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Showing papers in "Journal of Neurologic Physical Therapy in 2010"


Journal ArticleDOI
TL;DR: Vestibular rehabilitation should be considered in the management of individuals post concussion who have dizziness and gait and balance dysfunction that do not resolve with rest, indicating that vestibular Rehabilitation may equally benefit both children and adults.
Abstract: Background and Purpose: Management of dizziness and balance dysfunction is a major challenge after concussion. The purpose of this study was to examine the effect of vestibular rehabilitation in reducing dizziness and to improve gait and balance function in people after concussion. Methods: A retrospective chart review of 114 patients (67 children aged 18 years and younger [mean, 16 years; range, 8 –18 years]; 47 adults older than 18 years [mean, 41 years; range, 19 –73 years]) referred for vestibular rehabilitation after concussion was performed. At the time of initial evaluation and discharge, recordings were made of outcome measures of self-report (eg, dizziness severity, Activities-specific Balance Confidence Scale, and Dizziness Handicap Inventory) and gait and balance performance (eg, Dynamic Gait Index, gait speed, and the Sensory Organization Test). A mixed-factor repeated-measures analysis of variance was used to test whether there was an effect of vestibular rehabilitation therapy and age on the outcome measures. Results: The median length of time between concussion and initial evaluation was 61 days. Of the 114 patients who were referred, 84 returned for at least 1 visit. In these patients, improvements were observed in all self-report, gait, and balance performance measures at the time of discharge (P .05). Children improved by a greater amount in dizziness severity (P .005) and conditions 1 (eyes open, fixed support) and 2 (eyes closed, fixed support) of the Sensory Organization Test (P .025). Discussion: Vestibular rehabilitation may reduce dizziness and improve gait and balance function after concussion. For most measures, the improvement did not depend on age, indicating that vestibular rehabilitation may equally benefit both children and adults.

387 citations


Journal ArticleDOI
TL;DR: Moderate evidence is found that balance performance can be improved following individual, “one-on-one” balance training for participants in the acute stage of stroke, and either one- on-one balance training or group therapy for participants with subacute or chronic stroke.
Abstract: Background and purpose Stroke is a leading cause of long-term disability, and impaired balance after stroke is strongly associated with future function and recovery. Until recently there has been limited evidence to support the use of balance training to improve balance performance in this population. Information about the optimum exercise dosage has also been lacking. This review evaluated recent evidence related to the effect of balance training on balance performance among individuals poststroke across the continuum of recovery. On the basis of this evidence, we also provide recommendations for exercise prescription in such programs. Methods A systematic search was performed on literature published between January 2006 and February 2010, using multiple combinations of intervention (eg, "exercise"), population (eg, "stroke"), and outcome (eg, "balance"). Criteria for inclusion of a study was having at least 1 standing balance exercise in the intervention and 1 study outcome to evaluate balance. Results Twenty-two published studies met the inclusion criteria. We found moderate evidence that balance performance can be improved following individual, "one-on-one" balance training for participants in the acute stage of stroke, and either one-on-one balance training or group therapy for participants with subacute or chronic stroke. Moderate evidence also suggests that in the acute stage, intensive balance training for 2 to 3 times per week may be sufficient, whereas exercising for 90 minutes or more per day, 5 times per week may be excessive. Discussion and conclusions This review supports the use of balance training exercises to improve balance performance for individuals with moderately severe stroke. Future high-quality, controlled studies should investigate the effects of balance training for individuals poststroke who have severe impairment, additional complications/comorbidities, or specific balance lesions (eg, cerebellar or vestibular). Optimal training dosage should also be further explored. Studies with long-term follow-up are needed to assess outcomes related to participation in the community and reduction of fall risk.

91 citations


Journal ArticleDOI
TL;DR: A battery of vestibular-visual-cognitive tests seems to be reasonable to establish initial status and to evaluate participant progress associated with participation in VPT, and data suggest meaningful improvement in TF and DVA after 8 weeks of treatment.
Abstract: BACKGROUND AND PURPOSE:: Traumatic brain injury secondary to blast exposure is a significant international concern and a growing rehabilitation issue. Our objective was to determine whether a novel battery of vestibular-visual-cognitive interaction tests provides objective data to document functioning, and the changes in functioning associated with vestibular physical therapy (VPT) treatment, in individuals with blast-induced balance disorder. METHODS:: Eighty-two individuals with blast-induced mild traumatic brain injury were evaluated at baseline using a set of vestibular-visual-cognitive tests. Testing was repeated at 4-week intervals after beginning VPT. The tests included static visual acuity, perception time, target acquisition, target following (TF), dynamic visual acuity (DVA), and gaze stabilization tests. The VPT program consisted of exercise procedures that targeted the vestibulo-ocular reflex, cervico-ocular reflex, and depth perception. Somatosensory balance exercises, dynamic gait, and aerobic function exercises were also included. Participants attended VPT twice weekly for 1-hour appointments and were instructed to perform the exercises at home on other days. Mean test values were determined and compared with normative values previously collected in our laboratory from individuals without vestibular dysfunction. RESULTS:: Mean participant pre-VPT measures for perception time and target acquisition were similar to normative values, and there was no significant change in these measures. Initially, TF and DVA scores were below normative levels but returned to normative levels after 8 weeks of VPT. Gaze stabilization scores were below normative levels pre-VPT but improved by the time of the week 8 evaluation. CONCLUSIONS:: This battery of vestibular-visual-cognitive tests seems to be reasonable to establish initial status and to evaluate participant progress associated with participation in VPT. Our data suggest meaningful improvement in TF and DVA after 8 weeks of treatment. A treatment period of 12 weeks or longer may be required for gaze stabilization scores to return to normative values. Language: en

87 citations


Journal ArticleDOI
TL;DR: Improvements in step length symmetry were observed following training and these improvements were maintained 1 month later, suggesting that after stroke, short-term adaptation can be capitalized on through repetitive practice and can lead to longer-term improvements stroke.
Abstract: Background/Purpose Even after rehabilitation, many individuals with stroke have residual gait deviations and limitations in functional walking. Applying the principles of motor adaptation through a split-belt treadmill walking paradigm can lead to short-term improvements in step length asymmetry after stroke. The focus of this case study was to determine whether it is possible to capitalize on these improvements for long-term gain.

82 citations


Journal ArticleDOI
TL;DR: Evidence is provided that in older adults with symptoms of dizziness and no documented Vestibular deficits, the addition of vestibular-specific gaze stability exercises to standard balance rehabilitation results in greater reduction in fall risk.
Abstract: Background and purpose The purpose of this study was to determine whether the addition of gaze stability exercises to balance rehabilitation would lead to greater improvements of symptoms and postural stability in older adults with normal vestibular function who reported dizziness. Methods Participants who were referred to outpatient physical therapy for dizziness were randomly assigned to the gaze stabilization (GS) group (n = 20) or control (CON) group (n = 19). Dizziness was defined as symptoms of unsteadiness, spinning, a sense of movement, or lightheadedness. Participants were evaluated at baseline and discharge on symptoms, balance confidence, visual acuity during head movement, balance, and gait measures. The GS group performed vestibular adaptation and substitution exercises designed to improve gaze stability, and the CON group performed placebo eye exercises designed to be vestibular neutral. In addition, both groups performed balance and gait exercises. Results There were no baseline differences (P > .05) between the GS and CON groups in age, sex, affect, physical activity level, or any outcome measures. Both groups improved significantly in all outcome measures with the exception of perceived disequilibrium. However, there was a significant interaction for fall risk as measured by Dynamic Gait Index (P = .026) such that the GS group demonstrated a significantly greater reduction in fall risk compared with the CON group (90% of the GS group demonstrated a clinically significant improvement in fall risk versus 50% of the CON group). Discussion and conclusions This study provides evidence that in older adults with symptoms of dizziness and no documented vestibular deficits, the addition of vestibular-specific gaze stability exercises to standard balance rehabilitation results in greater reduction in fall risk.

64 citations


Journal ArticleDOI
TL;DR: The 14-item FIST is reliable and valid in adults following acute stroke and studies of intra- or intertester reliability and evaluative validity studies including applications to other patient populations with sitting balance dysfunction are now necessary.
Abstract: Background and Purpose: Research studies indicate that sitting balance ability is a substantial predictor of functional recovery after stroke. There are no gold standards for sitting balance assessment, and commonly used balance measures do not isolate sitting balance abilities. This study was designed to develop, pilot test, and analyze reliability and validity of a short test of functional sitting balance in patients following acute stroke. Methods: The Function In Sitting Test (FIST) was constructed after reviewing balance measures and interviewing 15 physical therapists. A written survey regarding the FIST items and scoring scales was designed, pilot tested, and sent to 12 additional physical therapists with expertise in measurement construction, balance assessment, and/or research. Thirty-one adults who were within 3 months following stroke participated in this study. Results: The expert panel survey was returned by 83.3% of the participants. Survey feedback and weighted rank analysis reduced the number of FIST items from 26 to 17. After subject testing, Item Response Theory analysis eliminated 3 additional items. The person separation index was 0.978 and the coefficient alpha was 0.98, indicating high internal consistency of the FIST. The Item Response Theory analysis confirmed content and construct validity. Concurrent validity was supported by high correlations to the modified Rankin Scale, static balance indices, and dynamic balance grades. Discussion and Conclusions: The 14-item FIST is reliable and valid inadultsfollowingacutestroke.Studiesofintra-orintertesterreliability and evaluative validity studies including applications to other patient populations with sitting balance dysfunction are now necessary.

61 citations


Journal ArticleDOI
TL;DR: The aim of this focused review is to provide an overview of recent findings investigating responses of individuals with vestibular deficits to a customized exercise program incorporating exposure to optokinetic stimuli via a “high-tech” visual environment rotator or a "low-tech" DVD with and without supervision.
Abstract: Individuals with vestibular dysfunction may experience visual vertigo (VV), in which symptoms are provoked or exacerbated by excessive or disorienting visual stimuli (eg, supermarkets). Individuals with VV are believed to be overly reliant on visual input for balance (ie, visually dependent). VV can significantly improve when customized vestibular rehabilitation exercises are combined with exposure to optokinetic stimuli. However, the frequency of treatment sessions (twice weekly for 8 weeks) and the equipment used (expensive and space consuming) make it difficult to incorporate these techniques into everyday clinical practice where exercises may be practiced unsupervised. The aim of this focused review is to provide an overview of recent findings investigating (a) responses of individuals with vestibular deficits to a customized exercise program incorporating exposure to optokinetic stimuli via a "high-tech" visual environment rotator or a "low-tech" DVD with and without supervision, and (b) the mechanism of recovery. Optokinetic stimulation will also be discussed in relation to other new innovations in vestibular rehabilitation techniques and future work.

59 citations


Journal ArticleDOI
TL;DR: Head movement, which is required by both exercise interventions, rather than the specific type of exercise, may be the critical factor underlying the observed improvements in motion sensitivity and DVA.
Abstract: Background and Purpose The efficacy of both habituation and adaptation exercise interventions in the treatment of unilateral vestibular hypofunction has been demonstrated by prior studies. The purpose of this paper is to describe the preliminary results of an ongoing study that compares the effects of these two different exercise approaches on outcomes related to vestibular function.

58 citations


Journal ArticleDOI
TL;DR: The data support the conclusion that the KVIQ is a reliable and valid test for indexing mental imagery ability in individuals with PD and are a good choice for clinicians who may wish to index motor imagery ability before implementing imagery as a rehabilitation intervention.
Abstract: Background and Purpose:It is not known whether individuals with Parkinson disease (PD) can practice movements mentally. Before this question can be addressed, a reliable imagery assessment tool must be established. The recently developed Kinesthetic and Visual Imagery Questionnaire (KVIQ) is valid f

54 citations


Journal ArticleDOI
TL;DR: In the rehabilitation of reaching function in individuals with stroke, the use of an auditory signaling device appears to be a feasible alternative to imposed trunk stabilization.
Abstract: Background and purpose For individuals poststroke, reaching with the paretic limb is often associated with compensatory trunk movement due to limited active arm movement. We conducted a pilot feasibility study to compare the effects of task-related training on reaching with the paretic limb using each of 2 different techniques for providing feedback about trunk position. We hypothesized that the use of an auditory feedback signal in response to pressure (Sensor group) would be more effective than feedback arising from an external device used to restrain the trunk (Stabilizer group). Methods Sixteen individuals with chronic stroke were enrolled. Participants had scores of 20 to 44 on the Upper-Arm subsection of the Fugl-Meyer Scale and demonstrated some trunk movement during the pretest assessment of the Reaching Performance Scale (RPS). Participants were randomly assigned to either the Sensor or the Stabilizer group. Both groups participated in 12 structured rehabilitation sessions with equal time duration, number of repetitions, and task-related training activities. Feedback was systematically and equally faded for all training. Clinical outcome measures were assessed prior to and following training. Results Both forms of feedback were associated with changes in active shoulder motion, Wolf Motor Function Test (WMFT), Fugl-Meyer Scale and RPS (near and far) as determined by a 2 x 2 (Group x Time) analysis of variance. An interaction of RPS-near revealed that the Sensor group improved more than the Stabilizer group for this measure. However, sample size may not have been sufficient to identify differences in other measures. Discussion Although both forms of feedback led to improvements in the majority of outcome measures, the auditory feedback signal was associated with greater improvement in RPS-near scores. Conclusion In the rehabilitation of reaching function in individuals with stroke, the use of an auditory signaling device appears to be a feasible alternative to imposed trunk stabilization. Additional studies with larger sample sizes are needed to determine whether one approach is superior to the other.

54 citations


Journal ArticleDOI
TL;DR: Both unimanual and bimanual MP training improve hand function and sensation in individuals with tetraplegia when combined with SS, and functional changes were accompanied by a strong trend toward increased corticomotor map area.
Abstract: Background and Purpose:In individuals with cervical spinal cord injury (SCI), damage to spinal pathways results in deficits of hand function; maladaptive cortical changes further impair function. Unimanual massed practice (MP) training with somatosensory stimulation (SS) has been shown to improve ha

Journal ArticleDOI
TL;DR: It is suggested that vibrotactile tilt feedback of subjects' body motion can be used effectively by physical therapists for balance rehabilitation and vestibular or balance prostheses.
Abstract: Background and Purpose: Balance rehabilitation and vestibular or balance prostheses are both emerging fields that have a potential for synergistic interaction. This article reviews vibrotactile prosthetic devices that have been developed to date and ongoing work related to the application of vibrotactile feedback for enhanced postural control. A vibrotactile feedback device developed in the author’s laboratory is described. Methods: Twelve subjects with vestibular hypofunction were tested on a platform that moved randomly in a plane, while receiving vibrotactile feedback in the anteroposterior direction. The feedback allowed subjects to significantly decrease their anteroposterior body tilt but did not change mediolateral tilt. A tandem walking task performed by subjects with vestibulopathies demonstrated a reduction in their mediolateral sway due to vibrotactile feedback of mediolateral body tilt, after controlling for the effects of task learning. Published findings from 2 additional experiments conducted in the laboratories of collaborating physical therapists are summarized. Results: The Dynamic Gait Index scores in community-dwelling elderly individuals who were prone to falls were significantly improved with the use of mediolateral body tilt feedback. Discussion and Conclusions: Although more work is needed, these results suggest that vibrotactile tilt feedback of subjects’ body motion can be used effectively by physical therapists for balance rehabilitation. A preliminary description of the third-generation device that has been reduced from a vest format to a belt format is described to demonstrate the progressive evolution from research to clinical application.

Journal ArticleDOI
TL;DR: The results of this project will serve as a preliminary work for the development of a clinical biomarker for PD that may help to identify subtle deficits in fine motor control early in the disease process and facilitate tracking of disease progression with time.
Abstract: BACKGROUND AND PURPOSE Motor symptoms of Parkinson's disease (PD) are typically assessed using clinical scales such as the Unified Parkinson's Disease Rating Scale, but clinical scales are insensitive to subtle changes early in the disease process. The goal of this project was to use current sensing technology to develop a quantitative assessment tool to document fine motor deficits in PD based on the ability to control grip force output. The assessment was designed to challenge deficits commonly encountered as a result of PD, including dual-task performance of a motor task and a cognitive task simultaneously. METHODS Two force sensors were used to measure the isometric pinch grip force between the thumb and index finger in 30 individuals with PD and 30 control participants of similar age without disability. Participants performed a target force tracking task with each of two different target waveforms (sinusoidal or pseudorandom) under each of three different cognitive load conditions (none, subtract 1, and subtract 3). Dependent variables calculated from the force sensor data included root mean square error, tremor integral, and lag. RESULTS In general, individuals with PD showed significantly less accuracy in generating the target forces as shown by larger root mean square error compared with controls (P < 0.001). They also showed greater amounts of tremor and lag compared with controls (P = 0.001 and <0.001, respectively). Deficits were more pronounced during the cognitive multitasking component of the test. DISCUSSION AND CONCLUSIONS These results will serve as a preliminary work for the development of a clinical biomarker for PD that may help to identify subtle deficits in fine motor control early in the disease process and facilitate tracking of disease progression with time.

Journal ArticleDOI
TL;DR: The results suggest that only certain aspects of turning may be responsive to anti-Parkinson medications, and additional rehabilitative approaches to address turning are needed because turning may not be effectively addressed by pharmacologic approaches.
Abstract: Background and Purpose: People with Parkinson’s disease often have difficulty executing turns. To date, most studies of turning have examined subjects ON their anti-Parkinson medications. No studies have examined what specific aspects of turning are modified or remain unchanged when medication is administered. The purpose of this study was to determine how anti-Parkinson medications affect temporal and spatial features of turning performance in individuals with Parkinson’s disease. Methods: We examined turning kinematics in 10 people with Parkinson’s disease who were assessed both OFF and ON medication. For both conditions, participants were evaluated with the Unified Parkinson’s Disease Rating Scale motor subscale, rated how well their medication was working on a visual analog scale, and performed straight-line walking and 180-degree in-place turns. We determined the average walking velocity, time and number of steps to execute turns, sequence of yaw rotation onsets of the head, trunk, and pelvis during turns, and amplitudes of yaw rotation of the head, trunk, and pelvis during turns. Results: Medication significantly improved the Unified Parkinson’s Disease Rating Scale scores (P 0.02), visual analog scale ratings (P 0.03), and walking velocity (P 0.02). Although improvements in turning were not statistically significant, medication did reduce the time and number of steps required to turn, slightly increased the amplitudes of yaw rotation of the various segments, and increased the rotation of the head relative to the other segments. Medication did not improve the timing of segment rotations, which showed en bloc turn initiation in both the OFF and ON medication conditions. Discussion and Conclusion: These results suggest that only certain aspects of turning may be responsive to anti-Parkinson medications. As such, additional rehabilitative approaches to address turning are needed because turning may not be effectively addressed by pharmacologic approaches. These results should be interpreted cautiously given the small sample size.

Journal ArticleDOI
TL;DR: The use of hand-held dynamometry to assess postural muscle strength for maintaining upright sitting in individuals with SCI has high intrarater and interrater reliability and future research is needed to identify the minimum muscle strength required to maintain the seated posture and to understand how this measure relates to seated postural control and balance.
Abstract: Background and purpose Muscle weakness frequently impairs the ability to maintain upright sitting in individuals with spinal cord injury (SCI). The primary purpose of this study was to examine the intrarater and interrater reliability of hand-held dynamometry to assess postural muscle strength for maintaining upright sitting in individuals with SCI. We also assessed reliability of forces measured in four directions of force application and of measures obtained by experienced versus student physical therapist examiners. Methods Twenty-nine individuals with SCI (mean age, 32.4 +/- 11.0 years; injury level C4-L1; American Spinal Injury Association Impairment Scale (AIS) classification A-D) participated in this study. The raters were two experienced physical therapists and two student physical therapists. Force was applied to the anterior, posterior, and right and left lateral trunk. Values were acquired in a group of participants who did not require upper extremity support for sitting (n = 22) and a group who did require upper extremity support (n = 7). Results Intrarater reliability was good to excellent (intraclass correlation coefficients, 0.80-0.98 [unsupported]; 0.79-0.99 [supported]) for all raters in the four directions of force application. Interrater reliability was excellent (intraclass correlation coefficients, 0.97-0.99 [unsupported]; 0.96-0.98 [supported]) for all directions. There were no significant differences among peak forces obtained among the four directions of force application or by experienced raters compared with student raters. Discussion and conclusion The use of hand-held dynamometry to assess postural muscle strength for maintaining upright sitting in individuals with SCI has high intrarater and interrater reliability. The direction of force application and experience of the rater did not influence the level of reliability. Future research is needed to identify the minimum muscle strength required to maintain the seated posture and to understand how this measure relates to seated postural control and balance.

Journal ArticleDOI
TL;DR: Although participants had no explicit memory of the program, four of five improved in at least two outcome measures, suggesting that a small-group functional balance intervention for individuals with AD is feasible and effective.
Abstract: Background and purpose Individuals with Alzheimer disease (AD) have a higher risk of falls than their cognitively intact peers. This pilot study was designed to assess the feasibility and effectiveness of a small-group balance exercise program for individuals with AD in a day center environment. Methods Seven participants met the inclusion criteria: diagnosis of AD or probable AD, medical stability, and ability to walk (with or without assistive device). We used an exploratory pre- and post-test study design. Participants engaged in a functional balance exercise program in two 45-minute sessions each week for eight weeks. Balance activities were functional and concrete, and the intervention was organized into constant, blocked, massed practice. Outcome measures included Berg Balance Scale (BBS), Timed Up and Go (TUG), and gait speed (GS; self-selected and fast assessed by an instrumented walkway). Data were analyzed by comparing individual change scores with previously identified minimal detectable change scores at the 90% confidence level (MDC90). Results Pre- and post-test data were acquired for five participants (two participants withdrew). The BBS improved in all five participants, and improved > or = 6.4 points (the MDC90 for the BBS in three participants. Four participants improved their performance on the TUG, and three participants improved > or = 4.09 seconds (the MDC90 for the TUG). Self-selected GS increased > or = 9.44 cm/sec (the MDC90 for gait speed) in three participants. Two participants demonstrated post-test self-selected GS comparable with their pretest fast GS. Discussion and conclusions This pilot study suggests that a small-group functional balance intervention for individuals with AD is feasible and effective. Although participants had no explicit memory of the program, four of five improved in at least two outcome measures. Larger scale functional balance intervention studies with individuals with AD are warranted.

Journal ArticleDOI
TL;DR: The impact of PPS on quality care indicators for inpatient stroke rehabilitation, trends for LOS, and trends for functional outcomes are insufficiently documented in the medical literature.
Abstract: BACKGROUND AND PURPOSE The purpose of this systematic review was to examine quality care indicators for inpatient stroke rehabilitation, trends for length of stay (LOS), functional outcomes, and discharge destination. In order to examine the influence of the prospective payment system (PPS), which was instituted in 2002, particular attention was paid to the pre-PPS to post-PPS period. This is the first review of literature to examine the quality of stroke care provided in inpatient rehabilitation facilities in the United States. METHODS A search of Ovid Medline and Ovid Cumulative Index of Nursing and Allied Health databases was performed for articles published between 1990 and 2007. Search terms included treatment outcome, outcome assessment, activities of daily living, exercise, rehabilitation, cerebrovascular accident, LOS, and rehabilitation centers. RESULTS Twelve articles met the criteria for review. A trend for shorter LOS was evident in the literature up until the time of implementation of PPS. An insufficient amount of literature was available to confirm whether this trend continued after the implantation of PPS. The most recent data indicated that average LOS in inpatient rehabilitation facilities for stroke was <20 days. Functional Independence Measure (FIM) discharge scores remained stable through the 1990s. After the implementation of PPS, discharge FIM scores may be decreasing, but revisions to the FIM tool may confound interpretation of post-PPS findings. Data for discharge to noninstitutional settings after stroke rehabilitation were inconclusive pre-PPS. There may be indications that discharges to institutional settings are increasing post-PPS. CONCLUSIONS The impact of PPS on quality care indicators for inpatient stroke rehabilitation, trends for LOS, and trends for functional outcomes are insufficiently documented in the medical literature. Further research is needed to understand the influence of LOS on functional outcomes and discharge destination. More information is needed on post-PPS outcomes to substantiate the benefit of inpatient rehabilitation for individuals with stroke.

Journal ArticleDOI
TL;DR: The findings suggest that some subjects can increase their aVOR gain in response to high-velocity active head movement training using a position ES, suggesting that retinal slip is a more powerful aVor gain modifier.
Abstract: Background and Purpose:Vestibular rehabilitation strategies including gaze stabilization exercises have been shown to increase gain of the angular vestibulo-ocular reflex (aVOR) using a retinal slip error signal (ES). The identification of additional ESs capable of promoting substitution strategies

Journal ArticleDOI
TL;DR: Data from this case study suggest that physical therapy management improves functional outcomes for individuals with postoperative changes in facial motor function from facial reanimation surgery.
Abstract: Background and Purpose:Facial paralysis can have a significant negative impact on an individual's social, physical, and emotional well-being; however, little information has been reported on the efficacy of physical therapy interventions for this condition. The purpose of this case study was to desc

Journal ArticleDOI
TL;DR: This accessible home program was safe and effective for decreasing impairment and improving function in an individual with long-term, chronic stroke and gains were maintained 4 weeks posttreatment.
Abstract: Background and purpose Impaired walking function and spasticity are common sequelae of stroke. Prior studies have shown that a rehabilitation program combining transcutaneous electrical stimulation (TES) with task-related training (TRT) improves motor function in individuals with stroke. However, it is unclear if this approach is beneficial for individuals with long-standing stroke. Case description The subject of this case study was a 61-year-old man who was 7 years poststroke. He exhibited limitations of walking function, impaired strength of the ankle muscles, and severe plantarflexor spasticity. Interventions For 4 weeks, the patient performed a 5-day/wk home program consisting of 60 minutes of TES (below motor threshold) to the acupoints in the affected lower leg, followed by 60 minutes of TRT. He documented his daily home program activities in a log, and 3 times a week he received a call from the therapist to verify his adherence. The patient also had 8 clinic visits, which focused on instruction to ensure adherence to the (TES + TRT) protocol and progression of the program. Outcomes After the 4-week program, plantarflexor spasticity decreased and ankle dorsi- and plantarflexor strength improved. More important, there were notable improvements in gait velocity, walking endurance, and functional mobility. These gains were maintained at 4 weeks posttreatment. Discussion This accessible home program was safe and effective for decreasing impairment and improving function in an individual with long-term, chronic stroke. The gains were maintained 4 weeks posttreatment. Details are provided for developing a home program integrating somatosensory TES and TRT.

Journal ArticleDOI
TL;DR: The Digit Quinti Sign, the Pronator Drifting Test, and the Finger Rolling Test are simple yet very useful maneuvers that clinicians can perform at bedside that suggest that comprehensive investigation for intracranial neoplams should be undertaken.
Abstract: BACKGROUND AND PURPOSE Prior to modern neuroimaging, neurological treatment decisions were based on findings obtained from patient history and clinical examination. Despite the availability of sophisticated neuroimaging methods, to identify intracranial tumors the clinical recognition of associated subtle motor deficits is important for practice. Precise clinical tests are particularly advantageous, as some tumors may remain unnoticed for many. The purpose of this study was to determine the sensitivity and specificity of 13 clinical tests for detection of subtle motor deficits in patients with unilateral brain tumors. METHODS Sixty patients with unilateral brain tumors without obvious focal signs and 30 controls with normal magnetic resonance imaging were examined. Thirteen clinical maneuvers described to detect motor deficits were performed and their sensitivity, specificity, and positive and negative predictive values were estimated. RESULTS The test with greatest sensitivity and specificity (with 95% confidence interval) was the Digit Quinti Sign: 0.51 (0.41-0.61) and 0.70 (0.61-0.79), respectively. The agreement measurement among the 3 most sensitive signs (Digit Quinti Sign, Pronator Drifting Test, and Finger Rolling Test) was 21%. The Kappa index for these 3 tests indicated no significant concordance. CONCLUSIONS The Digit Quinti Sign, the Pronator Drifting Test, and the Finger Rolling Test are simple yet very useful maneuvers that clinicians can perform at bedside. Even without apparent motor deficits, when present, these signs suggest that comprehensive investigation for intracranial neoplams should be undertaken.

Journal ArticleDOI
TL;DR: Elliptical training appears to be a safe and feasible training alternative for ambulatory individuals with chronic stroke, and participants did demonstrate variable improvements in endurance, balance, and functional mobility.
Abstract: Background and purpose Decreased functional walking capacity is a common consequence of stroke. Identifying practical and cost-effective methods to improve walking in individuals with stroke is an important goal of rehabilitation professionals. Participants Participants were 3 men with chronic (>6 month) stroke, who could walk on level surfaces either without an assistive device or with a single-point cane. Intervention Participants trained 2 to 3 times per week for 8 weeks, using an elliptical machine. The training target was 20 minutes of uninterrupted training, while maintaining predetermined parameters of heart rate and perceived exertion. Outcomes Outcome measures assessed before and after training included habitual and fast gait speed, 6-minute walk test (6MWT), Timed "Up & Go" test, and Berg Balance Scale. Following training there was no change in walking speed. There was no change in 6MWT performance for participants 1 and 2. While participant 3 showed a 25% improvement in 6MWT, this change did not meet the minimal detectable change for walking speed in individuals with stroke. All participants demonstrated improved Berg Balance Scale performance (9%-28%), with participant 1 exceeding the minimal detectable change in this measure. Timed Up & Go test performance improved by 5% to 15% in all participants. Discussion Elliptical training appears to be a safe and feasible training alternative for ambulatory individuals with chronic stroke. Training 2 to 3 days per week resulted in no improvements in walking speed; however, participants did demonstrate variable improvements in endurance, balance, and functional mobility. It is possible that a higher training frequency and/or training speed are required to influence walking performance in individuals who are ambulatory. Equipment design, principles of exercise prescription, and participant characteristics should be considered when selecting elliptical training as an intervention.

Journal ArticleDOI
TL;DR: Otolith dysfunction does not significantly influence the response to rehabilitation of individuals with a peripheral vestibular disorder and Vestibular rehabilitation is associated improvements in symptom severity, self-perceived handicap, and balance function in individuals with otolith dysfunction.
Abstract: Background and Purpose:Vestibular rehabilitation (VR) is a successful approach to the treatment of vestibular dysfunction. The purpose of this study was to investigate the influence of otolith dysfunction on the response to VR in individuals with a peripheral vestibular disorder.Participants and Met

Journal ArticleDOI
TL;DR: Individuals with vestibular disorders may show improvement in motor inhibition and perceptual inhibition after a 6-week physical therapy intervention program; those with abnormalities on caloric and rotational chair tests appear especially likely to experience improvement in PI.
Abstract: BACKGROUND AND PURPOSE:: Vestibular dysfunction has been shown to be associated with altered cognitive function. The purpose of this study was to examine changes in cognitive function in participants with vestibular disease during the course of vestibular physical therapy. METHODS:: Twenty-two participants (mean age = 52, standard deviation = 11) with previously diagnosed vestibular disorders were tested at the beginning and end of rehabilitation. The Motor and Perceptual Inhibition Test (MAPIT) was used to assess manual reaction times when responding to various stimuli presented on a computer screen. Additional physical performance measures and questionnaires related to dizziness, fear of falling, and activities of daily living were used to quantify change during the 6-week intervention period. The repeatable battery for the assessment of neuropsychological status (a measure of memory and executive function) was used to ensure that participants did not have memory or executive function deficits. RESULTS:: Overall, there were no significant differences in MAPIT score before versus after physical therapy intervention, however there were some participants who demonstrated improvements in motor inhibition (MI) and perceptual inhibition (PI) scores. Interstingly, 8 of the 9 participants with abnormal caloric test findings had improvements on 2 of the PI scores. Overall 50% to 64% of the participants demonstrated improvement in the 4 different MAPIT scores. There were improvements in physical performance and self-report measures at the end of the 6-week physical therapy intervention program. DISCUSSION/CONCLUSION:: Individuals with vestibular disorders may show improvement in MI and PI after a 6-week physical therapy intervention program; those with abnormalities on caloric and rotational chair tests appear especially likely to experience improvement in PI. Additional study is needed to determine whether individuals with vestibular disorders have remediable deficits in MI and PI. Language: en

Journal ArticleDOI
TL;DR: This Special Issue of the JNPT has and outstanding cadre of international authors and coauthors from the United States, the United Kingdom, Greece, Saudi Arabia, Jordan, and Australia, who work to enhance the care of persons with vestibular disorders.
Abstract: Vestibular rehabilitation has come a long way from Cawthorne and Cooksey exercises. Although revolutionary in their foresight and still in use today, the available options for rehabilitation of vestibular disorders has dramatically in recent years. Currently in our armamentarium are specific exercises to address gaze instability, postural instability (static and dynamic), motion sensitivity, and vertigo—all symptoms relative to pathology within the peripheral and central vestibular pathways. Cochrane studies have established that vestibular rehabilitation is effective for treating unilateral peripheral vestibular hypofunction. Recent treatment guidelines and systematic reviews suggest that repositioning maneuvers are the superior treatment for benign paroxysmal positional vertigo. Our knowledge of testing and treatment of pathologies affecting the peripheral vestibular labyrinth and/or the pathways mediating vestibular afference is exploding. Just as optimal intervention for individuals with vestibular disorders commonly involves multiple disciplines, so are multiple disciplines conducting excellent research that demands vigilance in the practicing clinician. As clinicians who treat people with vestibular disorders, our interventions would be enhanced by examining data from other disciplines: emerging evidence suggests that new tests may isolate utricular from saccular function, migraines can be triggered by vestibular stimulation, and technical advances in oculomotor equipment now enable video monitoring and recording of rapid head and eye rotations. Today there are many tests that can be used by clinicians, which provide clinically meaningful information. In addition, as members of the vestibular team, physical therapists need to become more involved in other professional meetings to inform other clinicians about what we have to offer. Important opportunities for collaborating might involve the American Academy of Head and Neck Surgery, the Association for Research in Otolaryngology, and the biannual Barany Society meeting. We are pleased to report that this Special Issue of the JNPT has and outstanding cadre of international authors and coauthors from the United States, the United Kingdom, Greece, Saudi Arabia, Jordan, and Australia. The topics covered are diverse and so is the authors’ expertise. The authors include physical therapists, engineers, and physicians who work to enhance the care of persons with vestibular disorders. The authors were asked to contribute to this issue based on their novel work, and we hope that their recent findings help to improve care for your patients. Most of the articles in this Special Issue include advanced technology as part of their methods. The use of the vibrotactors (Wall), scleral search coils (Scherer and Schubert), uniquely applied measures of attention (Mohammad et al), and optokinetic stimulation (Pavlou et al) all involve some degree of innovative technology to assess treatment effectiveness, measurement of vestibular function, or reveal behavior in people with vestibular dysfunction. Other articles in this issue attempt to describe treatment effectiveness in interesting patient groups including mild traumatic brain injury related to blunt (Alsalaheen et al) and blast (Gottshall) trauma, patients with report of dizziness but normal caloric findings (Hall et al), patients with canal-only versus canal and otolith dysfunction (Murray et al), and differences between treatment paradigms (Clendaniel). The future for vestibular rehabilitation is exciting and will involve interaction with multiple disciplines. In a recent survey of biomechanics laboratories , physical therapists who responded to an informal survey participated in projects in 75% of the laboratories.

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TL;DR: It is clear that motor behavior emerges not from an inefficient, immutable, and unidirectional heirarchy of control, but rather from a flexible, distributed system wherein interactive control is coordinated among subsystems.
Abstract: I n the later years of the 19th century, a good deal of evolutionary theory was grounded in zoologist Ernst Haeckel’s premise that “ontogeny recapitulates phylogeny,”1 the idea that human embryonic development mimics the biological evolution of the species. While the veracity of this theory was debated for much of the 20th century, it was finally laid to rest in 1977 with the publication of Stephen Jay Gould’s Ontogeny and Phylogeny.2 Gould showed that while ontogeny does not really recapitulate phylogeny, variations in the timing and rate of development are essential to the evolutionary process of adapting to the environment through natural selection. In our own world of neurorehabilitation, there has been a similar evolution in our understanding of the process of neural recovery and functional restoration. Prior to the 1980s, it was widely believed that functional restoration in individuals with neuropathology required recapitulation of the neurodevelopmental sequence of motor behaviors observed in the typically developing child.3 This theory was based on a hierarchical model of motor control in which phylogenetically simple behaviors, such as reflexes, were replaced with more complex movements over the course of motor development. With our present understanding, it is clear that motor behavior emerges not from an inefficient, immutable, and unidirectional heirarchy of control, but rather from a flexible, distributed system wherein interactive control is coordinated among subsystems.4 As with evolutionary biology, experience is a critical and compelling force driving normal development. Animals deprived of normal experiences during the critical periods of system development never develop the capacity for normal function in that system. As an illustrative case, the 1981 Nobel Prize in Medicine was awarded to David Hubel and Torsten Wiesel, whose work included a demonstration that kittens deprived of vision in one eye during the critical period of visual system development never developed normal binocular vision.5 While all the necessary structures were in place, the necessary functional development of the cortical binocular cells failed to occur in the absence of visual experience. As is true with normal development, functional restoration of motor control following neuropathology also requires exposure to the requisite experiences. The emergence of task-specific training as a focus of rehabilitation interventions6 shifted attention away from the postural sequences to the learning experiences provided by the environment in which one moves. Happily for neurologic physical therapists, the timeframe over which these forces have their influence on motor control is much shorter than the timeframe for driving evolution. Also happily and unlike evolutionary environmental influences, we have the capacity to structure the movement experiences to which our patients are exposed. Over the years, the pages of JNPT and other neurology-related rehabilitation journals have been filled with examples of activity-dependent plasticity and the impact of structured motor experiences on the capacity for improved human motor function. On many occasions, articles by basic scientists have offered valuable and relevant insights from animal models. Interestingly, while clinician scientists have long looked to animal models for scientific evidence of interventions that might be applicable to the rehabilitation of people with disability, more and more, science is applying to animal models the lessons that we have learned from functional restoration in people. The growing recognition that movement experience is a necessary component of optimal neural recovery is evident in the increasing use of “enriched environments,”7 animal housing that provides opportunities for the animals to run, climb, reach . . . opportunities for


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TL;DR: There is a need for all of us to understand the terms and appreciate the philosophical underpinnings of what translational research may mean in the area of neurorehabilitation, and a solution that is interactive, bidirectional, and respectful of the challenges of clinical practice is suggested.
Abstract: This year at the 2010 Combined Sections Meeting in San Diego, CA, the Board of Directors, leaders from our special interest groups and committees, and the membership discussed what the term translational research meant to each of us. Varied perspectives were heard from our own individual points of view as tenure-track research faculty, clinician scientists, clinical specialists, early career physical therapists, and students. Now more than ever there is a need for the Neurology Section to develop a research strategic plan that addresses practical and clinically important questions that have meaning to the patient, their families, and the frontline rehabilitation professionals that provide their care. This need is particularly relevant in the area of movement rehabilitation where findings from basic and clinical science research demonstrate that the nervous system has the capacity to respond and recover in response to motor training that is specific, intense, and involves the acquisition of motor skills. However, the diversity of needs that was reflected in our various discussions revealed to me a need for all of us to understand the terms and appreciate the philosophical underpinnings of what translational research may mean in the area of neurorehabilitation. In the National Institutes of Health (NIH) Roadmap,1 the term bench to bedside is used to describe the emphasis on NIH priorities to support translational research efforts to move scientific discoveries from bench research more rapidly to clinical practice. Translational research is the practical application of scientific discoveries from basic science research (ie, research of disease or injury at a molecular or cellular level) translated to clinical science research (ie, applied research that takes advances in basic science to generate new approaches to treatment of disease) to improve human health for people.2 Thus, translational science is an evolving discipline that could lead a basic science researcher or clinical science researcher to focus efforts on translational research. This terminology is even more confusing when translational researchers discuss the latest NIH terminology to describe the research enterprise, which is the process by which universities and academic researchers compete for NIH grant funding. Thus, the terminology of translational research type 1 (T1) or type 2 (T2) is used.2 T1 translational research describes the basic science research whereby understanding disease mechanisms from the laboratory (thus, the term “bench” research) leads to development of therapies (typically, pharmaceuticals or medical devices) that can lead to developments to improve human health. T2 translational research describes the translation of clinical studies into everyday clinical practice. Thus, clinical trials are examples of T2 translational research where the “laboratory” is now the clinical setting such as an ambulatory care center or a community-based hospital. As a note, this may be confusing to the practicing clinician who is encouraged to incorporate research evidence into his or her clinical practice. However, evidence-based practice is an approach to patient care by which a clinician such as a therapist, physician, or nurse integrates findings from current basic or clinical research with his or her own clinical expertise and the individual client’s perspectives to provide the client with optimal healthcare. In 2009, the Cumberland Consensus Working Group,3 a collective group of basic, applied, and clinical scientists, proposed an alternative model to the “translational research pipeline” based on their observations that the translation of basic science research from bench to bedside is “painstakingly slow.”3 The typical research pipeline is a relatively stepwise process from the translation of preclinical, findings at the molecular level to clinical interventions for a patient with disease or injury. This is particularly true for disease or injury to the nervous system because it has a huge impact on the individual and requires a complex intervention such as those inherent in neurorehabilitation. Thus, the traditional method of driving the translational research in a unidirectional and hierarchical manner has not been effective in driving substantial change in rehabilitation clinical practice. The Cumberland Group proposed a modification to the traditional, unidirectional research pipeline and suggests a solution that is interactive, bidirectional, and respectful of the challenges of clinical practice. Thus, a T2 translational scientists needs to understand the theoretical and design requirements of an randomized controlled trial that complies with CONSORT4 requirements but should also develop an appreciation for the challenges and culture of the clinical environment. The researcher who wants to conduct clinical trial research also needs to develop relationships with the administrators, managers, and clinicians who care for the patients in their “laboratory,” the community hospital or outpatient pracPresident, Neurology Section. Address correspondence to: Katherine J. Sullivan, E-mail: kasulliv@usc.edu Copyright © 2010 Neurology Section, APTA ISSN: 1557-0576/10/3402-0119 DOI: 10.1097/NPT.0b013e3181df7f56

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TL;DR: The PROFILE PD is a reliable and valid scale that can be used to quantify alterations in body systems and activity of individuals in early and mid-stages of PD.
Abstract: Background and Purpose:Individuals with Parkinson disease (PD) experience a range of deficits of body systems and activities A clinical test is needed that is reliable, valid, applicable to physical therapist practice, and appropriate for use in early and mid-stages of the disease PROFILE PD is on

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TL;DR: The case study by Hui-Chan and Ng serves to provide details of a research treatment protocol to facilitate translation to the clinic, with two recent randomized control trials showing the effects of TES in combination with task-related training (TRT) in persons with chronic stroke.
Abstract: T he ability to translate research to the clinic is a critical step in evidence-based practice to provide optimum care for our clients.1 The translation of research intervention protocols to the clinic is often challenging for many reasons. Results of research studies with narrow inclusion criteria may not generalize to results observed in the wider range of clinical presentation among clients with whom physical therapists work. The intervention protocol may not be feasible in the clinical setting (eg, expensive equipment, number of treatment hours, duration of sessions). Often times, the research article does not provide sufficient detail for the therapist to duplicate the intervention protocol in the clinic. The later is the unique contribution of this case study by Hui-Chan and Ng,2 in this issue—it serves to provide details of a research treatment protocol to facilitate translation to the clinic. In a series of experiments, these authors have studied the effects of transcutaneous electrical stimulation (TES) on spasticity and function. Their findings have spanned the range from physiology3 to function, with two recent randomized control trials (RCT) showing the effects of TES in combination with task-related training (TRT) in persons with chronic stroke.4,5 These RCTs used an intervention protocol similar to that used in the case study reported in this issue. The intervention consisted of home-based program of 60 minutes of TES to 4