Kimberly J. Miller

Effects of Augmented Exercise Therapy Time After Stroke A Meta-Analysis

Background and Purpose— To present a systematic review of studies that addresses the effects of intensity of augmented exercise therapy time (AETT) on activities of daily living (ADL), walking, and dexterity in patients with stroke. Summary of Review— A database of articles published from 1966 to November 2003 was compiled from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE, and PiCarta using combinations of the following key words: stroke, cerebrovascular disorders, physical therapy, physiotherapy, occupational therapy, exercise therapy, rehabilitation, intensity, dose–response relationship, effectiveness, and randomized controlled trial. References presented in relevant publications were examined as well as abstracts in proceedings. Studies that satisfied the following selection criteria were included: (1) patients had a diagnosis of stroke; (2) effects of intensity of exercise training were investigated; and (3) design of the study was a randomized controlled trial (RCT). For each outcome measure, the estimated effect size (ES) and the summary effect size (SES) expressed in standard deviation units (SDU) were calculated for ADL, walking speed, and dexterity using fixed and random effect models. Correlation coefficients were calculated between observed individual effect sizes on ADL of each study, additional time spent on exercise training, and methodological quality. Cumulative meta-analyses (random effects model) adjusted for the difference in treatment intensity in each study was used for the trials evaluating the effects of AETT provided. Twenty of the 31 candidate studies, involving 2686 stroke patients, were included in the synthesis. The methodological quality ranged from 2 to 10 out of the maximum score of 14 points. The meta-analysis resulted in a small but statistically significant SES with regard to ADL measured at the end of the intervention phase. Further analysis showed a significant homogeneous SES for 17 studies that investigated effects of increased exercise intensity within the first 6 months after stroke. No significant SES was observed for the 3 studies conducted in the chronic phase. Cumulative meta-analysis strongly suggests that at least a 16-hour difference in treatment time between experimental and control groups provided in the first 6 months after stroke is needed to obtain significant differences in ADL. A significant SES supporting a higher intensity was also observed for instrumental ADL and walking speed, whereas no significant SES was found for dexterity. Conclusion— The results of the present research synthesis support the hypothesis that augmented exercise therapy has a small but favorable effect on ADL, particularly if therapy input is augmented at least 16 hours within the first 6 months after stroke. This meta-analysis also suggests that clinically relevant treatment effects may be achieved on instrumental ADL and gait speed.

Goal-directed training: linking theories of treatment to clinical practice for improved functional activities in daily life

Background: Goal-directed training is an activity-based approach to therapy. Meaningful, client-selected goals are used to provide opportunities for problem solving and to indirectly drive the movements required to successfully meet the task demands. This is in contrast to interventions that focus on changing body functions. Here, the principles of goal-directed training will be studied through two case studies with the aim of linking theories of treatment to clinical practice. Principles illustrated: The approach is based on the dynamic systems motor control theory and occupation-based therapy models, which suggest that movement patterns emerge from the interaction between the persons abilities, environment and the goal. Motor learning principles are applied to structure and schedule practice. Theory in practice: Four components provide the basis for goal-directed training: (1) selection of a meaningful goal; (2) analysis of baseline performance; (3) intervention/ practice regime; and (4) evaluation of outcome. Two individuals with acquired brain injury practised self-care tasks: eating and tying hair into a ponytail. Intensive training was undertaken over four weeks and the intervention outcome measured using the Goal Attainment Scale. Conclusions: The positive achievements in the self-care tasks illustrated that theories of motor control and motor learning can be applied to goal-directed training. The examples demonstrated that the approach could be applied to individuals with a range of abilities.

Effectiveness and feasibility of virtual reality and gaming system use at home by older adults for enabling physical activity to improve health-related domains: a systematic review

BACKGROUND use of virtual reality and commercial gaming systems (VR/gaming) at home by older adults is receiving attention as a means of enabling physical activity. OBJECTIVE to summarise evidence for the effectiveness and feasibility of VR/gaming system utilisation by older adults at home for enabling physical activity to improve impairments, activity limitations or participation. METHODS a systematic review searching 12 electronic databases from 1 January 2000-10 July 2012 using key search terms. Two independent reviewers screened yield articles using pre-determined selection criteria, extracted data using customised forms and applied the Cochrane Collaboration Risk of Bias Tool and the Downs and Black Checklist to rate study quality. RESULTS fourteen studies investigating the effects of VR/gaming system use by healthy older adults and people with neurological conditions on activity limitations, body functions and physical impairments and cognitive and emotional well-being met the selection criteria. Study quality ratings were low and, therefore, evidence was not strong enough to conclude that interventions were effective. Feasibility was inconsistently reported in studies. Where feasibility was discussed, strong retention (≥70%) and adherence (≥64%) was reported. Initial assistance to use the technologies, and the need for monitoring exertion, aggravation of musculoskeletal symptoms and falls risk were reported. CONCLUSIONS existing evidence to support the feasibility and effectiveness VR/gaming systems use by older adults at home to enable physical activity to address impairments, activity limitations and participation is weak with a high risk of bias. The findings of this review may inform future, more rigorous research.

Smart-home technologies to assist older people to live well at home

Background: With the rapid population ageing that is occurring world-wide, there is increasing interest in “smart home” technologies that can assist older adults to continue living at home with safety and independence. This systematic review and critical evaluation of the world wide literature assesses the effectiveness and feasibility of smart-home technologies for promoting independence, health, well-being and quality of life, in older adults. Methods: A total of 1877 “smart home” publications were identified by the initial search of peer reviewed journals. Of these, 21 met our inclusion criteria for the review and were subject to data extraction and quality assessment. Results: Smart-home technologies included different types of active and passive sensors, monitoring devices, robotics and environmental control systems. One study assessed effectiveness of a smart home technology. Sixteen reported on the feasibility of smart-home technology and four were observational studies. Conclusion: Older adults were reported to readily accept smart-home technologies, especially if they benefited physical activity, independence and function and if privacy concerns were addressed. Given the modest number of objective analyses, there is a need for further scientific analysis of a range of smart home technologies to promote community living.

Clinical feasibility of the Nintendo Wii™ for balance training post-stroke: a phase II randomized controlled trial in an inpatient setting:

Objective: To investigate the feasibility and potential efficacy of the Nintendo Wii™ for balance rehabilitation after stroke. Design: Phase II, single-blind, randomized controlled trial. Setting: Inpatient rehabilitation facility. Subjects: Thirty adults (mean age 63.6 (14.7) years) undergoing inpatient rehabilitation who were less than three months post-stroke and able to stand unsupported. Interventions: Participants were allocated to a Balance Group, using the ‘Wii Fit Plus’ in standing, or Upper Limb Group, using the ‘Wii Sports/Sports Resort’ in sitting. Both groups undertook three 45 minute sessions per week over two to four weeks in addition to standard care. Main measures: The primary focus was feasibility, addressed by recruitment, retention, adherence, acceptability and safety. Efficacy was evaluated by balance, mobility and upper limb outcomes. Results: Twenty-one percent of individuals screened were recruited and 86% (n = 30) of eligible people agreed to participate. Study retention and session adherence was 90% and > 99%, respectively, at two weeks; dropping to 70% and 87% at four weeks due to early discharge. All participants reported enjoying the sessions and most felt they were beneficial. No major adverse events occurred. Wii use by the Balance Group was associated with trends for improved balance, with significantly greater improvement in outcomes including the Step Test and Wii Balance Board-derived centre of pressure scores. The Upper Limb Group had larger, non-significant changes in arm function. Conclusions: A Wii-based approach appears feasible and promising for post-stroke balance rehabilitation. A larger randomized controlled trial is recommended to further investigate efficacy.

Robotics to Enable Older Adults to Remain Living at Home

Given the rapidly ageing population, interest is growing in robots to enable older people to remain living at home. We conducted a systematic review and critical evaluation of the scientific literature, from 1990 to the present, on the use of robots in aged care. The key research questions were as follows: (1) what is the range of robotic devices available to enable older people to remain mobile, independent, and safe? and, (2) what is the evidence demonstrating that robotic devices are effective in enabling independent living in community dwelling older people? Following database searches for relevant literature an initial yield of 161 articles was obtained. Titles and abstracts of articles were then reviewed by 2 independent people to determine suitability for inclusion. Forty-two articles met the criteria for question 1. Of these, 4 articles met the criteria for question 2. Results showed that robotics is currently available to assist older healthy people and people with disabilities to remain independent and to monitor their safety and social connectedness. Most studies were conducted in laboratories and hospital clinics. Currently limited evidence demonstrates that robots can be used to enable people to remain living at home, although this is an emerging smart technology that is rapidly evolving.

Smart technologies to enhance social connectedness in older people who live at home

To examine the effectiveness of smart technologies in improving or maintaining the social connectedness of older people living at home.

EVALUATION OF THE PSyCHOMETRIC PROPERTIES OF THE UPPER LIMB SUBSCALES OF THE MOTOR ASSESSMENT SCALE USING A RASCH ANALySIS MODEL

OBJECTIVES To apply Rasch analysis to evaluate the psychometric properties of the composite score of the 3 upper limb subscales of the Motor Assessment Scale (UL-MAS) when administered in the acute/subacute phase post-stroke. DESIGN Prospective data collection of UL-MAS scores. PARTICIPANTS Eighty Eighty individuals a mean of 64.8 days (standard deviation 53.3; range 4-193 days) following the onset of unilateral stroke. METHODS All UL-MAS test items were administered in 30 participants assessed longitudinally over 3 occasions, and in 50 participants assessed on a single occasion. These 140 observations were pooled to be evaluated using Rasch analysis. RESULTS With the elimination of the wrist radial deviation test item, the UL-MAS demonstrated uni-dimensionality with no significant test item response bias. The test item difficulty hierarchy was validated in the Upper Arm and Hand Movements subscales, but not in the Advanced Hand Activities subscale. The acceptable floor (14%) and ceiling (9%) effects and the high Person Separation Reliability Index (0.96) indicated that the scale was appropriately targeted to discriminate statistically between groups of acute/subacute stroke participants with differing upper limb motor recovery. CONCLUSION The findings support the psychometric properties of the composite UL-MAS score in this clinical population.

Quantifying Individual Components of the Timed Up and Go Using the Kinect in People Living With Stroke

Background. The Microsoft Kinect presents a simple, inexpensive, and portable method of examining the independent components of the Timed Up and Go (TUG) without any intrusion on the patient. Objective. This study examined the reliability of these measures, and whether they improved prediction of performance on common clinical tests. Methods. Thirty individuals with stroke completed 4 clinical assessments, including the TUG, 10-m walk test (10MWT), Step Test, and Functional Reach test on 2 testing occasions. The TUG was assessed using the Kinect to determine 7 different functional components. Test–retest reliability was assessed using intraclass correlation coefficient (ICC), redundancy using Spearman’s correlation, and score prediction on the clinical tests using multiple regression. Results. All Kinect-TUG variables possessed excellent reliability (ICC(2,k) > 0.90) except trunk flexion angle (ICC = 0.73). Trunk flexion angle and first step length were nonredundant with total TUG time. When predicting 10MWT and Step Test scores, adding step length into regression models comprising age and total TUG time improved model performance by 7% (P <.01) and 6% (P =.03), respectively. Specifically, an interquartile range increase in first step length (0.19 m) was associated with a 0.15 m/s faster gait speed and 1.8 more repetitions on the Step Test. These effect sizes were comparable to our minimal detectable change scores of 0.17 m/s for gait speed and 1.71 repetitions for the Step Test. Conclusions. Using the Kinect to independently assess the multiple components of the TUG may provide reliable and clinically useful information. This could enable efficient and information-rich large-scale assessments of physical deficits following stroke.

The AsTex®: clinimetric properties of a new tool for evaluating hand sensation following stroke

Objectives: To investigate the clinimetric properties and clinical utility of the AsTex®, a new clinical tool for evaluation of hand sensation following stroke. Design: The AsTex ® was administered on two occasions separated by a week to appraise test—retest reliability, and by three assessors on single occasion to establish inter-rater reliability. Pilot normative values were collected in an age-stratified sample. Clinical utility was evaluated based on ease of administration, ceiling and floor effects, and responsiveness to sensory recovery. Participants: Test—retest (n = 31) and inter-rater (n = 31) reliability and normative values (n = 95) for the AsTex® were established in neurologically normal participants aged 18—85 years. Test—retest reliability was investigated in 22 individuals a mean of 46 months (range 12—125) post stroke and clinical utility was evaluated in an additional 24 subacute stroke participants a mean of 29.4 days (range 12—41) post stroke. Main measure: The AsTex ®. Results: The AsTex ® demonstrated excellent test—retest (intraclass correlation coefficient (ICC) = 0.98, 95% confidence interval (95% CI) = 0.97—0.99) and inter-rater reliability (ICC = 0.81, 95% CI = 0.73—0.87) in neurologically normal participants. Test—retest reliability of the AsTex® in individuals following stroke was excellent (ICC = 0.86, 95% CI = 0.68—0.94). The AsTex® was simple to administer, demonstrated small standard error of measurement (0.14 mm), minimal floor and ceiling effects (12.5% and 8.3%) and excellent responsiveness (standardized response mean = 0.57) in subacute stroke participants. Conclusion: The AsTex ® is a reliable, clinically useful and responsive tool for evaluating hand sensation following stroke.