Yocheved Laufer

Standing Balance and Functional Recovery of Patients with Right and Left Hemiparesis in the Early Stages of Rehabilitation

The objective was to determine the effects of the side of brain lesion on recovery of functional abilities and balance control among subjects 2 months following a stroke. There were 104 patients admitted consecutively to a geriatric rehabilitation center following their first stroke to the anterior brain circulation who were followed for 2 months. Fifteen age-matched individuals with no known impairments served as the control group. Functional ability was assessed with the Barthel Index and the Functional Ambulation Category. Posturographic testing was used to determine total sway and symmetry of weight distribution with eyes open and closed. Tests were performed 1 and 2 months poststroke. The results show that lesion side affects the recovery of independent stance 2 months following a stroke, with more patients with right hemiparesis able to reach this milestone. However, no difference was found in functional ability and balance control between patients with left and right hemiparesis who are able to stand independently by 1 month poststroke. Function and mobility improve during the 2nd month of rehabilitation (P = 0.001), but stance unsteadiness and asymmetry do not. The side of brain lesion seems to affect recovery of independent stance with an advantage to patients with right hemiparesis. However, there is no difference between balance control of individuals with left versus right hemiparesis in patients who reach independent stance by the end of the 1st month following their stroke.

Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights

Objective: To examine and compare the effect of stepping on stairs of various heights on lower extremity weight bearing in hemiparetic patients. Setting: Flieman Geriatric Rehabilitation Hospital, Haifa, Israel. Subjects: Fifteen ambulatory hemiparetic patients following an acute cerebrovascular accident, and 16 age-matched healthy controls. Interventions: Each subject was tested twice on two consecutive days in five weight-bearing positions which included level stance and stepping with either leg on 10-cm- and 17-cm-high steps. Data concerning weight distribution on the lower extremities were collected by two computerized forceplates. Main outcome measure: Weight borne by each foot expressed as percentage of overall body weight. Results: In the attempted symmetrical level stance, the percentage of body weight borne by the paretic limb of the stroke patients was significantly lower than that of the nonparetic limb. Placing one foot on a step induced a weight shift to the foot placed on the floor regardless of step height. Weight shifting to the paretic limb was, however, significantly lower than to the nonparetic limb. Weight shifting to the nonparetic limb was significantly lower than to the corresponding limb of healthy individuals. Step height had no significant effect on weight distributions on the feet. Conclusions: Raising a foot on a step appears to be an appropriate strategy for weight shift training of stroke patients. Since weight shifting to both the paretic and nonparetic limb of stroke patients is impaired, treatment strategies should include training in weight shifting to both lower extremities.

Effect of pulsed short-wave diathermy on pain and function of subjects with osteoarthritis of the knee: a placebo-controlled double-blind clinical trial

Objective: To examine the effects of pulsed short-wave diathermy (PSWD), delivered at an intensity sufficient to induce a thermal sensation and at an athermal intensity, in comparison with a placebo short-wave diathermy treatment, on reported pain, stiffness and functional ability and on mobility performance of patients with osteoarthritis of the knee. Design: A placebo-controlled double-blind trial with sequential allocation of patients to different treatment groups. Setting: Outpatient physiotherapy department. Subjects: One hundred and three consecutive patients, mean age 73.7 (9 = 6.6) years with osteoarthritis of one or both knees for at least three months. Interventions: All participants received three 20-min-long treatments per week for three weeks. One group received PSWD with mean power of 18 W (thermal effect), one group received PSWD with mean power of 1.8 W (athermal effect), and one group received sham short-wave diathermy treatment. Patients were assessed before the initial treatment, immediately following the last treatment, and at a three-month follow-up. Main measures: Outcome measures included the WOMAC Osteoarthritis Index, which assessed reported pain, stiffness, and functional ability, and four measures of mobility performance: Timed Get Up and Go test (TGUG), stair-climbing, stairdescending and a 3-min walk. Results: A difference across time was observed for the pain and stiffness categories of the WOMAC Osteoarthritis Index (p < 0.033 and p < 0.008, respectively), with no differences between groups. No other significant differences across time or between groups were observed in any of the other measures. Conclusion: The findings do not demonstrate pulsed short-wave diathermy, as it is utilized in clinical settings, to be effective in the treatment of osteoarthritis of the knee.

Light touch and center of mass stability during treadmill locomotion

PURPOSE To study the contributions of light fingertip touch on an earth-referenced object to body stability during treadmill locomotion. METHOD Twenty young healthy adults were tested in two blocks of five testing conditions while walking on the treadmill at 3 km/h. In each condition, subjects were tested with eyes open (EO) and with eyes closed (EC). In each block, four separate conditions of heavy (H) or light (L) touch to either a left or to a right force sensor mounted on the respective side rail, as well as one condition of no touch (N), were randomly applied. The 3D positions of the center of mass (COM) and the midpoint of the posterior aspect of each leg were monitored via a kinematic ultrasonic system, while the anterior-posterior (AP) acceleration of the COM was measured with a uniaxial linear accelerometer. RESULTS Light touch had a similar stabilizing effect as vision and as heavy touch on COM sway. Thus, COM sway and AP acceleration were comparable in conditions of eyes open and eyes closed as long as touch was applied. Conversely, without vision and touch, subjects drifted backwards, with complete disruption of the coordinated stepping pattern. CONCLUSIONS Somatosensory fingertip input from an external reference provides spatial orientation, which, similar to vision, enables the sustaining of body stability during treadmill walking.

Effect of burst frequency and duration of kilohertz-frequency alternating currents and of low-frequency pulsed currents on strength of contraction, muscle fatigue, and perceived discomfort.

Background: Low-frequency pulsed currents (LPCs) and kilohertz-frequency alternating currents (KACs) are used clinically to augment muscle contractions. Treatment effectiveness may be enhanced by selecting stimulation parameters that evoke the strongest contractions with minimal discomfort and fatigue. Objective: The objective of this study was to compare maximally induced strength (force-producing capacity) of contractions, muscle fatigue, and discomfort associated with an LPC and with 3 KACs differing in frequency and duration of burst modulation. Design: This was a repeated-measures trial, with randomized order of current presentation. Setting: The study was conducted in the physical therapy laboratory at the University of Haifa. Subjects: Twenty-six volunteers without impairments, with a mean age of 27.4 years (SD=5.0, range=21–45), participated. Intervention: All currents were applied in separate sessions to the wrist extensors of each subject. Currents consisted of an LPC with a 50-Hz pulse frequency and 3 KACs with a 2.5-kHz carrier frequency, including the “Russian current” (RC) burst modulated at 50 Hz with 25 cycles per burst and 2 currents burst modulated at 20 or 50 Hz with 10 cycles per burst. Measurement: The maximal electrically induced isometric force, the force integral of 21 electrically induced consecutive contractions, and the degree of discomfort were recorded. Results: Force of contraction was not affected by type of current. The LPC was least fatiguing, and the RC was most fatiguing, with the 2 other KACs having an intermediate effect. Degree of discomfort was higher with the KAC modulated at 20 Hz. Conclusions: When comfort, strength, and fatigue are considered jointly, the LPC is advantageous. Electrically induced fatigue is affected by the number of cycles per second, rather than the number of bursts per second.

Does Sensory Transcutaneous Electrical Stimulation Enhance Motor Recovery Following a Stroke? A Systematic Review

Background. Somatosensory input may lead to long-lasting cortical plasticity enhanced by motor recovery in patients with neurological impairments. Sensory transcutaneous electrical stimulation (TENS) is a relatively risk-free and easy-to-implement modality for rehabilitation. Objective. The authors systematically examine the effects of sensory TENS on motor recovery after stroke. Methods. Eligible randomized or quasi-randomized trials were identified via searches of computerized databases. Two assessors reviewed independently the eligibility and methodological quality of the retrieved articles. Results. In all, 15 articles satisfied the inclusion criteria. Methodological quality was generally good, with a mean (standard deviation) PEDro score of 6.7/10 (1.2). Although the majority of studies reported significant effects on at least 1 outcome measure, effect sizes were generally small. Meta-analysis could not be performed for the majority of outcome measures because of variability between studies and insufficient data. A moderate effect was determined for force production of the ankle dorsiflexors and for the Timed Up and Go test. Conclusions. Sensory stimulation via TENS may be beneficial to enhance aspects of motor recovery following a stroke, particularly when used in combination with active training. Because of the great variability between studies, particularly in terms of the timing of the intervention after the stroke, the outcome measures used, and the stimulation protocols, insufficient data are available to provide guidelines about strategies and efficacy.

Gait in individuals with chronic hemiparesis: one-year follow-up of the effects of a neuroprosthesis that ameliorates foot drop.

Purpose: Foot drop is a common cause of gait impairment in individuals with hemiparesis. The objective of this study was to determine the short-term and long-term effects on functional gait of a neuroprosthesis that provides functional electrical stimulation (FES) to correct footdrop. Methods: Sixteen individuals (mean age, 55.0 ± 14.6 years) with chronic hemiparesis (mean years since insult, 5.3 ± 4.8) were assessed immediately before receiving the neuroprosthesis and two months and one year after using the device. Both follow-up assessments were conducted with FES operating; the one-year follow-up also assessed gait without FES. Outcome measures were gait velocity on an even surface during a 10-m walk, during a six-minute walk, over obstacles, and over a carpet. Foot switches used during the six-minute walk determined stance time, stride time variability, and gait asymmetry. The effect of time and the one-year carryover effect on gait without FES were determined, with significance set at P = 0.05. Results: The neuroprosthesis had a significant short-term and long-term effect on most measured variables. Thus, mean 10-m walk gait velocity improved in two months from 0.67 m/sec to 0.86 m/sec and continued to increase to 1.06 m/sec by the one-year assessment. A carryover effect on gait velocity and stance time without FES were also noted. The 10-m gait velocity without the neuroprosthesis increased by 23.8% by the one-year follow-up assessment. Conclusions: The neuroprosthesis appears to improve gait performance, and gains were further enhanced over time and carried over to gait even without FES. These results suggest orthotic and therapeutic effects on footdrop after prolonged use of the neuroprosthesis.

Effects of a foot drop neuroprosthesis on functional abilities, social participation, and gait velocity.

Laufer Y, Hausdorff JM, Ring H: Effects of a foot drop neuroprosthesis on functional abilities, social participation, and gait velocity. Objective:To determine the long-term effects of a neuroprosthesis used to correct a foot drop on functional ability in activities of daily living, social participation, and gait velocity. Design:Prospective, single group, repeated measures 1-yr follow-up of 16 patients (aged 55 ± 14.6 yrs) with chronic hemiparesis who used a neuroprosthesis for 1 yr and were available for follow-up. Outcome measures included the Short Version of the Stroke Impact Scale, the Participation domain of the Stroke Impact Scale, and the gait velocity. Results:Significant increases of 18.0% in physical functioning and of 25.2% in participation in community life were attained 2 mos after the application of the neuroprosthesis. The gains were maintained at the 1-yr follow-up. Gait velocity increased significantly by 29.2% by 2 mos, with significant further increases of 22.6% observed at the 1-yr follow-up. Conclusions:Use of the studied neuroprosthesis to correct foot drop significantly enhanced functional abilities, social reintegration, and gait velocity. These results support the prolonged use of the neuroprosthesis in patients with chronic hemiparesis.

Does a wii-based exercise program enhance balance control of independently functioning older adults? A systematic review

Background Exercise programs that challenge an individual’s balance have been shown to reduce the risk of falls among older adults. Virtual reality computer-based technology that provides the user with opportunities to interact with virtual objects is used extensively for entertainment. There is a growing interest in the potential of virtual reality-based interventions for balance training in older adults. This work comprises a systematic review of the literature to determine the effects of intervention programs utilizing the Nintendo Wii console on balance control and functional performance in independently functioning older adults. Methods Studies were obtained by searching the following databases: PubMed, CINAHL, PEDro, EMBASE, SPORTdiscus, and Google Scholar, followed by a hand search of bibliographic references of the included studies. Included were randomized controlled trials written in English in which Nintendo Wii Fit was used to enhance standing balance performance in older adults and compared with an alternative exercise treatment, placebo, or no treatment. Results Seven relevant studies were retrieved. The four studies examining the effect of Wii-based exercise compared with no exercise reported positive effects on at least one outcome measure related to balance performance in older adults. Studies comparing Wii-based training with alternative exercise programs generally indicated that the balance improvements achieved by Wii-based training are comparable with those achieved by other exercise programs. Conclusion The review indicates that Wii-based exercise programs may serve as an alternative to more conventional forms of exercise aimed at improving balance control. However, due to the great variability between studies in terms of the intervention protocols and outcome measures, as well as methodological limitations, definitive recommendations as to optimal treatment protocols and the potential of such an intervention as a safe and effective home-based treatment cannot be made at this point.

Effects of one-point and four-point canes on balance and weight distribution in patients with hemiparesis

Objective: To examine the effects of one-point and four-point canes on postural sway and on the distribution of weight between the lower extremities and the walking aids in hemiparetic patients. Setting: Flieman Geriatric Rehabilitation Hospital, Haifa, Israel. Subjects: Thirty hemiparetic patients following a unilateral stroke, with moderate functional impairment, and 20 age-matched healthy subjects. Intervention: Subjects were tested on two forceplates, which were placed at a 30° angle from each other with the heel end of the plates separated by 3 cm. Each subject was tested under three conditions: with no cane, with a one-point cane, and with a four-point cane. Testing time was 30 seconds, and order of testing was randomized. Outcome measures: Weight borne by the lower extremities and by the walking aids expressed as a percentage of overall body weight, and Sway Index indicating vertical pressure ‘uctuations over both feet. Results: In both subject groups, the one-point cane did not reduce sway signi”cantly in comparison with no cane, while the four-point cane reduced sway signi”cantly in comparison with both no cane and one-point cane. Neither cane type affected weight-bearing on the paretic leg, while signi”cantly reducing weight-bearing on the uninvolved extremity. Mean percentage of body weight on the four-point cane was signi”cantly higher than on the one-point cane Conclusions: A four-point cane increases stability of moderately involved hemiparetic patients during stance more than a one-point cane. The noted shift of weight toward the walking aid does not adversely affect weight-bearing on the paretic limb.