Jennifer Moore

Enhanced Gait-Related Improvements After Therapist- Versus Robotic-Assisted Locomotor Training in Subjects With Chronic Stroke A Randomized Controlled Study

Background and Purpose— Locomotor training (LT) using a treadmill can improve walking ability over conventional rehabilitation in individuals with hemiparesis, although the personnel requirements often necessary to provide LT may limit its application. Robotic devices that provide consistent symmetrical assistance have been developed to facilitate LT, although their effectiveness in improving locomotor ability has not been well established. Methods— Forty-eight ambulatory chronic stroke survivors stratified by severity of locomotor deficits completed a randomized controlled study on the effects of robotic- versus therapist-assisted LT. Both groups received 12 LT sessions for 30 minutes at similar speeds, with guided symmetrical locomotor assistance using a robotic orthosis versus manual facilitation from a single therapist using an assist-as-needed paradigm. Outcome measures included gait speed and symmetry, and clinical measures of activity and participation. Results— Greater improvements in speed and single limb stance time on the impaired leg were observed in subjects who received therapist-assisted LT, with larger speed improvements in those with less severe gait deficits. Perceived rating of the effects of physical limitations on quality of life improved only in subjects with severe gait deficits who received therapist-assisted LT. Conclusions— Therapist-assisted LT facilitates greater improvements in walking ability in ambulatory stroke survivors as compared to a similar dosage of robotic-assisted LT.

Locomotor Training Improves Daily Stepping Activity and Gait Efficiency in Individuals Poststroke Who Have Reached a “Plateau” in Recovery

Background and Purpose— Individuals with chronic stroke often demonstrate a “plateau,” or deceleration of motor recovery, which may lead to discharge from physical therapy (PT). However, numerous studies report improvements in motor function when individuals are provided intensive practice of motor tasks. We suggest that reduced task-specific walking practice during clinical PT contributes to limited gains in ambulatory function in those with a perceived plateau poststroke, and suggest that further gains can be realized if intensive stepping, or locomotor training (LT) is provided after discharge. Methods— Twenty subjects with chronic stroke completed a repeated baseline measures, randomized crossover trial in which walking performance was assessed during the last 4 weeks of clinical PT before discharge secondary to reaching a plateau, followed by 4 weeks of intensive LT and 4 weeks of no intervention. Outcome measures included clinical and physiological (metabolic) measures of walking overground and on a treadmill, and measures of daily stepping activity in the home and community, including during clinical PT and subsequent LT sessions. Results— Stepping practice was more than 4-fold higher during LT versus clinical PT sessions, with significant improvements in daily stepping and gait efficiency only after LT. Changes in daily stepping after clinical PT and intensive LT were correlated (P<0.001) with the amount of stepping practice received during these interventions. Conclusions— Intensive LT results in improved daily stepping in individuals poststroke who have been discharged from PT because of a perceived plateau in motor function. These improvements may be related to the amount and intensity of stepping practice.

Allowing Intralimb Kinematic Variability During Locomotor Training Poststroke Improves Kinematic Consistency: A Subgroup Analysis From a Randomized Clinical Trial

Background: Locomotor training (LT) to improve walking ability in people poststroke can be accomplished with therapist assistance as needed to promote continuous stepping. Various robotic devices also have been developed that can guide the lower limbs through a kinematically consistent gait pattern. It is unclear whether LT with either therapist or robotic assistance could improve kinematic coordination patterns during walking. Objective: The purpose of this study was to determine whether LT with physical assistance as needed was superior to guided, symmetrical, robotic-assisted LT for improving kinematic coordination during walking poststroke. Design: This study was a randomized clinical trial. Methods: Nineteen people with chronic stroke (>6 months’ duration) participating in a larger randomized control trial comparing therapist- versus robotic-assisted LT were recruited. Prior to and following 4 weeks of LT, gait analysis was performed at each participants self-selected speed during overground walking. Kinematic coordination was defined as the consistency of intralimb hip and knee angular trajectories over repeated gait cycles and was compared before and after treatment for each group. Results: Locomotor training with therapist assistance resulted in significant improvements in the consistency of intralimb movements of the impaired limb. Providing consistent kinematic assistance during robotic-assisted LT did not result in improvements in intralimb consistency. Only minimal changes in discrete kinematics were observed in either group. Limitations: The limitations included a relatively small sample size and a lack of quantification regarding the extent of movement consistency during training sessions for both groups. Conclusions: Coordination of intralimb kinematics appears to improve in response to LT with therapist assistance as needed. Fixed assistance, as provided by this form of robotic guidance during LT, however, did not alter intralimb coordination.

Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis.

OBJECTIVE. We investigated the feasibility of delivering an individualized, progressive, high-repetition upper-extremity (UE) task-specific training protocol for people with stroke in the inpatient rehabilitation setting. METHOD. Fifteen patients with UE paresis participated in this study. Task-specific UE training was scheduled for 60 min/day, 4 days/wk, during occupational therapy for the duration of a participants inpatient stay. During each session, participants were challenged to complete ≥300 repetitions of various tasks. RESULTS. Participants averaged 289 repetitions/session, spending 47 of 60 min in active training. Participants improved on impairment and activity level outcome measures. CONCLUSION. People with stroke in an inpatient setting can achieve hundreds of repetitions of task-specific training in 1-hr sessions. As expected, all participants improved on functional outcome measures. Future studies are needed to determine whether this high-repetition training program results in better outcomes than current UE interventions.

Daily Stepping in Individuals With Motor Incomplete Spinal Cord Injury

Background In individuals with motor incomplete spinal cord injury (SCI), ambulatory function determined in the clinical setting is related to specific measures of body structure and function and activity limitations, although few studies have quantified the relationship of these variables with daily stepping (steps/day). Objective The aim of this study was to quantify daily stepping in ambulatory individuals with SCI and its relationship with clinical walking performance measures and specific demographics, impairments, and activity limitations. Design A cross-sectional study was performed to estimate relationships among clinical variables to daily stepping in self-identified community versus non–community (household) walkers. Methods Average daily stepping was determined in 50 people with chronic, motor incomplete SCI. Data for clinical and self-report measures of walking performance also were collected, and their associations with daily stepping were analyzed using correlation and receiver operating characteristic (ROC) analyses. Relationships between daily stepping and the measures of demographics, impairments, and activity limitations were identified using correlation and regression analyses. Results The ROC analyses revealed a significant discriminative ability between self-reported community and non–community walkers using clinical gait measures and daily stepping. Stepping activity generally was low throughout the sample tested, however, with an average of approximately 2,600 steps/day. Knee extension strength (force-generating capacity) and static balance were the primary variables related to daily stepping, with metabolic efficiency and capacity and balance confidence contributing to a lesser extent. Limitations The small sample size and use of specific impairment-related measures were potential limitations of the study. Conclusions Daily stepping is extremely limited in individuals with incomplete SCI, with a potentially substantial contribution of impairments in knee extension strength and balance.

Development and use of a knowledge translation tool: The rehabilitation measures database

Clinical translation of research evidence is a challenge for rehabilitation clinicians. Publicly accessible and free, online educational resources that summarize research evidence can support implementation of research evidence into practice. Several online resources have been developed recently to overcome common knowledge translation barriers. The Rehabilitation Measures Database (RMD) is a free, web-based searchable database of standardized instruments that was designed to support knowledge translation. It helps clinicians select valid and sensitive instruments for screening patients, monitoring progress, and assessing rehabilitation outcomes. The RMD was developed using feedback from focus groups and beta-test participants. Since its launch in 2011, RMD use has grown to an average of 1851 hits per day from 168 countries. As of September 2013, 202 instrument summaries are viewable in the RMD. Most summaries are linked to copies of the instrument or to purchase instructions. A challenge in updating and expanding the RMD is securing the resources to ensure its future. Collaborative relationships with professional associations and graduate programs in the health sciences are critical in sustaining this resource.

Influence of skill and exercise training parameters on locomotor recovery during stroke rehabilitation.

PURPOSE OF REVIEW Research findings from the fields of motor learning and exercise physiology suggest specific training parameters that can be manipulated during physical rehabilitation profoundly influence skilled task performance. This review details the rationale for some of these training variables and their application in selected intervention studies focused on improving walking function in patients poststroke. RECENT FINDINGS Basic and applied studies have shown that the amount, intensity, and variability of specific task practice applied during rehabilitation interventions can affect recovery of walking poststroke. Many studies detailing the effects of conventional, therapist, and mechanically assisted interventions may incorporate some of these training parameters but minimize others, and their relative contributions may influence walking outcomes. Specific patient factors, such as the stroke acuity and degree of impairments, appear to influence the relative contributions of these training variables, and different patient subgroups may benefit from greater emphasis on specific parameters. SUMMARY The present findings suggest these training parameters should be considered when evaluating or implementing physical interventions directed toward improving locomotor function poststroke. More work is needed to understand their optimal combinations to maximize walking outcomes in patients with different levels of impairment poststroke.

Changes in Upper-Extremity Functional Capacity and Daily Performance During Outpatient Occupational Therapy for People With Stroke

OBJECTIVE This study explored how upper-extremity (UE) functional capacity and daily performance change during the course of outpatient rehabilitation in people with stroke. METHOD Fifteen participants receiving outpatient occupational therapy services for UE paresis poststroke were enrolled. UE motor capacity was measured with the Action Research Arm Test (ARAT), and UE performance was measured using bilateral, wrist-worn accelerometers. Measurements were taken at or near the start of therapy, at every 10th visit or every 30 days throughout the duration of services, and at discharge. RESULTS Three patterns were observed: (1) increase in ARAT scores and more normalized accelerometry profiles, (2) increase in ARAT scores but no change in accelerometry profiles, and (3) no change in ARAT scores or in accelerometry profiles. CONCLUSION UE performance in daily life was highly variable, with inconsistencies between change in UE capacity and change in UE performance. UE capacity and performance are important constructs to assess separately during rehabilitation.

Excitatory synaptic potentials in spastic human motoneurons have a short rise-time

This study assessed whether changes in size or time‐course of excitatory postsynaptic potentials (EPSPs) in motoneurons innervating spastic muscle could induce a greater synaptic response, and thereby contribute to reflex hyperexcitability. We compared motor unit (MU) firing patterns elicited by tendon taps applied to both spastic and contralateral (nonspastic) biceps brachii muscle in hemiparetic stroke subjects. Based on recordings of 115 MUs, significantly shortened EPSP rise times were present on the spastic side, but with no significant differences in estimated EPSP amplitude. These changes may contribute to hyperexcitable reflex responses at short latency, but the EPSP amplitude changes appear insufficient to account for global differences in reflex excitability. Muscle Nerve, 2005

Item analysis of the berg balance scale in individuals with subacute and chronic stroke.

Abstract Purpose: The Berg Balance Scale (BBS) is one of the most commonly applied clinical measures of balance for individuals with stroke. This study used item analysis methods to investigate various psychometric aspects of the BBS in participants with subacute and chronic stroke. Methods: Secondary analysis of data from 69 participants was included. The Rasch measurement model was used to generate item fit statistics for each item of the BBS and assess scale precision across the continuum of balance. Results: Two of the 14 items of the BBS (standing on one foot and tandem standing) demonstrated misfit. The hierarchical scale demonstrated decreased precision at the higher end of the balance continuum. Discussion: The original instructions for the BBS indicate that the individual tested can choose the limb utilized in the single-limb stance and tandem stance items. Administration of these test items in this way to individuals with stroke may contribute to item misfit. Standardization of administration of the BBS to routinely use the involved lower extremity may support higher item difficulty, contribute to improved scale precision, and decrease the ceiling effect of the scale previously reported. Conclusion: The ability of participants to self-select the assessed lower extremity is most likely contributing to item misfit for 2 of the 14 BBS items. Standardized administration of these items may improve the ability of the BBS to more accurately measure initial balance impairment, as well as changes in balance due to spontaneous recovery and rehabilitation interventions.