Stacy L. Fritz

Active Finger Extension Predicts Outcomes After Constraint-Induced Movement Therapy for Individuals With Hemiparesis After Stroke

Background and Purpose— Constraint-induced movement therapy (CIMT) is a rehabilitative strategy used primarily with the post-stroke population to increase the functional use of the neurologically weaker upper extremity through massed practice while restraining the lesser involved upper extremity. Whereas research evidence supports CIMT, limited evidence exists regarding the characteristics of individuals who benefit most from this intervention. The goal of this study was to investigate the potential of 5 measures to predict functional CIMT outcomes. Methods— A convenience sample of 55 individuals, >6 months after stroke, was recruited that met specific inclusion/exclusion criteria allowing for individuals whose upper extremity was mildly to severely involved. They participated in CIMT 6 hours per day. Pretest, post-test, and follow-up assessments were performed to assess the outcomes for the Wolf Motor Function Test (WMFT). The potential predictors were minimal motor criteria (active extension of the wrist and 3 fingers), active finger extension/grasp release, grip strength, Fugl–Meyer upper extremity motor score, and the Frenchay score. A step-wise regression analysis was used in which the potential predictors were entered in a linear regression model with simultaneous entry of the dependent variables’ pretest score as the covariate. Two regressions models were determined for the dependent variable, for immediate post-test, and for follow-up post-test. Results— Finger extension was the only significant predictor of WMFT outcomes. Conclusions— When using finger extension/grasp release as a predictor in the regression equations, one can predict individual’s follow-up scores for CIMT. This experiment provides the most comprehensive investigation of predictors of CIMT outcomes to date.

Assessing the reliability and validity of a shorter walk test compared with the 10-Meter Walk Test for measurements of gait speed in healthy, older adults.

Background and Purpose:Walking speed is associated with several health-related outcomes. Research examining how differences in test walking distance affect walking speed reliability and validity is limited. The primary purpose of this study was to examine the reliability and concurrent validity of gait speed measurements obtained from a 4-Meter Walk Test compared with the commonly used 10-Meter Walk Test. A second objective was to similarly examine 2 different timing methods: stopwatch and automatic timers. Methods:Forty-three healthy, older adults (mean age = 84.3 ± 6.9 years) performed 3 consecutive walking trials on the 4- and 10-Meter Walk Tests at their self-selected walking speed. Results:Gait speed measurements for both tests were shown to have excellent test-retest reliability (ICC values of 0.96–0.98), with similar results for stopwatch and automatic timer assessments (ICC values of 0.99–1.00). Standard error of the measurement (SEM) values were small (0.004–0.008 m/s) across measurement methods. While the ICC value for gait speed measurements between the 2 walk tests was 0.93, the Bland-Altman analysis revealed a discrepancy of ±0.15 to ±0.17 m/s between measurement methods. Discussion:Both 4- and 10-m gait speed assessments had excellent test-retest reliability with similar SEM and minimal detectable change values. There was little difference in SEM values between the 2 timing methods. While the mean difference in gait speed between the 4- and 10-Meter Walk Tests was small, the range of the measurement differences was large enough to potentially mask meaningful changes in gait speed over time if both methods were used interchangeably. Conclusions:While the reliability of both walking tests is excellent, the 4-Meter Walk Test does not exhibit a high enough degree of concurrent validity with the 10-Meter Walk Test to be used interchangeably for gait speed assessments in healthy, older adults. We therefore recommend using the 10-Meter Walk Test to obtain the most valid clinical assessment of walking speed when using it as a 1-time indicator of health status.

Minimal Detectable Change Scores for the Wolf Motor Function Test

Background. The Wolf Motor Function Test (WMFT) is an impairment-based test whose psychometrics have been examined by previous reliability and validity studies. Standards for evaluating whether a given change is meaningful, however, have not yet been addressed. Objectives. To determine the standard error of measurement (SEM) and minimal detectable change (MDC) for the WMFT. Methods. Data were collected from 6 university laboratories that participated in the EXCITE national clinical trial and included 96 individuals with sub-acute stroke (3—9 months). Measurements were made by blinded evaluators who were trained and standardized to administer the WMFT, which was completed on 2 occasions 2 weeks apart. No intervention was given between testing sessions. Results. The WMFT Performance Time score has a SEM of 0.2 seconds and a MDC95 of 0.7 seconds. The individual task timed items MDC 95 ranged from 1.0 second (turn key in lock) to 3.4 seconds (reach and retrieve) with individual task items demonstrating notablly higher variability than the average WMFT Performance Time. The average WMFT Functional Ability Scale SEM and MDC95 is 0.1 points. Conclusions. When assessing the effect of a therapeutic intervention, if an individual experiences an amount of change equal to or greater than the MDC, then one may be 95% confident that this margin of change is truly larger than measurement error and not a chance result. Thus, the determination of SEM and MDC in outcome assessments allows researchers and clinicians to distinguish which results are actual differences versus which results are simply changes resulting from error or chance.

An intense intervention for improving gait, balance, and mobility for individuals with chronic stroke: a pilot study.

Purpose: Stroke is the leading cause of disability in the United States. At present, there is a paucity of experimental evidence available to indicate what physical therapy techniques are effective for improving mobility in an individual with chronic stroke. The purpose of this study was to determine the feasibility and effect size of an intensive mobility training program for people with chronic stroke. Methods: A convenience sample of eight individuals with chronic stroke received an intensive mobility intervention for 3 hours per day for 10 consecutive weekdays. Treatment outcomes were assessed using standardized outcomes of gait, balance, and mobility including the GAITRite to collect spatial and temporal parameters of gait, the Falls Efficacy Scale, Berg Balance Scale, Dynamic Gait Index, and Timed Up and Go. Data were collected at four different time points: baseline, pre-test, post-test, and 3 months after intervention. Results: The overall effect size of the intervention was 0.72, with changes in balance having much greater effects than changes in gait or mobility. The group demonstrated an average improvement from pre- to post-tests of 12 points on the Berg Balance Scale where a change of 6 is considered a minimal detectable change. Conclusions: This intense mobility training was a feasible intervention for this sample and demonstrated large effect sizes for balance outcome measures. Future studies incorporating more participants, a standard control, and more emphasis on gait would provide insight into the effectiveness and clinical relevance of this intervention.

Active Video-Gaming Effects on Balance and Mobility in Individuals with Chronic Stroke: A Randomized Controlled Trial

Abstract Background: Treatments that provide feedback, increase practice with multiple repetitions, and motivate patients are essential to rehabilitation post stroke. Objective: To determine whether playing active video games results in improved balance and mobility post stroke. Methods: Thirty participants with chronic (time since stroke = 3.0 [2.9] years) hemiparesis post stroke were randomly assigned to a gaming group or normal activity control group. Gaming systems provided participants with an interactive interface of real-time movement of either themselves or an avatar on the screen. Participants played games 50–60 minutes/day, 4 days/week, for 5 weeks. The intervention was strictly game-play, in standing position, without physical therapy. The control group received no special intervention and continued with normal activity. Both groups were tested prior to, following the 5 weeks (post test), and 3 months following the completion of the study. Outcome measures included the Fugl-Meyer Assessment, Berg Balance Scale, Dynamic Gait Index, Timed Up & Go, 6-minute walk test, 3-meter walk (self-selected and fast), and perception of recovery. Results: No statistically significant differences between or within groups were found through analysis of covariance (covaried for side of hemiparesis) at post test or follow-up. Although the within-group effect sizes were primarily indexed as “small” (< .36), the gaming group exhibited higher within-group effect sizes before and after testing than did the control group on all 7 dependent variables analyzed. Conclusions: Even though the only intervention was game-play, there were small positive effects. Therapist assistance in making more optimum movement choices may be needed before significant improvements are seen with commercially available, general purpose games.

Determining Risk of Falls in Community Dwelling Older Adults: A Systematic Review and Meta-analysis Using Posttest Probability

Background: Falls and their consequences are significant concerns for older adults, caregivers, and health care providers. Identification of fall risk is crucial for appropriate referral to preventive interventions. Falls are multifactorial; no single measure is an accurate diagnostic tool. There is limited information on which history question, self-report measure, or performance-based measure, or combination of measures, best predicts future falls. Purpose: First, to evaluate the predictive ability of history questions, self-report measures, and performance-based measures for assessing fall risk of community-dwelling older adults by calculating and comparing posttest probability (PoTP) values for individual test/measures. Second, to evaluate usefulness of cumulative PoTP for measures in combination. Data Sources: To be included, a study must have used fall status as an outcome or classification variable, have a sample size of at least 30 ambulatory community-living older adults (≥65 years), and track falls occurrence for a minimum of 6 months. Studies in acute or long-term care settings, as well as those including participants with significant cognitive or neuromuscular conditions related to increased fall risk, were excluded. Searches of Medline/PubMED and Cumulative Index of Nursing and Allied Health (CINAHL) from January 1990 through September 2013 identified 2294 abstracts concerned with fall risk assessment in community-dwelling older adults. Study Selection: Because the number of prospective studies of fall risk assessment was limited, retrospective studies that classified participants (faller/nonfallers) were also included. Ninety-five full-text articles met inclusion criteria; 59 contained necessary data for calculation of PoTP. The Quality Assessment Tool for Diagnostic Accuracy Studies (QUADAS) was used to assess each studys methodological quality. Data Extraction: Study design and QUADAS score determined the level of evidence. Data for calculation of sensitivity (Sn), specificity (Sp), likelihood ratios (LR), and PoTP values were available for 21 of 46 measures used as search terms. An additional 73 history questions, self-report measures, and performance-based measures were used in included articles; PoTP values could be calculated for 35. Data Synthesis: Evidence tables including PoTP values were constructed for 15 history questions, 15 self-report measures, and 26 performance-based measures. Recommendations for clinical practice were based on consensus. Limitations: Variations in study quality, procedures, and statistical analyses challenged data extraction, interpretation, and synthesis. There was insufficient data for calculation of PoTP values for 63 of 119 tests. Conclusions: No single test/measure demonstrated strong PoTP values. Five history questions, 2 self-report measures, and 5 performance-based measures may have clinical usefulness in assessing risk of falling on the basis of cumulative PoTP. Berg Balance Scale score (⩽50 points), Timed Up and Go times (≥12 seconds), and 5 times sit-to-stand times (≥12) seconds are currently the most evidence-supported functional measures to determine individual risk of future falls. Shortfalls identified during review will direct researchers to address knowledge gaps.

Counting Repetitions: An Observational Study of Video Game Play in People With Chronic Poststroke Hemiparesis

Background and Purpose: The use of video gaming as a therapeutic intervention has increased in popularity; however, the number of repetitions in comparison with traditional therapy methods has yet to be investigated. The primary purpose of this study was to document and compare the number of repetitions performed while playing 1 of 2 video gaming systems for a time frame similar to that of a traditional therapy session in individuals with chronic stroke. Methods: Twelve participants with chronic stroke (mean age, 66.8 ± 8.2 years; time poststroke, 19.2 ± 15.4 months) completed video game play sessions, using either the Nintendo Wii or the Playstation 2 EyeToy. A total of 203 sessions were captured on video record; of these, 50 sessions for each gaming system were randomly selected for analysis. For each selected record, active upper and lower extremity repetitions were counted for a 36-minute segment of the recorded session. Results: The Playstation 2 EyeToy group produced an average of 302.5 (228.1) upper extremity active movements and 189.3 (98.3) weight shifts, significantly higher than the Nintendo Wii group, which produced an average of 61.9 (65.7) upper extremity active movements and 109.7 (78.5) weight shifts. No significant differences were found in steps and other lower extremity active movements between the 2 systems. Discussion and Conclusions: The Playstation 2 EyeToy group produced more upper extremity active movements and weight shifting movements than the Nintendo Wii group; the number and type of repetitions varied across games. Active gaming (specifically Playstation 2 EyeToy) provided more upper extremity repetitions than those reported in the literature by using traditional therapy, suggesting that it may be a modality to promote increased active movements in individuals poststroke. Video Abstract available (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A50) for more insights from the authors.

Elbow Extension Predicts Motor Impairment and Performance after Stroke

Background and Purpose. Kinematic motion analysis has helped to characterize poststroke reaching strategies with the hemiparetic arm. However, the relationships between reaching strategy and performance on common functional outcome measures remain unclear. Methods. Thirty-five participants were tested for motor performance and motor impairment using the Wolf Motor Function Test (time and functional ability measure) and Fugl-Meyer assessment, respectively. Kinematic motion analysis of a forward reaching paradigm provided potential predictors of reaching strategy including shoulder flexion, elbow extension, and trunk displacement. A stepwise linear regression model with three potential predictors was used in addition to Pearson-product moment correlations. Results. Kinematic analysis of elbow extension predicted performance on both the Wolf Motor Function Test and Fugl-Meyer assessment. Shoulder flexion and trunk displacement did not significantly predict functional or reaching time outcomes. The Wolf Motor Function Test and the Fugl-Meyer assessment were highly correlated. Conclusions. The ability to incorporate elbow extension during reach is a significant predictor of motor performance and hemiparetic arm motor capacity after stroke.

Constraint-induced movement therapy: from history to plasticity

Constraint-induced movement therapy (CIMT) is a rehabilitative strategy applied primarily to the post-stroke population to increase the functional use of the neurologically weaker upper extremity through massed practice, while restraining the lesser involved upper extremity. Although recent Cochrane reviews have reported success with CIMT, this therapeutic technique is difficult to deliver because it requires proper allocation of resources by both clinicians and patients. Therefore, identifying those individuals who benefit most from the intervention is essential. Since most studies include heterogeneous populations, the effect of the intervention for certain subgroups could be masked. Therefore, understanding the possible neuropredictors of recovery can help target the appropriate populations. This special report briefly presents the history of CIMT and its underpinnings in the psychology literature; however, the focus is on brain plasticity with an emphasis on the importance of the type and location of stroke and how this factor might influence outcomes following CIMT.

Feasibility of Intensive Mobility Training to Improve Gait, Balance, and Mobility in Persons With Chronic Neurological Conditions: A Case Series

Background and Purpose: Intensive mobility training (IMT) is a rehabilitative approach aimed at improving gait, balance, and mobility through the incorporation of task-specific, massed practice. The purpose of this case series was to examine the feasibility and benefits of the IMT protocol across a sample of 4 individuals with diverse chronic neurological diagnoses, including incomplete spinal cord injury, Parkinsons disease, stroke, and cerebral hemispherectomy. Methods: The 4 participants enrolled in the IMT protocol and followed an intensive treatment schedule of 3 h/d sessions for 10 consecutive weekdays totaling 30 hours. Each session allocated 1 hour each to (1) body weight–supported treadmill-based locomotor training, (2) balance interventions, and (3) activities to improve coordination, strength, and range of motion. Interventions emphasized repetitive, task-specific training of lower-extremity movements in a massed practice schedule. Pain, fatigue, and time in activity were used to assess feasibility of the treatment. Temporal-spatial gait parameters, Berg Balance Scale, Dynamic Gait Index, Timed Up and Go test, and 6-Minute Walk test were used to assess changes in performance. Results: Participants were able to complete an average of 144 of 180 minutes of activity per day for 10 days. Participants demonstrated modest improvements after the intervention on at least one outcome measure for each target area of gait, mobility, and balance. Some improvements were maintained for 1 to 6 months after participation. Discussion: Despite differences in diagnosis among these participants with chronic neurological disorders, on average they were able to complete 80% of an intensive treatment schedule of 3 hours/day for 10 days with no adverse effects. It appears that some gains made during participation are maintained for a period of time after the end of training. IMT is a feasible intervention incorporating an intensive training approach to improve gait, balance, and mobility; however, a randomized trial is needed to further investigate the effects of the intervention.