Showing papers in "Journal of Rehabilitation Research and Development in 2016"

High-density force myography: A possible alternative for upper-limb prosthetic control.

Abstract: Several multiple degree-of-freedom upper-limb prostheses that have the promise of highly dexterous control have recently been developed. Inadequate controllability, however, has limited adoption of these devices. Introducing more robust control methods will likely result in higher acceptance rates. This work investigates the suitability of using high-density force myography (HD-FMG) for prosthetic control. HD-FMG uses a high-density array of pressure sensors to detect changes in the pressure patterns between the residual limb and socket caused by the contraction of the forearm muscles. In this work, HD-FMG outperforms the standard electromyography (EMG)-based system in detecting different wrist and hand gestures. With the arm in a fixed, static position, eight hand and wrist motions were classified with 0.33% error using the HD-FMG technique. Comparatively, classification errors in the range of 2.2%-11.3% have been reported in the literature for multichannel EMG-based approaches. As with EMG, position variation in HD-FMG can introduce classification error, but incorporating position variation into the training protocol reduces this effect. Channel reduction was also applied to the HD-FMG technique to decrease the dimensionality of the problem as well as the size of the sensorized area. We found that with informed, symmetric channel reduction, classification error could be decreased to 0.02%.

Psychometric evaluation of self-report outcome measures for prosthetic applications.

Abstract: Documentation of clinical outcomes is increasingly expected in delivery of prosthetic services and devices. However, many outcome measures suitable for use in clinical care and research have not been psychometrically tested with prosthesis users. The aim of this study was to determine test-retest reliability, mode-of-administration (MoA) equivalence, standard error of measurement (SEM), and minimal detectable change (MDC) of standardized, self-report instruments that assess constructs of importance to people with lower limb loss. Prosthesis users (n = 201) were randomly assigned to groups based on MoA (i.e., paper, electronic, or mixed-mode). Participants completed two surveys 2 to 3 d apart. Instruments included the Prosthetic Limb Users Survey of Mobility, Prosthesis Evaluation Questionnaire-Mobility Subscale, Activities-Specific Balance Confidence Scale, Quality of Life in Neurological Conditions-Applied Cognition/General Concerns, Patient-Reported Outcomes Measurement Information System Profile, and Socket Comfort Score. Intraclass correlation coefficients indicated all instruments are appropriate for group-level comparisons and select instruments are suitable for individual-level applications. Several instruments showed evidence of possible floor and ceiling effects. All were equivalent across MoAs. SEM and MDC were quantified to facilitate interpretation of outcomes and change scores. These results can enhance clinicians' and researchers' ability to select, apply, and interpret scores from instruments administered to prosthesis users.

Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program

Abstract: INTRODUCTION Hand impairment after stroke contributes substantially to disability in the United States and around the world [1]. Intensive movement practice can reduce hand impairment [2-6], but issues such as cost and access may limit the dose of rehabilitation exercise delivered one-on-one with a therapist. Because of these and other factors, most individuals do not perform the large number of exercise repetitions required during therapy to maximize recovery [7-8]. Home-based rehabilitation programs may be prescribed after stroke with the intent to increase the amount of rehabilitation exercise individuals perform. However, the most common approach to home-based hand therapy is following a printed handout of exercises. This approach is often not motivating and thus is associated with low compliance and high dropout rates [9-13]. To address this problem, other types of home-based rehabilitation programs for the hand have been proposed. For example, one pilot study explored a modified form of constraint-induced movement therapy performed under the supervision of a nonprofessional coach in the home and found similar benefits to the same program performed with a trained therapist in a clinic [14]; a larger study using this protocol found that home-based constraint-induced movement therapy led to significantly greater self-reported use of the impaired limb than conventional therapy [15]. Another common approach is telerehabilitation, which allows a therapist to guide therapy remotely [16]. While this approach is gaining popularity, a recent Cochrane systematic review of 10 trials with 933 total participants found limited evidence to support its use and no studies that examined its cost-effectiveness [17]. Other approaches to home-based hand rehabilitation include functional electrical stimulation [18], computer gaming with custom devices [19-21], and music-based therapy [22]. However, despite the variety of options, few home-based programs have been tested in controlled studies [23]. Further, it is still unclear which methods are the most effective and efficient means of providing an increased dose of rehabilitation, though the use of computer games and music has been found to be highly motivating [20,24-26]. We developed the MusicGlove, an instrumented glove with sensors on each of the fingertips and the lateral aspect of the index finger. The MusicGlove requires the user to practice functional gripping movements by touching the sensor on the tip of the thumb to one of the other five sensors in time with music through a video game that displays scrolling notes on a screen (Figure 1). In previous pilot studies performed in a clinical setting, we found that the MusicGlove motivated individuals with chronic stroke to perform hundreds of functional gripping movements during a 30 min training session and that exercise with the device led to a significantly greater improvement in hand grasping ability, measured with the Box and Blocks test, than a time-matched dose of conventional tabletop therapy performed with a rehabilitation therapist [27-28]. The individuals who used the MusicGlove also reported that the exercise was more motivating than conventional therapy and expressed interest in using the device to exercise at home. An important question, therefore, was whether self-guided exercise with the MusicGlove performed at home is feasible and improves hand function compared with conventional home therapy. [FIGURE 1 OMITTED] To address this question, we performed a randomized, controlled single-blind trial that compared home-based training with the MusicGlove to home-based conventional tabletop training directed using a pamphlet of hand exercises. We hypothesized that the participants in the MusicGlove therapy group would improve their hand function more than the participants in the conventional therapy group when assessed 1 mo after treatment. METHODS Study Design and Inclusion Criteria This study was a home-based randomized controlled trial that compared self-guided exercise with the MusicGlove to self-guided conventional tabletop therapy for individuals in the chronic phase of stroke. …

Association between mild traumatic brain injury and mental health problems and self-reported cognitive dysfunction in Iraq and Afghanistan Veterans.

Abstract: The Department of Veterans Affairs traumatic brain injury (TBI) screening program is intended to detect and expedite treatment for TBI and postconcussive symptoms. Between April 14, 2007, and May 31, 2012, of 66,089 Iraq and Afghanistan Veterans who screened positive on first-level TBI screening and later completed comprehensive TBI evaluation that includes the Neurobehavioral Symptoms Inventory, 72% reported moderate to very severe cognitive impairment (problems with attention, concentration, memory, etc.) that interfered with daily activities. This included 42% who were found not to have sustained combat-related mild TBI (mTBI). In contrast, 70.0% received a posttraumatic stress disorder (PTSD) diagnosis and 45.8% received a depression diagnosis. Compared with Veterans without mTBI, PTSD, or depression diagnoses, the lowest risk for self-reported cognitive impairment was in Veterans with confirmed mTBI only; a greater risk was found in those with PTSD diagnoses, with the greatest risk in Veterans with PTSD, depression, and confirmed mTBI, suggesting only a weakly additive effect of mTBI. These findings suggest that Veterans with multiple mental health comorbidities, not just those with TBI, report moderate to very severe cognitive impairment. Mental health treatment for conditions such as PTSD and depression (with or without TBI) may result in improvements in cognitive functioning and/or include assessment and support for Veterans experiencing cognitive problems.

Perceived health, caregiver burden, and quality of life in women partners providing care to veterans with traumatic brain injury

Abstract: Families of Veterans with traumatic brain injury (TBI) are often faced with providing long-term informal care to their loved one. However, little is known about how their perceived health and caregiving burden contribute to their quality of life (QOL). The purpose of this descriptive study was to describe perceived health, somatic symptoms, caregiver burden, and perceived QOL and to identify the extent to which these variables are associated with QOL in female partners/spouses of Veterans with TBI. Participants completed a written questionnaire including the Patient Health Questionnaire-15, Caregiver Reaction Assessment, Quality of Life Index, and the general health subscale of the 12-Item Short Form Survey version 2. Caregivers reported moderate levels of QOL, and over a quarter of the sample reported high levels of somatic symptoms, particularly fatigue and sleep disturbance. Age, perceived general health, somatic symptoms, the five subscales of caregiver burden (self-esteem, disrupted schedule, effect on finances, lack of family support, and effect on health) predicted QOL and explained 64% of its variance (adjusted r2 = 0.64, F(8,31) = 9.59). However, only somatic symptoms and the caregiver burden subscales of self-esteem and effect on finances were significant predictors in the model. These findings have implications for development of family-centered interventions to enhance the QOL of informal caregivers of Veterans with TBI.

Sensor-based balance training with motion feedback in people with mild cognitive impairment

Abstract: Some individuals with mild cognitive impairment (MCI) experience not only cognitive deficits but also a decline in motor function, including postural balance. This pilot study sought to estimate the feasibility, user experience, and effects of a novel sensor-based balance training program. Patients with amnestic MCI (mean age 78.2 yr) were randomized to an intervention group (IG, n = 12) or control group (CG, n = 10). The IG underwent balance training (4 wk, twice a week) that included weight shifting and virtual obstacle crossing. Real-time visual/audio lower-limb motion feedback was provided from wearable sensors. The CG received no training. User experience was measured by a questionnaire. Postintervention effects on balance (center of mass sway during standing with eyes open [EO] and eyes closed), gait (speed, variability), cognition, and fear of falling were measured. Eleven participants (92%) completed the training and expressed fun, safety, and helpfulness of sensor feedback. Sway (EO, p = 0.04) and fear of falling (p = 0.02) were reduced in the IG compared to the CG. Changes in other measures were nonsignificant. Results suggest that the sensor-based training paradigm is well accepted in the target population and beneficial for improving postural control. Future studies should evaluate the added value of the sensor-based training compared to traditional training.

Effect of clinical parameters on the control of myoelectric robotic prosthetic hands.

Abstract: Improving the functionality of prosthetic hands with noninvasive techniques is still a challenge. Surface electromyography (sEMG) currently gives limited control capabilities; however, the application of machine learning to the analysis of sEMG signals is promising and has recently been applied in practice, but many questions still remain. In this study, we recorded the sEMG activity of the forearm of 11 male subjects with transradial amputation who were mentally performing 40 hand and wrist movements. The classification performance and the number of independent movements (defined as the subset of movements that could be distinguished with >90% accuracy) were studied in relationship to clinical parameters related to the amputation. The analysis showed that classification accuracy and the number of independent movements increased significantly with phantom limb sensation intensity, remaining forearm percentage, and temporal distance to the amputation. The classification results suggest the possibility of naturally controlling up to 11 movements of a robotic prosthetic hand with almost no training. Knowledge of the relationship between classification accuracy and clinical parameters adds new information regarding the nature of phantom limb pain as well as other clinical parameters, and it can lay the foundations for future "functional amputation" procedures in surgery.

Reliability and validity of the inertial sensor-based Timed "Up and Go" test in individuals affected by stroke.

Abstract: The instrumented Timed "Up and Go" test (iTUG) has the potential for playing an important role in providing clinically useful information regarding an individual's balance and mobility that cannot be derived from the original single-outcome Timed "Up and Go" test protocol. The purpose of this study was to determine the reliability and validity of the iTUG using body-fixed inertial sensors in people affected by stroke. For test-retest reliability analysis, 14 individuals with stroke and 25 nondisabled elderly patients were assessed. For validity analysis, an age-matched comparison of 12 patients with stroke and 12 nondisabled controls was performed. Out of the 14 computed iTUG metrics, the majority showed excellent test-retest reliability expressed by high intraclass correlation coefficients (range 0.431-0.994) together with low standard error of measurement and smallest detectable difference values. Bland-Altman plots demonstrated good agreement between two repeated measurements. Significant differences between patients with stroke and nondisabled controls were found in 9 of 14 iTUG parameters analyzed. Consequently, these results warrant the future application of the inertial sensor-based iTUG test for the assessment of physical deficits poststroke in longitudinal study designs.

Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews.

Abstract: Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.

Caring for our wounded warriors: A qualitative examination of health-related quality of life in caregivers of individuals with military-related traumatic brain injury.

Abstract: INTRODUCTION Caregivers of individuals with military-related traumatic brain injury (TBI) are an underserved population [1]. TBI is a common injury among military servicemembers, including those returning from combat operations (e.g., Operations Iraqi Freedom and Enduring Freedom) and those injured through training, accidents, and other means [2-3]. From 2000 through 2015, more than 325,000 servicemembers were diagnosed with TBI (1.5% penetrating injuries, 1.0% severe, 8.5% moderate, 82.4% mild, and 6.6% unclassifiable) [4]. A better understanding is needed to determine how family members' health-related quality of life (HRQOL) is affected by having to provide care for a servicemember who sustains a TBI. HRQOL represents a multidimensional construct reflecting the effect of a disease, disability, or its treatment on mental, physical, and social well-being [5]. This can be contrasted with the more general term of "quality of life," which also encompasses general well-being [6-7] but lacks a consensus definition. The limited research examining caregivers of servicemembers with TBI suggests that these caregivers experience less family cohesion and nurturance, greater emotional distress and mental health problems, and greater financial strain than their civilian counterparts [8-13]. These difficulties are in addition to the burdens related to deployment and reintegration (e.g., high divorce rates and family disruption) [14-16]. Servicemembers with TBI are also more likely than civilians with TBI to experience repeat injuries as well as comorbid physical and psychological ailments simultaneous with the TBI (i.e., polytrauma) [14-15]. Polytrauma occurs when an individual experiences concurrent injuries to multiple body parts and organ systems; this can include major limb trauma (single or multiple amputations), musculoskeletal injuries, burns, spinal cord injury, auditory and visual impairment, and facial disfigurement. These injuries can result in chronic pain, sexual dysfunction, substance misuse, or other problems in addition to combat-related mental health problems (e.g., posttraumatic stress disorder), all of which may make long-term caregiving more complicated [17-27]. In order to address this underserved population, Congress mandated the development of a family caregiver curriculum--Traumatic Brain Injury: A Guide for Caregivers of Service Members and Veterans--to improve educational support and to increase attention to the respite needs of caregivers of patients with TBI; it is intended for family caregivers of servicemembers and Veterans who have sustained a moderate or severe TBI [1 (Sect 744)]. It is commonly provided to family caregivers by case managers and clinicians from the Departments of Defense (DOD) and Veterans Affairs (VA). In addition to the caregiver curriculum, the United Health Foundation funded the 2010 report Caregivers of Veterans--Serving on the Homefront [27]. This report identified caregivers of wounded servicemembers (regardless of injury etiology) as often experiencing marital strain, decreased personal time, and feelings of isolation. Relative to their civilian caregiver counterparts, caregivers of wounded servicemembers reported remaining in the caregiver role for a longer period of time and having greater physical strain, as well as higher levels of emotional stress, inability to work, and financial burden. Furthermore, in 2006, Congress mandated that family members of a servicemember who had incurred a TBI be one of the primary DOD research focuses for Operations Iraqi Freedom and Enduring Freedom servicemembers [1 (Sec 721)]. This mandate resulted in a 15 yr longitudinal study examining the long-term effects of TBI on both the surviving servicemember and his/her family system. Several authors of this article (Brickell, French, and Lange) are currently leading several research projects addressing this mandate. Although many of our wounded warriors receive high-quality medical care for service-related injuries, the caregivers and families of these individuals often do not receive the same level of attention. …

Usability evaluation of low-cost virtual reality hand and arm rehabilitation games.

Abstract: The emergence of lower-cost motion tracking devices enables home-based virtual reality rehabilitation activities and increased accessibility to patients. Currently, little documentation on patients' expectations for virtual reality rehabilitation is available. This study surveyed 10 people with stroke for their expectations of virtual reality rehabilitation games. This study also evaluated the usability of three lower-cost virtual reality rehabilitation games using a survey and House of Quality analysis. The games (kitchen, archery, and puzzle) were developed in the laboratory to encourage coordinated finger and arm movements. Lower-cost motion tracking devices, the P5 Glove and Microsoft Kinect, were used to record the movements. People with stroke were found to desire motivating and easy-to-use games with clinical insights and encouragement from therapists. The House of Quality analysis revealed that the games should be improved by obtaining evidence for clinical effectiveness, including clinical feedback regarding improving functional abilities, adapting the games to the user's changing functional ability, and improving usability of the motion-tracking devices. This study reports the expectations of people with stroke for rehabilitation games and usability analysis that can help guide development of future games.

Everyday sitting behavior of full-time wheelchair users

Abstract: The objective of this study was to describe the in-seat movement and weight-shifting behavior of full-time wheelchair users. We measured everyday sitting behavior for 192 d across 28 individuals who used manual wheelchairs as their primary mobility device. To obtain the measurements, we used eight thin force sensors placed under participants' wheelchair cushions. On a typical day, participants spent an average of 10.6 +/- 3.0 h in their wheelchair and transferred out of the wheelchair 8.4 +/- 4.3 times. Participants only performed pressure reliefs (90% off-loading of the entire buttocks for at least 15 s) 0.4 +/- 0.5 times per hour they were seated in the chair, but they performed weight shifts (WSs) (30%-90% off-loading of at least one side of the buttocks for 15 s) with a frequency of 2.4 +/- 2.2 times per hour. Despite the higher frequency of WSs, they were not performed in a routine manner. Half of the days studied included one segment of upright sitting lasting at least 2 h without a WS. Given these observations, we conclude that seating evaluations should emphasize positioning individuals in a way that facilitates reaching, leaning, and transferring in a safe manner, not only to improve function but also to affect buttocks loading.

The effects of prosthetic ankle stiffness on stability of gait in people with transtibial amputation.

Abstract: The ability to control balance during walking is a critical precondition for minimizing fall risk, but this ability is compromised in persons with lower-limb absence because of reduced sensory feedback mechanisms and inability to actively modulate prosthesis mechanical function. Consequently, these individuals are at increased fall risk compared with nondisabled individuals. A number of gait parameters, including symmetry and temporal variability in step/stride characteristics, have been used as estimates of gait stability and fall risk. This study investigated the effect of prosthetic ankle rotational stiffness on gait parameters related to walking stability of transtibial prosthesis users. Five men walked with an experimental prosthesis that allowed for independent modulation of plantar flexion and dorsiflexion stiffness. Two levels of plantar flexion and dorsiflexion stiffness were tested during level, uphill, and downhill walking. The results demonstrate that low plantar flexion stiffness reduced time to foot-flat, and this was associated with increased perceived stability, while low dorsiflexion stiffness demonstrated trends in temporal-spatial parameters that are associated with improved gait stability (reduced variability and asymmetry). Prosthesis design and prescription for low rotational stiffness may enhance gait safety for transtibial prosthesis users at risk of unsteadiness and falls.

Patient perspectives on virtual reality-based rehabilitation after knee surgery: Importance of level of difficulty.

Abstract: This article explored the perspectives of 25 patients regarding virtual reality (VR)-based rehabilitation following knee surgery and identified the important factors that allowed patients to immerse themselves in rehabilitation. Qualitative analysis of data collected via open-ended questionnaire and quantitative analysis of data from physical assessments and surveys were conducted. In the open-ended questionnaire, the majority of participants mentioned level of difficulty as the most common reason for selecting both the most and the least immersive exercise programs. Quantitative analysis showed that participants experienced a high level of flow (3.9 +/- 0.3 out of 5.0) and a high rate of expectation of therapeutic effect (96%) and intention of exercise adherence (96%). Further, participants with more severe pain or physical dysfunction tended to have more positive experiences (e.g., Difficulty-Skill Balance, Clear Goals, and Transformation of Time), leading to high levels of flow during VR-based rehabilitation. In conclusion, VR-based games are potentially acceptable as a motivational rehabilitation tool for patients following knee surgery. However, to best meet patients' needs, it might be useful to equip a VR program with varied levels of difficulty, taking into account the severity of the individual's knee injury. Additionally, severe pain or physical dysfunction might act as an indication rather than a contraindication for VR-based rehabilitation.

Iraq and Afghanistan Veterans report symptoms consistent with chronic multisymptom illness one year after deployment.

Abstract: Many Veterans returning from service in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) experience chronic pain. What is not known is whether for some OIF/OEF Veterans this pain is part of a larger condition of diffuse multisystem symptoms consistent with chronic multisymptom illness (CMI). We use data from a prospective longitudinal study of OIF/OEF Veterans to determine the frequency of CMI. We found that 1 yr after deployment, 49.5% of OIF/OEF Veterans met criteria for mild to moderate CMI and 10.8% met criteria for severe CMI. Over 90% of Veterans with chronic pain met criteria for CMI. CMI was not completely accounted for either by posttraumatic stress disorder or by predeployment levels of physical symptoms. Veterans with symptoms consistent with CMI reported significantly worse physical health function than Veterans who did not report symptoms consistent with CMI. This study suggests that the presence of CMI should be considered in the evaluation of OIF/OEF Veterans. Further, it suggests the pain management for these Veterans may need to be tailored to take CMI into consideration.

Pain and psychiatric comorbidities among two groups of Iraq and Afghanistan era Veterans.

Abstract: This study aimed to (1) identify the prevalence and severity of pain and psychiatric comorbidities among personnel who had been deployed during Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) and (2) assess whether the Department of Veterans Affairs (VA) Polytrauma System of Care and an OIF/OEF/OND registry reflect real differences among patients. Participants (N = 359) were recruited from two VA hospitals. They completed a clinical interview, structured diagnostic interview, and self-report measures. Results indicated pain was the most common complaint, with 87 percent experiencing pain during the prior week and 56 percent reporting moderate or severe pain. Eighty percent of participants met criteria for at least one of seven assessed comorbid problems (moderate or severe pain, postconcussional disorder, posttraumatic stress disorder [PTSD], anxiety disorder, mood disorder, substance use disorder, psychosis), and 59 percent met criteria for two or more problems. PTSD and postconcussional disorder rarely occurred in the absence of pain or other comorbidities (0.3% and 0%, respectively). The Polytrauma group had more comorbid psychiatric conditions (χ(2) = 48.67, p < 0.05) and reported greater severity of symptoms (p < 0.05) than the Registry group. This study confirmed the high prevalence of pain and concurrent mental health problems among personnel returning from military deployment.

Sex differences between Veterans participating in interdisciplinary chronic pain rehabilitation.

Abstract: The improved management of pain among the growing number of female Veterans receiving care through the Veterans Health Administration has been established as a priority, but studies suggest that females may respond differently to pain treatment. This study explored differences between female and male Veterans engaged in a Chronic Pain Rehabilitation Program and determined how female and male Veterans change following participation. Veterans (N = 324) in a 3 wk inpatient program completed self-report measures at admission, discharge, and 3 mo follow-up. Participants were 21% female (n = 67) and 79% male (n = 257). Compared with males, females were younger and less likely to be white or married/partnered. Females reported shorter pain duration and were more likely to have primary head or limb pain. At admission, fewer females were prescribed opioids than males and at lower doses. After opioid cessation in the program, however, there were no significant differences in use between the sexes at follow-up. Improvements in a range of domains were sustained at follow-up for both sexes, but females did not maintain gains in pain intensity or sleep while males reported more pain-related fear at discharge and follow-up. This study adds to the literature on sex-specific variations in chronic pain and implications for treatment.

Physical activity, ambulation, and comorbidities in people with diabetes and lower-limb amputation.

Abstract: We characterized physical activity (PA) and its relation to physical function and number of comorbidities in people with diabetes and transtibial amputation (AMP), people with diabetes without AMP, and nondisabled adults without diabetes or AMP. Twenty-two individuals with type 2 diabetes mellitus (DM) and transtibial amputation (DM+AMP), 11 people with DM, and 13 nondisabled participants were recruited for this cross-sectional cohort study. Measures included PA volume and intensity, a Timed Up and Go test, a 2-min walk test, and number of comorbidities. The nondisabled group performed greater amounts of PA than the DM group, who performed greater amounts of PA than the DM+AMP group. PA was related to physical function in the DM group and in the DM+AMP group, whereas no such relationship existed in the nondisabled group. PA was not related to number of comorbidities in any group. These findings suggest the ability to walk may affect overall performance of PA. Alternately, PA may alleviate walking problems. This possibility is of interest because issues with walking may be modifiable by improved levels and intensity of PA. PA's lack of relation to number of comorbidities suggests that factors beyond multiple morbidities account for group differences in PA.

Chronic Effects of Exposure to High-Intensity Blasts: Results of Tests of Central Auditory Processing

Abstract: Clinical Trial Registration: ClinicalTrials.gov: "Central auditory processing deficits associated with blast exposure"; NCT01567020; https://clinicaltrials.gov/ct2/show/NCT01567020 INTRODUCTION For well over a decade, the U.S. military has been engaged in conflicts that have changed the nature of injury and survival among Veterans because of changes in weaponry, battle armor, and medical technology that have taken place over the course of the past 20 yr [1]. According to the Institute of Medicine (IOM), these changes have resulted in a ratio of wounded to dead soldiers of 9.7 to 1 for the Global War on Terror, in contrast to rates of 4.3 to 1 or lower for all wars preceding it in the history of the United States [1]. Both the increased reliance upon explosives and the higher survival rate have created a landscape of new questions that must be answered in order to provide the best medical care for Veterans. This is true for hearing healthcare as much as for any other area of medicine. In 2014, the IOM issued a report on the chronic effects of exposure to high-intensity blasts [1]. In a systematic review of the literature, the IOM report found that symptoms of hearing loss are often present following blast exposure [2-3]. The report went on to state that while peripheral auditory dysfunction is likely to persist even after other effects have diminished, there was "inadequate" evidence in the literature to answer the question of whether or not central auditory effects persist beyond a period of 6 mo after blast exposure. The current report was motivated by ongoing research in our laboratory that has revealed evidence of an association between remote high-intensity blast exposure and the ability to process auditory information. Previous reports have described the ways in which blast exposure could [4] and does [3] cause changes in the ability of listeners to perform on tests of central auditory processing measured within a year of blast exposure. Tasks upon which blast-exposed participants were most likely to perform poorly included those relying upon temporal pattern perception, auditory temporal resolution, binaural processing, and dichotic listening. In addition, it has been demonstrated [3] that these problems occur even when traditional audiometric test results and electrophysiological measures primarily assessing the auditory brainstem remain largely in the normal range. Furthermore, electrophysiological measures evaluating cortical function indicate that some of these same listeners show delayed and reduced peak amplitudes relative to the responses expected from young listeners with normal peripheral auditory function. This pattern is consistent with the hypothesis that blast exposure can cause damage to cortical areas responsible for auditory processing, as well as potentially damaging the connections among central auditory processing areas. Clinically, these patterns of dysfunction are unusual in younger listeners but have similarities with patterns of abnormal performance sometimes observed in older listeners. Data collection and recruitment are currently ongoing, but this report has been compiled in order to provide timely information to the healthcare community regarding the question posed by the IOM concerning the possible persistence of the effects of blast exposure on the ability to process auditory information. To address this question, the behavioral data collected so far will be presented in a manner allowing direct comparison to the behavioral data from the previous study [3] of more recently blast-exposed patients. Additional measures not reported here, including a range of electrophysiological tests and a number of behavioral tests with speech and nonspeech stimuli, will be reported separately once the full cohort of participants has been recruited and tested. METHODS Participants The goal of the study was to test blast-exposed Veterans, but no database of such Veterans exists and the military records that might help to identify these Veterans are not available through the Department of Veterans Affairs (VA) electronic medical record system. …

Validity of activity monitors in wheelchair users: A systematic review.

Abstract: Assessing physical activity (PA) in manual wheelchair users (MWUs) is challenging because of their different movement patterns in comparison to the ambulatory population. The aim of this review was to investigate the validity of portable monitors in quantifying PA in MWUs. A systematic literature search was performed. The data source was full reports of validation and evaluation studies in peer-reviewed journals and conference proceedings. Eligible articles between January 1, 1999, and September 18, 2015, were identified in three databases: PubMed, Institute of Electrical and Electronics Engineers, and Scopus. A total of 164 articles (158 from the databases and 6 from the citation/reference tracking) were identified, and 29 met the eligibility criteria. Two investigators independently extracted the characteristics from each selected article following a predetermined protocol and completed seven summary tables describing the study characteristics and key outcomes. In the identified studies, the monitors were used to assess three types of PA measures: energy cost, user movement, and wheelchair movement. The customized algorithms/monitors did not estimate energy cost in MWUs as well as the commercial monitors did in the ambulatory population; however, they showed fair accuracy in measuring both wheelchair and user movements.

Scoping review of mobility scooter-related research studies.

Abstract: Mobility scooters are three- or four-wheeled power mobility devices regularly used by people who have difficulty ambulating. They also differ from power wheelchairs in terms of their driving controls, programmability, seating, and mounting method. Given their growing popularity and anecdotal concerns around their use, a scoping review was undertaken to identify empirical research about mobility scooters and to analyze their study design and purpose. Data sources included MedLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and PsychINFO. Thirty-two studies met the inclusion criteria. Most studies were descriptive in nature and reported information about scooter users' demographics, scooter-related activities, and accidents. The most common study design was a pre- and postintervention followed by a cross-sectional survey and retrospective review. Despite the increasing use of mobility scooters, surprisingly little scooter-related research has been conducted. Given the nature of most of the research in this area, further empirical evidence is needed to develop a better understanding about the frequency and causes of scooter accidents and the efficacy of interventions to improve users' skills, mobility, and safety.

Capturing nighttime symptoms in Parkinson disease: Technical development and experimental verification of inertial sensors for nocturnal hypokinesia.

Abstract: Although nocturnal hypokinesia represents one of the most common nocturnal disabilities in Parkinson disease (PD), it is often a neglected problem in daily clinical practice. We have developed a portable ambulatory motion recorder (the NIGHT-Recorder), which consists of 16-bit triaxial integrated microelectromechanical system inertial sensors that are specifically designed to measure movements, register the position of the body with respect to gravity, and provide information on rotations on the longitudinal axis while lying in bed. The signal processing uses the forward derivative method to identify rolling over and getting out of bed as primary indicators. The prototype was tested on six PD pairs to measure their movements for one night. Using predetermined definitions, 134 movements were captured consisting of rolling over 115 times and getting out of bed 19 times. Patients with PD rolled over significantly fewer times than their spouses (p = 0.03), and the position change was significantly smaller in patients with PD (p = 0.03). Patients with PD rolled over at a significantly slower speed (p = 0.03) and acceleration (p = 0.03) than their spouses. In contrast, patients with PD got out of bed significantly more often than their spouses (p = 0.02). It is technically feasible to develop an easy-to-use, portable, and accurate device that can assist physicians in the assessment of nocturnal movements of patients with PD.

Registering methodology for imaging and analysis of residual-limb shape after transtibial amputation.

Abstract: Successful prosthetic rehabilitation following lower-limb amputation depends upon a safe and comfortable socket-residual limb interface. Current practice predominantly uses a subjective, iterative process to establish socket shape, often requiring several visits to a prosthetist. This study proposes an objective methodology for residual-limb shape scanning and analysis by high-resolution, automated measurements. A three-dimensional printed "analog" residuum was scanned with three surface digitizers on 10 occasions. Accuracy was measured by the scan height error between repeat analog scans and the computer-aided design (CAD) geometry and the scan versus CAD volume. Subsequently, 20 male residuum casts from ambulatory individuals with transtibial amputation were scanned by two observers, and 10 were repeat-scanned by one observer. The shape files were aligned spatially and geometric measurements extracted. Repeatability was evaluated by intraclass correlation, Bland-Altman analysis of scan volumes, and pairwise root-mean-square error ranges of scan area and width profiles. Submillimeter accuracy was achieved when scanning the analog shape, and using male residuum casts the process was highly repeatable within and between observers. The technique provides clinical researchers and prosthetists the capability to establish their own quantitative, objective, multipatient data sets, providing an evidence base for training, long-term follow-up, and interpatient outcome comparison, for decision support in socket design.

Potential neurobiological benefits of exercise in chronic pain and posttraumatic stress disorder: Pilot study.

Abstract: This pilot study assessed the effects of cardiopulmonary exercise testing and cardiorespiratory fitness on plasma neuropeptide Y (NPY), allopregnanolone and pregnanolone (ALLO), cortisol, and dehydroepiandrosterone (DHEA), and their association with pain sensitivity. Medication-free trauma-exposed participants were either healthy (n = 7) or experiencing comorbid chronic pain/posttraumatic stress disorder (PTSD) (n = 5). Peak oxygen consumption (VO2) during exercise testing was used to characterize cardiorespiratory fitness. Peak VO2 correlated with baseline and peak NPY levels (r = 0.66, p < 0.05 and r = 0.69, p < 0.05, respectively), as well as exercise-induced changes in ALLO (r = 0.89, p < 0.001) and peak ALLO levels (r = 0.71, p < 0.01). NPY levels at the peak of exercise correlated with pain threshold 30 min after exercise (r = 0.65, p < 0.05), while exercise-induced increases in ALLO correlated with pain tolerance 30 min after exercise (r = 0.64, p < 0.05). In contrast, exercise-induced changes in cortisol and DHEA levels were inversely correlated with pain tolerance after exercise (r = -0.69, p < 0.05 and r = -0.58, p < 0.05, respectively). These data suggest that cardiorespiratory fitness is associated with higher plasma NPY levels and increased ALLO responses to exercise, which in turn relate to pain sensitivity. Future work will examine whether progressive exercise training increases cardiorespiratory fitness in association with increases in NPY and ALLO and reductions in pain sensitivity in chronic pain patients with PTSD.

Validity of the 8-Foot Up and Go, Timed Up and Go, and Activities-Specific Balance Confidence Scale in older adults with and without cognitive impairment.

Abstract: The purpose of this study was to determine whether (1) mild cognitive impairment (MCI) alters the validity of the Timed Up and Go (TUG), the 8-Foot Up and Go (8UG), or the Activities-Specific Balance Confidence (ABC) scale in the identification of fallers and nonfallers and (2) there were differences in the concurrent validity between the TUG and ABC when compared with the 8UG and ABC in those with and without MCI.. The classification of MCI was based on a score of <26 points on the Montreal Cognitive Assessment. For the 62 participants enrolled, excellent correlations were demonstrated in pairwise comparisons between the outcome measures (on a continuous scale). Based on frequently cited cutpoints, the sensitivity of the TUG was only 20% with a specificity of 94.6% and the sensitivity of the 8UG was 64% with a specificity of 75.7%. The TUG identified fallers at significantly different rates than the 8UG and the ABC (p < 0.05). For this reason, the 8UG is recommended as a more appropriate outcome measure for identifying fall risk in community-dwelling older adults. Fall history was found as the only significant predictor of test outcome for the TUG, 8UG, and ABC, indicating that MCI is not a significant determinant of test performance.

Effects of high-speed power training on muscle strength and power in patients with multiple sclerosis.

Abstract: This study examined the effects of a high-speed power training program in peak muscle power and maximal voluntary isometric contraction (MVIC) of knee extensors in patients with relapsing-remitting multiple sclerosis (MS). Forty patients, 20 women (age 42.8 +/- 10.3 yr) and 20 men (age 44.0 +/- 8.7 yr) diagnosed with relapsing-remitting MS were randomly assigned, with respect to sex, to either an exercise group or a control group. Participants from the exercise group performed 12 wk of supervised muscle power training of knee extensors. All subjects were tested for MVIC and peak muscle power at baseline and after the training intervention. A strain gauge was used to measure the MVIC, and peak muscle power was assessed with a linear encoder at five relative loads. The training-related effects were assessed using a t-test. The results showed no significant changes in the control group from baseline to postintervention evaluation. In contrast, the exercise group significantly increased MVIC (10.8%; p < 0.05) and muscle power at 40, 50, 60, 70, and 80% of the MVIC by 21.8, 14.5, 17.3, 19.4, and 22.3%, respectively (p < 0.01), after the training. These findings suggest that 12 wk of high-speed power training improve both MVIC and muscle power at five different loads in patients with relapsing-remitting MS.

The biomechanical response of persons with transfemoral amputation to variations in prosthetic knee alignment during level walking.

Abstract: Prosthetic alignment is an important factor in the overall fit and performance of a lower-limb prosthesis. However, the association between prosthetic alignment and control strategies used by persons with transfemoral amputation to coordinate the movement of a passive prosthetic knee is poorly understood. This study investigated the biomechanical response of persons with transfemoral amputation to systematic perturbations in knee joint alignment during a level walking task. Quantitative gait data were collected for three alignment conditions: bench alignment, 2 cm anterior knee translation (ANT), and 2 cm posterior knee translation (POST). In response to a destabilizing alignment perturbation (i.e., the ANT condition), participants significantly increased their early-stance hip extension moment, confirming that persons with transfemoral amputation rely on a hip extensor strategy to maintain knee joint stability. However, participants also decreased the rate at which they loaded their prosthesis, decreased their affected-side step length, increased their trunk flexion, and maintained their prosthesis in a more vertical posture at the time of opposite toe off. Collectively, these results suggest that persons with transfemoral amputation rely on a combination of strategies to coordinate stance-phase knee flexion. Further, comparatively few significant changes were observed in response to the POST condition, suggesting that a bias toward posterior alignment may have fewer implications in terms of stance-phase, knee joint control.

A conceptual model for vision rehabilitation.

Abstract: Vision impairments are highly prevalent after acquired brain injury (ABI). Conceptual models that focus on constructing intellectual frameworks greatly facilitate comprehension and implementation of practice guidelines in an interprofessional setting. The purpose of this article is to provide a review of the vision literature in ABI, describe a conceptual model for vision rehabilitation, explain its potential clinical inferences, and discuss its translation into rehabilitation across multiple practice settings and disciplines.

Balance confidence and activity of community-dwelling patients with transtibial amputation

Abstract: The purpose of this study was to examine the relationship between balance confidence and community-based physical activity. Twenty-two community-dwelling patients with right or left unilateral transtibial amputation who reported no falls in the past 6 mo completed the Activities-Specific Balance Confidence Scale (ABC) and wore a StepWatch Activity Monitor for 7 consecutive d in the community. Subjects were subsequently stratified as low ( /=3,000) steps/d) activity groups. Balance confidence was significantly lower among the low activity weekday group (LAG, 70.8 +/- 12.0 versus 88.9 +/- 8.7, t(20) = 3.97, p = 0.001). Further, correlation analysis revealed a positive correlation between ABC score and step total (r = 0.55, p < 0.01). It is unknown whether the LAG limited ambulation as an intentional strategy of fall-risk avoidance. Although clinicians routinely inquire about falls in the community among patients with lower-limb amputation, the results of this study emphasize the importance of contextualizing recent fall history relative to activity level. Clinicians can use this contextual information when considering the inclusion of appropriate fall-risk mediation strategies relative to activity levels and counseling patients of the benefits of physical exercise for maintaining functional capacity and general health.

Gait kinematics and kinetics are affected more by peripheral arterial disease than by age.

Abstract: Peripheral arterial disease (PAD) produces abnormal gait and disproportionately affects older individuals. The current study investigated PAD gait biomechanics in younger ( /=65 yr) subjects. The study included 61 patients with PAD (31 younger, age: 57.4 +/- 5.3 yr, and 30 older, age: 71.9 +/- 5.2 yr) and 52 nondisabled age-matched control subjects. Patients with PAD were tested during pain-free walking and compared with control subjects. Joint kinematics and kinetics (torques) were compared using a 2 x 2 analysis of variance (groups: patients with PAD vs control subjects, age: younger vs older). Patients with PAD had significantly increased ankle and decreased hip range of motion during the stance phase as well as decreased ankle dorsiflexor torque compared with control subjects. Gait changes in older individuals are largely constrained to time-distance parameters. Joint kinematics and kinetics are significantly altered in patients with PAD during pain-free walking. Symptomatic PAD produces a consistent ambulatory deficit across ages definable by advanced biomechanical analysis. The most important finding of the current study is that gait, in the absence of PAD and other ambulatory comorbidities, does not decline significantly with age based on advanced biomechanical analysis. Therefore, previous studies must be examined in the context of patients with potential PAD being present in the population, and future ambulatory studies must include PAD as a confounding factor when assessing the gait function of elderly individuals.