Emily J. Fox

Effects of stroke severity and training duration on locomotor recovery after stroke: a pilot study.

Background. Locomotor training using partial body weight-supported treadmill (BWST) walking has been widely investigated for people after stroke, yet there remains a lack of evidence concerning the optimal training duration and the effect of locomotor impairment severity. Previous protocols have not emphasized the transfer of locomotor skills from the BWST environment to overground. Objectives. To assess the feasibility of a program combining locomotor training using BWST with task-specific overground training and to obtain pilot data on the effects of severity and training duration on recovery of locomotion. Methods. Seven adults with chronic poststroke hemiparesis and gait speed less than 0.8 m/s were recruited to participate in a 12-week (36 session) locomotor training program. Each session comprised 20 to 30 minutes of training using BWST with manual assistance, followed by 10 to 15 minutes of overground training to transfer the skills trained in the BWST environment. Gait speed was the primary outcome measure. Results. Six out of the 7 enrolled individuals completed the intervention program; 1 was withdrawn due to transportation difficulties affecting compliance with the training schedule. Four of the 6 participants had a functionally significant improvement in walking speed after 36 sessions, defined as having achieved a 0.4 m/s gait speed or greater for those with initial severe gait speed impairment (<0.4 m/s) or as having achieved a 0.8 m/s gait speed or greater for persons with initial moderate gait speed impairment (≥0.4 m/s and <0.8 m/s). All participants improved in balance and distance walked over 6 minutes, and 5 of the 6 participants showed increases in their daily home and community step activity. Conclusions. A locomotor training program combining walking using BWST and manual assistance with overground practice is feasible for people with chronic poststroke hemiparesis and moderate or severe gait speed impairment. This intervention shows promise for achieving functionally significant improvements in walking speed.

Locomotor training with partial body weight support on a treadmill in a nonambulatory child with spastic tetraplegic cerebral palsy: a case report.

PURPOSE Recent findings by neuroscientists serve as the basis for a new approach to training stepping after neurologic injury. The purpose of this case report was to describe the outcomes for one child with cerebral palsy after locomotor training. CASE DESCRIPTION The child was a nine-year-old boy diagnosed with spastic tetraplegic cerebral palsy. He could not support his weight upright against gravity and had never experienced walking. METHODS Forty-four sessions of locomotor training with partial body weight support (BWS) included static step practice, weight shifting, and walk training on a treadmill. The Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI) were administered prior to and immediately after training. OUTCOMES The child demonstrated improvements in all domains of the GMFM and both domains of the PEDI. He was able to complete up to 60 independent steps on the treadmill while supported in the BWS harness. Four months after training, he was able to walk over ground short distances with a rolling walker and minimal assistance. DISCUSSION This case report is the first to report improvement in stepping on a treadmill with carryover to over-ground walking in a nonambulatory child of this age with spastic tetraplegic cerebral palsy.Purpose: This study examined the use of integrated models of service delivery by pediatric physical therapists (PTs) and occupational therapists (OTs). Child and environmental characteristics and variables that influence use of integrated models and perceptions of therapists regarding variables influencing the effectiveness of the model were identified. The study also compared outcomes achieved by subjects who received integrated or isolated therapy. Methods: Regional data were obtained using a questionnaire. Respondents were from 11 urban, suburban, and rural practice settings within a 30-mile radius of Rochester, NY. Outcomes data were gathered through retrospective review of records. Results: Of the 220 questionnaires sent out, 107 (49%) were returned. Results showed 55.3% of children (ages up to 13 years 10 months) received the majority of therapy services in isolated settings, while 24.7% received a majority of services in integrated settings. The remaining 20% of the children received therapy services that were equally blended between both models. Significant differences were noted when comparing the caseload percentages of PTs to OTs. Children with developmental delay and multiple handicaps received integrated therapy most frequently. Variables reported to influence use and effectiveness of integrated therapy included child behavior and attention span, classroom structure, and activities addressed in therapy. Conclusions: PTs and OTs provide services in both integrated and isolated settings often using both approaches based on the treatment objectives, child, and environment variables. We found no evidence that an integrated model is more effective than an isolated approach to intervention.

Walking Adaptability after a Stroke and Its Assessment in Clinical Settings

Control of walking has been described by a tripartite model consisting of stepping, equilibrium, and adaptability. This review focuses on walking adaptability, which is defined as the ability to modify walking to meet task goals and environmental demands. Walking adaptability is crucial to safe ambulation in the home and community environments and is often severely compromised after a stroke. Yet quantification of walking adaptability after stroke has received relatively little attention in the clinical setting. The objectives of this review were to examine the conceptual challenges for clinical measurement of walking adaptability and summarize the current state of clinical assessment for walking adaptability. We created nine domains of walking adaptability from dimensions of community mobility to address the conceptual challenges in measurement and reviewed performance-based clinical assessments of walking to determine if the assessments measure walking adaptability in these domains. Our literature review suggests the lack of a comprehensive well-tested clinical assessment tool for measuring walking adaptability. Accordingly, recommendations for the development of a comprehensive clinical assessment of walking adaptability after stroke have been presented. Such a clinical assessment will be essential for gauging recovery of walking adaptability with rehabilitation and for motivating novel strategies to enhance recovery of walking adaptability after stroke.

Ongoing Walking Recovery 2 Years After Locomotor Training in a Child With Severe Incomplete Spinal Cord Injury

Background and Purpose The authors previously reported on walking recovery in a nonambulatory child with chronic, severe, incomplete cervical spinal cord injury (SCI) after 76 sessions of locomotor training (LT). Although clinical measures did not predict his recovery, reciprocal patterned leg movements developed, affording recovery of independent walking with a reverse rolling walker. The long-term functional limitations and secondary complications often associated with pediatric-onset SCI necessitate continued follow-up of children with SCI. Therefore, the purpose of this case report is to describe this childs walking function and musculoskeletal growth and development during the 2 years since his participation in an LT program and subsequent walking recovery. Case Description Following LT, the child attended elementary school as a full-time ambulator. He was evaluated 1 month (baseline), 1 year, and 2 years after LT. Examination of walking function included measures of walking independence, gait speed and spatiotemporal parameters, gait kinematics, and daily step activity. Growth and development were assessed by tracking his height, weight, incidence of musculoskeletal complications, and gross motor task performance. Outcomes Over the 2 years, the child continued to ambulate independently with a reverse rolling walker, increasing his fastest gait speed. Spatiotemporal and kinematic features of his walking improved, and daily step activity increased. Height and weight remained on their preinjury trajectory and within age-appropriate norms. The child experienced only minor musculoskeletal complications. Additionally, he gained the ability to use reciprocal patterned leg movements during locomotor tasks such as assisted stair climbing and independent tricycle pedaling. Conclusions Two years after recovery of walking, this child with incomplete SCI had maintained and improved his walking function and experienced age-appropriate growth and development.

“Kinect-ing” With Clinicians: A Knowledge Translation Resource to Support Decision Making About Video Game Use in Rehabilitation

Microsofts Kinect for Xbox 360 virtual reality (VR) video games are promising rehabilitation options because they involve motivating, full-body movement practice. However, these games were designed for recreational use, which creates challenges for clinical implementation. Busy clinicians require decision-making support to inform game selection and implementation that address individual therapeutic goals. This article describes the development and preliminary evaluation of a knowledge translation (KT) resource to support clinical decision making about selection and use of Kinect games in physical therapy. The knowledge-to-action framework guided the development of the Kinecting With Clinicians (KWiC) resource. Five physical therapists with VR and video game expertise analyzed the Kinect Adventure games. A consensus-building method was used to arrive at categories to organize clinically relevant attributes guiding game selection and game play. The process and results of an exploratory usability evaluation of the KWiC resource by clinicians through interviews and focus groups at 4 clinical sites is described. Subsequent steps in the evaluation and KT process are proposed, including making the KWiC resource Web-based and evaluating the utility of the online resource in clinical practice.

Modulation of Force below 1 Hz: Age-Associated Differences and the Effect of Magnified Visual Feedback

Oscillations in force output change in specific frequency bins and have important implications for understanding aging and pathological motor control. Although previous studies have demonstrated that oscillations from 0–1 Hz can be influenced by aging and visuomotor processing, these studies have averaged power within this bandwidth and not examined power in specific frequencies below 1 Hz. The purpose was to determine whether a differential modulation of force below 1 Hz contributes to changes in force control related to manipulation of visual feedback and aging. Ten young adults (25±4 yrs, 5 men) and ten older adults (71±5 yrs, 4 men) were instructed to accurately match a target force at 2% of their maximal isometric force for 35 s with abduction of the index finger. Visual feedback was manipulated by changing the visual angle (0.05°, 0.5°, 1.5°) or removing it after 15 s. Modulation of force below 1 Hz was quantified by examining the absolute and normalized power in seven frequency bins. Removal of visual feedback increased normalized power from 0–0.33 Hz and decreased normalized power from 0.66–1.0 Hz. In contrast, magnification of visual feedback (visual angles of 0.5° and 1.5°) decreased normalized power from 0–0.16 Hz and increased normalized power from 0.66–1.0 Hz. Older adults demonstrated a greater increase in the variability of force with magnification of visual feedback compared with young adults (P = 0.05). Furthermore, older adults exhibited differential force modulation of frequencies below 1 Hz compared with young adults (P<0.05). Specifically, older adults exhibited greater normalized power from 0–0.16 Hz and lesser normalized power from 0.66–0.83 Hz. The changes in force modulation predicted the changes in the variability of force with magnification of visual feedback (R2 = 0.80). Our findings indicate that force oscillations below 1 Hz are associated with force control and are modified by aging and visual feedback.

Altered activation of the antagonist muscle during practice compromises motor learning in older adults

Aging impairs the activation of muscle; however, it remains unclear whether it contributes to deficits in motor learning in older adults. The purpose of this study was to determine whether altered activation of antagonistic muscles in older adults during practice inhibits their ability to transfer a motor task ipsilaterally. Twenty young (25.1 ± 3.9 yr; 10 men, 10 women) and twenty older adults (71.5 ± 4.8 yr; 10 men, 10 women) participated. Half of the subjects practiced 100 trials of a rapid goal-directed task with ankle dorsiflexion and were tested 1 day later with elbow flexion (transfer). The rest did not perform any ankle practice and only performed the task with elbow flexion. The goal-directed task consisted of rapid movement (180 ms) to match a spatiotemporal target. For each limb, we recorded the EMG burst activity of the primary agonist and antagonist muscles. The rate of improvement during task acquisition (practice) was similar for young and older adults (P > 0.3). In contrast, only young adults were able to transfer the task to the upper limb. Specifically, young adults who practiced ankle dorsiflexion exhibited ∼30% (P < 0.05) lower movement error and ∼60% (P < 0.05) lower antagonist EMG burst activity compared with older adults who received equal practice and young adults who did not receive any ankle dorsiflexion practice. These results provide novel evidence that the deficient motor learning in older adults may be related to a differential activation of the antagonist muscle, which compromises their ability to acquire the task during practice.

Age-associated impairement in endpoint accuracy of goal-directed contractions performed with two fingers is due to altered activation of the synergistic muscles.

The purpose of this study was to determine whether older adults compared with young adults exhibit impaired end-point accuracy during a two-finger task due to altered activation of the contributing synergistic muscles. Nine young (21.3 years ± 1.6 years, 4 men) and 9 older (73.1 years ± 6.4 years, 5 men) were instructed to accurately match the center of a target with concurrent abduction of the index and little fingers (synergistic two-finger task). The target comprised of 20% MVC and 200 ms. Visual feedback of the force trajectory and target was provided 1s after each trial. Subjects completed 40 trials and the last 10 were used for analysis. Endpoint accuracy was quantified as the normalized deviation from the target in terms of peak force (peak force error), time-to-peak force (time-to-peak force error), and a combination of the two (overall error). Motor output variability was quantified as the standard deviation and coefficient of variation (CV) of peak force and time to peak force. The neural activation of the involved synergist muscles (first dorsal interosseus (FDI) and abductor digiti minimi (ADM)) was quantified with the electromyography (EMG) amplitude (root mean square) and its frequency structure (wavelet analysis). Older adults exhibited significantly greater peak force (46.7 ± 10% vs. 24.9 ± 3.2%) and overall endpoint error (68.5 ± 9.7% vs. 41.7 ± 4.3%), whereas the time to peak force error was similar for the two age groups. Older adults also exerted greater peak force variability than young adults, as quantified by the CV of peak force (34.3 ± 3.5% vs. 24.1 ± 2.3%). The greater peak force error in older adults was associated with changes in the activation of the ADM muscle but not the FDI. Specifically, greater peak force error was associated with greater power from 13-30 Hz and lesser power from 30-60 Hz. These results, therefore, suggest that older adults compared with young adults exhibit impaired endpoint force accuracy during a two finger task because of altered activation of one of the synergist muscles.

The effects of backward walking training on balance and mobility in an individual with chronic incomplete spinal cord injury: A case report

ABSTRACT Background/Purpose: Individuals with incomplete spinal cord injuries (ISCIs) commonly face persistent gait impairments. Backward walking training may be a useful rehabilitation approach, providing novel gait and balance challenges. However, little is known about the effects of this approach for individuals with ISCIs. The purpose of this case report was to describe the effects of backward walking training on strength, balance, and upright mobility in an individual with chronic ISCI. Methods: A 28-year-old female, 11-years post ISCI (C4, AIS D) completed 18-sessions of backward walking training on a treadmill with partial body-weight support and overground. Training emphasized stepping practice, speed, and kinematics. Outcome measures included: Lower Extremity Motor Score, Berg Balance Scale (BBS), Sensory Organization Test (SOT), 10-Meter Walk Test (10MWT), 3-meter backward walking test, Timed Up and Go (TUG), and Activities-Specific Balance Confidence (ABC) Scale. Results: Strength did not change. Improved balance was evident based on BBS (20 to 37/56) and SOT scores (27 to 40/100). Upright mobility improved based on TUG times (57 to 32.7 s), increased 10MWT speed (0.23 to 0.31 m/s), and backward gait speed (0.07 to 0.12 m/s). Additionally, self-reported balance confidence (ABC Scale) increased from 36.9% to 49.6%. Conclusions: The results suggest that backward walking may be a beneficial rehabilitation approach; examination of the clinical efficacy is warranted.

Toward a Transformed Understanding: From Pain and Movement to Pain With Movement

Pain serves as a protective mechanism that leads to changes in movement.1,2 For more than 116 million Americans with chronic pain, however, the pain experience persists beyond a normal, protective phase and develops into a chronic, disabling disease.3 Altered movement may be appropriate in early protective phases, but, if maintained, this altered movement can contribute to poor recovery, continued disability, and decreased quality of life. The Institute of Medicine identifies chronic pain as a nervous system disease and a high-priority societal health concern.3 However, current management of this disease and its complications, such as movement impairments and subsequent reductions in function, is inadequate.3 The Institute of Medicine has called for the health care community to transform its understanding of pain as a key step for improving prevention, treatment, and assessment of pain.3 The Institute of Medicine specifically highlighted the need for “wider use of existing knowledge” as a main objective for transforming our understanding of pain.3 One way to meet this objective is to integrate existing knowledge into a comprehensive model that considers pain to be a dynamic, multifactorial experience that includes a movement component. Although researchers have extensively studied the sensory, psychological, and motor factors related to pain, they often have studied these factors separately or in limited combinations. Isolated investigation of these factors limits the advancement of our understanding of how pain impairs movement and how pain symptoms can cascade into a disabling disease process. Integrated study of sensory, psychological, and motor factors as primary drivers of the pain experience is needed to help establish the collective impact of pain processing on movement and recovery. The purpose of this point of view is to introduce a conceptual model for studying pain with movement. First, we present a historical overview identifying …