Nicol Korner-Bitensky

A New Approach to Retrain Gait in Stroke Patients Through Body Weight Support and Treadmill Stimulation

BACKGROUND AND PURPOSE A new gait training strategy for patients with stroke proposes to support a percentage of the patients body weight while retraining gait on a treadmill. This research project intended to compare the effects of gait training with body weight support (BWS) and with no body weight support (no-BWS) on clinical outcome measures for patients with stroke. METHODS One hundred subjects with stroke were randomized to receive one of two treatments while walking on a treadmill: 50 subjects were trained to walk with up to 40% of their body weight supported by a BWS system with overhead harness (BWS group), and the other 50 subjects were trained to walk bearing full weight on their lower extremities (no-BWS group). Treatment outcomes were assessed on the basis of functional balance, motor recovery, overground walking speed, and overground walking endurance. RESULTS After a 6-week training period, the BWS group scored significantly higher than the no-BWS group for functional balance (P = 0.001), motor recovery (P = 0.001), overground walking speed (P = 0.029), and overground w alking endurance (P = 0.018). The follow-up evaluation, 3 months after training, revealed that the BWS group continues to have significantly higher scores for overground walking speed (P = 0.006) and motor recovery (P = 0.039). CONCLUSIONS Retraining gait in patients with stroke while a percentage of their body weight was supported resulted in better walking abilities than gait training while the patients were bearing their full weight. This novel gait training strategy provides a dynamic and integrative approach for the treatment of gait dysfunction after stroke.

Usefulness of the Berg Balance Scale in Stroke Rehabilitation: A Systematic Review

Background: In a recent study of 655 physical therapists working with a stroke population, the Berg Balance Scale (BBS) was identified as the most commonly used assessment tool across the continuum of stroke rehabilitation. Given the widespread popularity of the BBS, it is important to critically appraise the BBS for its use with a stroke population. Objective: The purposes of this study were to conduct a systematic review of the psychometric properties of the BBS specific to stroke and to identify strengths and weaknesses in its usefulness for stroke rehabilitation. Results: Twenty-one studies examining the psychometric properties of the BBS with a stroke population were retrieved. Internal consistency was excellent (Cronbach alpha=.92–.98) as was interrater reliability (intraclass correlation coefficients [ICCs]=.95–.98), intrarater reliability (ICC=.97), and test-retest reliability (ICC=.98). Sixteen studies focused on validity and generally found excellent correlations with the Barthel Index, the Postural Assessment Scale for Stroke Patients, Functional Reach Test, the balance subscale of Fugl-Meyer Assessment, the Functional Independence Measure, the Rivermead Mobility Index (except for weight shift and step-up items), and gait speed. Berg Balance Scale scores predicted length of stay, discharge destination, motor ability at 180 days poststroke, and disability level at 90 days, but these scores were not predictive of falls. Eight studies focused on responsiveness; all reported moderate to excellent sensitivity. Three studies found floor or ceiling effects. Discussion and Conclusion: The BBS is a psychometrically sound measure of balance impairment for use in poststroke assessment. Given the floor and ceiling effects, clinicians may want to use the BBS in conjunction with other balance measures.

Virtual Reality in Stroke Rehabilitation: A Systematic Review of its Effectiveness for Upper Limb Motor Recovery

Abstract Purpose: It is estimated that 50% to 75% of individuals who experience a stroke have persistent impairment of the affected upper limb (UL). There is a need to identify the best training strategies for retraining motor function of the UL. One intervention showing promise is virtual reality (VR), using either immersive or nonimmersive technology. Before recommending VR for use in clinical practice, it is important to understand the evidence regarding its effectiveness. Method: Two questions about the effectiveness of VR for UL rehabilitation in stroke were posed: (1) Is the use of immersive VR more effective than conventional therapy or no therapy in the rehabilitation of the UL in patients with hemiplegia? (2) Is the use of nonimmersive VR more effective than conventional therapy or no therapy in the rehabilitation of the UL in patients with hemiplegia? Results: There is level 1b evidence suggesting an advantage to training in immersive VR environments versus no therapy in UL rehabilitation, and level 5 evidence for training in immersive VR versus conventional therapy. There is level 4 evidence showing conflicting results for training in nonimmersive VR versus no therapy, and level 2b evidence for training in nonimmersive VR versus conventional therapy. Conclusion: The current evidence on the effectiveness of using VR in the rehabilitation of the UL in patients with stroke is limited but sufficiently encouraging to justify additional clinical trials in this population.

Practitioner and Organizational Barriers to Evidence-based Practice of Physical Therapists for People With Stroke

Background and Purpose: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists’ implementation of evidence-based practice (EBP) for people with stroke. Subjects: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada. Methods: A cross-sectional mail survey was conducted. Results: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature. Discussion and Conclusion: Lack of education, negative perceptions about research and physical therapists’ role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.

Predicting ability to drive after stroke

OBJECTIVE To determine the ability of perceptual testing to predict on-road driving outcome in subjects with stroke. STUDY DESIGN Historical cohort study of 84 individuals with stroke who completed both the perceptual testing and the on-road driving evaluation conducted in a driving evaluation service. MEASURES Perceptual tests, such as the Motor Free Visual Perception Test (MVPT) and Trail Making B test, and an on-road driving evaluation. Based on driving behaviors, a pass or fail outcome was determined by the examiners. RESULTS Subjects who passed the on-road evaluation had better average scores on the majority of perceptual tests compared with those who failed. The MVPT was the most predictive of on-road performance (positive predictive value=86.1%; negative predictive value=58.3%). The combination of tests resulting in the most predictive and parsimonious model was the MVPT plus Trail Making B, such that those who scored poorly on both were 22 times more likely to fail the on-road evaluation. CONCLUSION A screening process is useful in identifying persons who are not ready to undergo an on-road driving evaluation.

Predictors of Driving Ability Following Stroke: A Systematic Review

Abstract Background and Purpose: The objective of this review is to identify the most consistent predictors of driving ability post stroke. Method: A computerized search of numerous databases from 1966 forward was completed. Measured outcomes included voluntary driving cessation or results of on-road driving evaluation. Studies were evaluated using the Newcastle-Ottawa Quality Assessment Scale. Results: 17 eligible studies were identified. The most useful screening tests were tests assessing cognitive abilities. These included the Trail Making A and B tests, the Rey–Osterreith Complex Figure Design, and the Useful Field of View Test. Conclusion: Cognitive tests that assess multiple cognitive domains relevant to driving appear to have the best reproducibility in predicting fitness to drive in stroke patients.

Horseback riding as therapy for children with cerebral palsy: is there evidence of its effectiveness?

A systematic review of the literature on horseback riding therapy as an intervention for children with cerebral palsy (CP) was carried out. The terms horse, riding, hippotherapy, horseback riding therapy, equine movement therapy, and cerebral palsy were searched in electronic databases and hand searched. Retrieved articles were rated for methodological quality using PEDro scoring to assess the internal validity of randomized trials and the Newcastle Ottawa Quality Assessment Scale to assess cohort studies. PICO questioning (Population, Intervention, Comparison, and Outcomes) was used to identify questions of interest to clinicians for outcomes within the context of the International Classification of Functioning, Disability and Health. Levels of evidence were then accorded each PICO question. There is Level 2a evidence that hippotherapy is effective for treating muscle symmetry in the trunk and hip and that therapeutic horseback riding is effective for improved gross motor function when compared with regular therapy or time on a waiting list. No studies addressed participation outcomes.

Barthel index information elicited over the telephone : is it reliable ?

ABSTRACT This study examined the comparability of estimates of functional status elicited through a telephone interview and a face-to-face interview. The Barthel Index, a commonly used measure to assess activities of daily living, was administered over the telephone and then again in the home to 366 individuals, up to 5 yr after their discharge from a rehabilitation hospital. One-half of the telephone interviews were performed by health professionals and the other half by trained lay interviewers; all of the home interviews were performed by health professionals. Proxy-respondents provided information for those unable to respond for themselves. The percent agreement between the scores on the telephone and on the home interview was always greater than 90%; the intraclass correlation coefficient for the telephone/home comparison was 0.89. Responses between the modes of interview were more consistent when provided by self-respondents than when provided by proxies. The telephone assessment worked well in identifying those who did not have functional disabilities; all individuals who scored 100 on the home interview, scored 95 or better on the telephone. When differences arose, they were always in those considered to have moderate to severe impairment and were most often (23 of 29 times) in the direction of higher scores, indicative of less disability, on the telephone. The results of this study suggest that, with the exception of a small subgroup of patients, functional status can be elicited reliably over the telephone by both lay persons and health professionals.

Recovery time of independent function post-stroke.

Stroke patients undergoing physical rehabilitation were monitored daily to determine the length of time needed to recover independent function. Of the 93 patients admitted, there were 45 who could not attain the sitting position independently, 75 who could not walk independently and 75 who could not negotiate the stairs independently. By discharge, 25 of 45 patients (55.6%) were able to attain sitting from supine independently, 35 of 75 patients (46.7%) achieved the ability to walk independently but only 25 of 75 patients (33.3%) learned to negotiate stairs independently. The time from admission to achievement of independent function and the time from onset of stroke to achievement of independent function was modeled in relation to explanatory variables: age, sex, side of lesion, comorbidity, the presence of depression and the extent of impairment in perception, cognition, auditory comprehension and verbal expression. Four variables were found to influence recovery time: age influenced the rate of recovery of walking and stair climbing; perceptual impairment influenced the rate of achieving independent sitting and stair climbing; and depression and comprehension influenced walking.

Predicting falls among patients in a rehabilitation hospital

A retrospective case-control study within a cohort was carried out to identify factors associated with falling by patients in a rehabilitation hospital. The cohort comprised all patients admitted during a 2-year period from 1984 to 1986. Cases were those who fell one or more times during their hospitalization. For each case, one control matched on sex and date of admission, was chosen. Material from the first year of the cohort (201 cases and 201 controls) was used to define a model to estimate the risk of falling. Of the more than 100 variables considered in the conditional logistic regression models, stroke, incontinence, anticonvulsant medications, and topical eye preparations were significantly associated with the risk of falling. Analyses carried out on the second year of the cohort (155 cases and 155 controls) confirmed the predictive ability of these four variables. By combining the material from both subcohorts we were able to determine that a program to reduce falls directed towards stroke patients and incontinent patients alone could, theoretically, prevent 44% of first falls.