Stephanie A. Combs

Accuracy of 2 Activity Monitors in Detecting Steps in People With Stroke and Traumatic Brain Injury

Background Advances in sensor technologies and signal processing techniques provide a method to accurately measure walking activity in the home and community. Activity monitors geared toward consumer or patient use may be an alternative to more expensive monitors designed for research to measure stepping activity. Objective The objective of this study was to examine the accuracy of 2 consumer/patient activity monitors, the Fitbit Ultra and the Nike+ Fuelband, in identifying stepping activity in people with stroke and traumatic brain injury (TBI). Secondarily, the study sought to compare the accuracy of these 2 activity monitors with that of the StepWatch Activity Monitor (SAM) and a pedometer, the Yamax Digi-Walker SW-701 pedometer (YDWP). Design A cross-sectional design was used for this study. Method People with chronic stroke and TBI wore the 4 activity monitors while they performed the Two-Minute Walk Test (2MWT), during which they were videotaped. Activity monitor estimated steps taken were compared with actual steps taken counted from videotape. Accuracy and agreement between activity monitor estimated steps and actual steps were examined using intraclass correlation coefficients (ICC [2,1]) and the Bland-Altman method. Results The SAM demonstrated the greatest accuracy (ICC [2,1]=.97, mean difference between actual steps and SAM estimated steps=4.7 steps) followed by the Fitbit Ultra (ICC [2,1]=.73, mean difference between actual steps and Fitbit Ultra estimated steps=−9.7 steps), the YDWP (ICC [2,1]=.42, mean difference between actual steps and YDWP estimated steps=−28.8 steps), and the Nike+ Fuelband (ICC [2,1]=.20, mean difference between actual steps and Nike+ Fuelband estimated steps=−66.2 steps). Limitations Walking activity was measured over a short distance in a closed environment, and participants were high functioning ambulators, with a mean gait speed of 0.93 m/s. Conclusions The Fitbit Ultra may be a low-cost alternative to measure the stepping activity in level, predictable environments of people with stroke and TBI who can walk at speeds ≥0.58 m/s.

Is walking faster or walking farther more important to persons with chronic stroke

Purpose: The purposes of this mixed-methods study were to (1) investigate whether walking faster or walking farther was more important for getting “out and about” to persons with chronic stroke and (2) explore explanations for walking preferences. Method: A convenience sample of 77 adults with chronic stroke completed questionnaires and walking outcomes in one visit. Participants were asked whether walking faster or farther was more important to them for getting “out and about”, and differences between response groups (faster vs. farther) were evaluated. Participants also described their preference for walking faster or farther. Qualitative responses were analyzed using content analysis. Results: The majority of participants (76%; n = 58) reported walking farther was more important, while 18% (n = 14) reported walking faster was more important. Statistically significant differences were not found between response groups for any variable. Primary themes identified from participant preferences for walking faster included: (1) faster speed equals better walking ability and (2) getting places faster/quicker. Primary themes from preferences for walking farther included: (1) engaging in activity and participation within home and community; (2) walking farther at a slower pace; and (3) fatigue with walking. Conclusions: Individual preferences for walking faster versus walking farther by persons with chronic stroke should be considered by clinicians when making decisions for rehabilitation. Implications for Rehabilitation Individual preferences for walking faster versus walking farther by patients with chronic stroke should be considered by rehabilitation clinicians when making decisions about examination and intervention. The majority of participants with chronic stroke in this study indicated the importance of walking farther in order to better engage in activities both at home and away from home. Interventions that focus on improving endurance and energy conservation may need to be used for persons with chronic stroke who want to walk father in order to maximize their potential for walking longer distances.

Boxing Training for Patients With Parkinson Disease: A Case Series

Background and Purpose A nontraditional form of exercise recently applied for patients with Parkinson disease (PD) is boxing training. The primary purpose of this case series is to describe the effects of disease severity and duration of boxing training (short term and long term) on changes in balance, mobility, and quality of life for patients with mild or moderate to severe PD. The feasibility and safety of the boxing training program also were assessed. Case Descriptions Six patients with idiopathic PD attended 24 to 36 boxing training sessions for 12 weeks, with the option of continuing the training for an additional 24 weeks (a seventh patient attended sessions for only 4 weeks). The 90-minute sessions included boxing drills and traditional stretching, strengthening, and endurance exercises. Outcomes were tested at the baseline and after 12, 24, and 36 weeks of boxing sessions (12-, 24-, and 36-week tests). The outcome measures were the Functional Reach Test, Berg Balance Scale, Activities-specific Balance Confidence Scale, Timed “Up & Go” Test, Six-Minute Walk Test, gait speed, cadence, stride length, step width, activities of daily living and motor examination subscales of the Unified Parkinson Disease Rating Scale, and Parkinson Disease Quality of Life Scale. Outcomes Six patients completed all phases of the case series, showed improvements on at least 5 of the 12 outcome measures over the baseline at the 12-week test, and showed continued improvements at the 24- and 36-week tests. Patients with mild PD typically showed improvements earlier than those with moderate to severe PD. Discussion Despite the progressive nature of PD, the patients in this case series showed short-term and long-term improvements in balance, gait, activities of daily living, and quality of life after the boxing training program. A longer duration of training was necessary for patients with moderate to severe PD to show maximal training outcomes. The boxing training program was feasible and safe for these patients with PD.

Balance Is Associated with Quality of Life in Chronic Stroke

Abstract Objective: To investigate the association between balance and quality of life (QOL) in chronic stroke survivors by (1) examining the associations between balance and QOL scores; (2) identifying the frequency of balance impairment and poststroke falls; and (3) determining the differences in QOL scores between persons with and those without balance impairment. Methods: This is a secondary analysis of a cross-sectional study. People who had a stroke more than 6 months earlier from 3 Midwest states were included in the study if they met the following criteria: were referred to occupational or physical therapy for poststroke physical deficits; had self-reported stroke-related physical deficits; completed all stroke-related rehabilitation; had residual functional disability; had a score of ≥4 out of 6 on the short 6-item Mini-Mental State Examination; and were between 50 and 85 years old (n = 59). The main outcome measures included the Berg Balance Scale (BBS) to assess balance and the Stroke Specific Quality of Life Scale (SS-QOL) to assess QOL. Number of falls since stroke was self-reported. Results: Mean BBS score was 44 ± 8 and mean SS-QOL score was 46 ± 8; these scores were significantly correlated (r = .394, P = .002). Seventy-six percent of the sample reported a fall since stroke. Persons with balance impairment (BBS score ≤46; n = 29; 49%) had an average BBS score of 39 ± 7 and significantly worse SS-QOL scores than those without balance impairment (42 ± 8 vs 49 ± 7; P = .001). Conclusion: In the chronic stroke population, balance impairment and fall risk are associated with lower QOL scores. If balance can be improved and maintained into the chronic phases of stroke, it is likely that individuals will benefit with improved QOL.

Fatigue and Pain: Relationships with Physical Performance and Patient Beliefs after Stroke

Abstract Background: Fatigue and pain are common after stroke, potentially impacting stroke recovery. Objective: This study examines the frequency and impact of fatigue and pain in people with chronic stroke. Method: Seventy-seven people with chronic stroke completed a one-time assessment consisting of a battery of self-report and performance tools to describe and quantify mobility issues post stroke. We assessed the proportion of individuals with fatigue and pain and the relationship between fatigue and pain and other variables including gait (10-meter walk and 6-minute walk test), balance (Berg Balance Scale), activity and participation (ICF Measure of Participation and Activities), chronic disease self-efficacy (Chronic Disease Self-Efficacy Scale), and balance self-efficacy (Activity-Specific Balance Confidence Scale). Additionally, subgroup comparisons were made between participants with and without coexisting fatigue and pain. Results: Fatigue and pain were reported by 66% and 45% of study participants, respectively. Thirty-four percent of the sample reported co-existing fatigue and pain. Participants with coexisting fatigue and pain demonstrated significantly lower chronic disease and balance self-efficacy and decreased activity than participants without coexisting fatigue and pain. Individually, fatigue correlated with balance, chronic disease self-efficacy, balance self-efficacy, activity, and participation, whereas pain correlated with chronic disease self-efficacy, balance self-efficacy, and activity. Conclusion: Fatigue and pain are common after stroke and are negatively correlated with outcomes important to rehabilitation. Efforts focused on examining the impact of interventions on fatigue and pain are warranted. It is possible that changes to these body structure limitations could positively impact functional recovery and community re-entry after stroke.

Effects of an intensive, task-specific rehabilitation program for individuals with chronic stroke: A case series

Purpose. The purpose of this case series was to determine feasibility and evaluate changes in activity and participation outcomes in persons with chronic stroke after an intensive, task-specific rehabilitation program incorporating whole-body and client-centred interventions. Method. Participants with chronic stroke (N = 12) who were ambulatory and had at least minimal arm/hand function were recruited. The program included whole-body goal-focused activities, gait training and strengthening exercises for 4 h, 5 days per week for 2 weeks. Daily educational sessions and a home activities program were also included. Activity-based measures including the Wolf motor function test, Berg balance scale, timed up and go test and 6-min walk test and participation-based measures including the Stroke Impact Scale and Canadian Occupational Performance Measure were collected at pre-test, immediate post-test and 5-month retention. Results. The effect of the intervention on participation-based outcomes was much greater than on the activity-based outcomes. Minimal detectable differences in self-perceived participation were reported for most participants. Conclusions. The intensive, task-specific intervention was a feasible program for these participants with stroke. Although minimal changes in activity-based outcomes were found, the participants perceived improvements in participation with personal goal-related activities that resulted in large effect sizes that were maintained for 5-months after the intervention.

Community-based group exercise for persons with Parkinson disease: A randomized controlled trial

The purpose of this study was to compare group boxing training to traditional group exercise on function and quality of life in persons with Parkinson disease (PD). A convenience sample of adults with PD (n = 31) were randomly assigned to boxing training or traditional exercise for 24-36 sessions, each lasting 90 minutes, over 12 weeks. Boxing training included: stretching, boxing (e.g. lateral foot work, punching bags), resistance exercises, and aerobic training. Traditional exercise included: stretching, resistance exercises, aerobic training, and balance activities. Participants were tested before and after completion of training on balance, balance confidence, mobility, gait velocity, gait endurance, and quality of life. The traditional exercise group demonstrated significantly greater gains in balance confidence than the boxing group (p < 0.025). Only the boxing group demonstrated significant improvements in gait velocity and endurance over time with a medium between-group effect size for the gait endurance (d = 0.65). Both groups demonstrated significant improvements with the balance, mobility, and quality of life with large within-group effect sizes (d ≥ 0.80). While groups significantly differed in balance confidence after training, both groups demonstrated improvements in most outcome measures. Supporting options for long-term community-based group exercise for persons with PD will be an important future consideration for rehabilitation professionals.

Running Training After Stroke: A Single-Subject Report

Background and Purpose: Although many people who have had a stroke are primarily interested in learning to walk, some are able to focus on a return to recreational and sporting activities. This study was carried out to investigate the feasibility and effectiveness of the use of intensive task-oriented training in the body-weight–support/treadmill environment to improve running for a subject after stroke. Subject: The subject was a 38-year-old man who had a stroke 2.5 years previously. Methods: A single-subject design with baseline, intervention, immediate postintervention, and 6-month postintervention phases was conducted. Dependent variables included 25-m sprint time, single-leg balance, running step width, running step length ratio, Stroke Impact Scale, 6-minute walk test, and lower-extremity strength (force-generating capacity). Results: At the 6-month postintervention phase, sprint speed, left single-leg balance, and step width changed significantly from the baseline phase. Step length ratio trended toward less symmetry but more consistency, and muscle strength improved more than 20% in 6 of 8 muscle groups in the involved lower extremity and 4 of 8 muscle groups in the uninvolved lower extremity. Discussion and Conclusion: Intensive task-specific training was feasible and effective for retraining running ability in the study subject. He returned to recreational running, which provided him with a greatly improved outlook and a better quality of life.

Effects of a repetitive gaming intervention on upper extremity impairments and function in persons with chronic stroke: a preliminary study.

Purpose: The purpose of this study was to examine the feasibility and effects of an upper extremity gaming system on impairments, activity and participation restrictions in persons with chronic stroke. Method: Nine participants with chronic (5.4 SD 3 years after stroke) upper extremity impairment due to stroke completed 18 sessions over 6 weeks with the Hand Dance Pro™ gaming system that included trunk restraint. Measures collected at pretest and posttest included three-dimensional motion analysis of paretic upper extremity reaching, Wolf Motor Function Test (WMFT) and Stroke Impact Scale (SIS). Data were analyzed across time, with effect sizes (Cohen’s d), and by categorizing participants with Fugl-Meyer Upper Extremity Motor Assessment scores (mild >50/66, moderate 26–50/66 and severe <26/66). Results: Statistically, significant improvements and medium-to-large effect sizes from pretest to posttest were found with ipsilateral reaching kinematic outcomes of movement duration, mean velocity and elbow excursion (p < 0.05). Participants with mild impairment demonstrated the greatest change in elbow excursion. No significant differences and small effect sizes were found for the WMFT and SIS. Conclusion: The gaming intervention with high repetitions of reaching to targets and trunk restraint was feasible and led to improvements in upper extremity movement kinematics in this group of participants with chronic stroke. Implications for Rehabilitation Persons with chronic stroke can tolerate a high number of repetitions (between 800 and 2000) of reaching for targets during 30 minutes of playing a video game. Gaming systems that incorporate multiple repetitions of reaching for targets with trunk restraint can improve movement patterns in the paretic upper extremity of persons with chronic stroke.

Motor and functional outcomes of a patient post-stroke following combined activity and impairment level training.

The purpose of this single-subject report was to determine the effect of a targeted training regimen aimed at improving motor and functional outcomes for a patient with chronic deficits after stroke. A 51-year-old woman with hemiparesis, 6 months post-stroke, participated in this prospective study. During the baseline, intervention, and immediate retention phases, performance was established by using repeated measures of four dependent variables: Fugl-Meyer assessment, Berg Balance Scale, 10-meter walk, and 6-minute walk. Two standard deviation band analyses were conducted on the four dependent variables with repeated measures. The Frenchay Activities Index and step length/single-limb support time measured at baseline and immediate retention were compared. During intervention, the participant was involved in a combined treatment protocol including body weight supported (BWS) treadmill training and strengthening exercises. Results indicated significant improvements in motor activity, balance, gait speed, and endurance. Progression was found in self-perceived participation. Although an improvement in step length symmetry occurred following training, a decrease in single-limb support time symmetry was found. BWS treadmill training, combined with strength training, significantly improved motor and functional performance in this participant with chronic deficits after stroke.