Steven L. Wolf

Reducing Frailty and Falls in Older Persons: An Investigation of Tai Chi and Computerized Balance Training

OBJECTIVE: To evaluate the effects of two exercise approaches, Tai Chi (TC) and computerized balance training (BT), on specified primary outcomes (biomedical, functional, and psychosocial indicators of frailty) and secondary outcomes (occurrence of falls).

The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques

OBJECTIVE To determine if short-term exercise reduces falls and fall-related injuries in the elderly. DESIGN A preplanned meta-analysis of the seven Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)--independent, randomized, controlled clinical trials that assessed intervention efficacy in reducing falls and frailty in elderly patients. All included an exercise component for 10 to 36 weeks. Fall and injury follow-up was obtained for up to 2 to 4 years. SETTING Two nursing home and five community-dwelling (three health maintenance organizations) sites. Six were group and center based; one was conducted at home. PARTICIPANTS Numbers of participants ranged from 100 to 1323 per study. Subjects were mostly ambulatory and cognitively intact, with minimum ages of 60 to 75 years, although some studies required additional deficits, such as functionally dependent in two or more activities of daily living, balance deficits or lower extremity weakness, or high risk of falling. INTERVENTIONS Exercise components varied across studies in character, duration, frequency, and intensity. Training was performed in one area or more of endurance, flexibility, balance platform, Tai Chi (dynamic balance), and resistance. Several treatment arms included additional nonexercise components, such as behavioral components, medication changes, education, functional activity, or nutritional supplements. MAIN OUTCOME MEASURES Time to each fall (fall-related injury) by self-report and/or medical records. RESULTS Using the Andersen-Gill extension of the Cox model that allows multiple fall outcomes per patient, the adjusted fall incidence ratio for treatment arms including general exercise was 0.90 (95% confidence limits [CL], 0.81, 0.99) and for those including balance was 0.83 (95% CL, 0.70, 0.98). No exercise component was significant for injurious falls, but power was low to detect this outcome. CONCLUSIONS Treatments including exercise for elderly adults reduce the risk of falls.

What Do Motor “Recovery” and “Compensation” Mean in Patients Following Stroke?

There is a lack of consistency among researchers and clinicians in the use of terminology that describes changes in motor ability following neurological injury. Specifically, the terms and definitions of motor compensation and motor recovery have been used in different ways, which is a potential barrier to interdisciplinary communication. This Point of View describes the problem and offers a solution in the form of definitions of compensation and recovery at the neuronal, motor performance, and functional levels within the framework of the International Classification of Functioning model.

Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS): A single-center RCT

Background: Constraint-induced movement therapy (CIMT) is among the most developed training approaches for motor restoration of the upper extremity (UE). Methods: Very Early Constraint-Induced Movement during Stroke Rehabilitation (VECTORS) was a single-blind phase II trial of CIMT during acute inpatient rehabilitation comparing traditional UE therapy with dose-matched and high-intensity CIMT protocols. Participants were adaptively randomized on rehabilitation admission, and received 2 weeks of study-related treatments. The primary endpoint was the total Action Research Arm Test (ARAT) score on the more affected side at 90 days after stroke onset. A mixed model analysis was performed. Results: A total of 52 participants (mean age 63.9 ± 14 years) were randomized 9.65 ± 4.5 days after onset. Mean NIHSS was 5.3 ± 1.8; mean total ARAT score was 22.5 ± 15.6; 77% had ischemic stroke. Groups were equivalent at baseline on all randomization variables. As expected, all groups improved with time on the total ARAT score. There was a significant time x group interaction (F = 3.1, p < 0.01), such that the high intensity CIT group had significantly less improvement at day 90. No significant differences were found between the dose-matched CIMT and control groups at day 90. MRI of a subsample showed no evidence of activity-dependent lesion enlargement. Conclusion: Constraint-induced movement therapy (CIMT) was equally as effective but not superior to an equal dose of traditional therapy during inpatient stroke rehabilitation. Higher intensity CIMT resulted in less motor improvement at 90 days, indicating an inverse dose-response relationship. Motor intervention trials should control for dose, and higher doses of motor training cannot be assumed to be more beneficial, particularly early after stroke.

Treatment Interventions for the Paretic Upper Limb of Stroke Survivors: A Critical Review

Despite a threefold increase in treatment interventions studies during the past 10 years, “best practice” for the rehabilitation of the paretic upper limb is still unclear. This review aims to lessen uncertainty in the management of the poststroke upper limb. Two separate searches of the scientific literature from 1966-2001 yielded 333 articles. Three referees, using strict inclusion and exclusion criteria, selected 68 relevant references. Cohort studies, randomized control trials, and systematic reviews were critically appraised. Mean randomized control trial quality (n = 33) was 17.1/27 (SD = 5.2, 95% CI = 15.2–19.0, range = 6–26). Mean quality of cohort studies (n = 29) was 11.8/27 (SD = 3.8, 95% CI = 10.4–13.2, range = 4–19). Quantitative syntheses were done using theZ-statistic. This systematic review indicated that sensorimotor training; motor learning training that includes the use of imagery, electrical stimulation alone, or combined with biofeedback; and engaging the client in repetitive, novel tasks can be effective in reducing motor impairment after stroke. Furthermore, careful handling, electrical stimulation, movement with elevation, strapping, and the avoidance of overhead pulleys could effectively reduce or prevent pain in the paretic upper limb. Rehabilitation specialists can use this research synthesis to guide their selection of effective treatment techniques for persons with impairments after stroke.

Associations of Demographic, Functional, and Behavioral Characteristics with Activity‐Related Fear of Falling Among Older Adults Transitioning to Frailty

OBJECTIVES: To determine, in a cohort of older individuals transitioning to frailty (defined by Speechley and Tinetti, 1991) who have previously fallen, whether there are significant associations between demographic, functional, and behavioral characteristics and activity‐related fear of falling, using both the Falls Efficacy Scale (FES) and the Activities‐Specific Balance Confidence Scale (ABC).

Efficacy of a child‐friendly form of constraint‐induced movement therapy in hemiplegic cerebral palsy: a randomized control trial

Constraint-induced (CI) movement therapy is a promising therapy for improving upper limb function in adults after stroke. It involves restraint of the non-involved limb and extensive movement practice with the involved limb. In this study, a single-blinded, randomized, control study was performed to examine the efficacy of CI therapy, modified to be child friendly, in children with hemiplegic cerebral palsy (CP). Twenty-two children (8 females, 14 males; mean age 6 y 8 mo [SD 1 y 4 mo]; range 4-8 y) were randomized to either an intervention group (n=11) or a delayed treatment control group (n=11). Children wore a sling on their non-involved upper limb for 6 hours per day for 10 out of 12 consecutive days and were engaged in play and functional activities. Children in the treatment group demonstrated improved movement efficiency and dexterity of the involved upper extremity, which were sustained through the 6-month evaluation period, as measured by the Jebsen-Taylor Test of Hand Function and fine motor-subtests of the Bruininks-Oseretsky Test of Motor Proficiency (p<0.05 in both cases). Initial severity of hand impairment and testing compliance were strong predictors of improvement. Caregivers reported significant increases in involved limb frequency of use and quality of movement. However, there was no change in strength, sensibility, or muscle tone (p>0.05 in all cases). Results suggest that for a carefully selected subgroup of children with hemiplegic CP, CI therapy modified to be child-friendly, appears to be efficacious in improving movement efficiency of the involved upper extremity.

The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke.

The Wolf Motor Function Test (WMFT) has been used in rehabilitation studies of chronic stroke patients, but until now its psychometric properties have not been evaluated in patients with subacute stroke. Two hundred twenty-nine participants with subacute stroke (3-9 months postinjury) at 7 research sites met inclusion criteria for the EXCITE Trial and were randomized into immediate or delayed (by 1 year) constraint-induced movement therapy treatment. All evaluations were undertaken by assessors standardized in the administration of the WMFT and masked to treatment designation. Participants were also assessed using the Fugl Meyer Motor Assessment (FMA). Delayed group members had measurements repeated 2 weeks following baseline assessment to determine learning or exposure effects. The results demonstrate that the WMFT differentiated higher from lower functioning participants across sites; scores were uninfluenced by hand dominance or affected side. Women exhibited slower performance times than men. The Functional Ability scale (FAS) portion of the WMFT also revealed lower scores among lower functioning participants and women. Minimal changes were observed after repeating the WMFT among delayed group participants 2 weeks later. The FMA revealed similar results when the total group was divided into higher and lower functional levels at its midpoint score of 33. The WMFT discriminates higher from lower functioning participants tested across research sites. Comparable findings using the FMA support the criterion validity of the WMFT.

Constraint Induced Movement Techniques To Facilitate Upper Extremity Use in Stroke Patients.

A new therapeutic approach to the rehabilitation of movement after stroke, termed constraint-induced (CI) movement therapy, has been derived from basic research with monkeys given somatosensory deafferentation. CI movement therapy consists of a family of therapies; their common element is that they induce stroke patients to greatly increase the use of an affected upper extremity for many hours a day over a period of 10 to 14 consecutive days. The signature intervention involves motor restriction of the contralateral upper extremity in a sling and training of the affected arm. The therapies result in large changes in amount of use of the affected arm in the activities of daily living outside of the clinic that have persisted for the 2 years measured to date. Patients who will benefit from Cl therapy can be identified before the beginning of treatment.

Constraint-induced movement therapy results in increased motor map area in subjects 3 to 9 months after stroke.

Background. Constraint-induced movement therapy (CIMT) has received considerable attention as an intervention to enhance motor recovery and cortical reorganization after stroke. Objective. The present study represents the first multi-center effort to measure cortical reorganization induced by CIMT in subjects who are in the subacute stage of recovery. Methods. A total of 30 stroke subjects in the subacute phase (>3 and <9 months poststroke) were recruited and randomized into experimental (receiving CIMT immediately after baseline evaluation) and control (receiving CIMT after 4 months) groups. Each subject was evaluated using transcranial magnetic stimulation (TMS) at baseline, 2 weeks after baseline, and at 4-month follow-up (ie, after CIMT in the experimental groups and before CIMT in the control groups). The primary clinical outcome measure was the Wolf Motor Function Test. Results. Both experimental and control groups demonstrated improved hand motor function 2 weeks after baseline. The experimental group showed significantly greater improvement in grip force after the intervention and at follow-up (P = .049). After adjusting for the baseline measures, the experimental group had an increase in the TMS motor map area compared with the control group over a 4-month period; this increase was of borderline significance (P = .053). Conclusions. Among subjects who had a stroke within the previous 3 to 9 months, CIMT produced statistically significant and clinically relevant improvements in arm motor function that persisted for at least 4 months. The corresponding enlargement of TMS motor maps, similar to that found in earlier studies of chronic stroke subjects, appears to play an important role in CIMT-dependent plasticity.