Sarah Tyson

Sensory loss in hospital-admitted people with stroke: characteristics, associated factors, and relationship with function.

Objective: To characterize the nature of sensory impairments after stroke, identify associated factors, and assess the relationships between sensory impairment, disability, and recovery. Methods: Prospective cross-sectional survey of 102 people with hemiparesis following their first stroke. Tactile and proprioceptive sensation in the affected arm and leg were measured using the Rivermead Assessment of Somatosensory Perception 2-4 weeks post-stroke. Demographics, stroke pathology, weakness, neglect, disability, and recovery were documented. Results: Tactile impairment was more common than proprioceptive (P < .000), impairment of discrimination was more common than detection (P < .000), and tactile sensation was more severely impaired in the leg than the arm ( P < .000). No difference in proprioception between the arm and leg (P = .703) or between proximal and distal joints (P = .589, P = .705) was found. The degree of weakness and the degree of stroke severity were significantly associated with sensory impairment; demographics, stroke side and type, and neglect were not associated. All the sensory modalities were significantly related to independence, mobility, and recovery (r = 0.287 [P < .011] to r = 0.533 [P < .000]). Conclusion: Sensory impairments of all modalities are common after stroke, although tactile impairment is more frequent than proprioceptive loss, especially in the leg. They are associated with the degree of weakness and the degree of stroke severity but not demographics, stroke pathology, or neglect, and they are related to mobility, independence in activities of daily living, and recovery.

The psychometric properties and clinical utility of measures of walking and mobility in neurological conditions: a systematic review:

Objective: To identify psychometrically robust and clinically feasible measures of walking and mobility in people with neurological conditions Data sources: MEDLINE, CINAHL, EMBASE, PEDro and AMED. Review methods: Independent reviewers selected and extracted data from articles that assessed the reliability, validity, sensitivity to change or clinical utility of measures of walking and mobility in adult neurological conditions. Measures with ‘good’ psychometrics and 9/10 clinical utility scores were recommended. Results: Seventeen measures were selected. Of these, the 5-m and 10-m walk tests, six-minute walk test, High Level Mobility Assessment Tool (HiMAT) and the Rivermead Mobility Index (RMI) reached the required standards and are usable in clinical practice. None of the recommended measures assessed wheelchair mobility. The least frequently assessed property was sensitivity to change. Further measures could be recommended if the minimal detectable change were demonstrated. Conclusion: The 5-m, 10-m and six-minute walk test, High Level Mobility Assessment Tool and the Rivermead Mobility Index are psychometrically robust measures of walking and mobility and are feasible for use in clinical practice.

Reliability and validity of functional balance tests post stroke

Objective: To contribute to the reliability and validity of a series of functional balance tests for use post stroke. Design: Within-session, test-retest and intertester reliability was tested using the kappa coefficient and intraclass correlations. The tests were performed three times and the first and third attempts compared to test the within-session reliability. The tests were repeated a few days later to assess test-retest reliability and were scored simultaneously by two physiotherapists to assess the intertester reliability. To test criterion-related validity the tests were compared with the sitting section of the Motor Assessment Scale, Berg Balance Scale and Rivermead Mobility Index using Spearmans rho. Setting: Stroke physiotherapy services of six National Health Service hospitals. Participants: People with a post stroke hemiplegia attending physiotherapy who had no other pathology affecting their balance took part. Thirty-five people participated in the reliability testing and 48 people took part in the validity testing. Main outcome measures: The following functional balance tests were used: supported sitting balance, sitting arm raise, sitting forward reach, supported standing balance, standing arm raise, standing forward reach, static tandem standing, weight shift, timed 5-m walk with and without an aid, tap and step-up tests. Results: The ordinal level tests (supported sitting and standing balance and static tandem standing tests) showed 100% agreement in all aspects of reliability. Intraclass correlations for the other tests ranged from 0.93 to 0.99. All the tests showed significant correlations with the appropriate comparator tests (r=0.32-0.74 p≤0.05), except the weight shift test and step-up tests which did not form significant relationship with Berg Balance Scale (r=0.26 and 0.19 respectively). Conclusion: These functional balance tests are reliable and valid measures of balance disability post stroke.

The Relationship Between Balance, Disability, and Recovery After Stroke: Predictive Validity of the Brunel Balance Assessment

Objective. To examine the influence of balance disability on function and the recovery of function after stroke and consequently to assess the predictive validity of the Brunel Balance Assessment (BBA). Methods. Cross-sectional study of 102 patients admitted consecutively to 6 National Health Service hospitals with weakness 2 to 4 weeks after their first anterior circulation stroke; 75 of whom completed follow-up assessment at 3 months. The BBA was assessed during admission and compared to the Barthel Index and Rivermead Mobility Index at 3 months. Results. Balance disability was the strongest predictor of function (in terms of activities of daily living [ADLs] and mobility disability) in the acute stages. Weakness was also an independent predictor. Recovery of ADLs was independently predicted by balance disability, weakness, age, and premorbid disability, whereas recovery of mobility disability was predicted by balance and age alone. At 3 months, a minority of people with limited sitting balance (0%-22%) and standing balance (25%-50%) recovered independent functional mobility. Most people who could walk initially recovered independent functional mobility (66%-84%), but 16% suffered a decline in their mobility and 44% had enduring limitations in everyday mobility activities. Conclusion. Initial balance disability is a strong predictor of function and recovery after stroke. These results demonstrate the predictive validity of the BBA.

Development of the Brunel Balance Assessment: a new measure of balance disability post stroke

Objective: To report the psychometric properties of the Brunel Balance Assessment (BBA), a new test of balance disability post stroke. Design: Data from 92 subjects were collected and cohorts used to test hierarchical scaling, reliability and validity. Data from 80 people were used to test the hierarchical scaling using an inter-item correlation for redundancy, coefficient of reproducibility (CR) and scalability (CS) for the hierarchy and Cronbachs alpha coefficient for the internal consistency. Thirty-seven people participated in the reliability testing. Test / retest and inter-tester reliability were tested using the kappa coefficient. The testing was repeated on consecutive days to assess test / retest reliability and was scored simultaneously by two physiotherapists for inter-tester reliability. Fifty-five people participated in validity testing. The BBA was compared with the sitting Motor Assessment Scale (MAS), Berg Balance Test (Berg), Rivermead Mobility Index (RMI) using Spearmans rho. Setting: Physiotherapy stroke services of six UK NHS trusts. Participants: Hemiplegic stroke patients were recruited from physiotherapy services and the BBA used to assess their balance. Results: The order of the items was revised and the original 14-point scale reduced to 12 points in the scale development. The revised scale formed a hierarchical scale. Inter-item correlations were < 0.9, coefficients of reproducibility and scalability were 0.99 and 0.69 respectively and Cronbachs alpha was 0.92. Reliability was high (100% agreement) for both aspects of reliability. Correlations with other balance measures were significant (0.83 / 0.97, p<0.01) indicating validity as measure of balance disability. Conclusion: The BBA is a reliable, valid, hierarchical measure of balance disability post stroke that is suitable for use in the clinical setting.

A systematic review and meta-analysis of the effect of an ankle-foot orthosis on gait biomechanics after stroke:

Objective: To systematically review the evidence on the effects of an ankle-foot orthosis on gait biomechanics after stroke Data sources: The following databases were searched; AMED, CINHAL, Cochrane Library (Stroke section), Medline, PubMed, Science Direct and Scopus. Previous reviews, reference lists and citation tracking of the selected articles were screened and the authors of selected trials contacted for any further unpublished data. Review methods: Controlled trials of an ankle-foot orthosis on gait biomechanics in stroke survivors were identified. A modified PEDro score evaluated trial quality; those scoring 4/8 or more were selected. Information on the trial design, population, intervention, outcomes, and mean and standard deviation values for the treatment and control groups were extracted. Continuous outcomes were pooled according to their mean difference and 95% confidence intervals in a fixed-effect model. Results: Twenty trials involving 314 participants were selected. An ankle-foot orthosis had a positive effect on ankle kinematics (P < 0.00001–0.0002); knee kinematics in stance phase (P < 0.0001–0.01); kinetics (P = 0.0001) and energy cost (P = 0.004), but not on knee kinematics in swing phase (P = 0.84), hip kinematics (P < 0.18–0.89) or energy expenditure (P = 0.43). There were insufficient data for pooled analysis of individual joint moments, muscle activity or spasticity. All trials, except one, evaluated immediate effects only. Conclusions: An ankle-foot orthosis can improve the ankle and knee kinematics, kinetics and energy cost of walking in stroke survivors.

A comparison of the biomechanical effects of valgus knee braces and lateral wedged insoles in patients with knee osteoarthritis

Increases in the external knee adduction moment (EKAM) have been associated with increased mechanical load at the knee and progression of knee osteoarthritis. Valgus knee braces and lateral wedged insoles are common approaches to reducing this loading; however no study has directly compared the biomechanical and clinical effects of these two treatments in patients with medial tibiofemoral osteoarthritis. A cross-over randomised design was used where each intervention was worn by 28 patients for a two week period. Pre- and post-intervention gait kinematic/kinetic data and clinical outcomes were collected to evaluate the biomechanical and clinical effects on the knee joint. The valgus knee brace and the lateral wedged insole significantly increased walking speed, reduced the early stance EKAM by 7% and 12%, and the knee adduction angular impulse by 8.6 and 16.1% respectively. The lateral wedged insole significantly reduced the early stance EKAM compared to the valgus knee brace (p=0.001). The valgus knee brace significantly reduced the knee varus angle compared to the baseline and lateral wedged insole. Improvements in pain and function subscales were comparable for the valgus knee brace and lateral wedged insole. There were no significant differences between the two treatments in any of the clinical outcomes; however the lateral wedged insoles demonstrated greater levels of acceptance by patients. This is the first study to biomechanically compare these two treatments, and demonstrates that given the potential role of knee loading in osteoarthritis progression, that both treatments reduce this but lateral wedge insoles appear to have a greater effect.

Interventions for coordination of walking following stroke: Systematic review

Impairments in gait coordination may be a factor in falls and mobility limitations after stroke. Therefore, rehabilitation targeting gait coordination may be an effective way to improve walking post-stroke. This review sought to examine current treatments that target impairments of gait coordination, the theoretical basis on which they are derived and the effects of such interventions. Few high quality RCTs with a low risk of bias specifically targeting and measuring restoration of coordinated gait were found. Consequently, we took a pragmatic approach to describing and quantifying the available evidence and included non-randomised study designs and limited the influence of heterogeneity in experimental design and control comparators by restricting meta-analyses to pre- and post-test comparisons of experimental interventions only. Results show that physiotherapy interventions significantly improved gait function and coordination. Interventions involving repetitive task-specific practice and/or auditory cueing appeared to be the most promising approaches to restore gait coordination. The fact that overall improvements in gait coordination coincided with increased walking speed lends support to the hypothesis that targeting gait coordination gait may be a way of improving overall walking ability post-stroke. However, establishing the mechanism for improved locomotor control requires a better understanding of the nature of both neuroplasticity and coordination deficits in functional tasks after stroke. Future research requires the measurement of impairment, activity and cortical activation in an effort to establish the mechanism by which functional gains are achieved.

Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review.

OBJECTIVE To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice. DATA SOURCES MEDLINE, CINAHL, EMBASE, PEDro, and AMED. STUDY SELECTION Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions. DATA EXTRACTION Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended. DATA SYNTHESIS The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test. CONCLUSIONS The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

The Immediate Effect of Orthotic Management on Grip Strength of Patients With Lateral Epicondylosis

STUDY DESIGN Controlled laboratory study using a randomized crossover design. OBJECTIVE To determine the immediate effect of 3 common types of orthoses (2 elbow counterforce orthoses and a wrist splint) on grip strength in individuals with lateral epicondylosis. BACKGROUND Lateral epicondylosis is a common cause of pain and upper limb dysfunction. Although the effectiveness of orthoses has been reported, comparisons of effectiveness among orthoses are limited. METHODS AND MEASURES Fifty-two subjects with lateral epicondylosis were recruited (20 men, 32 women; mean +/- SD age, 41 +/- 8 years). Maximum and pain-free grip strength were assessed using a digital hand grip dynamometer immediately after the application of each orthosis. The 4 testing conditions included a placebo orthosis as a control condition, an elbow strap orthosis, an elbow sleeve orthosis, and a wrist splint. Data were analyzed using a 1-way analysis of variance for each outcome measure. RESULTS Pain-free grip-strength was greater when using the elbow strap or the elbow sleeve orthosis compared to when using the placebo control orthosis or the wrist splint (P<.02), but there was no difference between the elbow sleeve and strap orthoses (P>.05), nor between the wrist splint and placebo orthosis (P>.05). Maximum grip strength was less when using the wrist splint compared to when tested with the elbow sleeve or the elbow strap (P< or =.003). Use of the elbow strap, elbow sleeve, or wrist splint did not change maximum grip strength compared to the control placebo orthosis condition (P>.05). There was also no difference in maximum grip strength between the elbow strap and the elbow sleeve conditions (P>.05). CONCLUSION The use of the 2 types of elbow orthoses (strap and sleeve) resulted in an immediate increase in pain-free grip strength. No differences between the 2 orthoses were found, suggesting that either can be used. A wrist splint produced no immediate change in pain-free or maximum grip-strength, indicating that it should not be used as a first-choice orthosis based on those outcome measures.