Archives of Physical Medicine and Rehabilitation - Articles in Press

Quality of Care Indicators for the Rehabilitation of Children With Traumatic Brain Injury - Corrected Proof

2012-01-27

Abstract: Rivara FP, Ennis SK, Mangione-Smith R, MacKenzie EJ, Jaffe KM; and the National Expert Panel for the Development of Pediatric Rehabilitation Quality Care Indicators. Quality of Care Indicators for the Rehabilitation of Children With Traumatic Brain Injury. Objective: To develop measurement tools for assessing compliance with identifiable processes of inpatient care for children with traumatic brain injury (TBI) that are reliable, valid, and amenable to implementation. Design: Literature review and expert panel using the RAND/UCLA Appropriateness Method and a Delphi technique. Setting: Not applicable. Participants: Children with TBI. Interventions: Not applicable. Main Outcome Measure: Quality of care indicators. Results: A total of 119 indicators were developed across the domains of general management; family-centered care; cognitive-communication, speech, language, and swallowing impairments; gross and fine motor skill impairments; neuropsychologic, social, and behavioral impairments; school reentry; and community integration. There was a high degree of agreement on these indicators as valid and feasible quality measures for children with TBI. Conclusions: These indicators are an important step toward building a better base of evidence about the effectiveness and efficiency of the components of acute inpatient rehabilitation for pediatric patients with TBI.

Quality of Care Indicators for the Structure and Organization of Inpatient Rehabilitation Care of Children With Traumatic Brain Injury - Corrected Proof

2012-01-27

Abstract: Zumsteg JM, Ennis SK, Jaffe KM, Mangione-Smith R, MacKenzie EJ, Rivara FP; and the National Expert Panel for the Development of Pediatric Rehabilitation Quality of Care Indicators. Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury. Objectives: To develop evidence-based and expert-driven quality indicators for measuring variations in the structure and organization of acute inpatient rehabilitation for children after traumatic brain injury (TBI) and to survey centers across the United States to determine the degree of variation in care. Design: Quality indicators were developed using the RAND/UCLA modified Delphi method. Adherence to these indicators was determined from a survey of rehabilitation facilities. Setting: Inpatient rehabilitation units in the United States. Participants: A sample of rehabilitation programs identified using data from the National Association of Children's Hospitals and Related Institutions, Uniform Data System for Medical Rehabilitation, and the Commission on Accreditation of Rehabilitation Facilities yielded 74 inpatient units treating children with TBI. Survey respondents comprised 31 pediatric and 28 all age units. Interventions: Not applicable. Main Outcome Measures: Variations in structure and organization of care among institutions providing acute inpatient rehabilitation for children with TBI. Results: Twelve indicators were developed. Pediatric inpatient rehabilitation units and units with higher volumes of children with TBI were more likely to have: a census of at least 1 child admitted with a TBI for at least 90% of the time; adequate specialized equipment; a classroom; a pediatric subspecialty trained medical director; and more than 75% of therapists with pediatric training. Conclusions: There were clinically and statistically significant variations in the structure and organization of acute pediatric rehabilitation based on the pediatric focus of the unit and volume of children with TBI.

Behavioral Recovery in Disorders of Consciousness: A Prospective Study With the Spanish Version of the Coma Recovery Scale–Revised - Corrected Proof

2012-01-27

Abstract: Noé E, Olaya J, Navarro MD, Noguera P, Colomer C, García-Panach J, Rivero S, Moliner B, Ferri J. Behavioral recovery in disorders of consciousness: a prospective study with the Spanish version of the Coma Recovery Scale–Revised. Objective: To describe the clinical characteristics and short-term pattern of evolution of a sample of patients within 1 year after acquiring a brain injury that led to a vegetative state (VS) or a minimally conscious state (MCS). Design: Cohort study. Setting: Inpatient brain injury rehabilitation program. Participants: Patients with acquired brain injury (N=32; 47% traumatic, 37.5% hemorrhagic, 15.5% anoxic) who were in a VS or an MCS according to Coma Recovery Scale–Revised (CRS-R) scores. Intervention: Integrative multisensory program comprising daily physical rehabilitation procedures and multimodal sensory stimulation. Main Outcome Measure: All patients were assessed with a Spanish version of the CRS-R at admission and then monthly for at least 6 months or until emergence from MCS. Results: At the time of admission, 12 patients were diagnosed as being in a VS and 20 as being in an MCS. Eight patients were able to emerge from their MCS during follow-up. Seven of these 8 patients were diagnosed as being in an MCS at inclusion, and only 1 was diagnosed as being in a VS. Emergence from an MCS was mostly associated with improvement in both the communication and motor function scales (n=4). Lesser chronicity (P=.01) and the presence of more than visual behavioral responses at admission (P=.05) were both significant predictors of emergence from an MCS. Conclusions: The CRS-R seems appropriate for establishing an immediate prognosis in this population. A quick referral of these patients for specialized assessment and rehabilitation facilities is recommended.

Preliminary Results of Patient-Defined Success Criteria for Individuals With Musculoskeletal Pain in Outpatient Physical Therapy Settings - Corrected Proof

2012-01-27

Abstract: Zeppieri G Jr, Lentz TA, Atchison JW, Indelicato PA, Moser MW, Vincent KR, George SZ. Preliminary results of patient-defined success criteria for individuals with musculoskeletal pain in outpatient physical therapy settings. Objectives: (1) To investigate patient-defined parameters of treatment success in an outpatient physical therapy setting with musculoskeletal pain, (2) to determine whether patient-defined treatment success was influenced by selected demographic and clinical factors, and (3) to examine whether patient subgroups existed for ratings of importance for each treatment outcome domain. Design: Cross-sectional study. Setting: Outpatient physical therapy clinic. Participants: Consecutive patients (N=110) with complaints of musculoskeletal pain. Interventions: Not applicable. Main Outcome Measure: We reported patient-defined treatment success targets for pain, fatigue, emotional distress, and interference with daily activities using the Patient-Centered Outcomes Questionnaire (PCOQ). We also investigated whether patient subgroups existed based on perceived importance of improvement for these same outcome domains. Results: Patient-defined criteria for treatment success included mean reductions (from baseline scores) in pain of 3.0 points, in fatigue of 2.3 points, in emotional distress of 1.4 points, and in interference with daily activities of 3.4 points. There were no differences in patient-defined criteria for treatment success based on sex, age, postoperative rehabilitation, prior physical therapy, other prior health care interventions, duration of symptoms, and anatomical location of symptoms (P>.01). Cluster analysis of the PCOQ importance ratings indicated a 2-cluster solution. The multifocused subgroup demonstrated higher importance for improvement ratings in each treatment outcome domain when compared with the pain-focused subgroup (P>.05). Conclusions: These data indicate that patient-defined criteria for treatment success required greater reductions in the studied outcome domains to be considered successful. These data suggest the potential existence of patient subgroups that either rate improvement in all outcome domains as important or rate pain relief as the most important outcome.

Investigating Changes in Quality of Life and Function Along the Lifespan for People With Spinal Cord Injury - Corrected Proof

2012-01-27

Abstract: Pershouse KJ, Barker RN, Kendall MB, Buettner PG, Kuipers P, Schuurs SB, Amsters DI. Investigating changes in quality of life and function along the lifespan for people with spinal cord injury. Objective: To track changes in quality of life and function for people with spinal cord injury (SCI) along the lifespan. Design: A wave panel design in which data were collected annually over 5 years across 6 strata that represented different periods since injury. Setting: Telephone interviews with participants in their home environment. Participants: People (n=270) who had sustained a traumatic SCI in Queensland, Australia, over the previous 60 years. Interventions: Not applicable. Main Outcome Measures: Quality of life was measured using the World Health Organization Quality of Life-8. Human functioning was measured in 3 components. Body structure/function was measured using the Secondary Conditions Surveillance Instrument. Activity was measured using the motor subscale of the FIM (mFIM) and the Clinical Outcomes Variables Scale. Participation was measured using the Community Integration Measure (CIM) and the Impact on Participation and Autonomy questionnaire. Results: Quality of life remained relatively constant across the lifespan. For body structure/function, there was a significant increase in secondary conditions with time since injury. There was a significant decrease in activity as measured by the mFIM for higher functioning individuals. Participation, as measured by the CIM, showed a significant increase with time since injury, but not when adjusted for the American Spinal Injury Association Impairment Scale, income level, and living situation. Conclusions: The findings of this study highlight that people with SCI are able to maintain quality of life and participation along the lifespan; however, increases in secondary conditions and a decline in function over time are likely. Rehabilitation services could work more effectively at addressing secondary prevention through enhanced monitoring over time, while broader societal responses are likely to hold the key to optimizing human functioning.

Invited Commentary on Quality of Care Indicators for the Rehabilitation of Children With Traumatic Brain Injury, and Quality of Care Indicators for the Structure and Organization of Inpatient Rehabilitation Care of Children With Traumatic Brain Injury - Corrected Proof

John Whyte — 2012-01-27

Abstract: Whyte J. Invited commentary on quality of care indicators for the rehabilitation of children with traumatic brain injury, and quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury. Measures of structure and process in health care have been shown to be associated with care outcomes in prior research. Two articles in this issue propose measures of structure and process that may be relevant to pediatric traumatic brain injury rehabilitation. This commentary considers how these potential measures may be related to the actual treatments and services that ultimately affect patient outcomes.

Inter- and Intrarater Reliability of Isokinetic Thigh Muscle Strength Tests in Postmenopausal Women with Osteopenia - Corrected Proof

Ingrid Eitzen, Kari Anne Hakestad, May Arna Risberg — 2012-01-24

Abstract: Eitzen I, Hakestad KA, Risberg MA. Inter- and intrarater reliability of isokinetic thigh muscle strength tests in postmenopausal women with osteopenia. Objective: To evaluate inter- and intrarater reliability of isokinetic muscle strength measurements during knee extension and flexion in postmenopausal women with osteopenia. Design: Reliability study assessing inter- and intrarater reliability. Setting: General community. Participants: A convenience sample of 27 postmenopausal women (mean age ± SD, 68.2±7.3y) with defined osteopenia from a bone mineral density T score of less than 1.5 and a wrist fracture within the last 2 years. Interventions: Not applicable. Main Outcome Measures: Isokinetic concentric muscle strength during knee extension and flexion was measured for 2 test conditions: 5 repetitions at 60°/s, and 25 repetitions at 180°/s. Agreement between tests was evaluated with the intraclass correlation coefficient (ICC2,1). Mean difference between tests, standard error of measurement (SEM and SEM%), and smallest real difference (SRD and SRD%) were calculated with 95% confidence intervals. SRD% and SEM% are emphasized in the results to allow congruent comparisons between the different test conditions. Results: ICC2,1 reflected high agreement both for inter- and intrarater reliability, with most of the values .90 or greater. There were no significant differences between the left and the right leg at any of the 3 tests. Some differences were apparent between the test sessions, but these were not systematic. Agreements were overall higher for assessments during knee extension than knee flexion. The SEM% was between 3.5% and 10.2% for knee extension, and 7.0% and 17.7% for knee flexion. SRD% was suggested to be between 15% and 20% for knee extension, and 25% and 30% for knee flexion. Conclusions: Isokinetic assessments of thigh muscle strength in postmenopausal women with osteopenia are of high reliability, with a level of agreement comparable to the levels found in previous reliability studies concerning both the healthy elderly and elderly with different health conditions. The measurement errors are small to moderate. The established SRD% provides thresholds for whether observed changes in strength in this patient group represent true change, which allows evaluations of minimal clinical importance in future studies.

Postural Adjustment of Children With Spastic Diplegic Cerebral Palsy During Seated Hand Reaching in Different Directions - Corrected Proof

Yun-Huei Ju, Ing-Shiou Hwang, Rong-Ju Cherng — 2012-01-24

Abstract: Ju Y-H, Hwang I-S, Cherng R-J. Postural adjustment of children with spastic diplegic cerebral palsy during seated hand reaching in different directions. Objectives: To examine the effect of reaching in different directions on postural adjustment in children with diplegic cerebral palsy (CP), and to examine the relationship between hand reach performance and postural adjustment, and between postural control ability and postural adjustment. Design: Cross-sectional study. Setting: A movement science laboratory at a medical university. Participants: Children with CP (n=12) and typically developing (TD) children (n=16). Interventions: Not applicable. Main Outcome Measures: Two force platforms were used to measure the ground reaction force (GRF) and center of pressure (COP) data. Absolute peak COP velocity, COP sway ratio (SR), and mean GRF in the anterior posterior direction during the acceleration and deceleration segments of a reaching task were the main outcome measures. Results: Children with CP showed a greater absolute peak COP velocity in the medial lateral direction, a smaller SR (wider COP pattern), and greater amplitude of force modulation (exaggerated postural adjustments) than TD children in lateral or medial reaches. There was a moderate correlation between SR and total Pediatric Reach Test score. The chair SR was also negatively correlated with the hand movement units. Conclusions: Children with CP showed wider, more crooked, and less efficient COP patterns than TD children, especially on medial or lateral reaches. Reaching medially or laterally involves trunk rotation, which produces more postural challenges than reaching anteriorly to children with CP. The patterns of postural adjustments in children with CP were correlated with their postural control ability and hand-reach smoothness.

Effect of Functional Status on Survival in Patients With Stroke: Is Independent Ambulation a Key Determinant? - Corrected Proof

Hsi-Ting Chiu, Yen-Ho Wang, Jiann-Shing Jeng, Bang-Bin Chen, Shin-Liang Pan — 2012-01-24

Abstract: Chiu H-T, Wang Y-H, Jeng J-S, Chen B-B, Pan S-L. Effect of functional status on survival in patients with stroke: is independent ambulation a key determinant? Objective: To investigate the effect of functional status, measured using the Modified Rankin Scale (MRS), at 3 months after stroke on survival in patients with stroke. Design: Cohort study. Setting: Referral medical center. Participants: Patients with stroke (N=1032). Interventions: Not applicable. Main Outcome Measure: Survival after stroke. Results: The Kaplan-Meier survival curves stratified by the 3-month MRS score showed 2 clear groups of patients with 3-month MRS scores of 0 to 3 (able to walk without assistance) and 4 or 5 (unable to walk without assistance). Accordingly, we grouped the patients into a high function (HF) group (3-month MRS≦3) and a low function (LF) group (3-month MRS≧4). Multiple Cox regression analysis showed that the LF group had significantly poorer survival (adjusted hazard ratio=4.69; 95% confidence interval [CI], 2.89–7.60; P<.001) than the HF group. Other significant risk factors of higher mortality were older age, history of diabetes mellitus, and heart disease. Conclusions: This study showed a significant influence of the 3-month MRS score on stroke survival. Moreover, independent ambulation may be a major determinant of a favorable survival prognosis. This finding suggests a potential role of rehabilitation in promoting stroke survival by maximizing ambulation function.

Relationship Between Gross Motor and Intellectual Function in Children With Cerebral Palsy: A Cross-Sectional Study - Corrected Proof

2012-01-24

Abstract: Dalvand H, Dehghan L, Hadian MR, Feizy A, Hosseini SA. Relationship between gross motor and intellectual function in children with cerebral palsy: a cross-sectional study. Objective: To explore the relationship between gross motor and intellectual function in children with cerebral palsy (CP). Design: A cross-sectional study. Setting: Occupational therapy clinic. Participants: Children with CP (N=662; 281 girls, 381 boys; age range, 3–14y). Interventions: Not applicable. Main Outcome Measures: Intelligence testing was carried out by means of the Wechsler Preschool and Primary Scale of Intelligence and the Wechsler Intelligence Scale for Children–Revised. Gross motor function level was determined by the Gross Motor Function Classification System Expanded and Revised (GMFCS E&R). Results: Of the children, 10.4% were at level I of the GMFCS E&R, 38% at levels II and III, and 51.5% at levels IV and V. The lowest level of intelligence or profound intellectual disability was found in children with spastic quadriplegia (n=28, 62.2%). Children at the lowest levels (I–IV, GMFCS E&R) obtained higher ratings in terms of intelligence in comparison with children at level V. Based on the present results, the diagnosis was statistically related to the intellectual level as dependent variable (P<.01); accordingly, hypotonic, quadriplegic, and hemiplegic patients had the highest odds to assign higher ratings in abnormal intelligence, respectively. Sex and age were not statistically related to the dependent variable. Conclusions: The study results demonstrated a significant association between GMFCS E&R and intellectual function. Therefore, we suggest that particular attention should be paid to the intellectual level in terms of evaluations of gross motor function. These results, in respect, might be interested for occupational and physical therapists who are involved in rehabilitation programs for these children.

Development of a Clinical Multiple-Lunge Test to Predict Falls in Older Adults - Corrected Proof

Ruth Wagenaar, Justin W.L. Keogh, Denise Taylor — 2012-01-16

Abstract: Wagenaar R, Keogh JW, Taylor D. Development of a clinical Multiple-Lunge Test to predict falls in older adults. Objective: To develop a new Multiple-Lunge Test to distinguish between fallers and nonfallers in community-dwelling older adults. Design: A cross-sectional design was used to establish the sensitivity and specificity of the test to predict faller status based on retrospective self-reported fall history. Setting: Local retirement villages. Participants: Community-dwelling older adults (N=130; mean age ± SD, 77±7y) with (n=40) and without (n=90) a history of falls. Interventions: The Multiple-Lunge Test required individuals to lunge forward to a step length determined as 60% of their leg length, and return to start, for 5 consecutive repetitions. Interday and intraday test-retest reliability of the Multiple-Lunge Test was established across 2 testing occasions. Main Outcome Measures: Number of steps performed correctly, total time to complete 5 steps. Results: The Multiple-Lunge Test was found to be reliable across trials (Intraday: intraclass correlation coefficient [ICC]=.79–.81 for steps, ICC=.86–.88 for time; Interday: ICC=.77 for steps; ICC=.84 for time). Sensitivity and specificity values were calculated as 73% and 63%, respectively, for predicting multiple fallers using the measure of all 5 steps done correctly. Conclusions: The test is easily administered and because of its challenging nature, it may be well suited to detect subtle differences in abilities of higher functioning, community-dwelling older adults. A practitioner can be confident in 7 of 10 cases that an older adult who cannot complete all 5 steps of the Multiple-Lunge Test is at high risk of falls. The results suggest that there is potential for the Multiple-Lunge Test to be used in clinical practice; however, additional research on how to further increase its validity appears warranted.

Biomechanical and Clinical Outcomes With Shock-Absorbing Insoles in Patients With Knee Osteoarthritis: Immediate Effects and Changes After 1 Month of Wear - Corrected Proof

2012-01-16

Abstract: Turpin KM, De Vincenzo A, Apps AM, Cooney T, MacKenzie MD, Chang R, Hunt MA. Biomechanical and clinical outcomes with shock-absorbing insoles in patients with knee osteoarthritis: immediate effects and changes after 1 month of wear. Objectives: To examine the effectiveness of shock-absorbing insoles in the immediate reduction of knee joint load, as well as reductions in knee joint load, pain, and dysfunction after 1 month of wear, in individuals with knee osteoarthritis (OA). Design: Pre-post design with participants exposed to 2 conditions (normal footwear, shock-absorbing insoles) with a 1-month follow-up. Setting: University laboratory for testing and general community for intervention. Participants: Community-dwelling individuals (N=16; 6 men, 10 women) with medial compartment knee OA. Intervention: Participants were provided with sulcus length shock-absorbing insoles to be inserted into their everyday shoes. Main Outcome Measures: Primary outcome measures included the peak, early stance peak, and late stance peak external knee adduction moment (KAM); the KAM impulse (positive area under the KAM curve); and peak tibial vertical acceleration. Secondary outcomes included walking pain, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale and total score, and a timed stair climb task. Results: There was a significant reduction in the late stance peak KAM with shock-absorbing insoles (P=.03) during follow-up compared with the baseline test session. No other immediate or longitudinal significant changes (P>.05) in the other KAM parameters or peak tibial acceleration after use of a shock-absorbing insole were observed. However, significant improvements in all measures of pain and function (P<.05) were observed. Conclusions: Shock-absorbing insoles produced significant reductions in self-reported knee joint pain and physical dysfunction with 1 month of wear in patients with knee OA despite no consistent changes in knee joint load. Further research using randomized controlled trials, with larger sample sizes and explorations into long-term use of shock-absorbing insoles and their effect on disease progression, is warranted.

Effect of Triage on Waiting Time for Community Rehabilitation: A Prospective Cohort Study - Corrected Proof

Katherine E. Harding, Nicholas F. Taylor, Sandra G. Leggat, Maree Stafford — 2012-01-16

Abstract: Harding KE, Taylor NF, Leggat SG, Stafford M. Effect of triage on waiting time for community rehabilitation: a prospective cohort study. Objective: To investigate how the allocation of referrals for a community rehabilitation service to triage categories affects waiting time from referral to first appointment, and whether other factors also contribute to variance in waiting time. Design: A prospective cohort study. Setting: A multidisciplinary outpatient community rehabilitation program within a large metropolitan health service. Participants: Consecutive adult patients (N=379) commencing rehabilitation over a 3-month period. Intervention: Allocation of referrals to a triage category of 1 (most urgent) to 4 (least urgent) by allied health clinicians guided by a written protocol. Main Outcome Measure: The primary outcome was waiting time from referral to service commencement. Results: The small group of patients (4%) allocated to the most urgent category had significantly shorter mean waiting times than the other 3 categories (mean, 4.8d vs 19.6, 26.6, and 19.4d for categories 2, 3, and 4, respectively). Regression analysis indicated that approximately 11% of the variance in waiting time was accounted for by the triage categories. Site of treatment (home or center) and diagnosis also made small contributions (4% combined) to variance in waiting time. Conclusions: The triage process ensured rapid service for a small number of urgent referrals, but made little difference to the waiting time of the vast majority of patients. Given the resources required for triaging patients, the results of this study lead us to question the value of the triage system in this setting.

Is There a Dose Response for Valgus Unloader Brace Usage on Knee Pain, Function, and Muscle Strength? - Corrected Proof

2012-01-13

Abstract: Hurley ST, Hatfield Murdock GL, Stanish WD, Hubley-Kozey CL. Is there a dose response for valgus unloader brace usage on knee pain, function, and muscle strength? Objective: To examine whether there was a dose response for valgus unloader brace wear on knee pain, function, and muscle strength in participants with medial compartment knee osteoarthritis. Design: In this single-group study, participants with medial compartment knee osteoarthritis were followed for approximately 6 months. Setting: Recruitment was conducted in the general community, and testing was performed at a university laboratory. Participants: A convenience sample of patients (N=32) who were prescribed a valgus unloader brace agreed to participate, met the inclusion criteria, and completed the baseline data collection. Twenty-four participants (20 men, 4 women) completed baseline and follow-up collections. Intervention: Participants wore their valgus unloader brace as needed. Main Outcome Measures: Knee extensor, flexor, and plantar flexor strength was tested at baseline and follow-up. Participants filled out Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Medical Outcomes Study 36-Item Short-Form Health Survey questionnaires to assess pain and function. Self-selected walking velocity and stride length were objective measures of function. Brace usage (dose) and activity (step count) were recorded at least 4 days/week for the study duration. Results: Positive relationships existed between brace wear usage and percent change in step count (r=.59, P=.006) and percent change in hamstrings strength (r=.37, P=.072). At follow-up, there was significant improvement in hamstrings strength (P=.013), and trends toward improvements in WOMAC pain (P=.059) and WOMAC function (P=.089). Conclusions: Our results indicate that greater brace use may positively affect physical activity level, but there was minimal effect of brace wear dosage on lower-limb muscle strength. Only knee flexion showed a positive relationship. Our finding of no decreased muscle strength indicates that increased brace use over a 6-month period does not result in muscle impairment.

Effect of Fluid Collections on Long-Term Outcome After Lower Limb Amputation - Corrected Proof

Rajiv Singh, Guruprasad Venkateshwara — 2012-01-13

Abstract: Singh R, Venkateshwara G. Effect of fluid collections on long-term outcome after lower limb amputation. Objective: To ascertain the long-term outcome for individuals found to have fluid collections in residual limbs after amputation. Design: Prospective cohort study. Setting: Outpatient follow-up at a prosthetic rehabilitation unit. Participants: Successive lower limb amputations (N=105) scanned for fluid collections after operation and followed up after 3 years. Interventions: Not applicable. Main Outcome Measures: Survival; secondary outcomes of prosthetic limb use, hours of prosthetic limb-wearing, anxiety and depression levels. Results: After 3 years, 70 individuals were alive, of whom 21 (30%) had fluid collections originally. There was no significant difference at follow-up between the group that had fluid collections in their residual limbs after surgery and the group that did not in terms of survival (χ21=.21, P=.64), numbers wearing prosthetic limb (χ21=.102, P=.75), hours of limb wearing (t37=.35, P=.72), anxiety (χ21=.77, P=.78), and depression (χ21=1.98, P=.16). A multivariable logistic regression confirmed that presence of fluid collection was not associated with survival. Conclusions: Fluid collections in residual limbs after amputation are common, but patients can be reassured that their long-term outcomes are not affected.

Effectiveness of Myofascial Release in the Management of Lateral Epicondylitis in Computer Professionals - Corrected Proof

M.S. Ajimsha, Saraladevi Chithra, Ramiah Pillai Thulasyammal — 2012-01-12

Abstract: Ajimsha MS, Chithra S, Thulasyammal RP. Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Objective: To investigate whether myofascial release (MFR) reduces the pain and functional disability of lateral epicondylitis (LE) in comparison with a control group receiving sham ultrasound therapy in computer professionals. Design: Randomized, controlled, single blinded trial. Setting: Nonprofit research foundation clinic in Kerala, India. Participants: Computer professionals (N=68) with LE. Interventions: MFR group or control group. The techniques were administered by certified MFR practitioners and consisted of 12 sessions per client over 4 weeks. Main Outcome Measure: The Patient-Rated Tennis Elbow Evaluation (PRTEE) scale was used to assess pain severity and functional disability. The primary outcome measure was the difference in PRTEE scale scores between week 1 (pretest score), week 4 (posttest score), and follow-up at week 12 after randomization. Results: The simple main effects analysis showed that the MFR group performed better than the control group in weeks 4 and 12 (P<.005). Patients in the MFR and control groups reported a 78.7% and 6.8% reduction, respectively, in their pain and functional disability in week 4 compared with that in week 1, which persisted as 63.1% in the follow-up at week 12 in the MFR group. Conclusions: This study provides evidence that MFR is more effective than a control intervention for LE in computer professionals.

Accurate Prediction of Cardiorespiratory Fitness Using Cycle Ergometry in Minimally Disabled Persons With Relapsing-Remitting Multiple Sclerosis - Corrected Proof

Robert W. Motl, Bo Fernhall — 2012-01-09

Abstract: Motl RW, Fernhall B. Accurate prediction of cardiorespiratory fitness using cycle ergometry in minimally disabled persons with relapsing-remitting multiple sclerosis. Objective: To examine the accuracy of predicting peak oxygen consumption (Vo2peak) primarily from peak work rate (WRpeak) recorded during a maximal, incremental exercise test on a cycle ergometer among persons with relapsing-remitting multiple sclerosis (RRMS) who had minimal disability. Design: Cross-sectional study. Setting: Clinical research laboratory. Participants: Women with RRMS (n=32) and sex-, age-, height-, and weight-matched healthy controls (n=16) completed an incremental exercise test on a cycle ergometer to volitional termination. Intervention: Not applicable. Main Outcome Measures: Measured and predicted Vo2peak and WRpeak. Results: There were strong, statistically significant associations between measured and predicted Vo2peak in the overall sample (R2=.89, standard error of the estimate=127.4mL/min) and subsamples with (R2=.89, standard error of the estimate=131.3mL/min) and without (R2=.85, standard error of the estimate=126.8mL/min) multiple sclerosis (MS) based on the linear regression analyses. Based on the 95% confidence limits for worst-case errors, the equation predicted Vo2peak within 10% of its true value in 95 of every 100 subjects with MS. Conclusions: Peak Vo2 can be accurately predicted in persons with RRMS who have minimal disability as it is in controls by using established equations and WRpeak recorded from a maximal, incremental exercise test on a cycle ergometer.

Reliability, Validity, and Responsiveness of Myotonometric Measurement of Muscle Tone, Elasticity, and Stiffness in Patients With Stroke - Corrected Proof

Li-ling Chuang, Ching-yi Wu, Keh-chung Lin — 2012-01-06

Abstract: Chuang L-L, Wu C-Y, Lin K-C. Reliability, validity, and responsiveness of myotonometric measurement of muscle tone, elasticity, and stiffness in patients with stroke. Objective: To assess the metric properties of a myotonometer. Design: Metric study. Setting: Three medical centers. Participants: Stroke patients (N=67). Intervention: Upper-extremity rehabilitation programs. Main Outcome Measures: The tone, elasticity, and stiffness of relaxed extensor digitorum, flexor carpi radialis, and flexor carpi ulnaris were measured using the myotonometer. Fifty-eight patients completed the myotonometer measures twice at pretreatment. The myotonometric measurement and the criteria measures, including hand strength (grip, lateral pinch, and palmar pinch strength) and Action Research Arm Test (ARAT) were administered at pretreatment and posttreatment. Results: The myotonometer showed high test-retest reliability for muscle properties in 3 muscles. Significant correlations existed between the tone and stiffness of the 3 muscles and palmar pinch strength, between those of the flexor carpi muscles and lateral pinch strength, and between those of the flexor carpi radialis and the ARAT at posttreatment. The posttreatment elasticity of the 2 flexor carpi muscles was significantly correlated with grip strength. The pretreatment elasticity of the flexor carpi ulnaris was significantly correlated with posttreatment grip strength, and the pretreatment muscle tone and stiffness of the flexor carpi radialis were significantly correlated with palmar pinch strength and the ARAT. The responsiveness of the extensor digitorum was higher than that of the flexor carpi radialis and ulnaris. Muscle stiffness was more responsive than tone and elasticity in 3 muscles. Conclusions: Myotonometry can be a reliable, valid, and responsive outcome measure for assessing muscle properties after stroke rehabilitation.

Relationship Between Obesity and Falls by Middle-Aged and Older Women - Corrected Proof

Noah J. Rosenblatt, Mark D. Grabiner — 2012-01-04

Abstract: Rosenblatt NJ, Grabiner MD. Relationship between obesity and falls by middle-aged and older women. It has been suggested that obesity increases fall risk, based on diminished static balance and increased fall-related injury risk. However, these findings only indirectly relate obesity and falls. The purpose of this study was to use existing data to directly explore the relationship between obesity and falls by community-dwelling women aged 55 years and older. Eighty-six subjects (42 obese) reported falls occurring during the previous year (retrospective falls), and over the following year responded to biweekly communications inquiring whether they fell or stumbled (prospective falls/stumbles). Because trips represent the largest fall cause by community-dwelling adults, we also analyzed outcomes and recovery strategies of 25 women (13 obese) after laboratory-induced trips. Obese and healthy weight women retrospectively reported similar fall rates (40.9% vs 40.5%; P=.97). Similar percentages of healthy weight and obese women prospectively fell (64.7% vs 64.3%; P=.98) and stumbled (38.9% vs 14.3%; P=.24). After laboratory-induced trips, 46.2% of obese verse 25.0% of healthy weight women fell (P=.44). Unlike healthy weight fallers, most obese fallers failed to initiate or complete the recovery step before full-body harness support. Obesity does not appear to increase overall fall risk; although, fall rates after laboratory-induced trips were notably higher, potentially due to altered recovery responses. An incomplete recovery step could increase impact force with the ground, predisposing obese individuals to injury. The fact that there is concurrence between 4 independent outcomes strengthens the findings, suggesting that further, large-scale studies are warranted to inform future clinical practice regarding fall-risk assessment for obese older adults.

Radial Nerve Mobilization Decreases Pain Sensitivity and Improves Motor Performance in Patients With Thumb Carpometacarpal Osteoarthritis: A Randomized Controlled Trial - Corrected Proof

Jorge H. Villafañe, Guillermo B. Silva, Mark D. Bishop, Josue Fernandez-Carnero — 2012-01-04

Abstract: Villafañe JH, Silva GB, Bishop MD, Fernandez-Carnero J. Radial nerve mobilization decreases pain sensitivity and improves motor performance in patients with thumb carpometacarpal osteoarthritis: a randomized controlled trial. Objective: To examine the effects of radial nerve mobilization on pain sensitivity and motor performance in subjects with secondary thumb carpometacarpal osteoarthritis. Design: Randomized controlled trial. Treatment and placebo were given for 4 weeks. Measurements were taken before intervention, after 1 month (first follow-up), and after 2 months (second follow-up). Setting: Patients from the Department of Physical Therapy, Azienda Sanitaria Locale 3, Collegno (Italy). Participants: Participants (N=60; age range, 70–90y) with right-dominant hand secondary thumb carpometacarpal osteoarthritis without other motor-related pathology. All patients completed the study. No patients were withdrawn from the study. Interventions: Sliding mobilization of the proximal-distal radial nerve or intermittent ultrasound therapy, used as placebo. Main Outcome Measures: We hypothesized that radial nerve mobilization induces hypoalgesia and increases strength in secondary thumb carpometacarpal osteoarthritis. We measured pressure pain threshold (PPT) at the trapeziometacarpal joint, the tubercle of the scaphoid bone, and the unciform apophysis of the hamate bone by algometry. Tip pinch strength and tripod pinch strength were measured by a mechanical pinch gauge. Results: Treatment increased PPT by 3.33±.24kg/cm2 (P<.001) in the trapeziometacarpal joint and was maintained until first follow-up and second follow-up. Also, PPT in the scaphoid bone and hamate bone was increased (P<.001 and P<.02, respectively). Variables in the placebo group remained unchanged. Tip pinch strength increased by 2.22±.22kg (P<.04) and tripod pinch strength by 2.83±.24kg (P<.019). Conclusions: Radial nerve mobilization decreases pain sensitivity in the trapeziometacarpal joint and increases tip pinch strength.

Sound Induced Vertigo: Superior Canal Dehiscence Resulting From Blast Exposure - Corrected Proof

Adam Mehlenbacher, Bruce Capehart, Dale Bass, James R. Burke — 2012-01-04

Abstract: Mehlenbacher A, Capehart B, Bass D, Burke JR. Sound induced vertigo: superior canal dehiscence resulting from blast exposure. Barotrauma is common in modern warfare. We present the first description of sound induced vertigo caused by superior canal dehiscence (SCD) precipitated by blast exposure. Patients who complain of balance or visual changes after military or terrorist blast exposure should be evaluated for SCD.

Reliability and Validity of Scores of a Chinese Version of the Frenchay Activities Index - Corrected Proof

Bita Imam, William C. Miller — 2012-01-03

Abstract: Imam B, Miller WC. Reliability and validity of scores of a Chinese version of the Frenchay Activities Index. Objective: To develop a Chinese version of the Frenchay Activities Index (FAI-C) and evaluate the reliability and validity of its scores. Design: A 2-week test-retest study. Setting: Chinese community in Vancouver, BC, Canada. Participants: Data were collected using a convenience sample of Chinese immigrants living in Vancouver, BC, Canada. Of the 73 participants, data from 66 participants were included in the analysis. The total sample included 2 subsamples: community dwelling (n=32), and assisted-living (n=34). Participants were 65 years or older, lived in Canada for more than 5 years, and were able to read Chinese. Interventions: Not applicable. Main Outcome Measure: FAI-C scores. Results: Test-retest reliability of the FAI-C scores assessed using an intraclass correlation coefficient was .86 (95% confidence interval [CI], .79–.92) for the total sample, .89 (95% CI, .78–.94) for the community-dwelling subsample, and .71 (95% CI, .50–.85) for the assisted-living subsample. The minimal detectable difference at the 95% CI was 8.64. Correlations between the FAI-C and the Reintegration to Normal Living Index (r=.61, P<.01), Activities-specific Balance Confidence Scale (r=.55, P<.01), and Timed Up & Go test (r=−.68, P<.01) were in the a priori hypothesized direction and magnitude. Conclusions: The FAI-C scores are reliable and there is support for validity. This tool enables us to measure social participation level in the Chinese-speaking population.

Gait Training in Human Spinal Cord Injury Using Electromechanical Systems: Effect of Device Type and Patient Characteristics - Corrected Proof

2012-01-03

Abstract: Benito-Penalva J, Edwards DJ, Opisso E, Cortes M, Lopez-Blazquez R, Murillo N, Costa U, Tormos JM, Vidal-Samsó J, Valls-Solé J, European Multicenter Study about Human Spinal Cord Injury Study Group, Medina J. Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics. Objective: To report the clinical improvements in spinal cord injury (SCI) patients associated with intensive gait training using electromechanical systems according to patient characteristics. Design: Prospective longitudinal study. Setting: Inpatient SCI rehabilitation center. Participants: Adults with SCI (n=130). Intervention: Patients received locomotor training with 2 different electromechanical devices, 5 days per week for 8 weeks. Main Outcome Measures: Lower-extremity motor score, Walking Index for Spinal Cord Injury, and 10-meter walking test data were collected at the baseline, midpoint, and end of the program. Patients were stratified according to the American Spinal Injury Association (ASIA) category, time since injury, and injury etiology. A subgroup of traumatic ASIA grade C and D patients were compared with data obtained from the European Multicenter Study about Human Spinal Cord Injury (EM-SCI). Results: One hundred and five patients completed the program. Significant gains in lower-limb motor function and gait were observed for both types of electromechanical device systems, to a similar degree. The greatest rate of improvement was shown in the motor incomplete SCI patients, and for patients <6 months postinjury. The positive response associated with training was not affected by injury etiology, age, sex, or lesion level. The trajectory of improvement was significantly enhanced relative to patients receiving the conventional standard of care without electromechanical systems (EM-SCI). Conclusions: The use of electromechanical systems for intensive gait training in SCI is associated with a marked improvement in lower-limb motor function and gait across a diverse range of patients and is most evident in motor incomplete patients, and for patients who begin the regimen early in the recovery process.

Further Assessment to Determine the Additive Effect of Botulinum Toxin Type A on an Upper Extremity Exercise Program to Enhance Function Among Individuals With Chronic Stroke but Extensor Capability - Corrected Proof

2011-12-29

Abstract: Wolf SL, Milton SB, Reiss A, Easley KA, Shenvi NV, Clark PC. Further assessment to determine the additive effect of botulinum toxin type A on an upper extremity exercise program to enhance function among individuals with chronic stroke but extensor capability. Objective: To determine whether dose-specified botulinum toxin type A (BTX-A) and a standardized exercise protocol produce better upper extremity function than placebo and the same exercise program. Design: Double-blind randomized trial. Setting: A rehabilitation research center. Participants: A convenience sample of patients (N=25, age range, 23–76y) who sustained a stroke 3 to 24 months previously but could initiate wrist extension. Interventions: Participants were randomly selected to receive either BTX-A (maximum 300U) or saline, followed by 12 to 16 exercise sessions. Main Outcome Measures: The primary outcome was the Wolf Motor Function Test (WMFT). Secondary outcome measures included the Modified Ashworth Scale (MAS), active range of motion, and the Stroke Impact Scale (SIS; quality of life). Results: There were no group-by-time interactions for changes in the WMFT and no treatment difference (P=.86), although the BTX-A group could complete more tasks governing proximal joint motions. MAS scores improved for the BTX-A group and worsened for the control group after injection (P=.02), as did the SIS emotion domain (P=.035). Conclusions: Among chronic stroke survivors, BTX-A did not impact function, movement, or tone more than a standardized exercise program.

Establishing the NeuroRecovery Network: Multisite Rehabilitation Centers That Provide Activity-Based Therapies and Assessments for Neurologic Disorders - Corrected Proof

2011-07-21

Abstract: Harkema SJ, Schmidt-Read M, Behrman AL, Bratta A, Sisto SA, Edgerton VR. Establishing the NeuroRecovery Network: multisite rehabilitation centers that provide activity-based therapies and assessments for neurologic disorders.The mission of the NeuroRecovery Network (NRN) is to provide support for the implementation of specialized centers at rehabilitation sites in the United States. Currently, there are 7 NRN centers that provide standardized activity-based interventions designed from scientific and clinical evidence for recovery of mobility, posture, standing, and walking and improvements in health and quality of life in individuals with spinal cord injury. Extensive outcome measures evaluating function, health, and quality of life are used to determine the efficacy of the program. NRN members consist of scientists, clinicians, and administrators who collaborate to achieve the goals and objectives of the network within an organizational structure by designing and implementing a clinical model that provides consistent interventions and evaluations and a general education and training program.

Balance and Ambulation Improvements in Individuals With Chronic Incomplete Spinal Cord Injury Using Locomotor Training–Based Rehabilitation - Corrected Proof

2011-07-21

Abstract: Harkema SJ, Schmidt-Read M, Lorenz D, Edgerton VR, Behrman AL. Balance and ambulation improvements in individuals with chronic incomplete SCI using locomotor training–based rehabilitation.Objective: To evaluate the effects of intensive locomotor training on balance and ambulatory function at enrollment and discharge during outpatient rehabilitation after incomplete SCI.Design: Prospective observational cohort.Setting: Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).Participants: Patients (N=196) with American Spinal Injury Association Impairment Scale (AIS) grade C or D SCI who received at least 20 locomotor training treatment sessions in the NRN.Interventions: Intensive locomotor training, including step training using body-weight support and manual facilitation on a treadmill followed by overground assessment and community integration.Main Outcome Measures: Berg Balance Scale; Six-Minute Walk Test; 10-Meter Walk Test.Results: Outcome measures at enrollment showed high variability between patients with AIS grades C and D. Significant improvement from enrollment to final evaluation was observed in balance and walking measures for patients with AIS grades C and D. The magnitude of improvement significantly differed between AIS groups for all measures. Time since SCI was not associated significantly with outcome measures at enrollment, but was related inversely to levels of improvement.Conclusions: Significant variability in baseline values of functional outcome measures is evident after SCI in individuals with AIS grades C and D and significant functional recovery can continue to occur even years after injury when provided with locomotor training. These results indicate that rehabilitation, which provides intensive activity-based therapy, can result in functional improvements in individuals with chronic incomplete SCI.