Charles E. Levy

Functional MRI evidence of cortical reorganization in upper-limb stroke hemiplegia treated with constraint-induced movement therapy

Levy CE, Nichols DS, Schmalbrock PM, Keller P, Chakeres DW: Functional MRI evidence of cortical reorganization in upper-limb stroke hemiparesis treated with constraint-induced movement therapy. Am J Phys Med Rehabil 2001;80:4–12. Objective The purpose of this pilot study was to test constraint-induced movement therapy for chronic upper-limb stroke hemiparesis and to investigate the neural correlates of recovery with functional magnetic resonance imaging (MRI) in two subjects. Both subjects had been discharged from traditional therapy because no further improvement was anticipated. Design Constraint-induced movement therapy consisted of 6 hr of daily upper-limb training for 2 wk; a restrictive mitt was worn on the nonparetic limb during waking hours. Functional MRI was performed on a 1.5-T MRI with echo-planar imaging; at the same time, the subjects attempted sequential finger-tapping. Results Compared with baseline, performance time improved an average of 24% immediately after training and also continued to improve up to 33% 3 mo after training. Lift, grip strength, and Motor Activity Log scores likewise improved. Initially, on functional MRI, subject 1 activated scattered regions in the ipsilateral posterior parietal and occipital cortices. Subject 2 showed almost no areas of significant activation. After training, subject 1 showed activity bordering the lesion, bilateral activation in the association motor cortices, and ipsilateral activation in the primary motor cortex. Subject 2 showed activation near the lesion site. Conclusion Constraint-induced movement therapy produced significant functional improvement and resulted in plasticity as demonstrated by functional MRI.

Effect of participation in physical activity on body image of amputees

Wetterhahn KA, Hanson C, Levy CE: Effect of participation in physical activity on body image of amputees. Am J Phys Med Rehabil 2002;81:194–201. ObjectiveThe purpose of this study was to examine body image in individuals with amputations and to determine if a relationship exists between body image and level of participation in physical activity and sports. A secondary objective was to examine correlations between two body-image assessments. DesignA nonrandomized survey was given to a convenience-volunteer sample of individuals of at least 18 yr of age with a lower limb amputation. ResultsTwenty-four participants were active and 32 were minimally active. Statistical significance was preset at P < 0.05, with a 95% confidence interval. An overall significant difference was found between groups on the MBSRQ and on three of the 10 MBSRQ subscales. Significant correlations were found between six MBSRQ subscales and the ABIS. ConclusionA positive relationship was found between regular participation in physical activity and body image among lower limb amputees.

Methodological challenges confronting researchers of wheeled mobility aids and other assistive technologies.

Purpose. To identify gaps in assistive technology (AT) research and solutions, with a focus on wheeled mobility. Methods. Literature review. Results. AT researchers have identified a need to move beyond determining whether a device works well in the laboratory or is perceived favorably by users. The vital next step in AT research is to determine the effects of AT when used for day-to-day activities by typical consumers. Four challenges affect AT research on everyday mobility: the heterogeneity of the population using AT, the environments in which AT is used, and the devices themselves; the dependency of empirical research on objective data for valid causal inference; the need for detailed information to capture the interaction between the person, the device, and the environment in which it is used; and the extent to which success or failure of AT is dependent on the personal perspectives of the individual using the device. These challenges are being addressed by AT researchers through use of new measures, novel data collection methods, and by linking quantitative with qualitative data. Conclusions. AT researchers are adapting traditional research designs and analytic methods to examine that effects of AT on everyday life.

Cost Effectiveness of a Telerehabilitation Program to Support Chronically Ill and Disabled Elders in Their Homes

Chronic illnesses account for approximately 75% of all healthcare costs in the United States today, resulting in functional limitations and loss of independence, as well as increased medical expenditures. The elderly population is at a higher risk for developing chronic conditions, increasing their risk for disabilities. Given the rapid growth of the aging population, and the chronic illnesses, disabilities, and loss of functional independence endemic to elders, novel methods of rehabilitation and care management are urgently needed. Telehealth models that combine care coordination with communications technology offer a means for managing chronic illnesses, thereby decreasing healthcare costs. We examined the effects of a Veterans Administration (VA) telerehabilitation program (Low Activities of Daily Living [ADL] Monitoring Program-LAMP) on healthcare costs. LAMP is based on a rehabilitative model of care. LAMP patients received adaptive equipment and environmental modifications, which focused on self-care and safety within the home. LAMP Care Coordinators remotely monitored their patients vital signs and provided education and self-management strategies for decreasing the effects of chronic illnesses and functional decline. The matched comparison group (MCG) received standard VA care. Healthcare costs 12 months preenrollment and 12 months post-enrollment were examined through a difference-in-differences multivariable model. Using actual costs totaled for these analyses, no significant differences were detected in post-enrollment costs between LAMP and the MCG. For LAMP patients, the provision of adaptive equipment and environmental modifications, plus intensive in-home monitoring of patients, led to increases in clinic visits post-intervention with decreases in hospital and nursing home stays.

Sports and recreation for persons with limb deficiency.

UNLABELLED Opportunities for persons with limb deficiency to participate in sport and recreational activities have increased dramatically over the past 20 years. Various factors have contributed to this phenomenon, including an increased public interest in sports and fitness as well as improvements in disability awareness. An even more essential element has been a consumer-driven demand for advances in prosthetic technology and design. Whether the activity is a music performance, a friendly round of golf, or a high-level track-and-field competition, the benefits of participation in sports and recreation are numerous both at the individual and at the societal level. This article provides an overview of the development and scope of sport and recreational opportunities available to persons with limb deficiency. In addition, specific prosthetic considerations for several common sport and recreational activities are presented in a case-discussion format. OVERALL ARTICLE OBJECTIVE To review the development and scope of sport and recreational opportunities available to persons with limb deficiency.

Botulinum toxin a, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study.

Levy CE, Giuffrida C, Richards L, Wu S, Davis S, Nadeau SE: Botulinum toxin A, evidence-based exercise therapy, and constraint-induced movement therapy for upper-limb hemiparesis attributable to stroke: a preliminary study. Am J Phys Med Rehabil 2007;86:696–706 Objective:To determine whether the combination of botulinum toxin A (BTX-A) treatment for the upper limb and a 4-wk course of exercise therapy could improve motor function sufficiently to allow those with poststroke hemiparesis and spasticity to achieve the minimal motor criteria (MMC) to be enrolled in constraint-induced movement therapy (CIMT), and to determine the feasibility of enrolling participants into CIMT if they meet MMC after treatment with a combination of BTX-A plus exercise therapy. Design:Twelve individuals received BTX-A and exercise therapy for 1 hr/day, three times per week, for 4 wks. Those who met MMC were enrolled in 2 wks of CIMT, and the rest received a home exercise program. Outcome measures included the Ashworth Scale, Wolf Motor Function Test (WMFT), the Motor Activity Log (MAL), the Box and Blocks Test (BBT), and the upper-extremity subtest of the Fugl–Meyer Assessment of Motor Function (FM-UE). Results:Ashworth Scale scores declined from a mean score of 2.0–1.2 (P = 0.01). Four of 12 subjects were able to achieve MMC (P = 0.026). CIMT participants improved in the BBT, the MAL, and the WMFT compared with their own baseline. Gains achieved during CIMT receded by week 24 as spasticity returned. Conclusion:BTX-A plus exercise therapy shows potential to improve function for those with severe hand paresis and spasticity after stroke. Those who meet MMC may initially realize further modest gains through CIMT. However, gains are likely to recede as spasticity returns. Adding medications or modifying the therapy protocol to include activities such as functional neuromuscular stimulation or robotic training may yield a more potent effect.

Pushrim-activated power-assist wheelchairs: Elegance in motion

Manual wheelchair propulsion has been linked to a variety of upper limb disorders, including rotator cuff tendonitis, lateral epicondylitis, cubital tunnel and carpal tunnel neuropathies, fibrocartilage metaplasia, and calcific tendonitis. However, manual wheeling also provides aerobic exercise. The benefits of exercise are well known and include promotion of cardiovascular fitness, reduction of hypertension, improved glycemic control, improved lipid profiles, reduction of anxiety, and an improved sense of well-being. Animal studies suggest that exercise can induce expression of genes associated with neural plasticity, long-term potentiation, neurogenesis, and resistance to injury such as that encoding brainderived neurotrophic factor. Manual propulsion has also been associated with positive self-esteem and positive body image. Thus, rehabilitation professionals should promote manual wheeling whenever possible and practical. Pushrim-activated power-assist wheelchairs (PAPAWs) decrease the biomechanical and physiologic stress associated with self-propulsion while preserving the opportunity to exercise while wheeling. Torque applied to the pushrims activates small, lightweight motors. These in turn provide brief bursts of power to drive the wheels, resulting in augmented wheeling. To keep a PAPAW moving, users repeatedly stroke the pushrim as they would if they were propelling conventional manual wheelchairs. PAPAWs are an intermediate alternative between conventional power and manual wheelchairs. Like power chairs, PAPAWs allow access to multiple environments (carpets, steep inclines, grass, etc.) that are often inaccessible to manual wheeling. However, like manual wheelchairs, PAPAWs are relatively lightweight (weighing as little as 57 lbs) and still provide an exercise challenge. Limitations to wide acceptance of PAPAWs include cost, greater difficulty in loading and unloading in motor vehicles compared with manual chairs, and lack of awareness among users and practitioners. Three power-assist options are currently available in the United States: (1) The e.motion M12, manufactured by Alber of Albstadt, Germany, and marketed in the United States by Frank Mobility Systems of Oakdale, PA; (2) the JW II, manufactured by Yamaha, Shizuoka, Japan, available in the United States as the Quickie Xtender from Sunrise Medical, Longmont, CO; and (3) the iGlide, manufactured by Independence Technology, Warren, NJ (Fig. 1) Significant differences exist between each of these models. These differences include the mechanisms and algorithms employed to link pushrim input to motor output, weight of each PAPAW, programmability, ease of wheel removal, number of available configurations, battery placement, ability to traverse challenging environments, downhill safety, motor noise, and others. As PAPAWs evolve, they are likely to become lighter, more powerful, and more widely and easily programmable. Familiarity with PAPAWs will aid in optimal wheelchair prescription.

Use of power assist wheels results in increased distance traveled compared with conventional manual wheeling.

Levy CE, Buman MP, Chow JW, Tillman MD, Fournier KA, Giacobbi P Jr: Use of power assist wheels results in increased distance traveled compared with conventional manual wheeling. Objective:To evaluate the impact of power assist wheels on the distance traveled by manual wheelchair users and analyze potential cofactors in the magnitude of response and to test the hypothesis that wheelers would travel significantly further with power assist wheels. Design:A 16-wk A (Preintervention)-B (Intervention)-A (Postintervention) repeated measures design. Seven women and 13 men (age, 43 ± 15 yrs) full-time wheelers participated. During the pre- and postintervention phases (4 wks each), participants used their own unaltered manual wheelchairs. During the 8-wk intervention phase, the manual wheels were replaced with power assist wheels. Daily distance was measured with bicycle-style odometers. A composite score of laboratory wheelchair tasks was used to classify wheelchair performance. Mixed model repeated measures analysis of variance analyzed changes across phases of the trial. A post hoc analysis tabulated the amount of days wheelers exceeded their individual daily averages in each phase by two SDs. Results:Wheelers traveled significantly greater distances during the intervention phase compared with pre- or postintervention phases regardless of baseline wheelchair performance. Wheelers who demonstrated higher baseline wheelchair performance traveled lesser average distances in the first 2 wks after receiving power assist wheels than in the subsequent 6 wks. Wheelers exceeded their individual daily averages per phase on a significantly greater number of days during the intervention phase. Conclusions:Power assist wheels enabled wheelers to travel farther and to travel beyond their usual distances on more days. Further studies may be strengthened by taking into account the 2-wk “adjustment phase” for power assist wheels.

Using Telerehabilitation to Support Elders With Chronic Illness in Their Homes

As the number of persons with disabilities increases because of factors such as aging combined with chronic illnesses, the challenge of providing rehabilitation also increases. Unfortunately, financial considerations have shortened length of stay in acute and subacute settings and reduced rehabilitation services. With earlier discharges, there is an increased need to deliver services to patients in their homes in an efficient and cost-effective manner. Telerehabilitation is an emerging practice that uses communications technology for the remote delivery of rehabilitative care. The Low ADL Monitoring Program is a telerehabilitation program designed to deliver rehabilitation services through the provision of home environmental interventions, together with communications technology and care coordination.

Acquired limb deficiencies. 3. Prosthetic components, prescriptions, and indications

UNLABELLED This self-directed learning module highlights indications for prosthetic components and prescription formulation for adults with acquired limb deficiency. It is part of the chapter on acquired limb deficiencies in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Advantages and disadvantages of specific components of upper and lower limb prostheses are discussed, and a sample prescription sheet for upper limb devices is included. Recent innovations in terminal devices for upper limb prostheses are reviewed. Special considerations for the adult with acquired multilimb deficiency are also examined. OVERALL ARTICLE OBJECTIVE To describe indications for prosthetic components and prescription formulation for adults with acquired limb deficiency.