The association of balance capacity and falls self-efficacy with history of falling in community-dwelling people with chronic stroke

OBJECTIVES: To describe the frequency of falls; to relate capacity-based and self-efficacy measures to fall history; and to determine to what extent capacity-based and self-efficacy measures are explained by subject characteristics and stroke impairments. DESIGN: Cross-sectional. SETTING: Community. PARTICIPANTS: Convenience sample of 50 people with chronic stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Fall history, Falls Efficacy Scale-Swedish Version, fear of falling, and the mood subscore of the Stroke Impact Scale. Balance, strength, and functional mobility were measured using the Berg Balance Scale, timed sit to stand, and Timed Up & Go, respectively. RESULTS: Falls were reported by 40% (n=20) of subjects; 22% (n=11) reported multiple falls. Subjects with fall history had more fear of falling (relative risk [RR], 2.4; 95% confidence interval [CI], 1.1-4.9), had less falls-related self-efficacy (P=.04), and more depressive symptoms (P=.02) than nonfallers. Subjects with multiple fall history had poorer balance (P=.02), more fear of falling (RR=5.6; 95% CI, 1.3-23), and used a greater number of medications (P=.04) than non- and 1-time fallers. Strength partially explained balance, mobility, and falls-related self-efficacy. CONCLUSIONS: Balance and falls-related self-efficacy are associated with fall history and should be addressed in people with chronic stroke.     

Subcortical vascular lesions predict falls at 12 months in elderly patients discharged from a rehabilitation ward

Guerini F, Frisoni GB, Marrè A, Turco R, Bellelli G, Trabucchi M. Subcortical vascular lesions predict falls at 12 months in elderly patients discharged from a rehabilitation ward.

Objective

To test whether subcortical vascular lesions are associated with falls in elderly patients with gait disorder discharged from a rehabilitation ward.

Design

Secondary 12-month follow-up analysis of an observational survey focusing on the prevalence of subcortical vascular lesions in a population of elderly patients discharged from rehabilitation hospitals.

Setting

A rehabilitation and aged care unit.

Participants

Consecutively admitted elderly patients (N=214) with gait disorder.

Interventions

Not applicable.

Main Outcome Measures

On admission, all patients underwent comprehensive geriatric assessment including sociodemographics, cognitive and depressive symptoms, nutritional status, physical health, and functional status. Subcortical vascular lesions were assessed on computed tomography films with a validated rating scale. All patients received a standardized rehabilitative program. Twelve months after discharge, all patients were interviewed by telephone, mainly focusing on the occurrence of falls during the follow-up period. Potential predictors of falls were assessed in univariate and multivariate analyses.

Results

Univariate predictors of falls were age, sex, Mini-Mental State Examination, Barthel Index on admission, and subcortical vascular lesions. In multivariate analyses, subcortical vascular lesions were the only significant predictor of risk of falling; patients with moderate and severe subcortical vascular lesions scores had a greater risk of falling (odds ratio [OR]=3.0; 95% confidence interval [CI], 1.3–7.1; P=.012; OR=3.9; 95% CI, 1.6–9.2; P=.002, respectively) than those with no subcortical vascular lesions.

Conclusions

Subcortical vascular lesions are associated with falls at 12 months in elderly patients with gait disorder discharged from a rehabilitative ward. Future research is needed to confirm our results.     

Validation of an adapted falls efficacy scale in older rehabilitation patients

Büla CJ, Martin E, Rochat S, Piot-Ziegler C. Validation of an adapted Falls Efficacy Scale in older rehabilitation patients.

Objective

To determine the psychometric properties of an adapted version of the Falls Efficacy Scale (FES) in older rehabilitation patients.

Design

Cross-sectional survey.

Setting

Postacute rehabilitation facility in Switzerland.

Participants

Seventy elderly persons aged 65 years and older receiving postacute, inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measures

FES questions asked about subject’s confidence (range, 0 [none]-10 [full]) in performing 12 activities of daily living (ADLs) without falling. Construct validity was assessed using correlation with measures of physical (basic ADLs [BADLs]), cognitive (Mini-Mental State Examination [MMSE]), affective (15-item Geriatric Depression Scale [GDS]), and mobility (Performance Oriented Mobility Assessment [POMA]) performance. Predictive validity was assessed using the length of rehabilitation stay as the outcome. To determine test-retest reliability, FES administration was repeated in a random subsample (n=20) within 72 hours.

Results

FES scores ranged from 10 to 120 (mean, 88.7±26.5). Internal consistency was optimal (Cronbach α=.90), and item-to-total correlations were all significant, ranging from .56 (toilet use) to .82 (reaching into closets). Test-retest reliability was high (intraclass correlation coefficient, .97; 95% confidence interval, .95−.99; P<.001). Subjects reporting a fall in the previous year had lower FES scores than nonfallers (85.0±25.2 vs 94.4±27.9, P=.054). The FES correlated with POMA (Spearman ρ=.40, P<.001), MMSE (ρ=.37, P=.001), BADL (ρ=.43, P<.001), and GDS (ρ=−.53, P<.001) scores. These relationships remained significant in multivariable analysis for BADLs and GDS, confirming FES construct validity. There was a significant inverse relationship between FES score and the length of rehabilitation stay, independent of sociodemographic, functional, cognitive, and fall status.

Conclusions

This adapted FES is reliable and valid in older patients undergoing postacute rehabilitation. The independent association between poor falls efficacy and increased length of stay has not been previously described and needs further investigations.     

Validation of the Berg Balance Scale as a predictor of length of stay and discharge destination in stroke rehabilitation

OBJECTIVE: To validate the utility of the Berg Balance Scale (BBS) in predicting length of stay (LOS) and discharge destination for patients admitted to a stroke rehabilitation unit. DESIGN: Prospective study. SETTING: Provincial tertiary inpatient stroke unit for a primarily geriatric population. PARTICIPANTS: A total of 313 of the 325 patients admitted consecutively between April 1998 and August 2000. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: LOS and discharge destination. RESULTS: Admission BBS scores correlated negatively with LOS (r=-.53, controlling for age). Logistic regression confirmed that the following were independent predictors of being discharged home rather than to an institution (adjusted odds ratio, 95% confidence interval): admission BBS (1.09, 1.06-1.12) and the presence of family supports (15.0, 7.2-31.3). These results generally concur with previously published results, obtained at a different stroke rehabilitation setting. CONCLUSIONS: This study validates the use of the BBS scores in assisting to estimate approximate LOS and eventual discharge destination. Age did not correlate significantly with the outcomes measured in this study, which was conducted in a geriatric population.     

Two years later: a prospective long-term follow-up of a training intervention in geriatric patients with a history of severe falls

OBJECTIVE: To study the long-term outcome of a physical training regimen of ambulant postward rehabilitation in community-dwelling geriatric patients with a history of injurious falls. DESIGN: Prospective 2-year follow-up of a randomized placebo-controlled intervention trial. SETTING: Postward rehabilitation in a geriatric hospital in Germany. PARTICIPANTS: Fifty-seven geriatric patients (mean age, 84.3+/-4.4 y) with a history of severe falls. INTERVENTION: Ambulatory training of strength, functional performance, and balance 3 times a week for 3 months for 31 patients versus placebo activities for 26 patients. MAIN OUTCOME MEASURES: Strength, functional performance, fall-related psychologic parameters, and physical activity assessed by standardized protocols 2 years after the training intervention, compared with baseline results. RESULTS: Motor performance decreased substantially in both groups. As patients in the intervention group declined from significantly improved motor performance levels achieved in the initial training intervention, differences between the groups were still significant in most functional performances 2 years later. Functional decline was greater in persons who were institutionalized or being cared for by family members. Physical activity, which increased during the exercise intervention, returned to low baseline levels. CONCLUSIONS: Improved functional performance in the training group did not lead to an increased level of physical activity after training, which might have preserved the functional improvements. In mobility-restricted, frail, geriatric patients such as our study population, training programs should continue to keep patients active and to prevent the decline in strength and functional performance that precedes loss of autonomy.     

Clinical analysis of risk factors for falls in home-living stroke patients using functional evaluation tools

Wada N, Sohmiya M, Shimizu T, Okamoto K, Shirakura K. Clinical analysis of risk factors for falls in home-living stroke patients using functional evaluation tools.

Objectives

To identify risk factors associated with falls in home-living stroke patients and to predict falls using patient information and functional evaluation tools.

Design

Cohort study.

Setting

Community.

Participants

We recruited 101 home-living stroke patients who had hemiparesis and could walk independently with or without supporting devices. Disease duration ranged from 1 to 22 years (mean, 6.1y).

Interventions

Not applicable.

Main Outcome Measures

The score of each item of the Stroke Impairment Assessment Set (SIAS), and the FIM instrument, sex, age, duration of disease, stroke type, affected side of the body, frequency of rehabilitation, use of sedatives, and Mini-Mental State Examination score were evaluated and the occurrence of falls was observed prospectively for 12 months.

Results

Forty-five (44.6%) participants fell, 20 of whom fell repeatedly. A logistic model for predicting falls was refined until it included 4 predictors: memory score on the FIM, range of motion of the lower extremities on the SIAS, duration of disease, and affected side. The predictive value of the logistic model was 86.7%.

Conclusions

Evaluation tools were useful for predicting falls and devising preventive strategies in the high-risk group of home-living stroke patients.     

Reconsidering the motor recovery plateau in stroke rehabilitation

Termination of motor rehabilitation is often recommended as patients with cerebrovascular accident (CVA) become more chronic and/or when they fail to respond positively to motor rehabilitation (commonly termed a "plateau"). Managed-care programs frequently reinforce this practice by restricting care to patients responding to therapy and/or to the most acute patients. When neuromuscular adaptation occurs in exercise, rather than terminating the current regimen, a variety of techniques (eg, modifying intensity, attempting different modalities) are used to facilitate neuromuscular adaptations. After presenting the concepts of the motor recovery plateau and adaptation, we similarly posit that patients with CVA adapt to therapeutic exercise but that this is not indicative of a diminished capacity for motor improvement. Instead, like traditional exercise circumstances, adaptive states can be overcome by modifying regimen aspects (eg, intensity, introducing new exercises). Findings suggesting that patients with chronic CVA can benefit from motor rehabilitation programs that apply novel or different parameters and modalities. The objectives of this commentary are to (1) to encourage practitioners to reconsider the notion of the motor recovery plateau, (2) to reconsider chronic CVA patients' ability to recover motor function, and (3) to use different modalities when accommodation is exhibited.     

The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program

Sze P-C, Cheung W-H, Lam P-S, Lo HS-D, Leung K-S, Chan T. The efficacy of a multidisciplinary falls prevention clinic with an extended step-down community program.

Objective

To investigate the efficacy of a falls prevention clinic and a community step-down program in reducing the number of falls among community-dwelling elderly at high risk of fall.

Design

Prospective cohort.

Setting

Community.

Participants

Community-dwelling elderly (N=200) were screened for risk of fall; 60 were identified as being at high risk and were referred to the intervention program.

Intervention

Twelve sessions of a once-a-week falls prevention clinic, including fall evaluation, balance training, home hazard management program, and medical referrals, were provided in the first 3 months. The community step-down program, including falls prevention education, a weekly exercise class, and 2 home visitations, was provided in the following 9 months.

Main Outcome Measures

Fall rate, injurious fall, and its associated medical consultation were recorded during the intervention period and the year before intervention. Balance tests included the Berg Balance Scale (BBS), Sensory Organization Test, and limits of stability test; fear of falling, as evaluated using the Activities-specific Balance Confidence (ABC) scale, was measured at baseline and after the training in the falls prevention clinic.

Results

Significant reductions in fall rate (74%), injurious falls (43%), and fall-associated medical consultation (47%) were noted. Significant improvement in balance scores (BBS, P<.001; endpoint excursion in limits of stability test, P=.004) and fear of falling (ABC scale, P=.001) was shown.

Conclusions

The programs in the falls prevention clinic were effective in reducing the number of falls and injurious falls. The community step-down programs were crucial in maintaining the intervention effects of the falls prevention clinic.     

The WalkAbout: A new solution for preventing falls in the elderly and disabled

OBJECTIVE: To evaluate the performance of a new walking aid, the WalkAbout, for severely disabled and elderly persons. DESIGN: Crossover design. SETTING: Laboratory and nursing home. PARTICIPANTS: Sixty-five patients who could not walk independently. INTERVENTIONS: The top rail of the WalkAbout completely encircles the user and is approximately waist high to provide user stability. The footprint of the base is larger in circumference than the top rail, with the legs angled outward to give the device maximum stability. The caster wheels roll easily along the floor as the user walks. Foot brakes on 2 wheels provide stability for entering and exiting the device by walking through the gate. A safety seat prevents falling but does not impede normal gait. MAIN OUTCOME MEASURES: Distance walked, a questionnaire used to assess function of the WalkAbout, and laboratory tests of safety in preventing falls. RESULTS: Seventeen subjects could walk only with the WalkAbout. Ninety-seven percent of subjects who could walk with another assistive device walked further with the WalkAbout. Ninety-five percent of subjects said they felt safe while using the device and 92% reported that the WalkAbout safety seat was comfortable. CONCLUSIONS: The WalkAbout prevents falls and subjects walked further using the WalkAbout than with any other assistive device tested.     

脑血管意外恢复期患者认知缺陷的测量和分析

作者根据脑血管意外(CVA)患者的特点和我国文化背景,专门设计了包括记忆力、注意力、定向力、语言能力和复杂作业操作能力等内容的认知功能测量表,并利用此表对30例CVA患者进行了初步认知测量阳分析。该表敏感度高,可重复使用,符合我国国情,患者容易接受。结果表明,中风后患者大多有不同程度的认知缺陷,如记忆力、注意力和复杂作业操作能力等。     

Dynamic gait stability, clinical correlates, and prognosis of falls among community-dwelling older adults

Bhatt T, Espy D, Yang F, Pai Y-C. Dynamic gait stability, clinical correlates, and prognosis of falls among community-dwelling older adults.

Objective

To establish an accurate measure for prognostic assessment of fall risk in community-dwelling older adults, this study examined the prediction accuracy of a dynamic gait stability measure and common clinical tests for slip-related falls among these adults.

Design

Participants were tested for their fall-risk likelihood on a slip-test.

Setting

Biomechanics research laboratory.

Participants

Community-dwelling older adults (N=119; ≥65y).

Interventions

Not applicable.

Main Outcome Measures

Participants performed a battery of clinical tests, including Berg Balance Scale, Timed Up & Go (TUG) test, static posturography, isometric muscle strength, and bone density. They were then exposed to an unannounced slip during gait. The dynamic stability during unperturbed gait was measured based on the center of mass position and velocity relative to the limits of stability against backward falling. Accuracy of each measure was examined for prediction of slip outcome (fall or recovery).

Results

On the slip, 59 participants fell, 56 recovered their balance, and 4 were harness-assisted. Dynamic stability predicted fall outcome with 69% accuracy. Except for TUG and bone density, no other measure could differentiate fallers from nonfallers; TUG predicted 56% of fall outcomes.

Conclusions

Reproduction of actual falls provides a new benchmark for evaluating the prognostic power of different performance-based assessment tools. The TUG was able to better predict fall outcome than other clinical measures; however, the new dynamic gait stability measure was more sensitive than TUG in its prediction of falls. Ultrasound bone scan could be used to screen older adults for fall risk.     

Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial

Smulders E, Weerdesteyn V, Groen BE, Duysens J, Eijsbouts A, Laan R, van Lankveld W. Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial.

Objective

To evaluate the efficacy of the Nijmegen Falls Prevention Program (NFPP) for persons with osteoporosis and a fall history in a randomized controlled trial. Persons with osteoporosis are at risk for fall-related fractures because of decreased bone strength. A decrease in the number of falls therefore is expected to be particularly beneficial for these persons.

Design

Randomized controlled trial.

Setting

Hospital.

Participants

Persons with osteoporosis and a fall history (N=96; mean ± SD age, 71.0±4.7y; 90 women).

Intervention

After baseline assessment, participants were randomly assigned to the exercise (n=50; participated in the NFPP for persons with osteoporosis [5.5wk]) or control group (n=46; usual care).

Main Outcome Measures

Primary outcome measure was fall rate, measured by using monthly fall calendars for 1 year. Secondary outcomes were balance confidence (Activity-specific Balance Confidence Scale), quality of life (QOL; Quality of Life Questionnaire of the European Foundation for Osteoporosis), and activity level (LASA Physical Activity Questionnaire, pedometer), assessed posttreatment subsequent to the program and after 1 year of follow-up.

Results

The fall rate in the exercise group was 39% lower than for the control group (.72 vs 1.18 falls/person-year; risk ratio, .61; 95% confidence interval, .40-.94). Balance confidence in the exercise group increased by 13.9% (P=.001). No group differences were observed in QOL and activity levels.

Conclusion

The NFPP for persons with osteoporosis was effective in decreasing the number of falls and improving balance confidence. Therefore, it is a valuable new tool to improve mobility and independence of persons with osteoporosis.     

Robotic-assisted rehabilitation of the upper limb after acute stroke

OBJECTIVE: To investigate whether early therapy with a novel robotic device can reduce motor impairment and enhance functional recovery of poststroke patients with hemiparetic and hemiplegic upper limb. DESIGN: A single-blind randomized controlled trial, with an 8-month follow-up. SETTING: Neurologic department and rehabilitation hospital. PARTICIPANTS: Thirty-five patients with acute (< or =1 wk of onset), unilateral, ischemic embolic, or thrombotic stroke. INTERVENTIONS: Patients of both groups received the same dose and length per day of standard poststroke multidisciplinary rehabilitation. Patients were randomly assigned to 2 groups. The experimental group (n=17) received additional early sensorimotor robotic training, 4 hours a week for 5 weeks; the control group (n=18) was exposed to the robotic device, 30 minutes a week, twice a week, but the exercises were performed with the unimpaired upper limb. Training by robot consisted of peripheral manipulation of the shoulder and elbow of the impaired limb, correlated with visual stimuli. MAIN OUTCOME MEASURES: The Fugl-Meyer Assessment (FMA) of upper-extremity function (shoulder/elbow and coordination and wrist/hand subsections) to measure each trained limb segment; the Medical Research Council (MRC) score to measure the strength of muscle force during 3 actions: shoulder abduction (MRC deltoid), elbow flexion (MRC biceps), and wrist flexion (MRC wrist flexors); the FIM instrument and its motor component; and the Trunk Control Test (TCT) and Modified Ashworth Scale (MAS). RESULTS: Compared with the patients in the control group, the experimental group showed significant gains in motor impairment and functional recovery of the upper limb after robot therapy, as measured by the MRC deltoid (P< or =.05) and biceps (P<.05) scores, the FMA for the proximal upper arm (P<.05), the FIM instrument (P<.05), and the FIM motor score (P<.01); these gains were also sustained at the 3- and 8-month follow-up. The FMA and MRC wrist flexor test findings did not differ statistically either at the end of training or at the follow-up sessions. We found no significant differences in MAS and TCT in either group in any of the evaluations. No adverse effects occurred and the robotic approach was very well accepted. CONCLUSIONS: Patients who received robotic therapy in addition to conventional therapy showed greater reductions in motor impairment and improvements in functional abilities. Robotic therapy may therefore effectively complement standard rehabilitation from the start, by providing therapeutic support for patients with poststroke plegic and paretic upper limb.     

Sit-and-reach test can predict mobility of patients recovering from acute stroke

OBJECTIVES: To establish the test-retest reliability of the sit-and-reach test (SRT) and to determine the capacity of the SRT to predict mobility of patients recovering from acute stroke. DESIGN: Study 1 consisted of repeating the SRT to examine its reliability over trials (same day) and sessions (alternate days). Study 2 consisted of measuring performance in the SRT 7 to 10 days poststroke and measuring mobility at discharge for prospective analysis. SETTING: Medical and rehabilitation wards in hospital in Hong Kong. PARTICIPANTS: Thirty-six subjects with acute stroke (study 1, n=10; study 2, n=26). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Between 7 and 10 days of stroke onset, distance reached on the SRT was measured. Mobility at discharge was assessed using the transfer and locomotion scale of the FIM instrument (FIM mobility) and a timed walk test. RESULTS: The intertrial and intersession reliability of the SRT were rated good, with intraclass correlation coefficients of .98 and .79, respectively. Distance reached on the SRT correlated with the FIM mobility score on discharge (r=.572, P=.002) and the distance achieved on the timed walk test (r=.524, P=.006). Distance reached on the SRT accounted for 32.7% and 27.5% of the variance in the FIM mobility score at discharge and the distance achieved on the timed walk test, respectively. CONCLUSIONS: Performance in the SRT is reliable and can significantly predict the mobility of patients with acute stroke at discharge.     

Pilot study examining the association between ambulatory activity and falls among hospitalized older adults

Fisher SR, Galloway RV, Kuo Y-F, Graham JE, Ottenbacher KJ, Ostir GV, Goodwin JS. Pilot study examining the association between ambulatory activity and falls among hospitalized older adults.

Objective

To examine the ambulatory activity of older patients who had a documented fall during hospitalization for acute illness.

Design

A retrospective case-control design was used in a pilot study of patients (n=10; ≥65y) who had a documented fall during their hospital stay and matched controls (n=25) who did not fall.

Setting

Acute care medical/surgical unit.

Participants

Men and women 65 years and older who wore a step activity monitor while hospitalized.

Interventions

Not applicable.

Main Outcome Measures

Fall incidents during the hospital stay were documented by the nurse in a standardized patient safety event report in accordance with hospital policy. The number of steps per 24-hour interval, time spent walking, and total number of activity episodes were determined for patients and controls.

Results

On average ± SD, patients who fell took 480.3±432.2 steps per hospital day, spent 53.8±36.9 minutes walking, and engaged in 25.8±16.9 episodes of activity. Mean daily steps, time spent walking, and number of activity episodes for patients who did not fall were 680.1±876.0, 50.1±58.6, and 21.6±23.8, respectively. Logistic regression results indicated no association between the fall outcome and mean daily steps (odds ratio=.95; 95% confidence interval, 0.84–1.06).

Conclusions

Ambulatory activity among patients who fell varied widely. Mean daily steps, time spent walking, and number of episodes of activity were comparable with matched controls who did not fall. Patient falls were more likely to be associated with cognitive and hospital environmental factors than actual amount of walking.     

Injurious falls among middle aged and older adults with multiple sclerosis

Peterson EW, Cho CC, von Koch L, Finlayson ML. Injurious falls among middle aged and older adults with multiple sclerosis.

Objective

To determine the prevalence of, and risk factors for, receiving medical attention for a recent injurious fall among middle-aged and older adults who have multiple sclerosis (MS).

Design

Survey.

Setting

United States.

Participants

Seven hundred people with MS, age 55 years or older and living in the United States, were randomly selected from the North American Research Committee on Multiple Sclerosis Registry and invited by mail to participate in the study. A total of 354 people, aged 55 to 94 years, completed the survey.

Interventions

Not applicable.

Main Outcome Measures

Participant's self-report regarding receipt of medical care for a fall-related injury (received care within the past 6mo, >6mo ago, or never).

Results

More than 50% of study participants reported injurious falls; 12%, in the 6 months before the interview. Proportional odds models were used to identify factors associated with increased odds of receiving medical attention for a fall-related injury within the past 6 months. Compared with study participants who reported receiving medical attention for a fall-related injury more than 6 months ago or never, participants who reported receiving medical attention for a fall-related injury within the past 6 months were more likely to report fear of falling (odds ratio [OR]=1.94; 95% confidence interval [CI], 1.27−2.96) and osteoporosis (OR=1.65; 95% CI, 1.03-2.62).

Conclusions

Injurious falls were commonly reported by survey participants. Findings suggest that management of fear of falling and osteoporosis are important components of comprehensive fall-injury prevention programs for people aging with MS.     

Circuit class therapy versus individual physiotherapy sessions during inpatient stroke rehabilitation: a controlled trial

OBJECTIVE: To compare the effectiveness of circuit class therapy and individual physiotherapy (PT) sessions in improving walking ability and functional balance for people recovering from stroke. DESIGN: Nonrandomized, single-blind controlled trial. SETTING: Medical rehabilitation ward of a rehabilitation hospital. PARTICIPANTS: Sixty-eight persons receiving inpatient rehabilitation after a stroke. INTERVENTIONS: Subjects received group circuit class therapy or individual treatment sessions as the sole method of PT service delivery for the duration of their inpatient stay. MAIN OUTCOME MEASURES: Five-meter walk test (5MWT), two-minute walk test (2MWT), and the Berg Balance Scale (BBS) measured 4 weeks after admission. Secondary outcome measures included the Iowa Level of Assistance Scale, Motor Assessment Scale upper-limb items, and patient satisfaction. Measures were taken on admission and 4 weeks later. RESULTS: Subjects in both groups showed significant improvements between admission and week 4 in all primary outcome measures. There were no significant between group differences in the primary outcome measures at week 4 (5MWT mean difference, .07m/s; 2MWT mean difference, 1.8m; BBS mean difference, 3.9 points). A significantly higher proportion of subjects in the circuit class therapy group were able to walk independently at discharge (P=.01) and were satisfied with the amount of therapy received (P=.007). CONCLUSIONS: Circuit class therapy appeared as effective as individual PT sessions for this sample of subjects receiving inpatient rehabilitation poststroke. Favorable results for circuit classes in terms of increased walking independence and patient satisfaction suggest this model of service delivery warrants further investigation.     

Tips and falls during electric-powered wheelchair driving: effects of seatbelt use, legrests, and driving speed

OBJECTIVE: To measure the response of a test dummy while traversing common obstacles encountered by users of electric-powered wheelchairs (EPWs) to determine whether optimal wheelchair fit, use of seatbelts, and driving speed affect the frequency and severity of EPW tips and falls. DESIGN: Repeated-measures comparison study. SETTING: Constructed environment both in and around a Veterans Affairs medical center. PARTICIPANT: A 50th percentile Hybrid II anthropometric test dummy (ATD) was used to simulate a person driving an EPW. INTERVENTIONS: The ATD was driven in 4 different EPWs over commonly encountered obstacles at speeds of 1 and 2m/s, with and without the use of a seatbelt, and at varying legrest heights. MAIN OUTCOME MEASURES: The response and motion of the ATD were observed and recorded as no fall, loss of control (the ATD falls forward or sideways but remains in the EPW), the ATD falls out of the EPW, or the EPW tips completely. RESULTS: A total of 97 adverse events out of 1700 trials were recorded: 88 were losses of control (instability) and 9 were ATD falls. No complete tips of any EPW occurred. Univariate statistical analysis indicated a significant relationship between the adverse events and the use of seatbelts, legrest condition, and test obstacles (P<.05). A mixed-model analysis confirmed the significant relationships between the adverse events and the use of seatbelts, legrest condition, and test obstacles (P<.05). However, the mixed model indicated that (1) there was no significant relationship between the adverse events and driving speed and (2) no one obstacle was designated to be the most problematic. CONCLUSION: Persons who use EPWs should use seatbelts and legrests while driving their EPWs, and clinicians should include common driving tasks when assessing the proper set-up of EPWs.