Malcolm Burnett

Physical inactivity post-stroke: a 3-year longitudinal study

Abstract Purpose: To explore change in activity levels post-stroke. Methods: We measured activity levels using the activPAL™ in hospital and at 1, 2 and 3 years’ post-stroke onset. Results: Of the 74 participants (mean age 76 (SD 11), 39 men), 61 were assessed in hospital: 94% of time was spent in sitting/lying, 4% standing and 2% walking. Activity levels improved over time (complete cases n = 15); time spent sitting/lying decreased (p = 0.001); time spent standing, walking and number of steps increased (p = 0.001, p = 0.028 and p = 0.03, respectively). At year 3, 18% of time was spent in standing and 9% walking. Time spent upright correlated significantly with Barthel (r = 0.69 on admission, r = 0.68 on discharge, both p < 0.01) and functional ambulation category scores (r = 0.55 on admission, 0.63 on discharge, both p < 0.05); correlations remained significant at all assessment points. Depression (in hospital), left hemisphere infarction (Years 1–2), visual neglect (Year 2), poor mobility and balance (Years 1–3) correlated with poorer activity levels. Conclusion: People with stroke were inactive for the majority of time. Time spent upright improved significantly by 1 year post-stroke; improvements slowed down thereafter. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify predictors of activity levels. Implications for Rehabilitation Activity levels (measured using activPAL™ activity monitor), increased significantly by 1 year post-stroke but improvements slowed down at 2 and 3 years. People with stroke were inactive for the majority of their day in hospital and in the community. Poor activity levels correlated with physical and psychological measures. Larger studies are indicated to identify the most important predictors of activity levels.

Kinematic analysis of head, trunk, and pelvis movement when people early after stroke reach sideways.

Background. Sideways reaching with the unaffected arm while seated is a component of everyday activities and can be a challenging task early after stroke. Kinematic analysis of a lateral reach task may provide potential rehabilitation strategies. Objective. The authors examined the difference between people with stroke and healthy controls in the movement sequence of head, trunk, and pelvis, as well as the difference in angle at maximum reach and peak velocity for each body segment during reach and return. Methods. Twenty-four people within 12 weeks of a stroke and 20 healthy subjects performed a standardized lateral reach. Using CODAmotion, movement sequence was determined and angles and peak velocities were calculated. Results. When reaching, people with stroke moved their pelvis first, followed by the trunk and head, whereas healthy controls started with their head and then moved their trunk and pelvis. Patients achieved significantly smaller angles at maximum reach compared with healthy subjects for all body segments and lower peak velocities during the reach (for head, trunk, and pelvis) and the return (for head and trunk). Conclusions. Lateral reaching to the unaffected side early after stroke revealed a different pattern than normal and patients reached less far and moved at a slower speed. Specific training strategies to improve reaching are needed.

Immediate effect of transcranial direct current stimulation on postural stability and functional mobility in Parkinson's disease

Fregni et al. reported on the application of transcranial direct current stimulation (tDCS) in people with Parkinson’s disease (PwPD), demonstrating a significant improvement after a single active anodal M1 stimulation for the postural stability cluster of the Unified Parkinson’s Disease Rating Scale (UPDRS) motor score. We tested the hypothesis that tDCS would improve more sensitive measures of postural stability and functional mobility in PwPD. We conducted a double-blind, experimental crossover study with participants as their own control and assessed in the on stage. Inclusion criteria were consultant-confirmed diagnosis of idiopathic PD, independently mobile and living in the community. Excluded were those with other neurological conditions, deep brain stimulation, impaired gross cognitive function, metal implants, pacemaker, history of epilepsy, or medication that altered cortical excitability. First, participants performed standardized clinical measures prestimulation: sitto-stand, functional reach, standing-start 180 degrees turning, timed up-and-go, and 10-m walk test. Then, active or sham tDCS was delivered while participants performed the measures during stimulation. Finally, the outcome measures were collected again poststimulation. The anode of the tDCS stimulator (Magstim Eldith, Whitland, Carmarthenshire, UK) was positioned over M1 of the primary motor cortex of the TABLE 1. Case-control association results for the LRRK2 variants that showed evidence for association in at least 1 South African ethnic group

Psychometric Properties of 3 Functional Mobility Tests for People With Parkinson Disease

Background Standardized outcome measures with high clinical utility are of paramount importance for clinical practice. Objective The purpose of this study was to examine interrater and intrarater reliability, construct validity, discriminant ability, and smallest detectable differences of the sit-to-stand test (STS), Timed “Up & Go” Test (TUG), and bed mobility test for people with Parkinson disease (PD). Design A cross-sectional, psychometric evaluation study was conducted. Methods A group of individuals with PD (PD group) and a group of individuals who were healthy (control group) were recruited through local PD groups and assessed in a movement laboratory in their “on” phase. Measurements of time to perform one STS, TUG, and bed mobility test were collected based on video recordings of that single performance. Results Thirty-eight individuals with PD (Hoehn and Yahr stages I–IV) and 19 age-matched control participants were recruited. Intraclass correlation coefficients for interrater and intrarater reliability for the PD group ranged from .95 to .99. Bland-Altman plots showed mean differences close to zero and narrow confidence intervals. Construct validity was established by means of moderate to good Spearman rho correlation coefficients with part III of the Unified Parkinsons Disease Rating Scale and the Hoehn and Yahr stage (range=.51–.63). Timings of all tests discriminated participants in the PD group from those in the control group and participants in the PD group in Hoehn and Yahr stages I and II from those in Hoehn and Yahr stages III and IV but did not discriminate “nonfallers” or those with single falls from repeat “fallers” or “nonfreezers” from “freezers.” Applicable smallest detectable differences were established. Limitations The results are not generalizable to people in the late stage of PD (Hoehn and Yahr stage IV: n=3). Conclusions Timings of video recordings of 3 functional mobility tests with high clinical utility showed good psychometric properties for community-dwelling, ambulatory people with PD.

Postural alignment is altered in people with chronic stroke and related to motor and functional performance.

Background and Purpose: Trunk control is impaired after stroke but little is known about how changes in posture relate to other deficits. We examined spinal postural alignment in people with chronic stroke and explored the relationship between postural alignment and clinical measures. Methods: Twenty-one subjects with stroke and 22 age-matched healthy comparison subjects participated in this observational, cross-sectional study. Data collection included measurements of thoracic, lumbar, sacral, and overall postural alignment in the sagittal plane in both sitting and standing. Measurements were made in different postures, including: upright, flexed forward, and extended backward. Clinical outcome measures included the Trunk Impairment Scale and its subscales, Fugl-Meyer Scale, Berg Balance Scale, Barthel Index, and Stroke Impact Scale. Results: Significant deviations in postural alignment for participants with stroke compared with comparison subjects were apparent in sacral alignment (P < 0.02) and overall postural alignment (P < 0.01) in standing. These measurements were also significantly correlated with clinical outcome measures poststroke. Participants with stroke who had a more forward leaning posture when upright scored worse on the coordination subscale of the Trunk Impairment Scale (r = −0.61) and Berg Balance Scale (r = −0.64). Participants with greater anterior pelvic tilt when flexed forward and more overall inclination when flexed forward and extended backward scored better on the Trunk Impairment Scale, its subscales, and Berg Balance Scale (r = −0.6-0.7). Discussion and Conclusions: People with chronic stroke have altered postural alignment in standing compared with subjects without neurological deficits. Investigating interventions focusing on increasing anterior and posterior pelvic tilt seem warranted. Video Abstract available. See video (Supplemental Digital Content 1, http://links.lww.com/JNPT/A76) for more insights from the authors.

Sequence and onset of whole-body coordination when turning in response to a visual trigger: Comparing people with Parkinson's disease and healthy adults

Turning round is a routine everyday activity that can often lead to instability. The purpose of this study was to investigate abnormalities of turning among people with Parkinsons disease (PwPD) through the measurement of sequence of body segments and latency response. Participants were asked to turn 180° and whole-body movements were recorded using CODAmotion and Visio Fast eye tracking equipment. Thirty-one independently mobile PwPD and 15 age-matched healthy controls participated in the study. We found that contrary to common belief, the head preceded movement of all other body segments (eyes, shoulders, pelvis, first and second foot). We also found interaction between group and body segment (P=0.005), indicating that overall, PwPD took longer to move from head to second foot than age-matched healthy controls. For PwPD only, interactions were found between disease severity and body segment (P<0.0001), between age group and body segment (P<0.0001) and between gender and body segments (P<0.0001). For each interaction, longer time periods were noted between moving the first foot after the pelvis, and moving the second foot after the first, and this was noted for PwPD in Hoehn and Yahr stage III-IV (in comparison to Hoehn and Yahr stage I-II); for PwPD who were under 70 years (in comparison with 70 years or over); and for ladies (in comparison with men). Our results indicate that in PwPD and healthy elderly, turning-on-the-spot might not follow the top-to-bottom approach we know from previous research.

Experiment in Recording Passive Spinal Movement

Summary This report describes an experiment in the measurement of the spinal movement which occurs during a mock session of vertebral manipulation. The potential of the equipment used, and present methods of recording spinal palpatory findings, are discussed.

Functional electrical stimulation with exercises for standing balance and weight transfer in acute stroke patients: a feasibility randomized controlled trial

Objectives:  To test parameters needed for the design of a larger trial including the following: 1) identifying eligible participants, recruitment, and retention rates; 2) the feasibility and acceptability of delivering functional electrical stimulation (FES) to the gluteus maximus and quadriceps femoris for acute stroke patients in a hospital rehabilitation setting; 3) the outcome measures; 4) obtaining initial estimates of effect size; and 5) clarifying the relevant control group.

Investigating head and trunk rotation in sitting: a pilot study comparing people after stroke and healthy controls.

BACKGROUND AND PURPOSE Healthy individuals have a top-down coordination pattern when turning while walking; they first rotate the head, then the shoulders, the pelvis and, finally, the feet. The aim of this study was to compare spatial and temporal characteristics of head and trunk rotation in sitting between people early after stroke and healthy participants, and investigate change over time. METHODS This was a pilot, quantitative, longitudinal study. We recruited participants from stroke wards and local groups. People with stroke were assessed at 3, 6 and 12 weeks after stroke. Healthy participants were examined with the same weekly intervals. Participants were in a seated position and were asked verbally to rotate their head and look at a visual signal placed at 90° to the left and to the right of the subject. CODAmotion (Charnwood Dynamics Ltd, Rothley, UK) was used for 3-D motion recording and analysis. RESULTS Healthy participants (two women and four men; mean age 66 years) showed significant rotation of the head before rotation of the shoulders at all three time points; people with stroke (one woman and five men; mean age 71 years) did not show this top-down pattern of movement. There was no significant difference between start times of head and shoulder rotation at 3 (p = 0.167), 6 (p = 0.084) and 12 weeks after stroke (p = 0.062). Conclusions. The results of our pilot study warrant further investigation into the recovery and pattern of axial coordination after stroke. Future studies could provide insight into the mechanisms behind impaired postural control in people after stroke.

Sequence of onset latency of body segments when turning on-the-spot in people with stroke

BACKGROUND Turning around is a common activity of daily living. The location of a target may be known or unknown while angle and direction may vary prior to turning. A stroke can compromise coordination of body movement during turning. OBJECTIVES To investigate the effect of target predictability, turn angle and turn direction on the kinematic sequence of rotation of body segments in people with stroke and healthy controls when turning on-the-spot. METHODS Ten people with stroke (age: 66±10 years; 8 males) and 10 age-matched controls (age: 65±8 years; 6 males) were asked to either turn to a specific light (predictable condition) or locate and turn to a random light (unpredictable condition) placed at 45°, 90° or 135° to the right or left when a light in front extinguished. RESULTS People with stroke initiated movement of the segments significantly later than the controls (p=0.014). The sequence of onset of rotation of the segments was not different between both groups. Target predictability affected the sequence of the segments; the eyes, head and shoulder started moving simultaneously when turning to unpredictable targets while the head and shoulder started moving before the eyes when turning to predictable targets. The sequence was also different across the three turn angles for each predictability condition. However, the sequence remained the same when turning to both sides in each group. CONCLUSION Similarities between the groups may be because the time since the stroke was long and therefore some recovery of function may have occurred. Slowness of movement in people with stroke may predispose them to falls.