Patrick W. H. Kwong

Timed 360° Turn Test for Assessing People With Chronic Stroke

OBJECTIVES To investigate (1) the intrarater, interrater, and test-retest reliability of the timed 360° turn test in subjects with stroke; (2) the concurrent validity of the timed 360° turn test by exploring its correlation with other measures of stroke-specific impairments; and (3) the cutoff times that best discriminate individuals with stroke from healthy older adults. DESIGN Cross-sectional study. SETTING University-based rehabilitation center. PARTICIPANTS Individuals with chronic stroke (n=72) and healthy individuals (n=35) of similar age (N=107). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The timed 360° turn test was administered along with the Fugl-Meyer assessment of the lower extremity, measurement of muscle strength of ankle dorsiflexors and plantarflexors using a handheld dynamometer, Berg Balance Scale, limit of stability test, five times sit-to-stand (FTSTS) test, 10-m walk test, and timed Up and Go (TUG) test. RESULTS The 360° turn times showed excellent intrarater, interrater, and test-retest reliability in individuals with stroke. A minimal detectable change of .76 seconds was found for subjects turning toward the affected side and 1.22 seconds for subjects turning toward the unaffected side. The 360° turn times were found to correlate significantly with Fugl-Meyer assessment of the lower extremity scores, dosiflexor strength of the affected ankle, plantarflexor strength of both ankles, FTSTS test times, balance performance, gait speed, and TUG test times. The 360° turn times of 3.43 to 3.49 seconds were shown to discriminate reliably between individuals with stroke and healthy older adults. CONCLUSIONS The timed 360° turn test is a reliable and an easily administered clinical tool to assess the turning ability of subjects with chronic stroke.

Fear Avoidance Behavior, Not Walking Endurance, Predicts the Community Reintegration of Community-Dwelling Stroke Survivors

OBJECTIVE To examine the contribution of walking endurance, subjective balance confidence, and fear avoidance behavior to community reintegration among community-dwelling stroke survivors. DESIGN Cross-sectional study. SETTING University-based rehabilitation center. PARTICIPANTS Patients with chronic stroke (N=57) aged ≥50 years. INTERVENTIONS None. MAIN OUTCOME MEASURE The Chinese version of the Community Integration Measure (CIM). RESULTS Our correlation analyses revealed that fear avoidance behavior as measured by the Chinese version of the Survey of Activities and Fear of Falling in the Elderly (SAFE) scores had the highest significant negative correlation with CIM scores among all the variables tested. Our regression analyses also revealed that walking endurance and subjective balance confidence were not significant predictors of CIM scores. Based on scores on the number of falls in the previous 6 months, Chinese version of the Geriatric Depression Scale scores, distance covered in the 6-minute walk test, and Chinese versions of the Activities-specific Balance Confidence Scale scores and SAFE scores, our final regression model predicted 49.7% of the variance in the Chinese version of the CIM scores. CONCLUSIONS The levels of walking endurance and subjective balance confidence are not significant predictors of community reintegration of community-dwelling stroke survivors but the fear avoidance behavior. Future studies addressing fear avoidance behavior is clearly warranted for stroke rehabilitation.

Foot Placement and Arm Position Affect the Five Times Sit-to-Stand Test Time of Individuals with Chronic Stroke

Objectives. To investigate the effect of two foot placements (normal or posterior placement) and three arm positions (hands on the thighs, arms crossed over chest, and augmented arm position with elbow extended) on the five times sit-to-stand (FTSTS) test times of individuals with chronic stroke. Design. Cross-sectional study. Setting. University-based rehabilitation clinic. Participants. A convenience sample of community-dwelling individuals with chronic stroke (N = 45). Methods. The times in completing the FTSTS with two foot placements and the three arm positions were recorded by stopwatch. Results. Posterior foot placement led to significantly shorter FTSTS times when compared with normal foot placement in all the 3 arm positions (P ≤ 0.001). In addition, hands on thigh position led to significantly longer FTSTS times than the augmented arm position (P = 0.014). Conclusion. Our results showed that foot placement and arm position could influence the FTSTS times of individuals with chronic stroke. Standardizing the foot placement and arm position in the test procedure is essential, if FTSTS test is intended to be used repeatedly on the same subject.

Transcutaneous electrical nerve stimulation improves walking capacity and reduces spasticity in stroke survivors: a systematic review and meta-analysis

Objective: To evaluate (1) the effectiveness of transcutaneous electrical nerve stimulation (TENS) at improving lower extremity motor recovery in stroke survivors and (2) the optimal stimulation parameters for TENS. Review methods: A systematic search was conducted for studies published up to October 2017 using eight electronic databases (CINAHL, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, PEDro, PubMed and Web of Science). Randomized controlled trials that evaluated the effectiveness of the application of TENS at improving lower extremity motor recovery in stroke survivors were assessed for inclusion. Outcomes of interest included plantar flexor spasticity, muscle strength, walking capacity and balance. Results: In all, 11 studies met the inclusion criteria which involved 439 stroke survivors. The meta-analysis showed that TENS improved walking capacity, as measured by either gait speed or the Timed Up and Go Test (Hedges’ g = 0.392; 95% confidence interval (CI) = 0.178 to 0.606) compared to the placebo or no-treatment control groups. TENS also reduced paretic plantar flexor spasticity, as measured using the Modified Ashworth Scale and Composite Spasticity Scale (Hedges’ g = –0.884; 95% CI = –1.140 to −0.625). The effect of TENS on walking capacity in studies involving 60 minutes per sessions was significant (Hedges’ g = 0.468; 95% CI = 0.201–0.734) but not in study with shorter sessions (20 or 30 minutes) (Hedges’ g = 0.254; 95% CI = –0.106–0.614). Conclusion: The results support the use of repeated applications of TENS as an adjunct therapy for improving walking capacity and reducing spasticity in stroke survivors.

The sitting and rising test for assessing people with chronic stroke

[Purpose] To investigate the inter-rater and test-retest reliability of the sitting-rising test (SRT), the correlations of sitting-rising test scores with measures of strength, balance, community integration and quality of life, as well as the cut-off score which best discriminates people with chronic stroke from healthy older adults were investigated. [Subjects and Methods] Subjects with chronic stroke (n=30) and healthy older adults (n=30) were recruited. The study had a cross-sectional design, and was carried out in a university rehabilitation laboratory. Sitting-rising test performance was scored on two occasions. Other measurements included ankle dorsiflexor and plantarflexor strength, the Fugl-Meyer assessment, the Berg Balance Scale, the timed up and go test, the five times sit-to-stand test, the limits of stability test, and measures of quality of health and community integration. [Results] Sitting-rising test scores demonstrated good to excellent inter-rater and test-retest reliabilities (ICC=0.679 to 0.967). Sitting-rising test scores correlated significantly with ankle strength, but not with other test results. The sitting-rising test showed good sensitivity and specificity. A cut-off score of 7.8 best distinguished healthy older adults from stroke subjects. [Conclusions] The sitting-rising test is a reliable and sensitive test for assessing the quality of sitting and rising movements. Further studies with a larger sample are required to investigate the test’s validity.

Effect of acceleration and deceleration distance on the walking speed of people with chronic stroke.

OBJECTIVE To examine the effect of acceleration and deceleration distance (0, 1, 2 and 3 m) on the comfortable and maximum walking speeds in: (i) the 5-m walk test (5mWT); and (ii) the 10-m walk test (10mWT) in people with chronic stroke. DESIGN Cross-sectional study. SETTING University-based rehabilitation centre. SUBJECTS Thirty individuals with chronic stroke. METHODS Timed walking at comfortable and maximum walking speeds in the 5mWT and 10mWT with different acceleration and deceleration distances (0, 1, 2 and 3 m). RESULTS The comfortable walking speed in the 5mWT with 0 m acceleration and deceleration distance was significantly slower than that with 1, 2 or 3 m acceleration and deceleration distances (p < 0.0083), but there was no significant difference among 1, 2 and 3 m acceleration and deceleration distances. No significant difference was found in the maximum walking speed in the 5mWT, or in the comfortable and maximum walking speeds of the 10mWT. CONCLUSION Adoption of 1 m acceleration and deceleration distance is recommended when measuring the comfortable walking speed in the 5mWT in people with stroke. Neither acceleration nor deceleration distance is needed when measuring the maximum walking speed in the 5mWT, the comfortable walking speed or the maximum walking speed in the 10mWT.

Effect of Leg Selection on the Berg Balance Scale Scores of Hemiparetic Stroke Survivors: A Cross-Sectional Study

OBJECTIVE To examine whether selection of the nonparetic or paretic leg as the weight-bearing leg in item 13 (standing unsupported one foot in front) and item 14 (standing on one leg) of the Berg Balance Scale (BBS) influences the item scores, and thus the total score. DESIGN Cross-sectional study. SETTING University-based rehabilitation laboratory. PARTICIPANTS Community-dwelling people (N=63, aged ≥50y) with chronic stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE BBS. RESULTS The 4 BBS total scores ranged from 48.4 to 50.7. The total score was significantly lower when a participant was asked to step forward with the nonparetic leg in item 13, and stand on the paretic leg in item 14. Fewer participants received a maximum score with the BBS1 formulation than the others. In addition, the correlations with walking speed and Activities-specific Balance Confidence Scale scores were greatest with the BBS1 score. CONCLUSIONS Our findings suggest that BBS1 was the most challenging formulation for our participants; this might serve to minimize the ceiling effect of the BBS. These findings provide a rationale for amending the BBS administration guidelines with the BBS1 formulation.

Effect of arm position and foot placement on the five times sit-to-stand test completion times of female adults older than 50 years of age.

The five times-sit-to stand test (FTSTS) is a clinical test which is commonly used to assessed the functional muscle strength of the lower limbs of older adults. The aim of this study was to examine the effect of different arm positions and foot placements on the FTSTS completion times of older female adults. [Subjects and Methods] Twenty-nine healthy female subjects, aged 63.1±5.3 years participated in this cross-sectional study. The times required to complete the FTSTS with 3 different arm positions (hands on thighs, arms crossed over chest, and an augmented arm position with the arms extended forward) and 2 foot placements (neutral and posterior) were recorded. The interaction effect and main effect of arm positions and foot placements were examined using a 3 (arm position) × 2 (foot placement) two-way repeated measures analysis of variance (ANOVA). [Results] There was no interaction effect among the 3 arm positions in the 2 foot placements. A significant main effect was identified for foot placement, but not arm position. Posterior foot placement led to a shorter FTSTS time compared to that of normal foot placement. [Conclusion] With the same arm position, FTSTS completion times with posterior foot placement tended to be shorter. Therefore, the standard foot placement should be used for FTSTS administration.

A structural equation model of the relationship between muscle strength, balance performance, walking endurance and community integration in stroke survivors

Purpose To use structural equation modelling (SEM) to determine (1) the direct and indirect associations of strength of paretic lower limb muscles with the level of community integration, and (2) the direct association of walking endurance and balance performance with the level of community integration in community-dwelling stroke survivors. Materials and methods In this cross-sectional study of 105 stroke survivors, the Subjective Index of Physical and Social Outcome (SIPSO) was used to measure the level of community integration. Lower-limb strength measures included isometric paretic ankle strength and isokinetic paretic knee peak torque. The Berg Balance Scale (BBS) and the 6-minute walk test (6MWT) were used to evaluate balance performance and walking endurance, respectively. Results SEM revealed that the distance walked on the 6MWT had the strongest direct association with the SIPSO score (β = 0.41, p <0.001). An increase of one standard deviation in the 6MWT distance resulted in an increase of 0.41 standard deviations in the SIPSO score. Moreover, dorsiflexion strength (β = 0.18, p = 0.044) and the BBS score (β = 0.21, p = 0.021) had direct associations with the SIPSO score. Conclusions The results of the proposed model suggest that rehabilitation training of community-dwelling stroke survivors could focus on walking endurance, balance performance and dorsiflexor muscle strengthening if the aim is to augment the level of community integration.

An investigation of the psychometric properties of the Chinese (Cantonese) version of Subjective Index of Physical and Social Outcome (SIPSO)

Objective: The objectives of this study were 1) to translate and make cultural adaptations to the English version of the SIPSO questionnaire to create a Chinese (Cantonese) version, 2) evaluate the internal consistency, test-retest reliability the C-SIPSO questionnaire, and 3) compare the SIPSO-C scores of stroke survivors with different demographic characteristics to establish the discriminant validity of the questionnaire Design: Translation of questionnaire, cross sectional study. Setting: University-based clinical research laboratory. Subjects Community-dwelling chronic stroke survivors. Interventions: Not applicable. Main measures: Subjective Index of Physical and Social Outcome, Geriatric Depression Scale, 10-metre Walk test. Results: Two bilingual professional translators translated the SIPSO questionnaire independently. An expert panel comprising five registered physiotherapists verified the content validity of the final version (C-SIPSO). C-SIPSO demonstrated good internal consistency (Cronbach’s α = 0.83) and excellent test-retest reliability (ICC3,1 = 0.866) in ninety-two community dwelling chronic stroke survivors. Stroke survivors scored higher than 10 in the Geriatric Depression Scale (U = 555.0, P < 0.001) and with the comfortable walking speed lower than 0.8ms–1 (U = 726.5; P = 0.012) scored significantly lower on SIPSO-C. Conclusion: SIPSO-C is a reliable instrument that can be used to measure the level of community integration in community-dwelling stroke survivors in Hong Kong and southern China. Stroke survivors who were at high risk of minor depression and with limited community ambulation ability demonstrated a lower level of community integration as measured with SIPSO-C