects: 29; 21 males, 8 females.
Materials/Methods: This multisite, RCT was approved by 3 internal review boards. Using SPSS version 21, a multiple regression analysis was performed to determine from our screening variables what formula best predicted peak aerobic capacity (
O2) using an arm cycle Ergometer. These available screening variables included body mass index (BMI), Physical Activity Scale for Individuals with Physical Disability (PASIPD), Insulin/Glucose, Time since injury, Injury level, Age, Gender, Ethnicity, AIS lower extremity motor scale (LEMS), step activity monitor (SAM). From our clinical experience, we postulated the following screening variables would best predict peak
O2: PASIPD, BMI, injury level, age, LEMS.
Results: The best-fit regression equation to predict arm cycle ergometer
O2 included PASIPD, BMI, and LEMS (F = 12.505; P = 0.001), accounting for a robust 78% of the variance. Our a priori thoughts including PASIPD, BMI, injury level, age, LEMS were partially correct as PASIPD, BMI, and LEMS were the main predictors of peak
O2 in our 29 individuals with chronic motor incomplete SCI.
Conclusions: PASIPD, BMI, and LEMS best predict arm cycle ergometer peak
O2 in our small sample size. Our clinical background requires we consider that with a larger sample size injury level, time since injury and age may indeed positively impact this peak
O2 prediction equation. We plan to continue collecting screening data on all RCT participants. The PASIPD is a 13-question multistep self report survey requiring moderate attention to detail to complete. After using this standardized activity scale, we originally questioned the PADIPD's ability to accurately predict activity levels. However, it appears for individuals with chronic motor incomplete SCI who demonstrate the ability to direct moderate cognitive attention, this scale with each individual's BMI and LEMS does indeed provide an accurate peak
Clinical Relevance: Using the available study screening factors, we determined what study variables best predicted baseline peak
O2, a measure of cardiovascular fitness, for adults with motor incomplete spinal cord injury. Research and clinical settings without access to peak
O2 computerized metabolic analysis may be able to use the PASIPD as a predictor of aerobic fitness to prescribe safe, individual activity and exercise levels for individuals with chronic motor incomplete SCI. Funding from the Department of Defense Congressionally Directed Medical Research Program Spinal Cord Injury. Research Program Clinical Trial: Award: FY2009-SC090147.
Somatosensory Stimulation in Combination With Locomotor Training in Spastic Upper Extremity After SCI
H.T. Schriver, S. Lebens-Fetherolf, NeuroRecovery Network, The Ohio State University Wexner Medical Center, Columbus, Ohio. D. Basso, School of Health and Rehabilitation Sciences, The Ohio State University, Columbus, Ohio.
Background and Purpose: Restoration of hand function is a primary rehabilitation goal after cervical spinal cord injury (SCI). Locomotor training (LT) has been used as an intervention to improve locomotor function, and bystander improvement in upper extremity strength has been reported (Buehner 2012). Somatosensory stimulation is an emergent intervention to improve hand function after incomplete cervical injury. However, reported doses are too extensive to implement clinically. The aim of this study was to apply somatosensory stimulation to the treadmill portion of LT and during massed practice after getting off the treadmill to improve upper extremity function after a cervical SCI.
Case Description: A 60-year-old female with chronic right hand dysfunction following C1 SCI participated in 8 weeks of intervention. Stimulation to her median nerve and UE training occurred 4 days per week. On 2 days, somatosensory stimulation was combined with LT for 45 minutes then followed with stimulation and massed practice for 40 minutes of gross UE movement, grip and rotation. The other 2 days had somatosensory stimulation + massed practice for 60 minutes of grip, pinch, and pinch with rotation. Subject rotated between 5 different tasks in each category of movement that were randomly selected out of 10 tasks per category.
Outcomes: Sensory measures as well as motor outcomes were collected. Semmes Weinstein Monofilament test and the Basic Kinesthesia tests were used to determine sensory change. Subject was initially within normal limits for her Kinesthesia, but showed improvement throughout the training. Tactile sensation improved from 90% of upper extremity nerves being impaired to only 33% with impairment by the end of an 8-week treatment program. Upper extremity hand function tests included 9 hole peg test, Neurolomuscular Recovery Scale (NRS), Jebson-Taylor Hand function Test, and hand grip dynamometry, fingertip pinch, 3 point pinch, and lateral pinch. Improvement included a 39-second decrease on the 9 hole peg test, up to 75% improvement in one of the subcategories of the Jebson-Taylor, up to 200% increase in strength, and up to a 2 point increase in a subcategory of the NRS. Movement quality improved with less compensation evident. Subject reported using her arm more by the end of the intervention.
Discussion: Compared to early studies, improved hand function and sensation can be achieved with shorter massed practice training when somatosensory stimulation is applied while a person is receiving locomotor training. Follow-up is needed to see if changes remain after intervention is taken away.
Motor Adaptation in “Broken Escalator Phenomenon”
J. Tajino, A. Ito, M. Nagai, X. Zhang, S. Yamaguchi, H. Iijima, H. Kuroki, Motor Function Analysis, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Kyoto, Japan.
Purpose/Hypothesis: The “broken escalator pheno-menon” represents an aftereffect of a gait adaptation. The existence of the motor aftereffect has been demonstrated using many paradigms. Among them, because aftereffect emerges despite of full knowledge of the context change, broken escalator phenomenon has been recognized as the consequence of the pure motor adaptation whereas other paradigms may involve sensory habituation. However, it is still unclear whether small size of error and repeated exposure to the perturbation affect the adaptation in this paradigm, while upper limb studies have denoted greater adaptation by those interventions. The objective of this study was to investigate the effect of error size and the repetitive exposure to the perturbation in the broken escalator paradigm.
Number of Subjects: 48.
Materials/Methods: 48 healthy volunteers participated. After the base line, a participant stepped onto the treadmill moving at 1.2 m/s from behind (Moving period). Following the 5 consecutive trials, the experimenter stopped the treadmill and gave a clear warning that the belt was stable from then on. The participant then stepped onto the treadmill that was not moving for another 5 times (Stable period). Those 10 consecutive trials composed one block of adaptation and deadaptation. Participants experienced 6 blocks. Trunk sways in the sagittal plane were measured at the beginning of each Moving and Stable period. The difference in trunk sway between the base line and those in the beginning of the Moving period was defined as the initial sway (IS). Also, the difference between the base line and the beginning of the Stable period was defined as the after effect (AE). The belt speed for the Moving period was set to either 1.2 m/s (Fast group) or 0.6 m/s (Slow group). 8 participants in the Fast group came back 1 week later and experienced the same task (Day 2).
Results: Participants in both groups showed significant AE (P < 0.05). Both IS and AE declined as the block number increased in both groups, implying that subjects learned to switch between moving and stable belt conditions. Between Fast and Slow group, IS of block 1 in Slow group was significantly smaller (P < 0.05) than those of Fast group. In contrast, significant difference was not find in AE (P > 0.05) of block 1, which suggests adaptation emerged even the initial perturbation is small. On Day 2 in the Fast group, IS of block 1 was significantly smaller than those of the Day 1, which implies the participants have saved the adaptation for 1 week.
Conclusions: Aftereffect in gait occurred despite of the knowledge of the context change, implies that locomotor adaptation could be more impervious to conscious control than other paradigms of motor adaptation. Further, adaptation occurred even when the perturbation is small, evoking only small initial error and the adaptation retained at least 1 week.
Clinical Relevance: The result of this study that conscious correction of motion is not mandatory for intervention to locomotion provides new evidence for the extent of perturbation in gait rehabilitation.
What Is the Relationship Between Perceived Fatigue and Walking in Persons With Multiple Sclerosis?
E.T. Cohen, M. David, M. Liberty, M. Mitchell, D. Pagano, G. Wixted, Rehabilitation and Movement Sciences, Doctor of Physical Therapy Program–Stratford, Rutgers, the State University of New Jersey–School of Health Related Professions, Stratford, New Jersey.
Purpose/Hypothesis: Fatigue is one of the most common and disabling symptoms experienced by persons with multiple sclerosis (PWMS). This perceived fatigue is difficult to measure because of its subjective nature and its multifactorial origins. There is much anecdotal evidence that higher levels of perceived fatigue in PWMS correlate with poorer walking and gait. The purpose of this systematic review was to describe the relationship between perceived fatigue and walking ability in PWMS, and to make relevant recommendations based on the results.
Number of Subjects: N/A.
Materials/Methods: A search of CINAHL and Ovid/MEDLINE databases was conducted in September of 2012 using the following key words: fatigue, gait and/or walking, and multiple sclerosis. Given the paucity of evidence, inclusion criteria were broad; articles included in this review were experimental, quasi-experimental, or correlational studies of a sample of PWMS that included outcome measures for fatigue and walking. Eight research studies met the inclusion criteria.
Results: Each article was examined for threats to internal validity by 2 group members using MacDermid's Evaluation of Effectiveness of Study Design (MEESD). The MEESD has a range of 0 to 48, with 48 meaning the highest quality. The average score of the 2 group members was recorded for each article. The mean MEESD score was 31.0 (range, 23.5-37.0). The systematic review was complicated by the inconsistency of outcomes used to measure fatigue and walking/gait in the 8 studies.
Conclusions: Despite anecdotal evidence to the contrary, the result from this systematic review does not support a relationship between perceived fatigue and physical performance measures of walking in PWMS. The evidence does, however, support a relationship between fatigue and biomechanical (eg, joint torque forces and angular motion) and temporospatial (eg, stride length and cadence) measures of gait. There is also evidence for a relationship between fatigue and health-related quality of life.
Clinical Relevance: Physical therapy clinicians should be cautious when considering the effects of fatigue on walking in PWMS. Despite anecdotal evidence to the contrary, the evidence from this systematic review does not indicate that a relationship exists between perceived fatigue and functional measures of walking. The evidence does indicate that a reduction in fatigue may correlate in improvements in body function-level walking outcomes, but not with activity-level walking outcomes. There are 2 possible explanations for this. The first is that there is not, in fact, a relationship between fatigue and walking ability in PWMS. The second is that the tools used to measure fatigue and walking ability in these studies were not sufficiently sensitive. Given the opinions of many expert clinicians and PWMS that perceived fatigue and walking are related, additional research is necessary to conclusively validate or refute this relationship.
The Relationship Between the RBANS© and a Dual Task Paradigm in People With Parkinson's Disease
C. Swank, A. Medley, M. Thompson, E. Trudelle-Jackson, Texas Woman's University, Dallas, Texas. M. Barisa, Baylor Institute for Rehabilitation, Dallas, Texas.
Purpose/Hypothesis: Walking is postulated to require executive function to negotiate the environment. Executive function is comprised of several attributes. Five attributes are measured by the subscales of the RBANS©: immediate memory, visuospatial/constructional, language, attention, and delayed memory. Dual task paradigms are often utilized to assess performance during ambulation. The purpose of this study was to evaluate the relationship between RBANS© and its subscales and a dual task paradigm in people with Parkinson's disease (PD) with executive dysfunction.
Number of Subjects: 20.
Materials/Methods: Twenty individuals with PD completed 2 methods of evaluating executive function: RBANS© and Timed Up and Go (TUG) dual tasks (manual and cognitive). Interitem correlation was determined by Pearson's correlation coefficient for RBANS© total scaled score, subscale categories, and TUG dual tasks. The predictability of TUG dual task performance from RBANS© presentation was determined by linear regression analysis.
Results: The mean RBANS© total scaled score was 88.85 (24th %ile) and the mean TUG manual and TUG cognitive times were 15.08 ± 13.81 seconds and 16.63 ± 13.72 seconds, respectively (>8.5 seconds = risk of falls). The RBANS© total scaled score was poorly related to both the TUG manual (r = −0.165) and TUG cognitive (r = −0.217). Subscales for immediate memory, visuospatial construction, language, and delayed memory were also weakly related to the TUG manual (r = −0.036 to −0.360) and TUG cognitive (r = −0.048 to −0.396). Though poor, the stoutest relationship for TUG manual and TUG cognitive was the Attention subscale at r = −0.413 and r = −0.502, respectively. While no RBANS© subscales were predictive of TUG manual performance, only the Attention subscale was predictive of TUG cognitive performance (R2 = 0.252; F(1,18) = 6.057).
Conclusions: Both the RBANS© and the dual task TUG conditions reflect deficits in executive function. However, the RBANS© and dual task TUG conditions are poorly related with each other in our sample of people with Parkinson's disease. The Attention subscale predicted only 25% of our sample's ability to dual task during walking in people with PD.
Clinical Relevance: The RBANS© and dual task paradigm may provide valuable information regarding executive function; however, they apparently measure different qualities. The clinician may find it useful to measure executive function using various methods.
The Effect of Manual Therapy and Upper Extremity Task Practice on Shoulder Range of Motion, Upper Extremity Function, and Quality of Life in a Person With Hemiparesis Poststroke
B. Gouillon, J. Freund, Elon University, Elon, North Carolina.
Purpose/Hypothesis: This case report illustrates the effects of manual therapy (shoulder and thoracic spine) and upper extremity task practice on shoulder passive range of motion (PROM), upper extremity function, and quality of life in a person with chronic stroke. While there is substantial evidence for the use of manual therapy in healthy subjects with limited shoulder PROM, there is minimal research on its use in individuals poststroke.
Number of subjects: 1.
Materials/Methods: The patient was a 77-year-old female with left hemiparesis due to a cerebral vascular accident 10 months prior. Her medical history included congestive heart failure, hypertension, and left mastectomy. Following her stroke, she received physical and occupational therapy in a skilled nursing facility, at home, and at an outpatient clinic. She walked using a single point cane. As a volunteer participant in a university physical therapy course, she attended 10 of 10 sixty-minute sessions in 5 weeks, including 2 evaluation and 8 intervention sessions. Her goal was to improve her left upper extremity function. She had limited functional use of her left upper extremity, active finger flexion and extension but poor fine motor control, mild elbow flexor spasticity, and decreased left shoulder PROM. She reported no pain. Interventions included grade III and IV joint mobilizations applied to the shoulder and the thoracic spine, muscle energy techniques, and left upper extremity task training performed in standing. She was also encouraged to increase the use of her left upper extremity in daily tasks.
Results: The following measures improved (pre- to postintervention): shoulder PROM flexion (80-92 degrees), abduction (46-57 degrees); left grip strength (10.66-13.33 kg); Box and Blocks Test (12-15 blocks); Stroke Impact Scale (78.8%-90%) including increases in the subscales of strength (65%-95%), activities of daily living (80%-92%), mobility (93.3%-100%), and upper extremity function (60%-88%). There was no change in Mini BESTest score. She reported increased use of her left arm in her daily life and rated her left arm function as +4 (a great deal better) on an 11-point Global Rating of Change scale at postintervention.
Conclusions: Manual therapy and upper extremity task practice may be effective interventions to increase shoulder PROM, upper extremity function, and quality of life in persons with limited shoulder PROM poststroke. Improvement of shoulder PROM exceeded the minimal detectable change (MDC). Stroke Impact Scale improvements exceeded the minimal clinically important difference for strength, activities of daily living, mobility, and upper extremity function subscales. Improvements in the Box and Blocks Test and grip strength did not exceed MDC values.
Clinical Relevance: This case report provides support for the integration of musculoskeletal examination and manual therapy interventions in persons with stroke.
Novel, High-Tech Walking Recovery Program Improves Motor Recovery
A.H. Chan, J. Vaught, M.W. Banta, M.R. Wilks, A.M. Devers, Sheltering Arms Hospital, Mechanicsville, Virginia. P.E. Pidcoe, A. Sima, Virginia Commonwealth University, Richmond, Virginia.
Purpose/Hypothesis: Although there are a number of research studies investigating walking recovery after stroke, most focus on one intervention or piece of equipment in order to achieve a controlled experimental environment. Such studies have yet to produce a comprehensive clinical practice guideline (CPG) for gait training. To fill this void, we implemented a clinical program for walking recovery, iWalk™, using a variety of advanced technologies, and an evidence-based CPG to assist in making assessment and intervention decisions. This study compares outcomes of patients treated using a traditional therapy program to those treated with the iWalk program. We assessed the hypothesis that the systematic application of a novel, evidence-based CPG for walking recovery would result in superior motor performance when compared to traditional therapy in patients post stroke during a similar length of stay (LOS).
Number of Subjects: 152 patients received the traditional regimen, while 165 patients were enrolled in the iWALK Program.
Materials/Methods: This study included all stroke survivors admitted to a rehab facility during a 24-month period, with the cohort split into 2 groups. The control group received traditional rehabilitation (n = 152) and the experimental group received the iWalk protocol (n = 165). Since full implementation of the protocol could not be assigned a specific date, a buffer group (n = 50) between the 2 groups was excluded from this analysis.
Results: Functional Independence Measure (FIM): An interaction between age and treatment program was detected (P < 0.001). Motor FIM scores showed greater improvement for younger patients in iWalk than in the traditional therapy program. Length of Stay: When examining LOS as an outcome, an interaction between treatment group and total FIM score was detected (P = 0.073). Patients who were lower functioning on admission were more likely to be discharged home if they were in the iWalk program. Examining LOS as a predictor, the difference in timed-up-and-go scores between the treatment groups reveals that iWalk seems to be better for a LOS around 3 weeks, but is not significant (P > 0.05).
Conclusions: This study demonstrates outcome differences that favor iWalk. Additionally, there may be a LOS range that optimizes motor recovery. It is unclear whether a patient's LOS is a reflection of the improvement of clinical variables or practical reasons. There was great variance in the sample, and further research building on this data set could help determine responders and nonresponders to the walking recovery program.
Clinical Relevance: This novel approach looks at the systematic application of a combination of techniques to reach the optimal outcome. The comparison of outcomes informs best practice for recovery of function after stroke, and this data will aid in the clinical decision making process for other physical therapists seeking to improve walking recovery in stroke survivors.
Effect of Rhythmic Auditory Stimulation on Gait Velocity in Patients With Parkinson's Disease: A Systematic Review and Meta-analysis
S. Trappe, A. Cathcart, R. Nix, J.B. Gore, Georgia State University, Atlanta, Georgia.
Purpose/Hypothesis: Parkinson's disease (PD) is a neurological disorder that impairs gait, balance, and posture. Recent studies have suggested that external cueing during gait training may improve gait in patients with PD. This systematic review and meta-analysis examined the effects of a specific form of external auditory cueing known as rhythmic auditory stimulation (RAS), which delivers an automated, repetitive tone during gait training in patients with PD.
Number of Subjects: 179 subjects in 10 studies.
Materials/Methods: From 11 electronic databases, 10 studies were found that met the inclusion criteria. Means, standard deviations, and sample sizes for baseline and post-RAS gait velocity were extracted to calculate an effect size (ie, standardized mean difference) for each study, and a meta-analysis was performed to assess the overall effect of RAS on gait velocity in patients with PD. Because the heterogeneity of between-study effect size was found to be moderate (I2 = 58%), the moderator variables of RAS pretraining (pretraining vs no pretraining) and frequency of beat (100%, 110%, or >110% of the patient's preferred cadence) were investigated using subgroup meta-analyses to determine if these variables could explain any of the between-study variance in effect size.
Results: Overall, a significant, moderately beneficial effect of RAS on gait velocity was found in patients with PD (overall effect size = 0.49; P < 0.05). Subgroup meta-analyses were conducted on how RAS pretraining affected gait velocity, but no significant differences were found between groups (P = 0.32). Subgroup meta-analyses were also conducted on how frequency of beat affected gait velocity, but no between-group differences were found (P = 0.16). This suggests that the presence of pretraining or the frequency of beat does not explain the variance between studies in effect size.
Conclusions: The overall findings of this study suggest that RAS improved gait velocity in patients with Parkinson's disease. More studies are needed to differentiate the benefits of RAS pretraining and the optimal RAS frequency of beat to allow for better comparison.
Clinical Relevance: The evidence shows that external auditory cueing via metronome is beneficial for increasing gait velocity in patients with PD.
Utilization of Forced Aerobic Exercise to Augment Motor Recovery Post-Stroke: A Randomized Clinical Trial
S. Linder, A.B. Rosenfeldt, J. Alberts, Cleveland Clinic, Cleveland, Ohio.
Purpose/Hypothesis: The benefits of intensive aerobic exercise on brain health has been documented in individuals with Parkinson's disease (PD), dementia, and to a limited extent, stroke. In our previous work in individuals with PD, we developed a forced exercise (FE) paradigm on a stationary bicycle to augment the voluntary efforts of patients, allowing them to achieve and maintain a rate of exercise thought to elicit neurophysiological changes in the brain resulting in improvements in motor and nonmotor functioning. Neuroimaging using fMRI and fcMRI demonstrated increased cortical activity and functional connectivity comparable to changes seen with medication, suggesting that medication and FE likely use the same pathways to produce improvements in motor function in patients with PD. Stroke patients experience similar motor and coordination deficits, resulting in the inability to attain or maintain high-rate, high-intensive aerobic exercise levels that may contribute to creating an environment in the brain optimal for neuroplasticity. Therefore, our aim was to conduct a preliminary randomized clinical trial to compare the effects of FE to voluntary exercise (VE) in promoting the recovery of upper extremity (UE) motor function in patients with stroke. Participants in both groups completed one 45-minute session of stationary cycling followed by one 45-minute session of UE repetitive task practice (RTP); however, the rate of cycling for the FE group was augmented to approximately 35% faster than their voluntary rate. A third control group completed two 45-minute sessions of RTP only. We hypothesized that those randomized to FE+RTP would demonstrate greater improvements in motor and nonmotor outcomes compared to the VE+RTP and RTP only groups. We also hypothesized that both the FE+RTP and VE+RTP groups would demonstrate significant improvements in aerobic capacity compared to the RTP only group.
Number of Subjects: 30.
Materials/Methods: 30 individuals 6 to 12 months poststroke were enrolled into one of the following groups: (1) FE + RTP, n = 10; (2) VE + RTP, n = 10; and (3) Dose-matched RTP, n = 10. Outcomes included the Wolf Motor Function Test (WMFT), Fugl-Meyer Assessment (FMA), and 9-hole peg test; Quality of life as determined by the Stroke Impact Scale; and changes in aerobic capacity as measured by
O2max and the 6-minute walk test.
Results: Preliminary findings reveal improvements in WMFT and FMA scores in all 3 groups and improvements in aerobic capacity for both groups participating in the aerobic exercise intervention.
Conclusions: Aerobic exercise can improve cardiovascular health, may augment the recovery of UE motor function, and as a result, decrease disability in patients with chronic stroke.
Clinical Relevance: Patients with chronic stroke can safely participate in intensive aerobic exercise. Aerobic exercise can improve cardiovascular health, may augment the recovery of UE motor function, and decrease disability in patients with chronic stroke.
Effect of Aerobic Exercise on Fatigue in People With Diabetic Peripheral Neuropathy
P. Kluding, R. Singh, L.J. D'Silva, M. Yoo, S. Billinger, Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, Kansas. L. Herbelin, M. DiMachkie, M. Pasnoor, Neurology, University of Kansas Medical Center, Kansas City, Kansas. D. Wright, Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas.
Purpose/Hypothesis: Exercise is generally recommended for people with diabetes, but little is known about exercise in people with diabetic peripheral neuropathy (DPN). DPN is one of the most common complications of diabetes, causing pain and sensory loss in the lower limbs, with increased risk of falls and injury. Feelings of fatigue may be exacerbated in people with DPN due to the complex interaction between decreased aerobic fitness, hyperglycemia, pain, and obesity. The purpose of this pilot study was to investigate change in fatigue and potential contributing factors following an aerobic exercise intervention in people with DPN.
Number of Subjects: All study participants had diagnosed DPN, were sedentary (Rapid Assessment of Physical Activity score), and did not have medical problems that would prevent safe participation in exercise. Fourteen participants have completed the study (9 female; 4 white/4 black/6 Hispanic; age 57.6 ± 4.5; 14.3 ± 6.7 years with diabetes).
Materials/Methods: All subjects participated in a supervised 16-week aerobic exercise program, 3×week at 50 → 70%
O2peak following a graded maximal exercise test. Outcomes included change in fatigue (Multidimensional Fatigue Inventory, MFI-20), aerobic fitness (
O2peak), peripheral blood flow (flow mediated dilation), hyperglycemia (HbA1c), pain (Brief Pain Inventory–-DPN), % body fat and fat mass on dual-energy x-ray absorptiometry scan, along with measures of peripheral nerve function (quantitative sensory testing, nerve conduction studies). Data were analyzed using paired t-tests (α = 0.05).
Results: In this small study, significant improvements were found in general fatigue (Δ −5.4 ± 5.1, P = 0.002),
O2peak (Δ 1.3 ± 1.7 mL/kg/m, P = 0.025), flow mediated dilation (P = 0.04), fat mass (P = 0.02), and total body fat % (P = 0.02). No improvements were noted in HbA1c, pain, or peripheral nerve function. Although no serious adverse events (AEs) occurred as a result of the study procedures, multiple AEs of mild severity required attention throughout the study. Most common AEs included hyperglycemia before exercise (>300 mg/dL), hypoglycemia after exercise (<70 mg/dL), and pain (most commonly in knees or hips).
Conclusions: Improvements in self-reported fatigue and several potential contributing factors were noted following participation in the exercise intervention. These findings are consistent with emerging research that shows potential benefit with supervised, individually prescribed exercise interventions for people with DPN. However, a future large randomized controlled trial will be important to fully assess the effect of exercise on these outcomes.
Clinical Relevance: This study provides new support for supervised aerobic exercise in people with DPN to improve fatigue, aerobic fitness, blood flow, and body fat. PTs can play an important role in the prescription of exercise intensity based on initial level of aerobic fitness and may need to provide close monitoring and patient education to address the anticipated AEs related to glycemic control and musculoskeletal pain as individuals begin an exercise program.
The Occurrence, Distribution, and Severity of Lower Limb Spasticity and Its Impact on Mobility in Ambulatory Persons With Multiple Sclerosis
J.M. Wagner, Physical Therapy and Athletic Training, Saint Louis University, St. Louis, Missouri. L. Van Dillen, Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri. R.T. Naismith, Neurology, Washington University School of Medicine, St. Louis, Missouri.
Purpose/Hypothesis: To document the occurrence, severity, and distribution of clinically assessed lower limb (LL) spasticity and its impact on mobility in ambulatory persons with multiple sclerosis (pwMS). We hypothesized that LL spasticity would be common in ambulatory pwMS but be mild in severity, most prevalent in distal muscle groups, and poorly associated with mobility problems.
Number of Subjects: 59 ambulatory pwMS (18 male, 41 female) with mild clinical disability (median EDSS = 3.5, range: 0-6).
Materials/Methods: Spasticity of the hip adductors, knee flexors and extensors, and plantarflexors (PF) was assessed bilaterally by the Modified Ashworth Scale (MAS). Mobility was assessed using the Timed 25-Foot Walk Test (T25FW), Six Minute Walk (6MW), and 12-item Multiple Sclerosis Walking Scale (MSWS12). PwMS were classified into 3 groups based on MAS scores for any muscle on either leg: no spasticity (MAS = 0), mild spasticity (MAS 1 or 1+), moderate to severe spasticity (MAS > 1+). For analysis, the raw MAS scores were transformed to a 0 to 5 scale to include the score 1+. Descriptive statistics were used to present numbers of participants with spasticity as well as the distribution and severity of spasticity. Spearman correlations were used to establish the association between spasticity and mobility. Kruskall-Wallis (KW) and post hoc Mann-Whitney U (MW) tests were used to evaluate group differences. Cohen's d was used to estimate effect size.
Results: Of the 59 pwMS, 36 (61%) had LL spasticity. Only 10 (17%) participants exhibited moderate to severe spasticity. Spasticity was documented in each of the tested muscles but was most common in the distal muscles. The PF were the most commonly affected muscle. For those with spasticity, most had one spastic muscle within a limb. Bilateral spasticity was documented in each of the tested muscles but was most common in the PF. There was a limited association (r ≤ 0.5.) between spasticity and mobility. Clinical disability and mobility problems were more pronounced in the moderate to severe spasticity group compared to the no spasticity (EDSS: 4.8 vs 3.0, KW P = 0.03, MW P = 0.02, d = −1.07; T25FW: 7.4 vs 5.2s, KW P = 0.01, MW P < 0.01, d = −1.02; 6MW: 376 vs 491 m, KW P = 0.06, d = 1.03; MSWS12: 52 vs 36, KW P = 0.2, d = −0.61) or mild spasticity group (EDSS: 3.7, KW P = 0.03, MW P = 0.09, d = −0.77; T25FW: 5.9s, KW P = 0.01, MW P = 0.04, d = −0.61; 6MW: 442 m, KW P = 0.06, d = 0.50; MSWS12: 52 vs 46, KW P = 0.2, d = −0.25). There were no significant differences in clinical disability or mobility between the no and mild spasticity groups (MW P > 0.05, d < 0.44).
Conclusions: Clinically assessed LL spasticity is common in ambulatory pwMS. Mild spasticity does not appear to affect mobility. The impact of more pronounced spasticity on mobility in pwMS is unclear, given that the moderate to severe group had greater clinical disability.
Clinical Relevance: An understanding of the impact of LL spasticity on mobility is required for targeted therapeutic interventions for pwMS.
Acute High-Intensity Locomotor Exercise Augments Expression of Serum Brain-Derived Neurotrophic Factor in Individuals With Incomplete SCI
K. A. Leech, Neuroscience, Northwestern University, Chicago, Illinois. T. Hornby, Physical Therapy, University of Illinois at Chicago, Chicago, Illinois.
Purpose/Hypothesis: Previous work suggests that intensity of locomotor practice may play a role in the recovery of functional locomotion in individuals with neurologic injury. Studies in animal models of incomplete spinal cord injury (SCI) have suggested that high-intensity locomotor practice increases expression of spinal neurotrophic factors, leading to improved recovery of stepping. Exercise intensity has also been shown to be an effective modulator of peripheral neurotrophic factor levels in healthy humans, though rigorous examination of these intensity-related effects has not yet been conducted in humans with neurologic injury. In this study, we investigated the effect of locomotor exercise intensity on expression of serum brain-derived neurotrophic factor (BDNF), which may serve as a biomarker of neuroplasticity in humans with motor incomplete SCI.
Number of Subjects: Four (3 male) subjects with motor incomplete SCI (ASIA D).
Materials/Methods: In a single day testing session, subjects participated in a graded-intensity locomotor exercise task during which intravenous blood samples and cardiopulmonary measures were collected at each level of intensity (manipulated in this experiment by increasing gait speed). Blood serum was analyzed with enzyme-linked immunosorbent assays to determine the sample concentration of BDNF. Serum concentration of BDNF and cardiorespiratory measures were compared at rest, low, moderate, and high intensity (33%, 66%, and 100% of peak gait speed, respectively) using a repeated-measures ANOVA for preliminary analysis.
Results: Preliminary results indicate an increase in serum BDNF at high locomotor intensity compared to resting levels (from 26 187 ± 14 314 pg/mL to 30 216 ± 17 072 pg/mL; P < 0.05), with no change in serum BDNF at either low or moderate intensities compared to rest. We found that the percent change in serum BDNF was correlated to the respiratory exchange ratio (R = 0.66; P = 0.02), an indirect marker of exercise intensity. Other indirect measures of exercise intensity such as percent change in oxygen consumption and heart rate were not significantly correlated (R = 0.47; P = 0.12, and R = 0.44; P = 0.20, respectively).
Conclusions: These preliminary results suggest that locomotor practice intensity may be an effective way to manipulate the expression of a specific neurotrophic factor in humans with incomplete SCI.
Clinical Relevance: This work will advance our understanding of the effects of locomotor exercise intensity and may elucidate an underlying cellular mechanism for improved locomotor function following high-intensity exercise paradigms in individuals with neurologic injury.
Return to Jogging Poststroke
G.T. Miller, B.K. Smith, C. Fox, A.D. Hill, E. Konopka, University of Florida, Gainesville, Florida.
Background and Purpose: Gait restoration is universally recognized as a key goal in stroke rehabilitation, and much emphasis is placed upon the attainment of community ambulation as an important functional outcome. There is currently limited research examining intervention strategies commonly used with high-level poststroke individuals, specifically with return to jogging. This case report characterizes an evaluation of recovery and a progressive, high-level treatment plan for an adult recovering from stroke to included jog retraining.
Case Description: The subject is a 62-year-old male retired professional dancer in good health prior to an acute R ischemic stroke 3 years ago. Early poststroke rehab included strengthening, locomotor retraining using both body weight support (BWS) with treadmill (TM) and overground training, balance retraining, and a progressive home exercise program. At 1 year, the subject made significant gains with strength, balance, gait speed (1.6 m/s), endurance, and independent ambulation in the community. Stroke Impact Scale (SIS) scores improved minimally with a perceived overall recovery of 5/100. Beck Depression scores indicated worsened clinical depression. The rehab program was advanced to incorporate interventions to promote recovery of jogging, an activity inclusive of subskills of dancing and a previous wellness activity for the subject. Jog retraining included TM training with BWS, overground jogging, and an outpatient exercise program targeting specific skills of jogging. The intensive 3-month jog retraining was followed by an independent jogging program 1 to 2 times weekly for 1 year.
Outcomes: Outcomes measures pre-jog retraining included strength, SIS, Beck Depression, HiMAT, and 25 m sprint. Jogging bouts at 4 mph started at 1-minute bouts on the TM with BWS and peaked at 4-minute bouts. Outdoor track running increased to ¼ mile bouts. Bouts overground and on TM were limited by elevated heart rate, perceived exertion, and increased tripping. After 16 months of intermittent jog retraining and ongoing independent jogging, no changes in SIS, Beck Depression, or HiMAT scores were noted. Analysis of jogging both with TM and BWS and overground showed reduced hip flexion, knee flexion, dorsiflexion, and plantarflexion on the LLE. Tripping and increased effort to overcome movement deficits appeared to correlate with elevated HR and perceived exertion.
Discussion: Despite modest gains in short-distance jogging, no changes were observed in high-level functional outcome measures. This plateau in jogging recovery elicited the need to identify possible limiting factors. A submaximal cycle test estimated
O2peak at 24.1 mL/kg/min (15% predicted), but the stopping factor was left leg fatigue. Isokinetic testing confirmed that muscles most affected by decreased muscular endurance were left knee flexors and ankle plantar flexors (36% and 25% predicted, respectively). Future work should investigate isokinetic training to increase muscle endurance and promote return to jogging after stroke.
Interventions to Improve Balance and Gait Deficits in a Patient With Normal Pressure Hydrocephalus: A Case Report
R.A. DeGrood, S.A. Meardon, University of Wisconsin La Crosse, La Crosse, Wisconsin.
Background and Purpose: Normal pressure hydrocephalus (NPH) is characterized by ventricular enlargement to accommodate increased cerebrospinal fluid pressure. Incidence is estimated at 1% to 5% in the general population and 14% in long-term care facilities. Balance and gait disturbances, urinary incontinence, and cognitive deficits are common in NPH and it is often misdiagnosed as Parkinson's disease. There are limited resources regarding physical therapy (PT) management of NPH. The purpose of this report is to describe outpatient PT management of a patient with NPH after shunting. A movement diagnosis and current literature regarding interventions for patients with comparable clinical presentations were used to guide plan of care development.
Case Description: The patient was a 70-year-old male with NPH who received a shunt 3 years after initial symptoms. He presented with increased sway during standing tasks, delayed postural adjustments to instability, fear of falling, impaired ambulation endurance, and a slow, shuffling gait, consistent with a movement diagnosis of movement pattern coordination deficit. Interventions included progressive balance and gait training. Balance exercises focused on improving postural stability during functional tasks, while gait training incorporated external cues and activities aimed at improving gait quality, speed, and endurance. Activities were progressed using Gentile's taxonomy of motor skills and included cognitive challenges. Sessions lasted 60 minutes and occurred twice weekly for 12 weeks. Measures taken at initial exam and at 4, 8, and 12 weeks included the Six Minute Walk Test (6MWT) (ICC = 0.95, MDC = 269 ft), self-selected gait speed (ICC = 0.96, MDC = 0.18 m/s), Berg Balance Scale (BBS) (ICC = 0.94, MDC = 5 pts), Activities-specific Balance Confidence (ABC) scale (ICC = 0.94, MDC = 13%), and Timed Up and Go (TUG) (ICC = 0.80, MDC = 3.5 seconds).
Outcomes: Qualitatively, coordination and postural stability during functional tasks improved with less shuffling during gait. Consistent gains were made on the 6MWT (+184 ft). Variable performance was noted for self-selected gait speed (0.06 m/s faster), BBS (+3 pts) and ABC scale (+0.63%). On the contrary, TUG scores gradually worsened (+4.43 seconds). Persistent pain and instability secondary to knee osteoarthritis likely influenced consistency of outcomes.
Discussion: This report is the first to describe outpatient PT management for a patient with NPH after shunting. With use of a movement diagnosis and evidence-based interventions, improvements were seen in movement coordination and ambulation endurance. Variable progress was likely due in part to the nature of NPH; however, confounding orthopedic issues made it difficult to discern the true benefits of PT. This report is an example of how a movement diagnosis and available evidence can be used when designing PT interventions for a patient with a medical diagnosis that has no best practice guidelines. Additional research is needed to determine efficacy of outpatient PT for patients with NPH after shunting.
Cluster Analysis as a Means to Show Changes After Upper Extremity Training in Participants With Stroke
S. McCombe Waller, W. Liao, J. Sorkin, J. Whitall, University of Maryland Baltimore, Baltimore, Maryland.
Purpose/Hypothesis: Our purpose was to use cluster analyses of temporal and spatial kinematic variables to define movement signatures for forward unilateral reaching and compare clusters before and after upper extremity training in participants status poststroke. We hypothesized that this analysis could provide a means to demonstrate changes after training.
Number of Subjects: 20 participants with chronic hemiparesis.
Materials/Methods: Participants were randomly assigned to 2 groups; one receiving bilateral arm training with rhythmic auditory cueing for 6 weeks followed by 6 weeks of unilateral task-oriented training (COMBO, n = 9) and the other receiving two 6-week sessions of unilateral task oriented training (UNI, n = 11). Data collected for hierarchical cluster analysis included kinematic variables during unilateral forward reach to a box, measured by a Motion Monitor analysis system. Variables were joint ranges of shoulder flexion, abduction, adduction, elbow flexion and extension, forearm supination, movement time, peak velocity, peak acceleration, and path ratio. Data were collected at baseline and after the total 12 weeks of training.
Results: At baseline, we retained 4 clusters accounting for 87% of the total variance. Upon examination of the clusters, key descriptors or movement signatures of baseline clusters, ordered most to least impaired were B1) very slow speed and limited movement at all joints, B2) average speed and limited motion primarily at elbow, B3) average speed and motion at all joints but compensatory strategies, and B4) average speed, appropriate movement strategies (reduced compensation). After training, a new cluster analysis again retained 4 groups accounting for 83% of the total variance. Movement signatures of posttraining clusters, ordered most to least impaired cluster were P1) average speed and limited motion primarily at elbow, P2) average speed and motion at all joints but compensatory strategies, P3) slower speed but appropriate movement strategies (reduced compensation), and P4) average speed and appropriate movement strategies. In the COMBO group, 5 participants improved, moving up on average by 2 clusters with 4 remaining in the same cluster. In the UNI group 5 participants improved moving up on average by 1 cluster, with 4 remaining in the same cluster and one worsening by 3 clusters.
Conclusions: Baseline cluster analysis on key kinematic variables permitted the identification of paretic arm movement signatures for unilateral reaching. Posttraining cluster analysis identified one new cluster and one dropped cluster indicating kinematic improvements for some participants in both groups. Overall, greater improvements were seen in the COMBO group.
Clinical Relevance: Cluster analyses can provide information of movement signatures during reaching, which can be used to evaluate the effectiveness of poststroke interventions.
The Feasibility of High-Repetition, Task-Specific Training for the Paretic Upper Extremity in an Inpatient Rehabilitation Setting
C.E. Lang, Physical Therapy, Washington University, Saint Louis, Missouri. R.L. Birkenmeier, Occupational Therapy, Washington University, Saint Louis, Missouri. K.J. Waddell, J. Moore, Rehabilitation Institute of Chicago, Chicago, Illinois. T. Hornby, Physical Therapy, Kinesiology, & Nutrition, University of Illinois Chicago, Chicago, Illinois.
Purpose/Hypothesis: While the amount of task-specific training during stroke rehabilitation is low, recent studies have indicated substantially more training is feasible in the outpatient setting. If more task-specific training could be delivered earlier after stroke in the inpatient setting (IRF), then overall outcomes might be better. The purpose of this study was to evaluate if persons with stroke in an IRF: (1) could achieve hundreds of repetitions of upper extremity (UE) task-specific training during 1-hour therapy sessions and (2) could tolerate a program of these sessions without sacrificing other critical IRF needs (eg, sufficient time to address basic activities of daily living [ADL]). An additional goal was to gather preliminary efficacy data for future studies.
Number of Subjects: 15 subjects with UE paresis due to recent stroke in an IRF.
Materials/Methods: Task-specific UE training was scheduled for 60 min/day, 4 days/wk during occupational therapy for the duration of a participant's IRF stay. Therapy services the remaining days/wk were focused on ADL retraining. During each session, subjects were challenged to complete 300 or more repetitions of UE task training. Tasks practiced were individualized, graded, and progressed according to established criteria. Feasibility measures included number of repetitions/session, minutes in active training/session, total sessions attempted, total sessions attended, fatigue, and pain. Functional measures included grip and pinch strength, the Action Research Arm Test (ARAT), and 6 items of the Functional Independence Measure (FIM). Descriptive statistics were generated on feasibility measures and paired t tests were used for functional measures.
Results: Subjects achieved 289 repetitions/session on average, spending 47/60 minutes in active training. The number of sessions attempted was 11.5 and the number of sessions attended was 10.9. Fatigue scores were appropriate to the level of activity (6.5 pts, 0-10 scale) and the average change in pain (postsession – presession) was 1.3 pts (0-10 scale). ARAT, grip strength, and pinch strength increased 9 pts, 6.5 kg, and 1.5 kg, respectively. FIM scores indicated a change from moderate assistance needed for ADL completion at admission to generally a supervision level needed at discharge.
Conclusions: Persons with stroke in an IRF setting can achieve hundreds of repetitions of UE task-specific training in 1-hour sessions and can tolerate a program of such sessions. Effort to achieve this training was high, as indicated by fatigue scores. Pain increased slightly but did not prevent subjects from participating in subsequent sessions. The task-specific training did not appear to detract from the critical ADL priorities of the inpatient setting. Future studies are needed to determine if this high-repetition training program results in better outcomes than current IRF UE interventions.
Clinical Relevance: Even early after stroke, people can engage in much more movement practice than previously expected within the confines of scheduled therapy sessions.
The Effects of 2 Years of Exercise on Spatial and Temporal Gait Parameters in People With Parkinson's Disease: A Randomized Controlled Trial
M.R. Rafferty, Graduate Program in Neuroscience, University of Illinois at Chicago, Chicago, Illinois. J.A. Robichaud, F.J. David, C. Poon, L.G. Chin, D.M. Corcos, Department of Kinesiology & Nutrition, University of Illinois at Chicago, Chicago, Illinois. J. Prodoehl, Physical Therapy Program, Midwestern University, Chicago, Illinois. D.E. Vaillancourt, Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida. C.L. Comella, Department of Neurological Sciences, Rush University Medical Center, Chicago, Illinois. S.E. Leurgans, Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, Illinois. W.M. Kohrt, Division of Geriatric Medicine, University of Colorado Denver, Aurora, Colorado.
Purpose/Hypothesis: Several exercise interventions improve gait speed in people with Parkinson's disease (PD). Some programs target spatial aspects of gait (eg, stride length), while others use cueing strategies to target temporal aspects of gait (eg, cadence). In a comparative clinical trial, we showed that progressive resistance exercise (PRE) improved the motor symptoms of PD over 24 months compared to a nonprogressive, PD-specific exercise program called modified Fitness Counts (mFC). This study examined the effects of PRE and mFC on gait speed, stride length, and cadence.
Number of Subjects: Spatiotemporal gait analysis was performed on 46 individuals (27 male, age 58.9 ± 5.2 years old) with mild-moderate PD who participated in PRE or mFC.
Materials/Methods: As part of a larger clinical trial, participants were randomly assigned to participate in PRE or mFC after matching on sex and disease severity. The PRE group lifted progressively increasing weight, while the mFC group performed nonprogressive flexibility, balance, and strengthening exercises. Participants exercised 2 days/week for 24 months, with testing every 6 months. As a secondary outcome measure, blinded assessors measured spatiotemporal gait parameters using the GAITRite walkway system at self-selected and “as fast as possible” walking speeds, both off and on medication. Linear mixed regression models were used to analyze changes in gait speed, stride length, and cadence over time.
Results: There were no significant differences between exercise groups for the parameters of interest, so groups were combined to look at the main effect of exercise over 24 months. Self-selected gait speed, stride length, and cadence all increased significantly in the off medication state (P < 0.001, P = 0.001, and P = 0.018, respectively). When on medication, self-selected gait speed and cadence increased, but stride length only showed a trend toward increasing (P = 0.024, P = 0.010, and P = 0.089, respectively). During fast walking, gait speed, and cadence increased in both off (speed P = 0.050; cadence P = 0.001) and on medication states (speed P = 0.002; cadence P = 0.004), but there was no significant increase in fast stride length (off P = 0.313; on P = 0.128).
Conclusions: Although our study was not powered to compare the changes in gait between the 2 exercise programs, the analysis demonstrated that participants in both PRE and mFC improved self-selected and fast gait speed across 24 months, in both off and on medication states. The exercise programs may increase gait speed primarily through increasing cadence (ie, speed of stepping), rather than changing stride length, particularly when participants walked as fast as possible.
Clinical Relevance: Consistent participation in progressive and nonprogressive gym-based exercise programs can be used to improve and maintain gait speed over 24 months in individuals with PD. These exercise programs may impact temporal aspects of gait more than spatial aspects.
The Immediate Effects of 3 Unique Treadmill Training Programs on Overground Gait Velocity, Stride Length, Cadence, and Swing Time in Healthy Adults: A Pilot Study
A. Rasch, M. McCormick, S. McDaniel, R. Merideth, S. Townsend, Physical Therapy Program, Maryville University in St. Louis, Saint Louis, Missouri. R. Duncan, Program in Physical Therapy, Washington University School of Medicine, Saint Louis, Missouri.
Purpose/Hypothesis: Treadmill training (TT) at an increased speed and inclined TT have increased stride length after and during TT, respectively. Attentional cues to increase stride length lead to increased overground gait speed and stride length in healthy adults. However, the effects of providing these cues during TT on overground gait have not yet been studied. The purpose of this study was to determine the differential effects among TT with increased speed, TT at an incline, and TT with attentional cues on gait velocity, stride length, cadence, and swing time in healthy individuals. The researchers hypothesized that all 3 TT protocols would increase gait velocity and stride length and decrease cadence and swing time.
Number of Subjects: Twenty-one healthy participants (15 female; mean age ± SD = 46 ± 13 years).
Materials/Methods: Each participant performed all 3 TT protocols for this research study. Participants performed 3 forward walking pretest GAITRite trials to measure gait velocity, stride length, cadence, and swing time. The participant then randomly performed 1 of the 3 TT protocols (increased speed of 10% above comfortable walking speed, at a 5% incline, or with attentional cueing for increased stride length) for 10 minutes. Posttest GAITRite trials were then performed. The same procedures were repeated for the second and third TT protocols.
Data Analysis: A 2×3 repeated-measures ANOVA determined main effects and condition-by-time interactions. If significant condition-by-time interactions were noted, a MANOVA of change scores with pairwise comparisons determined differences among groups (α = 0.05).
Results: There was no significant condition-by-time interaction or main effect of time for gait velocity. A significant condition-by-time interaction was noted for stride length (F(2,18) = 7.81; P = 0.001). Stride length significantly increased following attentional cues during TT compared to inclined (P = 0.006) and speed TT (P = 0.002). A significant condition-by-time interaction was noted for cadence (F(2,18) = 3.40; P = 0.04). Cadence was significantly reduced following TT with attentional cues compared to inclined TT (P = 0.035). A significant condition-by-time interaction was noted for swing time (F(2,18) = 3.71; P = 0.030). Swing time increased significantly following attentional cues compared to inclined TT (P = 0.029).
Conclusions: Attentional cues during TT increased stride length more than the other conditions in healthy individuals. Treadmill training with attentional cues also reduced cadence and increased swing time compared to inclined TT.
Clinical Relevance: Physical therapists may choose to use TT with attentional cues for increased stride to facilitate increased stride length and reduced cadence in healthy individuals with gait impairments. The findings from this study support future testing of the effects of TT with attentional cues on gait parameters for people with neurologic deficits.
Change in Balance Measures Following Aerobic Training in People With Diabetic Peripheral Neuropathy
L.J. D'Silva, K. Martin, M. Yoo, R. Singh, M. Pasnoor, P. Kluding, Physical therapy and Rehabilitation Science, The University of Kansas medical center, Kansas City, Kansas.
Purpose/Hypothesis: People with diabetic peripheral neuropathy (DPN) have postural instability and decreased balance. This is multifactorial due to impaired proprioception and kinesthetic sensation, impaired vision, and a possible involvement of the vestibular system. Glucose metabolism significantly influences the physiology of the inner ear as it is very active metabolically. The inner ear does not store energy and minor variations in blood glucose can affect its function and cause balance disorders. It is important to understand how diabetes affects the vestibular system to develop therapeutic interventions in this patient population. The purpose of this pilot study was to assess the effect of a 16-week aerobic training program on clinical measures of balance and dizziness in people with DPN.
Number of Subjects: 14 subjects (9 females/5 males, mean age 57.6 ± 4.5 years; 14.3 ± 6.7 years with diabetes) with a diagnosis of DPN completed the study. They were sedentary (Rapid Assessment of Physical Activity score) and did not have medical problems that would prevent safe participation in exercise.
Materials/Methods: All subjects participated in a 16-week supervised aerobic program, at 50% to 70% of
O2peak following a graded maximal exercise test. Outcomes included change in measures of hyperglycemia (HbA1c), body mass (BMI), gait (functional gait assessment, FGA), balance (Timed-Up-Go, TUG), handicap due to dizziness (Dizziness Handicap Inventory, DHI), confidence with daily function (Activities specific balance confidence scale, ABC), and aerobic fitness (
O2peak). Data was analyzed using paired t tests to look for significant change in these outcomes (α = 0.05). Wilcoxon signed rank test was used to analyze significant change in itemized FGA score.
Results: In this pilot study, significant improvements were found in
O2 peak (P = 0.02) and FGA (P = 0.03). No improvements were noted in HbA1c, BMI, DHI, TUG and ABC. Each item of the FGA was further analyzed and item 8, walking with eyes closed, showed significant improvement (P = 0.01).
Conclusions: Improvement in overall fitness was seen after participation in the supervised, individually prescribed exercise program validating the importance of exercise in people with diabetes. Significant improvement was seen in FGA item of ambulation with eyes closed. No change was seen in ambulation with head turns/tilts or with other items sensitive to vestibular dysfunction.
Clinical Relevance: Clinicians in physical therapy practice frequently encounter patients with diabetes who complain of balance problems and falls especially on uneven surfaces and in the dark. As we understand the effect of DM on the vestibular system, we can work with this patient population on targeted balance training like walking with head turns/tilts, balance on unstable surfaces to challenge the vestibular system. Future studies should include evaluation of vestibular function looking at performance with calorics, rotary chair, and vestibular evoked myogenic potentials to identify the site of lesion in the peripheral vestibular end organs.
The Other Side of the Rainbow ... Characteristics of Functional Outcome and Physical Therapy Services in Survivors of Stroke in a Rural State
M. Mandich, M. Burkart, B. Dennison, Physical Therapy, West Virginia University, Morgantown, West Virginia. L. Gutmann, Neurology, West Virginia University, Morgantown, West Virginia. P. Horstman, West Virginia University Hospitals, West Virginia University, Morgantown, West Virginia.
Purpose/Hypothesis: Research in neuroplasticity and functional recovery post CVA suggests task-oriented training guided by a dose-response perspective is the appropriate evidence-based intervention. Intensive practice in the period 2 to 6 months post-CVA appears most effective. The purpose of this study was to describe access to physical therapy and recovery in survivors of stroke living in rural communities. A secondary purpose was to determine if data obtained from a mail survey had concurrent validity with established clinical measures.
Number of Subjects: Nine hundred eighty-six individuals with a stroke diagnosis discharged from a teaching hospital within the past 2 years were identified from the stroke center database. One hundred ninety-one survey packets were returned, with 103 packets containing completed surveys.
Materials/Methods: Prospective participants were sent informational packets that included a cover letter, written informed consent, an investigator designed questionnaire about PT, a Modified Reintegration to Normal Living Index (MRNLI), and a Modified Rivermead Mobility Index (MRMI). A subset of the sample (n = 8) returned to the teaching hospital and were assessed with a Timed “Up and GO” (TUG), 15 Meter Walk Test, and hand dynamometry.
Results: Subjects who returned the questionnaires were high functioning, with a mean RMI of 12.6/15 and RNL of 9.5/11. A significant difference was found on both measures (P < 0.004 for MRMI and P < 0.019 for MRNL) between groups who did and did not receive physical therapy postdischarge. The mean scores for the group who received physical therapy (MRMI = 11.4; MRNL = 8.8) were LOWER than mean scores for the group not receiving physical therapy (MRMI = 13.5; MRNL = 9.9). Individuals whose scores fell in the top quartile were LESS satisfied with the amount of physical therapy they received than lower scoring groups. There was a good correlation between the MRMI and MRNL (r = 0.756) and between these 2 measures and the observed clinical measures in the sample subset.
Conclusions: First, it was evident the database for follow-up of stroke survivors returning to homes in rural communities is severely lacking and information about participation is absent. Second, individuals with severe disability are receiving significant physical therapy services. However, individuals with mild to moderate disability are dissatisfied with the amount of physical therapy they received. The individuals in this group may be the ones typical of the samples used in randomized clinical trials of task-oriented training paradigms. Finally, a preliminary analysis of reliability of measures shows good correlation between mail instruments and clinical tests.
Clinical Relevance: There appears to be a group of patients with mild to moderate participation restrictions who are discharged to rural communities and who are dissatisfied with the rehabilitation services they receive. These patients, who did not receive physical therapy, may be optimal candidates for contemporary, intensive task-oriented treatment.
A Kinetic Orthosis to Improve Rehabilitation From Stroke
M. Idstein, K. Allegro, E. Michel, J. Lynskey, Physical Therapy, A. T. Still University, Mesa, Arizona.
Purpose/Hypothesis: Many stroke survivors are left with lasting deficits in locomotor function, which can limit participation and promote a sedentary lifestyle. Most orthotic devices currently used to improve locomotor function are passive and limit movement, rather than assist it. The purpose of the current study was to investigate the use of a novel, nonpowered energy return orthosis, named the Kickstart (Cadence Biomedical). We hypothesized that the use of the Kickstart would improve locomotor function in chronic stroke survivors.
Number of Subjects: 4.
Materials/Methods: This pilot study used a single-group repeated-measures design. Four chronic stroke survivors (>26 months postinjury) with decreased locomotor function secondary to hemiparesis were recruited for this study. All 4 participants were fit with a custom Kickstart orthosis by a certified orthotist, and were instructed to wear the orthosis 1 to 5 hours per day 5 days a week for 4 weeks while being active. Locomotor function was assessed with and without the orthosis at weeks 0 and 4. The metabolic cost and spatiotemporal parameters of overground locomotion were measured.
Results: All 4 participants completed the initial testing with the device; however, 2 dropped out of the study prior to week 4 secondary to non–study-related illnesses. Initial use of the device decreased the metabolic cost of walking (average 12.2% decrease) and improved foot progression angle (average 5.3 degree decrease) but did not improve walking speed or other spatiotemporal parameters. After using the device for an average of 17.9 hours over 4 weeks, the 2 remaining participants demonstrated a decreased metabolic cost of walking (average 21.3% decrease), improved swing time symmetry (36.7% improvement), and improved foot progression angle (5.2 degree decrease) when walking without the orthosis compared to baseline measurements. Walking speed, however, did not improve.
Conclusions: The preliminary data presented here suggest that the use of the Kickstart kinetic orthosis may immediately impact locomotor function, while prolonged use may have therapeutic benefits for chronic stroke survivors. Future studies need to be performed to verify and extend these preliminary findings.
Clinical Relevance: Locomotion has a high metabolic cost for many stroke survivors. Devices, such as the Kickstart, that assist walking and decrease the metabolic cost may be used as either long-term orthotics or therapeutic devices. In addition, the use of the Kickstart, or similar devices, may allow for a greater number of stroke survivors to retrain walking outside of the clinic.
Efficacy of a Carbon Fiber Orthotic Toe-Off Brace in Adults With Cerebral Palsy
J. KumeKick, J. Magel, E. DiCandia, J. Hoffman, R. Issing, J. Little, T. Roden, Touro College, Bay Shore, New York. L. Bollinger, Department of Physical Therapy, United Cerebral Palsy of Suffolk, Central Islip, New York.
Purpose/Hypothesis: This pilot study evaluated the effects of a unique carbon fiber ankle/foot orthosis for individuals diagnosed with foot drop (“Toe-Off” design, Allard USA, Inc). We hypothesized that the use of this brace would be useful for adults with cerebral palsy (CP) as evidenced by improved gait characteristics including gait endurance and balance.
Number of Subjects: A convenience sample of 4 patients, between the ages of 29 and 55 years, with diagnoses of CP, was successfully recruited from United Cerebral Palsy (UCP) of Suffolk (Central Islip, NY). All individuals received regular physical therapy at UCP prior to and throughout the study.
Materials/Methods: Patients were assessed wearing their standard plastic orthotics (Pretest) and then fitted for their new carbon fiber bracing. Patients returned for testing at Day 1, Week 4, and Week 8 postinitiation wearing the new brace. At each testing session, patients were evaluated with the Berg Balance test, the GaitRite walkway system for gait analysis, a Six Minute Walk test for endurance, and an orthotic questionnaire incorporating quality-of-life measures including domains for (a) ease of wearing, (b) ease of functional movement, and (c) quality-of-life responses. At week 20, patients were reevaluated with the Six Minute Walk test and questionnaire. All data were assessed using nonparametric statistical comparisons using SPSS software.
Results: No significant differences between the use of standard plastic and carbon fiber composite bracings were noted in any of the parameters measured, which can be partially explained by the small sample size and the greater than normal variability in the data set. However, overall Berg Balance scores increased for all test intervals following pretest measures. In addition, patients reported a general increase in satisfaction in the new orthotics whether discussing ease of use, ability to negotiate the environment, or with respect to quality of life.
Conclusions: In this pilot trial assessing the use of a carbon fiber “Toe-off” brace for adults with CP, this bracing appears comparable in efficacy to that of conventional plastic orthotics. However, given the variation in response to testing and the encouraging self-reported satisfaction with the new brace in this patient population, future trials of this paradigm are recommended with an increased sample size.
Clinical Relevance: Technological advances of orthotic bracing have recently led to the use of carbon fiber composites due to the increased tensile properties of this material compared to those of conventional plastic bracing. Little has been established in the efficacy for using this type of bracing in adults with CP with foot drop. Future studies with larger sample size are necessary in order to increase the strength of statistical analysis given the variability typical of this patient population.
Community-Based Mobility Training for Persons With Chronic Stroke: A Pilot Study
C.A. Cagnet, C.C. Hall, J.M. Newblom, M. Nair, S.A. Combs, Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, Indiana. A.A. Schmid, Department of Occupational Therapy, Colorado State University, Fort Collins, Colorado.
Purpose/Hypothesis: To examine the feasibility and efficacy of a short-burst, community-based mobility training (CBMT) intervention for persons with chronic stroke.
Number of Subjects: Eight participants with chronic stroke who walked ≤1.0 m/s participated in this prospective, repeated-measures pilot study with 3-month follow-up (5 male; mean age 62.0 ± 9.6 years; 54.0 ± 26.5 months poststroke; 4 right hemiparesis).
Materials/Methods: CBMT was administered 5 times a week for 2 consecutive weeks, for 30 minutes each session. CBMT consisted of walking in a community setting while navigating environmental barriers including stairs, curbs, ramps, uneven terrains, intersections, carrying loads, and postural transitions. Intensity was monitored with the Borg Rating of Perceived Exertion Scale (RPE) at 5-minute increments to maintain a moderate training intensity. Walking speed (comfortable/fast 10-meter walking), walking endurance (6-minute walk), balance confidence (activities specific balance confidence scale), perception of mobility (mobility and self-care questionnaire, MOSES), and the ICF Measure of Participation and Activity were assessed before, immediately after, and 3 months following the intervention. A semistructured interview was conducted immediately after the intervention to evaluate participants' perspectives about the program.
Results: CBMT was feasible with 98% attendance rate and every environmental barrier presented was negotiated by participants during each session. Group main effects revealed statistically significant improvements over time in comfortable and fast walking speed, balance confidence, and perception of mobility (P < 0.05). Post hoc analysis demonstrated significant improvements from pre- to postintervention in fast walking speed (P = 0.01), balance confidence (P = 0.02), and MOSES subscales for walking with an assistive device (P = 0.02) and without an assistive device (P = 0.02). Significant improvements were maintained on these measures at the 3-month retention (P < 0.05). All outcome measures demonstrated large effect sizes (d > 0.9) across the 3 measurement periods. Common themes identified from postintervention interviews included negotiating environmental barriers they would typically avoid, being challenged to problem solve, and afterward they felt more confident with community mobility.
Conclusions: For this group of participants with chronic stroke, CBMT was feasible at a moderate training intensity and was effective at improving gait speed, balance confidence, and perceptions of mobility and participation. All improvements were maintained for at least 3 months, indicating that a short-burst training program may have long-term effects. Given the large effect sizes and positive participant perceptions of the intervention, further research is warranted.
Clinical Relevance: Community mobility and participation are often limited after stroke. It may be advantageous for clinicians to expose their patients with chronic stroke to common environmental barriers allowing exploration and development of strategies to increase community participation.
Effects of Intensive Physical Therapy and Onabotulinumtoxina Injections on Gait Kinematics and Functional Outcomes in Chronic Poststroke Hemiparesis: An N-Of-1 Study
B.J. Coleman Salgado, E. Barakatt, M. McKeough, S. Brost, N. Doan, K. Keck, S. Sylvester, Department of Physical Therapy, California State University, Sacramento, Sacramento, California. D. Mandeville, Department of Kinesiology and Health Science, California State University, Sacramento, Sacramento, California. N. Thakur, Sutter Neurosciences Institute, Sutter Health Sacramento Sierra Region, Sacramento, California.
Purpose/Hypothesis: A common chronic poststroke phenomenon is the presence of spastic hemiparesis. Spasticity impairs volitional movement and often leads to loss of function. Intramuscular injections of onabotulinumtoxinA (onabot) have been used to target focal hypertonicity in individuals with neurologic impairments, including stroke. While onabot alone has been shown to temporarily reduce muscle spasticity, the literature measuring functional improvement is scant. We hypothesized that the selective use of onabot in conjunction with intensive physical therapy (PT) would synergistically enhance positive neuroplastic changes, resulting in functional improvements. The purpose of this study was to determine the effects of intensive PT alone and in combination with onabot injections on gait kinematics and functional outcomes in persons with chronic poststroke hemiparesis.
Number of Subjects: 1.
Materials/Methods: We took measurements at several points over an 18-month period, before and after each of 2 trial periods of intensive PT and intensive PT with onabot injections, and periods of no therapy. Following baseline measures and a period of PT only, the patient received intramuscular onabot injections to the affected upper extremity, and select lower extremity muscles on the affected side. Interventions included weight-supported treadmill and overground gait training, endurance training, and neuromuscular reeducation. Outcome measures included the Berg Balance Scale (BBS), the Stroke Rehabilitation Assessment of Movement (STREAM), the Timed Up and Go (TUG), the Six Minute Walk Test (6MWT), and the 10-Ten Meter Walk Test (10MWT). The Vicon Nexus Motion Camera system was used for kinematic analysis of joint angles during the gait cycle.
Results: The initial period of intensive PT + Onabot showed improvements in excess of the minimally detectable difference for the STREAM, BBS, TUG, and 6MWT and for fastest gait speed. Following a control period of no treatments, we noted detectable declines in the BBS and STREAM scores, with retention of gait speed, 6MWT distance, and time to complete the TUG test. After resumption of the PT-only intervention, detectable losses were seen in the fastest gait speed. The final intervention period of PT + onabot resulted in detectable gains in gait speed and 6MWT distance. Kinematic measures demonstrated improvements in LE joint excursions, yet all gains were within the margin of measurement error.
Conclusions: Selective use of onabot combined with intensive PT can contribute to improvements in functional outcomes in individuals with significant poststroke chronic impairments.
Clinical Relevance: Functional benefits from intensive PT in patients with chronic poststroke spasticity may be enhanced with intermittent and selective use of onabot injections.
NeuroPhysZOU: Benefits of a Pro Bono Neurological Physical Therapy Clinic
J.B. Krug, L. Hughes, L. Sureck, K. Wideman, R. Mueller, Physical Therapy Program, University of Missouri, Columbia, Missouri.
Purpose: A pro bono clinic (NeuroPhysZOU), located in the University of Missouri (MU) PT Department, was established in September 2012. NeuroPhysZOU offers PT services to underinsured patients with neurological diagnoses located in central Missouri. This report describes benefits of this clinic.
Description: NeuroPhysZOU utilizes MU PT Program space weekdays and students volunteer for an ongoing 15-week time slot.
Equipment Already in Place: Theraband, BOSU ball, rocker board, Body-weight Support Treadmill, Functional Electrical Stimulation units, Balance Master system. A Standing Frame and Hi-Lo mat table were purchased using donations. MU PT students participated 1 to 2 hours/week. Two student PTs (combination of a first-year and a second- or third-year student) were assigned to each client with a PT supervising. Each client was seen 1 to 2×/week. Referral sources included Columbia area physicians and PT clinics.
Summary of Use:
Outcomes: The clinic ran for 15 weeks resulting in 211 visits for 17 patients. There were 21 cancellations and 7 “no-shows.” A variety of diagnoses were seen including cerebral vascular accident, traumatic brain injury, supranuclear palsy, paraneoplastic syndrome, Huntington's disease, and hydrocephalus. Fifty-eight MU PT students participated throughout the semester. (Data on student perceptions are currently being evaluated.)
Discussion: NeuroPhysZOU was developed as a way to serve underinsured neurological clients. Free PT services were made available to clients requiring ongoing PT who could not access this for financial reasons.
Treatment: Skilled interventions appropriate to neurological clients including gait training and balance activities. Clients demonstrated functional progress, even years postonset. Additional benefits: education and experience for PT students; they gained valuable experience performing neurological examinations, developing plans-of-care, which addressed client goals and appropriate treatment plans, and documentation. Due to neurological affiliations being limited, students have limited exposure to this population. This activity provided an opportunity to increase the students' level of comfort and PT skills. Also, students worked with a variety of diagnoses including challenging and rare conditions. Students reinforce these findings stating “NeuroPhysZOU has provided more hands-on experience and, the more the better” and “We get to work with people with variety of diagnoses so we become more comfortable in this setting.”
Summary: Benefits of this neurological pro bono clinic: (1) under/uninsured patients receive necessary ongoing skilled PT services and (2) students receive valuable experience seeing a variety of neurological diagnoses, instruction from experienced PTs, and practice in examining a patient, developing plans-of-care, providing skilled treatment, and documenting their sessions.
Importance to Members: This report illustrates the community service and educational benefits of a neurological pro bono clinic and is a model for a clinic that is mutually beneficial to underserved populations and students.
Home-Based Robot-Assisted Ankle Rehabilitation for Chronic Stroke Survivors
R. Madden, D. Gordon, S. Peterson, N. Schlictman, J. Lynskey, Physical Therapy, A. T. Still University, Mesa, Arizona.
Purpose/Hypothesis: Stroke is the leading cause of disability in the United States. Foot drop, a major sequela associated with stroke, contributes to locomotor impairments. Robot-assisted repetitive task practice is one approach that has been shown to improve lower extremity function and locomotion in stroke survivors. Robotic training, however, is typically confined to large clinics or research laboratories that few patients have access to. The purpose of the current study was to investigate the effects of home-based robot-assisted ankle rehabilitation on strength, locomotion, and quality of life in chronic stroke survivors.
Number of Subjects: Four.
Materials/Methods: This study used a single-group repeated-measures design. Isometric dorsiflexion strength, locomotor function, balance, and quality of life were assessed 3 times during a 2-week baseline period, 3 times during a 12-week intervention period, and once after a 4-week follow-up period. The intervention consisted of three 60-minute home-base robot-assisted training sessions (Foot Mentor, Kinetic Muscles Inc.) per week for 12 weeks. Use and performance data from the robotic device was monitored remotely and feedback was given weekly via telephone.
Results: All 4 participants adhered to the intervention protocol with no reports of adverse events. All 4 participants demonstrated increases in strength, gait speed, gait distance, and quality of life over time. At week 12, maximal isometric dorsiflexion force increased by an average of 37%, gait speed increased by an average of 0.2 m/s, distance on the 6 minute walk test increased by an average of 34.6 m, and the physical function composite score of the stroke impact scale increased by an average 7.5 points. Limited carryover was observed 4 weeks after the cessation of treatment. No consistent improvements in balance, as measured by the limits of stability test on the Balance Master (Neurocom), were observed.
Conclusions: Home-based robot-assisted ankle rehabilitation improves strength, locomotor function, and quality of life in chronic stroke survivors. Continued treatment, however, may be required to maintain the improvements. In addition, balance did not appear to be affected by this intervention.
Clinical Relevance: In the changing landscape of health care, it is important to investigate alternative methods for delivering physical therapy. Home-based robotic interventions are one such methodology falling under the heading of telerehabilitation. The results presented here provide preliminary evidence supporting the use of home-based robotics for the treatment of distal lower extremity dysfunction in chronic stroke survivors.
Comparison of an Advanced Ground Reaction Design Ankle Foot Orthosis and an Articulated Ankle Foot Orthosis on Gait and Balance in Individuals With Hemiparesis Following Stroke
J. Seale, Physical Therapy, The University of Texas Medical Branch at Galveston, Galveston, Texas. J.L. Hale, Physical Therapy, Texas State University, San Marcos, Texas. G. Olivier, Physical Therapy, University of Utah, Salt Lake City, Utah.
Purpose/Hypothesis: To compare the effects of 2 orthoses on gait and balance in persons with hemiparesis.
Number of Subjects: 10.
Materials/Methods: Inclusion: (1) able to walk 10 ms without assistance, (2) identified as appropriate for orthotic management, and (3) ≤ 3/5 Manual Muscle Test grade in affected plantarflexors. Exclusion: premorbid condition that affected walking. Subjects were provided a custom articulated AFO (AAFO) and a custom advanced ground reaction design AFO (GRAFO). The AAFO blocked plantarflexion, allowed free dorsiflexion, and provided mild transverse plane, inversion, and eversion control. The advanced GRAFO was a Dynamic Bracing Solutions Balancer™. Triplanar control of the limb was achieved through a segmented weight bearing casting technique, specific cast modifications and alignment parameters, intimate fit, and very rigid materials. Walking function and balance were assessed with the 10-m walk (10mW), 6 minute walk test (6MWT), and Timed Up and Go (TUG) by a blinded evaluator with subjects wearing shoes only, in the AAFO, and in the advanced GRAFO (order randomized).
Results: One subject's data were excluded due to extreme differences from remaining cohort. Remaining 9 subjects had mean age of 54.8 years and mean time since stroke of 3.53 years. There was a statistically significant difference between the no AFO and the AAFO condition for all outcomes (TUG, 10mW, 6MWT, P = 0.28, 0.28, and 0.008, respectively). A statistically significant difference was found between no AFO and advanced GRAFO in the 6MWT (P = 0.008) and 10mW (P = 0.028). No statistically significant differences were found between the AAFO and the advanced GRAFO for any outcomes. Observational analysis revealed that most subjects hyperextended the knee during stance in no AFO condition. This gait deviation was not fully corrected with the AAFO but was normalized with advanced GRAFO. Three of the 9 subjects had immediate positive responses to the advanced GRAFO, with the greatest improvements in all 3 outcomes occurring when using the advanced GRAFO. These 3 subjects had an average increase of 57.5 m in 6MWT, 0.19 m/s in 10 mW, and 14.87 seconds in TUG between the AAFO and advanced GRAFO.
Conclusions: An AFO immediately improves gait and balance in persons with hemiplegia. Some persons with plantarflexor weakness have superior immediate improvement from an AFO that controls dorsiflexion and plantarflexion compared to an AFO that only limits plantarflexion. The advanced GRAFO appeared to normalize knee joint angles on the hemiplegic side, while the traditional AAFO did not, and the advanced GRAFO appeared to have the greatest impact on walking endurance. Further study of this design is warranted.
Clinical Relevance: Orthotics are commonly used in persons with stroke, but the type most often used may not address all gait impairments. This pilot study suggests that providing rigid control of the lower leg may lead to immediate improvements in gait, balance, and stance phase stability.
Neural Activity During Imagined Walking in People With Parkinson Disease
D.S. Peterson, K.A. Pickett, R. Duncan, G.M. Earhart, Program in Physical Therapy, Washington University, Saint Louis, Missouri.
Purpose/Hypothesis: Our goal was to measure brain activity (via functional magnetic resonance imaging; fMRI) during simple (forward) and complex (backward walking and turning) imagined gait tasks in people with Parkinson's disease (PD) with and without freezing of gait (FOG) and healthy controls. We hypothesized that brain activity would be altered in PD compared to controls, and in freezers compared to nonfreezers. We also hypothesized that complex gait tasks would result in more pronounced differences between PD and controls and between freezers and nonfreezers.
Number of Subjects: Twenty healthy adults (mean age ± SD = 66.6 ± 7.6 years), 9 people with PD who do not experience freezing (nonfreezers; 62.7 ± 7.5), and 9 people with PD who do experience freezing (freezers; 66.6 ± 6.7).
Materials/Methods: Subjects imagined forward walking, backward walking, and turning in a small (0.6-m radius) circle during fMRI. Blood oxygen level dependent (BOLD) signal was measured during alternating imagined gait tasks and rest periods. BOLD signal was also assessed during imagined standing. Imagined stand data were subtracted from imagined gait data to control for brain activity associated with first-person imagery. A region-of-interest analysis was conducted to quantify changes in BOLD signal in 9 locomotor regions: bilateral supplementary motor area (SMA), bilateral putamen, bilateral globus pallidus (GP), bilateral mesencephalic locomotor region (MLR), and a midline cerebellar region just anterior to the fastigial nuclei (cerebellar locomotor region; CLR).
Results: Imagined walking resulted in a greater BOLD signal change compared to stand in controls (all regions), nonfreezers (all regions), and freezers (MLR only). PD showed a direct correlation between overground gait speed and BOLD signal in all regions except the CLR, indicating smaller BOLD signal change predicted worse gait function. Compared to controls, PD exhibited reduced BOLD signal change in the left GP during imagined gait (F(1,36) = 12.8; P = 0.001). A group-by-task interaction was observed in the right SMA (F(2,72) = 3.3; P = 0.042), such that PD exhibited higher change in BOLD signal during turning than controls. Within the PD group, BOLD signal change in the CLR was lower among freezers than nonfreezers during imagined gait (F(1,14) = 17.7; P = 0.001).
Conclusions: These results suggest reduced signal change in the basal ganglia may represent global PD pathology, while reductions in cerebellar signal may relate particularly to FOG. Further, the direct correlation between BOLD signal change and gait function suggests increased neural activity may be related to improved walking.
Clinical Relevance: This work and future studies to identify regions associated with dysfunction and freezing may inform targeting of surgical interventions such as deep brain stimulation to alter brain signals and improve gait. Our results also suggest that neuroimaging measures are related to gait performance. This finding suggests that fMRI may be used to enhance understanding of atypical gait characteristics in other clinical populations and help inform rehabilitation approaches.
Performance of Single Task and Dual Task Postural Control Measures in Subjects With and Without History of Concussion
M. Furtado, J.M. McGaugh, D. Wild, J. Bourgeois, J. Lemoine, T.E. Scott, C. Davenport, Physical Therapy, UTMB, Galveston, Texas.
Purpose/Hypothesis: Concussion is an injury that poses widely publicized challenges in our youth. Many states mandated baseline testing of athletes in a cognitive and physical domain at the beginning of every school year. Recent literature advocates that baseline testing should include a postural control measure and symptom history questionnaire in addition to cognitive assessment. Moreover, emerging evidence suggests that student athletes have significant deficiencies in the ability to divide attention or perform a dual task after concussion. Physical performance testing that includes dual tasking may provide a more sensitive measure of injury recovery, and we hypothesize there to be a difference between traditional single-task and dual-task activities. The purpose of this study was to gather data on postural control measures with and without dual tasking in a random sample of intermediate and high school student athletes.
Number of Subjects: 26.
Materials/Methods: Healthy student athletes aged 11 to 18 years were recruited at a preparticipation examination (PPE) screening. Subjects received a written questionnaire upon enrollment, which provided demographic information and asked questions regarding concussion history and concussion symptoms following a hit to the head. Subjects then performed 2 postural control measures, the Balance Error Scoring System (BESS) and the computerized modified Clinical Test of Sensory Interaction of Balance (m-CTSIB). Two trials were performed: (1) the standard single-task BESS and m-CTSIB followed by (2) a dual-task condition on the BESS and m-CTSIB in which subjects were provided an adapted Procedural Auditory Task to perform during the measure.
Results: The results of the m-CTSIB demonstrated that there is a relative increase in sway with each progression of the testing conditions in both single- and dual-task testing conditions. (standard: condition 1: 0.84 ± 5.3; condition 2: 1.07 ± 0.43; condition 3: 1.29 ± 0.72; condition 4: 2.96 ± 0.94) (dual task: condition 1: 0.96 ± 0.56; condition 2: 1.23 ± 0.56; condition 3: 1.20 ± 0.37; condition 4: 2.81 ± 0.78). There was no statistical difference between single- and dual-task testing conditions for any of the testing conditions (P > 0.05). The BESS showed similar results between the 2 testing conditions, with 17.11 ± 8.86 errors with the single-task assessment and 17.38 ± 9.57 errors with dual tasking (P = 0.73).
Conclusions: Sway increased expectedly throughout conditions in both single-task and dual-task testing. The sample included student athletes with and without history of concussion or symptoms who were all asymptomatic on testing date, suggesting that both measures may yield similar results at baseline.
Clinical Relevance: With evidence emerging over the deficiency in dual tasking following a concussion, testing may need to include a dual-task postural control assessment to establish physical performance baseline standards in student athletes at risk for concussion in season.
Effects of Botulinum Toxin Injections Into the Rectus Femoris Muscle on Gait Function in Stiff Knee Gait Following Brain Injury or Stroke
C.C. Harro, Grand Valley State University, Grand Rapids, Michigan. K. Chapin, M. Bontreger, K. Campbell, S.C. Bloom, Mary Free Bed Rehabilitation Hospital, Grand Rapids, Michigan. R. Karim, Lakewood Hospital, Cleveland Clinic, Cleveland, Ohio.
Purpose/Hypothesis: Stiff knee gait (SKG) is a common impairment following brain injury or stroke, which causes problems with limb clearance and an inefficient walking pattern. Functionally, this deviation results in slowed walking velocity and increased fall risk, limiting safe community mobility. One key contributor to SKG is Rectus Femoris (RF) spasticity, which acts as a constraint to knee flexion in pre- and early swing phase. Botulinum Toxin (BTX-A) injections to RF have been proposed for reduction of focal spasticity, but previous research is inconclusive regarding its effect on gait mechanics and function. The purpose of this double-blinded randomized controlled trial was to examine if there was a significant difference in swing phase knee kinematics and gait function between the experimental (BTX-A injections) and placebo (saline injections) groups in individuals with SKG following brain injury or stroke.
Number of Subjects: Nineteen subjects, mean age = 48.9 (16.2) years, who were > 6 months postinjury, were independent ambulators with or without assistive device, and met predefined criteria for SKG based on computerized gait analysis (CGA); were stratified based on diagnosis and randomly assigned to experimental (n = 10) and placebo (n = 9) groups.
Materials/Methods: A physiatrist who was blinded to group assignment and to vial solution injected RF at 4 sites with either BTX-A (200 units) or saline solution (2 cc). CGA using the Vicon Motion Analysis system, 6-Minute Walk test (6MWT), and timed stair ascent/descent were measured by raters blinded to group assignment at baseline, 1-month, and 4-month posttreatment. Dependent variables were peak knee flexion and peak knee flexion velocity in preswing and swing phase, distance walked and average gait speed in 6MWT, and time to complete stairs.
Results: Independent t tests revealed no statistically significant differences between groups at baseline for demographic characteristics or any dependent variables. Repeated-measures ANOVA revealed no statistically significant difference (P < 0.05) between BTX-A and placebo groups for any of the dependent measures at 1-month and 4-months posttreatment. Additionally, no differences were found in temporal-spatial gait measures between groups.
Conclusions: BTX-A injections to RF muscles showed no measurable effects on improving swing phase knee mechanics or gait function in individuals with SKG following stroke or brain injury. These CGA findings contrast previous research, which may be due to methodological and clinical cohort differences. However, the findings regarding lack of change in functional gait measures are consistent with previous research.
Clinical Relevance: The underlying cause of SKG is multifactorial, influenced by both biomechanical and neural components. Addressing the biomechanical constraint alone may be insufficient to change neuromotor learned gait patterns. Future research should investigate the combined effect of BTX-A followed by intensive gait training on improving gait outcomes in individuals with SKG.
Balance Treatment for an Individual With Peripheral Neuropathy Using Interactive Graphic Art Feedback
L. Worthen-Chaudhari, Physical Medicine and Rehabilitation, The Ohio State University, Columbus OH, Ohio. M. Butler, Outpatient Neurorehabilitation, The Ohio State University, Wexner Medical Center, Columbus, Ohio.
Background and Purpose: Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating issue associated with compromised balance and gait (Visovsky et al. 2007). No research to date has addressed the dose response for balance training among individuals with CIPN. We report movement dose and clinical outcome (Berg Balance Scale) for one individual with CIPN undergoing balance training within a neurorehabilitation outpatient clinic. Standard balance training exercises were augmented by using interactive arts feedback technology designed to quantify movement dose as well as to enhance patient engagement. Interactive arts paradigms have been shown feasible for use among neurorehabilitation patients with a wide range of movement and cognitive deficits (Worthen-Chaudhari et al., in press) and have the potential to augment care of individuals who require concentrated doses of movement therapy. The purpose of this case study was to provide initial data about the dose response to augmented balance training in a patient with CIPD.
Case Description: Patient: 62-year-old male, 3 months postdischarge from chemotherapy treatment for Stage IV Hodgkins lymphoma, diagnosed with CIPD and associated gait and balance deficits. Intervention: 6 sessions of augmented balance training over 3 weeks, embedded within therapy sessions of 30- to 60-minute duration. Measure: pre/post Berg Balance Scale scores.
Outcomes: Berg Balance score improved from 40 to 45. Total time spent performing balance exercises, over 6 sessions guided by a physical therapist, was 2 hours plus 2 minutes and 37 seconds. Per session, duration of exercise delivered (min:sec) and mean exercise bout duration were as follows: (1) 9:00 and 2:15; (2) 16:21 and 2:03; (3) 24:00 and 2:00; (4) 21:09 and 1:55; (5) 20:20 and 1:27; (6) 31:47 and 1:35. Mean exercise bout length, overall, was 1 minute 53 seconds (range of 6 seconds to 4 minutes 18 seconds) and decreased as exercises got harder over the course of the 6 sessions. The patient tended to rest for the same amount of time as the exercise bout just completed. For instance, if he worked for 1 minute before requiring a rest, he would rest for approximately 1 minute before commencing the exercise again without therapist prompt.
Discussion: Balance deficits may be interveneable among individuals with CIPN. This individual performed therapeutic balance exercise for 20 minutes per session, in sets of concentrated exercise performance paired with equivalent duration of rest. A 5 point change on the Berg Scale, that crossed the increased falls risk threshold of <45 (Thorbahn et al. 1996), was attained with 6 such therapy sessions. The effect of standard balance recovery exercises augmented with interactive arts feedback was comparable in magnitude to the effect of a longer novel balance intervention previously conducted among individuals with Parkinson's disease (Hackney et al. 2007). More study of novel balance interventions for individuals with CIPN is warranted; these data provide a starting point for dose-response analysis.
Intensive LE Task Specific Practice Approach to Improving Gait and Functional Balance for Individuals With Chronic Stroke: A Pilot Study
H. Hamilton, K. Hine, J. Freund, Elon University, Elon, North Carolina.
Purpose/Hypothesis: The purpose of this case report was to describe the effects of task specific training in an adult with impaired gait and balance secondary to a brainstem stroke. There is limited evidence on physical therapy for persons with brainstem stroke.
Number of Subjects: 1.
Materials/Methods: The patient was a 61-year-old male who sustained a cerebral vascular accident of the pons approximately 1.5 years ago. He had impaired vision due to constant vertical nystagmus and bilateral ataxia (left worse than right), but good strength in both upper and lower extremities. He walked with a single point cane and had a history of multiple falls. As a volunteer in a university physical therapy course, he attended 10 of 10 sessions, 1 hour, twice a week for 5 weeks. Interventions included walking on a treadmill with body weight supported, overground walking on various surfaces, stair training, bending and reaching activities and a home exercise program of repetitive sit to stand and step ups.
Results: The following measures improved (pre- to postintervention): fast gait speed (1.21-1.35 m/s), TUG (15.67-14.0 seconds), Berg (43/56-45/56 points), 6 minute walk distance (372.32-394.25 m), and stairs self-selected speed (20 steps with 2 landings) time up (45-36 seconds) down (40-26 seconds). He also rated his walking ability as +4 (a great deal better) on an 11-point Global Rating of Change (GROC) Scale at postintervention. There was no change in his self-selected gait speed (0.99 pre to 0.97 m/s post) or Stroke Impact Scale (70%). He reported no falls during the intervention period.
Conclusions: The patient's improved fast gait speed exceeded the minimal detectable change (MDC). Improvements in self-selected gait speed, TUG, Berg and 6-minute walk distance did not exceed MDC values. Self-reported improvement in gait may have been related to improved fast gait speed and stair climbing efficiency.
Clinical Relevance: Task specific training may be effective in improving balance and gait in individuals with chronic brainstem stroke.
Does Supine Versus Standing Position Change Joint Torque Coupling Patterns in the Paretic Lower Extremity?
R. Lopez-Rosado, S.M. Adkins, M.D. Gordon, C. Montejano, J. Dewald, Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois. N. Sánchez, Biomedical Engineering, Northwestern University, Chicago, Illinois.
Purpose/Hypothesis: Standard supine positioning is usually employed when assessing motor performance of the paretic lower extremity (LE). However, most activities of daily living are performed in standing. Assessments performed in supine may not account for the effect of vestibular drive on both impairment level and losses of independent joint control resulting in abnormal synergies. The purpose of this study was to compare the magnitude of the joint-torque coupling responsible for abnormal synergies in standing versus supine. We hypothesized that in a supine position a decreased vestibular drive would diminish the presence of abnormal joint torque coupling patterns.
Number of Subjects: 7 individuals with chronic poststroke hemiplegia (6 males, 1 female; 5 right, 2 left hemiplegia; mean age = 55.5 ± 5.6 years; mean time poststroke = 5.5 ± 2.7 years) were recruited. Impairment level and functional ability of subjects were measured by the LE Fugl-Meyer, Berg Balance Scale, and 10 Meter Walk Test.
Materials/Methods: The subjects' paretic lower extremity (LE) was rigidly secured to a custom isometric frame at the foot and mid-thigh. Both contact points were instrumented with 6 degree of freedom (DOF) sensors. Joint angles were: 30° hip and knee flexion (flex), 10° hip abduction (abd), 0° ankle PF. EMGs were placed on 10 muscles of the paretic LE. Subjects were instructed to perform isometric maximum voluntary torques (MVT) in a randomized order in 8 different directions: hip abd/add, hip flex/ext, knee flex/ext, ankle dorsi/plantar flex. Visual feedback of torque production was provided. MVT data was computed online from the two 6-DOF sensors for both the primary (torques in the instructed direction) and secondary (spontaneous) torques at other joints. Subjects performed these tasks in standing and supine positions. Paired t tests were used to compare differences in magnitude in the primary torques in upright versus supine. An ANOVA was used to compare magnitudes of secondary torques generated during MVT in a primary direction.
Results: Joint torque and EMG data revealed that body orientations did not significantly change secondary torques. However, a trend (P = 0.1) of greater hip abd torque generation was quantified in supine, also supported by EMG activity of hip abductors.
Conclusions: Joint torque patterns did not differ significantly in standing versus supine position. However, the ability to generate hip abd torques may be affected. Increasing the number of subjects could further test this preliminary finding as well as a future implementation of a dual task protocol, where the effect of submax hip ext/flex moments on the ability to generate maximum hip abd/add moment is being studied.
Clinical Relevance: Our preliminary results indicated that supine positioning on the assessment of the paretic LE does not have a great impact on the ability to generate MVTs, nor influence associated joint torque couples. Consequently, supine positioning may be safe yet effective for paretic LE assessment and for the implementation of paretic hip abduction strengthening interventions.
Impairments Contributing to Gait Variability in Community-Dwelling Chronic Stroke Survivors
C.K. Balasubramanian, D. Saracino, Clinical and Applied Movement Sciences, University of North Florida, Jacksonville, Florida. E.J. Fox, Physical Therapy, University of Florida, Brooks Rehabilitation, Gainesville, Florida.
Purpose/Hypothesis: Gait variability (GV), defined as variations in gait parameters from one step to the next, is altered in several clinical populations and shown to be an independent predictor of future falls. Poststroke, GV is reported to be increased in spatiotemporal (ST) parameters. However, underlying causes of this increased variability are not understood. The purpose of this study was to investigate the contribution of selected impairments to variability in ST parameters to gain insights into the causes of poststroke GV.
Number of Subjects: Twelve persons (57 ± 19 years) with chronic hemiparesis.
Materials/Methods: Participants had unilateral weakness and were able to walk without manual assistance or a walker. GV was assessed as participants walked at their usual and fastest speeds over an instrumented walkway that automated the measurement of ST gait parameters. Assessed impairments included muscle strength (measured using a hand-held dynamometer), hemiparetic severity (using the lower-extremity Fugl-Meyer Assessment [LEFMA]), dynamic balance (measured by the Dynamic Gait Index [DGI]), cognition (measured using modified Mini-Mental State Exam and the Trail Making Test [TMT]), sensation (measured using the Nottingham Sensory Assessment) and quality of life (assessed by Stroke Impact Scale [SIS]).
Results: Weakness in paretic hip abductors, ankle dorsi- and plantar-flexors were significantly (r = 0.82-0.94, P < 0.01) correlated with stance and swing time variability. Stance and swing time variability also correlated significantly (P < .01) with LEFMA scores (ρ = −0.68, −0.75), impaired tactile and kinesthetic sensations (ρ = −0.74, −0.83), DGI scores (ρ = −0.90, −0.91), and SIS scores (ρ = −0.72, −0.74). On the other hand, step length variability correlated with one of the cognitive measures: TMT-Part B scores (ρ = 0.60) and the DGI scores (ρ = −0.89). Stride time variability correlated only with the DGI scores (ρ = −0.77), whereas stride width variability did not correlate with any impairments (P > 0.05).
Conclusions: Increased variability in specific gait parameters could indicate specific underlying problems. Stance and swing time variability uniquely correlated with muscle strength, hemiparetic severity, and sensation, whereas step length variability correlated with cognitive impairments. Importantly, variability in all ST parameters correlated strongly with DGI scores, indicating that impaired dynamic balance could be an essential cause of variable gait.
Clinical Relevance: Variability in ST parameters should not be generically termed and types of GV should be specified. Specific patterns of GV may imply different underlying causes (like increased stance time variability may be due to muscle weakness whereas impaired cognition might manifest as increased step length variability). Dynamic balance seemed to be a common underlying cause for increased variability. Individually designed therapies based on the type of GV may result in greater improvements of walking function poststroke.
Altered Reflex Contributions to Increased Muscle Activation During Eccentric Contractions in Individuals With Incomplete Spinal Cord Injury
H.E. Kim, Graduate Program in Neuroscience, University of Illinois at Chicago, Chicago, Illinois. C.K. Thompson, Department of Physiology, Northwestern University, Chicago, Illinois. T. Hornby, Department of Physical Therapy, University of Illinois, Chicago, Illinois.
Purpose/Hypothesis: Recent data suggest that individuals with incomplete spinal cord injury (SCI) activate the quadriceps muscles more (ie, produce higher central activation ratio values) during eccentric maximal voluntary contractions (MVCs) than other modes of muscle contraction. This finding directly contrasts studies of neurologically intact individuals who typically demonstrate depressed activation during eccentric contractions. Intact subjects also demonstrate depressed H-reflexes during both passive and active muscle lengthening, indicative of inhibitory spinal mechanisms. The purpose of the current study is to expand our examination of the neural control of eccentric contractions in individuals with SCI by testing different muscle groups (plantar-/dorsiflexors) and quantifying voluntary activation and efficacy of Ia-α motoneuronal transmission (via H-reflex testing) during plantarflexor shortening and lengthening. We hypothesize that the presence of hyperexcitable stretch reflexes, common within this population, will contribute to decreased inhibition of the agonist motor pool and, hence, increased muscle activation during active lengthening.
Number of Subjects: 3 males (ongoing data collection).
Materials/Methods: Subjects sat with the tested knee flexed 40° and the ankle moved through a 30° range (0°-30° plantarflexion) at 20°/s. Torque, surface electromyography (EMG), and position signals were recorded during all trials. Soleus H-reflexes were elicited by stimulation of the tibial nerve at a constant reference angle of 15° plantarflexion. Recruitment curves were built during passive shortening and lengthening. Superimposed stimulation intensities utilized during MVCs include Hmax (intensity eliciting largest H-reflex) and Mmax (intensity producing largest M wave). Stability of stimulation conditions was monitored with reference M waves. Interpolated twitch technique was used to estimate voluntary activation.
Results: Peak torque, gastrocnemius EMG (root mean square values), and voluntary activation levels were higher during eccentric than concentric plantarflexion MVCs (+193%, +8.4%, and +9.5%, respectively), while tibialis anterior (TA) EMG activity was lower (−9.0%). Agonist (TA) EMG activity during maximal eccentric dorsiflexions was also greater than concentric values (+73.5%). Soleus H-reflexes were larger during passive lengthening than shortening in 2 of the 3 tested subjects. Larger H-reflexes (using Hmax intensity) were also observed during lengthening MVCs (+8.9%).
Conclusions: Individuals with motor incomplete SCI demonstrate unique neural activation strategies during eccentric contractions. Improvements in measures of central drive (voluntary activation, EMG) during eccentric MVCs appear to be correlated with increased efficacy of Ia-α motoneuronal transmission during muscle lengthening.
Clinical Relevance: Enhanced motor output during eccentric contractions may potentially be harnessed by specific interventions to more effectively increase strength in individuals with incomplete SCI.
Functional and Gait Predictors in Persons With Parkinson's Disease Receiving Home-Based Rehabilitation
F.Y. Asiri, P.J. Sparto, S. Whitney, Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania. G.F. Marchetti, Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania. J. Ellis, L. Otis, Gentiva Health Services, Atlanta, Georgia. F.Y. Asiri, Rehabilitation Sciences, King Khalid University, Abha, Saudi Arabia.
Purpose/Hypothesis: The purpose of this retrospective cohort study was to explore the effectiveness of home-based rehabilitation on functional (ADL) and gait performance for persons with Parkinson's disease and to identify the factors that affect ADL and gait outcomes at the end of care. It was hypothesized that age, baseline gait speed, memory deficits, cognitive impairment, and emotional factors (anxiety and depression) would be negatively associated with improvements in function and gait performance after HHC services.
Number of Subjects: 503 subjects, the mean age was 80 ± 7.6 years and 50.1% of subjects were female (n = 252).
Materials/Methods: Subjects were included in the program if they had a history of falls within the last year and/or one or extra modifiable fall risk factor and were included into the analysis if they were referred for home-care rehabilitation with the international classification of disease code version 9 (ICD-9) indicating Parkinson's disease. The primary outcome measures were the functional items of the Outcome and Assessment Information set version C (OASIS-C composite scores) and gait speed. The ADL composite scores for functional (ADL) items in the OASIS-C were used to measure functional performance at the end of care. The ADL scores were measured as the sum of the transformed scores in nine individual OASIS ADL items (M01800-1870). Associations between factors predictive of improvement and mean change in ADL composite scores and gait speed were identified using analysis of covariance and multivariate linear models.
Results: Subjects showed improvement in both mean ADL composite scores (1.58 ± 1.25 points) and gait speed (0.15 ± 0.23 m/s) after an episode of care. The best predictor factors for the change in ADL predicted 23% percent of the variance of the change in ADL scores. The final model included baseline ADL scores (P < 0.001, R2 = 0.215), memory deficits (P < 0.001, R2 = 0.025), and baseline gait speed (P = 0.003, R2 = 0.017). Change in gait speed scores was predicted by the following factors: age (P = 0.007, R2 = 0.015), baseline gait speed (P < 0.001, R2 = 102), and anxiety status (P = 0.029, R2 = 0.014) that explained 13% of the variance of gait speed at discharge from the HHC. Cognitive function and memory deficits had significant effects on adjusted change in ADL, while anxiety status had significant effects on adjusted change gait speed scores.
Conclusions: Subjects with Parkinson's disease improve after receiving home-based rehabilitation. ADL and gait speed at the start of care, plus memory deficits, were the best subset of predictors of ADL improvement. Baseline ADL and gait speed were positively associated with ADL improvement. Furthermore, age, anxiety status, and gait speed at the start of care were predictive factors for gait speed improvement at discharge. Age and gait speed at the start of care were negatively associated with gait speed improvement.
Clinical Relevance: Considering the predictive factors in people with Parkinson's disease are important for home health clinicians for better intervention planning and goal setting
Gait Smoothness During Treadmill Walking in Parkinson's Disease
K. Lowry, S. Perera, Department of Medicine, Division of Geriatrics, University of Pittsburgh, Pittsburgh, Pennsylvania. J. Bellanca, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania. J. VanSwearingen, J.S. Brach, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania.
Purpose/Hypothesis: Gait smoothness, derived from trunk accelerations, has been proposed as a quality indicator of the global motor control of walking. Persons with PD have exhibited reduced smoothness during overground walking compared to healthy adults, even when spatiotemporal performance was similar between groups. While treadmill training has been shown to improve spatiotemporal performance in persons with PD, we do not know the effect of treadmill walking on the smoothness (motor control) of walking in persons with PD.
Number of Subjects: Ten individuals with moderate stage idiopathic PD (PD: Modified Hoehn & Yahr Stage between 2 and 3) and 14 older adults (>65 years of age) without PD participated (OA).
Materials/Methods: One, 3-minute preferred speed walking trial was performed on a large custom computer-controlled treadmill with a safety harness system. A 3-D optical motion capture system and reflective markers were used to collect bilateral heel and toe trajectory data. Linear acceleration of the body was measured in the anteroposterior (AP), vertical (VT), and mediolateral (ML) directions using a tri-axial accelerometer secured over the L3 segment of the lumbar spine. The spatiotemporal variables derived were the means and standard deviations of step time, width, and length. Smoothness of walking was quantified by harmonic ratios (HRs) derived from AP, ML, and VT trunk accelerations. In addition, overground preferred gait speed was obtained from the average of 2 timed 4 m corridor walks.
Results: There were no group mean differences in overground preferred speed, preferred treadmill speed (PD, 1.16 m/s, OA, 1.19 m/s, P = 0.75), or treadmill walking mean step time, width or length. Persons with PDs exhibited greater step length variability, but lesser step width variability than OAs. During treadmill walking, adults with PD compared to OAs exhibited less smoothness in all directions of motion: mean AP smoothness (PD HR, 2.16, OA, HR 3.02; P = 0.01), mean ML smoothness (PD, HR, 1.89, OA, HR, 2.33; P = 0.05), and mean VT smoothness (PD, HR, 2.66, OA, HR, 3.44; P = 0.03).
Conclusions: Despite similar mean spatiotemporal performance during treadmill walking compared to healthy OA, persons with PD exhibited reduced smoothness in all directions of motion, suggesting underlying motor control dysfunction persisted during this short bout of treadmill walking.
Clinical Relevance: Given the current emphasis on engaging in exercise, including walking, early in the course of PD, it is important to examine measures of gait performance that are more sensitive than spatiotemporal gait characteristics to the underlying motor control abnormalities in PD. We suggest smoothness is an important measure of motor control and should be used in future clinical trials to quantify changes in control as a result of gait interventions in persons with PD.
Management of Posttraumatic Agitation due to Brain Injury: A Case Study Report
R. Myers, Lebanon Valley College, Annville, Pennsylvania. L. Krych, C. McGrath, MossRehab, Elkins Park, Pennsylvania.
Background and Purpose: Agitation is a common sequela associated with traumatic brain injury (TBI) with a prevalence of 25% recently reported in a sample of 228 patients with moderate to severe TBI. Clinicians identify that agitation is disruptive to the rehabilitation of individuals post-TBI and interferes with the patient's ability to attain functional goals. Unfortunately, the definition of agitation remains inconsistent among rehabilitation professionals and the methods of assessing and treating agitation in this population vary widely. This report illustrates a case of posttraumatic agitation and the methods employed to define, measure, and successfully treat this patient case.
Case Description: The patient was a 28-year-old male who sustained a TBI as a result of a fall. He was intoxicated at the time of injury with a Glasgow Coma Scale (GCS) score of 3 upon admission to the emergency department. Within 3 days of admission to an inpatient rehabilitation facility, the patient became increasingly agitated requiring supervision at all times and moderate assistance for mobility. Physical therapy treatment of this patient was limited to a structured environment with a consistent schedule and activities with the intent to minimize excessive sensory stimulation. With a pending discharge due to insurance, the team identified the primary antecedent of the agitation was confusion and recommended data collection with the Agitated Behavior Scale (ABS) during a drug trial of lorazepam (Ativan) followed by methylphenidate (Ritalin) to determine the most efficacious medication for discharge.
Outcomes: Data was collected throughout the day using the ABS to determine which medication regimen may be more effective in treating the aggressive behaviors. A scatterplot of multiple total ABS scores collapsed over time for the 4 days the patient was on lorazepam showed ABS scores above 30 indicating moderate to severe agitated behavior. A scatterplot of multiple total ABS scores collapsed over time for the 2 days the patient was on methylphenidate showed ABS scores between 14 and 21 indicating no agitated behavior. The patient was successfully discharged home requiring supervision for mobility on a dose of 20 mg of methylphenidate, twice daily.
Discussion: The use of methylphenidate is not supported in the literature for reducing aggressive behaviors, yet in this case it proved to be effective in reducing agitation. The treatment team's ability to objectively define and measure aggressive behaviors, through use of the ABS, enabled them to trial several medications and determine which one was the most effective within several days. A thorough understanding of methods to define and measure aggressive behaviors is invaluable for the practicing physical therapist working with the TBI population as there are often many treatment options that are utilized before the most beneficial regimen is discovered. An on-off drug trial would have been advantageous in this case to determine if the patient's improvement was due to spontaneous recovery or the medication.
Integration of a Core Strengthening Program to Improve Functional Mobility in a Nonambulatory Patient, Poststroke: A Case Report
L. Gale, J. Mowder-Tinney, Nazareth College, Rochester, New York, United States. D. Beauregard, Timothy McCormick Transitional Care Center at Unity Health System, Rochester, New York.
Background and Purpose: Chronic stroke is the leading cause of serious and long-term disability in the United States. One of the biggest early predictors of functional mobility is trunk control, since trunk control allows the body to remain upright, adjust weight shifts, and perform selective movements during sitting and standing balance. The majority of research focuses on distal limb movements, with little attention on the core/trunk, and lacks specific strategies for the patient who is nonambulatory to guide clinicians. The purpose of this case report was to assess the impact of an integrated core strengthening program into functional activities of a nonambulatory patient, poststroke.
Case Description: The patient was a morbidly obese, 69-year-old male arriving to a skilled nursing facility, following a TIA with left-sided weakness. PMHx was extensive. Prior to admission, patient was receiving 24-hour home care, required one-person assist with transfers and was not ambulating. At evaluation, the patient required 2 to 3 person assist with transfers and was unable to take a step in the parallel bars. The patient received a core strengthening program for 25 to 30 minutes, 5×/wk for 3.5 weeks. Interventions focused on core strengthening exercises incorporated into functional activities (ie, static/dynamic sitting balance and bed mobility). For all interventions, the number of repetitions and intensity varied depending on patient fatigue and quality of movement. These ranged from 1 to 2 sets and 5 to 10 repetitions the first 2 weeks, and progressed to 2 sets of 10 by week 3.
Outcomes: Postural Assessment Scale for Stroke (PASS), Modified Functional Reach Test (MFRT), and bilateral Straight Leg Raise, was used to assess proximal activation. Both the PASS and MFRT are reliable and valid outcome measures used in the assessment for balance and functional mobility in the subacute stroke population. The patient improved both in function and all outcome measures, with significant gains on the MFRT (MDC = 2.65 cm) and an increase in SLR on the affected side.
Discussion: Literature supports the importance of core muscle strengthening; however, it is challenging for the therapist to find optimal ways to find specific integration strategies for a lower-level patient. In both of Karthikbabu's studies, researchers found that exercises activating selective core muscles lead to improvements with core control, balance, and gait. These findings are consistent with the findings of this case report. At time of discharge, the patient had shown improvements in all functional outcome measures. Although the patient continued to require 2-person assist for transfers at the time of his unexpected early discharge, he was performing functional tasks of increased difficulty including standing and ambulation of short distances (up to 8 ft) in the parallel bars, which he was unable to perform prior to admission. Therefore, it may be inferred that integration of the core strengthening program was beneficial.
Effect of Medication on Gait Variables in Multiple Sclerosis
L. Muratori, Physical Therapy, Stony Brook University, Stony Brook, New York. C.L. Spragg, Rehabilitation and Movement Science, Stony Brook University, Stony Brook, New York. M. Gudesblatt, South Shore Neurologic Associates, PC, Patchogue, New York. S. Wu, J. Huang, Applied Mathematics, Stony Brook University, Stony Brook, New York.
Purpose/Hypothesis: To examine the relationship between spatiotemporal measures of gait and disease duration in persons with multiple sclerosis (MS). We propose that spatiotemporal measures of gait will be sensitive to disease progression. Specifically, we hypothesized that individuals with MS would demonstrate increases in step ratio (SR) and double support time (DST) and decreased stride velocity (SV) over time. We further hypothesized that disease modifying drugs would lessen these changes.
Number of Subjects: Data from one hundred and fifteen (115) individuals with MS were evaluated retrospectively for this study.
Materials/Methods: Spatiotemporal measures of gait were collected using the GAITRite instrumented mat. Data collection included step and stride length, swing and stance time, single and double support time, and stride velocity. Data were collected over the course of 2 years. We calculated SR (step length/cadence), DST, and SV across trials and analyzed these variables for change over time. In addition, to determine if medication would affect trending of the measurements, we analyzed type of medication (beta interferons, Copaxone, and Tysabri), with gait changes. That is, we applied a linear mixed model to test whether a significant “treatment-time” interaction exists.
Results: Neither SR nor DST showed a significant association with time or medication. However, SV had a significant tendency to decrease over time (P < 0.001), and specific medications had a strong association with changes in SV (treatment*time interaction: estimated coefficient = −0.009; P < 0.003). With regard to treatment*time interaction effects, further analysis demonstrated individuals using interferon medications (Avonex, Betaseron, and Rebif) showed significantly less change in velocity compared to individuals not taking medication (P < 0.05, 0.02, 0.05, respectively, for the 3 drugs listed).
Conclusions: Objective measures of gait have been used to classify movement in MS for many years. This study demonstrates that velocity is particularly sensitive to change over time. In addition, while the participants in this study were using several different medications, only those using beta interferons demonstrated long-term benefits for the variables measured. Each of the 3 medications in this drug category had a similar impact on velocity, allowing these individuals to maintain a faster stride velocity compared to participants not taking any medication.
Clinical Relevance: Velocity is a sensitive marker of disease progression in MS and appears to be amenable to beta interferon drug therapy. Other disease modifying medications may have benefits not assessed by this study. Therapists should be familiar with types of disease modifying drugs and potential clinical implications when working with patients with MS.
Standard Balance Rehabilitation Training (BRT) vs. Sensory Kinetics Balance System (SKBS) + BRT on Balance and Functional Outcomes in the Mild Traumatic Brain Injury (mTBI) Population
G. Mathur, K. Henry, K. Nance, A. Jayaraman, Max Nader Center for Rehabilitation Technologies and Outcomes, Rehabilitation Institute of Chicago, Chicago, Illinois. A. Heinemann, Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois. B. Mortimer, Engineering Acoustics, Casselberry, Florida.
Purpose/Hypothesis: Dizziness and vertigo are associated with nearly all reported studies of mild traumatic brain injury (mTBI) and are a significant and functionally limiting component of the overall disability. After assessment of disequilibrium, rehabilitation is often a course of physical therapy (PT). Compensation (without immediate sensory feedback) is problematic and prone to patient (and caregiver) interpretation and error, because it may neither address the underlying problem nor have long-term therapeutic benefits. The sense of touch is intrinsically linked with the neuromotor channel, at both the reflex and higher cognitive regions, which makes it uniquely tied to orientation and localization. Vibrotactile arrays are, therefore, intuitive and are an effective sensory feedback pathway. Recent research has also demonstrated that tactile cueing yields significantly faster and more accurate performance than comparable spatial auditory cues. The overall objective of this research effort is to use novel combinations of multimodal sensory-guided feedback (especially tactile) and traditional vestibular rehabilitation to retrain military/civilian personnel suffering balance disorders as a result of mTBI. Our therapeutic goal is to test technology that will return the patient, in the shortest period of time, to a level of balance performance consistent with return to the community.
Number of Subjects: Currently 20 subjects enrolled with chronic mild-moderate TBI. (The goal is 30 by the end of July 2013.) Materials/Methods: Engineering Acoustics Inc. has developed the Sensory Kinetics (SK) Balance System, which provides vibrotactile cueing by providing continuous and instantaneous feedback complimenting their postural and mobility decisions. Patients are randomized in to 2 treatment groups, standard BRT or Device (BRT + SKBS). Outcome measures evaluated at 0, 4 and 8 weeks are CTSIB, Berg Balance Scale, Functional Gait Assessment, 10-m walk and 6-minute walk test, and self-report questionnaires Dizziness Handicap Index (DHI) and Activities Balance Scale (ABC).
Results: Preliminary data indicate improvements in balance and function in both the BRT and BRT+SKBS group. However, the improvements in balance and function were larger in the BRT+SKBS group, and the improvements also occurred earlier.
Conclusions: This study aims to provide evidence on the use of vibrotactile feedback in vestibular rehabilitation. Further, the ability of the brain to reorganize and relearn functional movement activities may provide a potential pathway for the retention of learned functional mobility strategies. The additional sensory input may enhance rehabilitation of the sensory-kinetic and balance systems.
Clinical Relevance: Clinicians may consider integrating visual, somatosensory, and vestibular systems to improve body alignment and balance more efficiently and overall achieving better functional outcomes. We believe that vibrotactile feedback may increase spatial awareness and consequently mobility.
Evaluation and Treatment of Benign Paroxysmal Positional Vertigo for an Adult With an Acute Traumatic Cervical Spinal Cord Injury: A Case Report
J.M. Lamb, E.E. Hussey, Department of Physical Therapy, UW-La Crosse, La Crosse, Wisconsin. N. Van Heuklon, University of Wisconsin Hospital, Madison, Wisconsin.
Background and Purpose: The incidence of benign paroxysmal positional vertigo (BPPV) has been reported to be higher in the traumatic spinal cord injury (SCI) population than in the general population. More specifically, BPPV is 2.87 times more likely to occur following traumatic cervical SCI compared to traumatic thoracic and lumbar SCI. Positional testing is identified as a contraindication for patients who have potentially unstable spines, and yet, based on prevalence, there is a need for safe assessment and treatment of this population. The presence of BPPV reduces a patient's ability to tolerate movement, thus may complicate functional recovery. To diagnose and treat BPPV in a patient with movement restrictions, therapists must modify techniques to ensure safety. In 2012, a standardized approach to these modifications was published. Therefore, the purpose of this case report was to apply the recommended modifications to diagnose and treat BPPV within 1 month of an acute, traumatic cervical SCI.
Case Description: A 52-year-old male was admitted to an acute inpatient rehabilitation unit 2 weeks after sustaining a traumatic cervical SCI and undergoing urgent surgical stabilization. He presented with symptoms of nausea and room-spinning vertigo 21 days after his accident and underwent a variety of diagnostic tests to rule out autonomic dysfunction. Based on documented symptoms in the nursing report, the physical therapist performed a screening to determine if head motion was provoking symptoms, implicating BPPV as a possible explanation. This screening confirmed that BPPV could explain his symptoms; however, a “wait and see” approach was taken due to the subject's spinal precautions. When movement-provoked symptoms reoccurred 4 days later, he was formally evaluated using modified Dix-Hallpike (DH) testing positions and diagnosed with right posterior canal BPPV. Treatment was administered using 2 cycles of the modified canalith repositioning technique (CRT).
Outcomes: The subject demonstrated complete resolution of his BPPV symptoms following the one session of vestibular testing and treatment. Subjectively, patient did not experience any further movement-based limitations to his inpatient therapy progression. To confirm resolution and to be consistent with BPPV clinical practice guidelines, positional testing was repeated 1 week and 1 month later with confirmation of a negative DH assessment.
Discussion: This case report demonstrates the successful application of modifications of the standard assessment and treatment techniques for the diagnosis and treatment of BPPV for someone with posttraumatic movement restrictions due to SCI. It is important for clinicians to become comfortable with these modifications to allow patients in this population to return to full participation in a rehabilitation program. Further research is needed to determine the consistency and value of these modifications in testing and treating for BPPV in SCI subjects with movement restrictions.
The Effects of Vibrotactile Feedback on Postural Sway Under Dual-task Conditions in People With Unilateral Vestibular Hypofunction
C. Lin, P.J. Sparto, S. Whitney, Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania. J.M. Furman, Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania. P.J. Loughlin, M.S. Redfern, Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania. K. Sienko, Mechanical Engineering, University of Michigan, Ann Arbor, Michigan.
Purpose/Hypothesis: Vibrotactile feedback (VTF) has been shown to improve balance performance in people with vestibular hypofunction. Dual-task balance performance can be impaired in people with a vestibular disorder. Consequently, the purpose of the study was to investigate how well individuals with vestibular disorders can utilize VTF to reduce sway during dual-task balance performance.
Number of Subjects: Nine adults (mean age: 54 ± 11 years) who were diagnosed with unilateral vestibular hypofunction were recruited.
Materials/Methods: Seven participants completed the 3-visit experimental protocol consisting of 4 different sensory integration balance conditions lasting 120 seconds (level (L) and sway-referenced (SR) platform with either eyes open (EO) or eyes open in dark (EOD)). The secondary information-processing task was an auditory choice reaction time task (CRT) that required participants to push a button in their right or left hand as quickly as possible to discriminate between tones of different pitch. During the first visit, subjects completed screening tests and were trained in the use of VTF and practiced auditory CRT tasks. During the second and third visits, each of the 16 combination of the conditions (auditory CRT (on/off) * VTF (on/off) * Vision (EO/EOD) * platform (L/SR)) were tested in random order after a short retraining period. The average root-mean-square (RMS) of the center of pressure (COP) in the anterior-posterior direction was calculated during different time periods (1: 0-30 s, 2: 30-60 s, 3: 60-90 s, and 4: 90-120 s) from the second and third visits. For each of the 4 balance conditions (Vision*Platform), a repeated-measures ANOVA was conducted to test within-subjects effects of VTF, CRT, and period and all interaction effects.
Results: Overall, the CRT task had no effect on sway during using VTF. In the EO/L condition, subjects had increased sway when VTF was used compared with not used (P = 0.032). In the EO/SR condition, subjects had reduced sway with VTF on compared with VTF off (P = 0.019). In addition, there was reduced sway in period 2 compared with period 3 (P = 0.025). No significant within-subject effects were found in EOD/L and EOD/SR conditions.
Conclusions: Subjects with unilateral vestibular hypofunction only responded well to VTF under the EO/SR condition in which somatosensory feedback was reduced. There was no interference of the information-processing task on VTF performance.
Clinical Relevance: Compared to other single task studies that utilized VTF, this study demonstrated that people with unilateral vestibular hypofunction had difficulty utilizing VTF to reduce sway while performing a secondary CRT task, especially with EOD. Training people with unilateral vestibular hypofunction to use VTF as a balance aid might require more time under dual-task and complex sensory integration conditions.
The Effects of Manual Therapy, Balance, and Mobility Training on Functional Outcomes in a Person With Parkinson's Disease and Low Back Pain
A. Clodfelter, J. Freund, Elon University, Elon, North Carolina.
Purpose/Hypothesis: The purpose of this case report was to describe the effects of manual therapy, balance, and mobility training on functional outcomes in an individual with Parkinson's disease (PD) and low back pain (LBP). There is limited research on the use of manual therapy to decrease low back pain and improve functional outcomes in persons with PD.
Number of Subjects: 1.
Materials/Methods: The patient was a 67-year-old male diagnosed with idiopathic Parkinson's disease 6 years prior. He reported a history of multiple falls and LBP that limited his physical activity. The subject's medical history included atrial fibrillation, orthostatic hypotension, and multiple hernia surgeries. He was a community ambulator and typically walked without an assistive device. As a volunteer participant in a university physical therapy course, the subject attended 9 of 9 sixty-minute sessions in 5 weeks. His goals were to improve his endurance and balance, decrease his back pain, and return to a regular exercise program. His wife also wanted to improve the safety and efficiency of his car transfers. The patient had a flexed posture, limited trunk range of motion, balance impairments, and decreased step length and arm swing in gait. Initial interventions included balance and mobility (gait and car transfer) training with an emphasis on increased amplitude of movements. Manual therapy, including spinal mobilization and muscle energy techniques, was added to decrease activity-limiting LBP.
Results: The following measures improved (pre- to postintervention): Mini BESTest (17 to 21/28 points); 5 Times Sit to Stand (13.17 to 10.6 seconds); 6-Minute Walk Test (451.4 to 487.6 m); self-selected gait speed (1.0-1.27 m/s) and fast gait speed (1.34-1.45 m/s); step length right lower extremity (55.25-66.11 cm), left lower extremity (50.49-63.81 cm); timed car transfers in (18.83-10.1 s), out (16.63-10.3 s). The Parkinson's Disease Questionnaire −39 total score pre- to postintervention was 22.4 to 26.3. The patient rated his low back pain as +2 (somewhat better) and general activity level as +4 (a great deal better) on an 11-point Global Rating of Change (GROC) Scale at postintervention.
Conclusions: Manual therapy, balance, gait, and car transfer training may be effective in improving balance and functional mobility in persons with PD and LBP. The patient's postintervention Mini-BESTest score exceeded the cutoff score for predicting future falls in persons with PD. Mobility improvements included self-selected gait speed, which exceeded the minimal detectable change, increased step length, and increased efficiency with car transfers. The patient also reported positive changes in his LBP and general activity level.
Clinical Relevance: This case report provides support for the integration of musculoskeletal examination and a multimodal intervention of manual therapy, balance, and mobility training in persons with PD and LBP.
Physical Therapy Examination, Evaluation, and Management for a Patient With Acute Flaccid Paralysis From West Nile Virus: A Case Report
M. Bremner, R. Gisbert, Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Denver, Colorado. J. Fangman, Physical Therapy, Craig Hospital, Englewood, Colorado.
Background and Purpose: West Nile virus (WNV) emerged in the United States in 1999 with reports of encephalopathy in humans, birds, and horses in New York City. Over 12 900 cases were reported from 2005 to 2009 and 35% of the cases were the neuroinvasive form of WNV, including encephalopathy and paralysis. WNV may result in death and continued morbidity after infection. The virus is classified as an arbovirus that is transmitted to humans by blood-feeding insects, ticks, and mosquitoes. It is the leading cause of arbovirus infections in the United States and has become increasingly prevalent over the past decade. The neuroinvasive form of WNV manifests in 3 neurologic presentations: encephalitis, meningitis, and acute flaccid paralysis (AFP), with 56%, 38%, and 5% of all neuroinvasive cases represented, respectively. Thus, intervention frequently includes physical rehabilitation, yet there is little literature to guide physical therapist practice for these individuals. The purpose of this report is to describe the physical therapy management of an individual with AFP from WNV and to illustrate the clinical reasoning used in the case.
Case Description: A 55-year-old male presented to a local hospital in August after experiencing 5 days of worsening symptoms of fever, chills, muscle aches, headache, and weakness in his extremities. While in the intensive care unit, he tested positive for WNV. About 2 months after the initial onset of symptoms, he was transferred to a specialized long-term acute care hospital for skilled rehabilitation. He was formally diagnosed with the AFP form of WNV resulting in an incomplete spinal cord injury. Intervention focused largely on compensatory and preventative strategies due to the limited likelihood of physiologic recovery.
Outcomes: After 5 months of intensive physical rehabilitation outcomes from the selected tests and measures were taken. The primary outcome measures used were the International Standards for Neurologic Classification of Spinal Cord Injury and the Functional Independence Measure (FIM) yielding ASIA Impairment Scale (AIS) scores and FIM scores. The AIS and FIM scores did not change between baseline and discharge testing despite improvements in strength and flexibility.
Discussion: Clinicians should be aware of the poor prognosis of the AFP form of WNV as compared to the other neuroinvasive forms. It is arguable that this form is in fact an incomplete spinal cord injury and, therefore, it is appropriate to include reliable and valid measures for the spinal cord injury population. Clinicians should be aware of the similarities of this condition to both incomplete spinal cord injury and to lower motor neuron diseases, such as polio, in structuring examination and intervention strategies. Physical therapy management should follow current evidence for remediation, prevention, and compensation strategies clearly defined for other neurologic injuries similar to that of AFP-WNV.
Effect of Priming on Low-Frequency Repetitive Transcranial Magnetic Stimulation in Chronic Stroke: A Case Study
D. Anderson, Neurology, University of Minnesota, Minneapolis, Minnesota. J. Cassidy, B. Adams, A. Anderson, E. Appel, L. Baregi, C. Bartholet, K. Heberer, C. Ryer, J. Carey, Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, Minnesota.
Background and Purpose: Challenges encountered in stroke rehabilitation persist not only due to the death of brain matter but also from unbalanced interhemispheric inhibition (IHI), whereby the nonstroke hemisphere imparts abnormally strong inhibition onto the stroke hemisphere through transcallosal pathways. Repetitive transcranial magnetic stimulation (rTMS) is a promising stroke intervention that involves stimulation of the nonstroke hemisphere at low frequencies (≤3 Hz) to directly suppress the nonstroke hemisphere, which indirectly can disinhibit the stroke hemisphere. Previous research in healthy adults demonstrated a more potent effect of low-frequency rTMS when it was preceded by high-frequency (excitatory) priming stimulation, likely through homeostatic plasticity mechanisms. The purpose of this case study was to begin the exploration for optimal rTMS treatment parameters in stroke to restore excitability to the stroke hemisphere.
Case Description: A 64-year-old male with mild motor dysfunction from a left cortical-subcortical ischemic stroke received 3 different rTMS treatments on Wednesdays of weeks 1, 3, and 5. All treatments included 10 minutes of continuous 1-Hz conditioning rTMS preceded by 10 minutes of priming rTMS that consisted of either continuous 1-Hz rTMS (week 1), sham rTMS (week 3), or intermittent 6-Hz rTMS (week 5). All rTMS was given at an intensity of 90% of resting motor threshold. Baseline measurements occurred on Monday and Tuesday of weeks 1, 3, and 5. Posttests occurred on Wednesdays (immediately after treatment), Thursdays, and Fridays. Weeks 2 and 4 were washout weeks. Cortical excitability measurements (10 trials each) evaluated interhemispheric inhibition (IHI), short-interval intracortical inhibition (SICI), intracortical facilitation (ICF), and cortical silent period (CSP). Paired t tests assessed statistical significance in the change from baseline between treatments. Alpha was set at P < 0.05.
Outcomes: Baseline measurements verified IHI, SICI, ICF, and CSP were altered from normal in this person. However, no consistent picture emerged suggesting that one protocol was more effective than another in changing excitability. Interestingly, CSP measurements at 24 hours after treatment, but not immediately after or 48 hours after, suggested that both 6-Hz and sham priming of the 1-Hz conditioning rTMS were more effective than 1-Hz priming of the 1-Hz conditioning.
Discussion: The observation of no protocol showing a greater effect than another may be related to the already high level of motor function in this person. The CSP finding may reflect that the after-effects of one treatment do not peak immediately but also do not last 48 hours later. Further, the after-effects of 2 successive rTMS applications that are both suppressive in isolation (ie, 1-Hz priming of 1-Hz conditioning) can paradoxically erase the suppressive effects of low-frequency rTMS, consistent with principles of metaplasticity.
How Is Exercise Best Delivered to People With Parkinson Disease: A Home Program, Individual Instruction, or a Group Class?
L.A. King, K.C. Priest, F.B. Horak, Neurology, Oregon Health Sciences University, Portland, Oregon. Y. Chen, Z. Chen, Public Health & Preventive Medicine; Division of Biostatistics, OHSU, Portland, Oregon. J. Wilhelm, A. Serdar, Rehabilitation Services, OHSU, Portland, Oregon. R. Blehm, Rehabilitation, Portland VA Medical Center, Portland, Oregon.
Purpose/Hypothesis: While many people compare exercise interventions for people with Parkinson's disease (PD), it is rarely considered how one should deliver the intervention. The purpose of this study was to investigate whether the previously published Agility Boot Camp for PD could improve gait parameters when administered in a physical therapist–led group class, individual physical therapy, or a home program. We hypothesize that individual or group exercise would be more beneficial than a home exercise program for improving gait.
Number of Subjects: Fifty-eight people (mean age 63.9 ± 8 and mean Unified Parkinson's Disease Rating Scale Part III 36.9 ± 13) with PD were included in this study.
Materials/Methods: This randomized intervention study was conducted at Oregon Health & Science University outpatient rehabilitation services. Participants were randomized into 1 of 3 modes of delivery of the same exercise program; group class, individual or home exercise. The Agility Boot Camp program is based on a previously published protocol for improving mobility in people with PD. The intervention was 1-hour long, 3 times/week for 4 weeks. Pre- and postexercise testing was administered by a blinded examiner. Gait outcome measures included the freezing of gait questionnaire and an inertial sensor-based gait analysis to include stride velocity, peak arm speed, horizontal ROM of the trunk, peak trunk velocity, and variability of gait cycle time. All gait analysis was performed during 2-minute walk test.
Results: Overall, more gait changes were observed in the group class (n = 20) over home (n = 17), and even over individual therapy (n = 21) for some measurements. Paired t test results suggested significant improvement in freezing of gait (P = 0.0014), stride velocity (P = 0.0021), peak arm speed (P = 0.0006), horizontal peak trunk velocity (P = 0.0053), and variability of stride time (P = 0.0494) after group class intervention. The only gait measure that failed to show significant improvement in this group was Trunk ROM (P = 0.1665). As a comparison, none of the measurements showed significant improvement in the home group, and only peak arm speed (P = 0.0235) and horizontal peak trunk velocity (P = 0.0233) showed significance in the individual group. Two-sample t tests for comparing group class with the home group showed substantial difference of intervention effect in freezing of gait (P = 0.0052), stride velocity (P = 0.0516), peak arm speed (P = 0.0222), horizontal peak trunk velocity (P = 0.0257), and variability of stride time (P = 0.0614).
Conclusions: The data from this study suggests that the Agility Boot Camp was most effective for improving multiple components of gait when administered in a group setting.
Clinical Relevance: These findings have important implications for rehabilitation care management for persons with PD where home exercise is of often the standard of care. Our findings may have the potential to shape and guide best-practice/standard of care surrounding exercise and PD, specifically regarding rehabilitation service benefits.
Walking Recovery in a Patient With Idiopathic Lumbosacral Plexopathy: The Use of FES and Locomotor Training
L. Rogozinski, University of Florida, Gainesville, Florida. C.A. Sullivan, M. Dieterick, Magee Rehabilitation, Philadelphia, Pennsylvania. E.J. Fox, Brooks Rehabilitation, Jacksonville, Florida.
Background and Purpose: Lumbosacral plexopathy (LSP) is a rare peripheral nervous system disorder that causes lower extremity weakness and severe walking impairments. Effective rehabilitation interventions to promote walking recovery in individuals with LSP have not been identified. Locomotor training (LT) and functional electrical stimulation (FES) are beneficial interventions for promoting walking recovery in individuals with neurologic injuries, but the use of these interventions for promoting walking recovery in individuals with LSP has not been explored. Therefore, the purpose of this case report was to describe the effects of LT combined with FES on walking recovery in an individual with LSP.
Case Description: A 59-year-old female 3 months postonset of inflammatory idiopathic LSP presented with gross left lower extremity (L LE) weakness and severe gait impairments. She ambulated with a rolling walker and L foot orthotic with moderate assistance for L LE advancement. Her initial gait speed with a rolling walker as measured by the 10-meter walk test (10 MWT) was 0.24 m/s and she walked 80.47 m on the 6-minute walk test (6 MWT). She participated in 30 sessions of LT and 20 sessions, using the FES Bioness L300 system. LT was progressed by manipulating BWS, treadmill speed, duration of walking bouts, manual assistance, and verbal cues with the goal to walk with improved gait kinematics without manual assistance.
Outcomes: The combination of LT and FES allowed the patient to intensely and repetitively practice walking with appropriate limb kinematics and at near-normal speeds. The patient's compensatory gait pattern improved with a decrease in hip hike and internal rotation and she achieved independent ambulation with a single point cane and use of the Bioness; additionally, she was able to ambulate with supervision and the Bioness without an assistive device. The patient's self-selected gait speed and endurance over the 10 MWT and 6MWT over the course of the 10 weeks improved from 0.24 m/s to 1.18 m/s and from 64.49 m to 263.65 m, respectively, both surpassing the MDC boundaries of the 2 measures.
Discussion: The combined use of LT and FES may be effective for restoring walking in persons with idiopathic LSP. LT provides intense, repetitive practice of standing and walking to activate the nervous system. Specific sensory feedback is a critical component of this training. Because individuals with LSP have peripheral nerve inflammation, afferent feedback may be altered. Therefore, the underlying mechanisms associated with the effectiveness of these interventions should be further explored. The results of this case study suggest that combined interventions of LT and FES can promote walking recovery in patients with LSP.
Comparison of Rehabilitation Outcomes Before and After Implementation of a Clinical Practice Guideline Using Advanced Technology for Upper Extremity Recovery
A.H. Chan, K. Nuckols, J. Sandlin, M. Bowen, Sheltering Arms Hospital, Mechanicsville, Virginia. P.E. Pidcoe, Virginia Commonwealth University, Richmond, Virginia.
Purpose/Hypothesis: Current research for neurologic rehabilitation reinforces the importance of applying principles of motor control for neuroplastic change. For upper extremity recovery, advances in technology may improve application of these principles, but limited research exists on how these technologies can augment intervention in a thoughtful, methodical way. This rehabilitation organization initiated the iREACH Recovery Center, which implemented a clinical practice guideline (CPG) for upper extremity (UE) recovery using advanced technology. In this study, standardized outcome measures were compared before and after implementation of the iREACH Program. We assessed the hypothesis that the systematic application of a novel, evidence-based CPG for UE recovery would result in superior motor performance when compared to traditional therapy in patients poststroke.
Number of Subjects: 242 patients received the traditional regimen, while 100 patients were enrolled in the iREACH Program.
Materials/Methods: All patients in the pre-iREACH timeframe had bilateral arm function assessed using the following measures: Box & Blocks (B&B), Grip Strength (GS), and 9 Hole Peg Test (9HPT). Patients in the post-iREACH timeframe had these assessments, plus the Fugl-Meyer Assessment-UE (FMA-UE). Scores on the standardized assessments were used to categorize the patient, and the CPG provided specific recommendations of advanced technology interventions.
Results: Pre-iREACH and post-iREACH comparisons of the 3 UE outcome measures from admission to discharge indicated statistically significant changes in B&B for the post-iREACH group. When data were further separated by age, the “over 50” group showed significant improvement in B&B, while the “under 50” group showed significant improvement in GS. Patients in the post-iREACH data set improved by nearly 8 points on the FMA-UE from admission to discharge, suggesting those patients most likely had some type of functional change in arm use. In a comparison of LOS for pre-iREACH vs post-iREACH, there was an improvement in discharge to community specifically for the “under 50” group, increasing to 100% for the post-iREACH group.
Conclusions: Statistically significant gains were achieved in 1 of 3 outcome measures. In the post-iREACH timeframe, data gathered using the FMA-UE indicated strong improvements and captured gains in patients with and without distal UE function. Age appears to be a predictor for discharge to community with the iREACH Program.
Clinical Relevance: CPGs incorporate best evidence and reduce variability in practice. Implementation of CPGs requires the use of standardized outcome measures to track improvement in patient function, but can also be used to inform program refinement. This data will aid in the clinical decision-making process for therapists seeking to improve upper extremity recovery in stroke survivors.
For People Poststroke, Is There Evidence That Off-the-shelf Video Games Improve Upper Limb Function?
T. Schoenthaler, J. Wenger, M. Albano, A. Fehring, M. Guieb, A. Hernandez, N. Licameli, E. Marion, J.E. Deutsch, Rehabilitation and Movement Science, UMDNJ, Newark, New Jersey.
Purpose: The evidence to support the use of video games in rehabilitation has lagged behind both the clinicians' enthusiasm and their widespread adoption. It is important, however, to use the best available evidence in making the clinical decision to incorporate video games into the plan of care. Therefore, the purpose of this study was to evaluate the evidence supporting off-the shelf video games for improving upper limb function poststroke.
Description: MEDLINE, PubMed, and CINAHL databases were searched (between January 2008 and November 2012) using combinations of the following key words: video games, Sony Playstation, Nintendo Wii, Microsoft Kinect, and stroke. To be included in the review, articles had the following characteristics: upper limb rehabilitation, off-the-shelf console, people poststroke, and were at a level of evidence of 4 or greater on the Center for Evidence Based Medicine (CEBM) Scale. Articles were excluded if they used lab-based systems, focused on virtual reality, balance, and mobility. Four articles met the inclusion criteria. Two were level 2b and 2 were level 4. Information was extracted on acuity, level of motor involvement, console used, and outcomes (both impairment and activity-level measures) reported.
Summary of Use: At the time of the search, 2 consoles, the Sony Play Station and Nintendo Wii, had limited evidence of improved upper limb use. The most robust findings were for people who were 27 days and 4 months poststroke. Most participants had a low level (Brunstrom II and Chedokee McMaster 3.5) of motor function. The games targeted joint motions and were played between 8 and 10 hours in addition to traditional rehabilitation.
Importance to Members: People poststroke demonstrated improvements in both impairment and activity-level measures irrespective of the gaming system used for the rehabilitation. However, gaming was not superior to a dose-matched active treatment group. Evidence was available on the older consoles (Play Station and Nintendo Wii) but not the newer one (Microsoft Kinect), suggesting that when clinicians use newer off-the-shelf game consoles, they will rely on their experience and clinical judgement given the absence of evidence.
Lateral Stability Has a Significant Energetic Cost Following Spinal Cord Injury
J.H. Matsubara, K.E. Gordon, Department of Physical Therapy and Human Movement Sciences, Northwestern University, Evanston, Illinois.
Background and Purpose: Maintaining lateral stability during walking requires energy. Stability is more challenging for people with incomplete spinal cord injury (iSCI) due to impaired sensation and motor control. Thus, we hypothesized that people with iSCI adopt walking patterns that are energetically costly (such as taking wider steps) to increase their stability. The purpose of this case study was to quantify the energy used for lateral stability and describe the corresponding kinematics of a subject with iSCI during walking. This was accomplished by comparing the energy expenditure and kinematics of the subject during walking with and without external lateral stabilization. Providing external lateral stabilization through stiff springs decreases the need to maintain one's own stability.
Case Description: A 50-year-old male subject with C7, AIS (American Spinal Injury Association Impairment Scale) D spinal cord injury completed an experimental protocol consisting of 2 treadmill walking conditions: without external lateral stabilization, and with external lateral stabilization. In each condition, the subject walked for 3 minutes at his preferred speed of 0.85 m/s. During steady state walking, we used motion capture cameras to measure pelvis and foot kinematics and
O2 consumption to estimate energy expenditure.
Outcomes: With external lateral stabilization, the energetic cost of walking decreased 12% from 2.54 W/kg to 2.23 W/kg, step width decreased by 16% from 0.35 units of leg length to 0.30 units of leg length, and step width variability decreased 26% from 0.031 units of leg length to 0.023 units of leg length.
Discussion: The results of this case study support our hypothesis that people with iSCI choose walking patterns that increase both stability and energy expenditure. This is evident as the subject changed his walking kinematics to take narrower steps that corresponded with a large decrease in energy expenditure when the requirement for lateral stabilization was decreased. If people with iSCI use substantial amounts of energy to maintain lateral stability during walking, then developing rehabilitation strategies that improve the stability of people with iSCI may improve energetic efficiency and decrease walking fatigue.
Case Series: A Backward Walking Training Program to Improve Balance, Forward Gait Speed, and Decrease Fall Risk in Acute Stroke
L. DeMark, P.M. Spigel, J. Osborne, J. Beneciuk, Brooks Rehabilitation Hospital, Jacksonville, Florida. D.K. Rose, University of Florida, Gainesville, Florida.
Background and Purpose: Poststroke impairments are associated with a significant increase in falls at home after hospital discharge. Most falls leading to injuries occur while walking, with the majority in the backward or sideways directions. Backward walking ability was examined in community-dwelling elderly adults with the conclusion that backward walking velocity may be a better predictor of fall risk than forward walking velocity. No studies to date have examined the effect of overground backward walking training to decrease fall risk and improve balance in any population. The purpose of this series was to examine the effects of the addition of a backward walking program to standard care physical therapy on subsequent balance ability, gait speed, and fall risk throughout the first 6 weeks poststroke.
Case Description: Eight participants with first time stroke (5 male; average stroke onset 10 days; average age 67 years) participated in 20 minutes of backward walking training in addition to 60 minutes of standard care physical therapy. Treatment consisted of 5 days per week for 2 weeks upon initial admission to inpatient rehab setting.
Outcomes: Outcome measures assessed at baseline, 1-week, and 2-weeks postintervention included the 10-meter walk test (10MWT), 3-meter backward walk test (3MbwdWT), Berg Balance Scale (BBS), Timed Up & Go (TUG) Test, Computerized Modified Sensory Organization Testing (SOT), and Activities-Specific Balance Confidence (ABC) scale. Paired samples t tests were used to compare 1-week and 2-week outcomes to baseline. At each assessment, changes in all measures were statistically significant (P < 0.05). Thirty-eight per cent of participants achieved scores on all outcome measures that would indicate no fall risk. In addition, the average BBS (47.1 ± 7.6) and ABC (77 ± 17.3) scores for all 8 participants were above the cutoff threshold for fall risk. Following intervention, the average forward walking velocity was 0.88 ± 0.14 m/s. All participants met the minimally clinically important difference for forward gait speed as well as the minimal detectable change for BBS and TUG. Three participants achieved independence with forward walking with all participants requiring only supervision during backward walking.
Discussion: This case series describes an initial attempt to utilize backward walking training as an effective way to improve balance and mobility with decreasing fall risk in persons with acute stroke. Changes in clinical outcome measures indicated that both statistical and clinical significance did occur in relation to each participant's balance, forward gait speed, and backward walking ability. Gait velocity outcomes upon program completion categorize all participants as community ambulators. Participants required no assistive device for forward and backward ambulation. Physical therapy with the addition of backward walking appears to further improve functional mobility. These results provide a foundation for further investigation of backward walking training in acute stroke.
Preliminary Evidence for Changes in Biceps Brachii Fascicle Length in Individuals With Chronic Hemiparetic Stroke
C. Nelson, P. Krueger, J. Dewald, Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois. W. Murray, Department of Biomedical Engineering, Northwestern University, Evanston, Illinois.
Purpose/Hypothesis: Stroke is the leading cause of long-term disability in the United States, with approximately 795 000 new or recurrent strokes each year. Common impairments after stroke can include weakness, spasticity, contractures, and altered muscle activation, which can cause abnormal use of the affected extremity. Over time, these impairments can lead to morphological changes in the architecture of muscle, affecting function. It is hypothesized that because of the abnormal neural drive and altered use of the arm poststroke, and the commonly observed flexed posture of the affected arm, the paretic elbow musculature (biceps brachii) will have different fascicle lengths when compared to the nonparetic arm.
Number of Subjects: To date, 2 subjects with hemiparetic stroke participated in the protocol, 1 female (age 64) and 1 male (age 57), ranging from 6 to 9 years poststroke, in addition to 1 healthy control (male, age 22).
Materials/Methods: For this study, subjects were casted at the wrist and secured to a 6 degree of freedom (DOF) load cell under the elbow axis of rotation, with the limb approximately in the horizontal plane (85° shoulder abduction angle) and the wrist at 0° (midway between supination and pronation). Subjects had a harness on the trunk to prevent any accessory movements of the trunk during the experiment. The entire biceps brachii long head was imaged with extended field-of-view (EFOV) ultrasound in 3 different elbow positions and in 2 conditions: passive, with no muscle activity (verified with EMG), and with the muscle activated at 10% of its maximum voluntary torque, measured prior to the experiment. Extended field-of-view ultrasound has recently been used to measure muscle architectural parameters that cannot be seen in one 2D static image. Subjects were provided with visual feedback to ensure the biceps was activated at the appropriate level for each trial.
Results: Preliminary results suggest that biceps brachii fascicles are substantially shorter in the paretic extremity when compared to the nonparetic extremity in both active and passive conditions, and that these differences are more than that measured between arms in control subjects.
Conclusions: Changes in fascicle lengths after a stroke may signify changes in an individual muscle's properties, including its length-tension relationship and changes in the optimal sarcomere length or number. Continuation of this research will include additional data collection in both individuals with stroke and healthy controls, as well as expansion to other muscles in the upper extremity, and will also be continued using musculoskeletal modeling approaches.
Clinical Relevance: If shown that muscle fascicle lengths are altered poststroke, novel-training interventions could be developed to take into account changes in muscle properties and associated musculoskeletal mechanics. Ultimately, this may result in more functional paretic arm use following stroke.
Effect of Pulsed Electromagnetic Field Versus Low Level Laser on Radial Nerve Injury
T.K. Aly, Physical Therapy, el Sahel Hospital, Cairo, Egypt. O. Rashad, M.T. Aly, M. Abdelmegeed, Physical Therapy Department for Orthopedic Injury and it's Surgery, Faculty of Physical Therapy, Cairo University, Cairo, Egypt. N. Elshazly, Radio-diagnosis deLecturer of Radiation Oncology Department, El kasr el, Faculty of Medicine, Cairo University, Cairo, Egypt.
Purpose/Hypothesis: The purpose of the current study is to compare between influence of pulsed electromagnetic field and low level laser on radial nerve regeneration, wrist extensors power and hand grip after radial nerve injury.
Number of Subjects: Thirty patients.
Materials/Methods: Thirty patients from both genders (18 males and 12 females) aged between 20 and 40 years were assigned into 2 equal groups. Group (A): received pulsed electromagnetic field around humerus with frequency 12 Hz, 0.4 millitesla, for 20 minutes, and therapeutic exercise while group (B): received a low-level laser with a beam diameter of 0.5 cm, a wavelength of 904 nm. The irradiance used was 6.0 J per treatment site, which was delivered by applying 10 mW in continuous wave mode for approximately 90 seconds for each point at the site of injury and the same therapeutic exercise. The program was 3 times/week for 8 weeks. The evaluation procedures had been done for all patients in the 2 groups before starting the program and after 8 weeks of treatment including 4 variables Radial nerve motor and sensory conduction study, hand Grip strength using the Jamar hand-held dynamometer and Sensory assessment using Semmes_weinstein monofilament.
Results: Thirty patients (18 male and 12 female) mean age 29.7 (SD 5.4) years, Baseline characteristics between the 2 groups were similar for all variables (P > 0.05). there was significant difference in Radial motor conduction velocity (RMCV) between posttreatment data of group (B) and group (A)as P = 0.04, there was significant difference in hand-held dynamometer between posttreatment data of group (B) and group (A) as P = 0.02, there was very significant difference in Radial Sensory latency (RSL) between posttreatment data of group (B) and group (A) as P = 0.003 and there was very significant difference in Semmes Weinstein monofilament results Between posttreatment data of group (B) and group (A) as P = 0.001. The higher increase in the values of (RMCV) was found in the group (B) 13.4% in comparison with group (A) 5.7%, the higher increase in the values of hand-held dynamometer was found in the group (B) 30.3% in comparison with group (A) 11.6%, the higher decrease in the values of (RSL) was found in the group (B) 30.1% in comparison with group (A) 21.6%. and the higher increase in the values of Semmes Weinstein monofilament was found in the group (B) 54.7% in comparison with the group (B) 31.7%.
Conclusions: The results of this study provide evidence that low-level laser is more effective than pulsed electromagnetic field in treating patients suffered from radial nerve injury.
Clinical Relevance: Approximately 95% of peripheral nerve injuries associated with a fracture occur in the upper extremity. The most common form is radial nerve injuries associated with humeral fractures. The radial nerve is responsible for innervating the wrist extensors, which control the position of the hand and stabilize the hand during any movement. Radial nerve injuries usually result in a decrease in power grip and pinch primarily related to the loss of wrist extension.
Trigger-Point Dry Needling in a Person With Generalized Dystonia: A Case Study
B. Griffiths, S. Koppenhaver, Doctoral Program in Physical Therapy, U.S. Army Baylor, San Antonio, Texas. K. Wait, Keesler Department of Musculoskeletal Research, Keesler AFB, Biloxi, Mississippi.
Background and Purpose: Dystonia is an incurable, chronic neurologic condition of involuntary muscle contractions causing painful twisting, repetitive movement and strained posturing. Trigger-point dry needling (TDN) is increasingly used to treat musculoskeletal (MSK) conditions with pain and muscle spasm. Evidence for TDN effectiveness in MSK conditions is expanding; however, no study to our knowledge has explored the effect of TDN on a neurologic disorder such as dystonia. Consequently, the purpose of this case study was to document the effect of TDN as the primary treatment for dystonia.
Case Description: A 54-year-old female diagnosed with generalized dystonia in 1993 presented with a primary complaint of chronic neck pain and muscle fatigue. She had signs of cervical muscle weakness and limited range of motion (ROM) due to muscle spasm. The patient reported that her neck impairments limited her ability to operate as a pediatric physical therapist and perform instrumental activities of daily living (IADLs). She also presented with bilateral pain and hypertonicity of her lower extremities causing gait dysfunctions of forefoot strike and heel drag. The patient exhibited muscle spasm around her thoracic spine affecting her upper extremities resulting in reduced arm swing during gait. At initial evaluation, her treatments included daily Baclofen and Botox injections every 3 to 4 months into her neck and legs with inconsistent results. TDN was initiated in her neck (upper trapezius, levator scapula, scalenes, sternocleidomastoid, paraspinals C4-T1) up to twice per week. After 1 month, TDN treatment expanded to muscles in her legs (gastroc/soleus, tibialis anterior, hamstrings) and thoracic spine (paraspinals C4-T6). Concomitant in-clinic treatment included cervical/thoracic spine mobilizations and instrumented soft tissue mobilizations. Her home exercise plan consisted of deep neck flexor and lower trap facilitation exercises.
Outcomes: The patient reported an immediate decrease in tone and pain in her neck after each TDN treatment with progressive sustained increases in ROM after every session. With 1 month of treatment the patient regained full cervical flexion (67°) and extension (72°). After 2 months she regained cervical rotation of 80° bilaterally. Following 1 month of TDN treatment of her lower extremities and thoracic paraspinals, she exhibited normal upper and lower extremity gait mechanics. Treatment was then reduced to once per week. At 5 months, frequency reduced to once every 3 weeks. At 10 months after the initiation of TDN treatment, she maintained functional gains in her neck and extremities without Botox injections.
Discussion: With TDN treatments, in combination with indicated adjunct therapies, the patient subjectively and objectively improved symptoms of pain and tone allowing her to resume full-time work and IADLs. The patient's improvements suggest further study of TDN for patients with dystonia and similar neurologic conditions is warranted.
Comparison of Walking Function in Bilateral KAFOs to a Robotic Exoskeleton System for a Person With a Spinal Cord Injury: A Case Study
V. Eberly, M. Ibanez, E. Blydt-Hansen, P. Requejo, S.J. Mulroy, Rancho Los Amigos NRC, Downey, California.
Background and Purpose: Standing up and walking is an important goal for most people living with a spinal cord injury (SCI). Rehabilitation strategies for enabling gait including orthotic devices such as reciprocating gait orthoses and knee-ankle-foot orthoses (KAFOs) have limited utility because they are labor intensive and physically exhausting for the user. Advances in robotic technologies have recently led to the possibility of exoskeleton robotic orthoses to enable individuals with SCI to walk at functional velocities without excessive cardiovascular demand.
Case Description: J.C. is a 26-year-old male who sustained a T10 ASIA A SCI in 2008. He had completed a training program to ambulate in bilateral KAFOs and was ambulating with his KAFOs and a walker in his house 1 hour twice a week. He had used his KAFOs for 2.5 years when he began his gait training program with the ARGO ReWalk robotic exoskeleton system. ReWalk is a reciprocating gait orthosis with powered hip and knee joints. After his fitting, he received 48 training sessions (1 hour, 3 days/week for 16 weeks) to learn to operate the device to stand, sit, and walk. We collected temporal-spatial parameters and upper extremity (UE) assistive device weight-bearing forces during a 10-meter walk test and energy expenditure during a 6-minute walk test while walking in the KAFOs prior to and in the ReWalk at the completion of the training program. Temporal-spatial parameters were determined using compression closing switches taped to the bottom of each shoe and upper extremity weight-bearing forces were recorded with an instrumented walker or forearm crutches in a gait laboratory. Metabolic energy expenditure data were collected using a COSMED portable gas exchange system during the 6-minute walk test on an outdoor track.
Outcomes: Walking with the ReWalk increased velocity by over 200% (0.10 vs 0.22 m/s). UE weight bearing forces decreased 36% on the right and 21% on the left walking in the ReWalk compared to the KAFOs. In the 6-minute walk test, he walked over 3 times as far when using the ReWalk (61 vs 19.5 m) with a significantly lower O2 cost (1.1 vs 3.4 ml/kg*m).
Discussion: J.C. walked significantly faster and farther using the ReWalk compared to KAFOs. The external support provided by the exoskeleton reduced the need for upper extremity weight-bearing, which is a primary determinant of energy expenditure requirements during assistive device gait. While J.C. more than doubled his velocity walking with the ReWalk, his velocity was still less than 20% of normal gait velocity. Perhaps with more training in the ReWalk, his velocity would continue to increase and also lead to improved balance and further decrease use of the UEs. J.C. reported with the ReWalk his standing endurance was unlimited and walking was faster and easier on his arms. He also reported improvements in spasticity and his bowel program. Further evaluation of other physiologic measures will help identify other benefits of standing and walking for persons with SCI.
Implementation of a Clinical Practice Guideline for Walking Recovery: Standardized Users Improve Knowledge Translation
A.M. Devers, M.R. Wilks, M.W. Banta, J. Moore, K. Nuckols, Inpatient Rehabilitation, Sheltering Arms Physical Rehabilitation Centers, Mechanicsville, Virginia. P.E. Pidcoe, Department of Physical Therapy, Virginia Commonwealth University, Richmond, Virginia.
Purpose: The knowledge of plasticity in the central nervous system, combined with principles of motor control and motor learning, has changed the state of rehabilitation. This group reported the creation and outcomes of a program for walking recovery using advanced technology that follows a clinical practice guideline (CPG) for assessment and intervention decisions. Prior data analyzed on the CPG may have been limited by an inability to determine if clinicians were utilizing the CPG consistently. Effective knowledge translation has been identified as a barrier to implementing evidence-based practice. If clinicians are not able to adhere to practice guidelines, the intent of CPGs (ie, limiting variability in care to improve outcomes) is not fully realized.
Description: After studying initial outcomes on the clinical program for walking recovery, we sought a strategy to increase clinician engagement with use of the CPG. Engagement can be measured by adherence to the specific recommendations of the CPG. While clinicians must pursue the best treatment for the unique needs of every patient, the goal will be to limit unnecessary variability of practice with regard to initial and ongoing assessment, selection and application of interventions, and measurement of outcome. A standardized user methodology was created to increase engagement by improving knowledge translation.
Summary of Use: Several elements were determined to be important to developing and defining a standardized user: (1) expectation, (2) curricula, (3) proficiency assessment, and (4) reward. An online tutorial and assessment were given to standardized users to highlight and assess proficiency in important aspects of the CPG. Each user also performed a self-assessment, rating knowledge, and frequency of use of several behaviors. Self-assessment has been used to measure knowledge translation after continuing education, and this type of reflection may also be important in developing expert practice. The hypothesis is standardized users following the CPG will demonstrate better outcomes in similar patients than clinicians who have not been trained with this method, and pilot data will be presented.
Importance to Members: As physical therapists, we must take an active leadership role in defining the future of health care and our profession. Development of CPGs is a requisite step in helping to propel superior, reproducible outcomes through the reduction of unwarranted variability. Practically, the creation of a CPG is only the first step. Actual translation of CPG recommendations requires a robust group of strategies designed to engage clinicians and change practice patterns. Standardization of users is a process whereby clinicians are fully engaged with CPG usage and understand the interaction between population-based management and individualized treatment. In summary, CPGs, when applied uniformly by standardized users, allow for a better understanding of the efficacy of interventions and may be refined to help inform future practice patterns.
Overground Locomotor Training to Restore Walking in an Individual With Acute Incomplete Spinal Cord Injury
A.M. D'Alessandro, P.M. Spigel, E.J. Fox, Physical Therapy, Brooks Rehabilitation Hospital, Jacksonville, Florida.
Background and Purpose: Locomotor training (LT) is a beneficial approach for restoring walking after incomplete spinal cord injury (ISCI). The principles of LT are based on the neural control of walking and aim to activate the nervous system above and below the level of injury. LT is commonly performed on a treadmill with partial body weight support (PBWS) and most studies have examined the effectiveness of this approach on individuals with chronic ISCI. Recovery of walking, however, is a primary and immediate goal for individuals with acute ISCI, but these individuals often have medical precautions and are unable to participate in LT performed on a treadmill with PBWS. Furthermore, this specialized equipment is unavailable in many facilities. Intense overground training has been shown to be effective for improving walking function and the principles of LT may be applied in this environment. The purpose of this case report is to describe the use of intense overground LT used to restore walking and standing balance in an individual with acute ISCI.
Case Description: The individual was a 37-year-old male 20 days posttraumatic ISCI at the C5-C6 level that required cranial halo placement. His injury was classified as AIS C and his lower extremity motor score (LEMS) was a 12/50. He initially required total assistance for transfers, standing, and was unable to initiate steps due to paralysis throughout all extremities and trunk. His modified functional reach in sitting was 24 cm. Overground LT was carried out with manual assistance to maintain an upright trunk and to assist with stepping and weight bearing. Assistive devices were selected in order to minimize compensations. Treatment was 1.5 to 2 hours of physical therapy 5 days a week for a total of 4 weeks.
Outcomes: Following 4 weeks of overground LT, this individual recovered the ability to ambulate without the use of braces or devices with minimal assistance of one person. His WISCI II score improved from 0 to 17 and his gait velocity was 0.35 m/s. His LEMS improved to 33/50 and his sitting balance improved as evidence by his increased modified functional reach to 48 cm. At 6-month follow-up, he walked independently without devices at a speed of 1.5 m/s and was able to reach 36 cm forward during standing functional reach test.
Discussion: Overground LT may be an effective rehabilitation approach to restore walking and balance in individuals with acute ISCI. Principles of LT were applied to overground training to activate the nervous system and promote recovery. This individual achieved a critical threshold of overground ambulation at the time of his discharge from inpatient rehabilitation. This may have allowed him to self-train and continue his recovery.
Patient-Therapist Collaboration and Task Specific Training for Fitness Goal Achievement in a Patient With MS
E. Caudill, J. Hershberg, Re-active Physical Therapy and Wellness, Los Angeles, California. C. Smith, Northern Arizona University, Flagstaff, Arizona.
Background and Purpose: Collaborative goal setting is one of the most important components of the physical therapy (PT) program. Setting personal, patient-driven goals and ensuring patient adherence or follow-through can be challenging. In addition, patient expectation has been implicated as important in patients with musculoskeletal pain and may have prognostic value in a patient with musculoskeletal pain but this has not been studied in patients with neurologic diagnoses. The purpose of this report is to demonstrate successful attainment of a high expectation patient goal via patient and therapist collaboration.
Case Description: A 33-year-old female (R.M.) with multiple sclerosis since 2002 (EDSS 2.0) had unsuccessfully attempted to complete an organized 5K walk for 4 years. The patient and therapist collaborated to set a goal to complete an entire 5K walk through progressive intervention in 7 weeks (scheduled race date). The program included a customized walking training calendar and log for patient home adherence and 60-minute PT sessions 2×/wk. Patient's home program consisted of scheduled walks 5 days/wk developed in a progression based on the patient's 6-minute walk test (6MWT) pace. PT sessions involved task-specific training with overground gait training and supported treadmill training using the Alter G Treadmill. Her program also included addressing the patient and therapist identified underlying impairments through balance training, stretching, and hip strengthening exercises. 2D video analysis was performed before and after the training period using the Simi Motion Analysis system.
Outcomes: Patient had full adherence to her home program and met her goal of completing a 5K. In addition, R.M. demonstrated improvements in self-selected walking speed +0.15 m/s, timed up and go time (TUG) decreased by 1.9 seconds, TUG cognitive decreased by 2.15 seconds, Mini BesTEST +4 points, 6MWT +75 m. 2D video motion analysis demonstrated improvement in gait efficiency via improved LE and trunk alignment. Finally, per RM self-report, she had improved walking endurance and speed, which translated to improved participation and efficiency at work and in her personal life.
Discussion: These findings suggest that therapist and patient collaboration are critical components in goal achievement. Therapist support was critical in both program design with patient accountability, gait technique training for energy reduction, and support during goal activity to ensure achievement.
Evaluation of a Community-Based Brain Injury Education Program and Free Bicycle Helmet Distribution for Adults and Children in a Rural Community
C.C. Gazsi, R. Myers, Lebanon Valley College, Annville, Pennsylvania.
Purpose: As a component of a health promotions course for a Doctor of Physical Therapy education program, 4 students organized and conducted a Brain Safety Fair. The purpose of the Fair was 3-fold: to educate school-aged children and adults about the brain and its functions, discuss the importance of wearing a helmet, and provide free, properly fitted bike helmets. The primary aims for this follow-up study were to assess the impact of the fair and helmet distribution on the frequency of helmet use in both adult and child participants.
Description: In April 2012/2013 a community-based education program and free bicycle helmet distribution promoting bicycle helmet use was held at a rural college campus. The Fair was marketed through flyers distributed to regional elementary schools, the local cable channel, several area newspapers, and various Web sites. Brain safety education promoting helmet use and the importance of brain injury prevention was provided through 8 stations manned by student and community volunteers. Participants receiving helmets were educated on proper helmet fit and use through helmet fitting by faculty advisors and trained student volunteers. More than 200 helmets were fitted to fair participants. Consent to participate in a follow-up study to evaluate the impact of brain safety education on helmet use was obtained from 123 participant families. A survey was distributed 3 months after the fair to the parent or adult chaperone who accompanied one or more children to the fair and who agreed to participate in the follow-up study. Initial feedback from fair attendees was positive; children enjoyed the educational activities, and adults believed children were provided with appropriate information regarding brain safety and the importance of helmet use. Survey responses indicated new helmet use for participants who previously did not have a helmet and increased frequency of helmet use for previous users. Constructive feedback from participants was also received to improve future Brain Safety Fairs.
Summary of Use: More childhood injuries occur in conjunction with bicycles than any other consumer product, yet less than 50% of children regularly wear a helmet. Physical therapists have a professional responsibility to engage in health promotion activities to impact the health and wellness of the communities where they live and work. While these activities are perceived as a valuable contribution to the community, they are often not evaluated on their effectiveness. The evaluation of health promotion activities is needed to assist in determining the cost, in time, and resources, as compared to the perceived and actual benefits for the community served.
Importance to Members: Health promotion activities fulfill a professional responsibility of physical therapists. The time and resources required to develop and conduct such events can be significant, justifying the need for evaluation of the activities to determine if they achieve their intended goal.
Implementation of AM-PAC Adapted Short Form Into Neurological Outpatient Rehabilitation Setting
J. Nash, M. Murphy, C. Ross, Rehabilitation and Sports Therapy, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, Nevada.
Purpose: Background: Starting in January 2013, Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 states that the Centers for Medicare & Medicaid Services (CMS) must implement a claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services. CMS Final Rule defines the claims-based data collection strategy as claims-based outcomes reporting which mandates reporting of functional limitations and severity of limitations for all Medicare Part B claims. To comply with new CMS regulations, a large health care organization has mandated the use of a subjective outcome measure to document primary limitation necessitating care, severity of limitation, anticipated improvement with therapy services, and change of severity accomplished at completion of therapy services. The Boston University Activity Measure for Post Acute Care (AM-PAC) is 1 of 4 tools recommended by CMS in the Benefits Policy Manual to use for documenting outcomes from therapy services.
Purpose: Describe implementation process of The Boston University Activity Measure for Post Acute Care (AM-PAC) to provide claims-based data reporting to CMS and identify functional mobility profile of patients referred to and evaluated by a physical therapist in an outpatient neurologic physical therapy practice focusing on degenerative disease.
Description: Design: Descriptive study.
Setting: One neurologic outpatient neurologic physical therapy practice focusing on degenerative disease Participants: Adult patients with a degenerative neurologic diagnosis referred by in house neurologists (neurodegenerative specialty practice) for physical therapy evaluation from a sample of convenience of patients aged 20 to 90 years.
Main Outcome Measures: AM-PAC. Outcome measure completed prior to initial physical therapy evaluation of individuals referred to physical therapy.
Summary of Use: Normative data from all participants will be analyzed and reported by means and standard deviations to provide patient profile of investigating clinic's patient referral population.
Importance to Members: Details crucial steps needed for implementation and use of a single standardized outcome measure (AM-PAC) to monitor patient functional status regardless of diagnosis or age or setting, which facilitates ease of reporting data and translation across settings of across episode of care. Data provided in this study will allow for patient profile of physical function, which may be utilized to provide caregiver education regarding functioning levels and create programming geared toward functional level of patient population.
Future Investigations: Identify level of change in physical function after skilled therapy intervention. Examine patient level of change over continuum of disease. Determine length of time required for meaningful change to occur. Compare patients AM-PAC scores referred to physical therapy across regions, facilities, diagnoses, and practice types.
Comparison of Real World vs. Robotic Therapy Training for the Upper Limb in Individuals Poststroke: Randomized Controlled Training Investigation With Cortical, Kinematic, and Clinical Findings
G. Thielman, A. Markward, B. Remus, Physical Therapy, University of the Sciences, Philadelphia, Pennsylvania. P. Bonsal, N. Riviello, Occupational Therapy, Magee Rehabilitation Center, Philadelphia, Pennsylvania. F. Mohamed, Radiology, Temple University Hospital, Philadelphia, Pennsylvania.
Purpose/Hypothesis: One common compensatory strategy demonstrated in poststroke individuals is the use of the trunk rather than the affected upper extremity while reaching. Multiple new advancements in rehabilitation address these compensatory strategies, some allow individuals to virtually train in their environment. One new advancement in this area is the REO, which is a robotic upper extremity device used to assist with functional reaching. The use of comprehensive virtual environments can have the benefit of a decreased need for constant supervision during rehabilitation, while the use of external auditory feedback has been shown to assist with trunk control, and in conjunction may also have the added benefit for cortical reorganization for individuals poststroke. The purpose was to compare the use of external auditory feedback for trunk control during REO therapy and during task-related training (TRT) in individuals with chronic stroke. It was expected that TRT would lead to more efficient movement, but neuroplastic changes were expected regardless of training type.
Number of Subjects: 14 individuals, randomized to either training group, who met the inclusion criteria.
Materials/Methods: An fMRI was performed pre- and posttraining, along with a test session utilizing upper extremity sensors for kinematic analyses of reach, and outcome measures for body structure function, activity, and participation. All subjects were randomized to either training and were seated in a stable chair with feet flat on the floor and back firmly against their seat during training. Each session lasted approximately 60 minutes, with individuals performing 200 reaches. External auditory feedback was intermittent throughout treatment sessions, detecting compensatory trunk movements in efforts to advance the affected upper extremity.
Results: A 2 (Training Group) × 2 (Pre-/Posttests) ANOVA was used to reveal clinically relevant changes; present completed analysis are indicative of improvements overall for elbow ROM, Motor activity log, Reaching performance scale and Fugl Meyer scale, with no significant differences for Grip strength, MMSE, WMFT, and shoulder ROM. Increased activation of the contralesional primary motor and dorsolateral prefrontal cortices, as well as supplementary motor cortex activation and ipsilateral cerebellum were evident when using the impaired upper extremity.
Conclusions: Changes in impairment were evident regardless of training group. Real-world training is necessary to alleviate impairments of individuals poststroke. However, there is some vital training indications for the use of robotic therapy (REO) for the upper extremity of individuals poststroke.
Clinical Relevance: Therapists should incorporate virtual robotic therapy to supplement real-world training for the upper extremity of individuals poststroke. It is evident that for the purpose of gaining improved arm use in individuals poststroke, external auditory feedback monitors are effective.
Does Imagery of Whole-Body Rotation Induce Eye Movements?
J.D. Heick, H. Trahan, T. Hale, J. Lynskey, Physical Therapy, AT STILL, Mesa, Arizona.
Purpose/Hypothesis: The purpose of this study is to investigate healthy individuals (ie, those without known or suspected vestibular deficits) to determine if sensory motor imagery, in which whole-body rotation is reproduced mentally, evokes eye movement recorded by videonystagmography (VNG) that corresponds to actual rotational motion. Our hypothesis is that sensory motor imagery in healthy individuals will evoke eye movements that correspond to the imagined body rotation.
Number of Subjects: 40 participants.
Materials/Methods: Data was collected prospectively on participants between 20 and 55 years of age who speak English and weigh less than 110 kg (rotational chair weight limits), with no known history of vestibular dysfunction and videonystagmography (VNG) examinations that reveal normal caloric, positional, and ocular motor test responses in rotational chair sinusoidal responses at 0.02, 0.04, 0.16, and 0.64 Hz were included in this study. Informed consent was received from all participants. Independent variables correspond to the Rodionov et al., 2004, article except that VNG was used to measure change in corneo-retinal potential in response to eye displacement as opposed to electronystagmography (ENG). VNG is more common than ENG and VNG improves the resolution and detection of nonlinear motion. Completion of VNG to determine normal was completed for 40 participants in phase 1 of this study. In phase 2, participants imagined whole-body rotation and ocular motion was recorded. Participants repeated imagery 3 times to the right and then to the left. The dependent variable was oculometric response measured by VNG.
Results: The findings of this pilot study to date have 4 participants who have completed both phases with normal VNG findings that have completed imagery exercises. The results from these participants do not indicate that sensory motor imagery will evoke eye movements that correspond to the imagined body rotation.
Conclusions: Findings of this pilot study to date do not indicate that limited dosage of mental imagery can be used in patients with a vestibular deficit. The mental imagery phase of this study needs to be carried through to completion for participants. Future studies need to investigate the amount of dosage of mental imagery that will be associated with improved vestibular compensation.
Clinical Relevance: Much interest has been raised about the potential usefulness of mental practice of motor tasks, also called “motor imagery” as a neurorehabilitation technique to enhance motor recovery. Current rehabilitation programs favor physical activity during the acute stage of a unilateral vestibular insult; however, patients with these deficits typically develop strategies during this stage to avoid movement in an effort to reduce symptom severity. Including mental imagery for patients with a vestibular deficit may improve adaptation and compensation of the vestibular system. This could potentially help to reduce postural instability and falls as well as improve overall recovery time.
Using Accelerometers to Measure Postural Sway in Children With Concussion
A.A. Alkathiry, P.J. Sparto, S. Whitney, Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania. A. Mucha, Centers for Rehab Services, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. A.P. Kontos, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. J.M. Furman, Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania. B.E. Freund, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
Purpose/Hypothesis: Sport-related concussions affect many school-aged children and may result in balance impairment and dizziness. The Balance Accelerometry Measure (BAM), developed for the NIH Toolbox, is an inexpensive tool designed to quantify sway in clinical settings. The purpose of the current study was to investigate the effect of vision and foot stance on postural sway in children with concussion.
Number of Subjects: Fifty-seven children with a recent concussion (21 F/36 M, mean age 15 years, SD 1.4 years) were referred from a concussion clinic.
Materials/Methods: Data were collected within 44 days of injury (M = 13, SD = 11 days). Symptoms including dizziness, headache, and nausea were assessed using a Symptom Inventory, a self-report rating scale from 0 (none) to 6 (severe). Symptoms were assessed before and after each of the 6 testing conditions. The BAM is a test of static standing balance administered using 3 different foot stance conditions (feet together, tandem, feet together on foam), each performed during 2 vision conditions (eyes opened and eyes closed). In each condition, subjects were asked to stand as still as possible for 30 seconds. An accelerometer attached to the subject's lower back measured sway. The root-mean-square (RMS) of low-pass-filtered acceleration in the anterior-posterior (AP) direction was calculated. Repeated-measures ANOVA (P < 0.05) was used to test for the effects of vision and foot stance position on the AP-RMS acceleration.
Results: There was a significant interaction between vision and foot stance positions (F(2,80) = 5.632, P = 0.005, n2 = 0.123). With eyes open, there was an increase in AP-RMS acceleration in the tandem and foam stance positions compared with feet together on level surface. With eyes closed, there was a progressive increase in acceleration from feet together on level to tandem stance to feet together on foam.
Conclusions: The BAM elicits differences based on vision and stance conditions in sway among children with concussion.
Clinical Relevance: Many factors can be used to guide return-to-play decisions for children who have acquired a sports-related concussion. As demonstrated by the current results, the use of accelerometers such as the BAM that quantify balance performance in the clinic may help inform safer return-to-play decisions following concussion.
The Effect of the Using Vibrotactile Feedback (VTF) on Medial-Lateral Postural Sway in Individuals With Bilateral Vestibular Loss
S.F. Alsubaie, S. Whitney, P.J. Sparto, Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania. N.T. McClain, P.J. Loughlin, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania. J.M. Furman, Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania.
Purpose/Hypothesis: Many studies have shown beneficial results of using vibrotactile feedback (VTF) to reduce low-frequency body sway during standing; however, VTF also appears to increase high-frequency body sway. Older adults also demonstrate an increase in high-frequency sway during natural and perturbed stance, which is correlated with fall risk. The purpose of this pilot study is to explore the effect of VTF in reducing medial-lateral (ML) body sway, especially at higher frequencies ≥ 0.5 Hz, in 2 individuals with bilateral vestibular loss.
Number of Subjects: 2.
Materials/Methods: The VTF system consists of 4 small tactile vibrators (C-2 tactors, 250 Hz) placed in columns of 2 on the left and right sides of the torso at the level of the iliac crest. An inertial measurement unit (IMU, Xsens) is mounted on the back of the subject belt at the level of the iliac crest. The tactors are activated when the feedback control signal from the IMU (consisting of lateral body sway position and velocity) exceeds thresholds of 1.5° for the lower tactor and 3° for the upper tactor. The experiment consisted of 8 trials of pseudorandom surface tilts in the lateral plane (2° peak-to-peak), each lasting about 3 minutes with 2 minutes' rest in between trials. All trials were performed with eyes open. During the first trial, the VTF was turned off, to collect baseline measures of each subject's natural balance information followed by one practice trial where subjects stood on foam in order to become familiar with the VTF device. During the next 6 trials, VTF was active. A final trial without VTF was included in order to show any learning effect of VTF on balance. The overall root-mean-square (RMS) of the sway evoked by the surface tilts was computed, as was the RMS of low-frequency (<0.5 Hz) and high-frequency (>0.5 Hz) body sway.
Results: The VTF reduced ML body sway in the 2 individuals with bilateral vestibular loss. The overall RMS decreased 58.3% by using VTF as compared with the unassisted first trial. This finding is true for both low- and high-frequency body sway. We found that VTF reduced the RMS of low-frequency body sway by 67.2%, and high-frequency body sway by 46.5%.
Conclusions: The results suggest that VTF can reduce the RMS of both low- and high-frequency medial-lateral body sway in subjects with bilateral vestibular loss.
Clinical Relevance: The reduction of low-frequency body sway in individuals with bilateral vestibular loss is consistent with a previous study (Peterka et al., 2006). In contrast to other studies that have found increased high-frequency sway with VTF in healthy subjects (Goodworth et al., 2009), we observed reduced high-frequency body sway. It is possible that the reduction in high-frequency body sway occurred because the VTF was based on the angular position and velocity of medial-lateral body sway, whereas the VTF in other studies was based on the anterior-posterior body sway. It will be important to see if these preliminary results generalize to a larger sample of individuals with bilateral vestibular loss.
Gross Motor Coordination Patterns While Cycling Do Not Differ With Knee Bracing
D. Bonnel, P. Craig, E. Eiberger, B. Fletcher, H. Gregory, Physical Therapy Education, Rockhurst University, Kansas City, Missouri. S. Arnett, Exercise Science Program, Western Kentucky University, Bowling Green, Kentucky. D.L. Hoover, Doctor of Physical Therapy Program, Western Kentucky University, Bowling Green, Kentucky.
Purpose/Hypothesis: Studies show that gross motor coordination (GMC) patterns are affected by some knee braces (KB). Such KB-related changes in GMC may be desirable, or undesirable, depending on issues such as injury status, motor task, and environmental context. Cycling is a continuous motor task well suited for laboratory studies that may be used to assess GMC. Yet little is known about how KB influences GMC while cycling. Deeper understanding of these issues has clinical implications, as factors such KB during gross motor activity may influence the quality of exercise during rehabilitation. The goal of this study was to explore the effects of a “second generation” KB on GMC during high-intensity cycling.
Number of Subjects: Sixty-one women (23.37 ± 2.45 years, 167.98 ± 7.22 cm, 64.01 ± 8.71 kg) completed this study. Criteria was used to (1) include subjects who exercise at least 30 minutes 3 or more days per week and (2) exclude individuals (a) who possess any type of pathology which would, by itself, alter GMC or (b) who regularly cycle.
Materials/Methods: Two groups of participants visited the lab on 2 occasions, where they completed a vigorous cycling test under seated and standing conditions. The trial order was randomized for both groups; participants in one group (n = 32) wore knee brace on the dominant leg while performing the test, and the other group (n = 29) served as control. Following a standardized warm-up, subjects rode an electronically braked cycle ergometer at maximal intensity for 30 seconds. Conditions were controlled and measured by computer. The following variables were assessed during each trial: speed, watts, cadence, and measures of cycling efficiency (SpinScan, and average torque angle [ATA] throughout the 360o of pedal travel). A repeated-measures ANOVA was used for statistical analysis.
Results: Nonsignificant interactions were found between KB conditions over time for speed, watts, cadence, SpinScan, left ATA, and right ATA. Significant interactions F(5,55) = 15,567, P ≤ 0.000) were found within each KB condition-–for each of the above-noted dependent variables-–between seated and standing riding positions over time.
Conclusions: The findings support reports that 2 distinct attractor states likely control seated and standing cycling. But the results contradict reports that KB may affect lower extremity kinematics, as the present findings suggest that KB newer to the market may have lesser influence on lower extremity GMC measures.
Clinical Relevance: The GMC of the subjects was not influenced by the KB used in this study. Physical therapists may use this information in situations in which they believe KB is warranted by injury status, motor task, or environmental context but they do not want the lower extremity GMC of their patients altered in any way.
Changes in Ambulatory Function in People With Multiple Sclerosis Taking Fampridine: A Pilot Study
M. Vore, C. Douthit, K. Falter, D. Fuerstein, M. Seils, Physical Therapy, Nazareth College, Rochester, New York.
Purpose/Hypothesis: The purpose of this study was to assess the changes in ambulatory function including distance and gait speed in people with MS using the Six Minute Walk Test (6MWT) and Timed Up and Go (TUG). The hypothesis of the study was that people with MS taking fampridine would have improved gait speed and scores as measured by the 6MWT and TUG.
Number of Subjects: Six female participants (mean age: 51 ± 5.49 years), each diagnosed with relapsing remitting MS for an average of 10.67 years ± 6.28. The Expanded Disability Status Scale (EDSS) scores ranged from 1.0 to 6.5.
Materials/Methods: Data were collected at initial, posttest time 1 and posttest time 2 for the 6MWT and TUG for all subjects and a fourth data collection session (posttest time 3) was gathered for subjects 1, 2, and 5. All testing was completed over a 1-year period. Mean gait speed was calculated using 6MWT distances for each participant. Each subject had been prescribed by their physician 10 mg of fampridine per day.
Results: Subjects 4 and 6 had increases and subject 3 had a decrease in 6MWT distance, which met the MCID (107 m, 125 m, and −157 m). Subjects 1, 2, and 5 showed no clinically significant changes in 6MWT distance. Subjects 1 and 3 had increases in TUG time between initial and final testing session, which met the MDC (+8.22 seconds and +5.82). Subjects 2, 4, 5, and 6 showed no clinically significant changes in TUG time. Subject 3 had an EDSS score increase, which met the MDC (3.5 points). No minimal detectable changes in individual gait speeds over the year were found except for subjects 4 and 6. Mean gait speeds for subjects 1, 2, 3, 4, and 6 were below the normal average of 1.18 m/s for community ambulating women in their age group.
Conclusions: The results of this study indicate no consistent clinically significant changes in ambulatory function as measured by the 6MWT and TUG over a 1-year period. A possible explanation for the results includes the variable and progressive nature of MS regardless of the proposed mechanism of fampridine as a symptom-modifying drug. Individual variations in the outcome measures assessed may have been due to a self-reported MS exacerbation for subject 1, addition of an assistive device and a reported fall for subject 3, and a urinary tract infection for subject 5. Future research should investigate gait speed and distance in the first 3 minutes compared to the last 3 minutes in the 6MWT. Future research involving a larger sample size and a control group is required to conclusively determine the effects of fampridine on people with MS.
Clinical Relevance: Physical therapists and other health care professionals should recognize that, while people with MS taking fampridine may show improvements in ambulation, these are likely to fluctuate due to the variable nature of the disease.
Effect of Anti-Parkinson Medications on the Ability to Modify Dual-Task Walking in Response to Instructions Among People With Parkinson's Disease
V.E. Kelly, R.A. Archer, A. Shumway-Cook, Rehabilitation Medicine, University of Washington, Seattle, Washington.
Purpose/Hypothesis: Gait impairments are common in people with Parkinson's disease (PD) and are exacerbated under dual-task conditions requiring performance of a concurrent cognitive or motor task. However, people with PD retain the ability to improve dual-task walking in response to instructions to focus on walking. It is unknown whether instructions remain an effective way to modify dual-task walking in the off-medication state, despite the fact that medication fluctuations become increasingly common with PD progression. The purpose of this study was to compare the ability to modify dual-task walking in response to instructions in the off-medication and on-medication states. We hypothesized that the effect of instructions on walking would be greater in the on-medication compared with off-medication state.
Number of Subjects: We tested 8 people with PD in the off-medication and on-medication states.
Materials/Methods: Participants walked as quickly as they safely could while performing a concurrent cognitive task (auditory Stroop). Participants were given 2 different sets of instructions: (1) focus on walking and (2) focus on the cognitive task. Primary outcome for walking were gait speed and biomechanical stability, assessed as the frontal plane inclination angle. Primary outcomes for the cognitive task were response latency and accuracy.
Results: Mean (standard deviation [SD]) age was 72 (5) years and disease duration was 6 (4) years. Dual-task gait speed was faster in the on-medication compared to the off-medication state (P = 0.02) and was faster with instructions to focus on walking compared to focus on the cognitive task (P = 0.04), with no interaction between medications and instructions (P = 0.47). Biomechanical stability was comparable in both medication states (P = 0.59) and with both sets of instructions (P = 0.21), with no interaction (P = 0.53). Cognitive task response latency and accuracy were comparable in both medication states (both P > 0.37) and in response to both sets of instructions (both P > 0.07), with no interactions (both P > 0.34).
Conclusions: Contrary to our hypothesis, people with PD were able to modify dual-task walking in response to instructions to a comparable degree in off-medication and on-medication states, with no change in biomechanical stability during walking. Medications did not impact cognitive task performance.
Clinical Relevance: People with PD report the need for increased concentration to monitor and improve walking, and physical therapists often incorporate a cognitive strategy, in which attention is focused on specific gait parameters, into gait rehabilitation for people with PD. These data suggest that such a cognitive strategy is effective in both off-medication and on-medications in people with PD, suggesting that instructions to focus on walking can effectively improve dual-task walking even in people with PD whose response to medication fluctuates.
Identifying Aphysiological Balance Disorders Using Computerized Dynamic Posturography and Clinical Judgment: A Case Study
M.A. Ziman, Physical Therapy, Cadence Hospital, Winfield, Illinois.
Background and Purpose: A significant amount of people are seeking skilled physical therapists to help them overcome dizziness and falling. The purpose of this case report was to describe a patient with a difficult diagnosis that required a combination of advanced testing and clinical judgment.
Case Description: This case study follows a 44-year-old woman with reports of severe dizziness and falling throughout the physical therapy diagnostic process. Initially, she presented with subjective and objective data consistent with right posterior canal benign paroxysmal positional vertigo (BPPV); however, after canal repositioning maneuver was performed, objective data no longer supported this diagnosis. At multiple subsequent visits, the patient's subjective and objective data were determined to be inconsistent with a physiological etiology.
Outcomes: Cevette's equations were applied to objective data from Computerized Dynamic Posturography (CDP), which determined her deficits to be an aphysiological classification. CDP also provided objective data for circular postural sway patterns without falling, patient performing well on more challenging test conditions and poorly on easier test conditions. This information, as well as therapist's clinical judgment, further suggests the patient's reports of dizziness were not due to physiological deficits.
Discussion: The diagnostic and subsequent treatment of patients with reports of dizziness poses a challenge for many health care professionals. CDP can provide objective information to help generate hypotheses in the differential diagnostic component of patient evaluation. In conclusion, the use of CDP: with the application of Cevette's equations, appreciating postural sway patterns, noting which tests conditions the patient falls on (easy versus harder) and therapist's clinical judgment are helpful in identifying patients with dizziness due to an aphysiological nature.
Assessing the Effects of a Massed vs. Distributed Schedule for Treadmill Training on Gait and Balance in Individuals With Parkinson's Disease
C.L. Barnes, B. Tschoepe, M.B. Smith, N. Muligan, K. Aaron, R. Cohen, A. Fry, N. Heald, M. Hiller, K. Miller, School of Physical Therapy, Regis University, Denver, Colorado.
Purpose/Hypothesis: Incidence of individuals diagnosed with Parkinson's disease (PD) is approximately 17 per 100 000 each year, with peak incidence in the 7th decade. As this disease progresses, individuals experience gait impairments such as step length and speed, as well as festination, freezing, and loss of balance. Interventions that provide external pacing may compensate for basal ganglia deficiencies that are responsible for internally cueing rhythmic gait. High-intensity treadmill training (TmT) has led to gait improvements in the early stages of PD, but we lack evidence for a specific TmT schedule. The purpose of this study was to determine whether massed or distributed TmT was more advantageous for gait and balance in people with PD.
Number of Subjects: Thirty-four individuals (19 women, 15 men) with PD (Hoehn & Yahr I-III) met inclusion criteria. Subjects were randomly assigned to a massed or distributed practice group.
Materials/Methods: Subjects trained twice weekly for 6 weeks during the study. Target training speed was 80% of individual fast walking speed, determined by the GAITRite system. Both training groups walked for a total of 30 minutes on the treadmill each session. The distributed practice group walked 3 bouts of 10 minutes, with 12-minute rest periods. The massed practice group walked 2 bouts of 15 minutes, with a 5-minute rest period. Outcome measures included Unified Parkinson's Disease Rating Scale Motor Scale (UPDRS); temporal and spatial gait parameters; Six-Minute Walk Test (6MWT); Timed Up and Go (TUG); Functional Gait Assessment (FGA); and static balance measures. Assessments were completed at preintervention, postintervention, and a 4-week postintervention retention.
Results: Statistical analysis was performed using SPSS (version 17.0). One subject failed to complete the study. Significance was set a priori at P ≤ 0.05. No significant between-group differences were identified for outcome measures; thus, we examined differences across time. Significant differences from pretest to retention testing for backward walking at comfortable and fast speeds and between pretest and retention testing in TUG scores were identified across all subjects. There were significant differences across all assessments for the UPDRS. In addition, significant changes from postintervention to retention occurred in the FGA.
Conclusions: Our study agrees with other literature that high-intensity TmT interventions are effective for individuals who have mild-moderate PD. Results demonstrated no difference between massed and distributed TmT schedules, but when group data were combined, improvement in gait and balance was noted. This result suggests that the physical therapist can determine a specific exercise prescription schedule for TmT training based on a patient's presentation and time constraints as long as overall dosage and intensity is met.
Clinical Relevance: High-intensity TmT program 2 days per week for 30 minutes may improve balance, motor function, and gait parameters for individuals with mild-moderate PD.
Feasibility and Effects of Training With the Xbox Kinect on Dual Tasking and Balance in a Patient With Parkinson's Disease
E.J. Fox, Physical Therapy, University of Florida; Brooks Rehabilitation, Gainesville, Florida. M. Van Rees, M. Rademaker, Physical Therapy, University of Florida, Gainesville, Florida. S. Kulkarni, M. Defranco, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Florida.
Background and Purpose: Postural instability and difficulty during dual tasking exacerbates the risk of falls for individuals with Parkinson's disease (PD). Traditional therapy focuses on motor impairments and often does not address dual tasking. Virtual reality and video games may provide unified training of cognitive and motor deficits in an environment that represents common daily activities. The Xbox Kinect is a low-cost, commercially available video game system that may permit clinicians to more readily incorporate virtual reality and dual task training into therapy sessions. Our purpose was to determine the feasibility and potential effects of using the Xbox Kinect system to retrain postural instability and dual tasking in an individual with PD.
Case Description: The individual was a 68-year-old female with PD for 5 years. She reported a recent decline in function and increased frequency of falls, which was observed to be related to dual task conditions. She participated in training using the Xbox Kinect for a total of 5 sessions over 4.5 weeks. Each session included 45 to 60 minutes of playing Xbox Kinect games that focused on motor/motor or cognitive/motor dual tasking and standing balance. The Mini-BESTest and Timed Up and Go (TUG) (motor and cognitive) series were administered pre-, mid-, and posttraining to assess balance, mobility, and dual task effects.
Outcomes: Use of the Xbox Kinect was feasible based on the patient's ability to navigate the game system and play the games, expressing that she was motivated, challenged, and enjoyed playing the games. She demonstrated improvements in dynamic balance and dual tasking at the midtraining assessment. The change in both the TUG-Motor and TUG-Cognitive times at the first reassessment period exceeded the MDC of 2.5 seconds. The dual-task effect of a secondary cognitive task improved 10% at the mid-training assessments. The patient's scores on the Mini-BESTest and TUG series, however, declined at the final posttraining test. This decline was likely due to an unrelated neck injury and a subsequent 1-week period of inactivity.
Discussion: Use of the Xbox Kinect may be a cost-effective approach to incorporate virtual reality and video games into therapeutic interventions. Xbox Kinect games provide a variety of motor and cognitive challenges in a virtual environment that may be particularly useful for retraining dual tasking. Based on this preliminary case, it is both feasible and potentially beneficial to use the Xbox Kinect to improve dual tasking and postural instability in patients with PD.
Handrail Use During Treadmill Walking Diminishes Balance Improvements From Visual Feedback
E.R. Anson, L. Ma, T. Kiemel, V. Dean, Kinesiology, University of Maryland, Laurel, Maryland. J.J. Jeka, Kinesiology, Temple University, Philadelphia, Pennsylvania. T. O-phartkaruna, Physical Therapy Department, Mahidol University, Bangkok, Thailand.
Purpose/Hypothesis: The primary purpose of this study was to determine if training using visual feedback regarding center of mass position and trunk orientation during treadmill walking would translate into improved dynamic balance ability overground, and to determine if hand rail use limited improvements in dynamic balance.
Number of Subjects: Eleven older adults with balance difficulties or a history of falling completed an intervention study, using augmented visual feedback regarding trunk motion to improve balance ability when walking over ground.
Materials/Methods: The BESTest, mini-BESTest, Berg Balance Test, Timed Up and Go, cognitive dual task Timed Up and Go, Activities Specific Balance Confidence scale, and six-minute walk gait speed were used to measure balance and walking ability before and after a 4 week training period of visual feedback during treadmill walking. The training sessions consisted of randomly ordered visual feedback regarding trunk translation or orientation 3 times/week for 4 weeks. Repeated-measures ANOVAs tested the hypotheses of no overall treatment effect and no between-groups treatment effect. Post hoc repeated-measures ANOVAs determined which balance system(s) was responsible for the overall change on the BESTest.
Results: Improvement in over ground balance was demonstrated by all subjects based on improved scores on the BESTest (P < 0.005). Holding the handrails significantly diminished the improvement in dynamic balance measured on the mini-BESTest (P < 0.05). Improvement on the biomechanical constraints subsystem of the BESTest was responsible for the overall improvement effect (P < 0.05).
Conclusions: These results have direct implication for clinical practice, treadmill training with concurrent visual feedback for trunk motion translated into improved balance during over ground activities. When training balance while walking, holding on to stationary objects should be avoided to maximize the beneficial effects with regard to dynamic balance.
Clinical Relevance: When training dynamic balance during walking, upper extremity support may limit the amount of carryover.
Implementation of a Comprehensive Falls Prevention Program for People With Multiple Sclerosis
M. Vore, M. Lapinski, J. Martens, K. Pipher, B. Sheehan, Physical Therapy, Nazareth College, Rochester, New York.
Purpose/Hypothesis: The purpose of this study was to assess functional balance and risk for falls in people with MS following a comprehensive 8-week fall prevention program. It was hypothesized that people with MS who participate in this program will improve functional balance and decrease risk for falls as measured by the Timed Up and Go (TUG), Berg Balance Scale (BBS), and Activities-specific Balance Confidence (ABC) Scale.
Number of Subjects: Ten subjects (9 females, 1 male) were recruited through the MS society, Upstate NY Chapter. The median age of participants was 57 ± 8.13 years, median EDSS was 4 ± 2.58, and median years since diagnosis was 11 ± 3.29.
Materials/Methods: The 8-week, 2 hours per week pilot program designed by the National MS Society consisted of education in fall risk prevention and participation in exercises including balance, stretching, and strengthening. TUG, BBS, and ABC scores were collected on day 1 (pretest), week 8 (posttest 1), and at a 6-month follow-up (posttest 2) to assess fall risk. Data collected at the 3 time intervals were analyzed using repeated-measures ANOVA (P < 0.05). Pretest and posttest 1 data were analyzed using a paired t test (P < 0.05).
Results: The BBS results from the repeated-measures ANOVA (P = 0.067) and the paired t test (P = 0.182) were not statistically significant. The TUG data analysis showed significance following the 8-week program (P = 0.005) and at the 6 month posttest (P = 0.010). The data results of the ABC were significant at the completion of the program (P = 0.042), indicating increased confidence among subjects regarding risk for falls but not at the 6-month posttest (P = 0.106).
Conclusions: Subjects showed significant improvement on the TUG and ABC at the completion of the 8-week program as well as the TUG at the 6 month posttest. While the BBS is appropriate to assess risk for falls this measure may not be sensitive enough to detect changes in higher functioning people with MS. However, the BBS scores for subject 4 was clinically significant from pretest (24/56 moderate fall risk) to posttest 1 (47/56 safe independent ambulation) due to her initial lower level of function. Participation in a comprehensive Free From Falls program had a significant impact on balance, confidence, and risk for falls.
Clinical Relevance: Physical therapists implementing a program that includes education on fall risk and an exercise component could be beneficial for the MS population.
Gaze Instability Does Not Prevent Improvements in Trunk Control During Walking for Individuals With BVL
E.R. Anson, T. Kiemel, University of Maryland, Laurel, Maryland. J.J. Jeka, Temple University, Philadelphia, Pennsylvania. T. O-phartkaruna, Physical Therapy Department, Mahidol University, Bangkok, Thailand.
Purpose/Hypothesis: The purpose of this study was to determine if individuals with bilateral vestibular loss (BVL) can benefit from visual feedback (VFB) regarding center-of-mass (COM) position and trunk orientation during treadmill walking to improve trunk control.
Number of Subjects: Informed consent to participate in these studies was provided by 3 healthy young adults and 4 individuals with BVL.
Materials/Methods: Kinematic data was collected during walking trials on a treadmill at 5 km/h. Each subject completed 5 repetitions of 2 conditions: VFB or no-VFB. VFB was presented in the form of a bulls-eye target with a cursor overlaid on the target representing either the position of the subject's COM or their trunk angle with respect to vertical. During VFB conditions, subjects were instructed to keep the cursor as close to the center of the bulls-eye as possible. 2-D eye and 3-D head kinematics were recorded while walking on a treadmill at 5 km/h during a second experiment. Power spectral densities were computed to characterize movement at all frequencies of motion. Gain and phase for pitch eye movements were calculated for frequencies below 5 Hz during walking trials.
Results: Body position variability was reduced when visual position feedback was available compared to no-feedback conditions for both healthy individuals and individuals with BVL. The reduction in variability was most evident at low frequencies of body movement. Individuals with BVL demonstrated lower pitch gain than healthy individuals; however, the phase for individuals with BVL was not different from that of healthy individuals.
Conclusions: Individuals with BVL demonstrated greater movement variability than healthy individuals. Reduction in trunk motion (translation and orientation) power across low frequencies with feedback for individuals with BVL approached the level of the no-feedback condition for healthy individuals. The observed compensatory timing for pitch gaze stability indicates that the use of visual fixation targets to improve trunk control during walking for individuals with BVL may be an appropriate treatment.
Clinical Relevance: The individuals with BVL were able to use visual feedback, presented as a moving cursor over a bulls-eye which required visual fixation, during walking to improve control of excessive trunk motion despite oscillopsia related to impaired gaze stability.
Prevalence and Severity of Vestibular Pathology in People With Type 2 Diabetes
L.J. D'Silva, J. Lin, K. Sykes, P. Kluding, H. Staecker, Physical therapy and Rehabilitation Science, The University of Kansas medical center, Kansas City, Kansas.
Purpose/Hypothesis: Diabetes Mellitus (DM) is a metabolic disorder in which a relative or absolute insulin deficiency causes chronic hyperglycemia. As the inner ear does not have the capacity for energy storage, it is theoretically sensitive to fluctuations in blood glucose levels. The main purpose of this retrospective chart review is to analyze the vestibular function of people who present to the ENT clinic with complaints of dizziness and identify the prevalence of vestibular disorders in patients with and without type 2 diabetes.
Number of Subjects: Retrospective analysis of data from charts of patients between 40 and 70 years old seen in an ENT clinic for vestibular testing at an academic medical center during a 10-year period (from 1/1/2003 to 12/31/2012).
Materials/Methods: Patients who were unable to complete the vestibular testing, patients with comorbidities that would affect assessment of the vestibular system including intracranial tumors, head injury, Parkinson's disease, seizures, and CVA were excluded. Data were collected on results of calorics, rotary chair, and vestibular evoked myogenic potentials. Descriptive statistics were used to summarize the patient demographics. Quantitative variables were summarized by medians and ranges and categorical variables by frequencies. Z test analysis was used to compare differences in population proportions (α = 0.05).
Results: Database search at the medical center showed 2685 patients with vertiginous symptoms, of which 2296 were nondiabetic and 389 patients had diabetes. Common vertiginous syndromes at the ENT clinic were labyrinthitis, labyrinthine dysfunction, Meniere's disease, benign paroxysmal positional vertigo (BPPV), vestibular neuritis, central vertigo, and labyrinthine fistula. Significant difference in prevalence of labyrinthitis (P = 0), Meniere's disease (P = 0.0016), and BPPV (P = 0.05) were seen between people with and without diabetes. The difference was not significant in labyrinthine dysfunction (P = 0.31), vestibular neuritis (P = 0.25), central vertigo (P = 0.12), and labyrinthine fistula (P = 0.75).
Conclusions: People with DM have a higher incidence of labyrinthitis and BPPV while in Meniere's disease even though the difference was significant it is more common in nondiabetics. The relationship between severity of DM and response of vestibular function will be presented. Clinical Relevance: The vestibular system plays an important role in maintaining postural stability; hence, vestibular deficits result in altered body orientation in space and stability deficits. The presence of DM further affects vestibular function and this can destabilize balance and stability, which increases fall risk. Clinicians will benefit from this information and can use it to educate their patients regarding increased risk for falls. This information can be used to develop targeted interventions to increase utilization of the 2 remaining sensory systems for fall prevention or specifically challenge the peripheral vestibular end organs that are spared.
Virtual Reality Training and Unilateral Spatial Neglect
J.S. Jackson, A.K. Galgon, Physical Therapy, Temple University, Philadelphia, Pennsylvania.
Background and Purpose: In stroke patients with unilateral spatial neglect, gaining awareness on the side of neglect is a primary goal for rehabilitation. Unilateral spatial neglect occurs in 17% to 20% of individuals with stroke and may contribute to reduced functional recovery. Virtual reality (VR) training is a new intervention that may enhance recovery in individuals with unilateral spatial neglect. The purpose of this literature review is to answer the clinical question: Do stroke patients with unilateral spatial neglect gain better spatial awareness with the use of virtual reality as compared to those who receive traditional training only? Case Description: The results of this review helped to drive clinician decisions for intervention in a 63-year-old male, 1 month status post right middle cerebral artery ischemic cerebrovascular attack who demonstrated a left unilateral spatial neglect and no field cut.
Methods: The literature search was conducted using PubMed, CINAHL, and MEDLINE Ovid databases between September 12, 2012, and September 30, 2012. The search terms were virtual reality, unilateral neglect, hemineglect, and spatial neglect. Only studies whose participants were diagnosed with stroke and unilateral spatial neglect were included. Each article was rated for level of evidence with the CEBM scale and assessed for quality with the PEDro or Downs & Black research assessment tools. The effectiveness of VR training to improve performance on clinical measures of unilateral neglect was then evaluated.
Outcomes: Five studies were included for analysis for this critically appraised topic. One article was considered high-quality with a high level of evidence and 4 articles were considered low-quality with moderate to low evidence. A variety of different VR systems were used across these studies. Positive improvements in performance on measures for unilateral neglect were found in subjects who used VR. There were no adverse responses to the VR training. There was low to moderate evidence demonstrating VR training to be more effective than traditional visual scanning activities.
Discussion: Current evidence suggests that virtual reality training may improve unilateral spatial neglect in stroke patients. Higher-quality studies that examine optimal dosage and determine which VR systems have greater impact would enhance clinical decision to use of VR in this population. Virtual reality may benefit this patient by offering immediate feedback and engagement, maintaining his attention, and improving his neglect.
A Backward Walking Training Program to Improve Balance and Mobility in Acute Stroke: A Feasibility Study
L. DeMark, Brooks Rehabilitation Hospital, Jacksonville, Florida. D.K. Rose, University of Florida, Gainesville, Florida.
Purpose/Hypothesis: Decreased muscle strength and poor balance are common poststroke impairments that contribute to slow gait velocity and more significantly an increased risk for falls. Recent research has suggested that backward walking velocity in elderly adults may be a better predictor of fall risk than forward walking velocity. Backward Walking (BW) training has also been examined in people with chronic stroke with promising improvements observed in forward walking speed. Including BW training in acute stroke rehabilitation may serve to improve balance and walking speed in this population but has yet to be tested. The purposes of this study were to (1) determine the feasibility of administering a BW training program in an acute inpatient rehabilitation setting and (2) compare the effectiveness of a BW training program to standard Balance Training (BT) on walking speed and balance in acute stroke.
Number of Subjects: Thirteen participants, admitted to an inpatient stroke rehabilitation unit with first-time stroke (8 female; 8 LCVA; 61.8 ± 11.0 years old; 8.1 ± 3.9 days poststroke), were randomized to a BW (n = 6) or BT (n = 7) group.
Materials/Methods: Participants received 8 (1×/day for 8 days), 30-minute training sessions in addition to their regularly scheduled therapy. Treatment outcomes conducted by an assessor blinded to group were assessed using a 5-meter walk test (5MWT), 3-meter backward walk test (3MBWT), Berg Balance Scale (BBS), and Activities-Specific Balance Confidence (ABC) Scale.
Results: There were no differences in age, time poststroke, or in the outcome measures between the 2 groups at baseline (Ps > 0.05). Trends in both 5MWT and 3MBWT indicate greater change in the BW compared to the BT group (BW 0.53 ± 0.17 m/s; BT 0.15 ± 0.09 m/s) and 3MBWT (BW 0.52 ± 0.16 m/s; BT 0.06 ± 0.02 m/s) (P = 0.05). The change in gait velocity for the BW but not the BT group exceeded the reported Minimally Clinical Important Difference of 0.16 m/s. No group statistical differences in change scores were observed in BBS (BW 27.0 ± 4.1; BT 19.8 ± 4.2) or ABC (BW 24.9 ± 6.9; BT 11.7 ± 5.6) (P's > 0.05).
Conclusions: Individuals 1-week poststroke safely participated in a backward walking program demonstrating a tolerance for an additional 30 minutes of intense therapy per day. BW training resulted in greater improvements in both forward and backward walking speed although did not enhance balance or balance confidence compared to traditional BT. The improvement in gait speed for the BW group resulted in a functional walking classification of limited community ambulation, compared to a household ambulation classification for the BT group. BW may be an important addition to acute-stroke gait and balance rehabilitation. Continued investigation of this unique rehabilitation approach with a larger sample size is warranted. Clinical Relevance: The combination of a backward walking training program to standard inpatient rehabilitative care may further enhance motor recovery and functional mobility in people with acute stroke.
What Is the Proper Dosing and Prescription for Therapeutic Exercise in Neurological Populations: A Systematic Review of the Literature
G. Thielman, J. Thomas, S. Abraham, University of the Sciences, Philadelphia, Pennsylvania.
Purpose/Hypothesis: Lack of information exists on exercise prescription and dosing for effective therapeutic outcomes in individuals with neurological diseases, particularly in patients who have been discharged from inpatient care and still require functional strengthening in an outpatient setting. This review will establish guidelines for exercise prescription and dosing in the outpatient setting for patients with neurological diseases. It is expected that only the most common diagnoses will have discernible guidelines relevant for physical therapists to incorporate into clinical practice; all other diagnoses will weakly establish research to support any guidelines.
Number of Subjects: Special interest report.
Materials/Methods: Description: Two reviewers independently extracted data and determined the quality of the included trials using the SORT scale Strength of Recommendation Taxonomy (SORT) scale and inclusion/exclusion criteria. Literature searches were conducted on exercise prescription and dosing applicable in the outpatient setting for neurological diseases using PubMed database from 2003 to 2013. Diagnoses included Parkinson's disease, Multiple Sclerosis, Traumatic Brain Injury, Amyotrophic Lateral Sclerosis, Guillain-Barré, Post-Poliomyelitis Syndrome. Included MeSH terms were “physical therapy modalities,” “exercise therapy,” “outpatient,” and the specific diagnosis being researched. Excluded MeSH search terms were “inpatient.” Additional criteria: if these articles were classified as Level I-II SORT evidence, as well as the use of functional outcome measures. Search focused on the American College of Sports Medicine (ACSM) guidelines for exercise prescription in healthy adults. Disagreements were resolved by discussion among all authors.
Results: Summary of Use: 39 articles were retrieved that met the established inclusion/exclusion criteria. Of the 39, 23 were applicable to the ACSM recommended exercise modalities of resistance, aerobic and balance. Statistical pooling of data was not possible due to differences in measurements of outcome.
Conclusions: Lack of available research (evidenced by 23 articles fitting the inclusion/exclusion criteria) and variability of exercise parameters make it difficult to establish definitive guidelines. Current literature focuses on the effects of specific modalities rather than the effects of dosing on functional outcomes. A majority of current literature available regarding interventions for neurological populations occurs in an acute stage rather than in an outpatient setting.
Clinical Relevance: Importance to members: To establish consistency of dosing there should be utilization of accepted standards of prescription, such as ACSM. While ACSM is recommended for healthy adults and older adults, it may not be appropriate to generalize these recommendations to the neurological population due to unique issues with fatigue, heat intolerance, etc. Therefore, ACSM should only be used as a reference when establishing exercise parameters in these populations.
Community-Based Exercise Program for Stroke Survivors: A Study Examining the Effects of Function and Well-Being
A. Castagno, N. Elliott, M. Laine, M. Stippler, P.D. Gillette, Physical Therapy, Bellarmine University, Louisville, Kentucky. M. Lampe, L. Wallace, Physical Therapy, Baptist Health, Louisville, Kentucky.
Purpose/Hypothesis: Stroke is a major cause of disability in America and stroke survivors face challenges related to impaired mobility and well-being. The aim of this pilot study was to assess the effects of focused exercise intervention on poststroke survivors (>3 months) on muscle strength, balance, ambulation, function, and well-being. A 10-week community-based exercise program designed and led by physical therapists (PT) and PT students was implemented for participants who previously suffered a stroke.
Number of Subjects: Seven subjects poststroke > 3 months and had received traditional physical therapy.
Materials/Methods: Seven males (ages 44-73, mean 58.6 years) were recruited from 2 local stroke support groups. Prior to beginning the program, participants completed a health history and screening, Barthel Index, Mini-Mental State Exam to assess cognitive function, and provided a signed release from their physician clearing them for exercise. Pre- and posttest assessments were Timed Up and Go (TUG), 6-minute walk test (6MWT), Five Timed Sit to Stand Test (5STS), Modified Physical Performance Test (MPPT), grip strength, and SF-36 to subjectively measure physical function and well-being, Participants attended twice weekly and rotated through 3 stations: ambulation, strengthening, and balance. Exercises were progressed for each participant based on their physical ability.
Results: All participants improved their scores in TUG (mean 28%), 6MWT (22%), 5STS (27%), left grip strength (3.7%), and MPPT mean ratings improved from moderately frail (24.8) to mildly frail (25.6). The SF-36 mean score improved in 7 of the 8 subscales; one subscale did not change (role limitations to physical health).
Conclusions: A community-based exercise program for poststroke survivors (>3 months) can have a positive effect on strength, balance, ambulation, function, and well-being. All participants demonstrated improvement from baseline to posttest measures in the TUG, 6MWT, 5STS, grip strength, and MPPT outcomes used in this study. Clinical Relevance: Physical therapists have an important role in designing focused exercise programs for improving physical function and well-being in stroke survivors. This community-based focused program appears to improve function and may have a positive effect on well-being.
Effects of Balance Training in Parkinson's Disease
G. Singh, W. Liu, N. Sharma, Physical Therapy, KUMC, Kansas City, Kansas. R. Pahwa, K.E. Lyons, Neurology, KUMC, Kansas City, Kansas.
Purpose/Hypothesis: Balance impairment is a well-known risk factor for falls in individuals with Parkinson's disease (PD). About 50% to 70% of people with PD fall once or more in 12 months, at a much higher than the 30% fall rate reported for community-dwelling older individuals. Balance impairment worsens with the progression of the disease and is associated with decreased mobility and poor quality of life. To date, few studies have examined balance-specific interventions, and none have utilized the biodex stability system (BSS) for training individuals with PD. The purpose of this study is to evaluate whether a balance specific intervention using BSS will improve balance in individuals with PD. A secondary goal of the study is to evaluate if changes in balance also translate to improvements in spatiotemporal gait parameters, physical function, and quality of life.
Number of Subjects: 5 subjects (3 M/2 F) with PD participated in the study.
Materials/Methods: Participants completed 60 minutes of balance training on BSS 3 times a week for 4 weeks in our CORR lab at University of Kansas Medical Center. The outcome measures were tested once before and after 4 weeks of training. Balance was assessed using force plates and the Berg Balance Scale (BBS). The spatiotemporal parameters of gait were tested using GaitMat. Functional status was tested using functional scales such as a 6-minute walk and timed up and Go (TUG).
Results: We found that there were significant changes in balance as assessed by BBS (P = 0.001) and sway area (P = 0.05), center of pressure (CoP) path length in the mediolateral (ML) direction (P = 0.02) and in the anteroposterior (AP) direction (P = 0.02). Gait velocity increased from pre to post; however, the difference was not statistically significant. Additionally, we found that CoP path length in the AP direction was strongly negatively correlated with change in 6-minute walk distance (r = −0.715) and strongly positively correlated with changes in TUG (r = 0.951).
Conclusions: Balance-exercise could improve balance in individuals with PD. Additionally, improvement in balance can be translated in spatiotemporal gait measures such as gait velocity and functional measures such as a 6-minute walk test and TUG. Clinical Relevance: Gait and balance problems are very common in PD and often result in falls. Specific training intervention to improve balance and reduce falls in PD would be clinically beneficial. The initial results of the present study indicate that more specific and challenging balance exercises under supervision might help to improve balance and other gait-related measures. However, these preliminary findings need to be confirmed with more subjects. A longer-term follow of the effects of balance training should also be considered in the future.
Muscle Atrophy and Fat Infiltration of the Paretic Upper Limb in Individuals With Chronic Hemiparetic Stroke
L. Garmirian, A. Kuncel, A. Acosta, J. Dewald, Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois.
Purpose/Hypothesis: Spasticity, loss of independent joint control, and weakness are known to occur after stroke; however, the long-term effects of these motor impairments on muscle architecture are unknown. It is hypothesized that motor impairments may cause decreased neural activation and subsequent decreased use of the paretic limb, which over time, may cause muscle atrophy and fat infiltration. It is also hypothesized that changes in muscle architecture may be greater for distal muscles compared to proximal muscles. The goal of this research was to quantify long-term changes in muscle volume and fat infiltration following hemiparetic stroke.
Number of Subjects: 2 stroke and 2 control subjects.
Materials/Methods: Magnetic resonance images were acquired using a 3D gradient echo pulse sequence of muscles crossing the elbow and wrist (TR = 7 ms, flip angle = 12°, matrix size = 352×286, slice thickness = 3 mm). One set of images was acquired using an echo time (TE) of 2.45 ms, when water and fat are in phase, and another set was acquired using a TE of 3.675 ms, when water and fat are out of phase. Each muscle was manually segmented using 3D-Doctor software. Percent intramuscular fat was calculated using a ratio of the intensity of the fat image, compared to the intensity of the water image. The volume of each muscle was calculated and adjusted to account for intramuscular fat to determine the volume of contractile tissue. The percent difference in volume was calculated for each muscle individually for the nonparetic compared to the paretic limb in stroke subjects and by comparing the dominant to nondominant limb in control subjects.
Results: For muscles crossing the elbow, the percent intramuscular fat was 3% greater in the paretic limb compared to the nonparetic limb while the percent fat was similar for the dominant compared to the nondominant limb in control subjects. For muscles crossing the wrist, the percent intramuscular fat was 6% greater in the paretic limb compared to the nonparetic limb while the percent fat was similar for the dominant compared to the nondominant limb in control subjects. The percent difference in muscle volume for muscles that cross the elbow was 31% for stroke subjects and 8% for control subjects. The percent difference in muscle volume for muscles that cross the wrist was 41% for stroke subjects and 7% for control subjects.
Conclusions: The percent intramuscular fat was greater in the paretic limb compared to the nonparetic limb and these differences were more pronounced distally than proximally. The percent difference in volume for stroke subjects was greater than the percent difference in volume for control subjects. Within the stroke subjects, atrophy of the distal muscles was greater than atrophy of the proximal muscles. Clinical Relevance: Detailed information about the pattern of atrophy and fat infiltration after stroke will help guide and improve rehabilitation poststroke. Knowing which muscles are more atrophy prone could help improve the specificity and efficacy of strength training and the functionality of assistive devices.
Ischemia-Induced Reduction of Somatosensory Input Decreases Balance; Added Vibratory Noise Partially Restores Function
G. Rose, A. Nordon-Craft, R.M. Patterson, N. Bugnariu, Physical Therapy, University of North Texas Health Science Center, Fort Worth, Texas. R. Jafari, Electrical Engineering, University of Texas at Dallas, Dallas, Texas.
Purpose/Hypothesis: We investigated the feasibility of using vibrotactile biofeedback to improve balance in healthy young adults in which the somatosensory information from their feet has been temporarily decreased. We hypothesized that though stochastic resonance, vibratory noise applied just proximal to a region of reduced somatosensation will improve ability to maintain balance.
Number of Subjects: Ten healthy young individuals aged 18 to 25 years gave informed consent and participated in this study.
Materials/Methods: We experimentally induced “somatosensory loss” in young healthy subjects using pressure cuffs wrapped around the ankles and kept inflated at 220 to 250 mm Hg for 35 minutes. A vibrotactile biofeedback system was positioned just above the pressure cuffs, wrapped around the distal part of the leg. An array of vibrotactile actuators, under a Texas Instruments MSP430 microcontroller, produced vibration at 2 frequencies: a barely perceptible low frequency and a high vibration frequency. Data was collected at baseline before the pressure cuffs were inflated and during the last 15 minutes of the ischemic protocol, under 3 conditions: no vibration and low-frequency and high-frequency vibrations. Outcome measures included measures of center of pressure (COP) variability with subjects standing with feet side by side/one foot, with eyes open/closed; plantar surface pressure sensation and vibratory threshold evaluated with the use of Siemens Monofilaments and Rydel-Seiffer tuning fork, respectively.
Results: In single limb support with eyes closed, ischemia increases the COP variability (P = 0.01) and the addition of vibrotactile feedback at both frequencies decreases its baseline values. Plantar surface pressure sensation threshold increased after ischemia (P = 0.03) and was decreased with the added vibrotactile feedback. The vibratory extension threshold measured at the hallux IP joint was decreased by ischemia (P < 0.001) and vibrotactile biofeedback restored baseline values.
Conclusions: The ischemic protocol produced balance changes in healthy young adults. The vibratory biofeedback was able to partially compensate for the experimental induced sensory loss and improve balance function. Clinical Relevance: Peripheral neuropathy is the most common long-term complication in diabetes, resulting in gait and balance changes. Most diabetic patients who have experienced falls become “visually dependent,” decreasing the gain of somatosensory information in the control of balance. Visually dependent persons can maintain balance relatively well in environments that are illuminated properly and when they can concentrate their vision on watching their feet. However, they may experience falls at night or when they have to direct their vision toward other targets than their feet or walking path, such as turning their head and talking to someone while walking. The long-term goal of this research is to test the effectiveness of using a vibrotactile biofeedback to decrease the risk for falls in older adults and diabetic adults with peripheral neuropathies.
Benefits of a Tandem Cycling Intervention for Individuals With Parkinson's Disease: A Qualitative Study
R. Stein, K. Ramsay, E. McGough, Department of Rehabilitation Medicine, University of Washington, Seattle, Washington.
Purpose/Hypothesis: Motor and nonmotor impairments in individuals with Parkinson's disease (PD) adversely affect participation in regular exercise. Using standard and recumbent tandem bicycles mounted on trainers, the tandem cycling intervention aims to facilitate sustained cycling at a higher cadence and consistency than self-paced cycling. Offered within a class environment (60 minutes, 3×/wk × 10 wks) a healthy riding partner provides pacing and encouragement. In addition to high cadence aerobic exercise, the class atmosphere encourages social interaction and camaraderie among participants. Impairment-based improvements have been reported with tandem cycling; however, we lack understanding of its benefits to health and function in individuals with PD. The purpose of this study was to describe the benefits experienced by individuals with PD participating in a tandem cycling intervention across domains of the International Classification of Functioning, Disability, and Health (ICF).
Number of Subjects: 17.
Materials/Methods: This was a qualitative study involving semistructured interviews of individuals with PD at 5 and 10 weeks of a tandem cycling class. All participants in the tandem cycling class were included in this qualitative study. Class Inclusion: a diagnosis of PD, ages 45 to 75 years, Hoehn & Yahr I-III, able to walk at least 1 city block (cane or walker allowed), and physician approval. Class Exclusion: cardiac, pulmonary, musculoskeletal conditions contraindication moderate exercise, diabetes mellitus, and neurological conditions other than PD.
Data Analysis: Transcripts were coded in 3 phases: (1) based on ICF components and domains, (2) identification of domain themes, and (3) quantification of the number of participants identifying each domain theme.
Results: Within the ICF domain of Body Structure and Function, motor and nonmotor improvements were identified by greater than 75% and 65% of participants, respectively. Improved strength, endurance, and balance were the highest-frequency motor benefits. Improved mood was the highest-frequency nonmotor benefit. Within the ICF domains of Activity and Participation, participants reported improvements in sleep, energy, and everyday activities. Greater than 90% attributed benefits to 1 or more of the following 3 environmental factors: (1) camaraderie, (2) accountability, and (3) class accessibility. As a result of participating in the tandem cycling class, greater than 70% described a sense of accomplishment and improved sense of control.
Conclusions: The benefits of participating in a tandem cycling class crossed all domains of the ICF. Major themes included improvement in motor and nonmotor functions, improvement in sleep, energy, and everyday activities, and a sense of control and accomplishment. Clinical Relevance: The results of this study provide insight into the perceived benefits of a tandem cycling class for people with PD that may inform physical therapists on aspects of exercise program design.
Clinical Versus Accelerometry-Based Tests of Fall Risk in Older Community-Dwelling Adults
A. Gill, R. Avila, M.J. Thompson, P.R. Trueblood, Physical Therapy, CSU Fresno, Fresno, California.
Purpose/Hypothesis: It is well documented that 1 in 3 community-dwelling older adults (CDA) will fall at least once a year. Many of our clinical balance measures lack the sensitivity and specificity to identify fall risk. The purpose of this project is to compare the effectiveness of an accelerometry-based balance testing device with a clinical balance measure typically used within a fall risk screening program. We hypothesize that an instrumented Clinical Test of Sensory Integration on Balance (I-CTSIB) provides more qualitative and sensitive data about postural control and may assist in distinguishing fallers from nonfallers.
Number of Subjects: The average age of the subjects was 76.4 ± 6.40 (n = 28; 23 females, 5 males). The subjects were recruited by population of convenience through a balance screening program conducted by students and faculty in the Department of Physical Therapy and Nursing at Fresno State.
Materials/Methods: The clinical tool utilized for fall risk assessment in this study was the Modified Clinical Test of Sensory Integration on Balance (M-CTSIB). The M-CTSIB is a timed 4 condition test that determines whether a subject's balance is normal or abnormal, but may not be sensitive enough to distinguish between fallers and nonfallers. This study compares the M-CTSIB to the Instrumented CTSIB (I-CTSIB), which uses body-worn accelerometers for an objective measure of postural sway. The Fullerton Advanced Balance (FAB) Scale was used as the gold standard to determine fall risk with a cutoff score of 25/40 (7 at risk, 21 not at risk).
Results: The M-CTSIB was unable to discriminate any of the 7 subjects at risk, with all subjects completing 30 seconds of each of the 4 test trials. However, condition 2 (eyes closed, firm surface) of the I-CTSIB identified a significant difference between groups (P = 0.029). A receiver operator characteristic area under the curve (AUC) analysis identified the discriminate power of that condition to be 0.85 (95% CI: 0.715-0.992). Analysis of the AUC coordinates revealed a sway cutoff of 0.55 m2/s4 to have a sensitivity of 0.857, specificity of 0.238, positive Likelihood Ratio of 1.125, and negative likelihood ratio of 0.6 for fall risk identification.
Conclusions: Within this limited sample size and uneven distribution of the groups, one condition of the I-CTSIB was effective at differentiating fall risk and no fall risk in CDA. The M-CTSIB was unable to identify a difference, which could be attributed to the higher functioning of this sample. Clinical Relevance: A simple eyes closed firm test condition using the I-CTSIB may be sensitive enough to detect individuals at risk for falls, even in higher functioning individuals, offering a quick, safe, and easy alternative to the 4-condition clinical test.
The Effects of Motor Imagery, Physical Practice, and Combined Practice on Musculoskeletal Flexibility of Youth and Young Adults
C.R. Thompson, K. Barmann, J. Guinn, R. McCort, M. Meister, M. Ganser, PT Education, Rockhurst University, Kansas City, Missouri.
Purpose/Hypothesis: Few, if any, studies have compared the use of motor imagery, physical practice, and combined practice on musculoskeletal flexibility. This study examined the impact of using stretching, motor imagery, and combined practice on the musculoskeletal flexibility of youth and young adults to determine which type of practice had greater efficacy.
Number of Subjects: N = 54 (23 M, 31 F, ages 12-25 years).
Materials/Methods: Researchers randomly assigned subjects to 4 groups: Control (C), Physical Practice (PP), Motor Imagery (MI), and Motor Imagery + Physical Practice (MI + PP). All reported their background experience related to flexibility, including participation in sports and prior injuries (exclusion criteria), then were measured for anthropometrics. Pre- and posttesting included the Sit and Reach Test, hamstring ROM with 90 hip flexion, Vividness of Motor Imagery Questionnaire (Revised), and Vividness of Motor Imagery for Flexibility. Interventions involved: C and PP listened to 5-minute informational audiotape while MI and MI + PP listened to a 5-minute scripted motor imagery audiotape for relaxation and improved flexibility. PP and MI + PP also performed 3 repetitions of the Sit and Reach Test (holding 30 seconds each) following a contract-relax procedure. All groups documented thoughts pre- and post interventions and completed MI surveys to determine use of MI.
Results: In all groups the Sit and Test scores improved overall. As compared to the C, MI had an effect size of 0.61 with 95% CI of 4.8 to 8.6, indicating that 73% of the control group would perform below the MI mean. PP had an effect size of 0.28, indicating that 60% of the control group would perform below the PP mean with 95% CI of 4.91 to 9.09. MI + PP had an effect size of 0.71, indicating that 76% of the control group would perform below the MI + PP mean with 95% CI of 6.70 to 11.996. Comparing hamstring flexibility across groups, MI vs. PP had an effect size of 0.32, indicating 62% of the PP group would perform below the MI mean with 95% CI of −0.45 to 1.08. MI vs. MI + PP had an effect size of 27, indicating 60% of MI group would perform below the MI + PP mean with 95% CI of −0.47 to 1.02. Lastly, PP vs. MI + PP had an effect size 0.49, indicating 68% of the PP group would perform below the MI + PP mean with 95% CI of −0.31 to 1.29.
Conclusions: Motor imagery had a small to medium effect on interventions designed to improve musculoskeletal flexibility related to the Sit and Reach Test with the most notable effect when MI was used in conjunction with PP. These results suggest that motor imagery combined with physical practice may enhance interventions designed to improve musculoskeletal flexibility.
Clinical Relevance: Motor imagery combined with physical practice can enhance musculoskeletal flexibility exercises. Even used alone, motor imagery may be a clinically effective adjunct to physical practice for improving musculoskeletal flexibility.
Use of Hip Flexor Assist Orthosis for Adult Male With Multiple Sclerosis to Improve Functional Mobility: A Case Study on New Orthotic Technology, Patient Advocacy, and Community Resources
J. Nash, C. Ross, M. Murphy, Rehabilitation and Sports Therapy, Cleveland Clinic Lou Ruvo Center for Brain Health, Las Vegas, Nevada.
Background and Purpose: Chronic gait disturbance is a primary functional limitation for a large number of individuals with multiple sclerosis (MS). This clinical hallmark adversely affects quality of life and can be caused by lower extremity (LE) weakness, fatigue, and decreased range of motion. The hip flexion assist orthosis (HFAO) is a lightweight and carefully designed orthotic device that aids ambulatory individuals with unilaterally predominant hip flexor weakness. The HFAO supplements hip and knee flexors, with additional dorsiflexion assist at distal attachment. This single case design investigated the efficacy of the HFAO on gait performance. Dual purpose of this study was to provide an example of how this device can be obtained when finances and insurance availability are insufficient. This study demonstrates importance of patient advocacy with utilization of community resources.
Case Description: A 28-year-old Caucasian male diagnosed in 2011 with relapsing-remitting MS with left LE hip flexor weakness. Postcompletion of initial physical therapy evaluation, the physical therapist (PT) determined need for trial of the HFAO on weaker LE and trained individual in use. Objective examination was completed to evaluate gait performance with and without HFAO. Due to the individual's financial and insurance limitations, PT discussed options for seeking assistance to obtain this device. PT issued application for medical equipment assistance from the National MS Society (NMSS), after individual approval was obtained.
Outcomes: Timed Up and Go Test (TUG), preferred and fast gait speeds, Six-Minute Walk Test (6MWT), step length measured on Biodex Gait Trainer Treadmill 2, and Activities-Specific Balance Confidence (ABC) Scale. All measures were collected with the use of single point cane and with or without use of HFAO. Results without HFAO: TUG: 14.75 seconds; preferred gait speed (PGS): 2.99 ft/s, fast gait speed (FGS): 3.55 ft/s; 6MWT: 1266 ft; step length: left: 46 cm, right 61 cm; ABC Scale: 46%. Results with HFAO: TUG: 10.16 seconds; PGS: 3.11 ft/s, FGS: 3.72 ft/s; 6MWT: 1275 ft; step length: left: 63 cm, right: 65 cm; ABC Scale: 80%. No serious adverse events occurred. Outcome improvements with HFAO use were submitted to NMSS, with determination that HFAO necessity warranted funding.
Discussion: These findings suggest the HFAO is safe and associated with significant improvement in gait performance. This low-cost device serves to increase hip flexor weakness in individuals with MS. Subjective reports indicate improvements in confidence with daily activities. As PTs use clinical expertise, evidence-based practice, and patient advocacy for providing optimal care, community resources should not be overlooked. The use of these resources has potential to promote improved individual well-being. The NMSS serves as a positive resource for individuals with MS and their health care providers to partner for promotion of enhanced quality of life.
High Repetitions of Intensive Stepping Practice Delivered in the Inpatient Rehab Setting
P. Hennessy, SMPP, Rehabilitation Institute of Chicago, Chicago, Illinois. T. Hornby, Physical Therapy, University of Illinois at Chicago, Chicago, Illinois.
Purpose/Hypothesis: The need for task-specific stepping practice during the acute and subacute phases of rehabilitation is thought to mediate activity-dependent neuroplastic changes. A recent observational study investigating stepping delivered to persons with stroke during therapy shows averages of 357 steps per treatment session. This is significantly smaller than animal models, which demonstrated lasting neuroplastic changes with 1000 to 2000 steps per session. More so, interventions during inpatient rehabilitation lack adequate cardiovascular intensity. A recent longitudinal study shows that inpatients spend an average of 2.8 minutes of the therapy session in a target cardiovascular training zone. A primary purpose of the study is to offer a reflection of stepping dosage delivered on an inpatient stroke unit with treatments focused on delivering high repetitions of intensive stepping practice.
Number of Subjects: 150 consecutively admitted individuals with stroke collected, 21 individuals analyzed as pilot data.
Materials/Methods: A retrospective chart review was performed on an inpatient stroke unit. Physical therapy interventions focused on standardized methods of delivering high repetitions of stepping training with the goal of achieving and maintaining a cardiovascular training zone (70%-85% of age-predicted heart rate max or Borg rate of perceived exertion >13). Time spent in target training zones recorded in 5-minute increments during each training session was logged throughout the admission. Standardized locomotor and balance-related outcome measures were reassessed weekly. Daily stepping repetitions were monitored each minute by using Step Activity Monitors.
Results: In 21 pilot subjects, a daily average of 2683 ± 1780 steps were recorded. An average of 33.7 ± 17.3% of physical therapy sessions were spent in a target cardiovascular zone. During admission, the subset improved gait speed from 0.19 ± 0.24 to 0.66 ± 0.55 m/s, 6-minute walk test (6MWT) from 232 ± 310 to 600 ± 446 feet, and Berg Balance Scale (BBS) scores from 18.8 ± 18.2 to 35.6 ± 18.8. Positive correlations were observed between average max heart rate during training with improvements in 6MWT (r = 0.67735) and gait speed (r = 0.693), and average steps per day with improvements in 6MWT (r = 0.83).
Conclusions: The pilot subset achieved >7 times the dosage of stepping previously reported, which reflects feasibility of delivering repetitions administered in animal models demonstrating neuroplasticity. Individuals were able to maintain cardiovascular intensity >10 times previously documented. Moderate to strong correlations were found between intensity and stepping repetitions with improvements in locomotor-related outcome measures.
Clinical Relevance: Individuals poststroke in inpatient rehab can achieve high repetitions of intensive stepping practice. Pilot data suggest a positive relationship between stepping repetition, intensity, and functional outcomes.
Will High Intensity Aerobic Exercise Improve Aerobic Capacity, Gait, and Participation in Patients With Chronic Stroke Compared to Standard Aerobic Exercise or Standard Physical Therapy?
E. Crocitto, K. Halsey, M. Infusino, E. Lotz, M. O'Brien, S. Post, T. Ross, M. Saenz, A. Terrigno, M. Kafri, Rutgers University/UMDNJ, Newark, New Jersey.
Purpose: Ambulatory ability is a common functional loss in individuals poststroke due to deficits in motor control, strength, and cardiovascular function. On average, patients poststroke function at 50% to 70% of the cardiopulmonary capacity of their age and sex matched healthy counterparts. The purpose of this literature review was to determine whether administering high-intensity aerobic exercise (HIAE) to patients in the chronic phase poststroke results in positive changes in aerobic capacity, walking endurance, walking speed, and quality of life when compared to standard physical therapy or traditional aerobic training.
Description: Results. Evidence at a moderate level shows that HIAE significantly improves aerobic capacity, as measured by
O2max, compared to standard physical therapy and standard aerobic training. All papers reviewed show significant improvement in walking speed and distance with HIAE. Walking speed improvements were clinically important in 3 of the papers. HIAE improved fast walking speed more than standard PT but not more than standard aerobic training. Three studies found that the changes in walking distance with HIAE were clinically important, but only 1 study showed that HIAE was superior to standard PT. When compared to standard aerobic exercise, HIAE was not superior with regard to walking distance. There is not enough evidence to make a conclusion regarding the effect of HIAE on quality-of-life measures.
Summary of Use: Conclusion: HIAE is beneficial for patients with chronic stroke, but given the comparisons above, it is not more beneficial than standard PT and aerobic training. HIAE might be difficult to implement in the clinic due to lack of funds, time constraints for both the therapist and patients, and the lack of availability of adequate equipment.
Importance to Members: Application to Physical Therapy. When the time and resources are available, HIAE is a better option, relative to standard physical therapy and aerobic training, to increase gait variables in conjunction with increasing cardiovascular function and endurance.
Clinical Utility of the King Devick Test in Preseason Concussion Screening
D.W. Klima, B. Omess, S. Phillips, D. Witkowski, K. Davis, UMES, Princess Anne, Maryland. E. Hood, Physical Therapy, Concussion Center at St. Luke's Warren, Warren, Pennsylvania.
Purpose/Hypothesis: According to the National Center for Injury Prevention and Control, the most common form of head trauma in sports is concussion, a mild traumatic brain injury. It is essential that physical therapists utilize salient outcomes measures when assessing athletes along the sports season trajectory. The King Devick Test is an objective tool used to measure timed saccadic eye movements while reading a series of digits on designated test cards. The purpose of this study was to analyze psychometric properties of the King Devick Test (KDT) in preseason screening of high school soccer and football athletes, and specifically to (1) assess both reliability and concurrent validity with categories on the neurocognitive ImPACT test and (2) analyze differences in test performance between football and soccer athletes.
Number of Subjects: Two hundred sixty-eight high school football (n = 218; 81%) and soccer players (n = 50; 19%) participated in the study (mean age 15 ± 1.2 years) at a local hospital balance clinic.
Materials/Methods: Subjects performed a circuit of screening activities, including the KDT, the ImPACT neurocognitive examination, and sensory organization posturographic testing. Basic demographic data were obtained, including prior history of concussion injuries. Bivariate analyses included ICC comparisons, Spearman rho correlations, and independent t tests with Bonferroni correction. Multiple regression identified predictive determinants of KDT performance.
Results: Fifty-five subjects (21%) noted a prior history of concussion. KDT ICC's confirmed strong (0.95) test-retest reliability. KDT scores demonstrated significant correlations with the ImPACT visual motor speed composite scores (−0.46; P < 0.01), reaction time (−0.34; P < 0.01), and the Cognitive Efficiency Index (−0.15; P < 0.05). Significant baseline differences were noted between football and soccer players (47.9 ± 9.6 vs. 42.9 ± 8.1 seconds; P < 0.001). Visual motor speed, reaction time, and cognitive efficiency predicted 22% of the variance in KDT performance (P < 0.001).
Conclusions: The KDT shows excellent test-retest reliability and demonstrates concurrent validity with related constructs on the ImPACT test. The instrument may be administered both on the field and in clinical settings with standardized cards and a stopwatch. Baseline performance differences were identified between sports; moreover, further preseason and postinjury sport-specific comparisons are warranted.
Clinical Relevance: The KDT instrument is an effective tool for physical therapists to assess baseline optokinetic function during concussion screens in a variety of settings and may be utilized in tandem with other standardized measures.
How Concomitant Brain Injury Affects Functional Mobility for Patients With Spinal Cord Injury on a Pediatric Inpatient Rehabilitation Unit
P.D. Palma, E. Eggebrecht, E. Poplawski, E. Van Den Eynde, T. Zagustin, J. Vova, M. Sholas, Children's Healthcare of Atlanta, Atlanta, Georgia. J. Miller, Georgia State University, Atlanta, Georgia.
Purpose/Hypothesis: To investigate how functional mobility and length of stay will change in participants with spinal cord injury with concomitant traumatic brain injury (TBI) versus those with spinal cord injury only in an inpatient pediatric rehabilitation setting. We hypothesize that there should be a longer length of stay and lower discharge WeeFIMs set for those patients with spinal cord injury with a concomitant spinal cord injury or dual diagnosis (DDS).
Number of Subjects: 127 pediatric participants ranging from 0 to 21 years of age having sustained a traumatic or nontraumatic spinal cord injury having received services at Children's Healthcare of Atlanta from 2008 through 2012.
Materials/Methods: Five-year retrospective Study performing chart and database reviews on a comprehensive inpatient rehabilitation unit.
Results: Overall, SCI patients with concurrent TBI had significantly lower self-care, mobility, cognition, and Wee-FIM scores at admission and at discharge. The change, or improvement, in their scores from admission to discharge showed that SCI only patients had larger gains in self-care and mobility relative to patients with TBI + SCI (P < 0.05 for all comparisons). Admission to injury time and length of stay were significantly longer in SCI patients with concurrent TBI (P = 0.001 and P < 0.001, respectively).
Conclusions: These findings are instructive to health care professionals for setting longer lengths of stay and predicted Wee-FIM scores based upon severity of cognitive dysfunction for patients 0 to 21 with a spinal cord injury.
Clinical Relevance: A multidisciplinary approach should be considered to address the cognitive and psychosocial needs unique to patients with dual diagnosis. Furthermore, early detection of the concomitant brain injury is key in guiding the individualized plan of care.