Poster 9: Motivating, game-based stroke rehabilitation: a pilot study

Objective: To determine the efficacy and reactions of stroke patient to a game-based rehabilitation modality for more affected upper limbs. Design: Case series. Setting: Outpatient rehabilitation clinic. Participants: 4 persons with stroke (3 men; mean age, 60.0±4.9y; age range, 56-66y; mean time since stroke, 84.3mo; range, 10-264mo). Interventions: Each patient received thirteen 30-minute training sessions using the gaming device. Each session required participation in electronic table tennis using the more affected hand as the joystick, thus forcing use of the more affected limb. Instantaneous kinesthetic and force feedback was available via participation. Main Outcome Measures: Wolf Motor Function Test (WMFT) and patient interviews before and after intervention. Results: After the intervention, patients exhibited decreased median time to complete WMFT tasks (−5.3s), decreased mean time to perform WMFT tasks (−19.7s), and improved performance ratings as assessed by an objective rater. Interviews revealed high satisfaction and motivation; they also revealed that motor improvement had a high carryover to valued activities. Conclusions: This approach appears to be an efficacious, motivating, and enjoyable modality deserving of additional research. A larger, multicenter trial is planned.     

Poster 39: Total body reciprocal training improves hand function in chronic stroke survivors

Objective: To examine changes in hand function of chronic stroke survivors participating in exercise using a total body recumbent stepper (TBRS). Design: Case series. Setting: University medical school. Participants: 11 participants (8 men; age, 61.3±11.0y) >6 months poststroke with mild to moderate hemiparesis (6 with right side involvement). Intervention: An 8-week exercise program using TBRS 3 times a week for 30 minutes per session. Main Outcome Measures: Functional Rating Score (FRS) from the Wolf Motor Function Test and bilateral grip strength measured by dynamometry. Results: Statistical analyses were conducted using a repeated-measures 2×2×4 factorial analysis of variance for factors of gender and the more affected side along with time. Results indicated a significant interaction of the intervention with left grip strength. Left grip strength increased from 13.44±8.92lb to 16.72±7.23lb after intervention. Values were significant at P<.05. The average for right grip strength did not demonstrate significance after intervention. FRS improved, but not significantly. Conclusion: Improvements in function and strength are possible for chronic stroke survivors participating in exercise involving a TBRS.     

Poster 35: High-resolution electroencephalography and reorganization of posterior cortical potentials

Objective: To test whether reorganization after spinal cord lesions is “unfavorable” because of a takeover of cortical areas representing weak or paralyzed muscles. Design: Randomized study of electroencephalograms. Setting: Spinal cord research laboratory. Participants: 16 patients with spinal cord lesions and 10 normal controls. Interventions: Subjects were instructed in moving their right middle or index fingers. The fingers were also moved in a similar manner by an operator. Voluntary movement was monitored by electromyography. Main Outcome Measures: Movement-related cortical potentials and passive movements. Results: Posterior cortical reorganization represented reinforcement of residual motor pathways from somatosensory cortex (S1) to the spinal cord, and facilitated rehabilitation. Conclusion: Motor potentials can be generated by active and passive measurements of the fingers. Reorganization of somatosensory cortex is important in deriving potentials from proprioceptive input and creating the necessary templates to activate the motor networks and electroencephalographic activity.     

Abstract 6: Treadmill training with partial body weight support in children with cerebral palsy

Objective: To examine the effects on the gait pattern of treadmill training with partial body weight support using the gait analysis system in children with cerebral palsy (CP). Design: Open, nonrandomized, baseline-treatment study. Setting: Tertiary university hospital outpatient rehabilitation clinic in general community. Participants: 20 children under 10 years of age (mean, 5.2y) who were at level III or IV of Gross Motor Function Classification System, and were diagnosed as CP spastic diplegic type. They had received comprehensive rehabilitative management through the outpatient clinic for more than 1 year, but did not show specific improvements in their gait patterns. Intervention: 3 weeks of additional treadmill training, 5 times a week, for 20 minutes a session. Main Outcome Measures: Walking distance for 1 minute, muscle strength of both lower limbs, and gait analysis using a gait analysis system 1 week before the study onset, and within 1 week after the end of therapy. Results: Muscle strength of both lower limbs did not change. Walking distance for 1 minute was much increased from 2.7 to 8.1m. On liner parameters of gait analysis, there were significant improvements in speed (.17-.29m/s), cadence (55.4-77.4 steps/min), and stride length (.31-.40m). But kinematic parameters did not change significantly. Conclusions: Treadmill training with partial body weight support is an effective treatment method to achieve better gait ability and walking velocity in children with cerebral palsy. Therefore, it could be an adjunctive tool to improve the ambulatory function in children with CP.     

Presentation 5: An investigation of foot alignment and support in ankle foot orthoses

Objective: To investigate the effect that ankle-foot alignment and foot support in ankle-foot orthoses (AFOs) may have on the gait of subjects with hemiplegia after stroke. Design: Test-retest. Setting: Motion analysis research laboratory. Participants: 20 participants with hemiplegia. Intervention: Subjects underwent 3 gait analyses, each 2 weeks apart. The first tested walking with a conventionally aligned AFO; the second tested walking with a heel-height compensated AFO with full-length footplate; and the third tested walking with a heel-height compensated AFO with three-quarter length footplate. Main Outcome Measures: We acquired bilateral kinematic, kinetic, electromyographic, and plantar pressure data, as well as subjective information from the subjects using a questionnaire. Results: Preliminary data from 7 subjects suggests that, compared with a shoes-only condition, all AFO conditions improved ankle position at initial contact and in swing, and, where knee hyperextension was present, reduced the onset and magnitude of the hyperextension. All AFO conditions also changed the internal knee moment from flexor to extensor, decreased the heel strike transient present in the vertical ground reaction force, and improved roll-over shape. Conclusions: Compared with the full length AFOs, the three-quarter length AFO provided the shortest roll-over shape and had the highest peak pressures in the midfoot. We believe that this study will give us a better understanding of the effect of ankle-foot alignment and foot support on hemiplegic gait, and may enable us to recommend more appropriate AFO designs.     

Abstract 15: H-reflex latencies and sensory and motor nerve action potential latencies among diabetic patients seen at the outpatient service of a tertiary hospital: a correlative study.

Objective: To determine the correlation between the H-reflex latencies and the sensory and motor nerve action potential latencies in detecting diabetic neuropathy. Design: Prospective, cross-sectional. Setting: Outpatient departments of neurology and rehabilitation medicine in a tertiary hospital. Participants: 41 subjects with diabetes. Interventions: Not applicable. Main Outcome Measures: H-reflex latencies of the tibial nerve and nerve conduction studies (median motor and sensory, peroneal motor, sural sensory latencies) of the upper and lower extremity of each patient. Results: The correlation between the nerve action potential latencies and the H-reflex latencies was studied using the canonical correlation analysis method. The computed canonical correlation coefficient was .8379 (P=.0001). Conclusions: The findings suggest that there is a strong correlation between H-reflex latencies and sensory and motor nerve action potential latencies among patients with diabetic neuropathy. Based on this study, use of H-reflex latencies is a promising alternative electrophysiologic technique in the investigation of peripheral neuropathy among patients with diabetes mellitus.     

Poster 6: Complex regional pain syndrome and distal radius fractures: intermediate-term follow-up

Objective: To evaluate the impact of complex regional pain syndrome (CRPS) after distal radius fractures on function and health-related quality of life (HRQOL). Design: Retrospective and prospective clinical study. Setting: University orthopedic department. Participants: 28 patients with CRPS after distal radius fractures. Interventions: Fracture management (closed reduction, cast immobilization, external fixation, open reduction and internal fixation, percutaneous pinning) and CRPS management (autonomic nerve blocks, oral medications, hand therapy, median nerve decompression). Main Outcome Measures: Clinical findings; thermoregulatory testing (isolated cold stress testing, laser Doppler measurements of cutaneous perfusion and digital pulp temperature); and HRQOL instruments (McGill Pain Questionnaire, McCabe Cold Sensitivity Scale, Levine Symptom Severity and Functional Scale, Disabilities of Arm, Shoulder, and Hand [DASH] questionnaires, Wake Forest University Symptom Rating Scale). All 3 measures were compared at initial presentation and at a mean follow-up of 5 years. Results: At 5-year follow-up, patients with CRPS after distal radius fractures who received the active intervention showed diminished pain, improved strength, and decreased stiffness; however, numbness and cold intolerance was not improved. Conclusion: CRPS after distal radius fractures results in a significantly diminished function, HRQOL, and residual disability despite active and vigorous intervention.     

Article 10: Effect of cognitive retraining on reorganization of attention network in patients with traumatic brain injury

Objective: To identify the areas of reorganization in the neural network for attention after cognitive retraining in the patients with traumatic brain injury (TBI) using functional MRI (fMRI). Design: Controlled clinical trials. Setting: Department of physical medicine and rehabilitation in general hospital. Participants: Ten TBI patients and 12 healthy volunteers participated. Interventions: Patients had received computer-assisted cognitive retraining to practice diverse attention skills for 3 to 4 weeks. Main Outcome Measures: fMRI was performed on a 3T ISOL Forte scanner with single-shot echoplanar imaging sequences before and after the intervention using a modified Posner paradigm as an activation task. Data were analyzed using Statistical Parametric Mapping 99. Results: The accuracy was lower and reaction time was slower in the patient group (P<.001). fMRI results showed more activation in the right prefrontal and less activation in the cingulate, occipitotemporal, and cerebellar regions in the patients than in the normal group. After cognitive retraining, reaction time improved significantly (P<.05). fMRI analysis showed a decrease in activation of the bilateral frontal and an increase in activation of the medial frontal areas after cognitive retraining. Conclusion: The effect of cognitive retraining was accompanied by reorganization of attention networks in frontal areas.     

Poster 28: Comparison of hemi-field fresnel prisms versus patching for visual neglect after stroke

Objective: To assess the effect of bilateral hemi-field prisms versus patches for treatment of visual neglect after stroke. Design: Randomized, prospective, controlled trial. Setting: Inpatient stroke unit. Participants: 38 patients with stroke, visual neglect defined by the Behavioral Inattention Test (BIT), and visual acuity ≥20/200. Interventions: The prism group received 15 diopter Fresnel prisms over the affected hemi-field bilaterally; patch group received black tape of the unaffected visual hemi-field bilaterally; controls received no visual intervention. The interventions lasted 14 days. Main Outcome Measures: 3 subtests of BIT were recorded at baseline and on days 2, 7, 14, and 16. Results: Admissions demographic were similar for all 3 groups. There were no significant differences in BIT scores while wearing the optical devices. The prism group showed a trend for improvement in all 3 BIT scores 2 days after removal of the optical device. This reached statistical significance for the line bisection scores (prism group ± SEM, 1.5±0.3; patch group, .12±.12; controls, .33±.33; P=.004). Dropouts were highest for prism group (10/16) versus patch group (4/12) and controls (1/10) (P=0.2). Conclusion: Hemi-field Fresnel prisms showed a beneficial effect on visual neglect 2 days after their removal.     

Poster 29: Barriers to community integration treatment

Objective: To examine barriers to community integration treatment (CIT) among a consecutive sample of referrals. Design: A retrospective chart review of a consecutive series of referrals to CIT. Setting: CIT program for persons with brain injury. Participants: 138 consecutive referrals (n=72 nonadmitted) to CIT from January 1 to December 31, 2002. Interventions: All persons referred were evaluated by an admissions counselor and/or treatment team to determine appropriateness. Main Outcome Measures: Data comparing persons entering treatment with those not entering treatment were retrieved from summary admissions reports. Results: Persons entering treatment did not differ in age, gender, race, distance to the program, or time postinjury from persons who did not enter treatment. Common barriers to persons not entering treatment included: reliable transportation (14%), funding for treatment (8%), poor family support (6%), and awareness for relevance of treatment (14%). Conclusions: Among a sample of consecutive referrals not admitted to CIT, approximately 42% of cases were due to barriers such as reliable transportation, funding for treatment, poor family support, and education about the relevance of CIT. These data suggest points of intervention for policymakers and clinicians to decrease disability and handicap in states serving large rural populations.     

Poster 18: A method for quantitative analysis of central nervous system motor output during voluntary movements

Objective: To assess methods used to reduce surface electromyographic data during voluntary movements. Design: Retrospective analysis of surface electromyograms recorded from healthy subjects and subjects with spinal cord injury (SCI) using the Brain Motor Control Assessment protocol. Setting: Regional referral center for SCI. Participants: 9 subjects with SCI who had American Spinal Injury Association Impairment Scale classes C and D injuries and were drawn from another study; and 15 healthy subjects. Intervention: Supported treadmill ambulation training was provided to the subjects with SCI as a part of a separate efficacy study and was used to demonstrate analysis method sensitivity to changes in motor control. Main Outcome Measures: Surface electromyographic responses to voluntary maneuvers from 10 muscles in the lower limbs. They were used to calculate the inner product of vectors of each muscle’s average activity. Results: The electromyographic responses of intact subjects to voluntary maneuvers were consistent. Response vector similarity of SCI patients’ data set to prototype response vector was consistent. The magnitude of the response vector varied within a reliable range. Conclusions: This method of analysis shows the potential to differentiate between subjects with healthy and with damaged central nervous system movement control. It also appears that this method has the sensitivity to differentiate among subjects with SCI and changes in motor control over time, and to characterize those changes with respect to responses recorded in healthy subjects.     

Poster 14: Cost savings of pulmonary vest therapy

Objectives: To determine cost savings from using pulmonary vest therapy to prevent hospitalizations related to pneumonia. Design: Quantitative research using before-during treatment data. Setting: 2 pediatric skilled nursing facilities for children with severe cerebral palsy (CP). Interventions: Not applicable. Main Outcome Measures: The average hospitalization for pneumonia was 5 days, 4 of which were in the intensive care unit (ICU). The daily hospitalization rates were obtained from the business offices of 3 regional hospitals with pediatric ICU units that serve our patients. Results: During our 1-year study, the number of hospitalizations was decreased by 10. The average hospitalization charge was $8225. Thus, the cost savings for 10 hospitalizations was $82,550. The cost of a vest therapy unit was $15,000 and a total of 3 units were used. The vest therapy units continue to be in use for the third year, without mechanical failure or maintenance requirements. Conclusion: In the first year alone, there was a very significant cost savings. It should be noted that these sums do not include hospital laboratory testing, pharmacy costs, or physician costs, and so significantly underestimate the actual savings.     

Poster 13: Validation of the assessment of motor and process skills among older adults in the community

Objective: To assess the validity of the Assessment of Motor and Process Skills (AMPS), an occupational therapy tool, for epidemiologic research. Design: Population-based sample. Setting: Northern New York City. Participants: 217 elders aged ≥70 years were recruited from Medicare beneficiary files. Interventions: Not applicable. Main Outcome Measures: The AMPS composite motor and cognitive process scores. Results: In this sample of nondemented older people (32% men; mean age, 78.5±5.6y; two thirds minorities), motor scores correlated highly with gait speed (.53), grip strength (.34), and tandem stand time (.36) (P<.001). Process scores were significantly lower in people with mild cognitive impairment relative to those with normal cognition (P<.001). Correlations between process scores and physical indicators, and motor scores and cognitive performance, were much lower, indicating discriminant validity. 25% of participants scored in the impaired range in motor skills, 10% in process skills, and 7.5% in both. Self-reported deficits were related to both motor and process scores. Conclusions: The AMPS appears to be a valid tool for epidemiologic research.     

Poster 36: Neuropsychiatric symptoms in patients with traumatic brain injury: 2 years postdischarge

Objective: To assess the prevalence of neuropsychiatric symptoms in traumatic brain injury (TBI) 2 years postdischarge from inpatient rehabilitation and its associated caregiver distress. Design: Follow-up study. Setting: Inpatient acute rehabilitation hospital and community. Participants: 39 consecutive patients with TBI. Interventions: Not applicable. Main Outcome Measure: The Neuropsychiatric Inventory. Results: Neuropsychiatric symptoms were present in 75% of our sample 2 years postdischarge from acute rehabilitation. Among these symptoms, the most frequently encountered were: irritability, 48.7%; depression, 43.6%; appetite and eating changes, 25.6%; night-time and sleep behavior, 23.1%; apathy, 20.5%; anxiety, 17.9%; agitation and aggression, 17.9%; and disinhibition, 10.3%. The least frequently observed behaviors included: hallucinations, 5.1%; euphoria and elation, 2.6%; and delusions, 0%. At 2-year follow-up, anxiety, agitation and aggression, apathy, and irritability caused the most emotional distress to the caregivers, while hallucination and euphoria caused the least. Conclusions: Neuropsychiatric symptoms are prevalent in patients with TBI after discharge from acute rehabilitation. These symptoms are associated with significant caregiver distress. These findings further support the continued need for adequate psychologic assessment and possible intervention postdischarge.     

Abstract 8: Functional and societal limitation and disability outcomes in a randomized control trial of botulinum toxin type a for children with spastic diplegic cerebral palsy.

Objectives: To document the functional and societal limitation and disability level effects (National Center for Medical Rehabilitation Research framework) of gastrocnemius botulinum toxin type A (BTX) injections in children with spastic diplegic cerebral palsy (CP). Design: Randomized double-masked placebo controlled trial. Setting: Tertiary care children’s hospital. Participants: 33 children with spastic diplegic CP, (mean age, 5.5y; range, 3.0-11.9y), of whom 19 were boys (subjects’ Gross Motor Function Classification System levels: level I=12; level II=15; level III=6). Intervention: All participants were randomized to receive either 12U/kg BTX or placebo saline injections. Main Outcome Measures: Functional limitation and disability: Gross Motor Function Measure (GMFM-88, GMFM-66), energy cost index (ECI), and Canadian Occupational Performance Measure (COPM) performance scores were collected at selected weeks postinjection. Societal limitation: COPM satisfaction scores and Goal Attainment Scaling (GAS) were obtained at 12 and 24 weeks. Results: GMFM-88 total score (P=.00) and the GMFM-66 (P=.03) significantly increased for the treatment group compared with the placebo group at 24 weeks. No significant group differences were found for the ECI at any follow-up point. The COPM performance scores were significantly greater for the treatment group at 12 weeks (P=.04) and approached a significant difference at 24 weeks (P=.06). COPM satisfaction scores and GAS did not differ significantly by group at any follow-up point. Conclusions: The GMFM-88 and -66 scores and COPM performance scores demonstrated a significant difference at 12 weeks, with a diminishing effect noted at 24 weeks. In contrast, satisfaction with performance as measured by the COPM satisfaction scores and performance and importance of goals set as measured by the GAS did not differ significantly between treatment groups. These data documented consistent changes on the functional limitation and disability levels up to 6 months posttreatment, but not on the societal outcome level.